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                                       politics + culture

Sunday, November 27, 2005

critical condition

If you want an example of something that's emblematic of what's broken in America, try health care.

Sure, our Republican colleagues will mouth the exact same tired language about "the excellence of our hospitals" and those dreaded "trial lawyers."  Truth is, however, for twenty five years the United States, under Republican leadership and the hand of big business, has indulged in an experiment with allowing "market forces" to drive our health care system.

That experiment has failed.

We pay more for drugs, basic care, and insurance than ever before.  Due to an unchecked increase in the cost of catastrophic care and a change in bankruptcy laws, we are all more at risk of financial devastation when facing a serious illness.  Many of us are less healthy.  And all of us navigate a labyrinth of byzantine, hyper-duplicated and redundant bureaucratic formulas that consistenly favor profit over people.  Nothing exemplifies this better than the sight of millions of senior Americans struggling to read the fine print of the insanely complex new "Medicare Drug Plan."

Let's face it, health care is broken in America.2004 saw the publication of Critical Condition: How Health Care in America became Big Business and Bad Medicine by famed investigative journalists, Donald Barlett and James B. Steele.  The book is now available in paperback and can be read in an afternoon or a plane ride.  I highly recommend it.

Barlett and Steele lay it out:

Over the last few decades, American health care has radically changed.  A system that was largely not-for-profit has become a field where the profit motive and market forces affect every decision. [snip]

Much of the turmoil is a direct result of a national policy to run health care like a business, a misguided notion promoted by Washington over the last two decades that the free market and for-profit health care would restrain costs and bring high-quality care to all.  On both counts, the experiment has failed miserably. In the meantime, tens of billions of dollars--money that could have gone into patient care--has been drained from consumers and corporate subscribers and transferred to investors, executives, and others who have a stake in perpetuating this myth.

The result is a chaotic system that has shifted its focus from saving lives to saving dollars, one that discourages preventive medicine and rewards overtesting and overmedicating; a system that allows insurers to reject those most likely to require medical attention and keep only the healthiest; a system where six times as many people die from medical mistakes as from HIV/AIDS; a system that forces doctors to spend as much time negotiating with insurers over referrals and fees as they do treating patients.

Barlett and Steele don't mince words.   When you're sick, you're not a "customer"...you're not a "shopper"...you're a patient.  It's obvious.  When one of us gets cancer or has a car accident...it's not like we're wheeling a cart down the aisles of a grocery store comparing prices.  But that's exactly how the Republicans would like to have us imagine it.  (And when we do compare prices we realize, as the authors expose, that hospitals--even non-profit, "charitable" hospitals--price gouge uninsured Americans and send the inflated bills to collection agencies.)

Health care isn't like other "businesses" where it's perfectly expected and acceptable to make more money by selling more of your product.  When talking about our health, that's insane.  We want fewer diabetics and lung cancer patients.  We want healthier babies and children who grow up with good habits of diet and excercise.  As a society, we want our citizens to be healthy, to need less, not more,  intervention from the health care system.  That was the logic behind the initial governmental investment in "non profit" HMO's in the 1970s.  (It's also the logic behind most other countries vastly less expensive health care systems; countries we compete with in the world marketplace.)

Non-profit HMO's were invested in keeping all their patients healthy.  If you were in your 30s, and had a reasonable expectation of good health, you still knew that your HMO would cover you in the event of an accident or a chronic illness...and would cover the health care of your children from pre-natal check ups to doctor's visits for a cold or a broken bone.  If you were in your 50s you knew that your HMO was invested in proper diagnostics and preventive care...to keep you healthy, to intervene early, and to guide you into your senior years, and the medicare system, as a healthy senior citizen.

We've turned that on it's head.  Our government bought into the idea of for-profit HMOs and for-profit medicine...and that happened at exactly the point where conservative ideologues got their hands on U.S. government: during "the Reagan revolution."

Take this 1979 quote from David Stockman, who went on to become Ronald Reagan's budget director:

The secret is to liberate health consumers from the policy-induced stupor that has reduced them to passive, indirect payors when by nature they are accomplished, resourceful shoppers.  The activation of 150 million adult health care shoppers would dramatically transform the medical marketplace...

