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Unaffordable Unaffordable American Healthcare from Johnson to Trump Jonathan Engel The University of Wisconsin Press The University of Wisconsin Press 1930 Monroe Street, 3rd Floor Madison, Wisconsin 53711-2059 uwpress.wisc.edu Henrietta Street, Covent Garden London WC2E 8LU, United Kingdom eurospanbookstore.com Copyright © 2018 The Board of Regents of the University of Wisconsin System All rights reserved Except in the case of brief quotations embedded in critical articles and reviews, no part of this publication may be reproduced, stored in a retrieval system, transmitted in any format or by any means— digital, electronic, mechanical, photocopying, recording, or otherwise— or conveyed via the Internet or a website without written permission of the University of Wisconsin Press Rights inquiries should be directed to rights@uwpress.wisc.edu Printed in the United States of America This book may be available in a digital edition Library of Congress Cataloging-in-Publication Data Names: Engel, Jonathan, author Title: Unaffordable: American healthcare from Johnson to Trump / Jonathan Engel Description: Madison, Wisconsin: The University of Wisconsin Press, [2018] | Includes bibliographical references and index Identifiers: LCCN 2017015526 | ISBN 9780299314101 (cloth: alk paper) Subjects: LCSH: Medical policy—United States—History—20th century | Medical policy—United States—History—21st century | Medical care—United States—History—20th century | Medical care—United States—History—21st century Classification: LCC RA395.A3 E546 2018 | DDC 368.38/200973—dc23 LC record available at https://lccn.loc.gov/2017015526 aided with a grant from Figure Foundation in search of the increment of healing For Andrew and Samuel ‫ִה ֵ ּנה ַמה ּטֹוב ּוַמה ָנִעים ֶשֶבת ַאִחים ַגם ָיַחד‬ How good and pleasant it is for brothers to dwell together Psalm 133:1 Contents Timeline of Major Federal Legislation Introduction A System Run Amok Medical Free Markets Reining in the Excess The Lure of Profits Efforts to Rationalize 6 HillaryCare Managing Care Quantity and Quality Ethical Wrangling 10 Medicare and Medicaid: Evolving Government Programs 11 (Un)Affordable Care 12 Afterword ix 10 33 53 68 81 102 124 145 154 169 189 215 225 227 271 Acknowledgments Notes Index vii Timeline of Major Federal Legislation Affecting Healthcare Delivery 1964–66 1966 1972 1972 1973 1973 1974 1978 1978 1983 1985 Congress creates Model Cities and the Office of Economic Opportunity, leading to funding of Neighborhood Health Centers Medicare and Medicaid launched National Advisory Committee on Health, Science, and Society created for considering ethical parameters of care Beginning of Professional Standards Review Organizations to monitor quality of physicians and hospital services Health Professions Education Act passed to augment medical education budgets HMO Act passed to direct grants and start-up loans to HMOs Creation of Health Systems Agencies through the Health Planning Act Adoption of DRG payment scheme by New Jersey Medicaid Consumer Choice Health Plan proposed by Alain Enthoven Medicare adopts the DRG payment scheme Medicare offers risk contracting for all beneficiaries to enroll in HMOs ix Index AAMC (Association of American Medical Colleges), 26, 97, 185, 270n1 Aaron, Henry, 102, 106 AARP, 110, 177–78, 180, 199–200 abortion, 110–11, 155 Abramowitz, Kenneth, 116 abuse See fraud/abuse ACA See Affordable Care Act ACOs (accountable care organizations), 205–7 ADA (Americans With Disabilities Act; 1990), 99–100 administrative complexity, 209 adverse selection, 105, 176, 180 Aetna, 111, 119, 129–30 affirmative action, 23 Affordable Care Act (ACA; “Obama­ care”; 2010): administration of, 197–98; catastrophic plans eliminated by, 200, 202, 213, 267n21; conservatives’ opposition to, 206; constitutionality of, 202, 206–7, 268n26; and the Consumer-Choice Health Plan, 56; co-payments and 271 deductibles, 208, 213; cost control by, 203–4, 211; coverage expansion to age 26, 194; failures of, 207–10, 219, 221–22; healthcare costs under, 4, 192–93, 203; illegal immigrants under, 204; insurance exchanges, 195–98, 201, 266–67nn14–15; jobkilling aspect of, 196–97; liberals’ opposition to, 205–6; as managed competition, 192; mandatory buyin, 195–96, 206–7, 220–21; mandatory employer provision, 196–97; and Medicaid expansion, 198–202, 220; medical loss ratios under, 270n2; planning for/passage of, 191–94; preexisting-condition coverage, 194–95; premiums, 211; prescription drug coverage, 199–200; private insurance system preserved by, 196; public plan under, 192–93; reception of, 213–14; Republican opposition to, 198, 201–2, 206–7, 211– 12; revenue mechanisms of, 201, 203, 267n23; Ryan’s replacement 272 Affordable Care Act (continued) plan, 212–13; subsidies, 200–201; successes of, 203, 210–11, 