ObamaCare: All roads lead to single payer

ObamaCare: All roads lead to single payer

When the marketing of ObamaCare began in 2009, I always believed that the end game was for a federal single payer system. Since the present Affordable Care Act, (ACA), was passed in 2010, there has been nothing to convince me otherwise. The only reason single-payer wasn’t passed two years ago was because it was hard enough to arm-twist and bribe even Democratic legislators to pass the present 2,000+ pages of legislation. Following is my prediction of how this will unfold.

Remember the President’s marketing lines? “This won’t cost a dime. It will be funded by savings in fraud and abuse.” Millions of dollars in F&A have been recouped, but the dollars saved do not even come close to paying for this program. Or how about this one, “If you like your health plan and your doctor you can keep it.”

True––assuming that your employer still offers you health insurance, as many will drop this worker benefit come 2014.

Doctors have always been the weakest link in the healthcare chain. Compared to pharmaceutical companies, AARP, attorneys, health insurance companies, and hospital chains, we are poorly organized and underfund lobbing efforts. So like the slowest gazelle in the pack, we are the easiest to pick off first. By the end of 2013, estimates are that over one-half of cardiologists will be owned and or financially affiliated with a hospital corporation. Office based ancillaries such as imaging and cardiac cath labs have had reimbursements cut to below levels of provider cost, making it almost financially impossible for a cardiologist to remain independent. How did this happen? Let’s see.

The rap against cardiologists, and other specialists, has been that since they owned so much diagnostic and treatment equipment, that over-testing and procedures, largely due to self-referral, drive up the cost of healthcare. That is a legitimate hypothesis, but has never been proven. Medicare’s solution was to simply cut away at physician owned outpatient facility payments while simultaneously increasing the reimbursements for the same procedures at the hospital; thus eliminating any conflict of interest when a doctor orders a test or procedure. In theory, this idea seems sound, but in actuality, it ends up costing Medicare more, not less. That is because any test, or procedure, done in the hospital costs many times more than if it was done in the physicians’ office.

For example, in my area of Florida, a physician-owned cardiac cath lab can do a procedure for under $2,000 and still make a profit. The exact same procedure in the hospital, (even if it is done as an out-patient), can cost Medicare anywhere from $5,000 to $10,000. Plus the patient must pay a Medicare Part A deductible, which is more than Part B. None of this has dissuaded Medicare from cutting reimbursements to non-hospital owned outpatient cath labs, which will likely become extinct within the next two years.

Along with this big stick, is also a big carrot. Hospital-employed cardiologists are now paid on the basis of relative value of work units, or RVU’s. So now longer do they have to worry about being under, or non-reimbursed, for their work due to poor or no health insurance. The hospital can more than make up for these bad debts by write-offs and over-charging Medicare and other private carriers. Thus, it has become a win-win for the hospital and the cardiologist. Who looses? We all do. There is now even less of a free market system of health care testing and procedure purchasing, and costs will inevitably rise.

I believe that federal government policy makers are not blind to this. When most cardiologists are employed by hospitals in the not-to-distant future, Medicare and other payers will start to cut payments to the hospitals as well, under the guise of reducing costs of the program.  Inevitably rationing will then increase, as it has in every industrialized country with national health insurance. Private insurance premiums will escalate, and the populace will become increasingly angry and demand changes. The politicians will throw up their hands and say, “Oh well, we tried to do this through the private sector, but it just hasn’t worked out as we had expected.” Voila: single payer.

I hope I am wrong. But as implementation of ObamaCare rolls along, and Medicare directs better payments to hospitals than physicians, I doubt it. The only alternative is consumer-driven health care. But that is a subject for another day.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.

Image credit: Shutterstock.com

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  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    I predict people will get what they say they “want.”

    choice.

    they will have the choice of:
    Mediocre government subsidized care
    or
    Private pay care. (if they can afford it)

    • http://www.facebook.com/people/Rita-Chobanian-Swisher/1125771124 Rita Chobanian Swisher

      Exactly, just like Canada. Couldn’t agree more.

  • http://www.drwhalen.com/blog.html Santee Chiropractor

    Thank you for the insight. In you opinion is Obama care more effective than the past health care programs? What are it’s benefits?

