Dr. Feelgood

By

NASHVILLE, TENNESSEE

Right after New Year's Day, just over a week after his colleagues
elected him Senate majority leader, Bill Frist again popped up in
the news, not for any political deed but for trying to save the
lives of those injured in a gruesome Florida car crash. It sounded
too good to be true--except to anyone who knows Frist here in
Nashville. The thing that first strikes you when you start talking
to friends and former colleagues of the surgeon-turned-senator is
that everyone has a different story about his penchant for small
acts of kindness. Janie Webb, a social worker at the Vanderbilt
Transplant Center that Frist established, remembers the time Frist
found out one of his patients didn't have money to cover her
electric bill. He promptly paid the bill himself. Tom Nesbitt, a
local physician who has known Frist since they started first grade
together, recalls the senator making weekly phone calls about a
mutual friend's son, stricken with cancer, for months--and then
flying down for the funeral smack in the middle of a busy
congressional session. Mark Tipps, who was Frist's chief of staff
before returning to Nashville to practice law, still marvels at the
way Frist declined to attend a 1996 campaign rally with
presidential nominee Bob Dole and half of Tennessee's congressional
delegation. Frist had promised to accompany his son to the Cub
Scouts' Pinewood Derby races that night and wouldn't break his
word. "It was at a time when a lot of Republicans were talking
about family values," Tipps notes, "and he was actually doing it."These stories may not have circulated beyond Nashville, but the
image they suggest is already taking hold across the United States.
Everybody now knows that Frist is a man of good deeds, from his
medical crusades in sub-Saharan Africa to his on-the-spot treatment
of shooting victims on Capitol Hill in 1998. More fundamentally,
everybody now knows that Frist is a doctor--a profession people
associate with compassion and intelligence. "[I]t is a particular
stroke of genius that Bill Frist has been named Senate majority
leader in a time when our political trust is once again on shaky
ground," novelist Ann Patchett wrote recently in The New York Times
Magazine. "I think a healthy dose of doctoring may be what our
government needs." Or, as Maureen Dowd memorably put it, Frist is
"Dr. Perfect."

And that's exactly what the White House wants him to be. A major
reason Bush touted Frist as the successor to Trent Lott was that
Frist seemed to be Lott's opposite--thoughtful where Lott was
hardheaded, caring where Lott was indifferent, and smart where Lott
was just plain dumb. Just as important, Republicans realize that
Frist lends them cover on what may be their most salient political
vulnerability: health care. Even today, with Republicans having
narrowed the public opinion gap on many traditionally Democratic
issues, voters trust Democrats more than Republicans on health care
by overwhelming margins--53 percent to 33 percent, according to a
December ABC News/Washington Post poll. "He's very articulate on
issues where the Republican Party has been weak, like health care,"
Long Island Representative Peter King recently told Newsday. "We're
on the defensive on patients' bill of rights and prescription drugs
[for seniors], and Frist is probably the most knowledgeable about
these issues as anyone in Washington today."

But, while Frist may understand medicine, that doesn't mean he's the
best person to craft health policy. Ironically, his experience as a
transplant surgeon--an experience markedly different than, say, a
pediatrician's--has reinforced policy notions that could make our
health care system, already cruelly insensitive to the uninsured
and the underinsured,

even harsher. Moreover, he seems to have inherited from his family,
which founded one of the nation's largest for-profit health care
companies, a tendency to see the market as the solution to most
problems, even as the ways the market distorts health
care--everything from drug companies pushing unnecessary
medications to insurance companies neglecting beneficiaries--are
growing ever more evident. So, while Frist's record as a physician
certainly suggests he's an uncommonly decent fellow, it also
suggests that he's exactly the wrong man to address the nation's
health care woes.

William Harrison Frist is the least experienced politician in modern
history to hold the post of Senate majority leader, having served
in Congress for just eight years. But then, Frist has been
attaining unattainable goals for most of his life. Back in high
school, at the Montgomery Bell Academy for boys, Frist was a top
student, editor of the yearbook, and president of his class for
three of four years. As an underclassman, a motorcycle accident
shattered his knee, but, by the time he was a senior, he had worked
himself into a starting spot on the football team--at quarterback,
naturally.

