Keynote Address:
Thank you. I was very honored to be asked to give this keynote address, for reasons not the least of which, I am not expert in the field of maternal and child health. I am not a stranger to it, because both as an internist and in the policy role, one has to become aware of it. In fact, I have come to believe that the circumstances surrounding maternal and child health are sort of like the canary inside the coal mine. You all are the symbol of where we are going to go as we try to figure out a humane, decent, universal health system for the American people. It’s not amiss in any audience to remind you of how lavish the generosity of the American people is in the effort to seek health care. In terms of dollars, in 1996 we hit $1 trillion. That’s one thousand billion dollars. I’m not certain every dollar was given with enthusiasm. Much of it is in the form of taxes to pay for the many public health activities, such as Medicare, Medicaid, the Army medical system, the National Institutes of Health, the prison health system, and the state and local government. Those are tax supported.
Some of the money is in lieu of wages. We are in a situation where, tragically, our health system payment for private personal care is based on an arrangement whereby employers pay for that. Be it known that this is not a benefit or premium gift; it is nothing of the sort. Every business person will tell you he or she has so much to pay for labor. You can take it in a check, you can take it in holidays or pensions, or you can get health benefits. Obviously, people want health benefits, and the advantage of mass purchase that the system allows. But, ultimately you pay for it in lieu of wages and you pay for it out of pocket. I have just exhausted the ways in which we pay for health care. We pay an enormous amount out of pocket in this country compared to other similarly placed countries. Similarly placed countries have concluded that the only rational way for a society to work is to treat health care as a right, a social responsibility, a public health matter. With that, they have arranged for a national health system of some kind. We are seated here today because we don’t do it that way, and it creates great tension in the system.
I think I can tell you most of what I’m going to say is mostly "What." What is wrong? What is right? What are the opportunities? The "how" that eludes me will be implicit in my version of the "what," but let me say that I think we are in considerable trouble. As I speak there is great disarray in the country with the various arrangements that represent an experiment. The move toward market-determinants of health care allocation, quality, and access is an experiment which has been going on for a decade and a half. I think it is a failed experiment. Remediation is urgent. I think the public’s dismay with the way the system works, in terms of their health care and the growing readiness of the press to describe the problems in managed care is a brand new situation. Up until a couple of years ago, the prevailing wisdom was a remarkable cultural coup that this was somehow a divine arrangement, untouchable and sacred, with a few rough spots that had to be buffed out with regulation and legislation. Later, we learned the gag clause is obscene, that rewards for professionals who withhold care are not exactly the best way to ensure every one’s health. People are increasingly in anguish about the loss of confidence that their provider has their best interest at stake. I remind you that that is fundamental to professional responsibility, to the Hippocratic Oath. I am going to talk about the need for a new social contract between the health professionals and the public that address these issues. I hope it gets your enthusiastic support.
A little bit of history. I hope I’m not being didactic to this sophisticated group. There was, once upon a time, just before World War II, the first manifestation of something called "prepaid group practice." That has a much nicer sound than "health maintenance organization (HMO)." Pre-paid group practice was like everything else that happens. They grew out of a necessity, the necessity to offer health care to war workers, as we were preparing for the great conflict. People like Henry Kaiser had brought together thousands of workers where there were no health facilities. With no other goal in mind but to keep his workers healthy, he created one of the first big pre-paid group practices. Those are easy words to understand. That is to say, there was no fee-for-service, the doctors were on salary, and you had a capitated amount, which was related to the cost of delivering a whole array of services. Group practice, which we take for granted these days, was very novel. Fee-for-service on a solo practice basis was the model. It corresponded to the state of science up until about 1940. So, it is useful to remind even medically-minded people how recent what we do, is. We are just a little over a century since the germ theory was discovered by Pasteur.
