Crisis and Change in the Health Care System

Since the late 1960s, health care in the United States has commonly been described as being in a state of "crisis," "transformation," or "flux.'' While the specifics of what constituted a "crisis" varied widely, academics, journalists and politicians came to agree that we were embarking upon a period of major and significant change.

		Contemporary portrayals of the changes taking place in health care range from the highly optimistic to the very pessimistic. Most of the optimism derives from hoped-for advances in the techniques of care. The public expectantly awaits genetic interventions, improvements in surgical techniques, or new vaccines. But it has generally viewed the ongoing and rapidly accelerating changes in the organization of health care more ambivalently, if not ominously. This fearful or pessimistic view of the evolution of our health care system can be traced to many sources, with a wide range of opinions about which factors have primacy. However, the key elements, regardless of their relative import, are well agreed upon.

		The problem most frequently cited is simply the cost of health care to the society as a whole. In 1960 the United States spent well under 6 percent of its gross domestic product on medical care. By 1989 that proportion had doubled, and by 1994 it was just under 14 percent, where it has remained since. The 4.4 percent growth in health care spending for 1996 was the smallest percent change in over thirty years, but still about 25 percent above the overall rise in the gross domestic product. In absolute terms this expenditure exceeded $1 trillion for health care in 1996, or $3,759 a person. Even with such immense outlays, about forty-two million Americans have absolutely no health insurance coverage. While 99.7 percent of those aged sixty-five and older have coverage via Medicare or some other federally subsidized program, about 22 percent of those between the ages of sixteen and twenty-five have no health insurance at all. A 1996 report from the Census Bureau found that 38.2 percent of the Hispanic population and 30.1 percent of the Black population lacked health insurance for at least some portion of a twenty-eight-month period ending in August 1994, compared to 21.0 percent of Whites. No one is pleased by these figures. Not surprisingly, the majority of money is spent on individuals who are ill. Medical services for those who are the most sick, who also tend to be the oldest and most likely to be covered by insurance, account for a disproportionate amount of health care expenditures. Those with chronic conditions account for about three-quarters of all the nation's health care costs. Ten percent of all Medicare recipients account for 70 percent of the program's outlays. The aging of the American population can only exacerbate these spending patterns. For example, the expected rapid growth among the "oldest old," those aged eighty-five and above, is projected to yield a 600 percent increase in Medicare costs by the year 2040 when the surviving "baby boomers" reach that age. In that same year, the number of nursing home residents over eighty-five years of age is expected to be about three times the total of today's entire nursing home population. Concern regarding health care costs goes well beyond their absolute magnitude. In the United States, a higher percentage of total costs is devoted to administrative costs than in other industrialized nations, and these costs are growing. Despite widespread attention and concern, it appears that the health care system is becoming more inefficient. The current emphasis on managed care and converting nonprofit facilities and insurers, such as Blue Cross, into proprietary operations has heightened this trend. Administrative costs, profit, and costly high technology interventions for those most ill, often during the last few months of life, have been consuming ever larger shares of the nation's total health care expenses. Given the immense amounts of money involved, much of it flowing directly or indirectly from government coffers, it is surprising how little evidence there is that greater expenditures for medical care produce better health or more healing. Although some researchers have argued that there is a marginal gain in the health status of the population in an industrialized nation when expenditures for medical care go up, most economists, epidemiologists, and others have been more skeptical. The proportion of the national gross domestic product spent on health care has been of more interest to politicians, policymakers, and academics than to the average citizen. The typical patient is more concerned with the changing manner in which care has come to be provided. The decade after 1985 saw a massive change in the organization of American medicine in the form of the rise of "managed care." Simply put, this means that large for-profit corporations have become responsible for a growing share of health care services. By 1993, a majority of Americans who were privately insured were in managed care plans that restricted their choice of physicians. Large employers were the leaders in promoting this trend; 65 percent of their employees were covered under managed care plans. The most common form of managed care, the HMO or health maintenance organization, was fast transforming from what was a traditionally nonprofit organization, into a profit-making corporation. Managed care companies themselves were engaged in rapid consolidation. Mergers and acquisitions among managed care plans for the years 1993 and 1994 were valued at about $ 38 billion, and the rate and value of joint ventures has increased since that time. Medicine is no longer largely a cottage industry of small providers (typically individual physicians) who interact through professional organizations and informal networks, sometimes coordinate their work in hospitals, and receive compensation on a piecework basis from both clients and insurance companies. Increasingly, physicians work for large profit or nonprofit corporations under contracts that subject them to detailed oversight, restrict their ability to exercise clinical judgement, and offer financial incentives to limit or skew the services they provide as a means of enhancing corporate profit. Managed care companies behave just like any other large corporation. Medicine is now "big business" and health care is a commodity. It is not necessary here to judge whether managed care is a good or bad thing for the quality of American health care, or the health of the American population. A large quantity of both popular