by Joseph Green in CV #45, November 2010
The Obama health care plan has been signed into law, but the health care crisis continues. This much bally-hooed bill is long on promises, and short on what it provides. There are still tens of millions of Americans uninsured or unable, despite being insured, to afford needed treatment. And the history of the attempts by various states to accomplish, as in the Obama bill, universal coverage via private insurance shows that these plans usually fizzle after several years.
So health care is still very much of an issue. Many books and articles were written in the last few years during the debate leading up to the bill. One of the useful ones, which remains of interest, is The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (2009) by T.R. Reid, a long-time journalist and a commentator for National Public Radio. He surveys the medical systems of France, Germany, Japan, Taiwan, Britain, and Canada, where he went to study these health systems as well as to seek care for his suffering right shoulder, which was originally injured in an accident in the US Navy in 1972.
True, it's a commonplace these days to note that the US pays more for health care than other wealthy industrialized countries, and gets less actual care for it. For millions of Americans, medical insecurity is a modern-day horror, and Reid talks of 22,000 unnecessary death each year in the US from lack of medical care. (208)(1) But knowledge of how the systems in other countries work isn't so common, and that's where Reid's book helps fill a gap.
Well, it's hard to read about the health care systems surveyed by Reid without a feeling of envy that things are better over there. But it also expands one's viewpoint. Seeing how things are done elsewhere punctures the excuses given by the insurance companies, pharmaceutical firms and other medical industries about how they have to get everything they want if there is to be good health care. The truth is that medical care is better where private insurance companies either don't exist or are so heavily regulated that American free-market politicians would call it "socialism". I won't go into the details of other systems: one will just have to read these things for oneself in Reid's book.
A strong point of his book is the emphasis on how the profit motive turns private insurance into a complicated horror in the US, rather than a help. He writes "It's revealing that, in the lingo of the U.S. health insurance industry, the money paid to doctors, hospitals, and pharmacies for treatment of insured patients is referred to as 'medical loss.' That is, when health insurance actually pays for somebody's health care, the industry considers it a loss." (37)
He goes into the various crimes of private insurance, such as "rescission", that is, canceling the insurance of people who get sick. And he lays stress on an infuriating side-effect of the system: "The second major anomaly of the U.S. system . . . is sheer complexity. We have developed, more or less by accident, the most fragmented health care system in the developed world, with 'providers' sending bills to a vast array of different payers."
The ill effects of privately-funded health care aren't only manifest in the US. When he looks at China, he notes that the privatization of health care there has resulted in major hardships for the majority of the people there. He writes that "Since the 1980s, the cadres overseeing China's transformation to a market economy have also transformed health care, from a universal government system to a nonsystem that puts most of the burden of health care on the patient. In 1978, when Chairman Mao's 'barefoot doctors' were running government-funded clinics in almost every rural community, out-of-pocket payment in China came to 20 percent of health care costs, not much more than in some wealthy nations. By 2005, with medicine mostly privatized, about 60 percent of all health care costs were paid from the patients' pockets, . . . For wealthy people in the big eastern cities, Chinese today has excellent medical care . . . But for hundreds of millions of people in the desperately poor rural areas, medicine is an unaffordable luxury." (151)
But Reid will only go so far in criticizing medicine for profit. He emphasizes the failure of private insurance in paying for medical care, but he doesn't look closely into how the profit motive in the hospital, pharmaceutical and medical supply industries affects not just the financing of medical care, but its nature. Instead he repeatedly lauds the private sector in health care, and seeks to distinguish the universal care that he advocates from "socialized medicine". He writes that "Another basic building block in the health care systems of every wealthy country -- except the United States -- is the principle that financing health care must be a nonprofit endeavor. There's a crucial distinction between providing health care -- what doctors, hospitals, labs, and pharmacies do -- and financing health care. As we've seen around the world, most countries rely on free-market enterprise to provide health care -- but not to pay for it." (235, emphasis added)
Moreover, in his descriptions of various medical systems, in the US or elsewhere, Reid glosses over some things. He doesn't have a realistic feel for how these systems impact the poor, and assumes that if they are covered by some program, then they actually get reasonable care.