When I trained at Cook County Hospital, the way we treated pneumonia was as follows: you put on a pneumonia jacket designed to keep body heat in, then you gave quinine, which is an anti-pyretic to reduce the heat. Notice the dialectic. Then you waited for the crisis, which was a euphemism for waiting to see whether the patient lived or died. Can you guess what year I started my internship? This is a quiz. Well, in 1939 the first drug of any use, aside from quinine for malaria, was sulfonamide, a chemotherapeutic agent. Penicillin in 1941. In 1946 the first drug against tuberculosis, streptomycin, which wasn’t very good. But in 1951 we got a good one we still use now, INH. Public health practice was well-developed in case finding, isolation, and all the other things that brought the TB rate from the turn of the century of 150 deaths per 100,000 people down to the modest level it is now.
Coincidentally, this form of medical practice came on the scene. Of course, it was reviled by organized medicine as radical, socialized medicine. There were penalties for the doctor who chose to take posts there. They sometimes were not allowed in the medical societies around where they worked. These forums were very vigorous. Group Health Cooperative of Puget Sound, which had the added virtue of being a consumer-controlled effort, had around a half million subscribers. Group Health Association in Washington D.C. and a number of other ones grew to a certain point. They were safe and vigorous in their own local point-of-view, but they never became a model for the system. There was also a certain ostracism for the doctors and other people associated with them. By every standard they were a great success. That is to say they set the stage for the things that are in fashion, and we highly regard them. They did deal with large numbers of people, and they could accurately see the effects of this antibiotic versus another, not only in terms of efficacy and safety, but in terms of cost. They could also see what were the better operations, what operations were indeed archaic.
It was the concern with the rising cost that set the stage for what came to be known as Health Maintenance Organizations (HMOs). If you just take away the current baggage, this term had a nice sound. It was a departure from a sickness-oriented system to a health-oriented one. And, under the reign of President Nixon in the Seventies, the Health Maintenance Organization Act was passed. A number of things have since ensued. HMOs, to me, have one critical flaw, which is the reason we are in the anguish we're in. The Act provided for corporate investor risk-taking capital to enter the field of health care delivery. In the interval since the Seventies and through the Eighties, there was the advent of nothing but for-profit health systems. There hasn't been a new not-for-profit since 1990. More to the point, many not-for-profits were bought out by for-profits. Even more to the point is what I call the "Vampire Effect." The old style heroes like Kaiser-Permanente and Group Health Cooperative have had to behave, in this Vampire Effect, like the for-profits. They have had to speed up services. What I find particularly troubling is the de-professionalization of nursing services -- that is, denigrating nurses' practices by teaching lesser-skilled individuals parts of their practice, and then replacing nursing staff with these less trained personnel. I would like to add that if we continue in this fashion to dismantle the nursing profession it would take us a very long time to recover from that. I put that at the hands of for-profit HMOs and the Vampire Effect on the not-for-profits.
I think we should become extremely sensitive to the issue of human experimentation in the wake of the Tuskegee tragedy. I think you all know what that was, but I'll recapitulate anyway. For some reason no one knows, in the 1930’s, public health leaders decided to study the natural history of syphilis in the black male. Now, it's very hard to start the critique of that catastrophe which has been roundly critiqued. No more than six months ago the president gave an apology to survivors and their families. The reason I say it made no sense scientifically, as these kinds of things usually don't, is because we already knew the natural history of syphilis. We didn't know a lot more about it, but we sure knew its natural history. For 400 years our species has been ravaged by syphilis. This was before we had any treatment, and they proceeded with the experiment. Finally, in 1941, we did get penicillin -- an instant cure to the disease. Still, we went on into the Fifties and Sixties, until somebody said, "What are we doing?" Then, they finally stopped. However, during this time, some 300 very poor, poorly educated men were the subjects of this experiment. It has become the model for what human experimentation must not be. You can reduce to two things what was wrong with that experiment. 1) It was without informed consent. They were never told what was being done, what the alternatives were. 2) When we had an alternative to this experiment -- penicillin, it was our moral obligation to put an end to the experiment. It didn’t happen, however, for another 20 more years.
