Dr. Paul Goes to Washington

There is nothing unusual about the Bowling Green, Kentucky, ophthalmology practice—at least not to the naked eye. The smallish brick building, just off the beaten path from the standard two-lane highway laced with strip malls, is nondescript. Inside, the waiting room is small but tidy. Rows of stylish frames from Christian Dior, Dolce & Gabbana, and Calvin Klein line the walls.

Around 8:00 a.m., the first patients of the day shuffle slowly from their cars to the reception area. Like many ophthalmology practices, the majority of patients are elderly. Many are here for a consultation prior to cataract surgery, while others are having their post-surgery follow-up.

The first hint that this isn’t your every-day ophthalmology practice comes on a trip past the exam rooms and the surgical room, at a rectangle- shaped conference table. This is the makeshift office of Cayce Moffett, a young assistant who is helping the ophthalmologist relocate from Bowling Green to Washington, DC. Moffett’s phone rings at what appear to be two-minute intervals. Moffett has adapted to the pace as if she’s been doing this for years, despite her youthful appearance.

The ophthalmologist arrives at about 8:05 a.m., looking rushed. He has dark lines under his eyes. A moment before seeing his first patient of the day, he makes a deep inhale, then greets an elderly woman and her husband with a warm smile. Over the course of the day, he’ll see two dozen patients, perform a cataract surgery, speak with four different reporters, squeeze in a late lunch, and go through three different wardrobe changes. This is his new normal. It’s a ridiculous pace, and he somehow navigates it without seeming hurried.

Lunch is a 20-minute stopover at a local deli. Many gathered here for a late lunch recognize the doctor, but not because they are his patients. This particular doctor has made local and national news. He has been on television alongside David Letterman, Larry King, and famously, Rachel Maddow. His father recently formed an exploratory committee in advance of a run at the presidency. He may someday do the same. His practice isn’t relocating to Washington, DC. He is reluctantly giving up his practice for a U.S. Senate seat. He is Rand Paul, physician, senator, Tea Party representative.

Rand Paul is a family man first, a physician second, and a controversial politician third. He has a lovely wife (Kelley), and three sons (ages 11, 14, and 17). He has been a lightning rod, both in politics and within the medical profession. He has found himself at the center of many of the controversies surrounding the Tea Party, the burgeoning political movement that rose to prominence in last November’s mid-term elections, and seems poised to have a continuous impact on the political voice and direction of the country. Because of his politics, his medical career has also come under heavy scrutiny.

MD Magazine recently conducted an in-person interview with Paul at his office in Kentucky. The coverage of Paul’s politics has been plentiful. The majority of this interview focuses on Paul’s career as a physician: the licensure flap that has dogged him, his plans for fixing health care, and what his goals are in bringing a physician sensibility to Washington, DC, in an era of health care reform.

This last year has been a roller-coaster ride for you. Tell me what it has been like.

It’s been a bit of a juggling act. I continued to work through the whole campaign, really—about a year and a half. I was coaching my son’s baseball team, I left for a few minutes to see a Tea Party rally, and they asked me to speak. I thought there would be 20 people there; I showed up, and there were 700 people. That’s when I sort of knew a movement was going on, and it was a movement that had a lot to do with how I felt about the country. People are concerned about the foundation of our economy if we keep spending like there’s no tomorrow. From there, things got busier and busier. We drove to almost all of the events across the state. Fortunately, Kentucky is not as big as Texas, but it’s still three and a half to four hours to one side. So, we would drive, routinely, five hours a day on the road. We would go and come back almost every night, because I wanted to go work the next day and see my family.

Did you ever think of abandoning your practice for a period during the campaign?

My wife asked, to stop saying this, but I said I’ve got bills and a couple of mortgages to pay. She says that makes it sound like we have no money, but we have got a mortgage, and I have a building mortgage and salaries to pay here. While I consider myself wealthy, I’m not independently wealthy where I don’t have to work. I think that’s true when you talk to a lot of physicians; they’re not hurting but, they feel that they do have to work. They’re solidly part of the middle class, maybe the upper part of the middle class, but they have to work and those of them who have businesses have to meet payrolls. I couldn’t stop for a year and a half. Now, there were whole weeks where I wasn’t here. But even those weeks, if I had a day or a half a day, I’d see some patients. I enjoy seeing patients. If someone asks who I am, I’m a physician. I think I want to say that even if I’m in Congress for 12 years or so. I’m first and foremost a physician and a surgeon. And I enjoy doing it. The days I didn’t travel, it was relaxing to just be in the office. It was tricky doing both, but I think we’d have better people [representing the country] if they had real jobs in addition to just going to fundraisers.

As the campaign gained momentum, at what point did you wonder what would become of your practice?

