Healthcare Today by Cindy Reed, RN, ThD, PhD

The state of American health is declining, and the healthcare system is in crisis. Healthcare in the United States, while touted by Americans as the best in the world, is dysfunctional, costly, and a burden on the economy that threatens to bankrupt us. We need new solutions to the problems and issues that are outside the widely accepted medical model, solutions that take advantage of advances in other areas such as science and spirituality. Health is not an isolated physical condition, as depicted by the current medical model, but is an intertwined and interdependent blend of physical, emotional, social, spiritual, and environmental determinants. Health is an issue that is critical not only to the well being of our citizens, but to our economy and our way of life as well.

THE COST OF HEALTHCARE

Currently healthcare costs comprise one sixth of our national economy and consumed 15.4% of our Gross National Product in 2003, a higher percentage than any other major industrialized nation, and up from 7% thirty years ago. In contrast, education spending as a percent of the Gross National Product has remained steady during that same time period at 6%. In 2003, 45% of the costs of healthcare were borne by public programs like Medicare and Medicaid, which is predicted to increase to 49% by 2014. Another 40% of the cost of healthcare is borne by business: General Motors reportedly spends $1,400 per vehicle to provide healthcare for its employees and retirees, more than the cost of the steel. Some predict that in nine years, by 2014, we will spend 3.6 trillion dollars on healthcare, or 19% of the U.S. economy. As of the mid-1990’s, the federal government was spending 20% of its budget on healthcare. Still, a large part of the problem, identified by the Tufts Managed Care Institute, is the healthcare systems’ increasing capacity to provide care, which is not necessary or beneficial, and is of marginal utility.

The system that costs so much is also the leading cause of death in America: iatrogenesis, not heart disease or cancer, kills more of us than anything else. Bartlett and Steele explain how we spend more money and have less to show for it than other developed countries:

"We don’t adequately cover half of the population. We encourage hospitals and doctors to perform unnecessary medical procedures on people who don’t need them, while denying procedures to those who do. We charge the poor far more for medical services than we do the rich. We force senior citizens with modest incomes to board buses to Canada to buy drugs they can’t afford in America. We clog our emergency rooms with patients because they can’t get in to see their doctors. We spend more money treating disease than preventing it. We are victims of rampant fraud and over billing. We stand a good chance of dying of a mistake if we are admitted to a hospital, and we kill more people with prescription drugs than with street drugs like cocaine and heroin. We have an endless choice of healthcare plans, but most people have few real choices. We are forced to hold bake sales, car washes, and pancake breakfasts to pay the medical bills of family members when a catastrophic illness strikes."

It is a complicated, multi-interest system where the business incentives are aligned to keep people unhealthy. People are beginning to seek alternatives to the current system, and utilizing their own resources to improve their health. According to Paul Zane Pilzer:

"Approximately 1.4 trillion dollars a year is dedicated to the “healthcare industry”, while another 200 billion this year will be spent on what are commonly referred to as wellness products. It is projected that by 2010, the “wellness industry” will be an additional 1 trillion dollars of our US economy. Yet, 85% of individuals finance their medical care through a system of insurance that absolves them in large part from any direct responsibility for their medical expenses while disallowing any preventative services for reimbursement."

Healthcare costs to employers are skyrocketing in this system, and the proliferation of HMO’s and managed care, as a way to control costs, has been the beginning of the end of the free-for-all system of care. Health insurance plans attempt to control costs by restricting access to providers, eliminating costly treatment benefits, requiring pre-approval for care that meets medical necessity criteria, restricting access to certain medications through “approved formularies”, charging higher deductibles and co-payments for services, as well as increasing health insurance costs to the employee. These have all failed to impact the rising cost of care.

Paradoxically, as technology advances and systems of care proliferate, as interest in maintaining and improving health increases, and the appeal of complementary and alternative medicine grows, the health of our nation seems to be declining instead of improving. In June of 2004, Time Magazine reported that one of the latest health epidemics to strike the American people is the ‘Epidemic of Obesity’. Despite the proliferation of nutrition and exercise information, as well as health risk information available, in 2004 over one half of all adults in the U.S. are overweight, and one half of those are officially obese. By 2005, only 30% of Americans identified themselves as overweight or obese, while the Health and Human Services Department of the Federal Government classified 64% of Americans as overweight or obese. Starfield found 40% of the American population — 100 million people — to be suffering from serious chronic disorders. While some, such as Tufts Managed Care Institute and current political candidates tout the healthcare system of the United States as offering the highest quality of care in the world, the reality is that 15% of Americans have limited or no access to healthcare because they are uninsured. In addition, the United States falls behind other industrialized countries in population based healthcare measures such as life expectancy and infant mortality. Iatrogenesis is now the leading cause of death in the United States. In their definitive reviews of medical journals and government health statistics, Null, Dean, Feldman, Rasio, and Smith found:

