NATIONAL HEALTH INSURANCE: ITS POLITICS & PROBLEMS
Steinfels, Peter
Once again, national health insurance is said to be "impending," a condition reminiscent of the old quip about Brazil: "It is the land of the future, and always will be." NHI, to use the...
...Only traditional business ideology has kept industry from joining labor in the plea that government take the burden off their shoulders, and this may be changing...
...Individuals (or even cultures) may be drastically "treated," and lose their rights in the process, when they can be labeled "sick...
...Labor, to be sure, is motivated by genuine concern for the medically unprotected and many in its ranks are deeply committed to the social-welfare tradition...
...But, again, exaggeration is the enemy...
...Nonetheless, we tinker with the individualist striving of physicians at some risk...
...The power of reimbursement should be used to enforce the planning decisions of regional bodies, and to encourage whatever technological forms of practice and deployment prove the least expensive and most efficient in freeing the individual's time, skill, and energy...
...Or recall the example of the CAT scanner...
...The second, more novel, and in a sense more radical impulse is to call into question the value and efficacy (particularly the long-range effects) of the services themselves...
...Services provided outside this system would not be reimbursed, nor could private practitioners use national health service facilities...
...63 Historically, medicine has usually been a free enterprise endeavor...
...The drastic consequence of poor quality in the product, and the inability to test it beforehand, force the purchaser to rely on the seller to an unusual extent, and this in turn has led to restrictions on sellers from entering the market...
...What Senate investigators have recently publicized, neighborhood groups and radical health-care critics have been complaining about for years...
...Too many voices in the medical-care "backlash" assume that social initiatives automatically detract from personal responsibility, as though people became improvident because of Social Security, or unconcerned with their children's education because of public education...
...Formal structures alone do not make a system responsive...
...Ronald V. Dellums [Dem., Calif.] under the title Health Rights and Community Health Services Act...
...Some supporters of the Kennedy-Corman Bill see a national health service as the 69 ultimate goal...
...This person would act as "gatekeeper," directing patients to other services...
...In all this, 20th-century economists were only explicating a long-held intuition that medical care was not like other goods and services...
...The two states are similar in average income (Nevada's is somewhat higher), schooling, urbanization, climate— and in the number of physicians and hospital beds per capita...
...In the 1930s, nonprofit insurance schemes Blue Cross and Blue Shield—were initiated by hospitals and physicians whose clients could no longer pay their bills...
...Nor do these statistics measure the reassurance provided by accurate and compassionate diagnosis...
...By World War I, a movement for compulsory health insurance had risen and fallen, with the AMA originally favoring the measure, and such prominent labor leaders as Gompers opposing it as "paternalistic...
...But the theory has always been at odds with the practice...
...Many of those managing third-party payments share the interests of medical institutions and have little impulse to challenge dubious practices...
...If life-style is the crucial determinant of health, then one could take the individualistic tack of reducing the social problem of health to a lot of individual ones...
...Medical education should be free, should include a period of service in underserved areas, and be continued through such devices as minisabbaticals and periodic reexamination...
...Political philosophers in all eras have turned to medicine for examples of the kinds of decisions one does not subject to debate and vote...
...Finally and obviously, environmental and occupational health care should receive a far greater portion of the health budget and of professional attention...
...A mark of change in our era seems to be the proliferation of acronyms, and health care has lately produced PSROs (professional panels for monitoring quality and cost...
...NHI, to use the official acronym, has long been a brightly wrapped package marked, "Do not open until next election—or the one after that...
...If we take into account the incrementalism of American politics we must be aware that the alternative to Kennedy-Corman is not a national health service but a scheme for insuring against catastrophic illness that would reinforce the worst distortions of the present system...
...In general, Illich's mass of footnotes bear the same relationship to scholarship as Medicaid medicine to the real thing...
...Here is a "shopping list" of current ideas: • Consumer Organization...
...But the critics are wrong in not recognizing how many other changes are in fact underway, and how many more, whether or not tied into NHI, could be brought about...
...Many well publicized fears, such as that of Clockwork Orange prisons using psychosurgery on recalcitrant convicts, have been based on nine parts rumor to one part reality...
...The degree of promptness and attention we demand is relatively flexible—the hours the British must wait to see a doctor or the months to undergo certain types of surgery would not be tolerated by most Americans...