and academic literature has already emerged on that topic. What is clear is that the overall environment in which many, if not most, Americans receive their health care has shifted dramatically. Traditional arrangements and relationships between patients, physicians, hospitals, and insurers have all been changed in such a way as to limit long-term involvement, heighten distrust, and make medicine less "special" for all parties. The sense that health care is a commodity like any other is far more widespread and influential today than at any other time in the past. In addition to these broad changes in the organization of health care, and its rising cost to the nation, there is a growing mood of disenchantment with medicine. A number of recent polls report the public's growing dissatisfaction with managed care. Over half of Americans surveyed in a 1997 Lou Harris Poll felt managed care was actually harmful to their health. What doctors do, and how well they do it, has emerged as a matter of attention and concern in the minds of clients, policymakers, and the general public. A notable but typical example is the controversy regarding the treatment and prevention of breast cancer, which has been highly publicized in recent years. Initially, disputes emerged when data from trials conducted under the supervision of the National Cancer Institute suggested that lumpectomy (surgical removal of the tumor) followed by radiation treatment was as effective in treating breast cancer as mastectomy. These findings suggested that thousands of women had undergone unnecessary body-altering surgery. However, confidence in the enterprise of medical research itself was undermined seriously in April 1994 when the Chicago Tribune reported that one of the participating research physicians had falsified information about the patients he entered in the lumpectomy study, as well as those in a concurrent study, on the use of tamoxifen, a drug used in hormone therapy for breast cancer survivors. Though the falsifications did not influence the outcomes of the study, both the occurrence of the fraud and the fact that project administrators had not disclosed it in the more than four years in which they had known of its occurrence contributed enormously to popular disenchantment with the medical establishment. The public's confusion about breast cancer was heightened in 1997, when the guidelines for using mammography to detect breast cancer in asymptomatic women in their forties became the subject of ongoing debate. The official recommendations of national institutions such as the American Cancer Society and the National Cancer Institute had changed no less than six times during the proceeding few years. Therefore, at the request of the National Cancer Institute, the NIH convened a panel of experts to evaluate existing data and determine mammography guidelines for women younger than fifty years of age. As is common practice when research findings are confusing, the panel reached its decision through a "consensus conference." Traditionally, the conclusions of such conferences are so highly valued that they are used by insurance companies to determine benefits and by doctors and hospitals to determine standards of care. However, when the mammography panel announced its findings, both the health sector and the public responded with outrage. Neither group wanted to accept the panel's conclusion that "at the present time the available data do not warrant a single recommendation for mammography for all women in their forties. Each woman should decide for herself whether to undergo mammography." The director of the National Cancer Institute, Dr. Richard Klausner, at whose behest the panel was convened, said he was "shocked" and noted that an advisory board to the National Cancer Institute would review the decision the next month. The American Cancer Society issued a statement saying that it was "disappointed'' in the report and stood by its recommendation that women in their forties have regular mammograms. One radiologist said he believed that the panel's actions were "tantamount to a death sentence" for women in their forties and that he "grieved for them." Another radiologist from the Harvard School of Medicine called the report "fraudulent" and admonished that it should not be released to the public until it was "corrected." The panel stood by its findings, noting that the data indicates 98.5 percent of women who get mammograms in their forties receive no benefit and that mammography carries risks of its own, including falsely telling women that there might be a tumor present, treating as cancerous a tiny lump that might or might not be cancerous but would require treatment if it were cancer, and giving women a false sense of security. Members of the panel also characterized the reactions to their report as "scary," and the chairman of the panel noted that "the arguments have gotten so strident that people are unwilling to listen." Some analysts have explained the intensity of the reaction by noting that mammography is a big business in the United States. Others have commented that mammography has been widely promoted to women as a preventive measure that can save them from a dreaded disease, a reassurance and sense of protection with which women are reluctant to part. However, a more basic concern is that when the leading experts disagree so vehemently on how breast cancer should be diagnosed and treated, it raises basic questions about whom the public can trust. While the health issues brought up in the breast cancer and mammography controversies are highly specific, and of greatest concern to only a portion of the population, they are typical of many similar examples. Taken together, the frequency and intensity of such conflicts have abetted the broader decline in confidence about medicine in general. The outpouring of concern about specific medical procedures and practices is, in some large measure, due to the rise in health care costs and discontent about the changing organization of care. Those factors have been central in motivating government and insurance companies to begin evaluating more precisely where their money is going. Increasingly the government and the insurance industry have been funding and carrying out research, varyingly called "health services research," "evaluation research," and "outcomes research," in order to get "hard data" (i.e., statistical evidence, as opposed to clinical reports) about a vast array of clinical procedures and tests. Almost inevitably, the data supports their initial concerns that the interventions are ineffective or