No easy fixes for U.S. health-care system

BY JENNIFER EVANS
Rice News staff

Assessing the American health-care system as a “capitalist-dominated, profit-driven system” that fails to offer “accessibility, quality and reasonable cost for most Americans,” medical trailblazer and world-renowned surgeon Michael DeBakey acknowledged the need for reform but noted that past government involvement has proven to be a double-edged sword, contributing significantly to society but also creating “serious problems and thorny issues.” DeBakey, chancellor emeritus of Baylor College of Medicine, examined “The Role of Government in Health Care: A Societal Issue” last week in the final presentation of the 2004-2005 President’s Lecture Series.

As the call for health-care reform in America continues, so does the contention over the role government should play in health care. “Opponents of state intervention and proponents of privatization contend that the deeper government becomes involved in medical care, the more bureaucratic, complicated, inefficient and inferior the services,” he said. “The advocates argue that government participation is the best way to improve cost-effectiveness and accessibility of medical services.”

America’s experiment with government health insurance began in 1965 with the enactment of Medicare, created to provide low-cost hospitalization and medical insurance to the nation’s elderly. Considered by many to be successful in achieving these aims, Medicare also, because of its supplemental payments to hospitals, enabled remarkable growth and achievements in medicine since the 1960s, including impressive advances in medical technology, drug therapies and medical treatment for a widening array of diseases.

However, because of these very advances — as well as a growing population eligible for Medicare coverage — the program’s expenditures have increased more than 30-fold since 1970. Skyrocketing costs are further reflected in the expenditures for prescription drugs, as well as for ever-growing administrative costs. It is projected that by 2025, the government will use one-quarter of all federal income taxes for Medicare, he said.

Measures by Congress to contain escalating costs, such as the Balanced Budget Act of 1997, have dealt blows to the medical community, DeBakey said. Designed to balance the federal budget, the act drastically cut federal government reimbursements to physicians and hospitals and “severely lowered subsidies for education, crippling our academic health centers and raising grave concern among our academic health leaders.”

Another development aimed at containing the costs of health care earned DeBakey’s rebuke: the emergence in the 1970s of managed care plans and health maintenance organizations.

“Unfortunately, most for-profit HMOs have concentrated on producing substantial financial returns for their investors rather than quality and quantity of service,” DeBakey said. “The cost-containment policy encourages doing as little as possible for the patient.”

Solutions to the health-care quagmire are not straightforward. Some advocates of universal health insurance point to Canada and Europe, where per capita spending on health care is significantly less than in the United States. “But free and ready access is a far cry from the actual performance of good medical care,” he said. Having traveled the world, “working in the trenches” in virtually every system of medical care, “I can say unequivocally that I have not observed any form of universal health system or other state-operated medical system that functions in a highly satisfactory manner to provide high-quality care to all the people all the time when it is needed.”

A voucher system such as detailed by health economist Victor Fuchs and bioethicist Ezekiel Emanuel in a recent New England Journal of Medicine article could merit further study, DeBakey said. Fundamental among its features are universality, free choice of health plan, funding by an earmarked value-added tax, reliance on private delivery systems and administration by a federal health board modeled on the structure of the Federal Reserve System. Under this plan, Medicaid would disappear, Medicare would be phased out and employer-based health insurance would likely fade away.

Whatever solution is pursued, DeBakey cautioned against radical restructuring of health care or changes designed to cut costs rather than improve the level of care.

“Lets not throw out the baby with the bathwater,” he said. “The best features of our system should be retained, particularly support of our academic health centers, where future physicians receive quality medical education and training, where imaginative and innovative medical research has led to many domestic life-saving advances in health care and where optimal health care for the most seriously afflicted patients is available.”

He also called on the medical community to “reclaim its stewardship of its own profession, especially in medical decision-making and ethics that places the welfare of the patient above all else.”

The obligation to care for every citizen is strongly implied in our Declaration of Independence, our Constitution and our Bill of Rights, which proclaims our right to life, liberty and the pursuit of happiness, he said. “Without health, life … and the attainment of these rights is exceedingly difficult, if not impossible.”