Marjorie Williams died of liver cancer in early 2005, leaving behind a bereaved husband, two young children, and a network of loved ones and admirers who filled Washington’s National Cathedral to the last pew at her memorial service. Her legacies are many, including a brilliant career as a political writer for Vanity Fair and columnist for the Washington Post. Yet she will perhaps be best remembered for her sharp and revealing descriptions, written near the end of her life, of her struggle with cancer, and about what it’s like to be treated for it at some of America’s very “best” hospitals.
In the first two and a half years of her illness, Marjorie received treatment from thirty-two doctors in six hospitals. She and her husband, Tim Noah, also an accomplished journalist and a friend of mine, were shrewd and well connected. They consulted with many medical luminaries in search of the very best care and treatments. And yet their quest for quality in health care was as disappointing as Robin’s and mine.
“My most memorable brushes have been with an eminent surgeon,” Marjorie wrote in her next-to-last column for the Washington Post, “whose method is to stride into the examining room two hours late, pat your hand, pronounce your certain death if he can’t perform an operation on you, and then snap at your husband to stop taking notes, he can’t possibly follow the complexity of the doctor’s thinking.”
In the same column, Marjorie described another memorable moment on her journey.
During one hospital stay, as I sat in a wheelchair outside Radiology waiting to be pushed back to my room, I began idly flipping through my chart. A young female doctor-in-training I had never seen before stopped in front of me and said, “You know, you really shouldn’t be reading your chart.” I thanked her for her advice and continued reading. She repeated her admonition. I explained that I was 43 and couldn’t possibly read anything worse there than I had already been told by five real doctors. Upon which she actually wrested it from my grasp. (From this I learned always to go to a stall in the ladies’ room when I want to read my chart.)1
Such anecdotes by themselves prove nothing. But Marjorie’s experience helps us to visualize the reality behind a very odd truth in American medicine. Generally, the more prestigious the hospital you check into, and the more eminent and numerous the physicians who attend you, the more likely you are to receive low-quality, or even dangerous and unnecessary, care.
The evidence for this assertion is as overwhelming as it is threatening to the medical establishment. The first hint of its truth came in the 1970s, when researchers John E. Wennberg and Alan Gittelsohn noticed strange patterns across regions in how doctors treated patients. By combing through old medical records, Wennberg and Gittelsohn discovered wide and seemingly inexplicable differences in how often doctors diagnosed people with peptic ulcers, for example, or in how often people received such operations as tonsillectomies.2 In the town where Wennberg’s kids went to school, Waterbury, Vermont, 20 percent of the children had their tonsils out by age fifteen; but in next-door Stowe, 70 percent of the children got tonsillectomies.3
Differences in socioeconomic status could not explain the contrast. Nor was it plausible to believe that the kids in Stowe were far more in need of tonsillectomies than were kids in Waterbury. The wide variation in practice patterns suggested that something besides scientific rationality was at work in deciding which patients received what care—an idea that at the time was as radical as it was novel. Doctors, after all, were supposed to be professionals who put their patients’ interests before their own and who administered care according to the dictates of science.
Gradually, Wennberg and other researchers, most of them on the faculty of the Dartmouth Medical School, found clever ways to tease out what was going on, and the emerging truth was grim. For most Americans, the two biggest determinants of what kind of diagnoses and treatments they receive are how many doctors and specialists hang a shingle in their community and which one of them they happen to see. The more doctors and specialists around, the more likely they are to be “upcoded” as being sicker than they are, and more tests and procedures will be performed.4 And the results of all these extra tests and procedures? Lots more medical bills, exposure to medical errors, and a loss of life expectancy.
This last conclusion was truly shocking, but it became unavoidable when Wennberg and others broadened their studies. They found it’s not just that renowned hospitals and their specialists tend to engage in massive overtreatment. They also tend to be poor at providing critical but routine care. For example, Dartmouth researcher Elliott S. Fisher has found that among Medicare patients who share the same age, socioeconomic standing, and health status, their chance of dying in the next five years is greater if they go to a high-spending hospital in their community than to a low-spending hospital.
One reason is that patients in high-spending hospitals with lots of specialists and high technology are also less likely to receive many proven routine treatments. For example, standard, evidence-based medicine has identified aspirin as a highly effective treatment for heart attack victims. Yet, in the highest-spending hospitals, only 74.8 percent of heart attack victims receive aspirin upon discharge from the hospital, as opposed to 83.5 percent in the lowest-spending hospitals. This may be one reason why survival rates for heart attack victims are actually higher in low-spending hospitals than in high-spending hospitals.
