I had the opportunity this weekend—whilst flat on my back
with muscle spasms—to read an interesting paper about the state of the US
health care “system.” The Journal of Health and Social Behavior has a
special issue devoted to the sociology of he health care system. Its
introductory article, “A New History of the Health Care ‘System’”, recaps the
history and the rise of the major players in the current system. The premise
is, you can’t fix the system without some understanding of how things got the
way they are. The article also introduces the rest of the articles in the issue
of the journal.
The article refers frequently to one of the most interesting
books I’ve ever read, The Social Transformation of American Medicine, by
Paul Starr. I think most Americans think that the health system we see has
pretty much always been there. Not so. It was a 150-year crusade for doctors to
gain control of medicine and to dominate other early contenders such as
mothers, midwives, alternative healers, potion peddlers, public health clinics,
and others. The adoption of science-based medicine was one reason professional
physicians became ascendant, but there were al lot of political and economic
shenanigans that helped consolidate their power as well. Insurance came in in a
variety of guises in the 20th century. Government health programs
are even more recent in the US and have already had various forms. Star’s book
chronicled the very interesting twists and turns of medical politics and
economics up to its publication in 1982. But a lot has happened in the last 23
years and the Journal article brings things up to date.
I’m not going to try to recap. The paper is available as a
PDF. I think everybody in the health field should read it and other papers
about what ails the health care system. At the conclusion of the NVHA
conference John Seffrin issued a call to action for those attending. John
suggested we nonprofits need to work together to help correct the health care
system. None of us will achieve our mission if we don’t. I wholeheartedly
agree. When you read the paper you’ll see why the government and the major
stakeholders will not fix the system. They are locked in an uneasy truce for
the distribution of the money in the system. Any change will result in a
redistribution of the wealth, so they all fend off such perturbations through
influence on politicians.
Indeed, the discouraging thing about the history of health
care in the US is that it has gone through repeated crises and repeated
reshufflings to change it, but each re-alignment just results in another
crisis. They seem to happen every 20 to 30 years. I remember sitting in
discussions at UC Berkeley 15 years ago about how HMOs and managed care were
going to stop rising medical care costs and provide incentives for prevention.
Of course, it hasn’t happened and another crisis is looming. The average
consumer like you and me has negligible influence until public dissatisfaction
gets so great the politicians know they’ll be voted out unless they do
something. Opinion polls show that health care is the #1 concern of Americans
right now, even ahead of terrorism. I can’t imagine that by 2008 health care
will not be the #1 political issue—if not by 2006—save more war and new acts of
terrorism in the US.
The question to my mind is, how will the next phase be any
better than the last? It’s always the people with large financial stakes and
large financial influence that get to set the rules for the next round of the
game. What they want, of course, is to make sure they protect their share. The
public really has no representatives without heavy pre-existing financial
and/or power interests. So I think it’s the responsibility of the relatively
independent NPO community to get in and try to give some direction. We have a
lot of public trust, and I think that’s something other stakeholders lack.
Trust might be the coin of the realm in the next go-round.