It was when we started running neck and neck in the primary. We are a redder state than blue, so if you win the primary, you’ve got at least a 50-50 chance of winning. We started running even in January of 2010. Our polls were already showing us ahead, and we gained great momentum. But you can’t think about anything seriously until it’s done. My wife was telling me to check into all the rules on this, but I thought it was presumptuous to call them up and ask them all rules on how you practice medicine before you win. I really assumed all along that I’d be able to at least continue practicing for a salary to bring in my expenses. So, I was really surprised. The rules are different between the House and the Senate. The House allows members who are physicians to practice and cover their costs. The Senate does not. This really shows how out of touch Washington is with medicine—they don’t understand that a significant percentage of everyone’s practice covers expenses. In many practices, it’s at least 50% to 60%, of what covers expenses. If you can’t bill, how can you cover any of your expenses?

Why specifically does the Senate outlaw the practice of medicine, but not income from other pursuits?

They’ve basically made a decision between passive and active income. There are several people in Congress who are billionaires, and others who are multimillionaires. I don’t begrudge their wealth—I’m all for people being wealthy in our country; I want more people to be wealthy. I don’t begrudge them making a million dollars in passive income, but for someone like me, I can’t just abandon my practice and then pick it up again at some future date. Part of the problem is that the Senate rules are structured for attorneys, which most of them are. They’ve sort of lumped physicians in there as well. You can go back to being an attorney anytime, but being a physician is different. It’s a skill with your hands. Also, it takes time to build a practice. You can’t just go off to Washington for a period and pick right back up where you left off.

You’ve been a physician for a long time, but you are pretty new to politics, even though it runs in the family. What inspired you to become a doctor, and what made you run for office?

My family has always been involved in medicine. I grew up in a physician family and wanted to be a physician from a very young age. I’ve been doing surgery for 17 years, and I still get a rush from it. I saw this exponential rise in spending and the worst recession since the Great Depression. And I saw all this happening and everybody saying, “Government is the answer.” I think there are things in a very practical, down-to-earth way, the way I run my business or my family household income that I don’t understand. Would it be good for my family to get a bank loan and go to the mall? It would help consumption, but that’s sort of what we’re doing as a country. We’re borrowing money from China and telling everyone to go to the mall and spend it.

How will your experience as a physician impact your goals as a lawmaker?

Well, I think ObamaCare sort of inspired me in a sense that, government was already involved in 50% of medicine, and now they were going to be involved with every nook and cranny. From having my own practice and seeing what difficulty we have dealing with government now, I thought, gosh, they’re going to take over all the private practice aspect of this too. I think every government official, legislator or otherwise, should be made to come into a private practice and watch how we deal with a non-payable claim from Medicare. When you call, it can be 45 minutes on hold, and sometimes you get someone who knows nothing of what they’re doing. They say they can answer two questions and you are done. If they don’t answer the questions accurately, you’re still done. You had your two questions and get back in line and call and wait another 45 minutes and hope you get a smarter person next time. I don’t think politicians have any idea what it’s like to deal with Medicare. Also, government will always be inefficient. It’s not that they’re inherently stupid—although that is a debatable point. It’s just that they don’t get the same signals. If I get a signal that I don’t have enough money in one month to pay my payroll, I have to make changes. It’s the tough love of the marketplace, but it makes you be efficient. Before letting someone go, you try to cut other expenses. I have to watch my expenses on weekly and monthly basis. Medicare doesn’t do that. The other reason is that if something appears to be free, it will be inefficiently used. If a patient comes in with a deductible of $100, and the patient has already met their deductible and is on Medicare, the patient has no incentive to ask the doctor how much this costs. The rules of Medicare are always to charge exactly how much you are supposed to have done. Another problem in medicine is that there is no price differential between anybody. I charge exactly the same for cataract surgery as a physician in Montana. Every doctor in town charges the same, so you can’t choose your doctor at all based on price. Physicians may not like that, but that truly would be the marketplace answer to keeping prices down, as we would compete by price. In my practice, we do compete for price, for LASIK and for contact lenses—and it works. Prices have gone down every year for 15 years, but price in everything else covered either by private insurance or Medicare or Medicaid has gone up 15% a year.

Yes, but some would say that health care is unique. In the free market system, if you buy a watch, you can buy Timex and understand that at that price your getting a lower quality than a Rolex. But nobody wants low-quality health care.

You do see some competition on price for things like LASIK. Some of the premium you could pay is for pre- and post-op. When I do LASIK, I see all my patients before and after the surgery, and I do the whole thing. In some places where it is very cheap, you don’t see somebody else. The surgeon is there for 10 minutes of surgery and you never see him again. It still might be very good surgery, it’s just less personal. The marketplace sorts those things out pretty well. I don’t think you always give up quality because of price, depending on the efficiency of distributing the goods. It doesn’t work for everything. You can’t negotiate with your cardiologist when you have chest pains. Some of it needs to be negotiated through insurance. I got in trouble for saying this, but let’s imagine everyone had a $2,000 deductible for Medicare. You wouldn’t be negotiating your heart attack, or your cancer treatments, but everything under $2,000 would be negotiated. Think about it from a physician perspective too. You would have no price controls. What would happen if there was competition?