That made Bill Frist a rather remarkable young man--except, perhaps,
by the standards being set at the white, antebellum-style mansion
on Nashville's west side that Frist called home. Thomas Frist Sr.,
Bill's father, was the city's most prominent physician, an
internist who cared for the city's political elite, including a
string of seven successive governors. Bill's two brothers had each
gone to medical school as well, and the older one, Thomas Frist Jr.,
eventually teamed up with his father to establish the Hospital
Corporation of America, which, by Bill's high school years, was on
its way to becoming the nation's largest chain of investor-owned
hospitals. Bill's mother, Dorothy Cate Frist, was one of 14
children from a liberal Tennessee family who spent her spare time
starting up political arguments on such issues as Vietnam with her
more conservative husband or, when he wasn't around, the Nashville
establishment.

Despite Frist's high school success, something was still missing.
"Local rich kids, scions of socially prominent families, have few
crosses to bear in life, but one of them is that they can never
fail, not really, not the way others can," Frist would later
reflect in his 1989 memoir Transplant. "After all, as everyone
said, they had all the breaks." This would become a major theme in
Frist's life--a constant, almost compulsive need to find the next
mountain and climb it, to prove, as he put it, "that I could make
something out of my life outside the immediate reach of my family's
influence." And so, when it came time to pick a college, he decided
he needed to leave the South-- something no other Frist child had
done--and attend Princeton. Uwe Reinhardt, the esteemed Princeton
economist, still calls Frist "the brightest kid I ever had." And,
while Frist indulged his interest in politics by getting his
undergraduate degree from the Woodrow Wilson School of Public and
International Affairs, he stayed in the family business, winning
admission to Harvard Medical School and, four years later, a
surgical residency at Massachusetts General Hospital (MGH).

In medicine, ambition correlates with specialty in a relatively
predictable manner: The most ambitious medical students become
surgeons, the most ambitious surgeons choose fields like
cardiothoracic surgery, and the most ambitious cardiothoracic
surgeons try to do cutting-edge procedures such as transplants. But
having finished steps one and two, Frist in 1984 found no way to do
step three, since Boston's conservative teaching hospitals were
reluctant to do transplants, then still a new field. So Frist left
MGH for Stanford, where he could study under Norman Shumway, the
father of heart transplantation. "He was just a great guy, always
there to pull his share of the workload and compassionate toward
his patients," says Vaughn Starnes, a California surgeon who
trained with Frist at Stanford. There, he became a star again,
recognized by his instructors for his technical capabilities and
appreciated by his friends for his collegiality.

Vanderbilt University hired Frist back to Tennessee in 1986, where
his heart- transplant work lent him some celebrity. But it didn't
take long before Frist was restless again: Now he wanted to build
an institution. Previously, transplant surgeons worked within their
own specialties-heart-transplant specialists working with the other
heart surgeons, kidney-transplant specialists working with the
other kidney surgeons, and so on. Frist wanted to create a
multi-specialty unit where the transplant doctors could pool
expertise and resources. Vanderbilt went along, and, within a few
years, Frist's Vanderbilt Transplant Center had become a national
model. It was after establishing this center that Frist wrote
Transplant, not only a memoir but also a heartfelt polemic on the
life-saving importance of organ transplants. (Copies included
organ-donor cards.) Although not exactly a best-seller, the book
further increased Frist's visibility, even prompting interest from a
movie producer who wanted to cast Kevin Kline as Dr. Frist.

Transplant contains little hint that Frist was contemplating a
career in politics, let alone one that would require pleasing a
culturally conservative audience. He is frank about the
relationship that led him to break off his engagement to his high
school sweetheart two days before the wedding, even making a rather
unsubtle reference to spending the night with new love Karyn-- whom
he would eventually marry--days before he broke off his original
engagement. And, although Frist writes frequently about the ethical
issues surrounding transplants--for example, the question of when
death begins--he approaches these issues in starkly scientific
terms, with little patience for religious objections. Near the end
of the book, for example, Frist suggests changing the legal
definition of "brain death" to include anencephalic babies, who are
born with a fatal neurological disorder but show just the slightest
hint of brain-stem activity. Such a change would make it possible to
harvest their organs for transplant--something the Catholic Church
and pro-life groups oppose. "Three thousand anencephalic babies
were born a year, enough to solve our demand many times over-but we
never used them," Frist writes.

