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Still Broken

Stanford University Press

Contents

List of Tables and Figures.............................................................................................................................xiPreface................................................................................................................................................xiiiAcknowledgments........................................................................................................................................xv1. The Promise and Disappointment of U.S. Medical Care.................................................................................................32. How Much We Spend...................................................................................................................................153. What We Get for What We Spend.......................................................................................................................344. Trouble in the Delivery Subsystem...................................................................................................................495. Why the Problems Need to Be Solved and the Goals of Reform..........................................................................................716. What Caused These Problems, and How Can We Attack Them?.............................................................................................947. Competition and the Market or the Public Sector?....................................................................................................1208. Elements of a Solution for Increasing Access to Health Care, Improving Quality of Care, and Containing Health Care Expenditures.....................1529. A Short History of Health Care Reform Efforts.......................................................................................................18110. The Politics of Reform: Elements of a Strategy to Break the Logjam.................................................................................20611. Strategy and Compromise............................................................................................................................227Notes..................................................................................................................................................253Index..................................................................................................................................................281

Chapter One

FOLLOWING PUBLICATION of the influential Flexner Report on medical education in 1910, the United States built on a foundation of science a health care system that, by the end of the 20th century, was the envy of the world. A visible symbol of that accomplishment is the astonishing number of health-related Nobel Prizes won by American physicians and other scientists. Since 1950, of the 133 prize winners in medicine and physiology, well over half have been either Americans or scientists who trained or worked in the United States.

Indeed, modern medicine is one of the unnamed wonders of the contemporary world. But it is more than a collection of impressive intellectual achievements. It has made a huge difference in the lives of many ordinary people in the United States and throughout the world. New treatments developed over the past one hundred years cure previously fatal acute illnesses. Even when the impact has not been to improve mortality rates, patients often recover much more quickly and with much less disruption of their daily lives and reduction of household income than in earlier times. Moreover, many chronic conditions that once were tantamount to a death sentence can now be managed effectively so that people who have them can carry on relatively normal lives.

It is no exaggeration to say that new drugs, new medical devices, and new surgical procedures have changed the face of illness to the point that we no longer need to fear many diseases that once evoked only the grimmest of images for the future. Following are some examples.

From the time of the Black Death, which is estimated to have killed one-third of the population of 14th-century Europe, until the advent of antibiotics, there was no good antidote to the effects of deadly microbes. Before the development of antibiotics, infections were major killers. "[U]ntil 1936, pneumonia was the No. 1 cause of death in the United States, and amputation was sometimes the only cure for infected wounds." Penicillin, one of the first antibiotic drugs, discovered in 1928 by Sir Alexander Fleming, kills harmful bacteria that cause illness and infection in humans. In the early 1940s, two researchers discovered how to make it in powdered form and helped mass produce it in time to curtail the risk of infection leading to amputation of damaged limbs or even death on the front lines of World War II. After the war, penicillin and other antibiotics were used widely to fight infection in the civilian population, dramatically reducing the harmful effects of many infectious diseases and contributing to the upward kink in life expectancy in America in the latter half of the 20th century.

With people living longer, partly as a result of "wonder drugs" such as penicillin, illnesses associated with age have become increasingly important, leading to other new treatments. Among the most common-and most frightening-conditions that primarily afflict older Americans are cardiovascular events, including heart attacks (myocardial infarction) and strokes, both of which usually result from hardened or blocked arteries. Blood pressure measures how clear and flexible arteries are and is a direct assessment of their ability to handle the pressures of blood flow. Higher blood pressure indicates that a patient is having trouble maintaining adequate blood flow through arteries that probably are constricted. For that reason, doctors want to measure blood pressure frequently in patients at higher risk (say, above age fifty) and to lower it with medications in order to reduce the risk of heart attack.

Take Janet, a fifty-five-year-old female with high blood pressure unknowingly at risk of a heart attack. She experienced extreme fatigue and indigestion and, later, nausea and vomiting, and she felt faint. Janet went to the emergency room of a nearby hospital, and though she was almost sent home for not displaying a classic sign of a heart attack (chest pain), the attending physician decided to run more tests. An old technology, the electrocardiogram, showed no acute abnormalities, but the ER doctor's suspicions were raised when a serum troponin blood test suggested that Janet had microscopic amounts of heart muscle damage.

Partly because of the potential for false positive results from the blood test, a cardiologist was called in to make a more definitive diagnosis. Following an examination, the cardiologist suggested immediate catheterization. This technique involves inserting a thin plastic tube (catheter) into an artery or vein in an arm or leg and advancing it into the chambers of the heart or into the coronary arteries. In Janet's case, it revealed an important blocked artery that the cardiologist was able to treat by angioplasty, a procedure in which a balloon is used to open...