Jonathan L. Otten (*)


The American people often like to view themselves as being on the vanguard of all progress in science and technology and especially as these disciplines relate to medicine. And while there is no doubt that the United States' contributions to these developments are significant, the nation's own healthcare system is currently laden with a myriad of inadequacies. These shortcomings are complex and their basal causes are often obscured or even buried under a complex array of cultural, political, and economic factors. Without considering the history of the healthcare system, any action to improve it would likely prove futile.

There are three significant issues on which I will focus in this paper. There are many issues that will be addressed sub-categorically to these larger issues. The categories are somewhat artificial but assist in organization. The first two are in regards to shifts that have occurred over the history of our healthcare system that I believe contribute to some of the inadequacies of the current system. Additionally I will focus on what is both a historical and a contemporary debate that will ultimately determine what type of healthcare system we are to have. Certainly none of the shifts are to be viewed as complete or simply to have occurred in only one direction, but rather to be seen as general trends.

The first issue that I recognize to be a problem is the general trend of medicine transitioning from a field strongly associated with altruistic intentions and the object of philanthropy to an industry that is highly profit driven and is hardly distinct from any other sector of the economy. If the primary motivation for healthcare is profit, one can be sure that the results will not be the same as if this motivation was secondary or absent. While this drive for profit results in competition that fuels many advances in technology, we seem to forget that some people were healthy long before technology. While the successful can enjoy the benefits of this progress in science and technology, a large segment of the population is either uninsured or relies on a patchwork of government programs, such is the case with the Banes family in Mama Might be Better Off Dead: The Failure of Health Care in Urban America.

Government programs play a significant role in the industrial expansion of healthcare and it becoming profit-oriented. As Rosemary Stevens writes in Medicare and the Transformation of the Medical Economy, “Medicare was a catalyst, testing the organizational resilience and the social altruism of the voluntary enterprise - testing, that is its essential character…. [Medicare's] great expansion made possible by the dollars available for reimbursement was to lead, first, to a rapid expansion in hospital services and expenditures, but along preexisting lines; and second, in sequence, to a focus on capital expansion, an overtly profit-making nexus, huge industrial growth, and federal regulation.”

The problem with this approach of course is that eventually our high-tech solutions are bound to cost more than we have available resources. Eventually decisions have to be made, and it is here where I believe small, local philanthropic interests would manage resources better. With healthcare cost inflation becoming a significant issue, why is it that prevention has not been stressed? No healthcare cost analyst would deny that prevention costs are miniscule in comparison to heroic treatments following onset of disease. Not only is prevention not emphasized, it is often discouraged by the government's own programs. As Laurie Abraham writes, “Many devices or supplies that can prevent disease and disability from worsening are not covered by Medicare because its reimbursement criteria emphasize curing acute conditions rather than maintaining health or improving daily functioning - a policy that may be penny-wise but pound-foolish.” Perhaps the most likely reason that prevention is not emphasized is because of the very nature of it being low cost and therefore there is little to capitalize on.

The transition of medicine to a more profit-driven field cannot simply be considered a shift in attitudes of doctors and nurses, but is really a product of decisions made by our society. Some of these changes are indeed self-perpetuating and while this is perhaps most clearly seen in the government programs like Medicare and Medicaid, private insurers are definitely contributors to this transition as well.

The second disturbing trend is the increasing complexity of the entire third-party payer system. It is estimated that approximately one quarter of America's health care spending goes towards administrative costs. It is often apparent to myself that Laurie Abraham is explaining the government programs in probably the simplest way possible, and yet it could easily get a college-educated individual confused. How is a less educated person supposed to benefit from such a system without the help of a fulltime social worker? It is quite probable that the social worker is struggling to understand the system, which is of course under continuous modification? While I can see obvious problems in socialized medicine, one advantage I imagine is that a nation would not spend billions of dollars deciding who should get what kind of care when.

The incredible burden on the Banes family as a result of the complexity of the system permeates the entire story. Perhaps the best example of this in the book was all of the concern regarding the “spend-down” procedure for Mrs. Jackson to ensure her income was low enough that she would receive a medical card each month. The Banes family, particularly Jackie, expelled a tremendous amount of energy simply trying to “work the system.” Some of these measures seem completely ridiculous to a middle class person, but if one can only see through the eyes of the less fortunate, as Laurie Abraham has tried to allow in her book, we can see that what they are doing makes perfect sense to them - or at least seems to be the best option. With the accumulating evidence indicating that people who live under prolonged levels of elevated stress are at increased for developing heart disease, I believe that a priority in health care must be to simplify any type of government program with the purpose of benefiting the citizens' health.