Oddly enough, one of the book's few explicitly political passages is
a paragraph lavishing praise upon the public official most
responsible for establishing the nation's organ-transplant system:
then-Senator Al Gore Jr. But, then, partisan ambiguity was another
proud Frist family tradition. The list of famous patients that
Frist's father treated included such notable Democrats as former
Governor Prentice Cooper (father of Representative Jim Cooper) and
Senator Al Gore Sr. (father of the former vice president). Frist
himself had donated money to both Democrats and Republicans over
the years, and, in 1992, it was a Democratic Tennessee governor,
Ned McWherter, who gave Frist his first political job--presiding
over a commission charged with revamping the state's Medicaid
program. During the 1980s, Frist's medical friends say, they had no
inkling that he was strongly conservative. "He was so diplomatic I
never knew he was a Republican," Stanford's Shumway says of his
star pupil. "Folks out here are pretty liberal, so I just kind of
figured he was one of those people." The fact that Frist didn't
even vote until 1988 makes the mistake even more understandable.;
"... politics was yet one more way Frist could set himself apart
from his family's wealth and fame, particularly at a time when he
was tiring of medi-

cine."

This lack of a clear political vision is one reason to take at face
value Frist's oft-stated explanation for why he ultimately
abandoned medicine for politics in 1994: He wasn't out to enact an
ideological agenda; he simply felt the call of public service. As
famous as Frist's parents were for their philanthropy--a legacy
evident in Nashville today, where the city's gorgeous new cultural
arts center bears the name "Frist"--they were even more well-known
for giving their time. As one longtime friend recalled in a eulogy
for Frist Sr. , he "managed to find thirty-six hours in each of his
days, and, for his patients, there was a limitless amount of time."
Those who know Bill Frist say his political aspirations simply
became a natural, if slightly unorthodox, extension of his work as
a physician. "He told me that he'd had a rare privilege and
opportunity as a physician," recalls Gus Puryear, Frist's former
legislative director, "and that he thought he could affect more
people through public service than he could one-on-one."

It's also worth noting that politics was yet one more way Frist
could set himself apart from his family's wealth and fame,
particularly at a time when he was tiring of medi-

cine. "At Vanderbilt," says Nesbitt, "I think he felt like he'd gone
as high as he could go professionally." And it was surely this
ambition that explains the most important associate of his early
political life: Tom Perdue. Perdue's success in managing Paul
Coverdell's 1992 upset of Georgia Democratic Senator Wyche Fowler
made him an obvious choice for Frist's bid to unseat another widely
respected Democrat, Jim Sasser. But the two made a rather odd
couple given Frist's gentlemanly manner and Perdue's reputation for
brutal, extremely conservative campaigns. "He's a take-no-prisoners
type--he'd go to almost any length to get his candidate where he
wanted him to be," says M. Lee Smith, publisher of the Tennessee
Journal and one of the state's best-known students of politics.

Perdue flashed this side early on, publicly calling Frist's chief
primary rival "pond scum." But it took Frist a little while to get
the hang of campaigning. As Perdue cringed, Frist demonstrated an
unfortunate proclivity for candor, admitting at one campaign event
that he had no position on gun control and stating repeatedly that,
although personally opposed to abortion, he wanted to leave the
matter to the states. "I'll work hard to keep the federal

government out of that decision-making process," the Memphis
Commercial- Appeal quoted him as saying. Luckily for Frist, he was
running against five other primary

opponents--and he had the personal wealth to finance his own race.
That, plus his squeaky-clean image as a physician, won him the
nomination.

By the general election, Frist had mastered the art of Perdue-style
campaigning, calling Sasser a "liberal, taxing, two-faced" incumbent
who was "the personification of this unresponsive, out-of-touch
imperial Congress." One TV advertisement superimposed Sasser's face
on Mount Rushmore alongside likenesses of liberal icons Ted Kennedy
and Dan Rostenkowski. "Perdue was just cutting the living daylights
out of Jim Sasser," Smith recalls. "Frist had given him wide
latitude to do it, and it was a no-holds-barred effort." Sasser's
negative ratings soared, from 12 percent in February to 46 percent
in November, while Frist-outspending Sasser by a three-to-two
margin-missed no opportunity to remind people that he was a
compassionate healer and a brilliant surgeon. ("Listen, Diagnose,
and Fix" was the unofficial campaign slogan.) On Election Day, he
won by 200,000 votes.

