The Wasteland
Health care is one of the areas of American life most ready for reform. Health care affects every American; it touches directly on our ability to lead creative, comfortable lives, free of pain, sickness, or crippling disability. Every time a life is snuffed out prematurely or every time its productivity is limited for want of decent health care, we pay an unacceptable price for the failings of the health delivery system.
Our present system of health care delivery is failing, and it is failing to the point where we can no longer tolerate "Band-Aid" cures. Major surgery must be performed. Our goal must be consistently high quality care, available to all and of a preventive nature, all at reasonable cost and responsive to the needs of consumers. The present system falls short of these standards in many critical respects:
1. Both a shortage and a maldistribution of health care personnel and facilities exist today. There is a shortage of primary providers of health care, with a corresponding overabundance of specialists and superspecialists. Twenty-five years ago, sixty-four per cent of our physicians were general practitioners; now the number has dwindled to eighteen per cent. During this time, the total number of physicians has remained roughly the same. The shortages of primary care personnel and facilities are unfortunately most severe in ghetto and rural areas--the areas that need these services the most.
State laws and professional pressures have prevented us from making the most efficient use of the health care personnel we have. Medical planners have repeatedly indicated that the proper use of paramedical personnel can bring about better care at lower cost. There is no need to have a physician take a patient's blood pressure when a nurse or technician can do it as well. It is estimated that up to seventy per cent of the duties now performed by physicians could be done by trained nurse practitioners or physicians' assistants. There is no need for a dentist to clean or even fill teeth when a properly trained dental auxiliary could do it just as well and at a fraction of the cost. Yet, in dentistry, for instance, auxiliaries are legally prevented from performing such functions in most states, and the American Dental Association has been reluctant to advocate needed changes.
2. Costs for health services are rising steeply. We spend more than $80 billion a year for health care, an amount that makes it the third largest industry in the country, right after agriculture and construction. About 7.5 per cent of our Gross National Product now goes to the health care industry, compared to 4.6 per cent only twenty-five years ago. The Social Security Administration has projected that the health care portion of the GNP will rise to 7.8 per cent by 1980. The health care industry is big business, and growing.
The average American family spent $600 on health care in 1972. Of this, thirty-four per cent was for hospitalization, twenty-five per cent for physicians' fees, ten per cent for dental services, seventeen per cent for drugs, and fourteen per cent for miscellaneous expenses. For the poor, the near-poor, and even the lower middle class, the burden of health care costs is staggering. The poor spend fewer dollars on health care, but a higher percentage of their income, than the rich.
3. The health delivery system treats us primarily when we are sick, instead of trying to keep us healthy. The results are higher costs and lower health standards. Our present health delivery system, featuring episodic care provided by individual doctors working on a fee-for-service basis, clearly should not be considered sacrosanct. Instead, the success of Health Maintenance Organizations, such as the Kaiser-Permanente plan in California, shows that feasible alternatives do exist. HMOs have demonstrated that medicine can be practiced more effectively and more economically in a group setting, on a prepaid basis, where the focus is on preventive medicine.
With revenues fixed in advance, the HMO has incentives to keep patients healthy and out of the hospital, and experience shows that hospitalization rates for HMO patients are half of normal rates. HMOs have also demonstrated that they can provide comprehensive health care services, including hospitalization, specialists' services, in-home services, twenty-four-hour emergency care, and educational programs--all this at a cost not too different from what many people now pay for hospitalization and major medical coverage alone.
I am not certain that HMOs are the best manner in which to proceed in every care or that there are not even more, efficient ways to deliver health care. But it is clear that we must examine alternatives to our present system.
4. Mechanisms designed to guarantee the quality of health care have been sorely inadequate. Neither state licensing boards nor the professional societies have sufficed to rid the medical marketplace of the 15,000 incompetent or dishonest physicians conservatively estimated to be practicing across the country.
Once the state grants an initial license to practice, the license is, in effect, good for life. There is no requirement that continuing competence be shown, and state licensing boards are generally too underfunded and understaffed to identify and censure even the most flagrant violators.