He also has a patronizing smile for the people in other countries who are fighting the increasing pressure for cutbacks. He implies the threat of cutbacks isn't that serious, and he recites the semi-facetious "Universal Laws of Health Care Systems" from the American economist Tsung-Mei Cheng, their first principle being "No matter how good the health care in a particular country, people will complain about it." (27)
Yet as the current world economic crisis spreads, there is a growing drumbeat from the capitalists and financiers for major cutbacks in wages, pensions, social programs, health care, worker protections, and everything. It's beating louder and louder, and reaching new heights as budget crises spread from Ireland and Greece to Spain and the United Kingdom and beyond. Morality and the supposed cost-effectiveness of preventive health care be damned: the bourgeoisie has never been permanently reconciled to the existence of universal social programs. Major clashes over social programs have begun, and their fate depends on the strength of mass resistance.
Meanwhile, in the US, the conservative resistance to national health care isn't simply a matter of ignorance of the systems elsewhere. It's a matter of the class stand of the American bourgeoisie; its adherence to the program of neo-liberalism; and the presently-depressed state of the class struggle between the working class and the bourgeoisie.
Reid's focus on financial accounting may be understandable, given the financial nightmare of American medicine. But there is a lot more to medicine, and a lot which bourgeois medicine, even as practiced in the better universal systems, ignore. Moreover, many of these issues may become more severe in the future; medical practice can't simply stand still.
One such issue is workplace health and safety problems. From repetitive stress injuries and back problems to chemical poisoning, many health issues are related to the workplace. A better connection between health care and the workplace would be a great boon for workers.
Reid, however, ignores this. He doesn't consider the difficulty facing medical surveillance of the workplace in a capitalist economy where most employers have every financial incentive to block it. After all, even if a universal health plan can't drop patients, the individual workplace can get rid of injured workers. So the capitalists, unless pressured by their employees, will generally find it more convenient to overwork and injure workers, than to provide safe workplaces. But Reid ignores the need for health care to keep track of workplace issues, including the challenge of new technologies, and for workers to have a role in enforcing better practices on their employers.
Workplace issues slide over into environmental issues, and they are barely mentioned by Reid, who doesn't seriously consider what has to be done to deal with them. The chemical poisoning and other health dangers from bad industrial and agri-business practices affect not just particular workplaces, but whole communities, regions, and even countries. The health of people in the Nigerian delta poisoned by the oil industry can't be guaranteed by ordinary medical care alone, but requires the elimination of oil industry poisoning. In Colorado, Pennsylvania, and other states we see people being poisoned by bad water and other chemical contamination by the growing practice of hydraulic fracturing ("fracking") of rock layers to extract natural gas; this problem can hardly be answered simply by treating each individual case. Genetic engineering, new nanotech technology, and the continual development of more and more industrial chemicals show that medicine is going to have a face more and more environmental challenges, and suggest that medicine is going to have to change, not just its financing, but its methods of operation.
Reid praises the role of experts in devising this or that health system, and he doesn't talk about the need for a mass role in supervising medicine. He sees no further than the elitist system that prevails now. Yet a number of improvements in American health care have taken place because of mass pressure from the anti-racist movement, the women's movement, and other activists. In particular, the mass upsurge of the 1960s, and its aftermath in the following years, really shook up the medical establishment. It wasn't a panel of experts that oriented medicine to pay more attention to environmental poisons like DDT and various other pesticides; reform how it dealt with women's issues in general; provide contraception and abortion (insofar as abortion actually is available); take seriously the problem of sickle-cell anemia or of lactose intolerance; or even make a major effort on AIDS. It was mass pressure, to which the medical profession, the politicians, and the experts responded. Of course I don't mean that every idea from activists was right, or that a vote among the general population about some medical issue can replace the need for careful scientific and medical studies. But mass involvement has repeatedly brought a fresh wind into medical practice.
If things are left to bourgeois experts, it's unlikely that proper attention will be paid to workplace issues. Present-day professional associations are too isolated from working-class life to have a proper picture of what goes on. Indeed the growth of medical entrepreneurialism in universities, the privatization of hospitals, the gifts lavished on doctors by pharmaceutical companies, and the wealthy status of top doctors all combine to reinforce the connections of the leadership of the medical profession with the bourgeoisie. It will require pressure from the workers themselves if there is to be proper attention to their safety. And it will require coordination with the mass of workers to provide a real medical supervision over industrial and agricultural practices. For all these reasons, it's important that workers' organizations play a major role in health care and in a proper medical system. Progressive doctors should strive to stand by workers and orient the health care system in this direction. This is only possible to a limited extent under capitalism, but it's important to achieve whatever is possible in this regard.
