| The Reasons for Health Care Reform
By Dr. Quentin Young
For more than a year, the mainstream media, hitherto captive
of the market salvation myth, has shifted to seriously critical
reporting of the catastrophic reality of for-profit HMOs and
hospital chains. This sustained turn around is of obvious
importance to movement seeking a publicly-financed universal
system. In fact, an argument can be made for health care as the
decisive organizing tool today.
Health care has incomparable economic magnitude and a
gigantic workforce. No other issue embodies as large a social
base. Indeed, the struggle for decent health care crosses race,
gender, age, region, and even class divisions. And health care is
understood by everyone to be a necessity. An unusual egalitarian
consensus exists in favor of the right of a sick or injured
person to health care, which is remarkable in a society so deeply
divided by the worship of competitive advantage.
The possibility of success for progressive initiatives --
the condition of the health-care system in growing disarray --
seethes with opportunities. The system is highly vulnerable. The
number of uninsured has risen to 43.4 million (1998), and perhaps
50 million have insurance of such poor quality as to bankrupt any
policy-holder who contracts a major illness. Indeed, the most
frequent reason for personal bankruptcies continues to be unpaid
The large-scale takeover of HMO and hospital chains by
venture capital has Ied to an explosion of health care denial and
obscene executive salaries, as well as stock market profits for
investors. This has captured the headlines and the wrath of
millions of alienated patients. The effects on the health care
workforce of these systemic changes have also been severe:
* Large-scale displacement of skilled nurses by unskilled,
low-paid substitutes is seriously threatening their
profession. As a result, nursing organizations are growing
* Physicians, too, have been stunned by their abrupt,
dislocation from the pinnacle of power and prestige in the
health care hierarchy. And while the domination by organized
medicine of America's health care activity has eased the way
for HMOs the destructive by-product of this physician
autonomy has been a profound corruption of the
* The rest of the health care workforce, overwhelming
female, people of color and disproportionately immigrants --
continues to be highly exploited.
Each of these sectors -- nurses, doctors, and other health
care workers -- has become dramatically more receptive to the
protections of unionization.
The engine of this dramatic dysfunction is the Free Market
Solution that has been imposed on the previous doctor-dominated
system. The sequence of events began with the Health Maintenance
Organization Act of 1971 under President Nixon, touted to be the
antidote to the worrisome (but, in retrospect quaint) rise in
medical costs. Ironically, prepaid group practice, which was
initiated in the late 1930s and had an honorable records (but
faced AMA denigration), had offered a brake on rising costs.
But the authorization of venture capital's entry into the
ownership and administration of hospital chains and HMOs opened
wide the gates for a new era of robber-baron economics. Among
the destructive effects was a massive undermining of
not-for-profit, community-linked tradition of the U.S. hospital
system. While the record of these hospitals was certainly
checkered, they did have the civic virtues of being community
Through conglomeration and buyouts, giant for-profit chains
emerged. In the hospital sector the giant is Columbia/HCA, with
more than 400 hospitals. But it suddenly destabilized. Its value
plummeted, top officials were relieved (with breathtaking golden
parachutes, to be sure), and a hundred hospitals were put on the
block. The process was enhanced by federal indictments alleging
billions of dollars of Medicare fraud. With the massive
consolidation of the industry replacing promise of competition
with oligopoly, an effusion of alleged illegal activity is
speeding the unraveling of the market solution, a trillion-dollar
Yet another destabilizing burden is the rising tide of
bankruptcies of poorly capitalized ventures, alongside the
monumental profit-taking of the winners in this lottery. Giant
"physician management" corporations have emerged. They buy up
scores of variously sized practices and then rachet down
resources devoted to care. Currently, bankruptcy is the hallmark
of this sector as well.
In sum the market solution has spawned and army of
administrators and their minions who are dedicated to limiting,
restricting and denying benefits to patients, maximizing returns
to investors, and obscenely rewarding executives in salaries,
stock options, and dividends.
Recall that "free-marketers" pledged to improve the quality
of health care, provide better access and control rising costs.
The result has been a colossal failure. Quality is lower, even
compared with the highly flawed fee-for-service system. Access
has steadily worsened -- there are 100,000 more uninsured every
month and ten million more uninsured since 1989. This is a result
of basing insurance on employment. To avoid health care costs and
other benefits, corporations have redefined the workforce from
full time salary, or wage-earning employees to casual, part-time,
consultant or temporary workers.
A particular irony, given the shameful disinformation which
sank the star-crossed 1994 Clinton proposal, is the prevalence of
all the bad practices that a national governmental program was
supposed to bring us:
* Choice of care has become limited to one or two HMO plans
that management selects, generally for the lowest bottom
* Bureaucratic restriction could hardly be worse.
* Physician autonomy is now a fiction.
In the face of this collective experience and growing public
rage, the remedies proffered prove you can't leap an abyss in two
jumps. A particularly divisive strategy which has regularly split
off liberals and labor from commitment to a universal government
system has been what can be dubbed incrementalism. It offers
remedies to particularly egregious realities in health care
denial, but invariably at great cost, substantial inequity, and
with pork barrel giveaways to the insurers and venture
For example the Kennedy-Kassebaum law proposed to address the
horror of job lock and the inability to secure insurance when
there is significant history of illness by mandating coverage by
private insurers. The companies, obligated under Kennedy-
Kassebaum to offer policies, had no problem with this. They
could charge any rate they chose, making this "choice"
confiscatory and obliterating any intended reform.
Likewise, the children's insurance subsidy, through funds
transferred to the states, has resulted in a hodgepodge of
costly, unequal coverage to millions of unprotected children.
Two states so far, Wyoming and Washington, have decided to
decline the funds, fearing the babies would become welfare
dependent on this federal subsidy.
Similarly, the concentrated rage at for-profit HMO abuses
has lead to an explosion of "remedies" in all fifty states and
the Congress. Many proposals have been stalled by the HMO
industry which has well-financed friends in all of the
legislatures. In fact, a Managed Care or, alternately, a
Patients' "Bill of Rights" will be of little or no help, about
like an aspirin for a brain tumor.
So what kind of system do we want? The same one the
American people choose, steadfastly, whenever polled: universal,
comprehensive, publicly financed and progressively taxed. To
which we must add not-for profit governance of hospitals and
Several characteristics of the current System of U.S. health
care support the argument that it is ripe to become the
centerpiece of a new progressive Initiative:
* Its huge size and high sensitivity to burgeoning economic
* Its ubiquity and the unusually good prospects for unity
inherent in the anguish shared across the dividing lines of
race, gender, age, region and even class.
* Its vital necessity when you are ill and the widely held
and generally supported expectation that enhancing your
health should be a human right.
We are rich in health-care resources. If we handle what we
have intelligently, free of exploitation, we could easily and
promptly resolve the oppressions of our current system and its
market-generated abuses. Furthermore, the American people seem
ready for organized expression in local. state and national
venues. Our demand, of candidates, parties, organizations, and
institutions should be:
EVERYBODY IN! NOBODY OUT!
Quentin Young is the National Coordinator of Physicians for a
National Health Program.