Map of life expectancy at birth from Global Education Project.

Monday, June 11, 2007

Long, slow, ineluctable slide?

I was cleaning out some old files and I found a document from around 1997, a pre-publication draft entitled A Call to Action. It begins:

We are Massachusetts physicians and nurses from across the spectrum of our professions. . . .Mounting shadows darken our calling and threaten to transform healing from a covenant into a business contract. Canons of commerce are displacing dictates of healing, trampling our professions most sacred values. Market medicine treats patients as profit centers. the time we are allowed to spend with the sick shrinks under the pressure to increase throughput, as though we were dealing with industrial commodities rather than afflicted human beings in need of compassion and caring. The right to choose and change one's physician, the foundation of patient autonomy and a central tenet of American medicine, is rapidly eroding. . . "

Among their principals: Pursuit of corporate profit and personal fortune have no place in caregiving. (Funny thing about that - one of the signers of the manifesto, Mitchell Rabkin, at that time received a salary of $1 million per year as president of Beth Israel hospital.)

Anyway, the group, then the Ad Hoc Committee to Defend Health Care, went on to become the Alliance to Defend Health Care, which still exists. Their web site is here. The original manifesto, more or less similar to the draft, is posted there.

So where have we come in ten years? I would say that things are only slightly worse than they were back then. The proportion of the population that is uninsured has grown just slightly; takeovers of non-profit institutions by for-profit corporations have proceeded slowly. More of us are insured by business corporations than by non-profits, and there are more for-profit hospitals and specialty health care providers. However, it isn't really clear that the trend has made patients who are lucky enough to be insured terribly worse off. The main reason is that a physician and consumer rebellion against some of the worst excesses of managed care tempered the restrictions on physician decision making that I believe largely inspired the manifesto.

The fact is that the structural problems that existed then are about the same now: a patchwork of payers that leaves a lot of people out entirely and underinsures many more; and financial incentives that reward high tech, expensive interventions after people get sick, while discouraging adequate preventive care, interpersonal care, and public health programs. We have managed to reduce the death rate from cardiovascular disease by about half, for example, in good part due to drugs and surgery, with a very important boost from reduced rates of smoking, which is a creditable achievement. But we have more and more people living with heart disease and our expenses for treating them have increased dramatically. The obesity epidemic is probably going to exacerbate this trend notably in the near future.

The inequities in health status, access to health care, and health care quality have just gotten worse. The time physicians have to spend with patients is slightly less, although that is more a function of physicians' demands for high incomes than it is of corporate greed. (Hate mailers will find my e-mail address on the side bar.) Granted, if financial incentives shifted to better reward primary care, that would also help, but it doesn't matter whether insurers are for-profit, non-profit, or public, they all have the same incentives.

This is a very sketchy review, given that this is just a quick blog post. An in-depth discussion of where we've come in ten years would require a book, and I haven't been offered the contract yet. But we very definitely have not made any progress.

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