American Medicine and the Public Interest.
by Rosemary Stevens.
Yale University Press. 572 pp. $18.50.
Among the popular subjects of the past several publishing seasons, up there with the Vietnam crisis, the black crisis, the youth crisis, and the crisis of sexual technology, has been the American health-care crisis. I have read my share of; books and articles in the category and have come away informed, concerned, puzzled, and annoyed at doctors, politicians, bureaucrats, and the writers of the books and articles. The last-named tended to be more or less on my side—that is, on the side of the medical consumer rather than of the supplier—yet they were a punishment to read. Written for the most part in a fit of bad temper, real or worked up for the occasion, they managed to be provoking without being provocative. Though clogged with statistics and sizzling with case histories, they assumed too much and explained too little; their favored perspective was high dudgeon; and they shared an unseemly satisfaction in predicting catastrophe if something-or-other or everything were not done at once. The prescriptions, however, brought to mind those wide-spectrum antibiotics (which several of the writers condemned) which may relieve one’s current ailments but can induce troublesome side effects.
This is by way of welcome for American Medicine and the Public Interest. Rosemary Stevens, an associate professor of public health at Yale, sets out with the observation that our medical system is, yes, in “a state of crisis”—so far no different from what all the others have been telling us; but she has the courtesy to move on to elucidate the nature of the crisis. It should not, she notes, be interpreted “as one of imminent collapse of health services—the United States is well-stocked with personnel and facilities and can afford to spend even more on providing them.” We are, rather, “at a critical stage of health-care development. Perhaps a more appropriate word is maelstrom.” Perhaps not. In any case, since she doesn’t suffer from the journalist’s compulsion to show that she is more outraged than everybody else, she was able to go about her job in so reasoned a way that I ended up not only prepared to accept her diagnosis, swallow her medicine, and forgive her sentence structure, but to nominate her for the post of Secretary of Health, Education, and Welfare.
Professor Stevens’s book appears at a propitious time. The Congress is even now moving, without undue haste, to the passage of some sort of national health-insurance measure. Among the great issues to be resolved are: how credit will be apportioned between President Nixon and Chairman Wilbur Mills of the House Ways and Means Committee; whether Senator Edward Kennedy will improve his standing in the polls; and which plan will do the most for the profits of doctors, drug makers, insurance companies, and proprietors of hospitals and nursing homes. After these matters have been ironed out there will remain the question of how to provide for people’s health needs in an efficient way, to make full use of now uncoordinated medical specialties. To replace the present “disorganized system of private practitioners for the comparatively affluent, a disorganized clink system for the poor, and a mixture for those who fall between,” Professor Stevens envisions something resembling clusters of interrelated neighborhood clinics, offering all manner of specialties, from dental care to mental care—but she cautions that “national health insurance, like Medicare and Medicaid, could serve to increase further both the demand for services, and their costs, in an inflationary spiral, rather than necessarily affect the operation of the health-care system.”
The nation’s medical problems do not arise out of any failure of research or skills. Most of us have good personal reasons to count as blessings the techniques, instruments, and drugs brought into play since World War II. Unfortunately, the blessings are inequitably distributed and their cost is proving exceedingly burdensome. These failings are plain to see.
In addition to all the other ills that slum families are heir to, they must get along with something less than first-rate health care. Physicians, like the rest of us, prefer not to live or work in Bedford-Stuyvesant, and their professional organization has shown itself willing to forgo its licensed prerogatives when it comes to poor people, much as the taxi-driver profession has done. To the slum dweller, the endless argument over the fate of the beloved family doctor must seem remote, since his family doctor is likely to be whoever is on duty in the emergency room of some hospital, an environment not known for developing trust or lifting a patient’s spirits. The care he obtains in time of illness or injury may not be bad—most emergency rooms are better equipped than an ordinary doctor’s office—but something more, something different, is needed to keep him well between times, to reduce infant mortality in his neighborhood, to combat tuberculosis and other diseases which can now be cured but which continue to trouble our inner cities. To be sure, the health of poor people is not exclusively a medical matter; given the best will, physicians cannot cure poverty and all that goes with it. But the suffering of today must be eased as we await the millennium, and the medical profession has not shown itself eager to take on even that job.
There are other places besides slums where physicians do not care to reside—and so we find that rural areas, too, must do without doctors. Yet if by some magic more physicians were induced to leave urban discontent behind and settle in unspoiled Mississippi, they could not alone offer high-quality care. For they would need specialists and staff and facilities which no community of a few thousand people can afford. Even if the medical profession had the will to address itself to this problem, it would be beyond its capabilities.
