A Response to David Brooks’ NT Times Column “Death and Budgets”
It’s clear now that business and government want healthcare “reform” to control costs, not provide everyone with comprehensive, affordable healthcare.
Yet business and government are unwilling to do the real things that could control costs: (1) eliminate private insurance with its profit, administrative and marketing costs, (2) put doctors on salaries, so they’re no longer private businesses with incentives to either over-treat us or under-treat us, and (3) require the government to control drug prices. Without these tools for cost control, what’s left but rationing? And if $500 billion in savings in Medicare are to supposed to finance half the cost of healthcare “reform” over the next ten years, how can medical care for older people NOT be rationed?
Obama’s insistence that deep structural reform is needed for so-called “entitlement” programs (Medicare, Medicaid, and Social Security) gives no re-assurance. These programs have been under attack by liberals and conservatives alike because their funding automatically increases with the expanding senior population. The Brookings Institute, closely allied with Obama, is particularly vehement about this.
Given these troubling trends, it would be useful to examine earlier periods when there was a push for medical rationing, to see what it would look like. The mid 1990s was a period similarities to the period we’re entering. Remember the “Contract with America?” Working families were suffering from a jobless recovery but the financial sector was doing fine. Business-friendly healthcare reform had failed, and a major push was underway to reduce costs by limiting services.
What emerges is that business and government had collaborated for years to produce a climate favorable to rationing in the medical profession. Look at some of the quotes at the time:
The 1980s equivalent to David Brooks was liberal Colorado Governor Richard Lamm, who was touring the country giving lectures saying old people had the duty to die and get out of the way. Then, like now, it was all very poetic. They were leaves falling off a tree and forming humus for other plants to grow up. (NY Times, March 29. 1984)
“Given the competition for markets with foreign firms, US corporations can no longer afford to leave health care politics to the usual participants– professors, bureaucrats, physicians, and hospitals. Whether or not a hospital cost control bill is passed, or is passed but found inadequate, the big corporations are here to stay. They will work for federal and state attempts to control costs, preferably keeping the impetus in the private sector, but controlling costs by all means, at all costs.” (Hospital Progress, Dec., 1977)
“Only when society is fully able to come to grips with death and dying is it likely that policies and procedures for decisions not to treat will not only will be formulated, but will also be followed. This period is likely to be hastened as financial constraints force the issue.” (Journal of the American Medical Association, April 22, 1983)
“Yet it will be a hard pill for many Americans to swallow — the idea of doing with less so that big business can have more. … Nothing that this nation or any other nation has done in modern history compares to the selling job that now must be done to make people accept the new reality. And there are grave doubts about whether the job can be done at all. Historian Arnold Toynbee, filled with years of compassion, laments that democracy will be unable to cope with approaching economic problems — and that totalitarianism will take its place.” (Business Week, Oct 12, 1974)
Though 100,000 people were dying yearly from lack of health insurance, and two million adults on Medicaid had been denied care in the first half of 1992 because of low fees that states pay, corporations, government, and the health industry are saying that too much health care was being delivered. In particular, they are taking measures to reduce delivery of healthcare by reducing the number of doctors.
The Pew Health Professions Commission 1995 Report “Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century” recommended closing one fifth of the nation’s medical schools in the next ten years, and tightening immigration laws to ensure that foreign medical students leave after completing training. The report predicted that by the year 2000, half of all hospitals and 60% of beds would close and there will be surpluses of 100,000 to 150,000 doctors, 200,000 to 300,000 nurses and 40,000 pharmacists. The Commission includes former government officials, medical educators, public health professionals and insurance company executives. The commission is headed by the former Colorado Governor Richard Lamm, whom we already mentioned.
A 1978, a University of California San Francisco staff conference on cost-containment, “The Ailing Health Care System,” was addressed by a UCSF Associate Professor of Bioethics who paraphrased an article:
“The Hippocratic Oath declares ‘Into whatever houses I enter, I will come to help the sick.’ The oath did not oblige the Greek physician to enter every house where there was sickness. Today we may ask whether some houses cannot be entered because it is not cost effective to do so. … Are cost considerations permissible when clinical decisions are being made in view of the social costs? How can we apply the principles to broad social policy?” (“The Ailing Health Care System,” Western Journal of Medicine, June, 1978)
“Bioethics,” as a discipline, arose parallel to the cost-containment movement in response to “ethical” problems of denying patients care for economic reasons. One should note that in the period from 1980-1992, when medical cost containment became triumphant, and the Bioethicists balanced people’s medical care against “diminishing national resources,” tax changes increased the income of the richest 1% of the country by 74%. (NY Times, April 17, 1995)
In 1980, UCSF organized a full-blown Cost Containment Conference. The organizer stated “the culprit in the high cost of medical care is our current inability to make and enforce decisions about what medical services we need and can afford.”