Patients in high-spending hospitals are also far less likely to receive flu vaccines (48.1 percent versus 60.3 percent) as well as such routine preventive measures as pneumonia vaccines, Pap smears, and mammograms. This general lack of attention to prevention and follow-up care in high-spending hospitals helps to explain why not only heart attack victims but also patients suffering from colon cancer and hip fractures also stand a better chance of living another five years if they stay away from “elite” hospitals and choose a lower-cost competitor. By doing so, they not only gain a better chance of receiving effective preventive and follow-up care, but they also gain a better chance of avoiding unnecessary and often dangerous surgery and tests. Given this unexpected reality, it is perhaps not surprising that patient satisfaction also declines as a hospital’s spending per patient rises.5
This isn’t a statistical fluke. Sure, even among equally ill patients, those who are more aware of the risks of their illnesses may move closer to more prestigious and expensive hospitals. But, while that may be a small factor, the relationship between more money spent per patient and mortality exists among teaching hospitals themselves, even within the same region. And it also applies equally to patients who moved recently and to those who did not.
From evidence like this, Fisher and other doctors estimate that if medical practice in the highest-spending hospitals could be brought in line with medical practice only in the lowest-spending hospitals, financial savings of up to 30 percent could be achieved in Medicare, thereby preserving the solvency of its trust fund indefinitely. And, not only would we have that happy result, but Medicare patients would receive less dangerous and higher-quality care as well.6
Results like these have been repeatedly confirmed by a cascade of similar studies.7 Tellingly, doctors themselves seem to know instinctively the truth behind them. In 2006, when Time magazine had the brilliant idea of asking doctors what scared them most about being a patient, three frequent answers were fear of medical errors, fear of unnecessary surgery, and fear of contracting a staph infection in teaching hospitals.8
Once one becomes sensitized to the degree of mistreatment and overtreatment in U.S. healthcare, the perversity of our long efforts to expand access to our broken system comes into harsh focus. It turns out, for example, that the quality of care received by the uninsured is, by some important measures, better than that of insured Americans.
Yes, that’s right. A landmark RAND study, published in the New England Journal of Medicine, has found for example that uninsured patients receive only 53.7 percent of the care experts believe they should get, which is a tragedy. But according to the same study, patients with private, fee-for-service insurance are often even less likely to receive appropriate, evidence-based treatment. Indeed, among Americans receiving acute care, those who lack insurance stand a slightly better chance of receiving proper treatment than patients covered by Medicaid, Medicare, or any form of private insurance.9
How can this be, you might ask? It turns out that being uninsured paradoxically provides insurance against some of the leading causes of death and injury in the United States. Overtreatment, for example. Once patients who are unable to pay are in a hospital’s door, they cost it money until its doctors make them well enough to leave. There is no incentive whatsoever to give them tests or treatments they don’t need. Since about 30 percent of all health-care spending in the United States goes for overtreatment—much of it dangerous—this is no small advantage.
Also, the less time you spend in a hospital, the less likely you are to contract a staph infection, or to be killed or maimed by medical errors. Similarly, not having health insurance tends to reduce your exposure to ionizing radiation from imaging devices. With the possible exception of mammography, these scans provide no proven benefits yet are a growing cause of cancer, particularly among persons who have received repeated radiation exposures—typically well-insured elderly patients.10 As a recent commentary in the New England Journal of Medicine observed, “Exposure to even moderate degrees of medical radiation presents an important yet potentially avoidable public health threat”—one that the uninsured by and large do not have to worry about.11
You might think that at least insured Americans get better preventive care, what with their $10 co-pays to see a physician. Also not true. According to the RAND study, patients with private fee-for-service insurance receive only 53.3 percent of the preventive care they need, while those without insurance receive 54 percent.12 Even HMOs, though they do slightly better on this score, face the reality that their patients are constantly churning from one plan to the next and so, as we’ve seen, don’t have a business case for investment in true prevention. Meanwhile, fee-for-service providers will happily charge you for a high-radiation, full-body, three-dimensional, sixty-four-slice (cancer-causing) scan of no proven diagnostic value, and call it prevention.
Harvard biochemist Lawrence J. Henderson, one of the Progressive Era’s most renowned men of science, once observed that it wasn’t until somewhere around 1911 that the progress of medicine at last made it possible to say that “a random patient with a random disease consulting a physician at random stood better than a 50-50 chance of benefiting from the encounter.”13 Sadly, the RAND data and a growing pile of other studies suggest that this statement is essentially still true today, for those with or without insurance.