"…that American medicine frequently causes more harm than good. The number of people having in-hospital, adverse drug reactions (ADR) to prescribed medicine is 2.2 million. Dr. Richard Besser, of the CDC, in 1995, said the number of unnecessary antibiotics prescribed annually for viral infections was 20 million. Dr. Besser, in 2003, now refers to tens of millions of unnecessary antibiotics. The number of unnecessary medical and surgical procedures performed annually is 7.5 million. The number of people exposed to unnecessary hospitalization annually is 8.9 million. The total number of iatrogenic deaths is 783,936. It is evident that the American medical system is the leading cause of death and injury in the United States. The 2001 heart disease annual death rate is 699,697; the annual cancer death rate, 553,251."

Yet, our research dollars, institutions of higher learning, the government, and private organizations do not focus on finding a ‘cure’ for the sickness that is our healthcare system, but instead concentrate on diseases like cancer and heart disease. Overall, therefore, while there is lots of care being produced, it seems to be making us worse, not better. Clearly a change is needed if we are going to stay healthy and not bankrupt the country. But where to start?

THE PROBLEM

There are five principal parties in the healthcare system: consumers (clients), government, insurers, providers, and the legal system. Each plays a key role in maintaining not only the dis-ease of the system, but of our declining health as a nation. Though we call it an industry, the healthcare system it is really not structured like the other industries in a free market economy. In a free market economy, consumers and sellers of a product come together with the benefit of competition. In health care, the consumer is not really the purchaser. There are two purchasers of healthcare: employers, who purchase health care insurance from payors, and the government, which purchases care for its Medicare and Medicaid programs from providers. Employers and the government provide coverage for 85% of the population. The government mandates the price it will pay providers, based on complex formulas that providers can’t understand. Payors (who provide coverage to employers), who understand that the government prices are the lowest that providers will accept, try to negotiate prices as close to the governments rates as possible. The providers have no ability to negotiate with the government on pricing or scope of services covered, but they do negotiate with payors individually. Of course, providers, who have no option but to accept government prices, want to increase prices to the payors, so that they can maintain profit margins. The providers set charges for their services; however, the payors negotiate discounts on the charges. In reality, the only people who actually pay what the providers charge are the 15% of the American population with no insurance. The purchasers of healthcare (employers) are precluded from negotiating collectively with providers (the rules and regulations of the healthcare system make it cost prohibit for employers to do this), which means the payors have significant control. As long as the payors can charge purchasers more than they pay providers, they have little incentive to invest in new methods of health care provision. Providers, who are receiving discounted fees from payors, and deeper discounted fees from the government, also have little incentive and few resources to improve efficiencies or contain costs.

Managed care has attempted to control costs through capitation arrangements, in which providers are given lump sums to provide care for a group of people or for a set of services to a group. In theory, this gives providers an incentive to control the direction and costs of care. However, consumers now have an entitlement mentality because they have been taught that their insurance will pay for whatever they need. Consumers are insulated from the costs of care and have been trained by the system to expect that they can have whatever services they need while their insurance coverage lasts. This has begun to change recently, as employers have had to cut benefits or implement cost sharing strategies (such as deductibles, co-pays, and co-insurance) to attempt to deal with the rising cost of healthcare. However, consumers continue to demand what they perceive to be high quality in health care, much of which they learn about from television, advertising, and the internet. This puts providers in the position of explaining to consumers what is truly needed from a medical perspective and what is not. Yet providers have been trained to make treatment recommendations based on what a consumer’s insurance would pay for, and have not risen to the challenge of managed care: that providers would actually manage the care of the consumer. The interesting thing is that in our healthcare system, the definition of quality healthcare actually comes from the healthcare system itself. Pharmaceutical companies, insurance companies, healthcare systems and their suppliers, and powerful professional organizations through their advertising campaigns and lobbying of the public and legislature(s), all define quality healthcare in terms that protect their own parochial interests and profits.

