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I’m Sorry, the Doctor Is Busy Making Money

In Critical Condition: The Crisis in America’s Health Care

by Edward Kennedy
Simon and Schuster, 252 pp., $6.95

The Biological Imperatives: Health, Politics, and Human Survival

by Allan Chase
Holt, Rinehart and Winston, 399 pp., $8.95

Away with All Pests: An English Surgeon in People’s China, 1954-1969

by Dr. Joshua S. Horn
Monthly Review, 192 pp., $2.45 (paper)

I

I am horrified,” Senator Kennedy writes, “that we in America have created a health care system that can be so callous to human suffering, so intent on high salaries and profits, and so unconcerned for the needs of our people.” His book In Critical Condition is largely excerpts from the testimony taken by his Subcommittee on Health as it toured the country to promote the Kennedy-Griffiths Health Security Act, the most comprehensive of the several health insurance bills now before Congress, and the one supported by Senator McGovern (see box on next page).

We hear testimony from a Mr. Johnson of Chicago, whose ten-year-old son died in convulsions after a private hospital refused to treat the boy until Mr. Johnson could prove he could pay the bill. Mr. Tresky of Garfield Heights, Ohio, describes the $5,200 medical bill for his wife’s kidney disease that is draining his $140 a week salary, although he carried Blue Cross and another medical plan before his wife got sick. Others were callously ejected from hospitals in the middle of illnesses because they ran out of funds. Some were bankrupted by medical bills, submitted to unnecessary operations for the sake of a physician’s profit, or were treated like scum in a municipal hospital because they could not go anywhere else.

One of these real-life stories supporting the liberal attack on health care in America comes not from one of the witnesses before the Senate subcommittee but from Senator Harold Hughes of Iowa:

Last year in the state of Virginia my second daughter was seized one night with severe pain in the abdomen. We called an ambulance. We rushed her to a hospital, where we could get no medical help because we couldn’t find a doctor who knew us. The doctor whom we called on—and, as a United States Senator, I called the Senate physician—couldn’t make a recommendation to me. The pain was almost impossible to bear, yet they would give her absolutely nothing to relieve the pain. Seven hours later I was calling physicians in Des Moines, Iowa, trying to find out the types of pain relievers and drugs given to her during earlier illnesses…. When finally medical care was found and a diagnosis was made, she had suffered from an inversion of the small intestine, and gangrene set in three days later.

I threatened a doctor in the hallway of that hospital and told him I’d break his neck if he didn’t come in and do something about my daughter.

At the end of each chapter of testimony in Kennedy’s book he gives us an unexceptional statement, in the style of a political speech, of his conviction on the problem, such as, “No American in our affluent age should be forced to mortgage everything he owns for health care” or “People who are injured, sick and frightened should not have to pound on the system’s doors, overcoming obstacles, to reach health care.”

Unquestionably, national health insurance would give millions of people access to more care than they can now afford. As many others have pointed out, our disorganized, fee-for-service system of health care delivery, by virtue of the enforced scarcity of physicians, has made many if not most doctors rich. It has concentrated medical care in prosperous areas, and left the poor and those living in rural parts of the United States with virtually nowhere to turn. But Kennedy’s solution to the tragic situations described in the book is to “guarantee the doctor’s right to be both businessman and healer by taking actions which make sure that it is good business to respond to the needs and demands of the people for healing.”

A mixture of science, business, witchcraft, and occasional human tenderness, the enterprise of medicine serves many functions ranging from healing to generating profits for its practitioners. There are those who say we can make it good business for oil companies not to pollute. It remains to be seen whether the profit motive can be used to stop medicine from being, as Kennedy puts it, “callous to human suffering, intent on high salaries and profits, and unconcerned for the needs of our people.” Private physicians have traditionally argued that the best hope for humane medical treatment lies in finding a good “personal physician”—someone who will take some trouble over your welfare. This in turn requires payment of a fee, goes the argument, because no one in America will really help you unless you pay him cash.

Michael Halberstam, an internist in private practice in Washington, DC, argues for the traditional system of paying a fee for a doctor’s treatment in an intelligent essay in Ray Elling’s National Health Care, a collection of papers on the current debate. Pointing out the advantages that a doctor gains by knowing his patient when he makes a diagnosis, he argues that private practice should persist because “medicine still amounts to one man asking another for help. In many…fields of medicine effectiveness depends on a deep and continuing personal relationship between healer and patient.”