Now perhaps it becomes more evident why the VA’s health system keeps coming out on top in measures of health-care quality. Although the VA is exceptional in its use of evidence-based medicine, information technology, disease management, and root-cause approach to patient safety, its superior performance is also a measure of how fragmented and ineffective its competition is. America’s medical elites are very good at attracting money and prestige, and they have a huge technology arsenal with which they presume to attack death and disease. But they have no measurable positive medical results to show for it in the aggregate; in fact, many signs indicate that they are providing a lower quality of care than the much-maligned HMOs and assorted “St. Elsewheres.”
How can we possibly explain such strange findings? The beginning of all wisdom, when it comes to understanding the business of health care, is to understand that, in this realm, supply often creates its own demand. This of course seems counterintuitive and inconsistent with our experience. After you’ve waited two weeks to see a specialist or to have a PET scan, it is hard to imagine that there is anything but an acute shortage of medical professionals and money to equip them.
But the real reason you have to wait to see a specialist is not that there are too few of them but that there are too many. Specialists who move into a community induce demand for their services even if their treatments provide little or no benefits, or indeed are harmful to most patients. For a similar reason, hospital beds are almost always full because their supply is so great. Add another hospital bed, and one way or another, the local health-care system will find a way to fill it. The phenomenon is known as Roemer’s law, after the late health-care economist, Milton I. Roemer, who first described it in the late 1950s and early 1960s.14
There are two basic explanations for why Roemer’s law arises. The first involves a short circuit in the normal way supply and demand adjust to one another. In most realms of the economy, demand eventually meets supply through changes in prices. If GM produces more cars than people need or want to buy, it winds up cutting prices and offering rebates until the cars are sold. Eventually, if GM can’t cover its costs, it will make fewer and fewer cars, until it eventually goes out of business—or, as it happens, gets a bailout.
By contrast, health-care prices don’t drop when there is excess supply. One reason is because Medicare effectively controls health-care prices. Whatever Medicare will pay for a procedure becomes the benchmark for what other insurers will pay as well. This might not be a problem if market forces determined Medicare’s reimbursement rates for different procedures. But instead, it is an obscure bureaucratic and political process, dominated by the American Medical Association that for years has wound up setting rates and thus ensuring that whatever costs the health-care system accrues collectively are covered.15
So the more capacity the health-care system adds in the form of hospital beds, specialists, and high-tech equipment, the more money comes into the system. Some parts may wind up being more amply rewarded than others according to their success in influencing Medicare’s rate schedules, but for the system as a whole, there is little or no check on excess supply. Instead, excess supply is absorbed through overtreatment and inefficiency. In order for a hospital to go broke and shut down under these conditions, it takes extreme mismanagement or a decline in the surrounding community that creates large volumes of uncompensated care. If Medicare reimbursement rates prove insufficient to cover the cost of one kind of treatment a hospital offers—say, managing a diabetic’s care—then a hospital can divert its resources to treatments for which reimbursement rates are more lucrative, such as heart surgery or chemotherapy.
The second reason Roemer’s law applies is the stunning lack of scientific knowledge about which treatments and procedures actually work. Doctors are highly trained professionals, and most are committed enough to their calling that they would never knowingly subject patients to treatments and tests that are straightforwardly and unambiguously excessive. The problem, however, is that medical textbooks are silent about what constitutes appropriate care for patients with many different illnesses, particularly for those nearing the end of life. For example, medical textbooks offer no evidence-based clinical guidelines for how often doctors should schedule such patients for return visits, when they should be hospitalized or admitted to intensive care, or what palliative care they should receive. Nor do medical textbooks offer clear guidelines, grounded in science, about when a doctor should refer a patient suffering from a specific condition to a specialist, much less when it is appropriate to order a diagnostic or imaging test.
