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Rosemary A. Stevens, PhD

Are we in a healthcare crisis right now?

Rosemary A. Stevens, PhD Rosemary A. Stevens, PhD
Department of History and Sociology of Science University of Pennsylvania

To some extent, American healthcare's been in crisis for years and years. You go back and you look at the historical record and every single writer in every decade since World War II has said that American healthcare is in a crisis. So I'm not sure it's useful to call it a crisis. It's more hopeful to look at specific problems and see what we can do about them.

How did it get to this point?

First of all, this is in part the result of a success story. There's been a tremendous commitment in the United States to science and technology in medicine for the last hundred years. So on the one side, we are dealing right now with the complexity of modern medicine. And then how do we get people access to that? Now there've been problems of trying to get everybody insured, because as a country we've not had agreement about what the national role should be in medicine. Secondly, because we've really believed that many people, perhaps the majority of the population, could be covered through the private sector through private health insurance. So health policy, national health policy for the last six or seven decades, has been to try and put in governmental programs which assist the private sector to cover the whole population. And what we've done, bit by bit, is we've developed one program here. Such as Medicaid, for the poor. The poor can't be covered by the private sector. There are market failures. We have Medicare because there was general agreement that private health insurance cover couldn't cover the elderly. So we got Medicare in 1965, which I think is a very, very successful program, expensive, but successful. Now we've got this large group of people called the uninsured who aren't covered by the private sector. So we've got these things in combination, a commitment to bringing technology to people, concern about the role of the federal government, and a system whose basic fundamental precept has been, up to now, trying to prop up private health insurance, private markets for providing health care. And our crisis, if you want to call it that, has been every few years discovering that something isn't working with this public-private mix and tinkering at the edges. And we're doing it again.

After World War II Europe embraced social insurance. We didn't. Speak to that.

There have been discussions of government health insurance since 1915-1920. And then in the 1930s again, and then after World War II and then, of course, discussions through the Nixon Administration, Carter Administration, Clinton Administration. But there hasn't been a genuine consensus based on some sort of practical understanding about how the whole thing might work. And I think we're both an idealistic nation -- you ask people do they favor health insurance for everybody and people say, "Yes." You ask, should the federal government have a role and they may very well say yes. The problem has been translating that into a practical workable program that would have general support from the population, general support from the major interests, as well, in health care. And we have never to this point reached that stage. And, as you look around now into other countries of the world, many countries are having problems with the programs they've put in, either before or after World War II. So at this point no country knows how to do this, how to have an ideal healthcare system. What we have attained, however, is a very expensive healthcare system with a huge number of people excluded from it, the uninsured. So there's a bigger case I think right now for putting in universal national health insurance than there's ever been before.

Do we over-romanticize the past?

I think we over-romanticize the past. First of all, doctors went to bedsides to give cheer because they often couldn't do anything else, and the psychological aspect of bedside meetings was very important. But for the last 50 years, we've been dealing with a medicine which is having to deal more and more with chronic illnesses and pharmaceuticals and biotechnology. And the imagery has changed. We're in a very, very different potential for medicine right now than we were even 30 years ago. Antibiotics only came into general use in the 1940s. And there's been a real flowering of pharmaceuticals since the 1940s, which is not very long in in historical times.

Does the employer-based insurance model we have here still work?

I think the employer-based insurance system is falling apart. First of all, you could say why do we have it at all? And you have to go back to the history of healthcare to ask that question. Health insurance for many years was seen as part of a package of benefits for workers. You have Workers Compensation. You have insurance for workers when they retire. We call that Social Security. And somehow or other there should be health insurance in that package, too. Now, in the 1930s, when Blue Cross began private insurance, it was developed around working populations. It's much easier for employers to collect, to organize, to be the middle person and know who the employees are. And during and after World War II, there was a huge expanse of the private market for health insurance, spurred on by federal policy. So in the 1940s you've got the big unions involved, auto workers, steel workers, a lot of people were working for major enterprises in the 1940s. So employment-based insurance made some sense. Employers were given tax breaks to provide private health insurance to their workers for the healthy population. And we've continued this system of workers having private health insurance organized through employers. Now what's happened since, of course, recently is the market has changed. We've got a lot of small businesses, who find it difficult or impossible to afford health insurance. We've got a lot of people who are not working. We've got a lot of people doing contract work, temporary work, several part-time jobs. And at the same time the cost of insurance has reached such a pitch that some employers have been cutting back on their employee benefits. I don't think the employment-based system is sustainable.

Why is the HMO not meeting our needs?

