America's health care system is in the intensive care unit. Its prognosis: poor. Its recovery: doubtful. According to a spate of new books, medical care is poorly organized, substandard, much too expensive and unsustainable. Allowing the system to evolve into a profit-hungry, stock-market-watching enterprise is a big part of the problem. As the cost of care progressively rose in the 1970s and '80s, many economists and politicians argued that the latest free-market business practices -- production efficiencies, standardization, consumer price-consciousness, competition among purveyors -- could make health care more accessible and affordable. Ten years ago the market takeover was already well under way, but it was jump-started when the 1994 Clinton reform plan collapsed. Many medical editors and ethicists raised concerns then about the inordinate focus on the bottom line and the loss of a "human side" to health care, but the juggernaut was already rolling, and leaders in medicine felt powerless to stop it.
A System Nobody Likes . . .
Donald L. Barlett and James B. Steele's lively and accessible Critical Condition: How Health Care in America Became Big Business and Bad Medicine (Doubleday, $24.95) dissects the consequences of privatizing many medical institutions, including hospitals, HMOs, physician practices and nursing homes. They argue that this conversion to market-driven medicine caused many of today's deficiencies. Except for the minority who can afford the best insurance policies (and members of Congress, who get them for free), the rest of us face daunting challenges with each medical encounter. We are confounded by seemingly endless attempts to make appointments, struggles to be seen by the right doctor (or to be seen by one at all), ever-briefer office visits, bafflement over who is in charge when we're hospitalized and demands to leave the hospital long before we're ready.
Doctors are no less frustrated. They don't like managed care, and they don't like being managed. They endure stagnant or falling incomes and increasing expenses, malpractice threats and a nightmare of administrative hassles from multiple insurers, each with its own complex rules. Many for-profit medical businesses, including HMOs and hospital chains, have failed -- some of them the victims of fraud. Leaders of industry, which pays much of the cost of care, are disgruntled with the system.
Barlett and Steele diagnose the quality of American health care as second-rate "bad medicine." True, America's life expectancy trails that of many other countries, and on the World Health Organization's "healthy living" scale, the world's wealthiest country ranks 29th (behind Croatia!). But many of the examples in Critical Condition are sensational, high-profile cases of gross errors in small for-profit hospitals. Many doctors who work in academic medical centers would argue that their patients get quite good day-to-day care.
Both views fail to describe the whole picture. In fact, substantial variations in quality persist, effective treatments are often neglected, too many tests are performed, and the risks of medical mishaps are larger than they should be. Clearly Americans aren't getting their money's worth. We pay far more per capita than any other country for health care (a whopping total cost of about $1.7 trillion per year), yet 44 million Americans have no health insurance, and millions more are inadequately covered.
. . . Except the Drug Companies
In particular, Americans are paying a fortune for prescription drugs, far more than the citizens of other industrialized countries. Although drugs represent only 10-12 percent of total health care expense, they make up the fastest-growing segment. Increasingly, patients are taking more drugs and paying more out of pocket for them. Many Americans, especially the elderly, simply cannot afford to pay the high prices for their medications and sometimes go without some or all of them. Countless Americans -- and even whole cities such as Springfield, Mass. -- are buying cheaper medications in Canada and over the Internet, despite a federal ban.
Critics indict the pharmaceutical companies for profiteering and fleecing the public; the companies argue that they need their exceptional profits to finance research. In fact, they invest far more in marketing their current drugs than in developing new ones. Given the enormity of their operations, their productivity over the past five or six years has been unimpressive: Only a few new drugs are real advances, and the rest have no special advantages over existing ones. Industry representatives admit that their drug pipeline is running dry, but instead of pushing their research harder as major patents expire, they manipulate the system to extend their patents, modify molecules slightly, change a drug's name, advertise heavily and raise prices. Meanwhile, they avoid research on drugs unless they can predict substantial profits, so research on drugs for life-threatening diseases such as tuberculosis and malaria in developing countries is virtually nonexistent. Critics also complain that the federal watchdog, the Food and Drug Administration (FDA), is too close to the industry -- partly because it gets some of its funding for drug assessment from companies whose drugs it is analyzing.
In two new books, Jerry Avorn and Merrill Goozner provide the background and evidence behind many of these concerns. Avorn's Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs (Knopf, $27.50) is overly long, replete with references to his own work and written in a conversational tone that will put some readers off. Yet the persistent reader will find detailed explanations of the methods for running clinical trials, descriptions of how companies get marginally effective drugs to pass muster at the FDA and explanations of why rare but serious drug risks are often overlooked. Goozner's The $800 Million Pill: The Truth Behind the Cost of New Drugs (Univ. of California, $24.95) is more technical and will appeal more to medical practitioners and policymakers. But his careful analysis of the origin of drugs -- perhaps the most rigorous to date -- shows that the basic research on many of the hottest new drugs is performed in university laboratories, often largely funded by the federal government (that is, you, the taxpayers). Yet drug companies end up profiting from these discoveries and trumpeting industry-supported economic analyses that exaggerate their own costs for developing the drugs.
A Better Prescription
Better, cheaper health care depends on good ideas, the will to implement them and the strength of countervailing vested interests. There's no shortage of good ideas (all three books have them), and, unfortunately, no lack of powerful vested interests. Barlett and Steele propose revamping the system to provide basic benefits and catastrophic coverage for all citizens. Their variation on a single-payer system would expand a Medicare-like plan that, like the Federal Reserve system, would be kept at arm's length from direct government control. All three books recommend setting up an independent prescription-drug institute within the National Institutes of Health. Such an institute could administer clinical trials, provide information on drugs before they go on the market, generate best-practice clinical guidelines and inform consumers.
Unfortunately, good ideas are not the driving force now. The national appetite for revamping the health care system or messing with the drug companies' hegemony over their products has been dampened; no politician wants to chance the fallout of another failed attempt at comprehensive reform. The pharmaceutical companies, HMOs and for-profit enterprises like things the way they are, and they have the financial wherewithal to resist change through contributions to politicians and employment of former legislators-turned-lobbyists. Our country's leaders are being cautious, offering proposals that only patch up some of the defects. During this year's presidential campaign, President Bush wanted to introduce even more market-oriented incentives, cap malpractice claims and expand community clinics; Sen. John Kerry offered to expand employer-provided insurance, provide tax credits and ramp up some federal coverage. Senators Hillary Rodham Clinton (D-N.Y.) and Bill Frist (R-Tenn.) -- strange bedfellows indeed -- also jumped on the marketplace bandwagon, promoting more competition and focusing on advances in information technology that would disseminate high-quality medical information and provide access to patients' medical records. But nobody offers what is really needed: a thorough reexamination and perhaps a complete overhaul. Regrettably, nothing is likely to happen until the public feels enough pain and endures enough expense to demand reform.
Many citizens feel exploited by the pharmaceutical industry, and these books will only inflame their passions. People are fed up with pharmaceutical executives' huge salaries, tired of paying so much for prescriptions, skeptical about the companies' motives and increasingly weary of an industry that is always in your face -- in newspapers, on television, on racing cars, in airport terminals. If the drug companies aren't telling you to "ask your doctor what's right for you," they are hinting that you have some drug-treatable new condition or trumpeting their contributions to the conquest of some awful disease in full-page ads. The drug companies have lost our confidence. They need to stop telling us how wonderful they are and start proving it again. *
Jerome P. Kassirer, a former editor of the New England Journal of Medicine, is distinguished professor at Tufts University School of Medicine and the author of "On The Take: How Medicine's Complicity With Big Business Can Endanger Your Health."