The American Sickness: A Clinical Perspective

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Commentary — December 2017

Tex Med. 2017;113(12):15–17.

By Larry Buxton, MD; Eduardo Garcia, MD; and John Pettigrove, MD

American medicine has done more to relieve suffering and forestall death than any other health system in history. Today, this system is facing a major challenge: steadily rising cost. 

This rising cost has brought us where we are today. During our three careers, the twin pillars of American medical practice have been free enterprise and compassion.

Free enterprise is at the very core of what it is to be an American. Free enterprise is not simply capitalism, and the term "free enterprise" is not interchangeable with "corporate business." Free enterprise is unfettered American ingenuity, American diversity, and American collective effort, both native and immigrant, uniquely fused with individual genius. 

But free enterprise is not the essential heart of classic American medicine — conservative or liberal, Democrat or Republican. The essential heart is compassion. It is compassion for the poor, the less fortunate, and for those Americans who despite trying their best have been unlucky in genetics, social standing, money, family, and, yes, unlucky in health. While compassion is not uniquely American, it is at the heart of our values and is an expectation all physicians have been trained for.

In her best-selling book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, Elizabeth Rosenthal, MD, a New York journalist trained as a physician, calls the decades-old explosion of health care costs "the American sickness." High cost and limited access are part of the tsunami of challenges we face. Pharmaceuticals sell on the international market at a fraction of the price sold on the American market. There is disproportionate geographical distribution of health care in the United States: too many neurosurgeons in New York City and no physicians at all in some rural counties in Texas. Patients see midlevel providers who often resort to newer innovations such as telemedicine.

To understand the state of health care in the United States, we must understand the historical perspective and how our modern system of reimbursement evolved.

The Traditional Medical Paradigm 

The late Corpus Christi internist and cardiologist Robert Fordtran, MD, practiced medicine until just a few weeks before he died this past year. His practice ethic epitomized an entire generation of physicians who would not sell their integrity for any price. He was married to medicine. He was a scientist, a humanitarian, and a lover of his fellow men and women. He trained to believe that medicine was his life's responsibility. U.S. physicians like Dr. Fordtran usually were solo practitioners who charged a fee for service and, in some cases, did not charge patients at all. Few were what we would consider wealthy, though they enjoyed an elevated social status related to their rigorous training and dedicated lifestyle. Physicians did not advertise, and almost all died still practicing medicine. This picture began to change with the creation of Medicare.

The Rise of the Modern Medical Paradigm

During the Second World War, employer-based health insurance evolved, and soon health insurance became an employment benefit. At about the same time, the Canadians developed a single-payer health system championed by the radical socialist premier of Saskatchewan, Tommy Douglas. In the late 1940s, President Harry Truman considered Mr. Douglas' single-payer idea but shied away because Mr. Douglas' radical social ideas such as euthanasia and forced sterilization were repugnant to most American physicians. 

In 1965, Medicare became law as single-payer health care for the elderly. President Lyndon Johnson introduced the idea of "usual and customary fees." This concept changed the paradigm of health care. Usual and customary fees were left to the discretion of each provider. It was a stunt ― a stunt by President Johnson to get physicians and the American Medical Association to embrace universal coverage for the elderly. The president schemed to appeal to the greed of the providers. It worked. To understand how incredible this accomplishment was, you have to understand the power of the AMA in those days. It was the most powerful professional organization in the country. That power was not based on lobbyists or money but on the exalted status of the doctor. In a single blow, like cutting off the head of a snake with a hoe, President Johnson destroyed the power of the AMA. Today, fewer than one-quarter of U.S. physicians are AMA members.

Over the years, the same payment strategy spread to hospitals, durable goods manufacturers, and finally to the pharmaceutical industry. The incentive for providers became to increase prices for less service while at the same time appearing to provide more. It became a game for the business savvy: Prices rose each succeeding year and, in reflex, insurance premiums rose. Under the Affordable Care Act, the rising cost was exposed as 20 million covered lives were added. The middle class felt the bite of this new "tax" and wanted something to be done. The Republican Party champions repeal of the ACA. Bernie Sanders, a socialist senator from Vermont, has brought back Tommy Douglas' old ideas, while the Democrats have stuck their collective heads in the sand and believe the ACA is working. Insurance companies announce new rate hikes as the band plays on.

But neither the strategy of repeal of the ACA nor single-payer health care is worth considering as long as cost relentlessly rises. New technology and procedures add to cost as time-honored, hands-on health care continues to decline. Economies of scale have no impact on cost for the patient. Everyone needs health care, and they will pay what they must to get it or they will go without. 

So our country continues to drift toward a single-payer system, as Congress remains stalemated and divided. 

Larry Buxton, MD, is a retired neurologist and past president of the Nueces and Lampasas county medical societies; Eduardo Garcia, MD, is an internist in Corpus Christi; and John Pettigrove, MD, is a retired Corpus Christi critical care pulmonary physician.

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November 17, 2017

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