The middle-class suburbanite does not lack for doctors, or for specialists of all varieties, or for extensive facilities within a short drive—though some fancy hospitals with fancy prices are badly-run and badly-staffed. But he, too, is a victim of skewed distribution. Although the nation is lacking in certain medical specialties, it abounds in others. For example, we seem to have more surgeons than we need. Doubtless there are many reasons for the popularity of surgery in medical schools (in a survey some years ago, one senior explained, probably with a rolling of the eyes, “I like to cut”), but money has a great deal to do with it. Well, then, surely the law of supply and demand decrees that too many surgeons will mean more competition and reduced prices. But no, what the surplus has in fact meant in the controlled world of medical economics is more operations, and, it is suspected, more unnecessary operations. “Not only are there twice as many surgeons,” reports Professor Stevens, “but twice as much surgery is done in an average American city as in an English city, with no immediately apparent benefits.” This indignity, at least, the lower classes were once spared, since no one except an apprentice in need of a live body wants to operate on folks who are going to have trouble paying the bill. Though I have no figures at hand, I would guess that the advent of Medicare and Medicaid has been accompanied by a rise in the number of operations performed on the indigent—to some purpose, let us hope.
The eagerness with which people seek to have parts of themselves removed cannot be explained entirely by the availability of men to do the removing. It is, I suppose, part of the prevailing obsession with medical wonders, fed by popularizers within and without the industry. When it comes to drugs, the obsession turns into a mania, among doctors as well as among laymen. Our doctors are, by and large, no more sophisticated on the subject than our corner druggists and have proven highly susceptible to the ravishments of high-powered detail-men for the drug companies.
But I am going afield. What has been bothering middle-class citizens is not the quality or the nature of the medical attention available to them, which is better than they or any other comparable group has ever enjoyed, but the cost. The free market (which is not free at all, since the licensing requirements designed to maintain standards also restrict entry into the field, to the economic benefit of license-holders) has proven itself unable to provide good health care at a reasonable price. In response to the complaints of Middle America, a variety of insurance schemes have grown up as buffers against the costs of serious or prolonged illness. There cannot be many readers who have not had grateful recourse to some hospitalization policy or major medical policy. However—and this is the basic message of Professor Stevens’s work—the insurance schemes are in sum unsatisfactory. To resort to a favored doctors’ analogy, they treat symptoms, not causes. They are counter-productive.
The role of the health industry, an unhealthy alliance led by the American Medical Association, in fighting back innovations in health delivery systems since World War I has been amply celebrated; it is a triumph of American medicine. Professor Stevens sums up the AMA’s response, around 1920, to all plans which challenged the status of the independent practitioner: “Opposing the development of contract prepayment practice by corporations, urging physicians to avoid contact with hospitals which adopted any system of collecting medical fees, struggling against group hospital insurance schemes, and resisting any signs of government encroachment in medical care, the AMA sought to sustain a pattern of practice that looked not to the future but to the past.” The AMA no longer opposes all it once opposed, but the final observation holds. The strategy of the AMA, which has long since outgrown the reformist impulses of its youth, has been to resist, resist, resist—until the proposal is crushed (the fate of President Truman’s ambitious health program of the 1940’s) or altered to the benefit of medicine’s businessmen (the fate of the Kennedy-Johnson health programs of the 1960’s).
The nation’s interest in what AMA publicists and their friends in Congress have been pleased to call “socialized medicine” has ebbed and flowed with its interest in other social innovations. Plans for the reorganization of medical care were put forward in the early days of the New Deal, when health became “political” and group medicine became identified with leftist planners. Their plot was to make medical specialties, which had already come into their own, less expensive and more accessible. The leftists lost this one, and the outcome was the development of private insurance plans like Blue Cross and Blue Shield, which alleviated people’s anxieties over meeting big bills while they shored up existing inefficient arrangements. The AMA, habituated to rejecting new proposals of any sort, was slow to appreciate what a boon these superficial remedies would prove to its members. The insurance plans have afforded a considerable measure of protection, particularly to employees of corporations, but they have also had the effect of raising the cost of medical services; enriching physicians and others in the health business at the expense of the patient’s pocketbook and the public purse; and distracting the nation from working out alternative systems of medical care at a time when our technological capabilities have opened up promising alternatives.