...The medical system cannot do everything—redistribute income, substitute for decent jobs and housing, banish the anxiety and the sense of imminent failure inculcated by so many institutions in this society, remove the pangs of mortality, implant wisdom...
...Public health education ought to receive some of the talent and resources routinely assigned to the biochemical and technological facets of health care...
...What Labor hopes is that government will build effective cost controls into its insurance mechanism...
...National health insurance should be accompanied by more such initiatives, some achieved through legislative action, some a matter of consumer or professional action...
...One view holds that the problem originates within the individual...
...Medical school selection committees, for example, should include practicing physicians, other health-care workers, and consumers, as well as researchers and educators...
...Fuchs also notes that residents of Utah enjoy one of the highest levels of health in the U.S., while those in the neighboring state of Nevada rank 66 toward the bottom...
...Nothing will limit them except external restraints...
...What can one conclude about defining and limiting medical need...
...They prefer a national health service that goes beyond insurance...
...Yet "need" often turns out to be difficult to define...
...NHI, for instance, should be funded out of general revenues and not through a payroll tax with a cutoff point like Social Security's...
...But note that Medicaid has not brought on unreasonable expectations by patients...
...Subsidized by tax benefits and often won in union contracts, private insurance, too, affords a degree of security to about three-quarters of the population...
...Others are not so sure...
...The increase in expenditures can be laid in part at the feet of the profession: larcenous physicians have conspired to milk the program, respectable ones have looked the other way or, worse, never concerned themselves with care for the poor in the first place...
...THOUGH MUCH discussion about health care centers on the "right to health care," we now have something like a "half-right" to health care in the U.S...
...During World War II, private medical insurance finally reached a sizable portion of the population...
...Reliance on thirdparty payers has removed incentives to forgo medical care of questionable value...
...Running contrary to this drift toward NHI is a rather impressive intellectual "backlash" against any massive government initiative in the health-care area...
...By the 1960s, pressure was exerted to assure access to care for special groups—with mothers, infants, the elderly, and the poor the favorite targets...
...Education for the Public...
...Last summer saw a flurry of newspaper articles about a device called the CAT (computerized axial tomography) scanner...
...Physicians are trained to do their best for individual patients, not for the whole medical system or society in general...
...A regional structure will allocate funds and could lead to regional systems in which primary care, emergency care, ambulatory clinics, community hospitals, and major medical centers would be coordinated...
...In 1975 the nation spent $550 per person on health care—up from about $80 per person in 1950 (and $30 in 1929), and two-and-a-half times that of wages over the same period...
...Once we recognize to what extent medicine deals in intangibles, we realize just how elusive medical need can be...
...Or, how badly do how many people need how many scanners...
...The Hill-Burton program supplied funds for approximately a third of the hospital beds in the U.S., while congressional appropriations for medical research went from $7 million to over $3 billion in two decades...
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...The providers of medical care, after all, and not the patients, by and large decide what is "needed...
...What is the source of this pressure against capacity, and how great is it—and what are the best means for counteracting it, that is, for the delimitation of need...
...for white males between 15 and 24, the leading causes of death are auto accidents, other accidents, and suicide...
...Furthermore, the organizational structures of the medical system are a jumble that defies rational planning while also failing to provide the benefits of competition...
...State, local, and federal government now pay about 40 cents out of every dollar in the nation's total health-care bill...
...The bill should carry stronger provisions for democratic control at every level...
...Some of these problems are as pressing under private insurance schemes, some have posed no insuperable difficulties for other nations' health plans...
...2. Medical Care and Health IRONICALLY, at the same time that our medical needs seem to have expanded, there is a growing recognition that the relationship between additional health care and health may be tenuous...
...Others see the problem originating within the medical profession...
...A moderate estimate is that hospitals and physicians' groups may invest more than $1 billion in CAT scanners over the next four years, almost all of it coming out of insurance premiums and tax support...
...The same question can be posed about many other technological innovations or, for that matter, about standard procedures like the annual physical...
...Over half the hospital beds are in public institutions...
...At the moment, hopes are high...
...Since Medicaid reimbursement for private doctors is much lower than for visits to clinics, the Medicaid mills recoup the differences by 65 "ping-ponging" patients for unnecessary treatments...