overused, fostering still more concern and research. The results of research on medical techniques, judgement, and practices heightens the public's mistrust about mainstream medicine in a number of ways. For example, in the United States each year, over 2 percent of all women have hysterectomies—a rate almost ten times as high as it is for women in France. This finding is typical of repeated demonstrations that regional and national political boundaries strongly influence the utilization of specific medical procedures, even when the incidence of a problem is similar. Results like this, along with research specifying the personal and idiosyncratic factors physicians use in deciding who to treat or what new procedures to adopt, causes clinical decision-making to appear more a matter of social norms and values than of the objective application of rationality. Most unsettling for mainstream medicine has been the repeated finding that many "standard" medical procedures and therapies are of limited value, or even harmful. The culturally cherished "annual physical exam" for adults has been revealed as having no use in the screening for asymptomatic illness. A report in the Journal of the American Medical Association (JAMA) found that the widely publicized and heavily promoted PSA (prostate specific antigen) screening exam for prostate cancer leads to "a net health harm rather than a net health benefit." NEJM published a report concluding that it may be pure coincidence that people with chronic back pain, the second most common reason for visiting a physician, have disc abnormalities. The same prestigious journal reported that experienced board certified radiologists disagreed more than 20 percent of the time when reading mammograms on whether a biopsy should be performed. One study found that the medical records of 60 percent of elderly people admitted to the hospital failed to list the important medications being taken. A review of over thirty thousand randomly selected medical records from acute care hospitals in New York found 4 percent of the patients seriously injured by their treatment. More than 13 percent of these injuries led to death. A study by the American Hospital Association estimated that in 1983, 7 percent of all hospital admissions (approximately 2.7 million admissions in that year) were related to the misuse of pharmaceuticals prescribed by physicians and that such drug-induced illnesses cost up to $5 billion. A 1998 meta-analysis published in JAMA suggested that even when drugs are used properly, adverse reactions kill more than one hundred thousand Americans each year. The significance of these examples lies not in the "facts" they report. Rather, they are important because they represent a large and growing universe of similar findings in the medical literature and because each of them, along with numerous others, received prominent coverage in the popular media. Conflicts, ambiguities, and failures of modern medicine, along with news of "magic bullets" and medical heroism, are a regular part of the news in the 1990s. Cover stories in national magazines, front-page stories in the daily paper, and reports on radio and TV are commonly devoted to the sorts of critical findings cited above. This media attention indicates how important detailed information about health and medicine has become in our collective awareness. Yet often, the substance and tone of what is reported can only raise the consumer's level of skepticism, distance, and distrust. When medical researchers criticize their colleagues for undertreating pain and ignoring the evidence on how well pain medications work if used properly, while the chief medical writer for the Los Angeles Times gives major coverage to the overuse of pain medication and the resulting need for patients to "tolerate discomfort," the underlying message to the general public is one of confusion. Ironically, it is the application of the scientific method to study the effectiveness of medical care that has yielded the intellectual power and empirical analyses which inspire doubt in mainstream "scientific" medicine itself. Observers inside and outside of the medical profession have long commented upon how little of what is considered standard treatment has any documented scientific basis showing it is indeed efficacious. In 1978, a report from the Congressional Office of Technology Assessment indicated that only 10 to 20 percent of all procedures currently used in medical practice had been shown to work in clinical trials. There has been little, if any, improvement since that time. Yet until recently, these research findings have had minimal impact on the public and policymakers. Despite the equivocal evidence, scientific rationality and the practice of medicine have been inextricably linked in the public mind. As the dominance of the medical profession has grown and the expense of medical care burgeoned, the government, insurers, and industry (who foot the bills for most care) have become much more interested in knowing how much rational basis actually exists for the expenses they incur. It has become common for federal agencies such as the National Institutes of Health, the Health Care Financing Agency, and the Agency for Health Care Policy Research, as well as private foundations and "think tanks" such as Rand, to rely on randomized clinical trials, outcome evaluations, and epidemiological research to judge the true value of medical tests and procedures. Those who fund and carry out this research have been quite aggressive in publicizing their findings to the medical profession and the general public. Their predominantly negative or, at best, equivocal conclusions have helped foster and legitimize skepticism toward conventional medicine among policymakers and the general public. Beyond its own intrinsic merit, the outcome of this research has an affinity with a number of other streams of academic thought that have been critical of medicine and the medical profession, such as "labeling theory" in sociology, and "attribution theory" in psychology. These perspectives emphasize the way in which the words we use shape our reactions to phenomena in the world. Both perspectives have stressed the ways in which "medical names" for signs, symptoms, conditions, and behaviors can highly stigmatize the individuals to whom they are applied. Researchers have found this to be especially true in regard to disabilities, physical illnesses like AIDS, and mental illnesses such as schizophrenia. This extensive criticism of medicine has had a broad impact upon society. Analysts and policymakers have come to sharply divergent