    • http://www.facebook.com/robert.luedecke Robert Luedecke

      Obamacare is a significant improvement. Some of its benefits are:

      Children can stay on their parent’s insurance until age 26.
      Beginning in 2014 no one can be denied insurance or charged more based on pre-existing conditions. The “donut hole” of medication expenses for seniors will gradually close. The “upcharge” on premiums will decrease for getting older and will disappear for being female. The self-employed will get better insurance at a better price.

      • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

        1. Children can stay on their parent’s insurance until age 26. (YEAH!)

        2. Beginning in 2014 no one can be denied insurance or charged more based on pre-existing conditions. (looks great on paper, do you REALLY believe the insurance companies wont find a way of getting around this? Don’t be naive.)

        3. The “donut hole” of medication expenses for seniors will gradually close. (great… who’s going to pay for that?)

        4. The “upcharge” on premiums will decrease for getting older and will disappear for being female. (again, great… but there is a reason insurance charges more for these groups. They typically cost more. So we have just given them a great excuse to just charge more to everyone. they have already started.)

        5. The self-employed will get better insurance at a better price. (so you say. no evidence to support this and you may also believe in unicorns.)

        • Robert Luedecke

          1 Two of my children would have been uninsured after graduating from college until they could land a job that had benefits.
          2 I am sure some insurance companies will try to get out of insuring everyone, but they have already agreed to do this in return for more business.
          3 As a physician, I see seniors who take only half their medicine because they can’t afford to buy it all. I will gladly help pay for this and I hope you would too.
          4 Older people undoubtedly cost more to insure, as do those with severe illnesses. Should we continue to force those to pay for it who cannot afford it?
          5 Without a large employer negotiating for me, I got an expensive individual policy that didn’t cover much. When I was able to get insurance through my wife’s employer, my premium was lower for a better policy. Yes, this will happen for the self-employed under Obamacare.

  • NewMexicoRam

    I’ve been seeing it this way since just before ObamaCare passed.
    Medicare has raised it’s payments to doctors about 7% over the last 13 years. What will happen when they are the only game in town?

  • buzzkiller

    I’m not so sure. I agree that the feds are trying and will continue to try to cut payments to docs and hospitals, but the insurance industry is a big player and might have some meat thrown its way. We might wind up with a regulated insurance, to keep rates down but still allow insurance companies to make some money–which will come out of the hides of docs and patients, of course. We could end up with both public and private payers, all using their bargaining clout to cut our payments to the bone. Not much better than single payer, but at least the insurance cos can get a cut.
    Hard times acomin’ on the land, doc.

  • Zstimman

    The problem with Single Payor is that the patient will have little recourse when the managers at Obamacare say NO. I have been in Durable Medical Equipment for twenty years. When Medicare says no, it can be a start of a two year process of appeals, and hearings. Often, with a negative result. Which leads to providers refusing to provide patients with necessary medical equipment. In the private world, it is much smoother. The privates also are wise to the dollar. If treatment would save them money, they were up for it. With Medicare, we often made the argument that treatment would save a limb form amputation. They countered ” we have a code for the amputations”.

  • Docbart

    Reminds me of Reagan and the AMA predicting, at the start of Medicare 50+ years ago that it was the start of socialism. That happened, right Comrade?

    On one hand you talk about the huge sum of money it will cost, which goes into paying for medical care, and on the other how providers will be financially strangled. So, where will the trillions of dollars be going?

    I guess if Obama is doing it, it can’t be good. Somehow, when “lunar colony” Gingrich and the other conservative luminaries thought up the individual mandate, it was an admirable concept, a wonderful stroke of genius. When the Dems took up the idea, it became toxic. Good to know that we are looking at it objectively.

    • http://www.facebook.com/people/Rita-Chobanian-Swisher/1125771124 Rita Chobanian Swisher

      Fully agree that whoever thought the mandate was a great idea in and of itself (Gingrich or whomever) was an idiot. But you have asked fair questions, and I don’t think anyone can 100% predict the future, but let’s look at how the money is being divied: currently physicians (the real blood, life, and core NECESSARY piece of the system, as in, without docs, you got nothing) take about 20% of all healthcare expenditure. And yet, under Obamacare, guess who has been determined to be overpaid? The doctors. I agree that making cuts to this smaller piece of the pie is going to be disastrous to medicine and I actually even believe that the lawmakers know better than this, but the doctors are the only non-represented group in the bunch. In fact, the insurance lobby and the pharmaceutical lobby had first dibs at the bill. And of course, the AMA is not any true representation of doctors and goodwill toward care of patients. They are first and foremost interested in their own self-preservation (and frankly, I don’t really blame them, given that so many doctors have been so complacent for so long about allowing themselves to be abused and regulated and sued to death).