...It is finally the interaction of the professional monopoly, and half-way measures created to compensate for market deficiencies that, together, have led to these vast new "needs" for x-rays, eye examinations, and visits to podiatrists...
...During the election campaign, Democratic advocates of national health insurance were content with their party's surface consensus, hedging all bets with talk of "phasing in" NHI should money prove scarce...
...But given the amount government is now spending in the medical-care sector, given the fears even upper-middle-class families have of being financially wiped out by major illness, even these skeptics doubt whether the present system, or nonsystem, is viable...
...But this can spur different reactions...
...Today—though this has not always been the case—medicine is viewed as a benevolent force...
...This pressure produced Medicare, Medicaid, and a host of special federal programs...
...In my view, the Kennedy-Corman Health Security Bill is the only widely backed national health insurance plan with the potential for controlling costs and changing the practice of medical care...
...I feel ill thousands of times in my life, but when do I "need" a physician, when only a rest or chicken soup...
...Big companies are in the same position—General Motors recently discovered that its major supplier of goods and services was not U.S...
...And this is almost the opposite of the way things have been...
...Critics of national health insurance rightly state that NHI does not touch upon many of the medical-care system's problems...
...almost no one denies that many ailing individuals are eligible for Medicaid and do not avail themselves of it...
...What degree of certainty do we really need in diagnoses...
...And the grosser statistics measuring health care do not include the relief from affliction provided by drugs...
...3) the potential of health care as an instrument of social control...
...Institutions other than the medical profession, however, must be involved...
...While we need food, housing, and community services like sanitation every day, most of us are sick only intermittently and don't like to dwell on the prospect when we are well...
...Individual medical care made its contribution largely in the middle third of this century, above all with antibiotics...
...Consider the recent Medicaid scandals...
...rate more than a small step closer to the Swedish rate...
...Some radicals consider the KennedyCorman Bill precisely the commitment of government support to an irrational system I have here warned against...
...Yet, we have created a system that seems inherently unmanageable...
...Selection, Education, and Organization of Providers...
...These are real problems...
...Nurses are demanding a more independent role in hospitals...
...it must deal with the real settings in which people maintain health and cope with illness...
...Rubber 61 but Blue Cross/ Blue Shield...
...The model is inappropriate now when chronic illness, rehabilitative medicine, and life-style problems are the new challenge...
...On the other, even NHI's good friends express doubts about the measure's value...
...It is not a small matter to retain a mouthful of teeth, to have one's vision corrected, to walk without a limp because a bone was set properly, to have the effects of burns repaired, to regain mobility or agility through prosthetic devices...
...A greater social responsibility for health care might very well generate an intolerance for risky life-styles...
...The religious or cultural meanings once given to special moments in the life cycle have often come to be excluded by medical procedures...
...There are many ways of discussing national health insurance, and one fruitful way might be to explore this apparent inconsistency...
...Medicine has the authority to define "normal" behavior...
...The present separate-and-unequal pattern of medical education should be broken down: different health-care providers—physicians, gatekeepers, nurses, administrators, researchers—should pursue their education in a common institution with distinct though overlapping curricula...
...Health education cannot be, as it often has been, merely a watered-down version of scientific medicine...
...Utah is inhabited primarily by Mormons . . . [who] do not use tobacco or alcohol and in general lead stable, quiet lives...
...over half the hospital-care expenditures are paid by government, with the federal share increasing...
...Republicans were not eager to stir up trouble by opposing the one example of "big spending" that just might prove popular...
...We simply must go beyond our current "half-right" system with the aim, not only to pay for medical care and to distribute it equitably, but also to reshape the way it is practiced...
...New "allied" health providers, such as physician's assistants and nursepractitioners, are establishing their place in the delivery of care...
...Perhaps in no other field do the processes of selection and socialization have such an impact on the eventual attitudes of practitioners...
...A plan for such a communitybased service has been developed by activists at the Medical Committee for Human Rights • and the Institute for Policy Studies and is sponsored in Congress by Rep...
...There have been strikes of interns and residents...
...Everyone favors public health education, but no one knows very much about it...
...The special merits of the Health Security Bill, however, are found in its leverage as a national, comprehensive, compulsory program with the power of the purse strings...
...Medicaid first became a funding agency for the outpatient departments of inner-city hospitals...
