Health Care Reform: A History In Books
Amy Hertz, The Huffington Post: Health care reform, on everybody's mind as Obama's original plan gets watered down and twisted unrecognizably as it makes its way through the Senate, has been on a path to crisis for more than 30 years. Turning to the archives of The New York Review of Books, we can watch its trajectory and, perhaps, learn from what's come before. From the 1970s when costs skyrocketed forcing people to take on the cost of health insurance to the Clinton era, when not only did Americans have to deal with higher premiums, but new limitations on choice and a healthcare system that had one set of rules for those of greater means, and another set for those of lesser, see for yourself and why what's happening now is so crucial. See why we may be losing yet another opportunity by not pushing for far-reaching reform. What will history say about what Obama and Congress are doing now?
From The New York Review of Books, Volume 15, Number 11, December 17, 1970
"The Medical-Industrial Complex", by Barbara Ehrenreich
"Men, Money and Medicine", by Eli Ginzberg, by Miriam Ostow (Columbia, 291pp.)
The American crisis over health has finally taken a place alongside the urban crisis, the ecological crisis, and the "youth crisis" as the subject for solemn Presidential announcements, TV documentaries, and special features of magazines ranging from Fortune to Redbook. But to the average consumer of pills, hospital care, and doctors' services, the crisis in health care is nothing new, except that the stakes--health, beauty, and life itself--get higher with each advance in medical technology, from miracle vaccines to organ transplants. The odds against the sick are high, and getting higher all the time.
Health care is, first of all, a scarce and expensive commodity. With the increasing centralization of medical manpower and modern equipment in a few big city medical centers, rural areas, small towns, and urban ghettos have been left empty of even the most rudimentary, old-fashioned services. Where services exist, their high cost is the most serious barrier to health care, not only for the very poor, but for growing numbers of working people as well. As the price of medical care mounts, health insurance has become a necessity; but insurance premiums are becoming more expensive too, while benefits dwindle as rapidly as the costs of medical treatment increase.
Money aside, the consumer's major problem is finding his way about an increasingly impersonal, fragmented, irrationally arranged set of health services. The patient, rich or poor, treks from specialist to subspecialist, from clinic to clinic, from doctor to laboratory, losing more money and time at each stop. No one is concerned with the general state of his health, as opposed to his immediate illness; fewer and fewer doctors are even concerned with the patient's whole body, sick or well. Long waiting times and brusque service are now almost as characteristic of private doctors' offices as they are of the hospital clinics used by the poor. And for the very poor, usually black and brown people, the price of care in a hospital's "charity" ward or clinic is often the humiliation of having his body used as "material" for research and the training of doctors. (Read the rest of the article.)
From The New York Review of Books, Volume 41, Number 1 & 2, January 13, 1994
"Will Clinton's Plan Be Fair?" by Ronald Dworkin
"Health Security Act", 103d Congress, 1st Session (US Government Printing Office, 1,342 pp.)
President Clinton's Health Security Act is the most important piece of domestic legislation since the Civil Rights Acts, and because it is an attempt to reform one seventh of America's economy, it could prove the most significant economic change since the New Deal. Though no congressional vote is expected for about a year, the act has already been comprehensively analyzed and debated by politicians, doctors' associations, health-care economists, insurance companies, small and large business groups, and journalists. Very little attention has been given to the most profound issue it raises. How do we decide whether the Health Security Act, or any other structure for medical care in the United States, is fair?
Everyone agrees that the United States now spends too much on health care. Medical services accounted for 14 percent of our gross domestic product in 1991--France and Germany spent 9 percent and Japan and Britain 8 percent--and economists predict that without reform medical expenses would grow to 18 percent by the year 2000. But how much should a nation like ours spend on its citizens' health? How do we know that other nations are not spending too little, rather than that we are spending too much?
Most people also agree that health care is unjustly distributed in America. Forty million Americans have grossly inadequate medical coverage, or none at all, and many who do have adequate insurance now will lose it, because they will lose their jobs or develop a disease or condition that makes them uninsurable. In all, without reform, a quarter of all Americans will be without health insurance for some period during the next five years. But how much health care should a decent society make available for everyone? We can't provide everyone with the medical care that the richest among us can buy for themselves. How do we decide what lesser level of care justice demands even the poorest should have?
Clinton's act is long and elaborate--1,342 pages and 240,000 words. I shall summarize its main features. It aims to achieve universal coverage by requiring every resident of the United States to participate in some form of health plan. To reduce overall costs it would require people not to negotiate directly with a plan as individuals, but to join a large purchasing cooperative (called a regional health-care "alliance") which would use its size and bargaining power to secure the lowest possible rates for health-care coverage. Each alliance would enter into contracts with a variety of plans and would offer its members a choice among them. Under the Health Security Act, state governments must create these alliances by 1998, and each state has considerable leeway in deciding how many to create and what territory within the state each will administer. (Read the rest of the article.)