      But to speak to your idea of politics and scare tactics, I too resent extreme statements like the suggestion of socialism because of a social program- BUT, that is only because I believe that Americans are a reasonable, freedom-loving people who police their government to some degree. When Medicare was created, could it have become a complete takeover of medicine by the public sector? Absolutey, but it didn’t, because of opposition to such extremes. If I honestly still believed that our country was aware of what is happening in medicine, I would not be as concerned, but unfortunately at this point much of the public is unaware of how aggressive and damaging this bill is, and will be. Also, if I thought government officials were flexible and open to change, and would be willing to make changes as necessary to NOT destroy American medicine’s excellence, I too would be on board with President Obama. Unfortunately, and this is not the President’s fault, I do not have any such faith at this point.

      • Docbart

        You are incorrect in saying that Obamacare targets physicians only as being overpaid. The payments to physicians seeing Medicaid patients will jump sharply to reach Medicare levels. Payments to hospitals and insurers, medical equipment suppliers, and nursing homes in some instances, will be cut.

        Physicians may not be united, but we are far from unrepresented. Like it or not, the AMA exerts a great deal of influence, witness the repeated fixes to the scheduled Medicare fee cuts, like the one that just happened.

        Big programs like Obamacare are never perfect, especially at the outset. Medicare is still being tweaked after more than 50 years. Obamacare has already had positive impacts on getting insurance for more people and constraining insurance company profits. It will do much more in a couple of years, and will greatly improve access to healthcare as well as job mobility. Life expectancy gets demonstrably longer when people get even Medicaid coverage, which is pretty stingy. Fifty years from now, Americans will wonder what all the fuss was about, except as a political ploy by Republicans, and why America was the last major industrialized country to institute this sort of reform.

        • http://www.facebook.com/people/Rita-Chobanian-Swisher/1125771124 Rita Chobanian Swisher

          You don’t have to convince me that making coverage available to more people helps them live longer and improves society as a whole. Completely agreed. The question is this: do we truly want a better outcome for our people or are we obsessed with taking power away from doctors and placing it in the Federal government’s hands? It’s a fair question and there is absolutely nothing wrong with demanding that the government demonstrate goodwill and good faith during the process (and believe me, this is a process. Pelosi is not the expert healthcare guru and not everything in this bill is gospel.)
          True, the Medicaid to Medicare jump is great and overdue, but I guarantee you that it won’t last. In reality, what Obama wants to see is doctors making a relatively mediocre salary (an engineer’s salary or slightly higher) and working for a big institution that can be easily regulated by the government. Sure, cuts are being made elsewhere also, but I find it ironic that there is this level of audacity to demonize the very people who provide the actual care.

          I don’t mean to be Debbie Downer and I sincerely hope that all of this concern is for naught, and at the end of the day our government truly DOES listen to the input being provided to them (like the 100,000+ hardship exemptions filed for e-prescribe) rather than arrogantly tossing all humble criticisms aside just to make a political point. As for your hatred of the Republicans, as a true independent I can say that not everything that is opposed to your worldview is just a “ploy.” Sometimes people have legitimate reasons to ask questions and express concerns and it may very well end up being the work of the Republicans which will cause this program NOT to turn into a disaster but rather a success as you describe. You’re not always going to be correct. Sometimes your opponent has the correct idea, and that’s fine. It’s the way it’s supposed to work. If I thought the Democrats and Republicans of this government were honestly working together to watch out for the best interests of the country, I would not be as concerned. But if everything turns out for the best in the end, I will applaud not only President Obama but everyone who was instrumental in educating him and his party about how the system actually works.

          • Docbart

            Are you writing these replies in an organizational or salaried capacity?

          • http://www.facebook.com/people/Rita-Chobanian-Swisher/1125771124 Rita Chobanian Swisher

            No, as a follower of the site…? Why would you ask??