...Health-care spending will be capped, and further increases will have to be decided through the political process rather than through isolated, individual market purchases...
...indeed, there is sociological evidence that physicians fear death more than most patients do, which may be why they became physicians in the first place...
...and the more expensive the treatment, the more apt this is to be true...
...In cases of a serious problem, or whenever patients requested it, a primary-care physician would take over and would retain responsibility in matters of hospitalization or referral to a specialist...
...promoting short-run increases in services in the anticipation that these will be unattainable and therefore force more profound change...
...in the U.S...
...The long-range goal should be to allow every person a tie with two primary-care givers...
...Incentives will be provided for the expansion of prepaid group plans...
...In the presence of an actual legislative proposal, this pacific scene is likely to erupt into the old shooting war...
...A health-care system should be designed to extend and reinforce those institutions and social relationships, old or new, that are caring and serving, and not those that are simply innovating and productive...
...The need for medical services is extraordinary and unpredictable...
...Government involvement increased in areas that had been public-health concerns in the 19th century—treatment of contagious diseases and mental illness...
...Until the unlikely day when most people accept death as do the romantic followers of Elizabeth Kubler-Ross, there will always be pressure against our limited resources...
...A solution to the problem might require both changes in Medicaid and such imaginative measures as a city itself sponsoring "Medicaid mills" in place of exploitative landlords...
...Not even in the laissez-faire heyday of Herbert Spencer were most people, excepting that worthy gentleman, happy with the idea that health care could be bought and sold like pork bellies...
...Writing in Working Papers and The Hastings Center Report, Paul Starr has described the situation: Two antagonistic impulses now dominate criticism of social policy...
...The purchaser, afflicted, unable to defer care, and lacking information, is usually in no condition to shop around...
...As the economist Victor Fuchs has pointed out in Who Shall Live?, the differences between American and Swedish mortality rates cannot be linked with differences in medical care...
...At a meeting last January, Wilbur Cohen, veteran of social insurance wars, traced the struggle for health insurance from pre-New Deal days, announcing that we were now in round 10 of a 15-round fight...
...Except for some specific matters, such as prenatal and infant care among the poor, more visits to the doctor probably won't help most Americans, at least in regard to such easily measured matters as life expectancy or days of being bed-ridden...
...And the profession can be complacent about the social restraints on good medical practice when, as with the conditions in many public hospitals, these are so deeply embedded in the social structure as to be taken for granted...
...HSAs (regional agencies to assess needs and plan priorities, supposedly with strong consumer representation...
...The "Medicaid mills" came next...
...The answer almost surely lies in the different life-styles of . . . the two states...
...almost 90 percent of hospital expenditures come from thirdparty payers...
...Nonetheless, the idea that much of our current problem is caused by our unruly and insatiable human nature, or calls for a return to market medicine, appears unjustified...
...Even while NHI has been kept "impending," the health sector has been in a boil...
...for black males, homicide, auto accidents, and other accidents...
...Medicaid was, in fact, a good example of "throwing money" at a problem—not, however, out of a congressional weakness for free spending but because more thoroughgoing measures were politically unthinkable...
...On the one side, almost all, even NHI's foes, echo the line that the measure is "impending...
...In some ways they were examples of creative entrepreneurship, moving into slum areas, offering accessibility that hospitals did not provide...
...From 4.6 percent of the GNP in 1950, health expenditures have now leaped to over 8.3 percent—and the rate of increase that began with the introduction of Medicare and Medicaid in the mid-'60s has not leveled off...
...The model of the passive patient relieved of responsibilities, except to follow doctor's orders, is rooted in the postanesthesia triumphs of surgery and the past era of medicine's successful battle against acute infectious disease...
...but this is no more supported by evidence than are many of his other egregious claims...
...After an intervening period, reimbursement should be made only to hospitals that meet certain standards in democratizing the methods by which their officers are chosen and internal operations carried out...
...People are just insatiable—for good health as for other things...
...Nevada . . . [has] high rates of cigarette and alcohol consumption and very high indexes of marital and geographical instability...
...second, the professionals, who hope that gradual shifts in medical priorities will emerge from within the profession...
...Should smokers pay a tax on cigarettes that would enlarge the national health insurance fund for cancer treatments...
...One can also imagine 68 social interest in matters previously held private—the efforts of childless couples to have infants of their own even at the risk of great medical expense, or decisions about life support for the incurably ill...