If things are left to bourgeois experts, it's also the case that some of the presently-fashionable medical initiatives, such as greater emphasis on life-style issues in health care, can backfire and become oppressive. Under the present system, they could turn into penalizing people for having high cholesterol, bad blood pressure, or being overweight, or just not acting in accordance with someone's idea of clean living. Already a few employers are moving in that direction, a return to the oppressive practices of Henry Ford and other capitalists who thought they could dictate every aspect of their employee's lives. This is too close for comfort to what was depicted in Samuel Butler's satirical utopian novel Erewhon ("nowhere" more-or-less spelled backward), where the ill were sent to jail based on the belief that they must willfully have refused to take proper care of themselves. In real capitalist life, the working class ill aren't sent to jail, but they may lose their health insurance, their jobs, and their security of life.
No doubt Reid personally would oppose such abuses. But by neglecting the mass role in running the health system, he overlooks what is needed to prevent them. In his book, the role of the people is to be harangued and pushed into preventive measures.(2) Aside from that, the other role of the masses that he sees is to give their consent to cutbacks, and he writes: "In a democracy, universal coverage helps create the political will to accept limitations and cost-control measures within the system." (238) But that's about it. He doesn't even note that one of the main problems with the complexity of the American system, which he otherwise justly condemns, is that it keeps people divided, so they won't unite against the abuses of the health care system.
A good universal health system would be a major advance over private insurance and the Obama bill. But even the better universal plans in capitalist countries are not the same as what health care would be like under socialism. It's under when the workers control the economy as a whole that health care can really involve mass initiative and be fully integrated with workplace and environmental issues.
Reid discusses preventive care, and points out the importance of public health measures. He makes the significant point that "Dramatic surgical advances and biological breakthroughs that lead to new wonder drugs tend to draw the headlines . . . In fact, though, the long slog of extended observation and population studies carried out by unsung public health experts generally adds more to the span of our lives." (187) And he uses the example of the dangers of cigarette smoking as a prime example. He also points out that "We tend to think that twentieth-century medicine, like vaccinations and antibiotics, conquered such diseases as measles, scarlet fever, whooping cough, and tuberculosis; in fact, there was a sharp decrease in death rates from these ancietn killers decades before the wonder drugs came along. Most of the credit goes to public health advances in water purification, sewage disposal, and pasteurization of milk." (191-2)
But what will motivate the development of a comprehensive system of preventative care today? In Reid's view, and he is simply following bourgeois fashion on this, preventive medicine will mainly be the result of the push for cost-efficiency. He does mention that sometimes preventive care can actually cost the health system more than otherwise, although it's not clear whether he thinks it should carried out in that case: in the examples he gives, expensive preventive care is also medically questionable. (197-8) And he says that some preventive care is carried out because of "basic altruism". (185) But he stresses that "any health system needs a strong incentive -- an economic incentive -- to invest in preventive health care." (185)
This is another example of his dual attitude toward for-profit medicine. On one hand, he gives examples of how for-profit insurance results in irrational medical treatment and the neglect of many basic medical measure. But on the other, he expects that, if only for-profit insurance is eliminated, the drive for cost-control will result in preventive care and good practices. He may scoff at Adam Smith's invisible hand when it comes to private insurance, but he embraces that invisible hand when it comes to treatment in general.
In reality, the history of medicine is full of people, from ordinary people striving to ensure the well-being of their families to midwives, nurses, doctors and researchers, who were motivated by the struggle against disease and human degradation. It is also a story of the exploiting classes seeing nothing wrong with the working majority being forced to live and work in unsanitary and unhealthy conditions, and of working people organizing together to demand a decent life. But has all this struggle simply been due to a failure to realize that proper preventative health care would supposedly be something economical and profitable for all concerned, so that one needn't worry about the effect of class differences nor be overly dedicated to human, rather than financial goals? Or perhaps these concerns may have once been important, but the development of national health systems makes them obsolete, so that we have entered a new era for medicine in which financial goals and health goals coincide?
But no, the existence of universal health care systems doesn't tame the world of economic incentives. To show that it does, Reid's discussion of economic incentives has to be one-sided. He arbitrarily singles out some of the financial costs and benefits involved in national health care, rather than looking at them as a whole. And he doesn't consider that some people pay a disproportionate amount of the costs while others get a disproportionate amount of the benefits.