          • Docbart

            Glad to hear it, but you would not be the first. I asked because you are putting a great deal of effort into promoting a particular viewpoint.

  • Robert Luedecke

    As a solo anesthesiologist in private practice in San Antonio, TX, I know that something needed to be done about the 26% of uninsured citizens. There are a lot of jobs available here, but many of them are at very low pay with no benefits. Many here do not have college degrees (we have the highest rate of repeat teen pregnancy), and without Obamacare most have no chance of ever having health insurance. Other than a system where we use some government money to help these families get good medical care, diabetics are still going to go without treatment until we have to cut off their toes and put them on dialysis. Something is very wrong with a system which makes it impossible to take care of your medical problems until they are so severe that you are disabled and on Medicaid. It is very wasteful of our tax money to not use some of it to help families stay healthy and working.

    Obamacare is not perfect, but it is several steps in the right direction. I understand your angst, and my guess would be that Medicare would have forced cardiologists to become employees of hospitals with or without Obamacare. Thank God the AMA prevented us from having “Medicare for all.” I don’t think Medicare will try to force doctor’s payments too much lower, because in many fields it is already so low as to limit patient access. The politicians will not allow Medicare patients to go unseen or they will be voted out of office.

    Obamacare has already helped many patients I know, including me. Without its protection from being excluded for pre-existing conditions, I would have to worry about a future of being unable to get health insurance as someone who is self-employed.

  • http://twitter.com/RHR_Chat RHR_Chat

    I remember fighting against ObamaCare in 2008. At the time, I was still actively fighting cancer and used a walker. I begged physicians to get involved in educating the public that ObamaCare was not a good idea. I explained to physicians that they would become federal government employees and that ObamaCare marginalized the profession. ObamaCare made every doc a commodity who no longer practiced a profession but, instead, was functioning as a factory worker.

    I did get some docs to get on board. We scheduled appointments with our US Congressmen (D) who ignored the doctors. The Republican Senator from NC (Richard Burr) ignored us because he doubted he would get enough “air time.”

    Now ObamaCare is kicking in. Physicians are scared and they take it out on patients. And so the doc-pt relationship is jeopardized. Patients are confused bc they are starting to be examined more by PAs and NPs than docs. This will lead to liability issues.

    I walk the walk. I am uninsurable because of cancer and osteomyelitis. I refuse to have my healthcare regimented by the federal government. I will go without healthcare if ObamaCare is my only alternative. And if it means going without healthcare for cancer or osteomyelitis (or another disease), so be it.

    The concept of a single payor (the federal government) should alarm all Americans. My academic question is how we can reconcile HIPAA with a single payor system. We can’t.

    I dealt with many physicians who ignored the ObamaCare fight in 2008 because they just wanted to practice medicine and not get all political. Those physicians had a duty to their profession and their patients. Shame on them.

    • http://www.facebook.com/robert.luedecke Robert Luedecke

      I respect your hutzpa for sticking up for what you believe, but as someone who has been actively involved in healthcare reform since 2007, I think some of your concerns are not based on fact. It is a long way from Obamacare to a single payor system. Maybe we will eventually go there, maybe not. I don’t want to go there, but I don’t understand how that would violate HIPAA. The federal government is requiring people to buy health insurance because the only affordable way to be able to insure those with pre-existing conditions is for almost everybody to have insurance. You may not mind going without insurance, but I have worked way too hard to spend my retirement
      money on just healthcare. I respect your right to believe anything you
      want, but Obamacare contains as much free market competition as is
      possible. As for it being a violation of our duty to our patients, what
      about our desire to help more patients have access to healthcare? The laws passed by the Texas legislature that tell docs what they have to say and what tests they have to do for patients seeking abortion are a much greater violation of patient-physician relationship than anything I have seen in Obamacare.

      Obamacare is far from perfect but it helps end the time that the US is the only industrialized country in the world that has not figured out a way to insure all its citizens.

  • tlinville

    This isn’t a new concept, I’ve been saying the same thing since Hillary tried to organize it in the 90′s. Over the next 20 years rationing is going to be commonplace, many potential doctors will move away from Med school and we’ll have an even greater shortage of doctors. PA’s and NP’s will become the norm. (My wife is a PA). And I agree that there will be two classes of care, govt subsidized or private depending on what you can afford. Obama and his socialist agenda are ruining this country.

