Friday, June 19, 2009

Points of View on Health Care

I did something I almost never do: I "clicked through" on an advertisement placed on a Web page I was reading. This just happened to be a case where the connection seemed logical. The Web page was on Truthdig with the provocative title "Health Care Fail." This was in their Ear to the Ground section, where they report on what other sources are reporting, usually with a tempting introduction. In this case the introduction was as provocative as the title:

By one estimate, Sen. Max Baucus gets about $1,500 a day from the health industry. Who put this man in charge of health care reform? The senator’s latest innovation in compromise is to slash proposed insurance subsidies in a bid to get Republicans on board. And forget about a government-run insurance program.

Did the American people really fill the White House and both chambers of Congress with Democrats in order to placate Republicans?

The advertisement was placed by the Robert Wood Johnson Foundation. The "message" (with colors reproduced) was "When you need just the facts about" Other than this message, the ad consisted of nothing more than the name of the Foundation and its logo. Since I was curious as to what their position was on health care reform, I figured it was worth taking the "click," which took me to the following statement (which is on the page one would find by entering as a URL):

Health care is an economic as well as a social issue. In 2008, the United States spent more than $2 trillion on health care—nearly 17 percent of our entire economy. Meanwhile, 46 million people are uninsured. But extending coverage to the uninsured won't solve what's ailing the health-care system. Meaningful reform also requires improving quality, emphasizing prevention and reducing costs.

In order to read this statement in its proper context, we need to bear in mind just who Robert Wood Johnson was. It takes a few clicks to get there, but that information is provided on the Foundation's Web site. Here is the entirety of the description:

Robert Wood Johnson was one of the twentieth century's most innovative and colorful business leaders. He built Johnson and Johnson into a world-renowned company and gave new meaning to the need for corporations to serve the public interest. His generosity created one of the nation's most significant philanthropies dedicated to improve the health and health care of all Americans.

In other words this is the philanthropic arm of Johnson & Johnson, named for one of the two Johnsons. Does this reflect a bias in how the Foundation is committed to doing "good works?" There may be grounds for this being the case that I would like to explore.

I take, as my own point of departure, Arnold Relman's article in the latest issue of The New York Review, entitled, "The Health Reform We Need & Are Not Getting." In the spirit of the post I put up yesterday, Relman recognizes that the crux of the health care problem is all about the money. However, rather than going down the path I took yesterday concerned with who will pay out that money, Relman begins by asking why the expense is so great:

Health care in the US is about twice as expensive per capita as in other developed countries—nearly 17 percent of US GDP in 2008—and its costs are rising faster.

Relman's first explanation for this expense is basically one of a disconnect between supply and demand:

This difference is partly explained by a higher proportion of specialists in the US, who rely more than primary care physicians on expensive technical procedures for their livelihood, and in general are much more highly paid than primary care physicians—one reason why primary care doctors are now in short supply.

However, Relman saves the more significant differentiating factor for his final explanation:

Another very important but often overlooked reason for greater health expenditures in the US is that, more than in any other advanced country, large parts of the system are owned by investors. As a result, the entire system behaves like a profit-driven industry, as I described two years ago in my book A Second Opinion. The commercialization of our health system dates back only a few decades, but its consequences are profound. Investors now own about 20 percent of nonpublic general hospitals, almost all specialty hospitals, and most freestanding facilities for ambulatory patients, such as walk-in clinics, imaging centers, and ambulatory surgical centers. These medical care businesses, like other businesses, need profits to satisfy their investors, and for this purpose they use marketing and advertising, directed at physicians and the general public.

To remain competitive, many not-for-profit hospitals promote their bottom line just like their for-profit counterparts, vigorously advertising their facilities and services to the public. No other health care system is as focused on generating income as ours, and in no other country is medical care marketed and advertised so aggressively, as if it were just another commodity in trade. This increases health costs, while hospitals concentrate on the delivery of profitable, rather than effective, services. It also favors those who can pay over those who need medical care but can't afford it.

There is a lot of highly charged language in those two paragraphs, none of which puts a corporation like Johnson & Johnson in a particularly favorable light. Relman's perspective may also explain why the ostensibly philanthropic position statement by the Robert Wood Johnson Foundation should recognize heath care as an economic issue before recognizing it as a social one.

This brings us back to the Truthdig article and its first sentence. As long as health care is an industry, rather than some form of public service or public trust, all of the stakeholders in that industry (and their numbers are legion beyond imagination) will rally to maintain that industry status. The sharp point of their sword has always been, and will probably continue to be, the demonization of the concept of socialized medicine. We are all seeing that demonization at work through advertising campaigns; and, as Truthdig has reminded us, it is also at work through high-stakes lobbying. Unfortunately, it is also at work through institutions that, on the surface, appear to be philanthropic organizations interested in the public good; but when such organizations come to our attention through strategically-placed keyword advertising, we should be suspicious.

Can the public good prevail in the face of such opposition? Yesterday I was reading one of the chapters in From Max Weber in which he cited a favorite proverb of his contemporaries:

Mind you, the devil is old; grow old to understand him.

Weber then interpreted this text as follows:

It means that if one wishes to settle with this devil, one must not take to flight before him as so many do nowadays. First of all, one has to see the devil's ways to the end in order to realize his power and his limitations.

The devil of health-care-as-industry is, indeed, old (at least as old as Johnson & Johnson). His ways are subtle, but it does not take much critical inquiry on our part to see them. The trick will be to see his limitations and use them (perhaps in the spirit of judo) to restore health care to its rightful status as public service.

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