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U.S. health care in...
Critical condition

January 14, 2005 | Pages 6 and 7

A YOUNG man suffering from a severe asthma attack is turned away from the closest emergency room. They're out of beds. On the way to the next nearest hospital, the young man dies.

Another patient waits two days while a hospital's surgeons, who haven't been paid, argue over who should perform "emergency" surgery. This patient also dies.

In the parking lot of a suburban clinic, scores of people mill about, confused. They've come for long-awaited appointments and anxiously anticipated test results--only to find that the clinic has been closed, its records boxed up and shipped out to a warehouse many miles away.

And these patients--whose stories are told in the recent book Critical Condition: How Health Care in America Became Big Business and Bad Medicine--had believed that they were the lucky ones. Unlike 45 million Americans today, they had health insurance.

Such is the sorry state of American health care today. NANCY WELCH looks at the scale of the crisis--and what it will take to win real reform.

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HOW DISASTROUS has "free-market" medicine been for most Americans? Consider that in the past 20 years, the United States has gone from first in the world for life expectancy to 19th for women and 28th for men. According to the World Health Organization's healthy living index--which measures the number of years that someone can expect to live in good health--the U.S. ranks 29th, behind Slovenia. In the World Health Organization's overall rankings of health care, the U.S. has slid even further--to number 37.

Factor in race and racism, and an already dismal picture turns appalling. A young man in Bangladesh can expect to live longer than his African American counterpart in Harlem. A man living in a poor neighborhood in Washington, D.C., has a life expectancy of 40 years less than a woman living in a wealthy neighborhood just blocks away.


"A look at the Americans' health reveals astonishing inequalities in our society," write health policy researchers Lawrence Jacobs and James Morone in the issue of American Prospect magazine where these and other damning statistics appeared.

All this unequal care comes with a surprisingly high price tag. Some two decades ago, profit, competition and rationing began taking over what had been a largely nonprofit sector of the economy--and since then, per capita health care spending has shot up more than 400 percent. Today, the U.S. covers less of its population while spending more--much more--on health care than any other nation, including all 39 developed nations that provide universal coverage.

The high cost of health care hasn't made a dent in the ranks of the uninsured. Far from it, those ranks are growing. In 1980, 12.6 percent of Americans were without health care. Today, nearly 16 percent are uninsured--and that doesn't begin to measure the inadequate coverage of millions more.

In fact, as Pulitzer Prize-winning journalists Donald Barlett and James Steele argue in Critical Condition, only the top 2 or 3 percent of the wealthiest Americans can expect top-shelf medical care. For the rest, second- and third-rate care--including being sold prescriptions and procedures they don't need, while being denied services they do--has become the norm.

And for this system, Americans pay $1.7 trillion a year--more than any other country in the world. "Americans," write Barlett and Steele, "pay for a Hummer, and get a Ford Escort."

Actually, it's sometimes more like a Pinto or a Corvair. In this system, patients can be abandoned on an operating table, their appendix about to burst, because the hospital no longer deals with their insurers. In this system, people can ask their doctor for a drug promoted on the nightly news--one promising to help them shed a few pounds--and wind up dead. In this system, hospitals are free to charge the highest prices to the poorest patients--$35,200 for an appendectomy for someone without health insurance, as opposed to $7,000 for someone with coverage--and then sue the patients when they can't pay their bills.


Such are the stories of free-market misery recounted in Critical Condition. And in this system, an alarming number of desperately needed but decidedly unprofitable drugs--including not only this year's flu vaccine, but also childhood vaccines for diphtheria, tetanus, measles and whooping cough--are in short supply, while the drug companies turn out knock-offs of Viagra or re-package (and re-patent) Prozac.

"If you get bitten by a rattlesnake," observes Dr. Marcia Angell, former editor of The New England Journal of Medicine, "you may not be able to get antivenin, but you can certainly get something for your cholesterol."

