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Charting The Economic History of US Health Reform

By MIKE MAGEE, MD

Adam Gaffney’s recent Boston Review article, What the Health Care Debate Still Gets Wrong”, a landmark piece that deserves careful reading by all, reaches near perfection in diagnosing our health system malady.

Dr. Gaffney is president of Physicians for a National Health Program, and a co-chair of the Working Group on Single-Payer Program Design, which developed the Physicians’ Proposal for Single-Payer Health Care Reform.

A seasoned health policy expert, his article cross-references the opinions and work of a range of health commentators including Atul Gawande, Steven Brill, Sarah Kliff, Elizabeth Rosenthal, Zack Cooper, and Canadian health economist Robert Evans. But his major companion is Princeton health economist, Uwe Reinhardt, whose posthumous book, Priced Out: The Economic and Ethical Costs of American Health Care, was recently published by Princeton University Press.

Gaffney’s affection for Reinhardt is evident as he recounts his desperate upbringing in post-war Germany, challenged by poor living conditions, but made whole by access to health care.  Quoting a 1992 JAMA interview, Reinhardt states, “When we needed medical care, we got it at the local hospital, no questions asked. When you were sick, society was there for you.”

That acknowledgment is not only personal but historically significant, as I outline in my recent book, Code Blue: Inside the Medical Industrial Complex. The services Reinhardt received were part of a new national health care system funded fully by American taxpayers as part of the Marshall Plan. At the very same time, American citizens were denied a national health plan of their own as Truman was effectively branded a supporter of “socialized medicine” by the AMA and a cabal of corporate partners.

As Gaffney recounts, a young Reinhardt at age 19 relocated to Canada just in time to witness the birth of their National Health Care System. He travels next to New Haven to receive his PhD in Economics from Yale, and then settles into a long and distinguished career at Princeton.

In Priced Out, Gaffney finds an evolved Reinhardt, one who acknowledges that the problem is not simply opaque pricing (“It’s the prices stupid.“), and certainly not over-utilization of services as Atul Gawande popularly promoted, but rather the wasteful and rigged privatized system awash in ill-gained profits.

As Gaffney reports, “Reinhardt describes in Priced Out, hospitals and other providers have met insurers’ bloat through profound administrative distention of their own.” And “a cosmic law is that every dollar in expenditures is somebody’s income…(creating) fundamentally a political problem, not a technical one.”

For the solution, Gaffney turns to Canadian Robert Evans rather than Reinhardt, who “described in 1991 the special sauce of cost containment…universalism in conjunction with simple source funding.” In summary, Gaffney writes, “The way we pay for health care has produced a curious but deadly mix of deprivation and excess. There is no great mystery behind it. It’s the financing, stupid.”

As Code Blue’s tracking of the
medical history however reveals, this declaration is incomplete without two
important additions. The complexity Americans struggle with today was
intentional, and the MIC would have been unable to execute their opaque, profit
sharing conspiracy without the reinforcement of all sectors (including many
patient support groups) reinforced by an integrated career ladder for academic
medicine with overflowing and hidden conflicts of interest.

My own mentor, Columbia health economist Eli Ginzberg, cautioned in his 1990 book, The Medical Triangle, “The competitive market is an opponent, not an ally of cost containment.” Eight years earlier, Reinhardt’s Princeton colleague, sociologist Paul Starr, in The Social Transformation of American Medicine, commenting on similar risks with an air of hopefulness, wrote: “A trend is not necessarily fate.”

But my own research, tracking the
evolution of the collusive Medical-Industrial Complex over the three quarters
of a century following World War II and into the present, suggests that Starr’s
fears expressed in 1982 of  “private
plans controlled by conglomerates whose interests will be determined by the
rate of returns on investments” was well founded.

How and why American medicine arrived at
this point is now clear. Instead of embracing a thoughtful approach to
strategic health planning following WWII, our nation encouraged a free
enterprise and entrepreneurial attack on disease, even as our military built
out rational national health systems for Germany and Japan. Along the way,
major health sectors—including the medical profession, hospitals, insurers, and
pharmaceuticals—infiltrated government bodies, weakening regulatory controls as
they pursued self-interest and profitability ahead of the interests of American
patients, families, and communities.

Cross-sector leaders like myself helped
the various MIC sectors populate and socialize one another’s territories, at
times competing, and at other times colluding in the pursuit of career
advancement, deregulation, and federal funding. The new information age helped
spawn complex insurance and delivery systems focused on mining and monetizing
proprietary patient databases. These required expanding nonclinical workforces
and encouraged the opaque gaming of the system and diversion of profits. More
and more money flowed in to an ever-increasing number of derivative
organizations, many flirting at the edges of criminality, that figured out how
to gain entry into the increasingly complex pharmaceutical, insurance,
hospital, patient care, electronic medical record, medical education, and
scientific research supply chains.

As we entered the new millennium, players within the various MIC sectors discovered common political ground with the help of their overlapping lobbyists in Washington and statehouses across the land. But articles like Gaffney’s and books like Code Blue have increasingly exposed these opaque and collusive networks, making it clear that MIC complexity is intentional and conspiratorial, and must be opposed.

The majority of Americans now agree that
universal health coverage is a central underpinning of a civilized society,
essential to creating a stable government, an empathetic culture, and
productive healthy citizens. Implementing such a program requires careful and
thoughtful governmental planning and execution with integration of a wide range
of other social services. It must be budgeted with careful prioritization, but
it is certainly doable.

As Dr. Gaffney suggests, the required corrective action now is far more comprehensive and centers on the 800-pound gorilla we must subdue to truly free ourselves from the MIC syndicate’s stranglehold: our perverse, profit-driven, and incredibly wasteful health insurance system. Could the transformation we need be as simple as removing the age restrictions on Medicare and Medicaid, proposed by some on the left, thereby letting every citizen in on the benefits enjoyed by seniors and the needy during the past half century? Certainly that is one option worth discussing.

But to embrace true reform, we must follow
the money and follow the data, and build on progress already made. Clearly the
time has come for the US to join the rest of the industrialized world and
consolidate health insurance into a standardized single-payer/multi-plan system
that provides a secure package of basic benefits for all. The first step should
be establishing minimum standards and a centralized control system, which would
trigger a cascading series of changes leading to more detailed answers to the
question “How do we make America healthy?”

In the Declaration of Independence, our
nation’s founders proclaimed that equality was self-evident. Nearly 250 years
later, what has become equally self-evident is that there is no equality
without reasonable access to health care, and that universal insurance coverage
is the only system that truly can provide access that is reasonable. Rather
than resisting this approach once seen as “un-American,” our citizens are
beginning to see single-payer/multi-plan universal access to affordable and
effective care as the essential next step to ensuring what should be every
American’s birthright—life, liberty, and the pursuit of happiness.

Mike
Magee MD is a Medical Historian and Health Economist at the Presidents’ College
at the University of Hartford. He is the author of
Code
Blue: Inside the Medical Industrial Complex (Grove Atlantic/2019). (www.mikemagee.org)

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