Politics and Patients

...Politics and Patients Unequal Care: A Case Study of Interorganizational Relations in Health Care By Murray Milner Jr Columbia 204 pp $22 50 Reviewed by Bruce C. Vladeck Assistant commissioner, Health Planning and Resources Development, New Jersey Several years ago a band of neo-conservative economists and policy entrepreneurs began promoting the notion that keener competition, especially among insurers, would solve the major problems of the American health care system—in particular, its seemingly uncontrollable cost increases We suffer extraordinary inflation in the health sector, these theorists contended, because the excessive availability of comprehensive insurance renders consumers largely insensitive to prices at the point of service They thus have little incentive to resist the gouging of monopolistic physicians and hospitals Although notably weak both in evidence and historical understanding, this "pro-competitive' school acquired considerable respectability In a political climate ever more hostile to anything smacking of official meddlmg, it appeared to of f er the only alternative to government regulation of an msup-portably expensive health care enterprise The school might well have remained an intellectual curiosity, however, were it not for the fact that one of its strongest adherents was a young Michigan Congressman who has gone on to become director of the new Administration's Office of Management and Budget David A Stockman'spro-posed budget, in addition to eliminating support tor the extremely limited existing Federal health regulation programs, contemplates mo\ ing toward a more competitive' health care marketplace o\cr the next several \ cars Ultimately, Medicare and Medicaid would be replaced with fixed-dollar "vouchers"—health care stamps The success of Stockman's plans in this area is clearly not assured (certainly not in the instance of the virtually untouchable Medicare), and the whole pro-competitive approach deserves an extended critique Here, though, only one pomt needs to be emphasized Notwithstanding the very positive ef feet s of the programs Stockman wants to dismantle, in health services we are still two nations And that is the theme, as well as the most valuable contribution, of Murray Milner Jr 's Unequal Care Milner presents a sociological analysis of the interactions of four medical institutions in an unnamed urban area an economically and qualitatively weak voluntary hospital, a large public hospital, a prestigious and prosperous voluntary teaching hospital, and a community health center operated as a satellite by the more successful voluntary hospital In what he calls the "stratified inequality" of the relationships among the four, patients are the primary medium of exchange and the primary resource Johnson, the weaker voluntary hospital, is the base for a city-dispatched ambulance service that is the source of most of its patients—who, almost without exception, would prefer to go to Mercy, the better private institution Mercy would like an ambulance of its own in order to keep its trauma surgeons and residents fully occupied, but recognizes that theambulance is all that enables Johnson to stay in business, and Mercy is dependent on Johnson to serve the patients it doesn't want—the uninsured and the medicallv uninteresting Mercy's stake in keeping Johnson going extends to a willingness to make available, with minimum ditficultv, specialized services to Johnson s patients, so long as those patients go back The indigent are therefore able to have tar more effective care than thev could get at the poorer hospital alone Budget cuts would be likelv to exacerbate the inequalities between the two hospitals, perhaps to the point ot killing Johnson and forcing its patients into the street On this basic skeleton, and a surprisingly limited amount of empirical evidence, Milner elaborates complex theoretical arguments that may be of interest to academic sociologists but are burdensome, if not entirely irrelevant, for the more general reader The sociological literature of uiterorganizational relations that Milner cites at discomfiting length appears more concerned with terminology and abstract theorizing than anything a layman can sink his teeth into (Pondering this review, I was tempted to agree with one of Stockman's budget cuts He has sought to largely ehmrnateNational Science Foundation support for sociology, on the grounds that it produces little of direct social value) It is nevertheless important to remember that health care also involves a sociological dimension The recent preoccupation with financing has led to a tendency to ignore the fact that medical care is dispensed by complex organizations with intricate internal and external pressures, not all of them directly a matter of money Indeed, Milner's seeming ignorance of the economics of health care delivery becomes a strength in his analysis For the health care marketplace is dominated by institutional realities The medical market does not behave like other markets, and not merely because thereissomuchmsurancearound "Market solutions" that attempt to change health care without adequately comprehending this are likely to cause more problems than they solve Of the institutional factors, the most important is that this nation has historically had two separate but unequal health care systems, one for the poor and black and another for everyone else Medicare and Medicaid, by providing insurance-type benefits, have done much to break down the barriers between the two systems, but substantial inequalities remain Moreover, as budget-cutting becomes the order of the day these barriers are reasserting themselves with greater prominence For a reminder of this central truth, we should be thankful to Milner...