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8. THE U.S. HEALTH CARE SYSTEM
- Johns Hopkins University Press
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73 6 6 6 8 The U.S. Health Care System The U.S. health care system is the subject of multivolume tomes. It is too complex and has too many moving parts for it to be described in any detail in a single chapter, much less to provide a prescription for its salvation. But some key aspects and core issues are worth pondering. Calling U.S. medicine either “health care” or a “system” is an exaggeration. At its core, U.S. medicine is composed of individual physicians who are paid each time they treat a patient for a disease, mostly on a fee-for-service basis. They may work in solo practice or in small or large groups, but their organizational framework differs little from those of preindustrial craftsmen: they are paid for piecework. This has important implications: * Physicians are paid to treat our disease du jour, not to keep us healthy. “Health”has nothing to do with it (the most notable exception being pediatric “well-baby care”). 74 Getting WhatWe Deserve * As treatments have become more complex and the knowledge needed more demanding, physicians have focused on narrower and narrower slices of disease; they“superspecialize .”The piecework for which they get paid, never about health, is even less about optimizing outcomes for a sick person ; the piecework is about treating a specific, limited slice of a sick person’s disease(s). * Any other “diseases”the patient might have are of little interest to the treating clinician because he or she does not have access to other physicians’ records, doesn’t have the time to inquire, and lacks the knowledge to make much sense of it, anyway. * Nobody is coordinating our “care”; our most urgent illness receives all the attention. This poses enormous problems as we age and our litany of chronic diseases mounts: the treatment for some diseases makes others worse. In any case, who can keep track of all the medicines we are told to take (and who can afford them)? * “Personalized medicine”was once the standard of practice. Physicians didn’t just prescribe an antibiotic (during the heyday of personalized care, there were no antibiotics); the patient’s “situation”(social, economic, cultural) was known and taken into account. There was no point in advising someone to get more rest and to relax if no one else was available to milk the cow or punch the timeclock. Today“personalized medicine”is invoked as a golden future awaiting genetic discoveries that will allow the pharmaceutical industry to create new drugs uniquely our own. Don’t hold your breath!1 [54.224.52.210] Project MUSE (2024-03-30 06:36 GMT) The U.S. Health Care System 75 Could physicians and other health care professionals be trained and incentivized to focus on keeping us healthy and coordinating our care? Of course, but for that we would need a real system, one that coordinated payments and training positions in a rational and objective manner, a system whose design (and financing) was constructed from whole cloth. U.S. medical care is underwritten by a multiplicity of financing schemes,each of which was developed at a unique moment in time. “In the beginning,” patients paid a doctor directlyfor care (as some still do),which meantthatonlythe wealthy received care. (Because physicians didn’t have much of value to offer until relatively recently, this probably made little difference; the peasant and the merchant were equally likely to die from the plague.) As medical care became more effective (and expensive), it came into greater demand. A variety of prepaid insurance plans, such as Blue Cross (for physicians’ bills) and Blue Shield (for increasingly expensive hospital costs), were devised. The most radical formulation was Henry Kaiser’s insurance scheme, in part because it provided both preventive and curative services but more because it was provided as a benefit of employment. This gambit was a competitive edge Kaiser used to recruit workers at a time when salaries were frozen by federally imposed wartime wage restraints. Employees pay no taxes on health benefits, though increasingly they are forgoing pay increases to maintain those benefits. Employer-based health coverage has since prevailed as the cornerstone of private American medical financing. In 1964 it was augmented by two additional schemes, Medicare and Medicaid, to pay the costs of caring for elderly people (age 65 or older) and those who were poor or disabled. There we have it; the major (but by no means only) financial schemes that pay for...