From The New York Review of Books, Volume 41, Number 10, May 26, 1994
"For Their Own Good", by Alan Brinkley
"Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States", by Theda Skocpol (Harvard University Press/Belknap Press, 714 pp.)
"Recollections of the New Deal: When the People Mattered", by Thomas H. Eliot, edited and with an introduction by John Kenneth Galbraith (Northeastern University Press, 169 pp.)
If President Clinton's health care reform proposal becomes law in anything like the form he has proposed, it will be the first genuinely universal system of social insurance in American history, and a striking departure from all previous efforts to build and expand the welfare state. For until now, virtually all American social welfare policies have taken one of two quite different forms, separate and unequal.
One consists of programs designed for people who have, in theory, earned their benefits, either because of special service to society, as with military veterans, or because they (or their employers) have contributed to the funds from which they draw when they grow old or lose their jobs. The other form consists of programs designed for people whose major claim to benefits is their apparent need for them, people who seem in some special position of dependency that requires a social response. Those programs are what most Americans call "welfare": aid to families with dependent children, food stamps, and other forms of public assistance to the poor.
During much of the twentieth century at least, programs for those who have "earned" their benefits have been relatively generous and politically unassailable. Programs for those who simply "need" their benefits have been penurious and politically vulnerable. An unacknowledged result of this distinction is that the largest and most reliable benefits of the welfare state go primarily to men; the paltriest and least reliable go disproportionately to women.
How do we explain a welfare system in which those who most need assistance receive it grudgingly and inadequately while those who least need it receive it freely and relatively lavishly? No other major industrial nation is so stingy or so punitive in providing benefits to its citizens. Why has the United States, to use a term long popular among scholars in this field, been such a "laggard" nation? (Read the rest of the article.)
From The New York Review, Volume 44, Number 10, June 12, 1997
"The Medicine in Our Future", by Andrew Hacker
BOOKS REVIEWED IN THIS ESSAY
"Health Against Wealth: HMOs and the Breakdown of Medical Trust", by George Anders (Houghton Mifflin, 299 pp.)
"Beginnings Count: The Technological Imperative in American Health Care", by David J. Rothman
(Oxford University Press/Twentieth Century Fund, 189 pp.)
"Mortal Peril: Our Inalienable Right to Health Care?", by Richard A. Epstein (Addison-Wesley, 503 pp.)
"The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security", by Jacob S. Hacker (Princeton University Press, 239 pp.)
"Boomerang: Clinton's Health Security Effort and the Turn Against Government in U.S. Politics", by Theda Skocpol (Norton, 230 pp.)
"The Price of Life: The Future of American Health Care", by Robert H. Blank (Columbia University Press, 215 pp.)
"Market-Driven Health Care: Who Wins, Who Loses in the Transformation of America's Largest Service Industry", by Regina E. Herzlinger (Addison-Wesley, 379 pp.)
Ten years ago, 95 percent of the Americans who had health coverage at their place of work received close to full repayment for services provided by doctors and hospitals personally chosen by themselves. Today, half of them no longer have that freedom; they must use the doctors provided by the health maintenance organizations that their employers have selected. "Faster than almost anyone expected," George Anders says in Health Against Wealth, "managed care has become the de facto national health policy of the United States." And "managed" means that plans specify the scope of treatments:
--One prominent plan recently told its pediatricians to cut back routine examinations to 10 minutes.
--A national corporation reduced its employees' in-patient mental health coverage for such disorders as depression and schizophrenia, with the result that the length of a patient's average hospital stay fell from thirty-four days to ten days.
--Many plans use "formularies," limiting the drugs that may be prescribed, even if their own physicians feel that there are others that would be more effective.
--HMOs contract with hospitals willing to accept low payments, and then send patients there, even if they lack full facilities and doctors experienced in the requested procedures.
--In emergencies, almost all plans require using hospitals with which they have contracts, even if others are closer. Only three of Chicago's twenty-five HMOs let their members know that they might use 911 in urgent cases.
In Anders's analysis, managed care is based on a new pattern of mutual benefit within the corporate world. On the one hand, under traditional fee-for-service plans were thousands of companies upset that the costs of the health coverage for their employees were rising by as much as 20 percent a year, largely because medical providers were submitting lavish bills. Sentiment began to grow, Anders writes, that "doctors and hospitals, unsupervised, simply couldn't be trusted anymore." On the other hand, ready to furnish the needed discipline were insurance providers, some non-profit but most of them commercial enterprises. They made clear to their corporate clients that, in Anders's words, "managed care works only if administrators say no to some forms of care that patients or doctors request."
Much of Anders's book describes erroneous diagnoses by HMOs, as well as their failure to provide the kinds of advanced treatment available elsewhere. He describes how managers override the recommendations of HMO doctors. HMOs call such reports "anecdotes" taken from among millions of unremarkable cases and cite the high satisfaction rate reported by their patients. (Read the rest of the article.)