International Journal of Epidemiology 2002;31:696-697
© International Epidemiological Association 2002
Book Review |
Bleeding the Patient: The Consequences of Corporate Health Care.
D Himmelstein, S Woolhandler, I Woolhandler. Monroe, ME: Common Courage Press, 2001, pp. 238, $15.95. ISBN: 1-56751-206-2.
Unlike most books written by respected academics, this book is not directed at an audience of fellow researchers, but designed for polemical, not to say, political, purposes. It is a direct contribution to the debate about the funding of health care in the US. It is written for an American audience, and the authors assume a high degree of familiarity with the American health care system. No concessions are made for interested foreigners (or, indeed, Americans) who might need an introduction to the current state of play. For example, the key term, ‘HMO’ (health maintenance organization) is not explained.
As the authors state in their introduction, they wrote the book to rebut two arguments made in favour of market solutions in US health care: first, that ‘extending coverage, bridling HMOs' power or improving quality would break the bank’ and second, that ‘although high quality national health insurance is affordable and theoretically feasible, it is politically impossible, the opposition is too rich and our democracy is too weak’. They say that the book confronts the first argument by demonstrating how extending coverage to all Americans is indeed possible using non-profit national health insurance. They contend that the second argument needs to be rebutted by direct political action. This book is intended to ‘arm [...] activists and organizers' by providing them with a narrative outline (in the form of a précis at the beginning of each chapter) for speakers preparing a slide presentation using the charts in the book (which have been made freely available on the internet at www.pnhp.org). As that is the intention of the authors, there is less justification than would be the case were this intended as a scholarly work in complaining that the book is not referenced and that counter arguments to those proposed are not canvassed. However, for the academic reader, these are both matters of some annoyance. Indeed, in my view, they weaken the arguments made for any audience.
The argument put forward is as follows. Forty-three million Americans (most of whom are children and the working poor) lack any form of health insurance, despite the existence of federally funded programmes to cover the elderly and the very poor. The situation is deteriorating for people who do have insurance—few Americans have adequate health care coverage. Workers are paying a higher share of premiums and retired people are also facing rising out of pocket costs. Long-term care is hardly covered by insurance at all. That the introduction of market forces into medicine has had the effect of decreasing choice and responsiveness of corporations to consumer demands is illusory—patients rarely switch health plans voluntarily. The effect of lack of coverage and insufficient coverage is that many people forego care for life threatening symptoms such as a chest pain or breast lumps. Women who cannot afford it frequently delay prenatal care.
At the same time, there is a surplus of hospital beds, increasing numbers of administrators and an impending surplus of doctors. Competition in health care has been advocated to solve some of these problems, but it is not possible in many areas of low population density and does not help where it can occur. Profit driven HMO cannot afford to provide good quality care for expensively ill, non-profitable patients, and there is an incentive on them to recruit healthy, profitable patients instead (to ‘cream skim’). Several studies are mentioned which it is claimed demonstrate that HMO provide poor quality care. (But as this is not an academic book, insufficient detail is given of these studies for the reader to evaluate the claims made.) Moreover, where there is for-profit care, charity care decreases and research suffers.
Every other developed nation apart from the US assures health coverage for the entire population. The US does badly in terms of life expectancy while its health care costs per capita are nearly double that of any other nation. These costs are not attributable to a larger elderly population (as other countries have larger ones) nor to health care utilization rates (as these are higher in some other countries). Canada provides a good model for an alternative system. In Canada, through a single payer (the government), universal health care is provided at about half the cost of the American system (and these costs are not rising). This form of funding has ameliorated inequalities in health and the quality is as good as insured Americans receive. It is relatively free of bureaucracy, is a system that allows planning of services and an emphasis on primary care, while it imposes relatively few constraints on patients' choice.
Drawing on Canadian solutions to address the American problems, the authors suggest a universal, tax-funded, non-profit national health programme organized like Canada's, though better funded. Hospitals would negotiate global budgets with the national programme, and receive a single payment to cover all costs, eliminating most billing bureaucracy. Doctors in private practice would be paid under a single negotiated fee schedule. The costs saved by eliminating bureaucracy would pay for the extension of coverage to all Americans. In the past the medical profession has been opposed to this approach, but now many doctors support it. Surveys show wide support for universal coverage among Americans generally.
While the argument has much to recommend in it, because the book is entirely polemical, it does not deal with many of the counter arguments and complexities which the vast amount of existing research evidence indicates are relevant. For example, the question of how fee-for-service remuneration for doctors tends to inflate levels of use is not adequately discussed; and the difficulty of setting global budgets for hospitals which provide adequate incentives to provide good quality care, while also being good value for money, is not considered. In general, while the unacceptable incentives of the current system are made much of and lamented, the incentives of the proposed national programme are not addressed.
Furthermore, the initial exposition of the problem in the US is muddled. Due to the fact that no introductory description of the current system of funding and providing health care in the US is given, it is possible for the authors to confuse what are separate (albeit related) issues, namely the rise of ‘managed care’, mainly in the form of HMO; the increase in for-profit providers; and the advocacy of increased competition. None of these is inherently responsible for the lack of universal health care insurance coverage in the US. The book is designed to promote arguments in favour of such coverage. It would do so more effectively if it had made its initial analysis of the current organization and funding arrangements more clearly.
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