For example, consider the example of cigarette smoking, one of Reid's prime examples of how there is an economic incentive to have preventive care, that is, measures to discourage smoking. It would have been more realistic to have also taken note of the economic incentive of the cigarette companies to injure and kill -- slowly but surely -- as many people as possible through promoting a poisonous product.(3)
And with regard to preventive care in general, one has to look into the economic incentive to pollute the environment and underpay and overwork workers so that they can't lead healthy lives. This might have led to considering what type of pressure from the working majority is needed to counterbalance the economic incentive to the capitalist minority to ruin the health of millions of workers. In reality, it happens again and again that a single industry is able to stonewall for decades public health measures which affect it. The cigarette industry blocked preventive measures against smoking; the asbestos industry concealed the truth about the dangers of asbestoes; oil companies hide the truth about the dangerous pollution and water poisoning caused by the extraction of natural gas via hydraulic fracturing ("fracking"); and so on. The corporations make the profits, while the health costs -- both human and financial -- are borne by others. And effective public health measures would benefit the people, but would impose costs on the corporations.
Well, it might be said, what Reid is talking about is the economic incentive for the health system itself, not the overall economic effects of health measures, and not the economic effects on various businesses. But even here, the economic incentive isn't so clear. For example, a similar argument to what Reid's makes with respect to universal health care was once more with respect to HMOs. It was claimed that economic incentives would ensure that HMOs provided preventive care for their members. Keeping their subscribers healthy would supposedly be cost-effective for them, as the cost of preventive care would be outweighed by the reduction in expensive medical treatments as the HMOs' member stayed healthy. But things didn't work out that way. The HMOs gradually found other ways to cut costs, such as the heartless policy of rescission (denial of benefits) that Reid justly condemns in his book, and they have found that raising premiums provides abundant profits.
Of course, Reid doesn't think that HMOs aren't the answer. An important theme of his book is that for-profit health insurance doesn't work. But Reid claims that the invisible hand of economic incentives would work properly if only the health system is universal and unified. He writes that: "In a nation with a unified health system that covers everybody -- which is to say, all the industrialized democracies of the world except the USA -- it clearly benefits both the population and the [health] system to invest in public health." He holds that it is simply because in the US there is "a fragmented, multifaceted-system" that "the economic incentives for preventive care is dissipated." (185)
He ignores that the economic incentives for the various for-profit health industries, such as the pharmaceutical companies, are quite different from any incentive that the overall health system may have to stay within budget. He also ignores that, if preventive care is successful, then it might result in a number of additional expenses to the health plan or to the government: when retired people live longer, more money will be spent on their pensions, and also possibly on nursing care home, and on treatment for those diseases which have so far eluded preventive care.
Preventive care is important for the health and well-being of people. But an overall look at the economic consequences of preventive care casts doubt on whether improved preventive care will be brought about by the prospect of big financial savings for everyone. There are many financial interests involved, and even the immediate savings to the universal health system brought about by a better preventative system might be disappointing. No doubt a health system has to take account of the total resources, financial and otherwise, available to it; and waste should be avoided. But steps taken in the name of preventive care and public health are likely to be half-hearted or even abortive, if they are motivated mainly by the drive for cost-efficiency.
I have already referred above to the danger of workers being penalized for their own health problems on the pretext that it's the fault of their life-style. It should also be noted that the health profession has often been mistaken on what it has prescribed as treatment for various conditions or preventive care. But despite this history, the dream of making big savings in the cost of health care -- without stopping the rampant pollution from industry, without reforming agricultural practice, and without eliminating the exhaustion wearing down people having to work several jobs to feed their families or keep their children in college -- has resulted in the idea of developing and enforcing a system of "best practices". This appears in the Obama bill, and in the Massachusetts plan that preceded it.
In reality, there has long been a standardization of accepted medical practice in the US. And for some time now, the various health plans, private or government, have put forward their own restrictions on what they will authorize. But Obama's plan for developing and enforcing "best practices" would go further, and prescribe a more detailed set of "best practices". This is supposed to improve medical care while saving lots of money. To make this plausible, its advocates point to various hospitals and clinics that are slipshod and really should be reformed. But instead of looking into why such slipshod practices take place, and what type of oversight is needed, the solution is supposed to be an ever-more cut-and-dried set of rules which all treatment has to follow.
This threatens to systematize and make more rigid the restrictions on medical treatment pioneered by private insurance. Instead of increasing mass involvement in health care, it threatens to escalate the elitism of the health profession, and isolate it further both from the population in general and from the mass of health care workers.