You are no longer an anti-establishment politician. You are now a member of the establishment. How will you deal with that?

I am still trying to look at things from the outside. President Obama has seriously changed health care in our country. They finally got through a lot of their dreams of having government-run health care, without any Republican support. I think he did get some change, but just change in the wrong direction. His change is that government is the answer. I wasn’t afraid to get elected, and I’m going to go up [to Washington] and hopefully keep that attitude. We are going to shake up the debate and not be just led around the establishment. I think things will change. The American people sense that there is a serious problem. Within a decade, the entitlements and interest alone drown out all other spending. Within 10 or 15 years, the entire budget will be taken up with Medicare, Medicaid, Social Security, and interest. We can’t fix all that in one fell swoop. We have to make gradual changes to the entitlements, starting right now.

What’s going to happen to the Patient Protection and Affordable Care Act (ACA)?

We will have votes on repealing it. I think repealing it will be something we will introduce and will vote on, and I don’t like to give up on things before they happen, but practically speaking, we won’t have much of a chance. But there are hundreds of things in [the ACA] that can be repealed. The 1099 provision, where every transaction over $600 dollars you have to fill out a tax form for where you do business— there are some people who will have to fill out thousands of those every day. This is a horrendous provision and has nothing to do with health care, but it exists just to soak more taxes out of the economy. (ed. On April 15, President Obama signed law that effectively repealed the ACA’s “1099 Provision.”)

What about the legal challenge?

That’s our best chance. We definitely have a better chance repealing it in the courts than in the congress.

Let’s say you were successful in repealing the ACA in total. What would you replace it with?

I think you have to start from the beginning and look at what was wrong and what was right with our health care. The debate should start by acknowledging that we have the greatest health care in the world and that 100% of people in the country have 100% access to emergency care. Those things are sort of lost on people when they talk about the uninsured. Everybody in our country can receive medical care. The things that haven’t been working well and the biggest complaints I get from people are the expense of health insurance. Most people have health insurance, and the vast majority are the people who are complaining about the price. ObamaCare did nothing about that price. In fact, it will probably increase that price because it mandates to insurance a lot of new rules, and a lot of new people are covered. Health care doesn’t work as efficiently as the rest of the marketplace because it isn’t allowed to. Capitalism works everywhere in the marketplace, so there’s no reason we shouldn’t inject more capitalism into health care. Do we want more government control or more competition? In think we should add more capitalism and more competition. We should go back to what insurance is really intended for—buying a policy against the risk of unlikely events. If you want prepaid healthcare, that’s different; that’s very expensive. If you were to buy true insurance, it would be much less expensive with much higher deductibles. Patients would pay lower premiums, but they would have higher deductibles. The cost of medicine would come down, because competition works. The average LASIK patient goes to 5 different people before they decide.

A local paper reported here that, although you described yourself on your website as a “board-certified” ophthalmologist, you were not certified by the American Board of Ophthalmology, which is the board that certifies the overwhelming majority of ophthalmologists. They never indicated that you weren’t qualified to practice, but this has hurt your standing among the physician community. What happened?

I was board certified by the American Board of Ophthalmology (ABO). I disagreed with their policy that only young physicians should be recertified. I made the point and debated it for many years that recertification should be for either everyone or no one. Martin Luther King Jr. once said that, “The definition for an unjust law is any code that a numerical majority enforces on a minority that refuses to apply to themselves.” If what the ABO did was a law, it would be immediately struck down. They are a private group, so they can do whatever they want, but there is no way they can tell me I can’t be a member of the hospital because I’m 48 and the guy who is 55 doesn’t have to obey the same rules. It’s always been an argument of justice. And almost everyone under 48 agrees with me, and almost everyone over 48 disagrees with me. I think their position is less than honorable, to say the least. [As for the news outlet that first reported it], it was a hatchet job. It was a left-wing democratic newspaper. The article didn’t include my side at all. Look, I went to one of the top five medical schools, one of the top five residencies, and I’m a good surgeon. What I told [the reporter] is that by running that story, you are potentially destroying my career; you are damaging me in my community.

Let’s say for a moment that you only get one term in the Senate, and then you come back to your practice. What do you hope to have accomplished in that term?

Well, I tell people I’ll probably just turn around and come home in a month if I can pass the balanced-budget amendment and term limits. Because I think that would transform the way we do things. I’m not looking for any special project or any special bill. I want to change how things are done in Washington. And I think term limits would be part of a reform that is necessary. As it is now, we get people who are too distant from their careers or too distant from their states, and they stay [in Washington] too long.

Thank you, Dr. Paul.