Book Review
Stuck in the Muck
By Charles Meyer, M.D.
An economist and a physician share their ideas for how to get the United States
out of its health care quagmire. Will anyone go for them?
Rashi Fein’s and Julius Richmond’s book The Health Care Mess: How We Got Into It and How We Will Get Out contains no cartoons, but its title and content conjure up a doozy. The scene is the La Brea tar pits, and wading and wallowing in the goo are figures representing hospitals, doctors, and patients. Everybody is trying to move ahead, but nobody is getting anyplace, and nobody seems to be helping anybody else. Standing around the perimeter of the pits are insurance-company executives, politicians, and health care analysts exhorting the wallowers with instructions and suggestions on how to extricate themselves. The image of dysfunction and futility, the title of the cartoon would be “The United States health care system.”
That health care in the United States hardly functions as a “system” and hasn’t really ever is clear from Fein and Richmond’s book. They chart the developments in U.S. health care delivery from early in the 20th century to the present, frequently bringing in the personal experiences of Fein, an economist/adviser to presidents dating back to John F. Kennedy, and Richmond, a physician who developed the Head Start program under Lyndon Johnson and then served as Surgeon General under Jimmy Carter. While acknowledging the spectacular advances in medical science and the sterling training of medical practitioners, Fein and Richmond document the evolution of employer-based health insurance from an accident of World War II, when wage-controlled companies had to attract employees with lucrative benefits, to today, when the ballooning cost of those benefits is sabotaging company spreadsheets and dominating bargaining-table negotiations. A Kaiser Foundation survey estimated that the average employer-paid health insurance premium for a family of four is $10,000. And yet the parade of proposals for health care reform during the past 20 years has usually perpetuated the employer-based model.
Fein and Richmond see the past and current U.S. systems for paying for medical care as aberrations of any economic model. “In the traditional economic model there is a tension between the buyer and the seller, but the buyer is also the consumer. In medicine the tension between the purchaser and the seller still existed, but the purchaser—the employer—was not the consumer. That role belonged to the patient who, seemingly, was left out of the equation. There was little reason to believe that the purchaser truly represented the patient’s needs and desires. … Furthermore, the seller was no longer the producer. The seller was the insurance company—insurance, after all, is what the employer was buying. The producer, however, was the physician, the allied health personnel, and the hospital and its infrastructure. The insurer did not represent those interests either.” In such a system, standard supply-and-demand forces fail and textbook solutions flop.
The mess that is health care in this country, according to Fein and Richmond, won’t get straightened out with incremental solutions that continue the dysfunctional connection between employment, insurance, and care delivery: “We believe the financing and organization of the American health care delivery system are badly flawed. The link between insurance coverage and employment has impeded the achievement of equity in coverage and access, and has had deleterious effects on labor negotiations, labor peace, and economic competition. The fact that insurance companies also deliver health care (the typical for-profit HMO arrangement) has introduced a third party whose concern is maximizing profit into the medical encounter, and has led to a weakening of the role of clinical judgment and freedom.”
Their answer is a single-payer system, and they propose a number of different routes to achieving it. One is to gradually add participants, based on age, to the existing Medicare program, either by decreasing the age of entry or by adding children first. Another is to plug groups of people, perhaps starting with the uninsured, into the Federal Employee Health Benefits program, which already serves federal employees, their families, and retirees. Fein and Richmond would fund their system through tax revenues and divorce health insurance from employment.
Fein and Richmond’s proposals seem DOA. Medicarizing all Americans would garner the votes of few physicians and even fewer hospital administrators. A mere whisper about new taxes still is anathema in today’s political climate. And sidelining the powerful U.S. insurance industry to a virtual actuarial role promises a lobbying cannonade of tumultuous proportions.
No mess as intricate as American health care, with powerful players holding entrenched, opposing interests, will yield to simple unraveling. I fear all players, big and small, are destined to be stuck in the muck for years to come. MM
Charles Meyer is editor in chief of Minnesota Medicine.