American Medicine Is on the Right Track

OF THOSE WHO practice the profession, there are few who do not decry the state of medicine. Not only are wrenching changes percolating through all aspects of medicine, but the changes also are diminishing physician autonomy and authority, threatening the educational structure, and forcing alliances that often seem to be pacts with the devil, disguised as the contract officer of a capitated, for-profit managed care company. How then can anyone claim that this is the proper path for the beleaguered profession to embark on? While it helps to have a bent toward contrariness, the characteristics that foster such a view are the ability to become detached from individual circumstances without losing the perspectives of a physician and the ability to look long term. The argument rests on a foundation of political verities that are assumed to be solid. The bedrock assumption is that the United States as a collective political entity has decided that 15% of the gross national product is too much to pay for health care. Coupled with that is a belief, less widely held and as yet unsubstantiated, that this figure can be substantially reduced (let’s say to 10%) without compromising the health of the nation. The one part of the body politic that has some doubt, and clout, about this is the elderly. As all have noticed, the health care system for the elderly remains a third rail for politicians— touch Medicare and die! But, of course, even Medicare will change. A corollary to this is that maximal cost reduction will not occur until managed health care is universal. If prevention, early recognition, and disease management are effective in both reducing total health expenditures and serving health needs, then universal coverage is mandatory. The national commitment to this is not as clear as it is to cost reduction. The Clinton health plan, if anyone remembers it, was delivered with political flares, blaring trumpets, and arrogant moral imperatives festooned around the countryside. It was a real barn burner, until it fizzled with more finality than any major bill that anyone can remember. This proclaimed centerpiece of the Clinton administration simply disappeared. It has never resurfaced in the 5 years since it was launched. Certainly it was not a good plan; certainly its proponents were arrogant in the ways they dismissed medical input; certainly the very fact that it wanted to change things upset a lot of people. But to die unceremoniously? Committed administrations, as was the Clinton team, bring back proposals to Congress until a compromise is reached or a first-step bill is passed. Why did the Clinton administration drop this? The administration’s disastrous midterm returns of 1994 are cited often; Harry and Louise get some credit; and a national antipathy toward the “big government” built into the bill played a role. But this was to light the way toward a new era, proclaimed across the land for a year. Although the Clinton administration has not voiced this, I find an even more powerful political fact of life to explain the governmental abandonment of health care system reform in the early 1990s. The transformation of US health care to a system that reduces cost by one third will deprive nearly everyone of something they had or think they had. There will be less choice of physicians, less assurance that the best is available, and less income for physicians, hospitals, and suppliers, to list just a few. Elected governments take away things from those who elect them with great unease. It is not a politically astute policy. The recent French elections make this point with unabashed clarity. Most outside observers recognize that France must alter, and alter substantially, its social welfare and price support policies if it is to join the new European entity and compete long term in the new world order. The government that proposed these policies made its arguments clearly and well and was trounced at the polls. Mr Clinton had no intention of serving 1 term.