The health professions now have the responsibility to monitor themselves and to protect the public from incompetent and dishonest practitioners. But "peer review," in which doctors evaluate the work of other doctors, has proven to be a whitewash at best and a conspiracy against the public interest at worst. The American Medical Association itself admitted as much recently. In an editorial in the AMA Journal, it criticized doctors for not policing themselves and demanded that medical societies and state officials start disciplining dishonest or incompetent physicians. When the AMA gets around to recognizing a problem, you can be sure it is serious indeed.
5. Not only do we have unqualified doctors plying the trade, we also have the delivery of a vast amount of needless, expensive, and sometimes dangerous health care. Adequate cost control features are as lacking as quality control mechanisms. Experts have estimated that two million unnecessary surgical operations are performed annually, prescription drugs are dangerously misused and expensively overused, and patients are often hospitalized when a less confining, less expensive form of health care would do as well.
6. Hospitals, where most of the health care dollar is spent, have squandered billions of dollars through inefficient management and status-seeking expansion. About 7,000 hospitals in the country employ sixty per cent of our health care manpower. There are thirty-two million hospital admissions annually, with another twenty million out-patient visits each year. Hospitals have more than $40 billion in assets. It now costs as much as $100,000 or more per bed to build a hospital, although I might note that some hospitals have managed even recently to cut that figure by more than half.
My dealings with the hospitals in Philadelphia have, unfortunately, convinced me that the hospitals' answer to most health care problems is simply, "More money." They have resisted strenuously all efforts to institute reforms and economies widely accepted by health planners throughout the country.
Hospitals have long been known to many as accomplished status seekers. While some people collect Picassos and oriental vases, hospitals collect the number of expensive services they can offer. The greater the number of beds--no matter if they often lie empty--the greater the quantity of expensive devices and material, the more status the hospital has. In Philadelphia, there are eighteen open-heart units in operation when only four do enough procedures to be economically feasible or medically sound. Smaller cities have two when they need only one or none at all, and the same is true for burn treatment units, cobalt therapy, and other extravagant services. All of these extravagances, all of these duplications, do nothing but raise costs for health care consumers.
7. Doctors themselves, by virtue of their background and training, have further contributed to the nation's health care problems. Doctors control directly and indirectly more than eighty per cent of the health care dollar; they, are the gatekeepers of our entire health delivery system. Yet they seem to have little understanding of the economics of health care. Often they are ignorant of the costs of services they order, particularly in a hospital. They have failed to put basic health planning principles into effect in their own practices.
Doctors have also failed to perceive and respond to the needs of the poor and of minority groups, partly because most medical students are wealthy and white. Forty-one per cent of today's medical students are from families whose income exceeds $15,000 per year; this income group represents only ten percent of the population. Less than three per cent of all physicians are black, less than ten per cent are women.
8. Last, but certainly not least, we have a health delivery system that provides a markedly different quality of medical care to different economic, demographic, and racial groups. The poor and the black, the ghetto and rural dwellers, the migrant and even the elderly receive less care and lower quality care than others. They face a shortage of primary care providers, and what primary care they do get is in public clinics instead of doctors' offices. The Government has, to its credit, tried to remedy these discrepancies in part, through Medicare and Medicaid. But the implementation of both Medicaid and Medicare shows that we have only a piecemeal solution. Each state is permitted to set its own eligibility standards for Medicaid. The result is that while twenty-five million are living in poverty, only fifteen million are covered by Medicaid. And while Medicare now covers more than twenty million people, it pays less than fifty per cent of all health care costs.
All of the health care problems cited above have contributed to a health care system which takes too much and gives back too little. And it is clear that the health insurance system, as it presently operates, is no solution. Increasing insurance coverage--merely pumping more dollars into a system with serious, structural shortcomings--will aggravate present problems, not solve them.
Health insurers have contributed to our problems by adopting a "hands-off" policy toward both health care causes and solutions. Health insurers have typically operated on a "money-shoveling" approach. They simply take policyholders' dollars and, after deducting for operating expenses and profit, shovel them onto health care providers. They view themselves only as middlemen, with no responsibility for seeing that the dollars are dispersed wisely or well. As the providers want more money, premiums go up. In most states, sympathetic insurance commissioners complete the cycle by rubber stamping rate increases.