Now, I take this digression into the world of human experimentation to give you a harsh thought. I believe we have done that in the HMO experiment. The people who are being put into HMOs do not have informed consent; they have an employer who says "Maybe you can go to this HMO or that." The turnover in HMOs is the best symbol of it. The average stay for people who are in that system is two years. I argue as strongly as I can, nothing approaching informed consent takes place in today's HMOs. Also, I think there is much evidence that this doesn't work. It is supported with the sudden change in the newspaper and other public media that this was the only solution, that the market was the only way we could get out of the morass of rising costs and lack of access, and even poor quality. That was accepted in a strange way in the news columns, though not in the editorial columns. However, about a year ago the gag clause was exposed, and after that the arrangements of payment, that were essentially denial of care, and the more egregious behavior of these corporations was revealed.
I'd like to stress that you don't see before you a critic of pre-paid practice. At a time when it was there, many people like me hailed it. We felt that a doctor being paid a salary could act in a very honorable, effective way. There was nothing intrinsic in fee-for-service that made it better or holier than any other system. My criticism of HMOs doesn't stem from this, rather that the new arrangement of allowing venture capital is what is wrong. Let's imagine for a minute a system of two masters. Under the best of all worlds, every HMO, for-profit or not-for-profit, is dedicated to giving the best care it can, for the resources, to the public. But, they have another master, which is the investor, who took a risk with his money and wants maximum return. That's the market, and that's American as apple pie. Those are contradictory motivations, and it takes on grotesque forms. There are many examples in managed care and public health, to some of which I will allude.
So, I believe that the logic of this means that there must be a new social contract. I think the old one has been shredded, both of its legal aspects, and the possibly higher covenant of ethical professional practice. If we choose to take the prerogatives of prestige and economic reward of professionals, than we must give a contract that is good. In my book this contract would have at least three elements, maybe more. This would include all the old elements that resulted from literally thousands of years of human experience with health, beginning with the Hippocratic Oath. I would argue that the new contract from the health professionals to the public, with an emphasis on leadership from the public health sector on this, would include first, universal health care. We can no longer leave anybody out. We cannot live any longer with a system that is constantly turning people out. The number of people without health insurance across the nation stands at 43 million today. We all know that beyond those people with no insurance there are another 50 million people with very bad insurance. Over a third of our people are unprotected in terms of insurance. Now, I don't mean to represent that health insurance is the savior to health care, but it is very important in these circumstances. Ten million of those people are indeed children, and a big chunk of these are mothers and women who are single parents. This wrong-headed commitment to anti-government and anti-taxation is one of those ironies at the end of the century. This is a very serious problem -- raising adequate public funding for these critical public functions always runs into that. I am arguing the burden is on us to make that turnaround, although we have many allies with us on this.
The way this is played out in this new environment is to identify core public health functions: assessment, policy development, and assurance of quality delivery. I believe that a very bad thing has happened. There is a reductionist approach to public health activity, which is to limit us to core functions. The so-called safety net things were the only source of care for people. There was no place else to go. We, the public health sector, discovered the ways to do it. We took the facts, did the population-based studies, and did the best we could to deal with the people most oppressed by the way society works. That reality seems to be the centerpiece of where we should go. I see before you unreconciled reforming incrementalists, but I don’t really like incrementalists. Every time we see a Kennedy-Kasselbaum or a children's health insurance program, they give away so much more at the end of the day. They give us the seemingly attractive child health insurance based on states, but states are rejecting it. I read a lengthy article in the AMA News, and they described how in Iowa they have identified 17,000 people without insurance, and they are rejecting the money. That gives a sense of the magnitude of our struggle. But it is winnable, because those crazy ideas do not resonate with the American people. When things are presented to them well, the American people always say they feel everybody should be covered, and that the government should guarantee it.