The conservative kool-aid was flowing even then.  That quote might sound good to some, if you don't stop to think about what a 'medical marketplace' means.  According to Barlett and Steele:
In 1983 alone, five formerly not-for-profit HMO's with hundreds of thousands of enrollees converted to publicly owned corporations. [snip]

The move to for-profit health care companies was a profound transformation that would affect milllions of Americans.  It was rationalized, explained, and justified for one reason--as the only way to control costs.  "The object will be to slow the explosive rise in the nation's medical bill." Business Week reported, "and set in motion free market forces that will reduce the waste, inefficiencies, and misuse of health services that have eluded the corrective thrust of government regulations."  For-profit HMOs were the "Johnny-on-the-spot answer to the health care cost problem," said a Piper, Jaffray and Hopwood analyst in 1984. [snip]

At the time, in 1984, health care costs represented 10.5 percent of gross domestic product.  Twenty years into the experiment to "slow the explosive rise in the nation's medical bill," health care costs at the end of 2003 exceeded 15 percent of GDP.  They are sill rising.  The last time so many on Wall Street and in government were so wrong was 1929--but this time many would  make a great deal of money.

For those interested in what a "cost savings"...rrr, increase...of 4.5% of U.S. GDP represents:  it's about 500 Billion dollars...annually.

For-profit medicine, as relentlessly exposed in Critical Condition, has meant big business scamming patients, scamming investors and scamming the government.  Ask yourself, when you look at the health of your fellow Americans, and the vast numbers of uninsured...where do you think that $500 Billion a year goes?  From where I stand, it sure doesn't go to making average Americans more healthy or more secure.

In fact, the obvious fraud and waste involved in for-profit medicine changed the meaning of HMOs to such an extent that it likely scared voters from supporting any attempt to reform health care away from the failed for-profit system, even though that reform is in all of our best interest.  Average Americans who do have health care see first hand the waste, fraud and corruption in the system; but instead of reforming it, in voting for a Republican-controlled Congress we've voted to let the market fix itself!  Ironically, Republican policies and voter manipulation have had the effect of luring voters to vote for 'more of the same' instead of asking themselves why the system's broken in the first place.  That has to change.  

Truth is, some people have been getting VERY rich for a VERY long time with business as usual.  The only way to change that is to make the case that the Republican experiment in for-profit health care has failed. The experiment has failed our patients, our children, our doctors, and, in the end, it failed even our big companies.  For profit medicine has failed our country.

For the scare mongers who preach conservative "market based" values, I have one question.  Would you let market forces raise your child?  Of course not. Just as we have core values we want for our children, we have certain standards and core values that we should expect for health care in this country.  Access to affordable health care that has all of our best interests at heart with an emphasis on preventive and healthy lifestyle choices should be one of those values.

When we had a basically "not for profit" health care system in this country, it was not perfect...what is?...but one core thing held true: the system was invested in our health,  not in making money off our sickness.

We've come a long ways from that moment.  As Barlett and Steele point out, health care in the U.S. is like a lottery.  If you're one of the lucky, you're alright.  If you're not.  You're screwed.

But anyone looking at their neighbors and family knows that it's not that simple.  It's connected.  When GM shuts those factories, in part due to the huge costs of for-profit health care, they will be gone for good.  When our neighbors lose everything over a family health crisis, it's not good for anyone.  The entire United States suffers when we let kids fall victim to an epidemic of childhood obesity due to crappy corporate food and a health care system that isn't doing it's job:  to help keep us healthy.

Like in so many things, the Republicans have had their chance. Their ideas have failed. It's everyday Americans who have paid the price.

[Update: Badger Blues joins the call for reform.]



  • There is another category of screwee - the Docs, the Nurses, and other medical personnel. As a result, the people who actually do the work suffer financially along with their patients. Just like the insurance business, the "salesman" and the customer are both victims of the same system - ultimately they both lose. And any system that forces a Doc with a lifetime of training to spend her time discussing medical treatment with an insurance company clerk is simply insane.

    But perhaps we can all agree that it's a good thing that Clinton woman and her lackey Rahm Emanuel didn't go anywhere. Then we would REALLY be in a mess (sorry, no smileyface - the memory hurts too much).

    By Blogger Brenda, at 12:41 PM  

  • Sorry about the screwups I made in posting this:
    I urge all of your commenters and lurkers to visit pnhp.org so that they may consider joining a growing number of physicians, nurses, healthcare providers, and concerned citizens in this fight for universal healthcare coverage.
    On a lighter side to this issue (laughter is good medicine) check out placebojournal.com.
    Peace and love,

    By Anonymous reikirn, at 4:00 PM  

  • Question for you.

