The Medicine in Our Future

Beginnings Count: The Technological Imperative in American Health Care

by David J. Rothman
Oxford University Press/Twentieth Century Fund, 189 pp., $24.95

The Road to Nowhere: The Genesis of President Clinton’s Plan for Health Security

by Jacob S. Hacker
Princeton University Press, 239 pp., $39.95

Boomerang: Clinton’s Health Security Effort and the Turn Against Government in U.S. Politics

by Theda Skocpol
Norton, 230 pp., $27.50

Ten years ago, 95 percent of the Americans who had health coverage at their place of work received close to full repayment for services provided by doctors and hospitals personally chosen by themselves. Today, half of them no longer have that freedom; they must use the doctors provided by the health maintenance organizations that their employers have selected. “Faster than almost anyone expected,” George Anders says in Health Against Wealth, “managed care has become the de facto national health policy of the United States.” And “managed” means that plans specify the scope of treatments:

—One prominent plan recently told its pediatricians to cut back routine examinations to 10 minutes.

—A national corporation reduced its employees’ in-patient mental health coverage for such disorders as depression and schizophrenia, with the result that the length of a patient’s average hospital stay fell from thirty-four days to ten days.

—Many plans use “formularies,” limiting the drugs that may be prescribed, even if their own physicians feel that there are others that would be more effective.

—HMOs contract with hospitals willing to accept low payments, and then send patients there, even if they lack full facilities and doctors experienced in the requested procedures.

—In emergencies, almost all plans require using hospitals with which they have contracts, even if others are closer. Only three of Chicago’s twenty-five HMOs let their members know that they might use 911 in urgent cases.

In Anders’s analysis, managed care is based on a new pattern of mutual benefit within the corporate world. On the one hand, under traditional fee-for-service plans were thousands of companies upset that the costs of the health coverage for their employees were rising by as much as 20 percent a year, largely because medical providers were submitting lavish bills. Sentiment began to grow, Anders writes, that “doctors and hospitals, unsupervised, simply couldn’t be trusted anymore.” On the other hand, ready to furnish the needed discipline were insurance providers, some non-profit but most of them commercial enterprises. They made clear to their corporate clients that, in Anders’s words, “managed care works only if administrators say no to some forms of care that patients or doctors request.”

Much of Anders’s book describes erroneous diagnoses by HMOs, as well as their failure to provide the kinds of advanced treatment available elsewhere. He describes how managers override the recommendations of HMO doctors. HMOs call such reports “anecdotes” taken from among millions of unremarkable cases and cite the high satisfaction rate reported by their patients.

It is not hard to depict HMOs as heartless. We are all aware of their refusal to pay for more than one-day hospital maternity stays. Anders wants his title, Health Against Wealth, to be taken literally: in his view virtually every dollar allotted to profit in the managed care industry imperils the well-being of those under their plans. A Consumer Reports study found that commercial plans spend only 79 percent of their revenue on care, with much of the rest …

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Letters

Market-Driven Health Care October 23, 1997