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WHY DOES the United States spend so much and deliver so little when it comes to health care? How did the U.S. fall so fast and so far in virtually every measure of health care delivery for the majority of its residents? Those are the questions taken up by a flurry of recent exposés of the U.S. health care system, including Barlett and Steele's Critical Condition and Angell's The Truth About the Drug Companies.

The answer: American medicine's conversion into big business, big bureaucracy and--for a few--big, big profits.


In other words, amid the millions of losers in today's massive health care crisis, there are also some big winners. Among those winners:

-- Wall Street traders and investment bankers who cashed in on free-market medicine even as the drive for profits proved catastrophic for the actual practice of medicine.

Under Wall Street's guidance, for example, hospitals have shut down busy but unprofitable emergency rooms, while those remaining open have seen their budgets trimmed, rising infection rates and dangerous supply shortages. Now, with some hospital industry mainstays facing Enron-like scandals, Wall Street has even worse solutions in mind--answering the severe nursing shortage, for instance, not with better hours and more bearable working conditions, but with the rise of for-profit temp agencies.

-- Hospital Corporation of America (HCA), the country's first and largest for-profit chain with $21.8 billion in revenues in 2003.

According to Barlett and Steele, HCA has Medicare and Medicaid to thank for a third of its profits. And its founder, Thomas Frist Sr., can thank his son, Senate Majority Leader Bill Frist, for muscling through the 2003 Medicare "reform" bill that promises even more profits to HCA.

-- The new bureaucrats who turned the sea of paperwork and the one-in-three health care dollars that go to administration into a growth industry.

In the years before doctors and insurers battled one another over fees and reimbursements, Barlett and Steele note, there was little need for the American Academy of Professional Coders (now boasting 35,000 members) or the Professional Association of Healthcare Reimbursement Specialists.

At the bottom of this bureaucratic barrel are thousands of insurance-company call-center workers--located everywhere from Bismarck, N.D., to Bangalore, India--whose job is to counsel frightened patients and placate frustrated doctors. If they want to stay employed, their job is also to deny as many requests for referrals and reimbursements as they can.

-- The top 10 American and European drug companies, which posted profits (as a percentage of sales) of 17 percent in 2002--even in recession conditions.

How do they do it? With the generous assistance provided by major acts of Congress during the 1980s--such as Bayh-Dole, which lets drug companies license and profit from the publicly funded research of university labs and the National Institutes of Health, while hardly spending a dime on their own; and Hatch-Waxman, which extends patents and monopoly rights for top-dollar brand-name drugs, while keeping lower-cost generics off the market.

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THESE ARE some of the big winners in the for-profit health care bonanza. They all want us to believe that U.S. health care is the best the world has to offer. Even the drug companies have their apologists--such as Malcolm Gladwell, who recently peddled in the pages of The New Yorker the tired argument that the big pharmaceuticals are charging fair prices for innovative and life-saving drugs.

But with scathing indictments of the system on the best-seller list and TV's most heavily advertised drugs--Vioxx, Celebrex and the over-the-counter Aleve--exposed for their deadly side effects, this story is getting harder and harder to sell.

Barlett and Steele acknowledge that the disturbing stories gathered in Critical Condition won't be news to many readers. "Almost everyone knows somebody who has experienced the reality of what health care has become--a friend or relative who has no coverage, a young person who can't pay the premiums, a parent whose child needs expensive specialized treatment or an elderly person who can't afford prescription drugs," they write.

Yet even though health care was a top issue for most voters in November--one pre-election poll showed that more Americans are worried about losing their health care than about losing their job, paying the rent or mortgage, or being the victim of a terrorist attack--the two candidates of the major parties had little to offer.

George Bush called for health care savings accounts that would spell financial disaster for even more Americans when facing a catastrophic or chronic illness. John Kerry proposed government subsidies to help low-income people purchase private insurance--that is, funneling more public money into the coffers of the insurance industry, without addressing double-digit premium increases, inadequate benefits and bureaucratic waste.