We just had in Cook County, where half the people and half the voters in the state reside, a vote on a proposition which essentially reiterated a strong managed care bill of rights that passed through our House but got locked up in the Senate. The vote for it was, and 600,000 votes for it were cast, 94% for it to 6% against it. Now I don’t think we can solve the problem solely through legislation. By that I mean by outlawing one-day deliveries or two-day mastectomies. There are just too many things that medical practice is that you can't deal with it item by item in 50 states. We need systemic reform.
I want to also remind you of the very troubled and sometimes criminal behavior of Medicaid HMOs since they were first introduced. The Medicaid HMOs of five or 10 years ago are documented to have been incredibly abusive. The one I'm most familiar with is in Florida, where a whole bunch of people came in, created small operations, putting in trivial amounts of capital, and they signed up people in abusive ways. They did something to get poor people to join, such as threaten their welfare benefits, or maybe offer them a turkey. They got folks to join and set up dummy HMOs. This was all revealed in an expose in the Sun Sentinel. That obviously isn't the standard, but they can get this bad. Experiences such as this were echoed in California. There are no clear standards in place anywhere, including here in Illinois.
It would be my stand, and I want increasingly to see the public health community embrace this, that the public health discipline -- the state and local departments of health -- should be the regulator for the HMOs throughout the country. I believe they are the only ones whose history of altruism, clean hands, and dedication to the public's health enable them to do it. We won't need regulators, if we have any at all, who are essentially in the clutches of those being regulated. That is an all too familiar script in American life, whether it is utilities, environmental regulators, or what have you. I would like to think we could fashion an irresistible argument for the public health responsibility for this health matter.
I also want to share with you a notion that is moving through the American Public Health Association -- the need for a presence in our professional organization for a lay, non-professional sector. We floated the idea of a "public health citizen" to be members of APHA at a reduced rate, as we are talking typically of people of much less income and resources than the professionals they would be joining. We would encourage them to join with us in a variety of struggles that we face. If you think a minute, it's stunning how the American people are organized around issues of health, in particular, public health. Some of the organizations are household names, the American Heart and Cancer Societies, for example. These are organizations with literally millions of supporters, and they represent coalitions on their issue between lay and professional people. The size of the book that lists volunteer organizations in this country is that equal to the Chicago telephone directory. Invariably they represent some personal experience, either through the persons themselves, or through some family member or community. Alcoholics Anonymous. Alzheimer's support groups. Muscular dystrophy. It goes on and on. And I think that's good. It's a source of strength. I also think those energies have to be captured and focused. We do need such a support system in the field of public health.
The poll data that both invigorates and enervates me the most is the Harris Poll of January 1997. Lewis Harris, who I think is the best of the major pollsters, did a nationwide survey and asked people how they felt about a variety of public health activities, like immunizations, food safety, and air quality. Invariably, everything came in at the 90th percentile. Then he proceeded to ask the same people, after asking them how they feel about these activities, could they define public health. And by the most generous, liberal definition of what would pass for public health, one percent could identify what we do. So, that describes our plight. They love us, they love what we do, but they don't know who we are. That's a task, a winnable task, and I think the public health citizen strategy is just where it should be. It may be in place at our national meeting in Washington, to which I invite all of you. It will take place the week after the elections. We are going to have a town meeting of public health citizens, where we'll have people from all over the country.
I'll tell you one little anecdote that inspired me. I got invited to speak at Champaign County Health Care Consumers, an outfit that has been going for some 30 years, and its name says what it does. It's an activist group. I started to talk to the lady who was arranging for my visit, and I told her about this public health citizen idea. And she said, "You know, I think we could work with that." She then went on to tell me that until recently, Champaign County had no health services for its rural areas. Champaign-Urbana, of course, where the university is, has a good city health department. But 75,000 people in this populous county did not have elementary health department functions because they had voted down since 1950 the small tax it would take to give them a health department. Well, eventually they won. They enlisted 2,000 people and made a group called Friends of Public Health. She said she thought they'd be interested in joining. I've had similar experiences in Florida, Colorado, and other places. I'm convinced this is a strategy that can enhance our mission.
Thank you.