  • Paul

    I believe ObamaCare was designed to fail, on purpose. The law’s
    requirement’s for guaranteed issue, community rating, and medical loss
    ratios were designed to make private insurance fail, and to make what
    remains of the industry so prohibitively expensive as to make many, many
    more people uninsured. The tax penalty that was set for failing to buy
    insurance is so much cheaper than actually buying insurance that people
    will simply pay the fine. Guaranteed issue means doing so will swamp the
    insurance companies with horrendous losses. Was that a mistake or
    intentional? These uninsured will also look for relief from the federal
    government and free charity care from hospitals. With a substantial
    number of formerly privately-insured people now reduced to charity and
    Medicaid, with doctors and hospitals reluctant to see them, with the
    inevitable shortages and increasing wait times, the federal government
    will have created an opportunity for itself to come back in and offer
    something like Medicaid for everyone, posing as a savior. By that time,
    the people will be ready for it.

    If I wanted private health insurance to fail, what would I do? I would hamstring the industry with thousand of pages of new rules and harsh penalties, which would help to make the companies unprofitable, and push over the edge any that were now marginally profitable. When insurers consolidated to cope, I would accuse them of trying to form monopolies to destroy affordable health care. I would discourage innovation with a uniform insurance model applied everywhere, subject to constantly changing interpretations and regulations so as to introduce a large degree of uncertainty that would hamper planning and investment. Simply put: I would enact ACA.

    As Kevin states, they wanted national government health care for everyone
    in the beginning. They made no bones about it; they just couldn’t get it
    through all at once.

    There are probably only two possibilities here: 1) either the people who wrote the legislation are unbelievably stupid, incompetent and inexperienced; they didn’t understand what they were doing, or 2) they wanted to create the conditions for eventual monopoly national health care. Since they had tremendous access to a vast body of literature and economists, all at their beck and call, ignorance and incompetence is not a good guess. My bet is on the latter.

    • Robert Luedecke

      Paul, the language you use tells me you have a lot of knowledge about insurance and I agree that the ACA will squeeze insurance profits, but I do not agree that Obamacare was designed to fail. Insurance companies were involved in the negotiations and agreed to ease some of their restrictions in return for a lot more business. Insurance companies thought it was better to accept less profit per customer in return for more customers. The most difficult part of this is agreeing to accept everyone with pre-existing conditions without charging more (what you and the insurance industry call guaranteed issue). This is not so new of an idea and is what Mit Romney already did in Massachusetts. Do you really think the insurance companies would agree to something they think will put them out of business?

      One major reason the decision was made to give up on “national government healthcare for all” was that insurance companies have so much money for lobbying and campaign contributions they would be an overwhelming force to overcome. Politicians knew insurance companies would be glad to help the US get out of the position of being the only industrialized nation to not provide for the healthcare of its citizens. But the only way this would happen is if they could get a share of the pie. Obamacare is a free-market solution.

      Efficient insurance companies will thrive and inefficient ones may cease to exist. Because of the transparency in Obamacare, it will no longer be possible for each insurance company to use different accounting systems to hide profits in “expenses” so we cannot see how much money they are really paying out in medical costs (what you call medical loss ratios). Imagine a stock market where there were no uniform rules so you could not compare apples to apples. This transparency has been an objective of the Texas Medical Association for the last 10 years and few would call the TMA a liberal organization. Obamacare will help us know how much of our insurance premium really goes to pay our medical costs.

      Obamacare is not perfect, but we are finally addressing one of the major issues that keeps our country from competing internationally. The high cost of medical care in the US is not sustainable. Medical costs will bankrupt our country if we just continued with the status quo. As a physician, I know there is a huge amount of waste and inefficiency in our medical system. Some estimate 30% (one trillion dollars per year) of our total spending is wasted. Obamacare is a great step forward in making our system more efficient, but it is only the first step in a free-market solution.

