The over-hyped Dr. Frist, the new Senate majority leader, could become the primary roadblock to genuine health care reform in the United States.
The Doctored Image of Bill Frist
by Michael Byrne
It was an image made to order: A physician rushing into a hospital with a case carrying a human heart. The doctor has a vise grip around the handle of the cooler and, in all the excitement, a boyish grin surfacing at the still-remarkable idea of saving a human life.
There's another picture of this same surgeon hanging out of a helicopter, chilled heart in hand, showing that he, as a licensed pilot as well as a licensed heart surgeon, can go that extra mile to make sure that those in need of an organ transplant can get it.
But on a second or third pass, a niggling question arises. Why this doctor? Why now? How many transplant surgeons actually walk into a hospital carrying a heart? How many of them are captured on film?
Who is this medical superman? Why, it's William Frist, M.D., now Sen. Bill Frist - or, in his latest incarnation, Senate Majority Leader Bill Frist - at the head of the class.
If you want more dish on the good doctor, there are plenty of stories being floated out there by the GOP PR machine. You'll hear stories of how Dr. Frist was busied with saving lives in Africa or attending to the wounded when a gunman opened fire in the U.S. Capitol. And you can check the record according to Dr. Frist: He has written two books.
Yet, in spite of the images and the swooning pundits who declare, "Bill Frist is so smart he makes my brain sweat," there is a man in charge of our nation's agenda who has amassed a voting record and legislative history that is antithetical to good patient care. There is a man whose vision of health care is shaped not only by his transplant experiences, but also through the lens of corporate medicine personified - his family's billion-dollar fortune is wrapped up in the largest for-profit hospital chain in the United States, Hospital Corporation of America Inc. (HCA).
So, as one critic remarked, having Dr. Bill Frist serve as the GOP's point man on health care is "as appropriate as having Trent Lott be their point man on civil rights."
A Dubious Record
In fact, Frist voted with Trent Lott 90 percent of the time over the past eight years, making him one of the Senate's most conservative members. Of particular concern is his record on health care issues.
The first practicing physician to serve in the Senate since the 1920s, Frist spent little time from 1995 through 2002 on efforts to expand health care. Of 191 bills he introduced during that time period, only 14 could be considered real attempts to provide or extend health care services - or slightly more than 7 percent. Yet in each of his first four Congresses, the 104th through the 107th, Frist introduced a measure to establish a congressional commemorative medal for organ donors and their families. It was the first or second bill introduced by Frist in each session.
In 1996, Frist voted to strip the Domenici-Wellstone mental health parity bill of a core provision, one prohibiting insurance companies from imposing stricter limitations on coverage for psychiatric illness. That same year, Frist voted against a Democratic initiative that would have restored $18 billion in Medicaid cuts.
From his first year in the Senate, Frist has skirted ethical issues and taken advantage of Senate rules in seeking to cover his true stake in HCA and the impact of his votes on the company's bottom line. For example, in 1995, he voted for a budget package that includes Medicare appropriations to hospitals despite owning HCA stock. The measure sought to restart Medicare fund payments to for-profit hospitals for paying property taxes that had ended in 1992.
Frist is a virtual poster boy for corporate medicine. Consider the family business, HCA Inc., in which Frist holds millions of dollars in stock in a blind trust. His father, Thomas, founded HCA Inc. in 1968, and his brother, Thomas Jr., who has controlled the company for the past two decades, has built a personal fortune of roughly $2 billion off the company, according to Forbes magazine.
The Frist family made its millions by tightly controlling health care access for millions of Americans through HCA, which since its founding steadily has converted nonprofit hospitals into for-profit institutions. The company includes 200 hospitals and 70 outpatient surgery centers in 24 states, England and Switzerland. The basic premise behind HCA, writes Jonathan Cohn in The New Republic, is "that the profit motive will serve the public interest, in this case by forcing the providers of health care to be more economically efficient." Or, as Thomas Frist Sr. wrote in a 1997 letter to his family, "I believe the free-enterprise system can do a better job at most things than the government can."