...But as soon as medicine grew able to deliver on some of its promises, the distribution of individual services on the market came under challenge...
...1. The Question of Need ACCESS TO medical care based on need alone has always been an ideal for advocates of socialized medicine...
...The problem is that our expectations shift from class to class and culture to culture—and in our culture they seem to be continually expanding...
...Until our own century, those who missed out on the prescientific ministrations of physicians may have been more fortunate than those who underwent them...
...Even the main support for comprehensive health insurance, the labor movement, has the cost issue foremost in mind...
...its theories of mental health and illness are disseminated throughout society...
...The relevance of this analysis to defining and limiting need is obvious...
...Perhaps the most effective health measure of recent years was lowering the speed limit to 55 m.p.h...
...At worst, this is the familiar response of "blaming the victim...
...The problem, however, is not the small percentage of hypochondriacs among us, or the touch of hypochondria in all of us...
...Afflictions previously left to the preacher are now taken to the physician...
...Medical care must both acknowledge the bounds of its own competency and point beyond itself...
...Basically an x-ray machine for soft body tissue, the CAT scanner produces threedimensional cross-section pictures of such organs as the brain, pancreas, and liver...
...Hence, the sense that national health insurance, of some sort, is inevitable...
...Outside of this, attitudes toward the Dellums proposal vary...
...Since insurance premiums were not included under World-War-II wage controls, and are still not counted as taxable employee income, company contributions to insurance plans became a prime objective for union negotiators...
...After World War I, federal provision of medical services to veterans was initiated...
...Others emphasize the neoconservative themes that elites, in this case the medical and political elites, promise too much...
...But only a gross exaggeration of the evidence would lead one to dismiss the importance of medicine altogether, to rest satisfied with current inequitable patterns of its distribution, or to conclude, with Illich, that equal access to medical services "would only equalize the delivery of professional illusions and torts...
...These were ways congressmen could "cast a vote for health" without incurring AMA ire...
...The "need" for such equipment is not generated only by patient demand or professional pride...
...How badly do we need CAT scanners...
...The woman's movement has forced a reexamination of physician-patient relationships and the possibilities of medical self-help...
...The first and more familiar impulse of the left is to argue that the poor and minorities get inadequate services from schools, hospitals, public welfare agencies, and other institutions...
...If it is irrelevant or harmful to human welfare, then the poor would clearly be better off without it...
...Accordingly the normal opponents of NI-II have concocted their own versions: the AMA places doctors at the center of its plan, the insurance industry's is built around private insurers, the hospital association centers on hospitals, etc...
...Despite the rush of popular tales about medical atrocities, the public holds no group in higher esteem than physicians...
...Transferring responsibility to Washington would change nothing, except that politicians rather than union and company negotiators would have to deliver the bad news of accelerating costs...
...Nor did this "private" modification of the pure market model result from individual consumer calculations rather than government intervention...
...No matter how many consumers' representatives have a hand in decisionmaking, the reality of health care is still the distressed individual in need of personal 70 support...
...but when negotiation time arrives unions with broad health coverage for their members are hard pressed by premium increases, since the cost of existing health-care plans has eaten up much of the pot to bargain over...
...Yet, the "backlash," consumers' groups, and the women's movement are of one mind on the idea that doctoring should recapture more of its root meaning: teaching people how to live with and care for their bodies...
...Nor did rejection of insurance mean a comfortable acceptance of the market...
...One aspect of genuine health-care education would be the recognition (another legitimate point made by the medical "backlash") that medical care has its limits...
...Add to this the severe limits on consumer bargaining, the inevitable local monopolies (like the town's one hospital), and nearly overwhelming professional consensus—and you will understand the conclusion reached by Fortune editors in 1970: "most Americans are badly served by the obsolete, overstrained medical system that has grown up around them helterskelter . . . ." The result is the pattern of skewed priorities in medical care that we find throughout the welfare state...
...These important qualifications should not be used to ignore the very real limits of standard medical care that recently have been recognized...
...The physician who sees an infant die because there was no opening in a neonatal intensive-care unit is not going to be consoled by the knowledge that cost-benefit analysis demonstrates the funds for enlarging that unit were better invested elsewhere...
...The results of this "half-right...