Given the checkered history of past attempts at establishing such "best practices", this new technocratic plan is unwise. Dr. Groopman, a medical researcher who has written several books on medicine, commented earlier this year on the plans to enforce "best practices" in the health care bill. He wrote that "Over the past decade, federal 'choice architects' -- i.e., doctors and other experts acting for the government and making use of research on comparative effectiveness -- have repeatedly identified 'best practices,' only to have them shown to be ineffective or even deleterious."(4) He dwelt mainly on the technical obstacles to developing such cut-and-dried "best practices", obstacles that exist even when the committee are focusing simply on the quality of health care. The situation is worse if the "best practices" are motivated mainly by cost-cutting, which is how they ended up in the Obama plan. And worse yet, it can be expected that the pharmaceutical companies, biotech firms, and other health industries will have a major influence on the panels formulating the list of "best practices."(5)
A system of preventive care that is motivated mainly by cost-control will lead to this type of dead end. Reid ignores this because he only sees the problem of for-profit medicine as applying to the financing of health care; he tries to conciliate the other capitalist interests involved in health care rather than showing the continual clashes between medical capitalism and health care.
Reid provides a good deal of useful information in his book about the variety of universal health systems that presently exist in other countries. He explodes some of the lies about these systems told by the advocates of free-market medicine. But he recoils from looking at the class issues involved in the health care debate. This leads him into a dead end. This is reflected in his silence on the Obama plan.
In his book, he mentioned that attempts to make private for-profit insurance universal aren't going to work, and he wrote: "Efforts like the new Massachusetts plan, designed to enroll everyone in private insurance, are probably too costly to maintain. It's admirable that the state wants to see every citizen get health insurance; but the Massachusetts approach just loads more people into a system that is already the most expensive and the most inefficient in the developed world. If every state did that, the insurance industry would rack up even higher profits, but state budgets would implode." (225)
This is an important point. And one would think that it would also apply direct to Obama's "Patient Protection and Affordable Care Act" of 2010. But wait, one might say, the bill was passed after Reid's book was written. True, but the concept of the Obama bill had been around for some time. Indeed, it has been clear since the days of the Clinton presidency that the main Democratic proposals for universal health care were complex and based on maintaining insurance for profit, both things that Reid's book otherwise takes aim at. But Reid ignores this in his book. And since his book was published, he seems to have maintained his silence on the Obama bill. As far as I can tell, he has said nothing about it in public, and posted nothing about it on his website (www.treid.net). His failure to look into the class issues in the medicine has thus resulted in an inability to maintain a consistent stand even with regard to the issue of private insurance.
It's also notable that Reid averts his eyes from the new challenges for medicine in the future, He implicitly assumes things will remain the same, and that's a dangerous assumption in these days of economic and environmental crisis and of rapid scientific and technological progress. His book is important because he warns of the dangers of for-profit private insurance and introduces people to how health care is managed elsewhere, but it refrains from a deeper look at how the free-market in medicine is failing to deal with current and coming medical challenges.
(1)Numbers in parentheses are page references to Reid's book.
(2)Reid describes the pressures put on people to conform to various public health initiatives. He doesn't distinguish between measures enforced on business (safer or better-designed products) and measures enforced on individuals, but regards them all as enforced against the public. While supporting these measures, he does say that they raise the "Nanny State problem" (195), but it never strikes him to consider the mass rule with respect to public health and preventive measures.
(3)The high profits of the cigarette companies, and the economic incentives they provide, remain an issue to this day. For example, American cigarette companies, faced with restrictions on their product in the US, have stepped up their sales overseas. They have contributed to the growth of cigarette smoking in Asia as a whole, and recruited the US government to help fight Asian restrictions on their product.
(4)Dr. Jerome Groopman, "Health Care: Who Knows 'Best'?", The New York Review of Books, Feb. 11, 2010, p. 13. The article is posted on the internet at http://www.nybooks.com/articles/archives/2010/feb/11/health-care-who-knows-best/. Dr. Groopman is not an embittered conservative foe of reform, but a staff writer for the liberal New Yorker.
(5)The fact that the government's interest is to cut costs doesn't mean that the panel has the same interest. Drug companies, for example, will promote their drugs as a "best practice" in the name of cutting costs. The winning drug companies, the use of whose drugs are endorsed as the "best practice" for this or that condition, will end up with greater profits, while alternate therapies or drugs may be banned. The result may be neither cost-cutting nor good medicine.
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