The Value of Power

The legislative fight to secure government funding to provide the public with the disease specific treatments and interventions, created by the last 30 years of research, will cause the development of antagonism between health organizations that have been traditional political allies. Budget deficits and a slower economy will force internal redistribution of a flat Medicare budget, as always there will be winners and losers. For example the mechanical heart assist pump could require 15% of the current Medicare budget; if the over all budget is not increased some other interventions will need to have there reimbursements frozen or cut. The effect will be redistribution based more on the power of constituencies rather then on demonstrated needs.

In 1965 Medicare became law, and set off a golden age of medicine with the promise to pay “customary and usual fees’’. For the first time there was a third party payer for all Americans above age 65. Hospital construction boomed, existing procedures that had been effectively rationed became common, new innovative medical diagnostics and treatments arrived, and the income of health care professionals rose dramatically. In the Early 1970’s the Nixon Administration embarked on ‘wars’ against cancer and heart disease bringing the age of big science to heath care. In due course medical research spending dramatically increased leading to further technological improvements, new drug therapies, and advanced procedures. A knowledge boom was underway. In the late 1980’s concern developed that health care costs were going out of control; managed care arrived in force and Medicare began to cap the rate of spending. Hospitals saw shrinkage in patient days and a concomitant fall in income. In the 1990’s hospital closings and reductions in patient beds became the norm. The ratio of hospital staff giving care to patients dropped as a new bureaucracy and processes to manage the costs and reimbursement of care went into place. Health care costs were held close to the rate of inflation until the late 1990’s when rapid increases again materialized.

In the early 21st century we will see the potential for the rapid introduction of new pharmaceuticals, diagnostics and therapies that have resulted from the research investment of the previous 30 years. Unfortunately this potential for unprecedented health care progress coincides with a world wide economic downturn and an ageing demographic. With total Medicare spending capped, the number of uninsured under age 65 growing and the number of underinsured expanding rapidly, health care rationing exists and is a growing reality.

Economics dictate that not everyone, unless they can privately pay, can get every available treatment. It is an inevitable reality that decisions on care will increasingly be made in the political arena. New and existing treatments will compete for the same limited dollars. In order to secure care for their constituency health care organizations like ACS will depend increasingly on their ability to form and effectively manage coalitions, that out competes other coalitions, in the battle to influence government and other third party health care purchasers. Bone marrow transplants as therapy will compete with mechanical heart assist devices; stem cell therapy for spinal injury or MS will compete with both. The arguments will be emotional and attempts will be made to base them on the values and quality of life criteria. Decisions however will be made on the real and perceived power of the constituencies affected. It is likely that the treatment debate will result in a serious secondary debate on the wisdom of funding future research when we cannot afford to provide the treatments already in existence.

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  1. Mike, I hope the scenario you outlined doesn’t come to pass. I think there’s the chance of another alternative and the American Cancer Society might just be the organization to help it happen.

    It seems to me there was a regrettable fragmentation of our view of health and of the institutions during the 20th century. It was understandable that groups would form to put special effort into major diseases like cancer, heart disease, lung diseases, etc., etc. But somewhere along the way we lost our sense of responsibility as public health people to keep the wellbeing and overall health of the public in mind. Maybe it was the explosion of causes over the last 35 years or just the attitude of the ‘90s, but and a kind of winner-take-all mentality seems to prevail now. Our culture tends to reinforce a kind of single-mindedness about cancer that has a down side. I suspect all other categorical agencies are the same.

    However, under the current circumstances everybody trying to get somewhere with a health problem is faced with the same enemy: lack of resources and lack of access for constituents. Seems to me competing over the rations isn’t going to help.

    Funny, with the obesity thing we’re being forced back into recognition of how broad, common factors can adversely affect health across the board. I hear that the ACS, Heart and Diabetes are going to do a joint campaign about obesity next spring. Great. What I’d like to see come out of it is the beginning of an alliance to tackle the broader problem of our dysfunctional health care system.

    I think the American public is crying-out for leadership to look at and take on the broader issues of health care. A survey a couple of weeks ago found that 70% favored laws to allow importation of price controlled drugs from Canada; 44% are dissatisfied with health care in the US (up 10% from 2000); and 62% favored a universal health care program to the current employer-based program.

    Although there will be enormous hoo-ha about health care during the 2004 election, I have no faith in either political party to make much headway toward an equitable solution. And the providers and payers through whose hands billions of dollars pass aren’t going to help. We baby-boomers aren’t quite old enough or sick enough to demand that fixing the system take top priority—yet.

    Seems to me there’s a void of leadership toward a better health care system that would improve everyone’s chances of prevention, detection and treatment. Who’s representing constituents in a broad sense, AARP?

    I’d like to see a relatively neutral set of NPOs step back for a moment from their special interests and look at the bigger picture. They could come up with some goals or recommendations for the kind of health care we’d all like to see, a system that faces the reality that there are many awful health problems out there and that we’re never going to have the resources to do everything for everybody. Then they’d have to stick around to keep the politicians honest in delivering something. I think ACS constituents and donors would support our efforts to fix the broken system.

  2. I think the far bigger problem is that the health care system is bureaucratic and will never be truly efficient.