In our system, if a consumer perceives that quality services were not rendered, s/he can turn to the court system and use legal recourse to make the provider, insurance company, or health institution pay monetarily for the perceived mistake. Thus, the legal system and lawyers in particular are also beneficiaries of the structure of our healthcare system. Healthcare has provided a growth opportunity in the legal specialty of malpractice. Malpractice also provides additional business for insurance companies, as now providers must protect themselves against the consumers they treat, while consumers use this avenue of problem resolution to protect themselves from incompetent providers. This avenue of recourse for consumers has encouraged providers to give consumers the most healthcare possible, in an effort to avoid prosecution. This then increases costs to the payors (insurance companies), who, in order to maintain profit margins, increase prices to employers. The government does not respond to the same price increases, though it must be aware when its funding level puts the service delivery system out of business. Institutions that are primarily funded by the government have a very difficult time making a profit.

John McKnight, in his book The Careless Society: Community and Its Counterfeits, goes beyond the typical analysis of healthcare system failure to identify the roles that all the parties play in maintaining a system that is diseased itself. McKnight asserts that the problem is not that we have ineffective service producing systems, but that our systems are too powerful, and our communities too weak. He believes that:

"The most significant development transforming America since World War II has been the growth of a powerful service economy and its pervasive service institutions. Those institutions have commodified the care of the community and called the substitution a service."

McKnight believes that physicians, and the institutions that have grown up around healthcare systems, are exemplary models for professionals seeking imperial prerogatives. At the core of our healthcare system is a paradigm for modernized domination, which functions through the propagation of a therapeutic ideology. The basic creed of the ideology is: “1) the basic problem is you, 2) the resolution of your problem is in my professional control, and 3) my control is your help”. The essence of this is to mask the control that the healthcare system wields behind the smokescreen of therapeutic help.

Obviously, our healthcare crisis begs for reform of the system. Unfortunately, healthcare reforms perpetuate the dis-eased system, as the healthcare systems themselves define both the problem and the solution. Rather than significantly changing the system to benefit those it attempts to serve, each reform is a new growth opportunity for the system to exert control and expand its influence. McKnight views the current reforms in Table 1 as advancing medicine’s hegemony:

Table 1 . Healthcare Reforms and Their Result.

Reform

Result

1. Effort to ensure equal access to medical care (supporting doctors in underserved areas, programs to increase the number of healthcare workers, regulatory systems allocate beds based on medical need). 2. Focus on improving the quality of healthcare (increased professionalization and review processes are supported by federal, state and medical practitioners). 3. Attempts to deal with costs (comprehensive prepaid systems, HMO’s, Medicare/Medicaid and the national health insurance discussion represents efforts to conquer the medical systems’ growing capacity to consume the gross national product). 4. The effort to involve “health consumers” in the system (government and medical industry gradually enabling non-professionals to participate in the decision making processes of the system). 5. The increase concern over ethical issues posed by modern medicine (organ transplants, abortion, life extension technologies provide new crises and new public and professional policies). 6. The preventative healthcare movement (provides policy alternative to “get at the root of the problem”, calling for continuing check ups, screenings, and outreach plans designed to encourage and enable more people to use the system).

1. Achieving equal access broadens clientele base and establishes the right to consume services as a central issue, while litigation establishes the ‘right to treatment’. 2. The guarantee of quality services reinforces the popular belief that that health care professionals know what health is, while the critical issue is making the professionals produce “it”. 3. Cost control ensures a rationalized guarantee of the medical systems income, with the central issue being how to extend the system while lowering or stabilizing the price. 4. Consumer participation co-opts potentially disruptive citizens by providing participation in medicine as a substitute for political action that might affect the system. 5. Ethical reform could limit medical hegemony by concluding that such issues are not medical prerogatives, however, theologians and clergy have been co-opted by expanding their trade and becoming counselors for decisions 6. “Preventative” medical care can make every person a client everyday of his life—medicalized prevention tells us that we need the medical system precisely because we do not perceive a need.

Note: From McKnight, L. (1995). The Careless Society: Community and its Counterfeits. New York: Basic Books p.56-60.

Health care reform to date has not only promoted the growth of the system, but has had political implications as well. In our economy, the expansion of healthcare systems creates new markets, new income opportunities, and forestalls unemployment, all disguised as help. Expanding medical systems also require the manufacture of need, and as each need is created, citizens have an increased sense of deficiency and dependence. To meet the ever-growing demand, we have to have more trained professionals. McKnight believes that an essential function of professional training is to increase the capacity of the trainee to define others as deficient while decreasing their capacity to cope. Also, as physiological health diminishes while medical resources increase, political energies are increasingly consumed with healthcare system reform, which reinforces the need for and the dependence on the healthcare system. Medical care then becomes a placebo for political action. Almost half the patients seen in the U.S. are classified by physicians as being seen for non-physiological problems. When asked why, physicians identify a host of cultural, social and economic problems that might be addressed by political action if patients were not being taken care of in the healthcare system. As public belief in the need for medically defined services expands, people act less like citizens and act more like clients—people who believe that they are going to be better because someone knows better.

