The Commodification of Health Care
Consequences of Abandonment
At a time when doctors are performing the near miraculous, the profession’s reputation is increasingly discredited. More and more, patients complain about not being listened to and being abandoned. As medicine has conquered acute illness, it increasingly fails in coping with the growing toll of chronic disease - arthritis, cardiovascular ailments, cancer, diabetes, pulmonary impairments and neurological derangements. Lacking a cure, these illnesses require the art of healing for which the contemporary physician is poorly trained. And public, led to expect miracles which are not forthcoming, grows disillusioned and angry.
I shall touch on three of the many consequences now in evidence. One relates to the current litigation craze, a nightmare for physicians. Nearly one in three practicing doctors will be sued over a lifetime of medical practice for real or imagined wrongs. This is not surprising. As patients lose their individual identities, the ancient covenant of trust between doctor and patient unravels. When history taking is short shrifted, the doctor is likely to become lost in a sea of dire possibilities, warranting a profusion of technological interventions. In contrast, a careful history, a thorough physical examination, and a few simple routine tests provide about 85 percent of the basic information required for a correct diagnosis. Since it is uneconomic to spend much time with patients, diagnosis is performed by exclusion. This opens floodgates for endless tests and procedures in an effort to cover all diagnostic options and thereby parry accusations of negligence in a court of law. With this kind of defensive medicine, minor problems receive comprehensive and costly work-ups. However no procedure is completely safe. Even an innocuous intravenous line can become a source for infection or the nidus for a blood clot. It is ironic that the quest to avoid litigation sets the stage for the legal entrapments it aims to avert.
A second even more persuasive line of evidence of the public’s diminished trust of the medical profession is the increasing popularity of alternative medicine with its exotic and unproven treatments. Included among these are hypnosis, acupuncture, chiropractic, herbalism, homeopathy, biofeedback, guided imagery, relaxation, yoga, meditation, faith healing, prayer, Christian science, megadose vitamins, massage, naturopathy, chelation, urine therapy, Bach flower remedies, iridology, orgone accumulators, ozone generators and a host of others. Doctors deem these practices the negation of science, evoking images of 19th century charlatans hyping snake oil, leeches and astrology.
Yet national surveys indicate that in 1997 more than two-fifths of the adult population - 83 million people - used at least one of 16 listed alternative therapies, an increase of 20 million since 1991. Astonishingly, in 1997 visits to practitioners of alternative therapy exceeded the number of visits to all primary care physicians by an estimated 243 million. And the use of alternative therapies are not confined to a narrow segment of society. The largest users are women, the middle-aged (35-49), individuals with some college education, and people with annual incomes exceeding $50,000. This trend may be interpreted as a vote of no confidence in scientific medicine among the educated, affluent middle classes, or as a dissatisfaction with a chaotic and impersonal health care system, or as a search for values not provided by the modern physician.
A third line of evidence, which I believe is the most telling indication of the loss of trust in the profession, is the seeming widespread public indifference to the corporate take over of community-owned hospitals, and the stripping away of physicians’ clinical autonomy. The commodification of health care has been met by public silence. By contrast, whenever corporate interests have eyed popular programs such as Social Security or Medicare, angry public outcry has prevented a direct assault on these safety nets. No such outcry could be heard from Main Street as Wall Street privatized billions of dollars worth of public health institutions. Perhaps patients saw little reason to defend a dysfunctional system.
An Idiosyncratic Health Care System
In the late 1930’s, the Roosevelt Administration was moving toward a national single payer health care system. However mobilization for WWII put all social programs on a back burner. The war-time wage freeze forced unionized labor to seek higher pay through fringe benefits; mainly employer-financed private health insurance. Like any other business, the goal of health insurance firms is to make money. An opposite model had been adopted by nearly all developed countries, a social insurance model which shares the risk of sickness by spreading the cost to all of society. In the business model, the exclusion of the poor, the aged, the disabled and the sick is sound fiscal policy since it maximizes profit. In the social insurance model, denying coverage to some members of society contravenes the fundamental purpose of health insurance.
Indeed, failure of the business model is an ugly blot on the American escutcheon and deflates its pretense of moral global leadership. Today over 46 millions Americans are without health insurance, their numbers rising by about 1 million annually. If one considers that an additional 20-30 million are underinsured; close to 1 in 3 of the population face major problems in financing illness for their families.
Moreover, notwithstanding prodigious expenditures, the U.S. health care system often provides poor quality care. One robust proxy for quality is life expectancy, and in this index the U.S. ranks number 25, behind most other industrialized countries. Though others spend far less than the US, they deliver far more health care. One example should suffice. From 1960 to 1989, America’s two major industrial competitors, Germany and Japan, more than doubled psychiatric beds. During this same period, USA reduced psychiatric beds by three quarters, from 560,000 to 70,000. Mentally ill patients were dumped into inadequately prepared communities and became the street people and the drug culture now plaguing America’s large cities. Currently, a psychiatric patient needs to be violent, suicidal or homicidal to be hospitalized. Mental illness in now criminalized - many more of the mentally ill are in jail than are in psychiatric hospitals; 10% of prison inmates are schizophrenic.