    How much of this do you think is the fault of fault of a for-profit system, in and of itself, and how much do to a perverse system of financial incentives within the industry?

    I ask because back when almost all hospitals and insurers were non-profit, health care costs were going up at about the same rate they are today. The whole reason for the turn to HMOs and managed care was that the old system wasn't working, and this system was largely non-profit.

    My take on the industry is that it is far more significant that (a) providers are typically paid fee for service, rather than on a salary basis or according to how effective they are in healing; (b) insurers are relatively ineffective in managing care and controlling uneccesary expenses because of the consumer backlash in the 90's to HMOs and "rationing" care; (c) the fact that consumers are largely ignorant of what is appropriate care and so do not provide a check on services, nor are they motivated to because insurance covers most of the costs; (d) patients (I deliberately switched from "consumers" above) are in a position of fear and need. They are often in no state of mind to negotiate about price or take risks, and so opt for the cadillac over the hyundia if they can...and sometimes even if they can't.

    I completely agree that we need government involvement to initiate a universal health insurance system. What I don't think I agree about is that for-profit companies are at fault for all the rising costs. It is more about a perverse system of incentivs and relative lack of checks and balances on expenses.

    We need to pay providers differently; provide people insurance differently (using a universal pool created by the government); allow government to negotiate rates with drug companies and device suppliers at least in some cases; and use the power of large managed care organizations (run by the state or independent) to systematically and effectively manage care using best practice guidelines.

    My two cents
    (visitor from kos)

    By Anonymous Anonymous, at 7:48 PM  

  • Barlett and Steele make a distinction between the not-for-porfit HMO movement, exemplified by Kaiser in the post-war period, and the 80s evolution of "for-profit" care that fundamentally changed HMOs.

    They propose a "Federal Reserve" type overseer for health care. Here's their progam/goals:

    * Guarantee all Americans receive a defined level of basic care
    * Establish flexible co-pays for basic care that vary based on income and usage
    * Pay ALL costs of catastrophic illness
    * Restore freedom of choice of doctors/hospitals
    * Allocate money for preventive medicine, reign in "treatment by prescription"
    * Educate consumers on drugs and their limits
    * Concentrate health spending on areas like stemming childhood diabetes, smoking, preventive care etc.
    * Find out why Medicare spends more in some states than others...and use the learnings to fix the program.
    * End the unrealistic insurer-based rate "squeeze" visited on doctors, nurses, hospitals and nursing homes
    * Reverse the trend towards overdiagnosis and overtreatment

    Admittedly, not all of those "ills to be fixed" stem exclsively from "for profit care".

    They do, however, all relate to a lack of strategy and oversight. Frankly, there isn't much of that to be had in the current set up.

    I am quite sure there is common ground to be found here. Reading Critical Care, however, does reveal some atrocious ill of the current situation...ills which quite often relate to "bottom line" thinking about basic human needs.

    At $1.5 trillion a year....or $5,263 per U.S. citizen...there's gotta be a better way.

    By Blogger kid oakland, at 9:08 PM  

  • Thank you, Kid Oakland for fine summary of the state of our health. As the child of a 3-time cancer survivor, I have been concerned about our health care system for many years. As has my father who actually researched and designed and has proposed a single-payer health care plan.

    Our system makes so little sense and so unimaginably cruel -- it seems there could be only one explanation. The people who benefit, who are getting wealthy from this system, must consider that their personal wealth compensates for everything else.

    And the rest of us somehow think it does as well. Never mind that we can't start that business we dreamt of. Or that your brother is uninsured and has diabetes and will never be insured now. Or that you could retire early, but you'll lose your group coverage.

    And that's the situation before you need major surgery or a new kidney.

    My dream was that with a Democrat as president we would at least begin a serious national discussion about healthcare (I knew that with a Republican controlled congress anything more than that was a pipe-dream). But, sadly Bush is still there and we had to spend a year defending Social Security. Sigh.

    Anyway, thank you.

    By Anonymous Anonymous, at 4:55 PM  

  • Speak it!

    A great overview of the state of the health care system. Other than the fact that I think you are a little light on the Democrats for their role in kowtowing to the health care industry, I wish I'd written this piece.

    What I did write was a look at the near-term political implications of the health care crisis.

    By Anonymous sasha, at 9:08 PM  

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