We developed HMOs initially on an older pattern of what was called prepaid group practice, like organizations to provide health care such as Kaiser Permanente or Group Health Cooperative in Puget Sound. These organizations were both providers of care and insurers. Now in the 1990s these two roles, through the managed care movement, have tended to split apart. So we've got "HMO" as a term increasingly being used as the insurance part and not for the delivery part. The HMO, the insurer, had a network of providers, a network of doctors, and network of hospitals, but it didn't feel responsible for providing the care. It was a contractor of a network. And in the last 10-15 years, doctors have tried to get together into networks of various kinds. A lot of those haven't worked very well. Hospitals have been developing their own health care systems. A lot of those haven't worked very well. There's a crisis in many of these organizations. And somehow or other we have to bring these two aspects back in line, the insurance, on the one side, so that people are adequately insured, and also the networks that provide the care, on the other. The question is, how do you make sure people have to access the entire health care system? How is this behemoth of hospitals, of groups of doctors, specialty groups in many cities, home health services working in different corporations -- how are you, the poor subscriber the health insurance, going to be assured that all of these are going to work for you?

Do we ration health care?

We have rationed healthcare in this country largely by price, as we've rationed other commodities. We ration how many restaurants someone can go to or if they can go to a restaurant at all by how much income they have. And we've tended to likewise ration healthcare by price. If you're very well insured, you're likely to have a better access to a wider range of medical technology and advanced medical practice than if you're poorly insured. So we do have rationing. I hope we can get rid of the word "rationing" as a whole, because I think it's an old-fashioned word. And we've got so many problems now, we need to reinvent our vocabulary.

Who is at risk in our current system?

I think we're all at risk to some extent. People who are uninsured are at a particular risk. We have 43-44 million people who are uninsured -- now many of those people are young, working and healthy. It may be a reasonable for them as individuals not to pay for insurance because they're just getting going, they've got housing, they've got cars. But they're taking a big risk. I think people who are poor are at risk because the health care system, as it operates, doesn't necessarily work well for them. And because healthcare isn't just healthcare. It's what happens to people's families when someone is sick. So, the lower you are in the income scale, the more difficult it is for you to be able to work this combination of getting to healthcare with transportation, with work, with looking after your children if you're sick. It's a terrible burden on people. It's not just the individual patient who's at risk. It's often the family as well.

The family is always going to have to carry some responsibility for people in their families who are sick. But we could do a much better job on family policy, on sustaining families who are under great stress because an older person is bedridden or someone with Alzheimers needs to be watched the whole time, literally the whole time. How can we maintain families in a sensible way so that when somebody get sick, there isn't family break-down or excessive stress on those individuals. And that may meanmore home care for some people. It may mean additional respite services so that a care taker, can get out, go to a movie, go shopping. There may be other ways to do it, but, as family policy, we've really ignored the burden on those families who are faced with a seriously ill individual.

Won't the numbers of uninsured rise without some sort of fundamental shift?

Yes, I think we are going to see the number of uninsured go up, particularly if the economy shifts and more people are out of work. The movement has been towards an increasing number of uninsured. And the question is, does that hit a point whereby it just becomes untenable? I mean in a way it's been untenable for a long time, but it hasn't, because many of these people are members of the working population who were young and relatively healthy, it hasn't reached screaming pitch in terms of the number of uninsured. But I think the number of uninsured will go up and continue to go up unless something is done.

Anything you'd like to add?

I think it's important to stress some of the positive -- we're partly in this fix because the potential for healthcare is great and because we have assumed that technology and science are going to fix a lot of our healthcare problems. We believe in technology and we have a high cost system because we want a high cost system. We want to be able to stimulate science and technology in the American culture. L ooking at the pluses -- think of people you know who are in their 70s, 80s, 90s, who are functioning very well, who may have hearing aids. They may have had a cataract operation, which is now mundane. It used to be a big, big deal. They may have had hip replacements. They may be on a whole passel of drugs. And look at those people you know yourself whose lives have been qualitatively dramatically improved and who haven't been impoverished as a result of having to pay for healthcare. I think we are not in a crisis in a sense of everything falling apart. We are in a process of trying to reinvent our healthcare system so it works better.

The healthcare system is in part a system of hope in this country -- and giving people access to that system, can we do it better? Can we do it better without spending much more money? Can we do it better by using American know-how? Can we do it better by having everybody on the same page, the major corporations, Congress, the professionals associations, consumer groups, most important? Can we do it better? History has shown that we can be very inventive, we can move fast as a culture, as a nation. How we're going to do this is currently up for grabs. So this is an exciting period. It's a very alarming period, but I believe we can create a better health care system, and have to.

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