Correspondence
The Chances for Health Care Reform
N Engl J Med 1999; 341:1235-1237October 14, 1999
- Article
To the Editor:
Blumenthal asserts in his Sounding Board article on health care reform (June 17 issue)1 that the reason for the gap between evidence of poor care and the lack of political will to address it is that most Americans are satisfied with the status quo. But aggregated personal experience fails to motivate substantial political change, not because people are happy with the health care they receive, but for a deeper and simpler reason: most people are healthy most of the time. The explanation for the gap lies not in satisfaction with care, but in the difference between care and coverage. We are happiest with our health coverage when we do not need it and when it does not appear to cost us much. The great majority of us, who are free of chronic disease and whose premiums are paid largely by employers, are satisfied with our coverage precisely because we have little tangible experience with receiving care. At any moment, the number of voters who care deeply about the health services they personally receive is quite small.
Who does care? The sick do. Medical care, as distinct from the public health system, is intended to serve sick people. But the issues of concern to older, poorer, and sicker persons are likely to be washed out at the polls by younger, wealthier, and healthier persons who appear, unsurprisingly, more satisfied with their care. Blumenthal suggests that only a catastrophe resulting in widespread, direct experience with deteriorating care could create sufficient support for publicly financed universal coverage. Awaiting this sort of calamity may be unrealistic and is also misguided. What is needed instead is a pandemic of concern; the public must be convinced that the quality of medical care should be measured by how well it serves the sick. This effort must include conveying a realistic awareness that those of us who are well today will inevitably face illness, disability, and death. But it also requires promoting a sense of responsibility on the part of the healthy majority for the needs of the ill minority. What is politically possible today seems determined entirely by the perceived will of the voting majority.
Bowing to nihilism about striving toward higher goals, Blumenthal recommends incremental change through “moderate extensions of coverage” to politically popular subgroups of the uninsured. But poll-driven policy cannot change public perceptions of who has what at stake or shared beliefs about what it is right to do. When progressive health policy experts assert that all we can expect are marginal, short-term adjustments, their predictions run the risk of becoming prophecy.
1 ReferencesJeffrey Burack, M.D., M.P.P.
University of California, Berkeley, Berkeley, CA 94720-11901
Blumenthal D . Health care reform at the close of the 20th century. N Engl J Med 1999;340:1916-1920
Full Text | Web of Science | Medline
To the Editor:
It is astonishing that anyone can discuss health care reform without mentioning the disproportionate political power of the insurance industry. This great power arises from the immense financial resources of the industry, its eagerness to purchase influence, and the public's inability to secure widely popular measures to limit money in politics.
There are two general effects of this power. First, the insurance industry uses direct advertising to affect public opinion. The “Harry and Louise” campaign, which helped defeat health care reform efforts in 1994, is the best-known example. Not surprisingly, advertisements recently appeared to counteract the American Medical Association's endorsement of a physicians' union. Insurance companies are well within their rights to advertise, but the effect is substantial and must be dealt with openly by anyone contemplating reform.
The second effect is far more corrosive. Our system for financing electoral campaigns puts elective offices up for sale. In 1998, the winner of a seat in the House of Representatives spent an average of $664,000. The winner of a Senate seat spent $5.1 million, which averages to roughly $16,500 for each week of a six-year term.1 The past several presidents have devoted a substantial part of their time to a second job — fund-raising — and the presidential campaign of 2000 already has broken campaign cash records.2 In the 1994 election cycle, U.S. Healthcare, Blue Cross–Blue Shield, and CIGNA HealthCare alone gave nearly $1.2 million in campaign contributions to federal candidates and political parties. The results ensured that health care reform would not be considered for several years, allowing the industry valuable time to consolidate its hold on health care delivery. In 1997 and 1998, these three companies increased their giving to more than $1.8 million (unpublished data).
Influence purchased by the insurance industry through political contributions jeopardizes policy initiatives in all areas of health care reform, such as the “Patients Bill of Rights,”3 amendments to antitrust laws that permit private practitioners to join unions, thereby strengthening the bargaining power of physicians against the insurance oligopoly, and relief for financially foundering academic medical centers. Money talks, while none of these issues is considered on its own merits.
Physicians and their organizations need to give top priority to clean government and clean elections, both nationally and locally. The American Heart Association, the American Lung Association, and other health-related organizations have been extremely effective in Pennsylvania, where our coalition recently secured passage of a comprehensive disclosure law for lobbyists4 and shortly will push for state-wide campaign-finance reform.
4 ReferencesBarry L. Kauffman
Kevin Jon Williams, M.D.
Common Cause/Pennsylvania, Harrisburg, PA 171011
Common Cause. Incumbents dominate 1998 Congressional election fundraising activity, according to Common Cause. Press release of Common Cause, Harrisburg, Pa., April 8, 1999.
2
Berke RL. Bush announces a record haul, and foes make money an issue. New York Times. July 1, 1999:A1, A17.
3
Herbert B. Restless radicals. New York Times. July 1, 1999:A19.
4
Pennsylvania Act 93 of 1998.
