{"id":16,"date":"2020-01-17T10:46:00","date_gmt":"2020-01-17T14:46:00","guid":{"rendered":""},"modified":"2021-02-05T11:43:53","modified_gmt":"2021-02-05T15:43:53","slug":"priced-out-the-economic-and-ethical-costs-of-american-health-care-uwe-e-reinhardt-reviewed-by-christopher-m-hughes-md","status":"publish","type":"post","link":"http:\/\/blog.cmhughesmd.com\/?p=16","title":{"rendered":"Priced Out The Economic and Ethical Costs of American Health Care Uwe E. Reinhardt; Reviewed by Christopher M. Hughes, MD"},"content":{"rendered":"
Priced Out<\/em><\/div>\n
The Economic and Ethical Costs of American Health Care<\/em><\/div>\n
by Uwe E. Reinhardt<\/div>\n
Epilogue by Tsung-Mei Cheng<\/div>\n
Forewords by Paul Krugman & Sen. William H. Frist<\/div>\n
<\/div>\n
Reviewed by Christopher M. Hughes, MD<\/div>\n
<\/div>\n
If you are a novice to the subject of health care policy, the first few chapters of Priced Out <\/u><\/i>will leave you dumbfounded at the absolute mess we have made of healthcare in the United States. Professor Reinhardt calls it a \u201cwonderland,\u201d 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 \u201cthe market\u201d or \u201ccompetition\u201d or the illusion of \u201cchoice.\u201d<\/div>\n
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\u2019s great ability to make the complex comprehensible. For example, the highly \u201cpopular\u201d 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 \u201chaircut,\u201d as he likes to say, of the billions of dollars that flow through their accounts each year.<\/div>\n
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 \u201ccategories\u201d 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 \u2013 or not. He jokes that in most nations, there is only one category of human beings. We have made micro-categories a high art.<\/div>\n
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 \u201ccompetition\u201d and \u201cmarket freedom\u201d and other euphemisms for greed. Convoluted methodologies to \u201ccontrol costs\u201d by external administrative mechanisms rather than evidence-based practice infuriate physicians and have spawned the multitude of staff in doctor\u2019s offices and hospitals to obtain \u201cprior authorization\u201d to prescribe medications or perform surgeries or even to determine if one is sick enough to be in the hospital.<\/div>\n
The second half of the book focusses on the social ethic of our health care system. Uwe states it plainly: \u201cTo what extent should the better off members of society be made to be their poorer and sick brothers\u2019 and sisters\u2019 keepers in healthcare?\u201d<\/div>\n
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\u2019s, 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. <\/i>In it, he asked the precursor to the above question: \u201cshould 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?\u201d He was clearly stung by the idea that his adopted countrymen rejected this solidarity, in contrast to every other nation\u2019s resounding \u201cyes\u201d to the question.<\/div>\n
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<\/i>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<\/i> strive for universal healthcare.<\/div>\n
He has said elsewhere, \u201cA common incantation during debates on health reform, for example, is \u2018that we all want the same thing; we merely disagree on how best to get there.\u2019 That is rubbish.\u201d<\/div>\n
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 \u2013 as explicitly stated by his widow, TM Cheng in her epilogue \u2013 \u201che passionately believed in universal healthcare.\u201d<\/div>\n
In an exchange I had with him a few years ago, he wrote, \u201cthe 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.\u201d<\/div>\n
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.<\/div>\n
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 <\/i>as, \u201cAre we about me, or we?\u201d<\/div>\n
The glimmer of hope I still have rests on two foundations. Uwe\u2019s clear-eyed articulation of the questions we have before us and their obvious answers and<\/i> 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.<\/div>\n
In 2002, \u201cMedical Professionalism in the New Millennium: A Physician Charter,\u201d was published as a Project of the ABIM Foundation, the ACP\u2013ASIM 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 \u201cpromote 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.\u201d<\/div>\n
The Charter argues that \u201cMedical 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.\u201d<\/div>\n
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.<\/div>\n
I am taking Prof. Reinhardt\u2019s last book as the plainspoken economic and practical case to shake ourselves free from this embarrassment of a \u201csystem\u201d we have watched become a more hideous monster than we ever contemplated. I am also taking it as the simple moral argument for why<\/i>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?<\/div>\n","protected":false},"excerpt":{"rendered":"

Priced Out The Economic and Ethical Costs of American Health Care by Uwe E. Reinhardt Epilogue by Tsung-Mei Cheng Forewords by Paul Krugman & Sen. William H. Frist Reviewed by … Continue reading “Priced Out The Economic and Ethical Costs of American Health Care Uwe E. Reinhardt; Reviewed by Christopher M. Hughes, MD”<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"sfsi_plus_gutenberg_text_before_share":"","sfsi_plus_gutenberg_show_text_before_share":"","sfsi_plus_gutenberg_icon_type":"","sfsi_plus_gutenberg_icon_alignemt":"","sfsi_plus_gutenburg_max_per_row":"","footnotes":""},"categories":[4,94,146,17,6,16,11],"tags":[],"class_list":["post-16","post","type-post","status-publish","format-standard","hentry","category-universal-health-insurance","category-health-policy-general","category-medical-industrial-complex","category-medical-professionalism","category-moral-arguments","category-social-justice","category-uwe-reinhardt"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/posts\/16","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=16"}],"version-history":[{"count":3,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/posts\/16\/revisions"}],"predecessor-version":[{"id":1011,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/posts\/16\/revisions\/1011"}],"wp:attachment":[{"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=16"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=16"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=16"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}