conclusions. Some view the epidemiologic and health service research as reason for some sort of national health care restructuring based upon federal insurance and increased government involvement in medicine. Others have come to a very different conclusion, arguing that the best policies arc those which treat health care as any other commodity in the marketplace. Individuals, especially those most economically secure and highly educated, have heightened their skepticism about the medical profession and have developed a high degree of "consumerism" toward medical care. Consumer publications such as Consumer Reports magazine and other media directed toward general audiences, such as "lifestyle" sections of many daily newspapers, have begun to report in detail about all sorts of medical and surgical techniques. Much of this material offers "user friendly" summaries of health services evaluations and outcomes research. These popular accounts have encompassed the widest range of medical interventions, including many that emerge from alternative approaches. Typical examples include the use of beta carotene in preventing heart disease and cancer, spinal manipulation as a treatment for back pain, herbal remedies to relieve depression, diet and relaxation techniques to reduce blood pressure, and melatonin for just about everything. Each of these summaries is consistent in noting that regardless of the specific topic being considered, medical experts disagree. This combination of skepticism (sometimes carrying over into overt hostility) toward mainstream medicine and consumerism has become an important dimension of a number of social movements. The women's movement, the gay liberation movement, and movements for the rights of the disabled, chronically ill, and abused all have stressed that a medically dominated understanding of their members' problems is usually not helpful, and that medical solutions to these problems are highly questionable. The gay and lesbian communities' extensive advocacy for the declassification of homosexuality as an "illness" is one of the best examples of a successful challenge to a medically dominated characterization of a group of people. The women's movement has advocated for the reconceptualization of birth as a natural process, not a "medical condition," and the hospice movement has sought to redefine death and dying. Skepticism about medicine is one element all of these movements hold in common. These individuals and groups do not deny that medicine may have much that they need or desire Rather, they wish to carefully evaluate what medicine has to offer, instead of uncritically accepting medical explanations for their problems and medical strategies for their improvement. They want to use medicine on their own terms. They are acutely aware that in the past medicine has harmed minorities and women in their quest for both individual and collective advancement. This outlook is epitomized by The New Our Bodies, Ourselves, the best selling health manual of the women's movement. In the book's chapter entitled "The Politics of Women and Medical Care," the authors cite "thousands" of personal accounts of the harm done to women by physicians and other medical personnel in medical settings who have: not listened to them or believed what they said; withheld knowledge, lied to them, treated them without their consent; not warned of risks and negative effects of treatment; overcharged them; experimented on them . . .; treated them poorly because of their race, sexual preference, age, or disability; offered them tranquilizers or moral advice instead of medical care or useful help from community resources . . .; administered treatments which were unnecessarily mutilating and too extreme for their problem, or which resulted in permanent disability or even death; prescribed drugs which hooked them, sickened them, changed their entire lives; performed operations which they later found were unnecessary, and removed organs which were in no way diseased; and abused them sexually. The New Our Bodies, Ourselves debunks as "myth" popular ideas about the superiority of the American medical system, the contributions of medicine to world health, the scientific basis of medicine, the safety and efficacy of medical treatments, and the role of medicine in promoting health. Furthermore, the authors explicitly critique the medical system as an instrument for the social control and suppression of women. One outgrowth or manifestation of this skepticism is an openness to alternative approaches, as exemplified in the introduction to the book which states that while "we do need professional help with health problems . . . medical approaches are not always the best, with their excessive emphasis on drugs, surgery, and crisis intervention." The book includes information on both biomedical and alternative approaches to health care. Each of these criticisms of mainstream medicine—excessive cost, skewed access, inadequate current health care organizations, and lack of medical effectiveness—has its own history, proponents, strengths, and weaknesses. Yet increasingly they are presented as a coherent whole, reinforcing and deepening each other. Demonstrations that a particular treatment is not very efficacious are strengthened if the treatment is also costly. Organizational arrangements that lead to reductions in desired treatments are all the worse if the reductions are justified by the need for raising corporate profits, or the treatments are allocated such that those most in need are least likely to receive them. Criticisms of medicine and the organization of health care services are widespread across the political spectrum, and these views have taken on a quality of enhanced legitimacy. The coming together of these strands of critical thinking was epitomized in the findings and proposals of President Clinton's Health Care Commission. The commission's final report premised each of its proposals on the acceptance of the criticisms we've just described. The politicians who rejected, and eventually scuttled, the report's conclusions did so not on the basis of a rejection of its premises about the costliness, inefficiencies, or ineffectiveness of medicine. Rather, their opposing views were based upon belief that more governmental intervention would make things worse and/or that a greater role by market driven economic forces, not government mandates, could rectify the situation. Extensive criticism of medicine as an institution in American society is now commonly articulated at high levels of the government, the academy, and the corporate sector of the economy.