To the Editor:
Dr. Blumenthal documents the need for extensive reform of the American health care system, yet he feels that Americans lack the political will to support a single-payer system that would provide the universal access to health care that citizens of all other industrial nations enjoy. He believes that progressives should settle instead for “incremental” reform. Unfortunately, incrementalism has yielded disappointing results. The federal Health Insurance Portability and Accountability Act, which was supposed to protect 25 million citizens, has benefited only a few hundred thousand.1 The State Children's Health Insurance Program will probably assist less than 20 percent of the 10.6 million children it was designed to protect.2
Why can't we as physicians use our diminished but still considerable prestige to provide Americans with enlightenment and leadership as advocates for a single-payer system? The organization Physicians for a National Health Program has thousands of physicians who are dedicated to this cause. There is evidence that a considerably larger proportion of physicians would be willing to support their efforts. A survey of students, residents, faculty members, and deans of U.S. medical schools revealed that 51.7 percent supported a single-payer system, as compared with 21.7 percent who supported managed care and 18.7 percent who favored a fee-for-service system.3 Perhaps if physicians assumed a leadership role in advocating universal access to health care, then our widespread discontent and dissatisfaction would be replaced by renewed pride and dignity in our profession.
3 ReferencesEvan B. Weisman, M.D.
833 Campbell Hill St., Marietta, GA 300601
Light DW . Good managed care needs universal health insurance. Ann Intern Med 1999;130:686-689
Web of Science | Medline2
Kuttner R . The American health care system -- health insurance coverage. N Engl J Med 1999;340:163-168
Full Text | Web of Science | Medline3
Simon SR ,Pan RJD ,Sullivan AM , et al. Views of managed care -- a survey of students, residents, faculty, and deans at medical schools in the United States. N Engl J Med 1999;340:928-936
Full Text | Web of Science | Medline
To the Editor:
I agree with Dr. Blumenthal when he says that “the large and growing number of uninsured Americans, the high overall costs of our health care system, and pervasive evidence of the suboptimal quality of care” are “health policy demons” that have been with us for more than 30 years. He is also correct when he states that governmental regulation of managed-care organizations does not address the fundamental problems. His solution, however, is the acceptance of the failure of our “ongoing experiment with private health care markets” so that we can bring back the goals of universal access and “agree to entrust [the government] with new authority over the financing and organization of a vital, personal service.”
There is a major flaw in Blumenthal's reasoning: we do not have a private health care market. The principles of the founding fathers, which produced the unprecedented explosion of progress in all fields, including health care, have been gradually replaced by the principles of socialism. Examples of this include the institution of employer-based insurance coverage in the 1940s in response to the freeze in wages during World War II, which destroyed portability and produced “uninsured Americans”; the institution of Medicare in 1965, which was responsible for “the galloping escalation of health care costs that occurred from 1965 to 1993”; and the HMO Act of 1973, which exponentially expanded managed care in the hope of smuggling in rationing under the veneer of private enterprise, thereby instituting suboptimal care. The “innate skepticism of government” typical of the American public has saved us so far from a total collapse into socialism.
The solution to the health care crisis cannot consist of “wholesale government intervention,” which would certainly allow voters to experience “real deterioration in their personal health care, day in and day out” as is typical of countries with socialized medicine. The solution is for government to get out of medicine. Steps in the right direction could be lifting taxation for self-insured persons, privatization, and the phasing out of Medicare.
Cristina Rizza, M.D.
213 Jasmine Ave., Corona del Mar, CA 92625Author/Editor Response
Dr. Blumenthal replies:
To the Editor: Burack asserts that most Americans are healthy, which explains their lack of dissatisfaction with our health care system. I agree that this is a contributing factor. However, the good health of most voters does not change the fundamental reality that it is difficult — for multiple reasons — to create a voting bloc that will support change. I disagree with Burack's assertion that an honest appraisal of the current situation (as I and many others interpret it) is “bowing to nihilism.” For years, advocates of health care reform have let the perfect be the enemy of the good, with the result that opportunities for constructive change have been sacrificed.
Kauffman and Williams believe that a corrupt electoral system dooms health care reform. Certainly, it makes reform harder. However, as the managed-care debate in the House of Representatives seems to be demonstrating, an aroused public can overcome the power of special interests. The American people are not witless dupes of the mass media. I have faith that, when voters see a clear contradiction between what special interests tell them and their personal experience, they will move the political process. The personal experience of most voters has not yet convinced them of the need for change.
I agree with Weisman that incremental reforms have been disappointing, and I said so in my article. However, they are not damaging. Far from it. Who are we to dismiss the benefits that the State Children's Health Insurance Program will provide to more than 2 million children who would otherwise lack health insurance? As for the influence of physicians in achieving health care reform, they can be helpful, but they are neither big donors to political campaigns (which would get them access to politicians) nor numerous enough to make a difference at the polls. Their support for reform should be sought, but it will not be a decisive factor.
Rizza asserts that our current problems result not from too little government involvement in health care, but from too much. The American people will never be content with a truly free health care market, because they do not trust business any more than they trust government. Advocates of free enterprise in health care, like advocates of comprehensive health care reform, must come to terms with the innate moderation and incrementalism of the American political culture.
David Blumenthal, M.D., M.P.P.
Massachusetts General Hospital, Boston, MA 02114