...At younger ages the difference lies in the percentage of cases of violent death...
...No one supposes that the Dellums measure is politically viable...
...In our own time, economists have identified the factors that render health care ill-suited for the market...
...For the moment a proposal for a national health service is primarily educative: by staking out a territory to the left of Kennedy-Corman it reveals that bill's essential moderateness, indicates the limits of all insurance schemes, and suggests the need for further change...
...Some of these observers, Friedmanites on the right and such anarchists as Ivan Illich on the left, espouse a return to a freer market in medical care, seeing the present problems essentially as the outcome of a socially guaranteed professional monopoly...
...Agitation continued, and meantime "charity" was maintained as a pillar of the profession's ideology, sometimes of its practice...
...We should also stop letting the "invisible hand" decide whether we get a shortage of general practitioners or a surplus of neurosurgeons...
...Over 20 million Americans are enrolled in Medicare...
...Since time immemorial, treatment of the ill has been hedged about by a religious aura, by ethical codes, sacred oaths, state law, and guild regulation...
...A third view sees the problem of expanding need as originating precisely in the incompatability of medical care and the market, and in our half-hearted attempts to cope with this incompatibility...
...and (b) from prepaid Health Maintenance Organizations with members who have a standing interest and a direct role in controlling their premiums...
...Medicare and Medicaid, while extending medical services to many who were not getting them, also raised physicians' already high incomes and boosted the cost of health care...
...Therefore, what otherwise might be resisted when proposed in the name of political or moral ideals is readily accepted when blessed with medical authority...
...We have created much of the problem by our makeshift arrangements, and can relieve much of it by better ones...
...While some supporters of a national health service accept the Kennedy-Corman Bill as an inevitable stepping stone, others oppose it as a dangerous diversion...
...Throughout modern history improvements in life expectancy have been the result of improved living conditions—plus some public health measures...
...A health care constituency is needed...
...Other studies seeking patterns of behavior that best predict good health have come up, alas, with just those rules mother always harped on: don't smoke, get enough sleep, eat a good breakfast, keep your weight down, don't drink too much, get exercise, and don't eat between meals...
...Consumers pay only about one-third of health expenditures out-of-pocket, while private health insurance covers another 26 64 percent...
...Remarkable and expensive technologies62 like organ transplantation or the implantable, artificial heart now being researched—hold out promises that both physicians and patients are loath to set aside...
...There is much talk of "informed consent" and patient's bills of rights...
...In sum, the new perception of the relationship between medical care and actual health status raises important questions about the priority of medical care among other social reforms and suggests that medical practice should take new forms emphasizing prevention, education, and personal responsibility...
...What about mountain climbers, or professors who don't get enough exercise...
...Now social critics have begun to worry about the expansion of the medical model and its possible inclusion of all sorts of deviance...
...When you're sick, you're sick...
...They are indeed disenchanted with the AMA's combination of boosterism and defensiveness and profess a deep skepticism about the medical enterprise in general...
...others, like myself, remain agnostic, uncertain about its potential bureaucracy and uniformity...
...The plan would establish a complete publicly owned and controlled health sector that would employ salaried health-care workers, organize free services in public institutions under the direction of elected local and regional health boards, and would be funded by general revenues and a steeply progressive tax on income...
...there are more than 8 million recipients of Medicaid in the average month...
...without the new drugs, the institutionalized mentally ill now would number nearly a million instead of 250,000...
...MEDICINE HAS traditionally been authoritarian...
...and third, the researchers, who expect that just as earlier research produced inexpensive treatments for infectious diseases (polio vaccine instead of iron lungs is the favorite example), basic biomedical research will eventually produce breakthroughs in treating killers like cancer and heart disease, or psychological afflictions like schizophrenia...
...In the U.S., government and the medical profession cooperated —as they had never done during the 19th century to enforce licensing, close marginal medical schools, and sharply limit the number of practitioners...
...Physicians can obtain diagnostic information previously attainable only by surgery or, in some cases, through the uncomfortable process of injecting dyes into the system...
...The motivation, of course, was profit, the real profiteers being the landlords who now set up the facilities and recruit the physicians in return for a high percentage of the earnings paid back as "rent...
...3. Health Care as Instrument of Social Control...
...For if the services are worthless or in some way destructive, why worry about the poor—or, for that matter, anyone—not getting enough of them...
