In mid-July 3 Quarks Daily posted an essay written by Umair Haque, a London-based consultant and frequent contributor to the online Harvard Business Review, that argued “the American experiment is at an end.” This is because unlike every other rich country the US lacks, Haque stated, essential moral universals defined as “sophisticated, broad and expansive public goods that improve by the year.” These include higher education, a responsible media, transport, welfare and healthcare. Democracies depend on these moral universals available to everyone because these benefits educate, inform and allow us to lead healthy lives. Absent these civilizing mechanisms we are left unable to act morally, democracy breaks down and we are left with our best universities churning out hedge fund managers, are economy recording paper profits and our media, when it bothers, debating climate change. We are left with perverse inequality, a declining middle class and falling life expectancy. Instead of our society producing a sense of “people cooperating by voting to give each other greater prosperity,” we have, Haque wrote, one that takes “prosperity away from one another.”
Though she does not frame her work in these terms, that health care is far from a moral universal in this country is documented at length in Dr. Elisabeth Rosenthal’s recent, “An American Sickness, How Healthcare Became Big Business and How You Can Take It Back.” Dr. Rosenthal, Kaiser Health News’ Editor-in-Chief, makes clear what poses as US health care is neither a moral universal nor actually health care. Instead, what purports to be health care is a profit maximizing industry with possibly at best only an incidental interest in actually improving our health. The “American health system,” Rosenthal states in her very first sentence, “attends more or less single-mindedly to its own profits.” Commercial forces “stole our healthcare.” It is therefore “rigged against you.”
Arguing we have monetized health care delivery beyond recognition or that we have moreover medical commerce posing as health care, is not a difficult argument to make. Beyond ongoing efforts to sabotage coverage expansion under the Affordable Care Act (ACA) and the still unaddressed opioid epidemic (annual drug overdose deaths now roughly approximate the total number of US military fatalities over the 16 years we were involved in Vietnam), there are still over one-in-ten Americans without health care coverage, our country is without a long term care policy, integrating social service supports and dental care for the elderly are either completely, or largely, ignored, we care for a large number of the mentally ill by torturing them (see my THCB February 7 blog post), we have made at best nominal progress in reducing medical errors and/or in measuring quality improvement, we appear to have no interest in correlating quality and spending; and, because health care is so inefficiently delivered we are forced to pay unnecessarily an additional $1 trillion annually causing us to both drown in medical debt and ironically forgo necessary care.
Over the first two-thirds of her work, Dr. Rosenthal explains how the health care “industry” is designed such that “at every point there’s a way to make money,” or where “everything is monetized to the maximum, without much regard for the implications for patient health.” She does this using a ten rule framework. Rosenthal’s rules include: more and more expensive treatment is always better; there is no free choice; there are no economies of scale and no competition; there are no fixed prices nor price transparency; no billing standards; and, prices are whatever the market will bear. Rosenthal illustrates these rules via a long list of examples, many, if not most, of these will be familiar to the THCB reader. These include for example, service overuse, risk adjustment coding creep or upcoding, exploitation of medical residents, obscene pharmaceutical and medical device marketing and pricing practices, billing practices, physician entrepreneurialism, hospital consolidation, and profiteering by not-for-profit medical societies, “hospital conglomerates,” charitable foundations and venture philanthropists.
The latter third of Rosenthal’s book addresses how patients or consumers “can take back” their health care or presumably subvert or mitigate industry profit taking. She proposes several long-debated structural reforms, for example, negotiated drug pricing, price transparency and FDA drug and medical device regulatory reforms, anti-trust and tax exempt status reforms, medical school curriculum reform, payment reform including reference pricing and bundled payments and medical liability reform. All of these, except with possibly the exception of the last, appear likely off the table at least in the near term. Rosenthal, moreover, proposes patients or consumers essentially challenge providers and payers by, for example, asking your physician why he/she is ordering a particular test, asking what is the price tag for care before hand, vetting your hospital, shopping around for medications and requesting bill itemization and/or negotiation. She makes these suggestions and related others because, she argues, “we patients have allowed this heist of our healthcare by commercial factors.” Leaving aside the accuracy of our “allowing,” as other reviewers have noted these remedies are, to be polite, naïve, particularly since reconciling her ten rules with being an informed patient is likely impossible. For example, concerning the absence of free choice, both my mother and wife had surgical procedures over the past eight months. When I attempted to learn more about both procedures, both surgeons as if reading from a script immediately responded by stating if I was not “comfortable” with them or their protocols they would be happy to refer me to another surgeon. (The first surgeon initially refused to physically examine my 85-year-old mother before surgery and the second refused to ensure my wife with prescription pain medication after surgery.)
The relevance of Rosenthal’s work, particularly in light of Haque’s criticism (and similar criticisms by Benjamin R. Barber, among others), forces one to question how perverse or morally bereft the just concluded seven-month debate over repealing the ACA has been and more productively forces us to wonder how going forward health policy reform should be debated. Health care is not, cannot, simply be a cost or a tax paid at the expense of profit taking but instead be a public good, something that protects us, uplifts us, civilizes us, allows us dignity.