The Future of Health Care In America, Part I

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Robert Michels
Title: “The Future of Health Care in America”
VTR: 10/30/96

I’m Richard Heffner, your host on The Open Mind. And my guest and I today are both such youngsters that it’s really hard to believe that we first met here on The Open Mind more than 21 years ago, and that our topic then was our topic now: How best to achieve HealthCare for all Americans, 200 million then, 260 million plus now, without lessening the quality of medicine in our country. All that time ago, Dr. Robert Michels was Chairman of the Department of Psychiatry at the Cornell University Medical College, and Psychiatrist-in-Chief at New York Hospital. Since that time, Dr. Michels has also served as Dean of Cornell’s Medical College, and is now the Walsh-McDermott University Professor of Medicine.

Well, I’ve asked Dr. Michels here again today to offer his usual, tough-minded analysis of the question that is uppermost on the minds of so many of us: What is the future of HealthCare delivery in America, qualitatively speaking as well as quantitatively? Bob?

MICHELS: Well, when you ask the same question you asked somebody 21 years ago, the one thing you can be absolutely certain of is there hasn’t been a satisfactory answer in that period of time. I would say the problem has gotten greater, and the dilemma has gotten more painful, and perhaps one of the most important changes is where that question wasn’t the center of a national dialogue 21 years ago, it sure has become the center of a national dialogue today. So we’re grappling with the question now as a society, and that’s a big advance.

HEFFNER: But, of course, then I should ask you to what end all of the grappling.

MICHELS: Well, I have immense confidence that we’re going to end up with a system of high-quality health care that will care for all of our citizens in a dignified and scientifically effective way. What I’m not sure of is when that will occur, and what’s going to happen between now and then. I have concerns about both of those.

HEFFNER: Bob, is it because you were for some years Dean of the Medical College that you are now speaking in such optimistic terms?

MICHELS: Well, to say someday we’ll solve the problem, I’m not sure that’s totally optimistic.

HEFFNER: No, but the picture, the rosier picture of what will happen someday, is it really that possible?

MICHELS: I think so. I think that our scientific advances are incredible. And the power of what we’re able to do in HealthCare has advanced more rapidly than almost any other area of our public life or private life. I think I told you this 21 years ago, hut I’ll use it again in the off chance that some may not remember it, Dick: We would happily go to a restaurant from 1940, ride in a train from 1950, go to the opera from 1930, go to the museum from 1950, but none of us would want to go to a hospital for major HealthCare from 1980. That’s because we’ve learned so much and we’re so much more powerful aM so much more effective in what we can do, and frankly we’ve only begun to reap the benefits of the new scientific knowledge that’s coming to us now

HEFFNER: Now, does that mean that you’d be less comfortable back then, back in 1950, than you are now?

MICHELS: Oh, no, we were much more comfortable then, because the potential power that we’ve gained means that not being able to use it as we’d like to is all the more painful. I would’ve been most comfortable in 1680 when I would have no concern at all about citizens who couldn’t achieve or acquire the HealthCare then available, because it was worthless. Today it’s valuable, and so the pain of it not being universally available and universally accessible is all the greater.

HEFFNER: You know, there’ve been a number of people on this program over the years to whom I’ve put the question concerning the potential in this country given its resources for us to be our brother’s keeper, not just in the area of jobs, not just in the area of race relations, but in the area of medical care too. And I gather you’re expressing an optimistic belief that we can provide for the 260 million Americans now, and later for the 300 millions, and so on, appropriate and adequate care.

MICHELS: I think so. And I think we will. But we’re not there yet. And we don’t yet have a consensus on how to get there. I think we now pretty much have a consensus that it’s a desirable goal. I think the dialogue a few years ago about the Clinton proposal for a change in the HealthCare system mandated at the national level achieved a consensus about that goal, although when we started talking about how to achieve the goal, the consensus fell apart. But the greater power of our healthcare will make leaving some without it all the more painful and unacceptable. And I think, as our society moves forward, we’re not going to be able to accept having 40 million people without access to what’s an essential commodity in modern life.

HEFFNER: Well, I appreciate what you say about there being disagreements, that there isn’t consensus yet. But I’m talking to someone now who’s been a practitioner and an administrator and a head of a medical school, and a head of a great department in a major university, major hospital. What’s your own sense of what we should be doing to achieve what you think we should achieve?

MICHELS: Well, first of all, the dialogue is the first step, and we’re having that. There has to be public discussion and public awareness of what the problem is. And that’s being developed. Secondly, there are incredible inefficiencies and inappropriate expenditures in our HealthCare system.

HEFFNER: Like what?