219; tiers for policies, 208 AFL-CIO, 110 Agency for Healthcare Research and Quality (AHRQ), 152–53 Agudath Israel of America, 120 AHRQ (Agency for Healthcare Research and Quality), 152–53 AIDS, 74, 76, 157, 183, 186 Allegheny Health (Philadelphia), 139 Alliance for Managed Competition, 119 Allied Health Professions Act (1966), 25–26 Altman, Stuart, 11 AMA (American Medical Association): on the Affordable Care Act, 192; Code of Ethics, 66; cost containment opposed by, 63–64; Council on Ethical and Judicial Affairs, 165; Council on Medical Education, 26; on employer-mandated health insurance, 105; on federal health planning, 41, 43; on overcharges, 14; on price controls and transparency, 15; RBRVS opposed by, 92 ambulatory surgery, 95 American College of Physicians, 105 American Heart Association, 147 American Hospital Association, 15 American Indians, 22–23, 231n55 American Medical Association See AMA American Medical International (AMI), 48–49 American Medicorp, 48, 50 American Surgical Association, 65 Americans With Disabilities Act (ADA; 1990), 99–100 Amgen, 79 AMI (American Medical International), 48–49 Angell, Marcia, 128, 148, 168 Annas, George, 163 antibiotics, 145–46 Index Appel, Uranus, 49 army medical corpsmen, 28 Arthur D Little, 87 Association of American Medical Colleges (AAMC), 26, 97, 185, 270n1 Australia, 152 AZT, 76 Baby Boomers, 262n1 Baby Doe, 7–8 Bakke decision, 185–86, 265n52 Balanced Budget Act (BBA; 1997), 141, 143, 175–76, 178, 257n70 Ball, Robert, 182 Ballantine, Thomas, 63 bankruptcies, medical, 190 Baron, Charles, 158 Baucus, Max, 110 BBA (Balanced Budget Act; 1997), 141, 143, 175–76, 178, 257n70 Begala, Paul, 102 Bentsen, Lloyd, 110 Berss, Marcia, 115–16 Berwick, Donald, 208–9 Beth Israel Deaconess Medical Center (Boston), 137, 139 Beveridge Report, 61 bioethics, 7–8 biomedical research, 66, 147–48, 257–58n5 bipolar disorders, 145 black Americans, 22–24, 232n61 See also racial disparities in health Blue Cross/Blue Shield, 38; costreimbursement principles of, 15; cost savings by, 125; for-profit plans, 129; growth of, 15; organization of, 238n52; on overcharges, 14; premium increases by, 50–51; reimbursement schedule of, 47 Bodenheimer, Tom, 147–48 Boren, David, 118 “brain dead” patients, 154–55 Breaux, John, 118, 180 Bredesen, Phil, 187 Brigham and Women’s Hospital (Boston), 138–39, 141 Index Bristol-Myers Squibb, 79 Brookings Institution, 213 Brown, Scott, 193 Bush, George H W., 99, 104, 249n10, 249n12 Bush, George W., 178, 181, 199–200 Calahan, Daniel, 156 Califano, Joseph, Jr., 51, 96 California, 14, 143, 204 Canada, 59–60 See also Medicare (Canada) Canada Health Act (1983), 61 cancer, 31, 183–84 Cannon, Michael, 204 capitation: by HMOs, 36, 43, 49, 53, 56, 93; by IPAs, 55; physicians’ incentives affected by, 126–27; total vs modified, 126–27 cardiologists, 47–48, 151 care delivery/coordination failures, 209 Carlucci, Frank, 40, 236n23 Carter, Jimmy, 58 Carville, James, 102 Cassell, Eric, 31, 135 Catastrophic Care Act (CCA; 1988), 103–4, 249n10 Catholic Church, 120 Catholic Health Association, 110–11 Cavanaugh, James, 37 CBO (Congressional Budget Office), 113, 181, 203, 247n47, 264n37 Celebrex, 149 Centers for Medicare and Medicaid Services (CMS), 182, 203–4, 209, 217 cesarean sections, rate of, 128–29, 255n38 chronic disease, 210 Chrysler, 51, 95–96 CIGNA, 119 Claiborne, Robert, 240n9 Claritin, 149 Clement, Kenneth, 17 clinicians, nonphysician (physician’s assistants and midwives), 28–30, 32, 42, 172 273 clinics, community, 239n3 Clinton, Bill, 56; healthcare reform by, 107, 109, 175, 250n24 (see also HillaryCare); unemployment under, 144 Clinton, Hillary Rodham, 111, 119 See also HillaryCare CMS (Centers for Medicare and Medi­ caid Services), 182, 203–4, 209, 217 Coakley, Martha, 193 Collins, Susan, 193 Columbia/HCA, 70, 140 Commerce Clause (US Constitution), 202, 206, 268n26 Committee for National Health Insurance, 32 Committee on the Costs of Medical Care, 53 Committee on the Life Sciences and Social Policy, 156 Community Health Service, 39 community medicine, 20–21 community rating, 107, 115, 118 Comprehensive Health Manpower Training Act (1971), 25–26 Congressional Budget Office (CBO), 113, 181, 203, 247n47, 264n37 Connecticut, 181, 264n38 CON (certificate of need) program, 88, 100 consent, 156–57, 260n10 Consumer-Choice Health Plan, 56–59 consumer price index, 8, 78, 113, 143 Consumers’ Union, 170 Contract with America, 173 Cooper, Jim, 107, 118 coronary artery bypass surgery, 47–48 cost containment, 53–67; by Chrysler, 96; Consumer-Choice Health Plan, 56–59; by consuming less, 106, 250n22; by for-profit hospitals, 71; IPAs (independent practice associations), 55–56; other countries as models for US, 59–63; physician/ AMA opposition to, 63–67; quality affected by, 142; by staff reduction, 71, 241n28; by vaccination, 145–46; 274 cost containment (continued) voluntary, 96–97 See also HMOs; managed care Council on Ethical and Judicial Affairs, 165 Council on Graduate Medical Education, 171 Cruz, Ted, 202 Cruzan, Nancy, 7–8, 163–64, 261n27 cyclosporine, 76 Danbury Hospital (Connecticut), 125 Daniels, Norman, 162 Darman, Richard, 104 Dartmouth Atlas of Health Care (Wennberg), 150 Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, 90, 140 DeBakey, Michael, 64 DeMint, Jim, 206 Democratic Party’s healthcareindustry ties, 109–10 diagnostic related groups (DRGs), 83–84, 86, 244n7, 245n13, 245n16 dialysis, 13 Dinnerstein, Shirley, 158 diseases, infectious/congenital vs lifestyle, 31 Dole, Robert, 84, 117, 123 “do no harm” mandate (Hippocratic oath), 34, 48, 63, 75 “do not resuscitate” orders, 158, 163– 64, 261n27 Drew University of Medicine and Science (Willowbrook, CA), 23–24 Dreyfuss, Robert, 109 DRGs (diagnostic related groups), 83– 84, 86, 244n7, 245n13, 245n16 Driver, Deamonte, 183 drug manufacturers: and academic vs applied biomedical research, 147–48, 257–58n5; advertising by, 148–49, 258nn12–13; on the Affordable Care Act, 192; congressional donations by, 110; cost effectiveness of new drugs, 145–46; for-profit, Index 75–80; marketing by, 76–79; profits of, 148, 217, 270n3; research and development costs for, 77–78 Duke University, 28–29 Durenberger, David, 110, 118 EBM (evidence-based medicine), 151– 53, 259n22, 259n24 Economic Opportunity Act (1964), 17, 231n48 education as a public good, Egeberg, Roger, 24 Elbaum, Jean, 163 ElderChoices, 250n24 the elderly See Medicare (US) electronic health records, 209 Ellwood, Paul, 6, 36, 107, 235n7 Emanuel, Ezekiel, 205 Empire Blue Cross and Blue Shield of New York (now called WellChoice), 129 endoscopic surgery, 146 Enthoven, Alain, 56–59, 107–8, 112 Epstein, Helen, 257–58n5 errors, 152 erythropoietin, 76 Eskimos, 22 ethical issues, 154–68; “brain dead” patients, 154–55; conjoined-twin separation, 164, 166, 261n30; consent, 156–57, 260n10; costs of extending life, 158, 163–64; Cruzan case, 7–8, 163–64, 261n27; Dinnerstein case, 158; distribution of health care, 161–62; “do not resuscitate” orders, 158, 163–64, 261n27; Elbaum case, 163; extreme medicine, 154–59, 260n10; genetic engineering, 155–56; hospices, 167; late-term abortions, 155; living wills, 166; “permanent vegetative state,” 154– 55 (see also Cruzan, Nancy; Quinlan, Karen Ann); physician-assisted suicide, 167–68; Quinlan case, 7–8, 154–55, 157–58; research protocols and abuses, 156; Saikewicz case, 157–58; spending, ethics of, 164–68; Index vulnerable populations, 156–58, 260n20; withholding treatment, 159–62, 165, 260n20 Etzioni, Amitai, 155 Evans, M Stanton, 249n10 Evans, Robert, 60–61 evidence-based medicine (EBM), 151– 53, 259n22, 259n24 Exploitation (Wertheimer), 260n10 Fein, Rashi, 3, FICA payroll tax, 50 Studies Every Doctor Should Know (Hochman), 259n22 fluoridated water, 145–46 FMGs (foreign medical graduates), 27–28, 32, 171, 217, 233n87 Forbes, Malcolm, 114–15 Ford, 95–96 foreign medical graduates (FMGs), 27– 28, 32, 171, 217, 233n87 France, 59, 89, 152 fraud/abuse, 125–26, 156, 177–78, 209, 253n10 free markets, 33–52; competition’s role in, 95; as disorganized, 33; entrepreneurial model of medicine, 33–39, 51; greed in, 34, 46–52; health planning, 39–42, 50, 236n23; indemnity policies (fee-for-service), 34–35; physician culture, 42–46, 51; and preventive medicine, 35; supply and demand in, 34, 50 See also HMOs; profits Frum, David, 114 Fuchs, Victor, 162, 205 Gandy, Fred, 118 GAO (US Government Accountability Office), 97, 116, 126, 177, 209, 253n10, 258n13 Gawande, Atul, 8, 259n24 GDP (gross domestic product), 8, 59, 208 Genentech, 79, 147 General Motors, 95–96 genetic engineering, 78–79, 155–56 275 Genzyme, 79 Georgetown University School of Medicine (Washington, DC), 8, 141 George Washington University Medical School (Washington, DC), 141 Germany, 59, 152 Gingrich, Newt, 173–74 Ginzberg, Eli, 58–59, 240n14 Golden Rule, 111 Goodman, John, 115 Goodwin, Tom, 110 Gore, Tipper, 111 Gotlieb, Allan, 109 Gradison, Willis (“Bill”), 103 Graduate Medical Education subsidy, 85 Gramm-Rudman-Hollings Balanced Budget Act (1987), 88 Great Society programs, 39 greed, 34, 46–52 See also physicians, income/compensation incentives for Greenberg, Daniel, 180 Griffin, Martha, 138 Gross, Samuel, 68–69 gross domestic product (GDP), 8, 59, 208 Group Health Association (Washington, DC), 35 Group Health Cooperative of Puget Sound (Seattle), 35 Guardian, 217 Gurdon, John, 155 Hackbarth, Andrew, 208–9 Hacker, Jacob, 123 Hadley, Jack, 122 Halberstam, Michael, 21–22 Hall, Judith, 135, 256n42 Harvard Medical School, 23, 137 Hawaii’s insurance reform, 98, 100, 248n65 HCA (Hospital Corporation of America), 48–50, 70, 110, 167 HCFA (Health Care Financing Administration): dialysis and kidney transplants covered by, 13; on fraud, 276 HCFA (continued) 85–86; HEDIS created by, 150; on HMO billing, 37; investigators employed by, 178; Medicaid standards set by, 18–19; Medicare reimbursement by, 82; RBRVS used by, 92, 247n47 Health, Education, and Welfare Department (HEW), 13, 36–37 Health and Hospitals Corporation (New York City), 74 healthcare: charity (see poverty, medical programs); for illegal immigrants, 204; market failures in, 5–7; physician shortages, 11, 21–22, 24–30, 32, 171–72, 184–85, 262n8; poor health indicators, 30–32; poor people’s health challenges, 16–22; as a public vs private good, 5; quantity vs quality of, 145–53, 257– 58n5, 258nn12–13, 259n22, 259n24; racial disparities in, 20, 22–24, 184– 85 See also healthcare costs; healthcare reform; healthcare system; rationalizing healthcare healthcare costs: under ACA, 4, 192– 93, 203; age-based distribution of, 7, 220–21; GDP percentage spent on, 59; inflationary innovation, 88– 89, 145–47; inflationary nature of, 10–16, 145; out-of-pocket, 8, 174– 75, 228n12; US vs other countries, 208 See also cost containment Health Care Financing Administration See HCFA healthcare reform: Bush plan, 104, 249n12; Bill Clinton plan, 107, 109, 111–12, 144, 175 (see also HillaryCare); congressional reluctance about, 103–4, 249n10; employermandated health insurance, 104–6, 250n18; Heritage Foundation plan, 104; insurance premium caps, 113; vs insurance reform, 97–98; lobbyists’ role in, 110–11; managed care’s role in, 103 (see also HMOs); managed competition, 58, 107–10, 113 Index (see also HillaryCare); Obama plan (see Affordable Care Act); physicians’ opposition to, 42–43, 63, 66, 103; popular support for, 102–3, 249n2; single-payer, 105–6; statelevel, 97–100, 248nn65–66 healthcare system (US): benefits and shortcomings of, 3–4, 215; as broken/irrational, 4–5, 215–16; definition of “healthcare system,” 3; future of, 221–23; losers in, 219–21; vs other countries, 101 (see also specific countries); winners in, 216–18, 270nn1–4 Health Facilities Planning and Construction Service, 39 Health Insurance Association of America (HIAA), 105, 118, 192 Health Insurance Plan of Greater New York, 35 health insurance purchasing cooperatives (HIPiCs), 107–9, 112 health maintenance organizations See HMOs Health Plan Employer Data and Information Set (HEDIS), 150 Health Planning Act (1974), 88 health planning in free markets, 39–42, 50, 236n23 Health Professions Education Act (1973), 25–26 Health Security Act See HillaryCare Health Stop, 93 Health Systems Agencies (HSAs), 41–42 Heartland Health System (Connecticut), 125 HEDIS (Health Plan Employer Data and Information Set), 150 Heinz, John, III, 102 Heritage Foundation, 104 HEW (Department of Health, Education, and Welfare), 13, 36–37 HIAA (Health Insurance Association of America), 105, 118, 192 HillaryCare (Health Security Act), 56, 110–23; administrative costs of, Index 116, 121; community rating mandate of, 115, 118; complexity and size of, 114, 117–18; conservative criticism of, 114–16; vs the Cooper plan, 118; cost-saving potential of, 113, 116–17, 121–23, 251n41; defeat of, 123–24; defense of, 120; employer mandate, 112–13, 118, 120– 21; goals of, 115; health alliances, 112–14, 117–18, 120–21; insurance premium caps, 117, 121; and the labor market, 113; liberal/centrist criticism of, 116; lobbying against, 119; Magaziner’s role in, 111–13, 118–19; managed care, 121; managed care companies’ opposition to, 119; as managed competition, 112–13, 119, 121; Medicaid under, 112, 122–23; Medicare under, 112, 122; as price control, 115–16; public opposition to, 118–20, 124; religious organizations’ opposition to, 119– 20; subsidies, 113; vouchers, 175 Hill-Burton Act grants, 40–41 Himmelstein, David, 116, 134–35 HIPiCs (health insurance purchasing cooperatives), 107–9, 112 Hippocratic oath (“do no harm” mandate), 34, 48, 63, 75 HMO Act (1973), 36–38, 42–43 HMOs (health maintenance organizations): acceptance of, 65–66; administrative costs of, 116; advantages of, 53–54; AMA’s opposition to, 64; capitation by, 36, 43, 49, 53, 56, 93; collaboration of physicians in, 38–39, 53–54; under the Consumer-Choice Health Plan, 57; cost savings by, 54–55, 116–17, 129, 239–40n8; Ellwood’s role in, 6, 36; emergence/growth of, 35–36, 53– 54; forms of, 36; vs for-profit hospitals, 49–50; gag clauses in, 126, 253n10; incentives to undertreat, 93–94; managed care by, 53; and managed competition, 108; and c are, 37, 42, 84–85, 176; Medi­ 277 nonprofit vs for-profit, 129; open enrollment season for, 37–38; opposition to, 37, 42–44, 55–56, 239– 40nn8–9; premium hikes by, 143; successes of, 38, 56 Hochman, Michael: 50 Studies Every Doctor Should Know, 259n22 Holt, Matthew, 204 hospices, 167 Hospital Corporation of America (HCA), 48–50, 70, 110 hospitals: charitable missions of, 15; closures of, 86–88, 217, 253n68; cost increases in/billing practices of, 3, 10–11, 137, 