Soon after World War II, the country again seemed ready for a health plan. President Truman’s proposals looked not only toward compulsory health insurance, but toward the expansion of medical education; the establishment of community health centers, diagnostic clinics, and specialist group practices; and an improvement in disease prevention and control programs. The money and the bile that the AMA expended in the 1940s to defeat the Wagner-Murray-Dingell bills constitutes one of the more flagrant chapters in the history of American lobbying.
To move ahead some twenty years, the fate of Medicare at the hands of AMA and insurance-industry lobbyists is a prime example of a noble impulse being perverted into a bureaucratic horror. The mild Professor Stevens writes: “Seduced by the elusive image of small-scale, fee-for-service, private practice, the American medical profession of 1965 was running in its political thinking at least three decades behind the social implications of specialized medicine.” The public, though troubled, does not seem to understand how poor a bargain our representatives got for us. Medicare and Medicaid have contributed to the inflation of health costs, have invited exploitation by physicians, and have short-circuited an opportunity to provide comprehensive care for the elderly and the poor. The lessons of the 1960’s ought to be studied at least twice a day by the legislators now mulling over proposals for national health insurance.
AMA campaigns, during a half-century of extraordinary medical change, against group medicine, against prepayment plans, and even against the expansion of medical education, have been so self-serving and so dishonest that they have obscured reasonable criticism. All one remembers is phony image-making, pompous self-regard, and unremitting greed. The AMA has won every battle of this long war, but at considerable cost to its reputation. It is losing members, particularly young ones, and few chairmen of Congressional committees are any longer likely to defer to its spokesmen on professional grounds. Tributes to “Your Family Doctor” and expositions of the glories of fee-for-service medicine are not likely to bowl anybody over this time around. Still, the small-town physician, for whom the AMA speaks, continues to pack considerable punch with politicians. Doctors are notoriously rich and influential constituents. With conservatives in office and radicals doing their best to antagonize the populace, 1972 will probably not go down as the year of Socialized Medicine.
Although Professor Stevens believes that increasing demand, rising costs, and lack of coordination will force the federal government to play “a more directive” role in health care, she offers no blueprint for a health utopia. In this pluralist country, she sensibly observes, any one ideal system is undesirable as well as unattainable. Instead, she sketches a number of possible arrangements which would utilize combinations of multispecialist medical firms, hospital-based group practices, and regional health networks—the object being to make more medical services available to more people at less cost.
The AMA’s performance over the years should make it easier for us to ignore its objections and look calmly into the ways national health plans have been working elsewhere and the way group plans have been working in this country, as we go about drawing up a publicly-financed health-care system. The failure to provide sound preventive care to large numbers of people should inspire unconventional means of bringing the capabilities of our university medical centers into poor neighborhoods and out to rural areas. The experience of Medicare and Medicaid should stand as a lesson that merely pouring funds into an industry without setting standards for its performance, and most particularly for its prices, is a way of subsidizing a rich minority at the expense of a middle-class majority, a bad old American custom. It should also alert us to prepare beforehand for the increased demand on medical facilities which will follow the passage of any extended health-payment program. The fact that the federal government is already in large part supporting America’s medical schools should suggest that their graduates owe rather more to society than they have up to now been prepared to acknowledge; and the fact that the government pays for medical research should suggest that the benefits of this research belong to the nation, not to middlemen. The high and increasing price of medical care should certainly suggest that there are better ways of paying for health than by buying off an already privileged profession and a few big industries.
Such are some of the shoulds prompted by a reading of American Medicine and the Public Interest. The book also raises questions which Professor Stevens has the modesty not to attempt to answer even in her 572 pages. Is health care to be regarded as a social service, and the physician as a public servant? How far do we want to go in regulating the medical profession, or any profession? And who exactly is to do the regulating? What part is there for the family doctor, whose function has been in question since the turn of the century, in a modern system of health care? Is he a costly anachronism who can be replaced by a nurse with some additional training and diagnostic equipment? If so, then how are we to go about revising state licensing requirements which are now in the grip of medical societies? Can we permit the drug industry to continue to exercise its enormous influence over health for purposes of profit? Are we wasting costly resources on headline-grabbers like heart transplants at the expense of fundamentals like training more nurses? Are the exhortations to keep checking oneself for signs and symptoms and then rush off to one’s doctor at the slightest hint of anything, a way of diverting resources from those who need them desperately to those who may not need them at all, and who might in fact be mentally healthier if they didn’t worry so much about their health?
The Congressmen now studying national health-insurance proposals need not address themselves to such questions. It will be enough if they ask themselves, as Professor Stevens has, wherein yesterday’s insurance plans have failed, and go on from there.