And so we see results like these: in Elyria, Ohio, a small town near Cleveland, citizens have been receiving angioplasties at a rate of four times the national average. It turns out that nearly all these angioplasties were performed by a group practice of thirty-one surgeons in town who have exceptional enthusiasm for the operation, perhaps because it is what they know how to do and it pays well. In the absence of any definitive protocols concerning the effectiveness or appropriateness of angioplasties, regulators or insurance companies can do little or nothing to crack down on even such obvious examples of overtreatment.16
And if the medical establishment is this much in the dark about what might be an appropriate way to treat your disease, where does this put you? It puts you in a spot where you can be very easily manipulated into just going along with whatever has become the customary way of treating your disease in the local medical community. Conversely, if you have made up your mind that you or a loved one should receive this or that operation or should try out some drug you saw on television or the Internet, you can probably find a doctor who will go along with your plans. Lacking clear guidelines about what constitutes appropriate care, a doctor stands a very real chance of losing a lawsuit for refusing to offer some specific treatment or referral, especially if most other doctors in town routinely go along with it. At the same time, doctors, unless they’re on salary, know that deferring to patient demands will put money in their pocket.
Other dynamics are involved as well. Dr. So-and-So performs a bypass operation on a patient. This invasive procedure may or may not have been the most effective way to treat the patient; it may not have been needed at all. But the patient believes that Dr. So-and-So saved his life and tells friends and neighbors. Word spreads, and gets reinforced by some other patients of Dr. So-and-So. Other doctors in the community, who have little ability to evaluate the quality of Dr. So-and-So’s work except by word of mouth, hear these reports from their own patients, friends, and neighbors, and soon Dr. So-and-So’s reputation builds as the hottest cardiologist in town.
For local hospitals and health-care plans, this means they must compete to get Dr. So-and-So on board, come what may. No mere hospital administrator gets to point out that there is no evidence of Dr. So-and-So’s treatments being effective or even safe. Why would he or she want to anyway, since Dr. So-and-So’s building practice is bringing so much money to the hospital. The administrator’s job is to keep Dr. So-and-So happy.
This is pretty much what happened in one notorious case, that of Shasta Regional Medical Center in the small town of Redding, California. There, two rogue cardiologists, Chae Hyun Moon and Fidel Realyvasquez Jr., headed a team that performed extraordinary volumes of unnecessary and recklessly dangerous heart operations. In the end, both would lose their licenses, and each would pay a $1.4 million fine in lieu of federal criminal prosecution. Yet for years before, their building reputations as top-notch cardiologists brought in patients from all over Northern California. In gratitude, the hospital pampered them with department chairmanships and perks. Dr. Moon even enjoyed occasional use of the hospital’s emergency helicopter to fly to golf tournaments.
Our Lady of Lourdes Regional Medical Center in Lafayette, Louisiana, provides another example of how high-volume rogue surgeons can escape scrutiny for years, either because hospital administrators don’t know, or profit from pretending not to know, how dangerous they are. At Lourdes, there were rumors for years that one of its surgeons, a Dr. Mehmood Patel, was performing vast amounts of unnecessary heart operations. Yet it wasn’t until one of Patel’s fellow doctors at last secretly sued him in federal court under a special whistle-blower law that the hospital revoked his admitting privileges. The hospital subsequently agreed to pay a fine of $3.8 million but still denies it had any way of knowing about the safety or effectiveness of Dr. Patel’s care.17
As the number of specialists in a community grows, many people cut out visits to their primary care physicians altogether. Instead, they skip from one specialist to another according to what body part gives them reason to complain that day, all the while gathering more and more bottles for the medicine cabinet.
Many other patients are like “Peggy,” an elderly woman profiled in a case study of the fragmented care typically delivered under Medicaid and Medicare. At age 83, Peggy went into mysterious decline, losing her appetite and eventually becoming so dizzy that she fell and injured herself in the bathroom. For a long time, she convinced herself and others that she was simply experiencing the natural consequences of aging. But when a worried son at last arranged for a comprehensive medical examination by her primary physician, it turned out she was taking four different arthritis medications prescribed by four different doctors. Embarrassed, she explained to her primary physician that she had heard of a few other doctors who were good at treating arthritis and sought them out.
It’s a common delusion that when one doctor or pill doesn’t do the trick, maybe adding a few more to the mix will help one to feel better. As the supply of doctors and specialists increases, the culture of medicine becomes transformed. No longer is any single physician treating the whole patient or taking responsibility for coordinating a patient’s care. In places such as South Florida and Manhattan, it is no longer uncommon for patients to be seen by dozens of different specialists over the course of an ailment, each of whom will happily make referrals to still more.
Over time, this pattern of care starts to seem normal to all involved. Some lonely elders even come to enjoy retelling their stories to different doctors or to those they meet in waiting rooms. It beats staying home and watching television. This fragmented form of medicine, which exists nowhere else in the world, might go on forever except that its financial costs are unsustainable, and its toll in medical errors, overtreatment, and neglect of prevention is, or ought to be, unacceptable.