189–90, 217; emergency room closures at, 137; expansion of, 11–13, 122; federal funding for construction of, 40–41; federal subsidies to, 85, 87, 141–42, 171, 246n24; forprofit, 48–50, 52, 69–75, 139–40, 217; history of, 68–69; vs home care, 15–16; length of stays (LOSs) at, 87, 137–38; managed care, response to, 136–42, 256nn54–55; morbidity/ recovery rates at, 142; networks/ mergers of, 138–39, 256n54; nonprofit and public, 69–71, 73–75, 84, 140–41, 242n18; nonprofits converted to for-profit, 139–40; occupancy rates, 12, 86–88, 122, 136–37, 217, 253n68, 270n4; PHOs (physician hospital organizations), 72– 73, 125, 139, 256n55; as profitable, 217; quality of, 71–72, 142; religious orientations of, 68–69; surgical progress in, 68–69; teaching, 73, 85, 87, 141–42, 171, 246n24; uninsured patients dumped by, 138; voluntary cost containment by, 96–97 Howard University College of Medicine (Washington, DC), 23 Hsaio, William, 92 HSAs (Health Systems Agencies), 41–42 Humana, 48–50, 70–71 Humphrey, Hubert, 16 278 Iglehart, John, 61 IHS (Indian Health Service), 23 illegal immigrants, 204 Illinois, 181, 264n38 Immunex, 79 Independent Payment Advisory Board (IPAB), 205, 207 Independent Payment Advisory Commission, 201 independent practice associations (IPAs), 55–56 India, 28 Indian Health Service (IHS), 23 induced demand, 7, 88–91 infant mortality: racial disparities in, 16, 22, 231n55; US vs other countries, 30, 59–60 Institute for Health and SocioEconomic Policy, 189 Institute for Quality and Efficiency, 152 Institute of Medicine ( formerly National Academy of Sciences), 29, 65, 71–72, 150, 152, 156 Institute of Society, Ethics and the Life Sciences, 156 insurance: adverse selection in, 105, 176, 180; ambulatory coverage, 31– 32; bronze-tier policies, cost of, 8, 228n12; co-payments and deductibles, 190; corporations’ absorption of cost of, 95–96; government mandates for purchasing, 6–7; holes in coverage, 31–32; indemnity policies (fee-for-service), 34–35; market failures in, 6–7; people rejected for coverage, 213, 269–70n55; physicians’ opposition to, 64–65; private companies on the Affordable Care Act, 192; profitable companies, 216, 270n2; redistributive quality of, 222; state-level reform of, 97–99, 248nn65–66; uninsured rates, 143– 44 See also healthcare reform; Medicaid; Medicare (US) insurance exchanges, 195–98, 201, 266–67nn14–15 Interstudy, 36 Index in vitro fertilization (IVF), 134, 165–66 IPAB (Independent Payment Advisory Board), 205, 207 IPAs (independent practice associations), 55–56 IVF (in vitro fertilization), 134, 165–66 Jackson Hole Group, 107, 111 James, George, 16 John Deere, 95 Johns Hopkins Hospital (Baltimore), 65, 241n28 Johns Hopkins University’s School of Nursing (Baltimore), 30 Johnson, Lyndon B., 42 Johnson, Roger, 161 Johnson, Timothy, 91 Kaiser Health Plan (California), 35– 36, 55–56, 132 Kansas’s physician shortages, 24 Kaplan, Robert, 248n66 Kass, Leon, 156 Kassirer, Jerome, 134 Keisling, Phillip, 82 Kennedy, Edward M (“Ted”), 14, 107, 193 Kentucky Frontier Nurse Service, 30 Kerrey, Bob, 118 Kessler, David, 77, 79 Kevorkian, Jack, 167 kidney transplants, 13 King, Martin Luther, Jr., 25 Kings County Hospital (Brooklyn), 30 Kinnock, Neil, 62 Kinsley, Michael, 104, 173 Kitzhaber, John, 98–100 Klagsbrun, Samuel, 167–68 Klein, Rudolf, 62 Knights of Columbus, 119–20 Koop, C Everett, 161, 260n20 Korea, 28 Krugman, Saul, 156 Kübler-Ross, Elizabeth, 167 Lafayette Clinic (Detroit), 156 Lakeberg, Ken and Reitha, 166 Index LaLonde, Mark, 109 Lammers, Stephen, 261n30 legal advocacy, 20–21 Lewin and Associates, 71 Lewin/VHI, 141 Lieberman, Trudy, 174 life expectancy: following eradication of common diseases, 31; income disparities in, 183; racial disparities in, 22, 183, 231n55; US vs other countries, 30, 59, 62 Lippert, Barbara, 118 lithium treatment, 145 living wills, 166 low-carbohydrate diet, 234n112 Lown, Bernard, 134 Luft, Harold, 142, 239–40n8 Magaziner, Ira, 111–13, 118–19 malpractice, 44, 122, 255n38 managed care, 124–44; abuses in, 125– 26, 253n10; capitation, 126–27; cost savings of, 125, 129–30, 143–44; doctor–patient relationship under, 135–36; gag clauses in, 126, 253n10; and HillaryCare, 121; hospitals’ response to, 136–42, 256nn54–55; and malpractice, 255n38; for Med­i­ caid enrollees, 143–44, 186–87, 257n70, 265n55; movement to, 124– 30, 143; out-of-network physician options, 129–30, 190; physicians’ resistance to, 127–28, 130–36; POS plans, 129; PPO plans, 129–30, 143; quality affected by, 127–29 See also HMOs managed competition, 58, 107–10, 113 See also HillaryCare Mantle, Mickey, 165 Marcus, Sanford, 94 Marine Hospital Service, 40 Marmor, Theodore, 109 Marshall, Eliot, 64 Martin Luther King, Jr., Health Center (New York City), 20 Maryland, 181, 264n38 Massachusetts, 98, 100, 197 279 Massachusetts General (Boston), 139, 141 Massey, Jack, 49 Mayo Clinic (Rochester, MN), 111, 116, 137 McCarthy, Carol, 88 McCaughey, Betsy, 115, 124, 253n1 McCurdy, Dave, 118 McNerney, Walter, 11 measles, 31 Medicaid: under the Balanced Budget Act, 143, 257n70; barriers to access, 219–20; under the ConsumerChoice Health Plan, 57; cuts to, 74– 75; and DRGs (diagnostic related groups), 83; dual eligibles, 175; eligibility for, 19–20; expansion/reform of, 13–14, 97–100, 198–202, 220, 248nn65–66; funding for, 19, 187–88, 202, 265n57; and healthcare reform, 111; holes in coverage, 175, 182–88; increased costs of, 19; inflationary nature of, 11–14; longterm care, 249n7; managed care, 143–44, 186–87, 257n70, 265n55; NHCs underwritten by, 18–19; num­b er of claims filed, 264n29; physicians’ refusal to accept patients, 6, 123, 187, 220; and racial disparities in medical care, 20; reimbursement rates for, 19, 106; rising costs of, 8; vs the single-payer plan, 106; under the Social Security Act, 19; successes of, 19 Medi-Cal (California), 242n18 medical bankruptcies, 190 Medical Economics, 26–27 medical schools: Canadian, 270n1; community medicine taught at, 20; cost/demands of medical training, 220; federal grants to stimulate enrollment, 25–26, 232n73; fiscal responsibility taught by, 97; growth of, 25–26, 171; historically black, 23–24; medical humanities curricula in, 45–46; minority students in, 23– 24, 32, 185–86, 232n61, 265n52; 280 medical schools (continued) specialty care emphasized in, 27, 45; students as disadvantaged by the system, 220; US vs other countries, 216 See also individual schools Medicare (Canada), 60–62, 106, 116 Medicare (US): under the Balanced Budget Act, 141, 175–76, 178; billing guidelines of, 14; under the Catastrophic Care Act, 103–4; choice, 173–74, 182; under the ConsumerChoice Health Plan, 57; cuts to, 82, 141; and DRGs (diagnostic related groups), 83–84, 86, 244n7, 245n13, 245n16; dual eligibles, 175; and elder living, 170; expansion of, 12– 13; fraud/abuse in, 177–78; heroic end-of-life procedures, 166; under HillaryCare, 112, 122–23; and HMOs, 37, 42, 84–85, 176; hospices, 167; inflationary nature of, 10–14; and length of hospital stays, 87; long-term care, 103–4, 249n7; and managed care, 121, 173–74; and Medigap insurance, 103–4, 174–77; number of claims filed, 264n29; physicians’ opposition to, 64, 170; political influence on, 13; prescription drug coverage, 112, 177–82, 263n25, 264n31, 264n35, 264nn37– 38 (see also Medicare [US], Part D); reception of, 213–14; reimbursement rates, 19, 47, 82, 87–88, 113; rising costs of, 8, 81–82, 86; risk contracting, 84–85; and the singlepayer plan, 106, 173–74; under the Social Security Act, 19; successes of, 218; trust fund for, 169–70, 218, 262n1; vouchers, 175 Medicare (US), Part A: age-based payment of cost of, 7; deductibles, 13, 82; definition of, 12, 81; funding for, 81; inflationary nature of, 12–13; inpatient drug coverage, 264n31 Medicare (US), Part B: adverse selection, 180; deductibles, 82; definition Index of, 12, 81; funding for, 81–82, 180; growth of, 170; out-of-pocket costs to the elderly, 174–75; premiums vs costs of, 170, 264n34 Medicare (US), Part C (Medicare+ ­Choice), 175–77, 179, 181, 205–6 Medicare (US), Part D, 177, 181–82, 199–200, 217 Medicare Prescription Drug, Improvement and Modernization Act (2003), 181 medicine: caretaking roots of, 94–95; error avoidance in, 152; evidencebased (EBM), 151–53, 259n22, 259n24; extreme, 154–59, 260n10; professional vs corporate model of, 94; technological advancements in, 94–95 Medigap insurance, 103–4, 174–77 Meharry Medical College (Nashville), 23 Mengele, Joseph, 156 meningitis vaccine, 145 Merck, 76 Merit Behavioral Care Corporation (New Jersey), 125 MetLife, 119 Michaelson, Michael, 21 middle class, as disadvantaged by the system, 189–91, 200, 210, 219 midwives, 29–30, 172 Miner, Roger, 168 Minnesota, 98, 100 MinnesotaCare, 98 Mitchell, George, 123 Model Cities program, 17–18, 21 Mondale, Walter, 156 Montefiore Medical Center (the Bronx), 20–21, 164 Moon, Marilyn, 251n41 Morehouse School of Medicine (Atlanta), 23–24 Mount Sinai Hospital (New York City), 139, 256n54 Mount Sinai Medical School (New York City), 20 Moynihan, Daniel Patrick, 141–42 Index Nation, 99 National Academy of Sciences See Institute of Medicine National Advisory Commission on Health, Science, and Society, 156 National Committee for Quality Assurance, 150 National Federation of Independent Business (NFIB), 110, 119 National Health Board, 107 National Health Program (PNHP), 105–6 National Health System (NHS), 61– 62, 151–52 National Information Center on Health Services Research, 39 National Institute for Health and Clinical Excellence (NICE), 151–52 National Institute of Mental Health, 39 National Institutes of Health, 40, 66 National Leadership Coalition for Healthcare Reform, 105, 249n14 National Medical Enterprises, 70 National Prevention, Health