These days, Frist still invokes his medical background at every
turn. "Until today, I've always regarded my most profound
professional responsibility in my professional life the blessing I
had to hold in my hands the human heart, recognizing all its glory
and all its potential, and then technically seating it into the
chest of a dying woman to give her life and a future she would not
otherwise have," Frist said upon being elected majority leader last
month. "A few moments ago, my colleagues gave me a responsibility
equal to that--some would even say a heavier one." While this cant
gets tiresome, Frist's medical background does help explain his
interest in such issues as technology and global AIDS funding. It
also helps explain one of Frist's boldest political acts, his
position on the nomination of Henry Foster as surgeon general in
1995. Although conservatives were attacking Foster for, among other
things, his support of abortion rights, Frist knew Foster through
the Frist family's long involvement with Nashville's Meharry
Medical College, the nation's oldest private African American
medical school. Frist voted for Foster, and although Republicans
ultimately defeated the nomination anyway, Foster remains a Frist
booster to this day: "This man has demonstrated his ability to be
courageous and vote his conscience."

Another episode on which Frist's medical expertise came to bear was
the controversy over stem-cell research two summers ago. In what
had become a familiar ritual to his staff, Frist buried himself in
original research, convened briefings by advocates from both sides,
then produced a list of ten principles for governing stem-cell
research. Under his proposal, scientists would be permitted to use
embryos to generate stem cells just so long as they were going to
be discarded anyway, as often happens with in vitro fertilization.
But there was to be no creation of embryos specifically for
stem-cell creation- -i.e., no cloning of embryos specifically for
harvesting stem cells--and the government would eventually limit
the number of stem-cell lines. This position was to the right of
the scientific community, which wanted no such restrictions, but to
the left of hard-core conservatives, for whom any embryonic
stem-cell research was immoral.

Such heresies explain why some conservatives eye him suspiciously.
Just before Frist became majority leader, conservative activist
Paul Weyrich, president of the Free Congress Foundation, told
reporters that "Senator Bill Frist is not somebody conservatives
would be comfortable with given his disposition. He's a moderate
Republican at heart, who's not really pro-life." After Frist's
opening address on December 23, a speech that talked about reducing
racial disparities in medicine and getting health care to the
uninsured, conservative columnist Robert Novak discerned an
ideological heretic of a different sort: "On Dec. 23, Frist did not
mention taxes. Instead, he delivered a pronouncement on health care
that, with hardly any editing, could have been echoed by Senate
Democratic Leader Thomas Daschle." But, as anxious Democrats have
pointed out frequently during the last few weeks, Frist has voted
with Trent Lott 90 percent of the time over the last eight years,
making him one of the Senate's most conservative members. On nearly
every important vote during his tenure, Frist has voted with the
Republican leadership: for banning partial-birth abortion, against
raising the minimum wage, for convicting Bill Clinton on
impeachment charges, against the McCain-Feingold campaign finance
reforms, and for the Bush tax cut. Notably, Frist's conservative
record holds even on his signature issue, health care. 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.

So how does a man with no history of conspicuously partisan behavior
before 1994 end up with such a conspicuously partisan voting record
in the years since? One answer is that Frist is determined to win,
and, as he did in his 1994 campaign, he's willing to act like a
conservative firebrand if that's what it takes. Consider abortion
and stem cells. Frist today calls himself "pro-life, " and, indeed,
the National Right to Life Committee gives him a perfect voting
record on their issues. But, of the eight former medical colleagues
I interviewed, not one believes that Frist's voting record is
indicative of his true thinking. "I saw his comments on television
just before Christmas, but I want to see what he really does," says
Gus Vlahakes, who trained with Frist at MGH and remains a friend
today. "If I had to take a guess, I'd say he's starting from a more
moderate viewpoint than his recent comments would suggest."