      • Paul

        “Free market” means no government involvement. A free market means buyers and sellers can come together without government interference. It means they can each buy and sell whatever is mutually agreeable to them, at whatever terms are mutually agreeable to them. ObamaCare is about as far away from the free market as you could get. Nor is the current system a free market system. It is government dominated and highly regulated. More than half the states still have certificates of need, and there are moratoriums on building new facilities and new types of facilities, like specialty surgery hospitals. That’s free market? Not quite. Half the patients in the U.S., at least, are government subsidized through taxes. ObamaCare continues along the same path. The end game here is national government monopoly health care. That is the next logical step after ObamaCare. Whether the eventual system is privately run but government controlled, or government run and government controlled, makes little difference.

        A free market in health care would resemble, more or less, what we had before 1965–before Medicare and Medicaid. In those days, the cost of an average hospital stay was a few days’ average wages. Doctors made house calls (there were more doctors per capita then). Seniors paid less out of pocket than they do today under Medicare. Although you can argue all sorts of factors have increased the cost of health care, by far the largest one is mass government subsidies into the industry. As soon as government became involved, medical inflation took off. Same thing happened with education.

        Medicare and Medicaid will bankrupt the country on their present course. These programs, too, were marketed as making health care cheaper and more affordable. Having more government involvement is hardly the fix, unless the idea of strict rationing appeals to you. Which, by the way, is inevitable in a government-controlled system.

        Government health care systems are every bit as wasteful as anything in private enterprise. If you believe that 30% of health care expenditures are for waste, you can bet at least the same waste exists in the VA, Medicare, Medicaid, the Indian Health Service, Tricare, and any other government systems of any other country you can name. Waste exists everywhere, in all systems. Having the government run it hardly makes it disappear.

        It’s true that the insurers supported ObamaCare. So did the AMA and the AHA. They did so out of fear that if they didn’t, they would lose out. Better to have some say in shaping the eventual law than not. Insurers agreed to support the scheme in exchange for the government forcing its citizens to buy its products: thus the mandate. Without the mandate, insurers would go bankrupt under guaranteed issue, community rating, and medical loss ratios. If the mandate proves ineffective or unenforceable, then the insurers will go bankrupt.

        Now, the government could have forced people to buy insurance under threat of imprisonment, but it chose a different way. It would use tax penalties (fines). Once the insurers were effectively bought off, the penalty could then be set. If the penalty proves to be too low, it will encourage people to pay the fine instead. If it’s really high, say, enough to bankrupt an average family, then the penalty would be really effective at compulsion, which is what this is all about. One difficulty they faced at the time was that setting a really high penalty might have people up in arms. They didn’t want to call it a tax, but a penalty, if you remember. A tax wouldn’t play well in the polls, but a penalty could maybe pass muster with the public if it were initially low enough that most didn’t care. And if you think of the penalty as a low price for free health insurance, then so what? Sounds like a good deal, right?

        So is the penalty too low? I believe so. I think it is low enough that people will wait until they need hospital care and then sign up for insurance, preferring, in the meantime, to just pay the penalty–or to evade it. An interesting thing about the penalty is that it is to be paid from any tax refund owed. This will induce people to set their deductions high enough so that they are not owed a refund from which the IRS could steal. Another reason they created a penalty through taxes owed is that it helped dissipate the nasty mental image of armed men arriving at your door for your failure, or refusal, to pay the penalty. But who knows–perhaps the IRS will place a lien on your property or business, or perhaps they will eventually qualify noncompliance for criminal prosecution. Not paying taxes owed, after all, is a very serious business. Be that as it may, only time will tell. We shall know the actual behavior of people vis a vis penalties and policies in the real world soon enough. It will no longer be the subject of conjecture.

        Another possible way to bail out the insurers, should they run into real trouble, is by more heavily subsidizing whatever emerges on the health care exchanges. To be attractive, it would have to be subsidized below the level of the penalty. This would be extremely expensive, however, and the country is already facing national bankruptcy without the burden of even more government spending. Also, bailing out the hated insurers wouldn’t be politically popular. It may be easier, and preferable to many, to just let them go bankrupt, cursing them and their evil ways while they go down. And then the government would be free to implement national health care, which is what they wanted to do in the first place. Or have a taxpayer-financed “public option” which would drive the insurers into oblivion. All roads lead to Rome.

        I wouldn’t call the Texas Medical Association a liberal organization. I would call it a labor union. Like any union, they look out for the interests of their members. They do this primarily by restricting competition through restrictive licensing laws and opposing the building of new medical schools.