MICHELS: Well, for example, we have good scientific evidence of how to prevent certain diseases, and we know that the money spent on prevention is far more cost-effective than the money spent on treatment. Yet our prevention efforts tend to be under-funded, while our expenditure system tends to be geared toward treating the results of our failure to prevent. That’s not rational. You can understand why it happens in the system. It’s because individuals are highly motivated to treat their diseases when they get them, but aren’t motivated to vote for the taxes necessary for the public efforts at prevention activities. But as we move toward wider understanding of that, we’re going to see changes. We’re going to see better prevention, and therefore dollars saved that can be used to spread the benefits of HealthCare.

HEFFNER: Where will they be saved?

MICHELS: Well, I mean, the most honest example and the one that’s talked about so much, of course, is the horrendous health consequences of smoking. That’s something that we know. It’s been well demonstrated. And that our society has grappled with for several decades now. But, over that time, a consensus is beginning to emerge that we haven’t gone far enough in trying to limit the negative health consequences. We’ll make advances in terms of the social consensus about what kinds of taxes or political activities or educational activities will reduce smoking, and we may even make advances in terms of scientific knowledge so we can separate the negative health effects from the pleasureful effects of smoking, and allow people to have an addiction without a price to pay at the end of it.

HEFFNER: What’s your own bet about that, as a scientist?

MICHELS: I think we’re going to do both. My guess is we’ll have trouble getting an addiction with no price, but we’ll lower the price.

HEFFNER: It won’t be death, presumably.

MICHELS: Well, one step that seems fairly close is we might be able to identify that subgroup of the population that’s most genetically at risk for the negative consequences of smoking. The remainder have less danger involved. And we could focus our preventive efforts on those who have the most to lose. That would be a way to get greater bang for the buck for our preventive dollar, to allow people who are paying a smaller price to pay that price for the smoking, and to improve the economy of the HealthCare system.

HEFFNER: What are some of the other areas that you have in mind?

MICHELS: Well, we’ve seen major advances, of course, in prevention of infectious diseases. And at the same time we’ve seen major new epidemics of infectious diseases. But our advancing knowledge is moving at a pace… We’re in the latest epidemic, the AIDS epidemic. We know more about that disease within a decade or two after it first appeared than we’ve known about other infectious diseases centuries after they’ve first appeared. I think we’ll see preventive strategies there that are just over the horizon, and then we’re going to make a difference. I think we’re going to see major preventive strategies in some of our chronic and degenerative diseases as we learn more about environmental factors and as we learn more about dietary factors, for example, affecting cardiovascular disease. And, of course, the overwhelming, exciting area of biomedical science these days is genetics. And as in other areas than smoking and cancer, we’re going to be able to identify high-risk groups virtually at birth and be able to target expensive preventive strategies at those who are most vulnerable to succumbing to a disease if they don’t have the prevention.

HEFFNER: Where along the line, Dr. Michels, do you find the statement, “We don’t have the resources now to spread around to everyone, so we’re going to begin to radon our resources”?

MICHELS: Well, there’s one word in that statement that’s deceptive, and it’s “begin.” We’ve been rationing for years, of course. The question is how we ration and who rations. We’ve always had a variety of qualities of HealthCare.

HEFFNER: I see.

MICHELS: Everyone’s never gotten the same care. There’ve always been decisions that have been made by providers or insurers or families. And I think even the very definition of the word “resources” has to imply there aren’t enough, that they’re limited, and that more could he used. I don’t think we have enough resources to give everyone the very highest quality, most luxurious, most user-friendly, optimal HealthCare. That’s impossible. But I think we have enough resources to identify a socially acceptable, minimal, but adequate package of care which every citizen and every resident of our community is entitled to and should get. And, frankly, it’s aesthetically offensive to live in a community that doesn’t do that.

HEFFNER: Now, wait a minute. You say “aesthetically offensive,” and I agree with you. Politically and otherwise offensive too. But I detect something of a shift in what you’re saying. And stop me if I’m wrong, please. You said we’ve always rationed; there’s never been a time when some receive this treatment and others did not. Before, I thought… And you said that in all likelihood that’ll always be the case. But earlier, when you were discussing that Never-Neverland of the future, I thought you were relating yourself to a Never-Neverland that would come about in which we would all have what we needed individually.

MICHELS: We’ll all have what we need at that minimal level of care, or that adequate level of care. But I’m sure there’ll always be those who reasonably want more than that, want greater luxury, want greater convenience, and perhaps want a higher level of care than the community can reasonably provide to everyone, and are willing to give up other things for it.

HEFFNER: Ah, but there we come to it. “A reasonable level of care. What do you mean? No dialysis over 60, but dialysis machines available before on demand? What sort of thing are you talking about?