The ongoing debate in the history of U.S. health care is over the question as to what extent the government should be responsible for the health of each individual citizen. Recently this was manifest on the political scene with the debate over prescription drugs for seniors in the Medicare reforms.

I believe that the government's future role in health care is dependent on determining what we as a nation collectively value. On the political right we have voices saying that there is no constitutional basis for any involvement by the federal government in health care (other than as it relates to the military). Therefore any change would require amendments. However, the reality is that the government currently plays a significant role. The political left probably desires some type socialized medicine and will view any steps towards such a system as being too painfully slow.

While it is apparent as to the general political stance of Laurie Kaye Abraham, it is interesting that in her work there appears to be an ongoing dichotomy in which she brutally exposes the inadequacy of government's contributions to the system while not really acknowledging the fact that perhaps it is this same large bureaucracy that is the causative factor of many of the problems. Not to say that Abraham is ignorant of this fact, rather I believe the purpose of her work is more of an expository of the insufficiencies rather than a solution manual.

Are we concerned with the health of each individual within our borders or must a person meet certain social standards that will determine what type of care they are to receive? Is healthcare a “right”? If so, what level of healthcare will fulfill such a “right”? And in a world of limited resources - which many people who are highly emotionally involved in an issue seem to forget - who will determine the amount that should be devoted to healthcare? And though this may sound unintelligible: what finally does constitute “healthcare”? It seems that the majority of our resources go to something that would be more appropriately labeled “disease-care” or “sickness care.”

While personally I believe in a society in which each individual is concerned with the wellbeing of the rest of the citizens - often at the sacrifice of his/her own interests - I find in myself great reservation and lack of confidence in the ability of a large federal government to effectively administrate such a colossal task as insuring healthcare for all its citizens. I have little faith that a nation that cannot even agree on a definition of its own system of government (i.e. “Are we a democracy or republic?”) has the resolve to solve its healthcare dilemmas. And if history is any indication as to the future, I think my lack of confidence may be well founded.

References:
Abraham, Laurie Kaye. Mama Might Be Better Off Dead: The Failure of Health Care in Urban America. University of Chicago Press, 1994. p. 53.
Stevens, Rosemary, “Medicare and the Transformation of the Medical Economy.” Major Problems in the History of American Medicine and Public Health. Boston: Houghton Mifflin Company, 2001. p. 486.
Abraham, Laurie Kaye. Mama Might Be Better Off Dead: The Failure of Health Care in Urban America. University of Chicago Press, 1994. p. 48.
Abraham, Laurie Kaye. Mama Might Be Better Off Dead: The Failure of Health Care in Urban America. University of Chicago Press, 1994. p. 53.
http://www.whitehouse.gov/infocus/medicare/
(*) A note about the author and this article

Jonathan L. Otten happens to be the editor's nephew and is a pre-med student at the University of Minnesota, majoring in human nutrition. Before reaching the age of twelve, he lost his mother to breast cancer. (Because chemo by its very nature kills fast growing cells indiscriminately - not just cancer cells - it has a devastating effect on the entire digestive system's rapidly growing lining cells. Consequently many chemo-treated cancer patients actually die of malnutrition, not cancer per se.) This event had no small effect on Jonathan's interest in wellness, prevention and nutrition.

American medical history is filled with all kinds of extremely unsavory - often gruesome and even criminal - events, pursuits, and practices, as well as great advancements, especially in technology. (But technology per se does not equate health.) This paper was written as part of a class assignment in Medical History, an extremely interesting topic for anyone to pursue.

Some readers may still remember how little we spent on healthcare before the introduction of Medicare by the federal government in the early 1960s. (The editor and two others had a near-fatal car accident in California in 1960, requiring hospital care for ten days for all three. The total cost of ambulance, operating rooms, hospital stay and care, was less than $6,000 in 1960 dollars.) You may also remember the close relationships we typically had with our family doctors who positively worked for us and our health, rather than negatively to protect themselves from malpractice lawsuits and the coffers of some distant HMO and Big Pharma. It is our hope that this brief overview will be of assistant to readers in understanding the historical background and why health-care as a whole today is not about our health at all. It is little more than a euphemistic label that covers a multitude of profitable activities, many of which have little positive relationship to our health. Within this system there are numerous knowledgeable, conscientious and caring health practitioners who unfortunately have to work in an extremely stressful and unhealthy environment. Many of them are as frustrated with this “health-care” system as we are. - Editor