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Current Health Care System Policy for Vulnerability Reduction in the United States of
America: A Personal Perspective
Edward J. EckenfelsRush Medical College, Chicago, Ill, USA Aim. To raise questions about how the United States of America - which spends 1.3 trillion dollars on health care, con-
ducts cutting-edge biomedical research, has the most advanced medical technology, and trains a cadre of highly com- petent health professionals - cares for the most vulnerable members of its population.
Methods. Relevant statistical data were extrapolated from the most current statistical sources and research reports, and
assessed in terms of existing practices and policies.
Results. The data clearly demonstrated that particular population cohorts - the elderly, the poor, new immigrants, the
homeless, the HIV-positive, and substance abusers - were especially vulnerable to illness and its consequences.
Conclusion. Since American medicine, despite all of its science, technology, and clinical competence, operates in a
"non-system," there is currently no efficacious approach to vulnerability reduction. To turn health care in the U.S. into a high quality, comprehensive, and cost-effective system, government officials, health care planners, and medical practitioners must address a series of fundamental social, economic, and political issues. What other countries, like those in South Eastern Europe, can learn from this is not to duplicate these mistakes.
Key words: academic medical centers; cost-benefit analysis; delivery of health care; health policy; health maintenance orga-
nizations; health services accessibility; insurance, health; poverty; public health; United States Any attempt at proposing a policy for vulnerabil- less, persons with acquired immunodeficiency syn- ity reduction in the U.S. must address an initial ques- tion: How can the world's wealthiest and most pow- erful nation - the United States of America - have anyone who is "vulnerable" when it a) spends 1.3 tril- The most rapidly growing population in the U.S.
lion dollars (US$4,400 per capita) annually on health is the elderly - those 65 years of age and over (7). Cur- care (1); b) has the National Institutes of Health with a rently, there are about 27 million people in this cate- budget of over 23 billion dollars annually to conduct gory that makes up about 12% of the total population.
biomedical research (2); c) has 125 academic health Sixty percent of them are women. There are 3.2 mil- centers where doctors, nurses, and other allied health lion who are 85 and older. With an aging population, personnel are trained and the latest medical proce- there is an increase in vulnerability, especially with dures performed on a routine basis (3); d) has 5,810 respect to heart diseases and cancer - the leading hospitals with 983,628 beds (almost three beds per causes of death. The very old (over 85 years of age) person) (4); e) has approximately 777,000 physicians, are also vulnerable to falls and other kinds of physical over 2 million nurses, and over 10 million personnel accidents. As people grow old, they also become less in the health care workforce (5); and f) and has a gov- mobile, and in many cases, they require home health ernment-sponsored public health system dispersed care and placement in a long-term care setting.
The PoorAccording to the census 2000, there were over Categories of Vulnerability
31 million people (11%) in the U.S. below or at the poverty line (8). A rough estimate of poverty thresh- Nonetheless, even with such an all-encompas- old in the U.S. is about US$17,600 for a family of sing and costly health care system, it is still possible to four. The poverty threshold is based upon the cost of a identify particular groups that are most susceptible to nutritionally adequate diet for a family of four, which illness on the basis of current statistical and research is then multiplied by a factor of three, since it is esti- reports. The most prominent categories of vulnerabil- mated that a family expends about one-third of its to- ity are the elderly, the poor, immigrants, the home- tal income on food. Poverty is concentrated among Eckenfels: U.S. Policy for Vulnerability Reduction ethnic minorities, women, and children. About one paid for by the employers of working families (14).
out of five African American or Latino American fami- Health insurance companies, over 300 of them, man- lies is poor, and 41% of all families headed by age the payments to the health care providers, many women live in poverty. For immigrants, the figure is of whom work in medical service settings called 16%. Over 17% of those in poverty are children and Health Maintenance Organizations (HMO). Retired people get most of their health care paid for by Medicare, the federal government's Social Security fund that comes from joint contributions of the em- Since 1980, more than 18 million immigrants ployer and employee (1). Medicaid, another govern- have come to the U.S. (9). That is more than "the great ment-funded program, is the primary source of health immigrant wave" that came at the turn of the last cen- care provided for the poor (1). The result of this highly tury. Most immigrants are from Southeast Asia, Cen- complicated and costly system is that over 40 million tral and South America, and Eastern Europe. There are people are without health insurance (15). A large part an estimated 3-5 million illegal aliens; most come of this group is what we call the working poor - they from Mexico and Central America, crossing the work at minimum wages or part time and do not get southern borders of the U.S. Although all immigrants health insurance as a benefit of their job.
cannot be characterized as vulnerable, new arrivals tend to be ignorant of how to use the complicated U.S. health care system. Furthermore, there is essen- Not everyone in our health care system has tially no access to medical services for the indigent il- equal access to health services (13). This circum- legal aliens and for any health services they receive, stance is a function of a number of things. In rural ar- eas, for example, you have to travel a great distance to get to a doctor or clinic, and the hospitals are small and not well equipped. If you do not have the appro- The homeless in the U.S. live on the streets, beg priate insurance or the cash to pay for expensive treat- for survival, and are susceptible to alcoholism and in- ments, you simply do not get them. In large urban ar- fectious diseases (10). A conservative estimate is that eas like Chicago, there are some hospitals and clinics about 2 million people are homeless at some time for the indigent - the poor who cannot afford to pay - each year, with 20% of them being children. On any but they are over-crowded and require long waits not given night, there are about 600,000 in homeless only to have complicated technical procedures per- shelters or sleeping in the streets.
formed but to see the health care professional.