Neoliberalism proclaims the supremacy of the market to bring efficiencies to all human transactions. According to its more avid ideologues, the market’s power derives from biology and is imbedded in our selfish genes. They aver, in the jargon of economists, that most people are maximizers of utility, meaning they navigate life by rationally calculating their self interest. Supplied with proper information their decisions are consistently on target. Forgotten in this economic babble is that the market episodically implodes, spewing woe and misery for all who are caught in its web. The liberal economist, Robert Kuttner has reflected, that historically, government has had to intervene, not only to redress the gross inequality of market determined income and wealth, but to rescue the market from itself when it periodically goes haywire. It is no secret that markets cannot properly value a host of essential societal needs such as education, health, public infrastructure, clean air and water, food safety, etc. As evidence one might reflect on ozone depletion, deforestation, species extinction, desertification, ocean pollution, global warming, and the systematic despoiling of the natural world, the mindless exposure of human beings to numerous carcinogens. John Kenneth Galbraith captured the essence in his oft quoted phrase that we live in a society characterized by “Private affluence and public squalor.” Marx phrased it even more pungently, “With an adequate profit, capital is very bold. A certain 10% will seek its employment anywhere; 20% will produce eagerness; 50% positive audacity; 100% will make it ready to trample on all human laws; 300%, and there is no crime which it will not scruple, no risk it will not run, even to the chance of its owner being hanged.”
While one can debate these matters endlessly, the serious flaws in the theory and the practice of market-driven managed health care are neon lighted. Key assumptions in market theory are that the consumer knows what he needs, appreciates differences in quality, is offered these at different price levels, has bargaining power and can exercise free choice to buy or not to buy. None of these is true in health care. Patients usually do not know what is wrong; they do not comprehend the diagnostic possibilities; they are not familiar with the therapeutic options, they cannot assess the quality of care needed, and they do not appreciate the numerous potential outcomes. No amount of surfing the internet, browsing the media, reading popular health books, or sharing nostrums with neighbors can provide the necessary insights. These are the very reasons that they seek out the expertise of intensely trained and experienced health professionals. They need to nurture a relationship of trust with their doctors on whom they must rely on for their well being and even survival.
Furthermore, being sick is incompatible with acting as a savvy consumer. People do not shop for new homes or automobiles while in pain, bleeding or short of breath. Market forces can regulate the costs of houses and cars, things we choose to buy. But nobody chooses to be sick. The patient has little choice but to buy and therefore lacks bargaining power.
There is a deeper problem. Healthcare does not lend itself to the efficiencies of industrialization. Common sense indicates that patients cannot be standardized, and most of their parts are not interchangeable. Health care is a customized service resisting commodification and is incompatible with the efficiencies of industrialized assembly line or other mass production technologies. Such basics are ignored by the high priests of market medicine.
Market medicine is additionally flawed because it diverts economic resources from the community, from medical education and from research. The profits generated are not reinvested locally, but are distributed to remote investors and senior management as large dividends, hefty bonuses and egregious salaries. The market has been presented as the solution, but now we know it to be the problem.
As Neoliberalism sweeps the globe, it is important for people in other nations to grasp the dimensions of the health care crisis in the USA. Sooner or later they will be facing the proponents of marketization of their own medical arrangements. The impact of corporate privatization and the commodification of health care is now eminently clear. Health care costs continued to soar, exceeding two trillion dollars annually - 16 percent of GNP - by 2006, nearly twice what is spent other industrialized countries. High administrative overhead, a mark of business inefficiency, is double that in other industrialized nations. Masterminding the system is a prodigious bureaucracy that inundates health workers with a glut of paperwork, while health policy is being defined in corporate boardrooms from which the public is totally excluded.
Patient dissatisfaction is at an all time high, as assembly line medicine puts a premium on hastening patient throughput. Downsizing, common in industry, is now depleting hospital staffing. Experienced as well as novice nurses, overburdened with high patient loads and administrative responsibilities, are often unable to provide competent and compassionate bedside care. The current mantra of reducing costs, whatever the human consequences, translates into burdening the sick with their own care. The anxiety, anguish, pain and sense of abandonment experienced by the sick and their families is not computed as debits in the outcome ledgers of marketized medicine.
The most fundamental of questions can no longer be ignored; in a democratic society is health a fundamental right of the many or a privilege for the few? The underlying concept of market philosophy is that those without means go without some products or services. The dissolution of the Soviet Union, has hastened the tempo of global capitalism in expanding the reach of market dominion to all precincts of human life.
But the public is not about to succumb to this Darwinian philosophy. People are not about to sacrifice education, health, safety nets for the aged and the afflicted, a healthy environment and a host of other areas defining the commons, the gains of which entailed more than a century of intense struggle. Numerous public opinion polls document the fact that Americans overwhelmingly oppose transforming health care from a social service to a mere economic commodity. They are unwilling to replace the ancient bond of understanding between patients and doctors with a business contract.
Conditions are ripe to mobilize the public around the issue of health care, for few issues are more intimate or more potent. Indeed a powerful backlash is in evidence across the USA. Newspapers daily proclaim the mounting crisis in care and cost. Surveys show most Americans favoring national health insurance - despite a virtual blackout on mention of this option in the mass media now dominated by corporate interests. Hundreds of local citizen groups and labor unions across the nation join with thousands of doctors and nurses in rejecting the precepts of market medicine.
Only a wide mobilization of health professionals and patients can reclaim the soul of medicine. And the political movement for this transformation must educate the public on issues transcending health, nourishing resistance to corporate domination in other spheres of life. The health of a civil society is ultimately secured by interacting dependencies of people expressed in communal life. We are bound together by a moral set of values that sees the welfare of other human beings as a benefit to the self . Citizenship must afford not only equal rights but equitable opportunities to share in the wealth produced by the many for the benefit of society writ large. The medical plains offer a unique challenge for progressives to mobilize people ready and eager to be engaged.