Roemer’s pioneering work in documenting how supply creates its own demand in health care had a deep intellectual influence on the once idealistic movement to create health maintenance organizations. Today, many Americans view HMOs simply as organizations designed to make money by denying them care. And it’s a sad fact that many HMOs have wound up doing just that, or else using clever marketing techniques to make sure they cherry-pick only young and healthy customers who are unlikely to get sick. But it is important to remember that HMOs and other forms of managed care came into existence in large measure because of a big problem that is still with us and getting worse—namely, vast amounts of poorly coordinated, dangerous, and often excessive treatment.
The original vision of those who championed HMOs was that this form of care would vastly improve the quality of American medicine and only incidentally lower its cost. Paul Ellwood, a pediatrician who more than any other single advocate built the case for HMOs, put it this way: “My own most compelling interest as a physician was in the integration of health care, quality accountability, and consumer choices based on quality first and, secondarily, price.”18
In the late 1960s and early 1970s, a group of doctors saw two trends that worried them—a movement toward ever greater specialization and the increasing prevalence of chronic disease in an aging, sedentary population. Recognizing that this combination required a far more systematic, integrated, and scientifically driven approach to health care, they organized the precursors of what came to be known as HMOs. Specifically, they wanted an “integrated delivery system,” in which “primary care” physicians would coordinate care in large, multispecialty medical group practices that would in turn be part of a system of hospitals, labs, and pharmacies. Moreover, to address the problems of overtreatment and lack of prevention, care providers would be prepaid. As Alain Enthoven, another champion of managed care, once wrote, this would give “doctors an incentive to keep people healthy.”19
Already by this time, it was becoming apparent to those who studied the actual effects of modern medicine on the population as a whole that a new model of care was desperately needed. The crude death rate, or total number of deaths per year per 1000 Americans, was no longer declining by the 1960s. Partly this was because the fall in birthrates since the end of the baby boom years meant that children and young adults constituted a smaller share of the population. But modern medicine itself was also a factor. Its very successes were causing a pandemic of chronic disease.
How? you might wonder. Until right before World War II, it was a truism of medicine that, as the once famous medical textbook The Principles and Practice of Medicine, put it: “Persons rarely die of the disease with which they suffer.” Instead, secondary terminal infections, primarily pneumonia, carried off most patients with incurable diseases, which is why pneumonia was once characterized by medical authorities as the “old man’s friend.”
Then in 1937, for the first time in history, effective treatments for infection became available. The introduction of sulfa drugs, followed by the discovery of even more effective penicillin and other powerful antibiotics, radically changed the way most people aged and died. Between 1936 and 1949, the death rate from pneumonia declined from slightly under 60 per 100,000 to just 15 per 100,000. But this triumph of modern medicine came at a price. The old man’s friend and other secondary infections no longer claimed as many sick patients, so more and more people were left alive and still suffering from their primary diseases while also bearing an increased risk for such chronic conditions as cancer, congestive heart failure, or the disease that came to be known as Alzheimer’s.
The unexpected result was that the incidence of chronic illness exploded while mortality rates for the population as a whole stopped improving. By the 1970s, far-sighted researchers such as Johns Hopkins’s Ernest M. Gruenberg started characterizing the rapid spread of chronic diseases as examples of medicine’s “failures of success.” Modern medicine, in a quite literal sense, was enfeebling the population. Obviously, the answer wasn’t to stop using antibiotics and other modern medical techniques. But the spread of chronic disease throughout the population did call for a new model of care.20
At the same time, the family doctor who made house calls and knew the circumstances of his patients was passing from the scene, and no one was taking his place. The family doctor may have carried in his bag little more than a stethoscope and various vials of opiates and alcohol, but the personal attention he paid to patients had huge, and by the 1960s, increasingly well-documented, curative powers.
Professor Kerr White showed in study after study how important an intimate and long-term relationship between doctor and patient was to health. Partly this was due to reasons you would expect, but White also found that much of the benefit of such a relationship came simply from the placebo effect. The very presence of a familiar doctor laying on hands or writing a prescription gave patients hope and strengthened their will to live.
Also involved, White found, was “the Hawthorne effect.” This was a phenomenon, already famous in managerial circles, that was first observed in the 1920s among women workers in a Westinghouse plant in Hawthorne, Illinois. During the course of a company study, the workers’ productivity continuously increased under both good and poor working conditions. It didn’t matter, for example, if they were forced to work in dim light or bright; the women kept on working harder so long as the study continued. Eventually, researchers could only conclude that the women were flattered that someone cared enough to pay close and careful attention to what their jobs were like. White demonstrated a similar effect in health care. He showed that patients in the care of a familiar and trusted physician are demonstrably more likely to modify their behavior—quit smoking, reduce drinking, take their medications—in ways that benefit their health.