Looking at one of our latest epidemics in healthcare, the epidemic of obesity, 88% of those surveyed thought the government was doing too little or the right amount. Only 8% thought the government was doing too much, and 4% were unsure. Curiously, the Time magazine poll indicated respondents thought that the top two causes of obesity were not getting enough physical exercise (86%) and poor eating habits (84%). Lack of information as a cause for the epidemic was at the bottom of the list. This suggests that McKnight is on the right track with his ideas about how the current system of care keeps the public dependent and despondent: the top two causes are well within individual control, however, 88% of the respondents wanted the authorities to continue or increase addressing the problem.

Healthcare, through its processes and institutions, has had the unintended side effect of making health and healing mysterious, to the point of commodifying the service so that people consume it, even if they don’t understand it. The system clearly appears to be set up to serve those who run it. We have all been co-opted as consumers and/or players in the system services. As McKnight points out:

"Many people encounter a life interruption, call it a disease, and take it to a doctor or a hospital where it is treated un-understandably by people who speak in mystifying tongues. The result is for the “person” to become a “patient” in the face of the malady. The malady becomes a commodity of the medical profession, and health becomes a consumable as citizens become “health consumers”. There is, of course, no possibility that health can be consumed. [The] health consumer….is a medically engineered mythical being has entered the fantasy life of modern society and emerged as a client…[which] is the necessary commodity to meet the needs of the medical system. Thus health becomes a new medium for converting citizens into clients who consume the systems commodities in order to achieve well being."

The fact that 15% of the population has no health insurance and thus limited access to the system might just save their lives. McKnight quotes the motto placed on bottles of famous medicine maker, Eli Lilly, in his early days: “a drug without side effects is no drug at all”. In fact, McKnight asserts that the negative side effects of the healthcare system are now manifest at multiple levels of our everyday lives, so much that we hardly notice the program to perpetuate dis-ease running in the background. In the future we will see increasing public awareness of the abdication of our power as individuals within the healthcare system, the ways in which we unwittingly participate in advancing the growth of the system, and the steps we can take to reclaim what is actually our health.

REFERENCES

1. Healthcare can be cured: Here’s how. (2004, October 11). Time Magazine, 164, p. 50.


2. Numbers. (2005, March 7) Time Magazine, 165, p. 25.


3. Health, United States, 2001(on line). Available from http://www.cdc.gov/nchs/products/pubs/pubd/hus/heexpend.pdf; accessed 24 November 2001.


4. Tufts Managed Care Institute. (1998). The Healthcare System in the United States: Integrating Costs and Quality [Data file].Tufts University. Retrieved June 10, 2004 from http://www.thci.org/downloads/USHealthSystem.pdf


5. Healthcare can be cured: Here’s how. (2004). Time Magazine, 164, p. 53.


6. Dean, C., Null, G., Feldman, M., Rasio, D., & Smith, D. (2003, October). Death by Medicine. Retrieved April 22, 2004, from http://www.newmediaexplorer.org/sepp/Death%20by%20Medicine%20Nov%2027.doc


7. Bartlett, D. & Steele, J. (2004) Critical condition: How Healthcare in America became Big Business—and Bad Medicine. New York: Doubleday, p. 50.


8. Pilzer, Paul Zane. (2001).The Next Trillion. Lake Dallas, Texas: VideoPlus Inc. Edition, p. 10.


9. Lemonick, M. K. (2004). America's Obesity Crisis. Time, 163, 57-113.


10. Starfield, B. Primary Care 21st Century Challenges to Quality. Paper presented at the May 2002 Primary Healthcare Conference, Wellington, New Zealand. Retrieved February 12, 2003 from http://www.moh.govt.nz/moh.nsf/Files/bStarfieldpdf/$file/bStarfield.pdf. pv(' http://www.moh.govt.nz/moh.nsf/Files/bStarfieldpdf/$file/bStarfield.pdf ','1', 600)


11. Tufts Managed Care Institute. (1998). The Healthcare System in the United States: Integrating Costs and Quality [Data file].Tufts University. Retrieved June 10, 2004 from http://www.thci.org/downloads/USHealthSystem.pdf


12. Goran, M. (2004). The Health Care Cost Crisis; Can it be Managed?. Retrieved June 10, 2004, from http://www.bryancave.com/FILES/tbl_s23News/PDF118/783/goran,%20ingrams.pdf
    
13. McKnight, J. (1995). The Careless Society: Community and its Counterfeits. New York: Basic Books.