ISSUE: Winter 1988
Many of us feel confronted by a cacophony of messages about contemporary health and medical issues in America. We hear about a devastating AIDS epidemic escaping the confines of the socially deviant community (if deviance can be said to exist in as relentlessly pluralistic a society as ours), about technical marvels like artificial hearts, dietary and exercise rituals guaranteeing health, costs of medical insurance becoming intolerable to government and corporate sponsors, prepaid medical plans, high physician incomes, and enormous malpractice awards. Can these fragments be assembled into any comprehensible pattern? How can we see clearly enough to make the necessary choices as patients, as self-interested consumers, and as voters for or against proposed public solutions to the problems raised?
Dr. Hiatt’s America’s Health in the Balance is an admirable introduction for general readers to this area. It begins, perhaps necessarily, with some rhetorical alarm: “We have more doctors per capita than most other industrialized societies. Yet medical tragedy stalks our nation: Many citizens, rich and poor, are not benefiting from medicine’s achievements when they need them. . . . Every day lives are lost that could be saved. . . . Some have too many tests, medications, operations; billions of dollars are wasted on efforts that don’t help anyone.”
Having thus presumably aroused our concern, Dr. Hiatt then offers an informative combination of statistics and individual case scenarios to indicate the bases for concern. The broad picture shows the U.S. among nations to be 17th in infant mortality, 14th in average life expectancy, and “the only industrialized country without medical insurance for all.” Later in the book are summarized studies showing that there is often little correlation between the intensity of medical services in an area and many of the usual indices of population health.
One direction such an observation might take us would be toward better analyses of the effectiveness of existing diagnostic tests and treatments. (Indeed, a later chapter in this book devoted to medical technology assessment is especially valuable.) Another inference, however, might be that “medical practice” (as it was called prior to its replacement by the more euphemistic “health care”) is not so much the determinant of a population’s health as are the nonmedical, social factors of prudent behavior, education, prosperity, and family or community support. Those who incorporate all of society’s problems under a medically oriented framework of responsibility will have an endless expansion of medical costs, as well as disappointment in its results. Although Dr. Hiatt late in the book acknowledges this, his general posture is more that of an optimistic, liberal reformer with a belief that remedial, collective action is possible and desirable.
The case illustrations make statistics and generalizations more real and palpable by bringing us close to the circumstances and individual texture of living with disease, uncertainty, and fear, , Stories are given which illustrate the value of a primary, personal physician (as both “gatekeeper” to specialists and source of personal counsel); some assets and limitations of high technology; the adverse impacts of limited insurance, especially for chronic nursing needs; the effect of ample insurance encouraging the performance of tests and treatments of questionable benefit; the performance of procedures tending to inhibit needed personal communication and advice from physicians; and the incentives, including malpractice litigation, for attempting aggressive rescues of relatively little benefit for many terminally ill persons.
Before offering proposals for reform in the United States, Dr. Hiatt offers lessons from Britain and Canada. In Britain central budgeting of tax-derived funds, administered regionally for hospitals and physicians, results in universal access of citizens to some medical care at about one-third of the cost per capita spent in America, and with no major differences in health status (at the whole population level of measurements). Unrecognized rationing in America now occurs to the extent that the poor and uninsured cannot pay for major medical expenses and may be denied care. Rationing in Britain takes the form of ineligibility for kidney dialysis of persons more than 70 years old, long waits for elective operations, probably more “do not resuscitate” orders, and others. British physicians’ salaries and freedom to specialize are less. Some observers like the author consider the British advantages persuasive, especially as concerns about cost here become dominant. Nevertheless, the growth of a “private” medical establishment in Britain in recent years as a means of circumventing the austerity of the National Health Service suggests the existence there of a market for escapees from their rationing.
Central management of resources also in Canada permits allocation by government rather than by free market— whether to nursing homes or development of cardiac surgery or CT scanners—on the basis of the government’s perception of public need. This results in slower diffusion of innovation, especially in expensive new technologies; it also produces more efficiency and less overutilization in order to recover the costs of development seen in the private American system. Dr. Hiatt does not mention the dissatisfaction of Canadian physicians, resulting in several major strikes by doctors in recent years.
Having provided a survey and selected illustrations of both our problems and our successes, Dr. Hiatt wisely divides his recommendations into two general areas. The first addresses broad policies—disease prevention as preferable to diagnosis and treatment, and support for research at both the biological and socioeconomic levels. The second area is a relatively specific proposal, devised by himself and Harvard colleagues in 1977, for universal medical insurance and the management of resources by quasi governmental regional health authorities, approximating the systems in place in Britain and Canada.
Prevention of disease through environmental improvement and immunization in the first half of this century accomplished much at relatively little cost. For many of our currently preventable diseases, however, the needed actions appear to require compromises with some individual privileges dear to many—tobacco smoking, alcohol abuse, free access to firearms, and reckless driving, to name a few. Dr. Hiatt, a loyal academic, recommends “more research” on human behavior in order to reduce these. Others might simply suggest that both fiscal and preventive goals could be achieved by requiring that major payments to the medical system be made by both the producers and consumers of tobacco, alcohol, and handguns, perhaps in proportion to that portion of the system’s cost generated by them.
The differences between purely theoretical, biological research and evaluating applications in diagnosis and treatment are described well, including the risks involved in the necessary division of support. The gains from basic research are uncertain and delayed in arrival, but of greater lasting impact in general than the results of applied research. Hence, the need for an arbitrary commitment to support of such studies as the molecular biology of cell replication, which might give a clue to eventual prevention or control of many cancers. Applied research, including technology assessment, requires simultaneous pursuit. Many “cures” were introduced and widely applied in the recent past—gastric freezing for ulcer, radical mastectomy for breast cancer, and others— before they were proven ineffective, or less effective than simpler treatments already available.
The author’s preference for an ostensibly or almost-one-class system of medical services under the direction of a public agency undoubtedly seems out of step with the conservative or libertarian 1980’s. Realistically he proposes options for regional policy variations, such as the use or avoidance of medical co-payments and deductibles by patients to discourage overuse of medical resources. Amenities, such as cosmetic surgery and single-patient hospital rooms, would still be available to those willing and able to pay extra for them. There is wide agreement that the United States is moving toward more corporately managed systems for providing medical services, all of which require some degree of rationing by some mechanism. Some of the national leadership has confidence in the ability and willingness of industry and the profit motive to achieve much of what is needed. Competition within the private sector in offering managed health systems is advocated as the device for achieving maximal quality at minimum cost. On the other hand, many physicians believe that such an environment would lead to more entrepreneurial behavior and less idealistic and humanistic activity by physicians. Still others believe that the medical area tends to defy the usual market rules, that the poor would remain neglected, and that such policies would repolarize society into classes based on ability to pay.
An important reminder in Dr. Hiatt’s book is that some of our social pathology, especially among the poor, may result in part from lack of access to basic medical services, as well as contributing to a need for those. Thus 20 years after Medicare and Medicaid in America, concern about equitable access to basic medical needs is appropriate not only from compassion but also from long-term self-interest. Not all will agree with Dr. Hiatt’s choices, but all will leave his book more informed about the nature of choices having to be made.
