Priced Out
The Economic and Ethical Costs of American Health Care
Uwe E. Reinhardt
Forewords by Paul Krugman & Sen. William H. Frist
Reviewed by Christopher M. Hughes, MD
If you are a novice to the subject of health care policy,
the first few chapters of Priced Out will leave you dumbfounded
at the absolute mess we have made of healthcare in the United States. Professor
Reinhardt calls it a “wonderland,” and not in the pleasant sense. The
wonderland is the morass of payment schemes that allow a multitude of
administrators (insurers, pharmacy benefits managers, etc.) to skim just a few
cents off each health care dollar spent before the remainder makes its way to
those actually providing services to patients. Example after example highlight
the mess we have created at the altar of “the market” or “competition” or the
illusion of “choice.”
If you are in the morass, as a physician or nurse or student
of health policy, you will sigh in recognition of the things you may have
already known, but you will see more clearly with Prof. Reinhardt’s great
ability to make the complex comprehensible. For example, the highly “popular”
Health Savings Accounts, are known to be a sop to high income households,
especially healthy households, but Uwe points out that they have also sprouted
a cottage industry of administering these accounts, taking just a little
“haircut,” as he likes to say, of the billions of dollars that flow through
their accounts each year.
For me, as someone in the morass as a physician, a physician
currently working in the health insurance industry and someone who teaches
health policy, I was aware of most of the accretions and detritus that make our
health delivery system a mess, but Uwe always manages to add this kind of level
of detail to, well, just infuriate me! Other examples are the “categories” of
human beings we have in the US, from the poor to the near poor to the wealthy,
to those covered by Medicare or Medicaid or both or neither or those covered by
employer-based insurance to those in the Affordable Care Act Marketplace – or
not. He jokes that in most nations, there is only one category of human beings.
We have made micro-categories a high art.
Chapters on the outrageously complex mechanisms we use to
price services and how we pay the bills are head slapping. Even as one in the
middle of the morass, I am still shocked to see the insane specifics of how we
have passively allowed this all to go on under the banner of “competition” and
“market freedom” and other euphemisms for greed. Convoluted methodologies to
“control costs” by external administrative mechanisms rather than evidence-based
practice infuriate physicians and have spawned the multitude of staff in
doctor’s offices and hospitals to obtain “prior authorization” to prescribe
medications or perform surgeries or even to determine if one is sick enough to
be in the hospital.
The second half of the book focusses on the social ethic of
our health care system. Uwe states it plainly: “To what extent should the
better off members of society be made to be their poorer and sick brothers’ and
sisters’ keepers in healthcare?”
This is clearly more troubling to Uwe than the economics or
health care and how deranged our system has become. After the failure of the
Clinton Health Plan in the 90’s, he wrote a powerful article in the Journal of
the American Medical Association (JAMA) called, Wanted: A Clearly
Articulated Social Ethic for American Health Care. In it, he asked the precursor
to the above question: “should the child of a poor American family have the
same chance of avoiding preventable illness or of being cured from a given
illness as does the child of a rich American family?” He was clearly stung by
the idea that his adopted countrymen rejected this solidarity, in contrast to
every other nation’s resounding “yes” to the question.
He explains that our tendency in American political life is
to pretend that our disagreements on health care are due to the details and how
to get to universal health care. So rather than have the broader ethical
discourse that could answer the two extremely important questions he has posed,
we camouflage and misdirect and devolve our discussions to the best way to
bring market forces to bear or how to properly fund Medicaid in the states. We
never answer the basic question of whether we should strive for
universal healthcare.
He has said elsewhere, “A common incantation during debates
on health reform, for example, is ‘that we all want the same thing; we merely
disagree on how best to get there.’ That is rubbish.”
He spends a significant section of the book exploring his
framing for this fundamental disagreement among conservatives and liberal. But
he does not have an answer for us on how to get where he clearly wants us to go
– as explicitly stated by his widow, TM Cheng in her epilogue – “he
passionately believed in universal healthcare.”
In an exchange I had with him a few years ago, he wrote,
“the problem in America is that the elite does not share a consensus on what
the social ethic governing American health care should be. I am not sure it
ever will reach such a consensus.”
In the epilogue by Dr. Cheng, she documents his hopes and
thoughts and, surprising to me, his optimism in America. We would hobble along,
he thought, and continue to figure things out as we went, and perhaps
technology can improve our lot.
The book left me less optimistic about our chances to reach
consensus, but more committed to trying to make it so. Profs. Reinhardt and
Cheng spent decades trying to advance American healthcare and continually try
to engage on the ultimate questions of our social ethic, paraphrased by Michael
Moore in Sicko as, “Are we about me, or we?”
The glimmer of hope I still have rests on two foundations.
Uwe’s clear-eyed articulation of the questions we have before us and their
obvious answers and my faith in the doctors and nurses who provide
healthcare in the trenches, as we like to say, and who have long ago had
enough.
In 2002, “Medical Professionalism in the New Millennium: A
Physician Charter,” was published as a Project of the ABIM Foundation, the
ACP–ASIM Foundation, and the European Federation of Internal Medicine. In the
Charter are calls around the Principle of social justice, Commitment to
improving access to care, and Commitment to a just distribution of finite
resources. It specifically charged the medical profession to “promote justice
in the health care system, including the fair distribution of health care
resources. Physicians should work actively to eliminate discrimination in
health care, whether based on race, gender, socioeconomic status, ethnicity,
religion, or any other social category.”
The Charter argues that “Medical professionalism demands
that the objective of all health care systems be the availability of a uniform
and adequate standard of care. Physicians must individually and collectively
strive to reduce barriers to equitable health care. Within each system, the
physician should work to eliminate barriers to access based on education, laws,
finances, geography, and social discrimination. A commitment to equity entails
the promotion of public health and preventive medicine, as well as public
advocacy on the part of each physician, without concern for the self-interest
of the physician or the profession.”
This Charter has been endorsed by virtually every group
within organized medicine, from the American Medical Association to the
American Board of Radiology to the American Nurses Association. While it is not
explicitly a call for universal healthcare in America, it is hard to view the
principles and not see this as the logical conclusion. And in fact, at the time
of its publication, there were quite a few dissenting commentators who saw it
as just that, and so rejected it.
I am taking Prof. Reinhardt’s last book as the plainspoken
economic and practical case to shake ourselves free from this embarrassment of
a “system” we have watched become a more hideous monster than we ever
contemplated. I am also taking it as the simple moral argument for why
we need to change. We must stop allowing ourselves to be pulled into
discussions about what flavor of health care reform we like best, and have that
knock-down, drag-out fight about who we are as a nation. Are we the nation that
cheers when one of us gets struck by a car and is left to die because they
chose to forego health insurance? Or are we the nation that sees ourselves in
the suffering of others and wants to help?
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