Another person’s interest is indeed comforting when you are sick. Medicine remains as much an art as a science, and even where scientific knowledge is crucial, someone’s concerned attention might guard against injections of the wrong drug, removal of the wrong organ, or any of the other horrendous possibilities that crop up when patients are processed like faceless bodies. Unfortunately, however, the “deep and personal relationship” offered by a private physician often resembles that offered by a ticket scalper. For as many others have pointed out, medicine in America is a scarce commodity offered to those who pay the price.

Private doctors may be willing to give good treatment, but only if you pay. Their humanity, as well as their medicine, is sold as a product. Profits increase so long as both commodities are offered only by private doctors and are thus held in short supply. An indigent patient may obtain medical treatment in a municipal hospital, but the system carefully guards against his being treated competently and with dignity. So long as medicine is viewed not as a service but as a product, with financial incentives necessary to induce the providers to give decent care to more people, scarcity seems inevitable. Even the phrase “health consumer,” originated by liberal reformers and now used regularly by nearly everyone from the AMA to the most radical critics of health care, perpetuates the notion of health care as a product. Consume is defined as “to do away with completely; to spend wastefully; to use up.” The term hardly seems consistent with the notion of the right to physical well-being.

As with many other consumer products, health services have been kept out of the reach of the poor, and this could doubtless continue. The current wave of reforms began when many middle-class people found their efforts to obtain the medical care they were expecting only led to experiences such as those described before Kennedy’s subcommittee The reasons for this shortage of medical services have been set out ad infinitum in the reams of books and documents accompanying the current debate over health care. For one thing, the AMA overdid its efforts to limit the number of doctors, so that even those who could afford an MD’s office fee were buying a twominute encounter instead of that “deep and continuing personal relationship.” At the same time, already inadequate medical facilities were subjected to an even greater strain by Medicare and Medicaid.

To deal with this shortage facing the middle class, Kennedy would first try to increase buying power by having the federal treasury pay for everyone’s treatment. But this is not enough. In National Health Care, Elling writes that “additional money suddenly added in the form of universal health insurance, without increases in health manpower or change in medical care organization, would only generate more inflation and general chaos.” Experience with Medicare and Medicaid has taught health policy makers that enabling more people to buy treatment without regulating the sellers leads only to rampant profiteering and higher prices.

Kennedy, the liberal reformers in academic medicine, and the Nixon Administration all offer nearly identical solutions to keeping the price down. All offer the same product being sold now, but in a different package. The “good personal doctor” will be found not in his office for a fee but working for a salary in a health maintenance organization (HMO) or group practice with full prepaid coverage for each person who consults the group. Kennedy’s plan offers strong, and Nixon’s mild, financial incentives to encourage such new arrangements. These reforms, go the arguments, would make services cheaper, spread them more widely and efficiently, and cut back on needless treatment that might have been performed merely for profit under fee-for-service. In addition, the government or insurance companies would be able to budget accurately the costs of care for a given population.

Reformers point out that as a bonus under prepaid systems more money could be spent for preventive medicine, now only a small part of American health care. In The Biological Imperatives, Allan Chase quotes Dr. Wallace Cook, director of one of the hospitals in the West Coast Kaiser Permanente Health Plan, the first, largest, and now prime example of a health maintenance organization.

With prepayment to the provider of medical care, the usual economics of medical care are reversed; that is, the healthy member is the asset and the sick member is the liability.

Here the business-minded prodding of the medical profession clearly comes into play. Preventive medicine is obviously needed, but no matter how much prevention is offered, people will still need acute treatment, and that is the worst time to be a liability. HMO gets a certain amount of money for its year’s operation, and the less service it provides the more profit it earns. In view of the profit seeking of the medical profession to date, it is not difficult to imagine that, with prepayment, shortages of some services could become even more severe than they are now. In fact one of the criticisms most often heard about the Kaiser Plan is that while it strongly supports giving regular check-ups and administering elaborate diagnostic tests, you may have a hard time when you need to see a doctor.

As another cost-controlling device, the Kennedy-Griffiths bill would set limits on the budget for medical care for each region of the country. Congress has demonstrated that when health costs more than it anticipated, as with Medicaid, it will choose to cut back services rather than to put out more money. There is no reason to think it would not do the same if the Kennedy bill were law. Furthermore, while the reorganization of medical services into larger units would rationalize services and offer increased efficiency, larger health care institutions are in themselves no more a guarantee of a break for the public than replacing the corner grocery store with a Safeway or an A&P.

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