Health Care for All?
Book Review : A Second Opinion: Rescuing America’s Health Care, Arnold S. Relman, M.D., The Century Foundation, Public Affairs, N.Y. 2007. Critical: What We Can Do About the Health Care Crisis Tom Daschle, St. Martin’s Press, 2008. Code Red: An Economist Explains How to Revive the Healthcare System Without Destroying It, David Dranove, Princeton Univ. Press, 2008
These three books, none of them very long, give us three quite different perspectives on the health care system. Arnold Relman is a former editor-in-chief of the New England Journal of Medicine and an emeritus professor at Harvard Medical School. During his career he witnessed the gradual commercialization of American medicine. A system based on nonprofit institutions turned into one based on investor owned profit making hospitals, nursing homes, dialysis centers, health insurance companies, and after the HMO Act of 1973, Health Maintenance Organizations. And a system composed largely of primary care physicians motivated by professional values turned into one made up largely of specialists and based on business practices. (Today some medical schools are even offering prospective doctors joint M.D./M.B.A. degrees).
Dr. Relman believes this transformation is the chief cause, but not the only cause, of the high and rising costs of medicine in the U.S. and also of our poor showing in comparison with the overall health status of the population in other industrialized countries (we are 36th in line). His book is an extended argument for de-commercializing health care and doing that by instituting a single-payer universal health insurance system.
Senator Tom Daschle had hoped to be the new Secretary of Health, Education and Welfare. After years of experience in Congress working for health care reforms, his book presents what he considers a realistic estimate of what can be expected from Congress in the Obama administration. And what we can realistically expect on his view are some reforms that build on the existing system. Reforms that make it possible for more people to have health insurance, that make it hard for insurance companies to deny insurance to persons with pre-existing medical problems, and hopefully, establishing a voluntary public health insurance plan that will compete with the private sector plans. Daschle also wants to create an impartial public/private entity similar to the Federal Reserve Board to regulate the health insurance companies. I don’t believe students of the Federal Reserve would agree that the Fed does an impartial regulatory job (William Greider, for example, certainly does not in Secrets of theTemple: How the Federal Reserve Runs the Country, Simon and Schuster, 1987). Dashle, however, is convinced that Congress is not capable of doing the job itself
David Dranove is a Professor of Health Industry Management at Northwestern University. His book is a short course in the history and problems of health care policy in the United States, largely since the war. And that history illustrates the main problem for a commercialized system: what carrots and sticks can government best apply to drive the system in the direction of what best serves the public interest? The difficulties here are virtually endless. For example, if investor owned hospitals are paid by Medicare or Medicaid on a per diem basis, they will be tempted to keep patients days longer than really necessary. If they are paid on a set fee for a specific operation, they will be tempted to release the patient as soon as possible, even if - as we learned not long ago - that means simply dumping the person on the street. And how many of the 117 million CAT and MRI scans performed in 2007 were actually necessary? Did the equivalent of a third of the population of the U.S. really need scanning in one year, at a cost of $300 to $3000 a scan? It’s not that doctors deliberately order unnecessary scans, but if one is in doubt and the hospital needs to pay for it’s machine and one is worried about a possible malpractice suit, better to be safe than sorry. So what sort of policies could be established to deal with this problem? My impression from Prof. Dranove’s book is that reasonable policies can be devised by trial and error, but as long as the system is based on profit making, it will be a very rickety structure as far as the public interest is concerned.
None of these books addresses what I believe is a further source of the rising cost of health care in the U.S., and that is the increasing incidence of diseases that we have found to be produced by our high level of chemical, radiological and electromagnetic pollution. Instead of our industries shouldering the costs of dealing with these pollutants, the costs continue to be shifted onto the public in the form of disease, the diseases of industrial civilization.
- Editor.