At the conference, a speaker said medical costs were too high because there were too many doctors providing healthcare. He suggested cutting medical school admissions by 1/5 and eliminating foreign post-graduate MDs. (personal memory)
Another speaker described a 3-year program at UCSF to discourage residents from ordering automated blood tests, measurements of blood clotting times, stat (emergency) orders, X-rays, vital signs, weights, fluid Intake-and-Output tracking, and medicines administered four times daily. He advised doctors not to worry about malpractice suits, because residents were not legally liable. When asked why the residents were being trained, and not the attending doctors, he explained that there is private health care, used by the wealthy, where decisions are made by attending doctors, and there is public health care, used by the poor, where decisions are made by the residents. Therefore, it is the residents who need to be taught cost-containment. (personal memory)
In the early 80’s, mainstream medical journals carried statements like:
“Persons will be recognized as in need of, and then denied, benefits that the medical care provision system is capable of providing. … These decisions (to withhold treatment) are likely to be made when any of the following conditions are met: (1) the treatment is determined to be futile, (2) the patient declines treatment, (3) the quality of the patient’s life is unacceptable, or (4) the cost of providing care is too great. … Only when society is fully able to come to grips with death and dying is it likely that policies and procedures for decisions not to treat will not only will be formulated, but will also be followed. This period is likely to be hastened as financial constraints force the issue.” (Health Care Technology and the Inevitability of Resource Allocation and Rationing Decisions, Journal of the American Medical Association April 22, 1983)
This period also saw the beginning of a large-scale campaign in medical journals warning the medical community of the economic dangers of an aging population with disabilities, chronic diseases, and expectations of receiving complete medical care.
“The longer people live, the greater the likelihood that they will exhibit chronic disease, have subsequent disability, make use of new and expensive medical technology, and ultimately fall into the category of high-cost users of medical care. Fully 85.2% (of the civilian population) indicated that they were limited in or unable to carry on major activities, affecting their ability to work or manage a household. … The total cost of illness should reflect not only actual medical treatment costs but (also) the costs of services and other benefits the person receives because of his illness.” (Health Care Technology and the Inevitability of Resource Allocation and Rationing Decisions, Journal of the American Medical Association, April 15, 1983)
There was also a campaign in the popular press and medical journals questioning whether dialysis patients had a right to treatment because of the cost. (Philadelphia Bulletin, Jan. 21, 1981) There was also a flood of articles in medical journals on cost-effectiveness analysis, and articles justifying withholding medical treatment. Some examples:
In 1980, the Secretary of Health and Human Services announced that new health technologies must be evaluated not only on the basis of their medical efficacy and safety, but also on the basis of their “social consequences” before financing their wide distribution. (Health Care Technology and the Inevitability of Resource Allocation and Rationing Decisions, Journal of the American Medical Association, April 15, 1983)
A cost-benefit analyses showing that care of very low birthweight babies is not economically warranted, based on the expected lifetime earnings of the infant. (“Economic evaluation of neonatal intensive care of very-low-birth-weight infants”, New England Journal of Medicine 308:1330-1337, 1983)
A UCSF Health Policy Program conference report on neonatal resuscitation stated: “Resuscitation criteria should be established with full awareness of the economic and medical implications of providing this care. Estimates should be made of the financial cost to society of prolonging life, at a humane level, depending upon the condition at birth.” (Pediatrics, June 6, 1975)
A survey was published of patient deaths in Seattle extended care facilities, demonstrating that doctors were willing to withhold antibiotics to 40% of patients with fever, the majority of whom died. “Physicians have been accused of prolonging life at any cost. However, surveys of health professionals have found that many (50 to 70 per cent) are disposed to withdraw or withhold life-prolonging treatment.” The question of whether the patient expressed a desire to continue living is never even mentioned in the article. (“Nontreatment of Fever in Extended-Care Facilities, New England Journal of Medicine, May 31, 1979)
A UCSF Health Policy Program published a paper analyzing factors affecting survival of patients with hospital bills over $4,000. The paper suggested that patients with cancer, patients with medical as opposed to surgical service, patients over 64 years of age, and patients with hospital bills over $10,000 have poor survival and are a bad investment. (Journal of the American Medical Association, April 10, 1981)
So although at the time, it seemed like our health care is being taken away with breathtaking rapidity, the truth is that the policymakers and academics have been working for at least fifteen years preparing the groundwork for this assault on us.
What was happening to our healthcare at the time, and what did we expect might happen in the next fifteen years? Much of medical practice at the time was embodying the idea that people who were not economically valuable did not deserve care.