Frist's floor statement during the stem-cell debate tends to support
this interpretation. "Upon fertilization," Frist explained, "there
is a continuum from a sperm and an egg, to a blastocyst, to a
fetus, to a child, to an adolescent, to an adult. That continuum is
indeed life. ... I wish to make it clear to my colleagues that from
my perspective I do value life and give moral significance to the
embryo and to the blastocyst and to that full continuum." Parse
those sentences carefully: Frist conspicuously refers to "life"
rather than "human life." And his use of the word "continuum"
suggests that, while Frist may assign "moral significance" to an
embryo, it's not necessarily the same significance he applies to a
well-developed fetus or a newborn out of the womb. That position
would put Frist at odds with the position of anti-abortion
activists; indeed, the idea that the moral value of an embryo
changes as pregnancy proceeds happens to be the precise logic of
Roe v. Wade, the 1973 Supreme Court decision legalizing abortion.

But if Frist's positions on superheated social issues seem to
reflect mostly political posturing, his record on bread-and-butter
issues--taxes, welfare, and, most significantly, health care--seems
generally consistent with what we know about his character. In a
letter to his family written in 1997 and later published as part of
a memorial to him, the 87-year-old Thomas Frist Sr. said, "I am a
conservative. I believe the free-enterprise system can do a better
job at most things than the government can. People should learn to
be self-reliant; when they are self-reliant, they will have
self-respect." And, while people might assume that Bill Frist's
experience as a healer would blunt this perspective, it may have
actually enhanced it.

Medicine has an established sociology to it. On one end of the
spectrum you have the specialists: orthopedists, ophthalmologists,
cardiothoracic surgeons. On the other end, you have the primary
care doctors: pediatricians, family practitioners, and some
internists. Not only do surgeons make a lot more money than primary
care doctors, fostering different worldviews on issues like taxes
and government re-

imbursement levels; they also practice medicine in strikingly
different ways. Surgical specialists, as the term suggests, develop
deep but narrow expertise on one part of the body

or even one particular procedure that a patient may need just once
in a lifetime. Primary care physicians, by contrast, must consider
patients as large, interrelated systems whose health they must
maintain over the course of years. "The medical profession is not a
monolithic community," says Howard Markel, a professor of
pediatrics and the history of medicine at the University of
Michigan. "Just look at the way different physicians deal with
obesity. Getting somebody to go on a diet, not to eat McDonald's so
much, to exercise, that's very hard to do and very frustrating, but
it's important, and that's how a family doctor would approach the
problem. Now what's the surgical solution? Stick a tube in
somebody's gut, and suck out the fat."

What's more, surgeons worry a great deal about anything that might
stunt technological innovation, a problem they see as related to
government regulation and cost controls. Primary care physicians,
on the other hand, spend a lot of time watching how outside
factors--environment, poverty, lack of insurance--affect their
patients' well-being,

and they frequently see government as a means for correcting these
problems. As Markel explains, "A lot of medicine has become much
more organ-based, much more

procedure-based, so the cardiologist thinks just about the heart,
the surgeon who does gall bladders thinks just about that
operation, and so on. The pediatricians, the internists, they tend
to look at the body as a whole, thinking not just about the
problems within but some of the problems without as well."; "...
the fact that Frist has practiced medicine at the very top of his
field seems to have insulated him from the experiences of people who
suffer most under the current health care regime..."

These distinctions translate into politics. Surgeons have
historically been the most conservative doctors, with organizations
like the American Academy of Ophthalmology among the most hostile
to Medicare and government regulation. The American Academy of
Pediatrics, by contrast, has long been among the nation's most
persistent advocates of national health insurance. Today, seven
physicians hold positions in Congress. Of the five Republicans,
four are surgeons. Of the Democrats, one is a family practitioner
while the other is a psychiatrist. (Psychiatrists, whose long-term
relationships with patients resemble primary care doctors' more
than surgeons', are also pretty liberal as a group.) There's also
one physician, former Vermont Governor Howard Dean, who's running
for president. He's a former family practitioner, so, naturally,
he's a Democrat.