Promotion, and Public Health Council, 204 National Right to Life Committee, 99 Native Americans, 22–23, 231n55 Neighborhood Health Centers (NHCs), 17–21 Newhouse, Joseph, 146–47 New Jersey: DRGs in, 83, 244n7; pharmacy-assistance program in, 181, 264n38 New Mexico, 14 New Republic, New York State, 181, 264n38 NFIB (National Federation of Independent Business), 110, 119 NHCs (Neighborhood Health Centers), 17–21 NHS (National Health System), 61– 62, 151–52 NICE (National Institute for Health and Clinical Excellence), 151–52 Nikias, Mata, 22 Niskanen, William, 114 281 Nixon, Richard, 10, 25, 36, 42–43 Northwestern University, 26 Nunn, Sam, 118 nurses: cost-cutting reductions in, 138; demand for, 218; nurse-midwives, 29–30; nurse practitioners, 32, 172, 263n11; shortages of, 173; as subordinate to physicians, 42 NYU Hospital (New York City), 139, 256n54 Obama, Barack, 56, 111–12, 191–94, 198, 211 Obamacare See Affordable Care Act obesity, 183, 210 OBRA (Omnibus Reconciliation Act; 1981), 82 OEO (Office of Economic Opportunity) grants, 17–18 Office of Health Resource Opportunity, 22–23 Omnibus Budget Reconciliation Acts (1989 and 1990), 87 Omnibus Reconciliation Act (OBRA; 1981), 82 Oregon, 98–100, 106, 248n66 O’Rourke, Kevin, 75 overpricing, 209 overtreatment, 209 Oxford (HMO), 129–30 Oxford Health Plans (New York), 125 Partners (Boston), 139, 141 PAs (physician’s assistants), 28–30, 32, 42 Pataki, George, 115, 253n1 patient capture initiative, 73 See also PHOs Patient-Centered Outcomes Research Institute, 203–4 Patient Protection and Affordable Care Act See Affordable Care Act Patient Self-Determination Act (1990), 166 Pellegrino, Edmund, 157 Pelosi, Nancy, 193 Pennsylvania, 181, 264n38 282 pentamidine, 76 Pepper, Claude, 175 pharmaceutical industry See drug manufacturers Philadelphia, managed care in, 137 philanthropy, 11–12, 46, 72 Philippines, 28 PHOs (physician hospital organizations), 72–73, 125, 139, 256n55 physician-assisted suicide, 167–68 physician hospital organizations (PHOs), 72–73, 125, 139, 256n55 Physician Payment Review Commission, 92 physicians: activist, 21–22; Asian, 233n87; concierge practices of, 131; congressional donations by, 111; corporate funding of, 147–48, 257– 58n5; cost containment opposed by, 63–67; culture of, 42–46, 51; doctor–patient relationship, 44–45, 66, 93, 135–36, 148–49; “do no harm” mandate of (Hippocratic oath), 34, 48, 63, 75; drug endorsements by/corruption of, 76–78; EBM resisted by, 151; excess of, 170–71, 262n8; fee splitting by, 134–35; female, 136; foreign medical graduates, 27–28, 32, 171, 217, 233n87; fraud by, 177–78, 209; gang visits by, 14; group practices, 131– 32; hospitalists, 132–33; income/ compensation incentives for, 46– 48, 90–94, 130, 134–35, 217, 220; licensing laws for, 30; and malpractice, 44, 122, 255n38; managed care resisted by, 127–28, 130–36; Medicaid patients refused by, 6, 123, 187, 220; minority, shortages of, 21–22, 32, 184–85; number of, US vs other countries, 25; vs nurse practitioners, 172; paternalism of, 66; primary care, as disadvantaged by the system, 220; quality of, 150– 51; shortages of, 11, 24–30; social medicine programs for, 20–21; Index specialists vs GPs, 26–27, 45, 47, 90–91, 171–72, 217; treatment by, variations in, 150; unions for, 94; unnecessary procedures by, 89–90, 95–96 physician’s assistants (PAs), 28–30, 32, 42 Physicians for National Health Insurance, 66 Pilot Neighborhood Service Centers, 21 PNHP (National Health Program), 105–6 point of service (POS) plans, 129 polio vaccines, 145 POS (point of service) plans, 129 poverty: causes of, 17; health disparities due to, 183–84; medical programs, 13–14, 17–21; poor people’s health challenges, 16–22 See also Medicaid PPO (preferred provider organization) plans, 129–30, 143 preferred provider organization (PPO) plans, 129–30, 143 prepaid group practices See HMOs Presbyterian Hospital (New York City), 138 price controls, 115–16 Price Waterhouse, 141 Professional Standards Review Organizations (PSROs), 41, 44 profits, 67–80; AIDS patients’ impact on, 74; drug makers, for-profit, 75– 80; vs the Hippocratic oath, 75; hospitals, for-profit, 48–50, 52, 69– 75, 139–40, 217; Medicaid patients’ impact on, 74; overview of, 79–80; via PHOs (physician hospital organizations), 72–73, 125; via redundant procedures, 75 Project 3000 by 2000, 185 Project CHILD, 18 prospective payment system See Medicare (US) Prudential, 15, 116, 119 Index PSROs (Professional Standards Review Organizations), 41, 44 psychologists, 218 psychotherapy, 111 public goods, Public Health Service, 18, 39–41 Quality Assurance Reform Initiative, 265n55 Quality Improvement System for Managed Care, 265n55 Quinlan, Karen Ann, 7–8, 154–55, 157–58 racial disparities in health, 16, 20, 22– 24, 183–85, 231n55 rationalizing healthcare, 88–101; induced demand, 7, 88–91; RBRVS, 91–95, 100–101, 