Frist shares the family view that the market is the solution to most problems, even as the ways the market distorts health care are growing more evident - everything from drug companies pushing unnecessary medications to insurance companies neglecting beneficiaries. It is a family view that has had a direct impact on caregivers in HCA facilities, as Robert Kuttner noted in the New England Journal of Medicine six years ago. HCA (then Columbia/ HCA) "systematically downsized expensive sources of labor costs - chiefly nursing and social workers - even though they were critical for patient well-being."
"When your company is first responsible to shareholders instead of patients, it can be a horrible situation," says Tracey Ledbetter, an RN at Good Samaritan Hospital, an HCA hospital in San Jose, Calif. "Health care has no business being a business ... a lot of people believe our services belong to the community we serve and not the company - especially not shareholders."
Skeletons in the Closet
As HCA made millions for its shareholders, often at the expense of employees and patients, it faced down numerous federal criminal and civil charges in its 34-year history - and paid out more than $1.7 billion in fines to atone for its misbehavior.
As a result of its corporate practices, the company was required by the Department of Justice to sign a corporate integrity agreement, which it subsequently foisted off onto its employees rather than those running the company.
"We all have to suffer for the sins of the top dogs," San Jose RN Ledbetter says. "We have to go to ethics training class once a year. Doctors have to go to the trainings, too, but they get to go to fancy restaurants. We have to go to the auditorium before or after a shift because of something we had nothing to do with."
Interestingly, a series of raids in 1993 on 19 HCA offices seeking evidence of overcharging and fraud corresponded with Frist's decision, one year later, to enter politics. "It was the family's dirty money that bought Frist a place in the Senate," wrote Doug Ireland in LA Weekly. "In 1994, Frist - who'd never bothered to vote before first running for the Senate that year - spent some $3.4 million of his personal fortune to buy the seat from Tennessee (HCA's headquarters) that he now occupies."
Charges against HCA included billing the government for services ineligible for reimbursement (advertising and marketing costs, for example) and inflating expenses. "The company increased Medicare billings by exaggerating the seriousness of the illnesses they were treating," according to Forbes. "It also granted doctors partnerships in company hospitals as a kickback for the doctors referring patients to HCA. In addition, it gave doctors 'loans' that were never expected to be paid back, free rent, free office furniture - and free drugs from hospital pharmacies."
Seven years later, the company pleaded guilty to 14 felonies and paid $840 million in penalties - at that time the largest fraud recovery in history.
A second action in the nation's longest-running health care fraud inquiry - involving charges of kickbacks, overbilling and improper physician investment arrangements - wound its way through the system until a sudden $880 million settlement was announced Dec. 18, 2002. That came a mere five days before Frist's election as majority leader.
"I think it looks like hell," the Center for Public Integrity's Charles Lewis told Newsweek magazine the week the settlement was announced. "It's not some obscure company he owns stock in. ... It is the source of his wealth ... you've got to wonder: If there was substantial fraud committed in that company, what did the Frist family know and when did they know it?"
Lewis wasn't alone in questioning the settlement or its timing.
"Senator Frist has close family and financial ties to HCA," Rep. Pete Stark (D-Calif.) said Dec. 20. "I find it remarkable that at the same time as the Republican Party is coalescing around Senator Frist's candidacy for Senate majority leader, the administration is poised to strike a potentially unjustifiable bargain that would benefit his family's company at the expense of American taxpayers."
Yet because Frist's own stake in the company - valued at $13 million in 1994 - is in a blind trust, he claims this allows him to vote on any health care issue to "carry out the nation's business."
The Medical-Industrial Complex
HCA, which would be at the head of the trough in a privatized Medicare system, provides what many think is the real reason behind Frist's carefully doctored image as he has emerged in the political arena.
"Frist ran for the Senate to protect the family fortune," Max Fine, a Nashville-based benefits consultant and former director of the Committee for National Health Insurance, told Revolution. "He placed himself on two committees with jurisdiction over health care - Finance and Health, Education, Labor and Pensions. Now he also controls the Senate calendar. He ought to recuse himself from health care issues."
That sentiment was echoed by Quentin Young, M.D., national coordinator of Physicians for a National Health Program, commenting on Frist's stake in his family's for-profit enterprise. "Given this monumental conflict of interest, Senator Frist, ethically, has no other choice than to recuse himself from legislative activity in health matters."
