Counting Beans, Losing Lives
Bleeding the Patient:The Consequences of Corporate Health Care
Dying in the City of the Blues:Sickle Cell Anemia and the Politics of Race and Health
As a presidential candidate, George W. Bush described his health care ambitions in the following terms: “We will not nationalize our health care system, we will promote individual choice. We will rely on private insurance, but make no mistake: In my administration, low income Americans will have access to high quality care.” Throughout his first year in office, the President kept his word on resisting nationalized health care. But make no mistake indeed: Low income Americans have not enjoyed access to high quality care.
The books reviewed here explain the reasons for this failure from different, but complementary, perspectives. Together, they challenge the premises supporting privatized health insurance while making a powerful case for universal coverage. With 43 million Americans currently uninsured, these books offer timely and accessible studies of a topic that future historians will grasp as one of our most conspicuous failures.
Of the two books, Bleeding the Patient more directly exposes the status of America’s health care system. More a wonkish primer than a sustained investigation, this nonetheless important study challenges the idea that the free market will improve health care. The authors, professors at Harvard Medical School, hinge their analysis on the belief that “The responsiveness of corporations to consumer demands is illusory.” They, then release an avalanche of evidence to support their hypothesis. And they drop their load of evidence with prose that grates like fingernails on a chalkboard. Despite this stylistic drawback, their findings are significant enough for us to suffer through their wooden presentation.
As corporate entities, HMOs and other care providers are structured to satisfy their investors. Driven primarily by profit, they practice a kind of “economic profiling” whereby they peg a physician’s salary to his or her “contribution to profitability.” This arrangement motivates doctors to “triage healthy, low-cost seniors to a Medicare HMO and sick ones to traditional Medicare.” The ways doctors are currently paid “distort clinical and moral judgment, and seldom improve it.” HMOs are thus “tethering physicians’ incomes to behaviors that further corporate profitability.” As health care currently operates, HMOs win contracts by “promising employers the modern version of the company doctor,” a physician “willing to squeeze care, avoid embarrassing diagnoses of workplace-induced illnesses, and equate quality with lower absenteeism.” The authors argue that given the sprawling confines and slippery moral imperatives characterizing private health care today, “it’s hard to be a good doctor.”
For many industries, generic cost-cutting measures result in a cheaper, better product. When applied to health care, however, they backfire. In today’s decentralized environment 42 percent of non-elderly adults have no choice in their health plan, a figure that rises to 91 percent for those in small businesses. Forty percent of physicians report that the time they spend with patients has decreased, while 20 percent said they lacked the time to keep their medical knowledge updated. Thirty-six percent of primary care doctors were unable to authorize non-emergency hospitalizations, and another 25 percent “said they could not provide high quality care to all of their patients.”
The authors apply a similarly sound, if somewhat scattershot, statistical approach to a variety of related issues. For-profit hospitals, we learn, have a 7 percent higher death rate compared to patients with similar conditions treated in non-profit hospitals. Insurance firms, the organizations that own HMOs, invest heavily in tobacco. Canada, with universal coverage, has a life expectancy that is two years longer and an infant mortality rate 25 percent lower than that of the United States. Wealthy Americans who can already afford preventive care receive a disproportionate chunk of tax subsidies for private health benefits. Those making more than $100,000 a year, for example, comprise only 10 percent of the population but absorb 23.6 percent of the tax subsidy. The authors also explore racial disparities in health care, practices of U.S. drug companies, contributions of these companies to political candidates, and legislation that resulted from those contributions. (Orrin Hatch wins the contest, hands down, as the HMO poster boy.)
Despite the progressively cranky and despairing tone, the book ends with the firm conviction that a national U.S. health care system is an attainable goal. Whereas conservatives foresee a nationalized system mired in a bureaucratic bog, the authors explain that it’s actually private HMOs that currently force us to “walk a tightrope between thrift and penuriousness, too often under the pressure of bureaucrats.” The public administration of insurance funds, they argue, wouldn’t clog the system, but would instead minimize the expense of billing and thereby save “tens of billions of dollars each year.” Hospitals, liberated from this administrative burden, would free up funds that would move them “away from the bottom line and toward the provision of optimal clinical services” (i.e., focus on caring for patients). This is a novel, politically savvy justification for nationalized health care. But given the current climate, it’s also a plan that’s politically moot.