Health insurers, like health care providers and licensing boards, have not been responsive to consumer needs and demands. Pennsylvania 'Blue Shield, for instance, has since its inception been controlled by physicians. It was only at my insistence--and with the carrot of a needed rate hike dangling before it--that Blue Shield began adding more consumers to its important committees. The same disregard of consumers had been shown by Blue Cross plans which, in the past, have consistently represented the interests of hospitals, not patients. My experience with Blue Cross and Blue Shield has shown me that we cannot have effective programs of cost and quality control until we have consumer control. Health services are too important to be left to their providers alone.
Health insurance has also contributed to the cost of health care by providing cost incentives in favor of hospitalization. Many policies provide coverage for a service only if it is performed on an in-patient basis, even though the same procedure could be performed less expensively on an out-patient basis. It has been estimated that at least fifteen to twenty per cent of all hospital admissions are unnecessary; many were undoubtedly promoted by health insurance policies that provided in-patient coverage only.
I have already touched on some of the reforms I think are needed. Here, by way of illustration rather than comprehensive cataloging, are some others:
1. All health care providers should increase the number of consumer representatives on their boards of directors. Consumer control, I am convinced, is the key to all other reforms. We must also explore new ways of obtaining and facilitating consumer participation and input.
2. Monitoring of incompetent and dishonest doctors must be stepped up. If the professional societies prove unable to clean their own houses, someone else must be given the task. My own conclusion is that self-policing will not work and that we must seek alternatives now.
3. State licensing boards must be reconstituted and standards toughened. An initial license must not continue to provide a lifetime consent to practice. Licensure must be combined with ongoing methods to determine a physician's present competence. And licensing boards also must have consumers added to the ranks. Special interest representation should be phased out altogether.
4. Both state laws and professional attitudes must be changed to permit and, indeed, encourage the maximum use of qualified paranledicals and other auxiliary personnel.
5. Hospitals must be made into efficient businesses, meeting the real needs of the community instead of their own status goals. Extravagance, duplication, and ineptness can no longer be tolerated. To make sure all planned hospital construction is needed, each state should pass comprehensive certificate-of-need laws with adequate staffing, budget, and authority.
6. Medical schools must try to increase opportunities for blacks, women, and other minorities.
7. Incentives, or disincentives, must be put into effect to increase the number of physicians, paramedicals, and other health care providers practicing in inner-city and rural areas.
8. Similar incentives, or disincentives, must be used to increase the number of primary care providers.
9. Doctors should prescribe drugs only when medically necessary, and they should prescribe expensive brand-names only if generic equivalents are not available. Doctors also should become aware of the costs of the drugs they are prescribing.
National health insurance represents a possible solution to many of the problems I have cited. I emphasize the word possible because a national health insurance bill that takes a simplistic approach to the problem--and by that I mean "more money"--will do more harm than good.
Without attempting to assess the specific merits and failings of the various health insurance bills that have been proposed, I have some general comments about what I think a good national health insurance bill should do: It should have features designed to bring about cost and quality controls. It should operate on a "money's worth," not "money shoveling" theory of insurance. It should provide both a basic hospital/medical/surgical plan and a major medical plan covering catastrophic illnesses. And it should provide benefits to all persons.
Apart from national health insurance, Congress and the states should provide additional funds to encourage the development of Health Maintenance Organizations and other innovations in health care delivery. At the same time, strict standards must be set for HMOs to make certain that the quality of care and financial management remain sound.
Congress should establish minimum standards to which each state's health delivery system must conform. For example, each state should be required to have a medical licensing board that meets specified standards and health insurance regulatory procedures that meet specified standards.
Good health and good health care are fitting goals for this country to set for its people, and the American people should expect no less. Good health care at reasonable cost should be considered a right of all people, not--as it is today--a privilege accorded the few. A massive effort in the 1960s took an American to the moon and back. A similar national effort, I believe, will soon develop a cure for cancer, find alternative sources of energy, and develop economically feasible systems of mass transit. Surely health care is no less important than these other projects, and no further from our grasp, if we have the will to mount the same type of dedicated national effort.
Herbert S. Denenberg, Pennsylvania's insurance commissioner since 1971, has pioneered in transforming that commission into a consumer-protection agency. Shortly after writing this article, he resigned to become a candidate, for the U.S. Senate. Mr. Denenberg less previously written two other articles on health for The Progressive: "Those Health Insurance Booby Traps," in the September 1972 issue and, in May 1973, "Dr. Strangelove Joins Alice-in-Wonderland in Quest of a National Health Plan."