The Senate ethics committee disagreed with that assessment, ruling that Frist is not prohibited from voting on any "legislation of general applicability to the health care industry." In an institution noted for its close relations with corporations, with members often moving from insiders to outside lobbyists, this ruling should surprise no one. In fact, Frist's staff director on the Senate public health subcommittee, Dean Rosen, is a former general counsel of the Health Insurance Association of America.
Frank Clemente, director of Congress Watch, part of the consumer advocacy group Public Citizen, told The Washington Post that Frist "represents the medical-industrial complex." The proof of that assessment is in a breakout of Frist campaign donors, as provided by the Center for Responsive Politics.
Major contributors to Frist over the past five years include numerous arms of the health care industry, such as the American Society of Anesthesiologists, the American Medical Association, the American Dental Association, the American Hospital Association and the American Pharmaceutical Association; lobbyists and law firms focused primarily on corporate interests, such as Bass, Berry & Sims, Verner, Liipfert et al and Locke, Liddell & Sapp; as well as the pharmaceutical industry and hospital/nursing home interests, such as Vanderbilt Medical Center, Massachusetts General Hospital, Life Care Centers of America, Aetna Inc., Pfizer Inc., Eli Lilly and a host of others, including his No. 1 health industry benefactor, HCA. In the current election cycle, the CRP says, these donors have given Frist nearly $1 million.
"Frist isn't the senator from Tennessee - he's the senator from the state of Health Care Industry Influence," Nick Nyhart, executive director of Public Campaign, told LA Weekly. "He's gotten more than $2 million from the health care sector, giving him the dubious distinction of raising more cash from health care interests than 98 percent of his colleagues."
Medicare at Risk
And many of these backers have an agenda for Frist, including limiting liability for pharmaceutical companies that make vaccines; shifting more Medicare patients to private insurers; limiting access of consumers to information about medical errors in health care facilities; capping damages available to patients injured by medical malpractice, restricting lawsuits and offering greater protection to practitioners and insurers; and creating private medical savings accounts with tax breaks.
Frist indicated just how much his priorities jibe with those of the medical-industrial complex soon after he was selected to lead the Republican majority in the Senate, when he threw his support behind a Bush administration proposal to make a drug benefit to Medicare patients contingent on their enrollment in a managed care health system. Previously, in June 2000, he co-sponsored a bill that would allow private insurers to compete in providing coverage to Medicare beneficiaries.
Marcia Angell, the senior lecturer in social medicine at Harvard Medical School and the former editor of the New England Journal of Medicine, criticized the prescription for Medicare that Frist and the Bush administration are promoting:
"They want to introduce commercial competition, encourage Medicare recipients to join managed-care plans
, cap what Medicare will pay for services and pass more of the costs on to recipients themselves. Yes, they include a prescription drug benefit, but apparently without any regulation of the pharmaceutical industry's prices or of the drugs covered . . . In other words, Sen. Frist and the White House would introduce the blessings of the private health market to Medicare."
To benefits consultant Fine, the Frist agenda for Medicare has a decided HCA stamp. "He wants to privatize Medicare because, to the extent that Medicare is privatized, it relieves the family company of a good part of their problem," Fine said. "If Congress can shift Medicare recipients to private insurers - Blue Cross Blue Shield, for example - it means that HCA can charge more for Medicare services, and not get sued."
In Charge of the Henhouse
In the rush to pass the homeland security measure in the waning days of the 107th Congress, an amendment was added to shield the pharmaceutical company Eli Lilly from legal liability over Thimerosal, a preservative used until recently in children's vaccinations that has been linked to the development of autism. It was a Frist-authored measure that previously had failed in the Senate.
The amendment was jettisoned in January, just as the Federal Election Commission was releasing reports that showed Eli Lilly's political action committee contributed more than $100,000 in the last election cycle to GOP candidates shepherded by Frist. While Senate rules protect the identity of senators who insert provisions such as the Lilly rider, the LA Weekly, in typical blunt style, said, "Frist engineered the insertion."
Now, with the entire Senate agenda under his right wing, Frist has even more power to operate for corporate medicine, at the expense of the millions of seniors who can't afford prescription drugs and the 43 million Americans who currently lack health insurance. The corporate doctor is "In." It's a frightening image.