MICHELS: Well, those are specific decisions that have to be made. We already live in a society where reasonable care means that there is no age limit on dialysis. I think reasonable care certainly includes emergency care for anyone who falls in the street with a chest pain or sudden stroke or any other disease, is injured in a fire.

HEFFNER: What doesn’t it mean?

MICHELS: I think it doesn’t necessarily mean… Let’s start at the easy end. I don’t think it means cosmetic surgery for everyone…

HEFFNER: Okay.

MICHELS: …who chooses it. I don’t think it necessarily means that everyone who has a chronic disease that limits their ability to pursue pleasure is entitled to the full treatment that would rehabilitate their capacity to do that. What do I mean? Somebody who loves an athletic activity and at 80 finds that their hips or knees can’t support it anymore, I think we may not be able to afford for the full range of possible rehabilitation that would allow them to go back to their tennis or their running at that age. We may have to make choices about that. I think that there will be choices certainly about the hotel and creature-comfort aspects of care. We don’t all stay in the most luxurious hotels when we travel to a distant city. I don’t think we can all have the same quality of room in a hospital, or perhaps the same meals when we’re forced to stay in it for three or four days for some acute procedure. Those are all cost differences. People will wait longer for elective appointments. Others will choose to pay to have them immediately. People will pay extra to be able to select the doctor they find most pleasant to converse with rather than the one to whom system assigns them. Those are all reasonable ranges that our society would feel somebody who wants that extra rather than fur coat or a vacation in Europe should be able to pay for it, but somebody else who doesn’t have the resources may have to settle for an adequate package.

HEFFNER: You know, I don’t know why, but that scares the hell out of me. Because somewhere along the line somebody is going to be saying, “Adequate package over here. Luxurious package over there.” You’re not suggesting… Well, I guess you are suggesting that if I can pay for the luxurious package, fine, all well and good.

MICHELS: That it scares the hell out of you, Dick, means that you’ve denied the fact that it’s already true, and that it’s always been true. It would be scary f h had always been other and I’m advocating something new. What I’m advocating is that we will recognize and rationally discuss the way it’s always been to make sure that it’s really the way that we want it to be rather than do it while we’re pretending to do something else.

HEFFNER: Well, now, let’s take this situation: Somebody loses, somebody gains. Who is going to be losing, and who is going to be gaining?

MICHELS: I think that’s a central question in what happened when we tried to revise the system just a few years ago. In most parts of the world, of the industrialized world, of the West, where the society provides HealthCare for most of the citizens – in England, in most of continental Europe – there are two levels of HealthCare, at least, really. The majority of the population gets one level, and a small group buy these extras in the private system. The small group is maybe 10 or 15 percent of the total. That’s not the way it’s been in our country. We’ve had the majority of the population having a fairly luxurious level of HealthCare provided by health insurance, but at the cost of the bottom 15 or 20 percent having nothing or very close to nothing, and maybe a very thin margin at the top with super luxury. In order to include that bottom group in an adequate package, we either have to add money to the system, or we have to take money out of the care that’s provided for the top 75 or 80 percent, or we have to do it more efficiently and more effectively. Certainly the third is desirable. But, in the short run, that won’t produce enough money. And the proposals that were made and discussed suggested squeezing some of the luxury out of the majority of the people in the middle of the system, and using those extra resources to include the bottom. And when that became clear, there were screams. We don’t have a social consensus about doing that yet. We’re moving toward greater and greater efficiency, creating money that way. We certainly don’t have a social consensus about putting more money into the system. We may he able to disguise that a little bit because the growth of health costs has been so great that if we can slow the real growth we might be able to use that margin between what the historic growth has been and what the new growth has been to add some new services at the bottom. And we may at some point – I think we will — move back toward a greater sense of our community’s responsibility for the health of the least-advantaged as well as for our own health.

HEFFNER: For the least-advantaged, as well as our own. You mean because of the fear of what continuing to deprive the least-advantaged of health will mean for the health of the rest of us?

MICHELS: Well, that’s one motive, and you see that in terms of the possibility of infectious disease epidemics or something like that. I don’t think that’s a real problem. I think a more important problem is for the social cost of not doing it. I’m not sure I want my children to grow up in a society where their classmates don’t have adequate HealthCare. I’m not sure I want to live in a neighborhood where my neighbors have to steal from me to get the resources for essential HealthCare for their families. I’m not sure I want to walk down the street and see people in the street who I know could need help and aren’t getting help. I don’t think I would enjoy my dinner that night. So I think it’s more than fear; I think it’s also what I called “aesthetic’ before. It’s the kind of culture we want to live in, the kind of place we want to raise our children.