Keith Wailoo’s fascinating history of sickle cell anemia in Memphis, Tennessee lends the quest for a centralized health care system strong historical support. Wailoo, a historian at UNC—Chapel Hill, works within an emerging scholarly trend that contextualizes disease within broader social movements. Dying in the City of the Blues tells us less about sickle cell anemia itself than “the slow process by which invisible suffering has been made visible.” This process evolved within an ongoing political tension that pitted local interests against federal oversight of urban health care. As Wailoo fleshes out this tension, one overriding lesson becomes especially clear: Diseases are best treated when medical information and resources are managed and distributed by experts organized at the federal level. Local control feels like a good thing, but too often, it leads to bad medicine.
His study generates ample support for this claim. After an introduction muddled with distracting academese (“the performance of pathology,” “disease discourse”), Wailoo lays a solid foundation for a gripping story. He begins with a description of Memphis’s health care in the early twentieth century. The city’s “local political economy,” he explains, determined “which disorders attracted great attention, which health crises made local headlines, and which suffered in the solitude of home and the privacy of family.” Race naturally played a central role. White Memphians, men whose local control over health care policy resulted in the stereotype of the “naturally diseased Negro,” excluded blacks from hospitals, health insurance programs, and research grants. Blacks juggled an unreliable mixture of rural remedies, folk medicine, and the scant professional resources available at the city’s struggling black hospital to combat a disease that they often mistook for malaria. In this local crucible of misinformation, “an emerging health care system with its own diagnostic habits left many complaints unrecognized.” Chief among them was sickle cell anemia.
Most white Memphians weren’t losing sleep over the matter of black health care. Their “diagnostic conservatism,” however, drew fire when a 1934 U.S. Children’s Bureau study made Memphis’s disturbingly high infant mortality rate a source of embarrassing national news. Sensitive about their bruised civic image, white business leaders, elected officials, and medical practitioners adopted “new habits of mind and habits of surveillance” over black health care that gradually diminished medical provincialism and opened doors for federal funding, oversight, and control. The flow of federal dollars from New Deal programs and military research projects transformed black health care from a backwater dilemma into a “collective concern in the 1940s.” As “federal paternalism” became entrenched after World War II, “Jim Crow medicine” encountered “troubled times.” Memphians promoted “their city’s good works on behalf of its black citizens,” and, with the help of Linus Pauling’s famous 1949 Science article on sickle cell anemia, “invisible suffering [was] made visible.” Federal control, in short, pulled the disease out of its locally nurtured dark age.
Sickle cell anemia became a powerful magnet for ample federal and philanthropic funding. Academic research exploded as university scientists chased fame, fortune, and a cure throughout the 1950s. The city also fought a well-publicized battle against the disease. As Wailoo explains, “The changing political economy of health care resulted, slowly, in the perception of sickle cell disease as a cutting edge disorder and as a disease with increasing ability to mobilize civic sentiment.” By the 1970s, the “pain and suffering of sicklers endowed medicine with a moral and social dimension,” a transition in outlook that redefined the relationship of black Americans to “a health care system that was blind to their existence.” The association between “disease and African-American social identity,” in turn, “made sickle cell anemia into a cultural signpost.”
Political trends in the 1980s and early 1990s put the brakes on this progress. “[T]he fight against disease was rapidly transformed into the fight to lower heath care costs” during the Reagan and Bush administrations. Memphis’s health care system became a “declining model of health care in the age of privatized medicine.” Managed care, Wailoo concludes, “threatens to bring a new kind of invisibility to people with sickle cell disease.” His point resonates well beyond blacks, Memphis, and sickle cell anemia to speak directly to America’s current health care crisis.
James E. McWilliams teaches history at Southwest Texas State