These are stereotypes, to be sure, and Frist doesn't fit them
precisely. Everything we know about Frist's medical practice
suggests that he was an unusually warm surgeon, and transplant
surgery, by its nature, requires more post-operative contact with
patients than many other specialties. But transplant surgery also
fosters an unusually strong ethos of rugged individualism. With
transplants, success often rests ultimately on the patient's
willingness and determination to go through rehabilitation and
adopt a healthier lifestyle. And transplant surgeons must
constantly make decisions about which patients deserve to go on
transplant lists and which ones don't. Like his father, a self-made
man who disdained handouts and preached the up-by- your-bootstraps
ethic, Frist became comfortable with the idea of making sharp
judgments about people--something more in tune with Republican
values than Democratic ones. A passage in Transplant recalls this
advice from Frist's father: "Now we have the know-how to save some
of them. Some of them--not all of them. Well, I raised you to make
that decision. I raised you, and this society trained you
specifically for that purpose, and you spent years learning how to
make it."

Then there's Frist's family connection to hospital management
company HCA. When Frist first became majority leader, accusations
of conflicts of interest on health care swirled, as reporters
pointed out that his family fortune-- including several million
dollars in HCA stock that Frist once owned and placed in a blind
trust upon taking office--is tied to the company's success. In the
last few weeks, critics have also raised the specter of more
egregious improprieties, noting that late last year HCA agreed to
pay the federal

government more than $1.7 billion to settle long-standing
allegations of Medicare fraud.

This is the same tack that Sasser took in 1994--and it's not working
any better this time around. (Not yet, anyway.) In part, this is
because Frist has never been involved in HCA's business directly.
Also complicating the attacks: The fraud problems apparently
occurred after HCA merged with Columbia and the Frists temporarily
stepped down from company management. As for the conflict-of-
interest issue, Frist notes that the Senate Ethics Committee blessed
his arrangement; at this point, he says, he doesn't even know how
much stock he owns.

But this doesn't mean the HCA experience is irrelevant. It's just
that its significance lies in what it says about Frist's view of
health care policy. The basic premise behind HCA goes back to the
bedrock conservative principles that Frist Sr. wrote in that letter
to his family: that the profit motive will serve the public
interest, in this case by forcing the providers of health care to
be more economically efficient. And that same thinking underlies
Senator Frist's ideas for health care. Frist has co-sponsored with
Senator John Breaux the major Medicare overhaul now favored by the
Bush administration, one that would transform the large government
insurance program into a system under which private insurance
companies compete with Medicare for the business of beneficiaries.
On the dilemma of the 43 million Americans who currently lack
insurance, Frist is once again in lockstep with the White House,
proposing the creation of tax credits that individuals could use to
buy private health insurance coverage on the open market. And Frist
has long favored laws that would expand the use of Medical Savings
Accounts (MSA), a form of private insurance in which people save
money in tax-shielded accounts, then use it to cover their medical
bills. "When I directed the Vanderbilt Transplant Center, our
entire program was transformed because one patient questioned how
we differed from our competitors," Frist once said. "Establishing
MSAs would encourage patients to make prudent, cost-conscious
decisions about their health care needs."

Quotes like that, which Frist throws around constantly, are typical
of the way he uses his medical experience to make his ideas sound
sensible and compassionate. But, as HCA's history shows, the profit
motive doesn't always foster tenderness. Particularly in the 1990s,
as health care became far less profitable, one of the quickest ways
for hospitals to make money were to see fewer charity cases.
Scrutiny of the Columbia/HCA hospitals during the '90s--in the form
of both academic studies and government reports--found the company
engaging in exactly that practice. Moreover, as Robert Kuttner
reported in a scathing series of articles that appeared in the New
England Journal of Medicine six years ago, Columbia/HCA
systematically downsized expensive sources of labor costs--chiefly,
nursing and social workers--even though they were critical for
patient well-being. Thomas Frist Jr., who was lured back to the
company in 1997 in order to clean up its image, insists his family
would never let the company encourage bad medicine. But, even if
the Frist family really has had the best of intentions, that merely
proves the point: Making money and serving patients are so
fundamentally at odds that even the most enlightened executives
can't always keep their companies from going astray. (Author's
disclosure: My father, a Florida surgeon, has his own legal action
pending against a former Columbia/HCA subsidiary over an unrelated
matter.)