In the San Francisco General Hospital Dialysis center, doctors had to explicitly state that black patients were not drug addicts and Latin patients were not undocumented in order to get them renal dialysis. (Personal communication from former doctor in the unit.)
The Indian Health Service barred dialysis for reservation Indians in southern Arizona if they were approaching end-stage renal failure, cutting 20 Indians off and saving $500,000.
A 34 year old Sacramento woman was denied a heart and lung transplant by Stanford and UC San Diego Hospitals because she has Downes Syndrome and mental retardation. She lives on her own, graduated from high school, and has a job. She is also a past president of Capitol People First, a Sacramento disabled rights group, and her work on behalf of those with Down’s syndrome and other disabilities has been widely recognized. Stanford Hospital rejected her without even a physical examination. (SF Examiner, Aug., 11, 1995) Due to widespread protest, this decision was reversed.
In the fall of 1994, the newsletter of the Los Angeles chapter of Mensa (an organization for people with high IQs) published an article calling for the sterilization of individuals with low IQs.
At Children’s Hospital of Oklahoma, secret “quality of life” experiments on children born with spina bifida were conducted between 1977 and 1982. 25 parents were advised by doctors not to have their babies treated; of these, 24 died. 36 parents were advised by doctors to have their babies fully treated; all 36 lived. The decision of which parents were advised to have their babies treated was based on a formula devised by the doctors, involving the baby’s functionality, the parent’s financial resources and education, and how little public resources would have to be used for treatment and rehabilitation. The US Supreme Court refused to hear a lawsuit filed by the parents of children who were allowed to die. (Progressive, October 1994)
A prominent British neurologist wrote in 1975 that “no person with severe handicaps is likely to be able to earn his living in competitive employment, unless his IQ is at least 100.” He developed a set of rigid criteria to determine which newborns with spina bifida should receive aggressive therapy. These criteria include consideration of the infant’s “social condition.” (J Roy Coll Phys, 10:47, 1975)
A pediatrician writing on genetic disorders stated, “ the unchecked accumulation of undesirable genes constitutes a clear and present danger,” and criticized “the salvage of nature’s rejects.” (Ross Conference on Pediatric Research, 65:1, 1973)
In 1983, the Journal of the American Medical Association wrote about end-stage renal disease: “Once it is apparent that all who are in need cannot be treated, the question then becomes which of the potential recipients are going to derive the greatest benefits. … The preferred candidates were selected on the basis of a variety of criteria, e.g. age, medical suitability, mental acuity, family involvement, criminal record, economic status (income, net worth), availability of transportation, likelihood of vocational rehabilitation, (some other criteria) and educational background, occupation, and future potential.” (Journal of the American Medical Association, April 22, 1983)
A committee was established in Seattle which established guidelines for eligibility for dialysis based on social worth criteria as well as medical criteria. (“The Ailing Health Care System,” Western Journal of Medicine, June, 1978)
It’s no exaggeration to say that medical practice was bringing us closer to the idea that persons without economic value do not deserve health care, reminiscent of Nazi Germany’s rhetoric denying care to the “useless eaters.”
Approximately 5,000 mentally deficient and physically deformed children were killed in Germany between 1939 and 1944 under Nazi euthanasia policies. At the Nuremberg trials of high-level Nazi doctors, various American doctors were brought in as observers and prosecutors. Later, they published articles on how the German medical system was transformed, so that it was willing to carry out the mass killing of disabled children, old people, and disabled adults.
Leo Alexander wrote: “It started with the attitude, basic in the euthanasia movement, that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself with the severely and chronically sick. Gradually the sphere was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted, and finally all non-Germans” (“Medical Science under dictatorship, New England Journal of Medicine 1949, 241, 39-47)
Alexander Ivy wrote: “In my opinion, medicine is doomed if it ever consents to take part or permits any member in good standing to take part in a program of euthanasia applied for socioeconomic purposes.” (New England Journal of Medicine, 139, 131-135, 1949)
The 1990s cost-containment movement was part of the wholesale and bi-partisan attack on the working class that began with the mass firing of the Air Traffic Controllers, included the deliberately-induced recession of the 1980s, and led to the 1990s Contract on America.
Because we have not broken ties with the Democratic Party, we have no movement capable of resisting this attack, and it continues with heightened ferocity. The current cost-containment movement centers around the debt, brought on by oil wars, tax breaks for business and the rich, and bailouts of banks that went bankrupt following corrupt dealings brought on by deregulation. Generations-old health and income programs for seniors, disabled people, and poor workers that corporations and politicians did not dare touch are now under attack. Academic and media prostitutes like David Brooks can be depended on to do their work for the bosses.
Michael Lyon is co-chair of the San Francisco Gray Panthers Health Committee and is a member of the American Public Health Association.