247n47; state-level reforms, 97–100, 248nn65–66; waste, 95–97 See also Medicare (US) RBRVS (resource-based relative value scale), 91–95, 100–101, 247n47 Reagan, Ronald, 81, 103 recombinant DNA technology, 78–79 reform See healthcare reform Rehnquist, William, 163 Reich, Robert, 111 Reid, Harry, 193 Relman, Arnold, 89, 205 Reno, Janet, 167 rent-seeking behavior, 71–73, 216, 222 Republican reform plans, 173–76 Rhode Island, 181, 264n38 Ribicoff, Abraham, 14 Rivlin, Alice, 213 Robb, Charles, 180 Roberts, John, 207, 268n26 Roche, 257–58n5 Rochester (New York), 96–97 Rockefeller, David, 109 Romney, Mitt, 197 Roosevelt, Franklin, 40, 42, 120 Ross-Loos Clinic (Los Angeles), 35 Roy, William, 28 Rubin, Robert, 85–86 283 Rubio, Marco, 202 rural areas, physician shortages in, 24–25, 32, 171–72, 262n8 Ryan, Paul, 212–13 Saikewicz, Joseph, 157–58 Sammons, James, 43–44 Samuel, Peter, 115 Samuelson, Robert, 117 Sasich, Larry, 148–49 Saunders, Cicely, 167 Schering-Plough, 149 S-CHIP (State Children’s Health Insurance Program), 182, 186–87, 190, 198–99, 265n57 Schwartz, William, 106 self-employed people/independent contractors, 143 Shalala, Donna, 109, 119, 146 SHARE (Standard Hospital Accounting and Rate Evaluation System), 244n7 Shine, Kenneth, 146 Shulman, Bruce, 265n52 Silver, George, 157 smoking, 183 Snowe, Olympia, 193 social medicine, 20 Social Security Act (1965), 19, 213–14 social workers, 218 South Dakota, 24 Standard Hospital Accounting and Rate Evaluation System (SHARE), 244n7 Stanford University, 26 Stark, Peter, 110 Starr, Paul, 37, 120 State Children’s Health Insurance Program (S-CHIP), 182, 186–87, 190, 198–99, 265n57 Stenholm, Charles, 118 Stockman, David, 82 Supreme Court, 202, 207, 268n26 surgery rates, 14–15 Tamiflu, 257–58n5 284 Tax Equity and Fiscal Responsibility Act (1982), 84 taxpayers as disadvantaged by the system, 221 Taylorism, 241n28 Tea Party, 206 TennCare, 187 Tennessee, 100, 187 Texas, 143 Thailand, 28 Thatcher, Margaret, 62 therapists, occupational and physical, 218 Thomas, Bill, 180 Thornburgh, Dick, 102 Thurow, Lester, 161 Time magazine, 203 Todd, James, 89, 114, 122 To Err Is Human (Institute of Medicine), 152 transplants, 99, 165, 248n69 Travelers, 119 TriCare, 218 Trilateral Commission, 109 Trudeau, Pierre, 61 Truman, Harry, 40, 42 Trump, Donald, 198, 211–13 Tupper, John, 63 Tuskegee syphilis experiment, 156 UCLA medical center, 137 undertreatment, 209 undocumented workers, 204 unemployment, 17, 143–44 uninsured rates, 143–44 United Autoworkers, 96 United Healthcare, 128–29 United Kingdom: GDP percentage spent on healthcare, 59; infant mortality rates in, 59; life expect­ ancy in, 59, 62; NHS (National Health System), 61–62, 151–52 United Methodist Church, 119 United States: economy of, 222; GDP percentage spent on healthcare, 59; healthcare costs in, vs other Index countries, 208; infant mortality in, vs other countries, 30, 59–60; life expectancy in, vs other countries, 30, 59, 62; medical schools in, vs other countries, 216; number of physicians in, vs other countries, 25 universal coverage, 120 See also Affordable Care Act; HillaryCare University of Mississippi, 30 urban areas, physician shortages in, 25 US armed forces, 218 See also Veterans Administration health system US Catholic Conference, 110–11 US Children’s Bureau, 18 US Government Accountability Office (GAO), 97, 116, 126, 177, 209, 253n10, 258n13 US News, 111 US Public Health Service, 25, 156 vaccines, 145–46 value of life/health, 7–8 See also ethical issues Verrilli, Donald, Jr., Veterans Administration health system, 106, 184, 218, 270n8 violent criminals, neurological castration of, 156 Vioxx, 149 VISTA (Volunteers in Service to America), 20, 231n48 Vladeck, Bruce, 110, 256n55 Volunteers in Service to America (VISTA), 20, 231n48 Warren, Elizabeth, 190 waste, 95–97, 208–9 Weiss, Ted, 74 Welch, Jack, 114 Weld, William, 98 WellChoice ( formerly Empire Blue Cross and Blue Shield of New York), 129 Wennberg, John: Dartmouth Atlas of Health Care, 150 Index Wertheimer, Alan: Exploitation, 260n10 Wilensky, Gail, 88 Williams, Ronald, 119 Willowbrook State Hospital (Staten Island), 156 withholding treatment, 159–62, 165, 260n20 285 Wofford, Harris, 102–3, 106–7 Woodruff, Bob, 29 Woolhandler, Steffie, 116, 134–35 Zelman, Walter, 120 Zimmermann, Adam, 109 Zuckerman, Stephen, 122 Zwiebel, David, 120 .. .Unaffordable Unaffordable American Healthcare from Johnson to Trump Jonathan Engel The University of Wisconsin... edition Library of Congress Cataloging-in-Publication Data Names: Engel, Jonathan, author Title: Unaffordable: American healthcare from Johnson to Trump / Jonathan Engel Description: Madison, Wisconsin:... but removes mandate for Medicaid expansion Universal mandate begins under the terms of the ACA Unaffordable Introduction A 1971 editorial in the New Republic, the small but highly influential