None of this is to say Frist's perspective on health care is
entirely without merit. In keeping with his free-market
orientation, he thinks the basic underlying problem with our
nation's health care problems--everything from Medicare spending to
the uninsured to managed care abuses--is a lack of sufficient
economic incentives for patients. The current insurance system
insulates people from the cost of their medical care, he says, so
they seek more and more of it with little concern for how much it
costs. That's why Frist favors his particular health care
solutions, each

of which would require people to consider the trade-offs between
quality and access on the one hand and cost on the other. Under his
vision for Medicare, for example, people who wanted lavish
coverage--free choice of doctor, unfettered access to experimental
treatment, total prescription-drug coverage-- could opt to have it,
but only if they were willing to pay higher premiums and
co-payments. Those willing to live with less could go a cheaper
route, presumably a traditional Health Maintenance Organization
(HMO). Medical Savings Accounts would accomplish the same goal, by
letting people decide whether they wanted to spend their
tax-sheltered money on medicine or save it for other uses later
on.

As insights into the problems with medical economics, Frist's ideas
are sound. But they are also incomplete and ultimately lead to
counterproductive policies. Transferring some responsibility for
making health care spending decisions onto patients makes sense if
it's done in a measured way--say, by modestly increasing premiums
or co-payments for each person. But the schemes Frist favors would
go much further in that direction, creating financial incentives
against seeking expensive care so dramatic that they would disrupt
the entire health insurance market. The more costly health care be-

comes on an individual basis, the more healthy people--who can
afford to go without expensive care--will opt for the skimpiest
plans. That will leave the truly ill, whose health situations force
them to opt for more complete coverage, alone in their plans,
driving their costs up. For example, one respected analysis of
Medical Savings Accounts, published in 1996 by the Urban Institute,
estimated that if large numbers of healthier people opt for medical
savings accounts, insurance premiums for everybody else could
increase by

60 percent--likely more than many could afford, thereby swelling the
ranks of the uninsured even more.

On a more basic level, the fact that Frist has practiced medicine at
the very top of his field seems to have insulated him from the
experiences of people who suffer most under the current health care
regime: the uninsured. Frist apparently saw some charity cases at
Vanderbilt, but, as he notes in his memoir, the university had
special funding to help pay for many of them. Late in the book, he
notes that the high numbers of uninsured in the United States is a
growing crisis, but then he insists, as he continues to today, that
it's going to be up to private insurance to solve the problem. A
physician who had actually spent extensive time working closely
with the uninsured--say, in a public clinic, where their financial
hardship would be in plain view--would understand instinctively
what academics are now showing: that a market approach to the
uninsured inevitably leaves out those who need insurance most. "Tax
credits for non-group health insurance would not make a major dent
in the number of the uninsured," says Jonathan Gruber, a
Massachusetts Institute of Technology economist who has done
influential research on the subject. "The credits are simply too
small relative to the high and variable cost of non- group
insurance to make a difference for most low-income uninsured
families. Moreover, the small number of uninsured who do take up
the credits will be the most young and healthy uninsured who can
find affordable policies."

Finally, Frist's views on Medicare also reflect a perspective wildly
out of sync with what most people actually on Medicare seem to
believe. Frist, a regular critic of the Medicare bureaucracy,
frequently speaks of the need to "modernize" the program--as if its
antiquity were a source

of massive dissatisfaction. That may reflect how most surgeons feel,
since they don't like Medicare's paperwork, but it couldn't be
further from the sentiments of Medicare recipients. Although they
desperately want a drug benefit, seniors want it as part of
Medicare as it exists now. And who can blame them? In contrast to
private managed care plans, which limit patient choice about
doctors and treatment, Medicare allows beneficiaries to see almost
anybody. A study in Health Affairs released this October compared
satisfaction rates between Medicare beneficiaries with people on
private insurance. The Medicare beneficiaries were overwhelmingly
happier with their insurance, even without the prescription-drug
coverage.

Of course, many people assume that Frist will never get to remake
Medicare anyway, that the program's popularity will preclude
sweeping changes. Many of the same people assume that, however
extraordinary Frist's talents, he is bound to fail as Senate
majority leader: He's too green, too wonky, too nice. But, as
Sasser can attest, Frist knows how to play hardball. He got away
with it, in part, because voters

in 1994 couldn't bring themselves to see a physician--

particularly such a compassionate and dedicated one--as the
calculating and ambitious politician he had become. Who's to say he
can't do it again?

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