Real health care reform--not more corporate welfare for the insurance and drug industries--is possible. The evidence lies in the creation of Medicare and Medicaid, a key legacy of the civil rights movement--or Canada's dismantling of the private insurance industry in the early 1970s to establish a universal, government-administered program.

David Himmelstein and Steffie Woolhandler of Harvard Medical School have documented the gains made by Canada since winning universal health care, including moving past the U.S. in life expectancy, infant mortality and--tellingly--nurse-to-patient ratio and the number of doctor visits per year.

In November, Canadians expressed their feelings about universal health care by giving the most votes in the Canadian Broadcasting Corp.'s "Greatest Canadian" contest to Tommy Douglas, who is known as the architect of the Canadian system.

Universal health care is also affordable. A study by the reputable Lewin Group, for instance, found that with the elimination of excess bureaucracy, a national single-payer system would reduce health care spending in California in one year by more than $56 billion--while covering all of the uninsured and reducing the cost of health care for 95 percent of the people.

Real reform--especially when it comes to prioritizing treatment and prevention for the most serious diseases--is badly needed, too. While the drug companies launch more designer remedies for chronic conditions such as high cholesterol and heartburn (remedies that, as Angell points out, haven't always proven more effective than the lower-cost treatments they've replaced), the U.S. death rate from cancer hasn't changed. According to Barlett and Steele, who draw on federal government statistics, 194 out of every 100,000 people died of cancer in 1950; in 2001, the figure was 196 out of every 100,000 people.

Without strong pressure, the drug companies aren't going to prioritize the development of new antibiotics, chemotherapies or malaria treatments--all desperately needed, all limited moneymakers--over another pill for mood disorders that can be marketed to millions of people, including children.

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WINNING THIS kind of reform won't happen by writing to our representatives in Congress, as Angell recommends at the end of The Truth About the Drug Companies. Republicans and Democrats alike are the architects and beneficiaries of the current system--from Republican Bill Frist, who became a millionaire thanks to his father's for-profit hospital chain; to Democrats Birch Bayh and Henry Waxman, who co-authored the major legislation creating huge public subsidies and near-monopoly rights for the big pharmaceutical companies.

Democrats as much as Republicans are beholden to the pharmaceutical and insurance industries that reward them with generous campaign contributions--and that money has been on the rise. In the 2004 election, for example, the health care industry gave nearly four times more in donations to candidates than it did in 1990. And 44 percent of total contributions went to candidates of the Democratic Party.

No wonder, then, that when he geared up to "reform" health care, Bill Clinton didn't look to the proposals of, say, Physicians for a National Health Program. Instead, he turned to the insurance industry-funded Jackson Hole Group, with its plan for rationing care and boosting profits. "Clinton didn't try and fail," say Harvard Medical School's Steffie Woolhandler and David Himmelstein. "He refused to try."

Clinton doesn't even recognize that he made a terrible mistake by protecting the interests of the privatized health care industry. Recently, when George Bush crowed, "We live in a great country that has got the best health care system in the world," Clinton publicly echoed him. "We do have the best health care system in the world," he said.

Tell that to all the workers – grocery workers in California, teachers in Kentucky, nurses in Oregon, workers for Pepsi and Coca-Cola, to name just a few– who have gone on strike recently to oppose proposals to cut their health care benefits.

We can't depend on Democrats to deliver a better health care system--any more than we can rely on them to end the occupation of Iraq or defend a woman's right to choose abortion. History tells us that mass movements from below do deliver change. For that, we need to rebuild a strong left and organize for a winning rank-and-file strategy in our unions. And to win enduring change, we have to challenge the capitalist system and push for an alternative that puts people before profits.

The insurance companies, drug makers and for-profit hospitals are organized to keep health care out of our hands. We need to get organized to take it back.

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