...A new nonphysician role would be developed for treatment of minor illnesses, administration of simple tests, provision of health information, periodic follow-ups, and routine preventive services...
...We are at the edge of our concern...
...Thus an effective health-care constituency is apt to be built (a) from organizations existing for other purposes...
...It is doubtful, however, that the poor, thrown back upon the services of hospitals, will be much better off...
...But the problem goes beyond physicians' avarice...
...Psychoactive drugs developed in the last two decades have allowed the release of hundreds of 67 thousands from mental hospitals...
...When medical schools increased enrollments in exchange for federal aid, the first result was to increase the number of specialists and decrease the number of primary-care physicians...
...The force of this "backlash" is based on several new perceptions about health care: (1) the difficulty of identifying and limiting genuine medical need...
...For we have created social "cushions" to soften the worst blows of the market mechanism...
...HMOs (group prepaid medical plans...
...The situation is peculiar indeed...
...There are crucial moments— childbirth, for instance—when motivation for learning about health might be high, and attractive incentives could be offered for participation in education programs...
...Physicians themselves now are organizing both on the right and the left of the AMA...
...According to Illich, morbidity rates (sickness and disabilities) have been no more affected by modern medicine than mortality...
...Even the most lavish use of medical care," Fuchs concludes, "probably would not bring the U.S...
...The lesson that should be drawn from the medical-care "backlash" is not, return-to-themarket, lower-your-expectations, or waitandsee...
...Quiescent for the moment, yet certain to show itself once any specific proposal comes up for debate, this backlash consists of many sophisticated observers, both on the right and the left...
...Local officials are now repeating pledges of stricter regulation, which is fine as far as it goes...
...but the reason that Republican as well as Democratic administrations have extended federal intervention in the medical sphere—even Nixon, mouthing the pieties of the American Medical Association, sponsored a health-insurance bill not all that different from one sponsored by the AMA's number one villain, Edward M. Kennedy—is simply cost...
...people must lower their expectations, and the elites must direct their energies toward debunking claims, e.g., for a "right to health care," which provoke an easily misled citizenry...
...One is simply that many people receive medical care who would otherwise be without it...
...Established because the market left millions of people without medical care, Medicaid supplied funds but did nothing to increase the number of health-care providers for the poor, and did next to nothing about regulating costs...
...In New York, the courts have prevented the City from finding out who these landlords are...
...As Bernard A. 0. Williams wrote in an article on "The Idea of Equality": "Leaving aside preventive medicine, the proper ground of distribution of medical care is ill health: this is a necessary truth...
...Yet this second impulse undercuts the first...
...The average expense of a stay in the hospital went from $127 in 1950 to almost $900 in 1973, and may be more than $1,000 by 1977...
...Why the difference...
...One argument for concentrated federal responsibility for the national health budget is that government, as purchaser, becomes a partner in the consumer constituency...
...Incentives for surgery of questionable value e.g., between 2 million to 3 million unnecessary operations are said to be performed yearly— exist in Blue Cross/Blue Shield and private insurance plans...
...One might, however, take a more social tack, emphasizing preventive medicine, educational efforts, and more attention to the health benefits of expenditures on housing, schooling, nutrition, and on reducing environmental and occupational hazards...
...And perhaps the society is producing natural antibodies to these new dangers in the form of patients' rights, an expanding legal notion of privacy, and a growing resistance to professional authority of all sorts...
...This conclusion, however dispiriting in the light of the socialist tradition, we can wisely accept from the medical-care "backlash...
...hoping that accumulated experience will make the services effective rather than destructive...
...Here philosophical assumptions, political outlooks, and socioeconomic analyses make a difference...
...We may discover how to cure lung cancer long before we learn how to convince people to stop smoking...
...Even in the best of medical systems, need is likely to run ahead of capacity and, unless delimited carefully by society, will not suffice as the distributive principle of medical care...
...The Medicaid scandals may even divert attention from the fact that the same pressures exist in nongovernment programs...
...Credit for carrying this perception to its most extreme form belongs to Ivan Illich, who writes, in Medical Nemesis, that health care is worse than useless, it has become a "sickmaking enterprise...
...Thus not even the average person's lack of enthusiasm for being drugged and doctored can be relied upon as a homeostatic limit for absorbing medical resources...