Taken together, the placebo effect and the Hawthorne effect accounted for about half the benefits of all medical interventions, White showed. Armed with this insight, he went on to invent the concept of primary care and to pioneer the idea of an integrated or “managed” health-care system centered on primary care physicians. The hope was that patients in the future would not simply get lost or be ignored as they passed from specialist to specialist.21
Such were the highly idealistic and data-driven concerns and issues behind the emergence of HMOs. What went wrong? Eventually, HMOs morphed into many different forms and hybrids. Some were nonprofits, others were publicly traded companies answerable to Wall Street. Some were “staff models” that put physicians on salary and effectively eliminated the problem of intentional overtreatment; others became little more than loose networks of doctors on contract. Some were run by idealists; others by shysters, crooks, and knaves who convinced themselves that the road to riches could be found by lowballing on pre-paid contracts and then denying their patients necessary care.
Even the many HMOs that tried to do the right thing often ran into a fundamental flaw in their business model. Most remained small enough that the majority of their customers changed plans every few years, either because they moved to a different market or because their employers switched to a cheaper plan. For all but the largest HMOs, this circumstance demolished the business case for prevention and effective management of long-term conditions like diabetes. Before any returns from investing in a patient’s long-term health could be realized, the patient was likely to be enrolled in some other plan.
By the 1990s, most people enrolled in any particular HMO had little or no choice in the matter; they were there because their employers were trying to save money. It didn’t help that many fee-for-service doctors felt threatened by the growing dominance of HMOs and other managed-care providers and complained to their patients about it. Nor were the negative press and lawsuits that some HMOs attracted helpful to the industry’s image.
The result was a public backlash. But with the benefit of hindsight, we can see that it didn’t have to turn out this way. Proof of that are the big exceptions to the often poor performance of HMOs over the last several decades. These are institutions with high levels of patient satisfaction that are also lauded by health-care quality researchers for their patient safety, adherence to evidence-based protocols of care, and general cost effectiveness. They include integrated providers like Intermountain Health Care, the Cleveland Clinic, the Mayo Clinic, Geisinger Health System, Kaiser Permanente, and preeminently the VA, which ranks highest of all on most metrics of cost and quality and is in effect the largest—and purest—nonprofit, staff-model HMO in the land.
What do these exceptions to the rule have in common? First, they are all large enough to achieve significant economies of scale. The VA’s scale, for example, has been an important precondition for the deployment of its highly effective system of electronic medical records, the cost of which it has been able to spread across a large base of hospitals and clinics. The same is true of Kaiser Permanente and the other examples of “best-practice” health-care delivery system mentioned above. Similarly, the size of these institutions means that the data generated by their digitalized information technology about what works and what doesn’t has far greater scientific value because the records are drawn from a very broad population. Also, their scale allows them the opportunity to integrate and coordinate care among a broad range of specialists who all work for the same institution and use the same patient records so that the care patients receive is far less fragmented (and dangerous) than found generally in fee-for-service medicine.
So it’s important to take the right lesson from the HMO revolution. Though it produced many failures, it also produced institutions of exceptional excellence. Moreover, as we move closer to examining the lessons the VA has to offer to the rest of the American health-care system, it is important to remember that the problems that led to America’s experiment with HMOs and managed care did not go away. Instead, they got worse, and will get worse still in the future.
Today, more than 90 million Americans live with chronic illnesses such as diabetes, cancer, and heart disease; and seven out of ten American deaths are caused by chronic illnesses. An aging population, combined with the sedentary habits of modern Americans and medicine’s own “failures of success,” will continue to increase the burden of chronic diseases. On our current road, the human toll from medical errors will also increase as drugs become more potent and care becomes more fragmented. As Americans grow older, more and more people will also be killed by a health-care system that fails to deliver routine preventive measures while neglecting or mismanaging chronic illnesses like diabetes. Finally, there are limits to how much Americans can pay for health care without ruining both their own finances and those of their country. For-profit HMOs are not the answer, most people would agree. Nor is the answer simply to create more subsidies so that more people can have greater access to a fragmented health-care system that is grossly inefficient, ineffective, and unsafe. So what is the answer? The last three chapters of this book point the way.