HEFFNER: Let me go back to this question of rationing our resources. You say we’ve always done so. Are we going to do so with greater pain in the future than in the past?

MICHELS: I think there’s always been pain connected with it.

HEFFNER: Right.

MICHELS: What I think would be helpful is, if we do it consciously and explicitly, we’re more likely to do it rationally. And we’ve already seen experiments in this direction. So, for example, as I’m sure you know, the State of Oregon has been involved in trying to come up with a system for developing a rank-order priority of health services and which are most important and which are less important. What we’ve done in the past is, that’s left up to the selection choice of patients and of doctors. And they don’t always select correctly, because they select under urgent pressure. So the selection that’s made when someone’s in pain, or terrified or fearful of death may not be the optimal selection. And when you have a society make such selections rationally, they’re more likely to rely on scientific data than myth and belief.

Let me go to an area I know something about. The public’s view about the treatability of mental diseases is wrong. They think we have better treatments for most physical diseases than for most mental diseases. But, in fact, our treatments for manic-depressive disease or schizophrenia are more effective per dollar than our treatments for heart disease. I think the public should be involved in making choices, but I think those choices have to be informed by the knowledge we’ve developed rather than by the myths they’ve learned from previous generations. Oregon tried to put together a system that would mix both public belief and scientific knowledge. And I think that’s a reasonable way to do it. I think that might lead to changing the rank order of priorities of what we provide and what we don’t so that, although there’ll be pain, it’ll be less painful at the same cost.

HEFFNER: Well, while we were very much involved in disputing one way or, on one side or the other, the Clinton proposals, Oregon was developing its plans. But I haven’t seen very much of a report on Oregon.

MICHELS: Well, let’s go back to the Clinton proposals, because what’s happened, of course, in the middle of, or at the end of a major national dialogue about whether or not we should have a total revision of our HealthCare system, the public became concerned and frightened about: A) the size and complexity of it; and B) what they might lose as this went forward. And the system came to nothing. Except that’s an event in a long-term process, one that started before and is continuing after. We shifted at that point from public process to a market process. The whole process of the evolution of managed care and of the role of major insurers and large providers of HealthCare replacing the cottage industry of individual patients and doctors negotiating with each other. And those changes have had a dynamic of their own not driven toward developing the optimal system, but toward following market principles as a system evolves. An imperfect system. A system that we pay a heavy price for in some areas, but gain efficiencies in other areas. I think that system is shaking a lot of the inefficiencies out of our prior system, but it’s not solving some of the basic ethical dilemmas of care for the uninsured, and of an adequate level for our community. But it may allow us to solve them more effectively because of the resources that’ll he conserved through the efficiencies it’s creating.

HEFFNER: Please spell that out, the marketplace, its advantage.

MICHELS: The old system of HealthCare – and “old” in this case is a few decades ago – was largely a cottage industry: individual physicians, practicing alone, took care of patients who rang their doorbell. Nobody was concerned about the total health of the community, and nobody monitored the expense of the total system. The result is our health expenditures exploded. They were taking over 10, 11, 12, 13, 14 percent of our gross national product. And it became too big of a problem to ignore. As we’ve attended to the problem, one quick way of stopping that explosive growth was to shift from a cottage industry to highly organized delivery systems of multiple doctors and hospitals and providers who get together and rationally construct the way they do business, and patients who are banded together, often by other organizations, to contract with those large providers. That gives an industrial efficiency to the whole system that was lacking before. It probably raises the lowest level of care, because nobody’s working alone or in isolation, and people are looking over each other’s shoulders. But it probably lowers the highest level of care as the virtuoso practitioners are burdened by their administrative responsibilities and the monitoring of what they do. It also funnels a lot of resources from the system into the market where HealthCare is a major growth industry in our stock market. How we can keep those resources doing good for the country, and how we can make sure that the upper edge of care is maintained as much as possible, and how we can preserve the humanity and dignity of the old system while promoting the efficiencies of the new system, are the problems of the first decade of the next century.

HEFFNER: Well, of course, we come to an end of this program as we begin the problems of the first decade of the next century, so you’ve got to stay where you are so that next week people can hear how we’re going to resolve those problems.

Thanks so much, Dr. Robert Michels, for joining me today.

MICHELS: Thank you, Dick.

HEFFNER: And thanks too, to you in the audience. I hope you join us again next time as well. If you would like a transcript of today’s program, please send $4 in check or money order to: The Open Mind, P.O. Box 7977, FDR Station, New York, NY 10150.

Meanwhile, as another old friend used to say, “Good night, and good luck.

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.