...Barron's reports "a fierce scramble among manufacturers" for orders with such companies as General Electric, North American Philips, Siemens, and Hitachi engaged in international competition...
...The best committees in the world won't help at that point—only a small group of professionals, family, and friends...
...The physician's drive to do as much as possible for individual patients, regardless of overall imbalances in the medical system, is a safeguard against a crude utilitarianism...
...Even hard-working advocates of the "right to health care" have voiced fears that such a right could become an oppressive obligation...
...Medical care and health services would more easily point to this truth if their form as commodities to be either marketed or delivered were dissolved into the human reality of actions and social relationships—if care was revealed as caring and services as serving...
...Though government protects and funds the quasi-monopoly of medicine, major decisions—what to build, buy, and research, whom to educate, where to practice, and how much to charge—remain in the hands of the medical profession and the elite that controls medical schools, major hospitals, insurers, the drug industry, and foundations...
...The market would either enforce consumer "realism" about medical needs or, by competition among physicians, break the profession's power to prescribe more tests and treatment than would otherwise be allowed by the patient...
...IRBs (cornmittees for reviewing the ethical propriety of research...
...Its features have been thoroughly advertised: it promises relief to families threatened by medical bankruptcy, extends coverage to those not now insured, widens benefits considerably, and does these things without the qualifications of deductibles and co-payments...
...If medical care nevertheless continued to be organized like other craft services, it may well have been because distribution didn't matter much...
...NHI is not on the national agenda because health care in this country is inaccessible to many, generally maldistributed, often dehumanizing, and sometimes perilous...
...At a time of fiscal austerity, when public services to the poor are frequently in jeopardy, it becomes extremely difficult to resist cutbacks if one simultaneously concedes that schools and hospitals, welfare programs and mental health centers, legal services and employment bureaus don't make much difference in the long run, or are positively damaging to the interests of the people they serve . . . . The possibility remains that this crisis could be -beneficial in the health sector, if those concerned about medical care learn to make careful distinctions...
...Thus we find that the HillBurton support for hospital construction led to a wasteful surplus of beds...
...Instead, Congress passed the 1946 Hill-Burton Act for hospital construction and vastly increased federal support for biomedical research...
...Steel or U.S...
...social and behavioral research should be given an equal footing with traditional biological research...
...Local governments and private charities operated hospitals for the poor...
...There are, writes Starr, various strategies for resolving the conflict—distinguishing between the short and long run...
...Rather than insist on a national health service, it may be politically wiser to concentrate on improvements in the Health Security Bill...
...People often listen respectfully to physicians and then do as they please...
...Even in less extreme versions, the questionable relationship between medical care and improved health has led to a crisis of the social services...
...After the war, another push for national health insurance was staved off by the AMA's cry of "socialized medicine...
...All of this may be true...
...Or, to put the matter negatively, we must resist proposals that lock us into the "medical-industrial complex," financing medical care at points where the system threatens breakdown but leaving cost, quality control, and the allocation of money and manpower to the very mechanisms that have given us accelerating costs and skewed priorities...
...Such a force is not easily mobilized or maintained...
...Federal legislation now is pressuring medical schools to produce primary-care physicians and place them in underserved regions...
...Still others are attentistes, of three sorts: first, the revolutionaries, who insist that improvements in health care must wait upon more radical transformations in society...
...they regularly "ping-pong" you to an array of sources that do not document the assertion footnoted...
...But these, he concludes, are weak reeds: Distributive justice is a morally compelling concern only when what there is to distribute, or redistribute, is genuinely important and valuable...
...Either of these two views is nicely compatible with an advocacy of the market in medical care...
...The measures of "health" employed in the literature questioning medicine's efficacy are often rough-andready, and usually mortality rates...
...2) the uncertain relationship between medical care and actual health...
...Outrageous examples of the profession's power to dictate "need" are found in the "ping-ponging" of Medicaid clients from one specialist to another...
...In middle age the difference is due to heart disease in turn linked to diet, exercise, smoking, and stress...
...It was not imagined that this posed any great complications...
...This impulse, however, can be self-serving: the physician's striving may reflect his or her own need to win the battle against disease and death more than the need of the patient...
...Ultimately, health means wholeness, and wholeness is the achievement of an entire way of living...
Vol. 24 • January 1977 • No. 1