The AIDS epidemic was first identified in the Quality of care varies widely in the U.S. by re- U.S. in the early 1980s (11). What started as primarily gion (e.g., North vs South), by state (e.g., Mississippi an illness concentrated among homosexual men vs California), by type and size of community (e.g., spread to IV drug users, and now is transmitted het- large urban metropolis vs. small rural hamlet), and erosexually as well. There are between 750,000 and even within communities (e.g., inner-city ghetto vs af- one million people in the U.S. who are HIV-positive.
fluent suburbs). The best health care professionals Over 400,000 have died of AIDS. Drug therapy is ex- tend to work in the academic health centers and ma- tremely expensive and costs around US$15,000 a jor hospitals. If you are well-insured, wealthy, and can afford the latest procedure or technical innova- tion (which is probably not covered by your insur- A national survey conducted in 1999 found that ance), then you can choose where you go for health over 14 million people over 12 years of age (7%) had used some form of illegal drug within the past month (12). Hard drugs - cocaine, heroin, and crack - are easily accessible. The rates of addiction are higher Unfortunately, the public health system has among African Americans and Latino Americans.
some serious problems (6). Its major role in the pri- Treatment is sporadic, facilities are poorly funded, vate health care system is to serve as a "safety net" for and the War on Drugs has turned abusers into crimi- those who slip through the cracks. Since the public health system is not a medical service or curative sys- tem, it focuses essentially on prevention, particularly in the area of immunization. But this also varies from Causes of Vulnerability
state to state or region to region because the financial But still, with such a highly sophisticated and support of public health agencies is dependent more technological health care system, how can anyone, on state than on federal funds. One shameful result is even these groups, become vulnerable? A part of an that one out of every five children is not vaccinated answer to this question lies outside the health system (immunized) at the minimum requirement when they per se and is in the economic, social, and political start school. Public health clinics have tried to have some impact on controlling chronic disease by offer- ing free blood pressure measurements and medica- tions, health education materials, and the like but The average annual cost of health in the U.S. is without any really systematic approach. The U.S.
around US$4,400 per person (1) and almost 90% is Public Health Service does administer health care Eckenfels: U.S. Policy for Vulnerability Reduction programs for migrant workers and oversees the U.S.
center. If the patient cannot afford this kind of care or Indian Health Services, which was established to pro- does not have access, he or she is left out. "De- vide free health care for Native Americans. The health mand-side" thinking, which concerns the patient and departments of each state and major cities are also re- the health expectation, needs, and trends of commu- sponsible for sanitation control in terms of clean wa- ter, uncontaminated food, and sanitary restaurants.
The system must move from a supply-side orienta- This is one of their major contributions to our health tion to a demand-side approach (19). The latter takes into account societal needs and creates a system that responds to those needs through concerted efforts by Issues to Be Addressed
health professionals, politicians, and the public.
The combination of all these factors presents the essential paradox of American medicine: all of our Such a system promotes two or more delivery science, technology, and clinical competence oper- systems - one for the haves and another for the ate in a "non-system." If we are to provide compre- have-nots, and no system at all for the truly disadvan- hensive, quality, and cost-effective care, then some taged (20). It is obvious where the best health care is provided. Some communities are without access to any health professionals or hospitals.
The system is riddled with fragmentation (16).
A single-tiered system should be established that Not only is not everyone covered by health insur- gives access to comprehensive quality care to every- ance, but services are fragmented as well. For exam- one, regardless of income, race, ethnicity, or country ple, mental health services are not funded except for of origin. Along with social justice, equality is a fun- psychosis or suicidal intent. Also, without the proper damental principle of a democratic society. Again, insurance coverage, many patients do not have ac- there are strong social, economic, and moral argu- cess to tertiary care procedures, such as open-heart ments that suggest a single system would be more surgery. Fragmentation can be ended by instituting a cost-effective, easier to administer, and less compli- system of universal health care that includes costs as well as services. There are many well thought-out proposals and well-documented studies that demon- The system is run like a business and health care strate the efficacy of such an approach. The U.S. is the is considered a market commodity (13). Compassion only country in the West that does not have some and empathy are too often left out of the equation. Ef- ficacy is measured in terms of how many patients you see (the more the better), how much time you spend The system is cost-ineffective (17). Some proce- with them (the shorter the better), and how much in- dures are prohibited by high cost, and redundancy surance coverage they have. The same approach ap- and duplication are rampant. Due to lawsuits and the high cost of malpractice insurance, many physicians Health care in a democratic society, like public practice defensive medicine by putting the patients education and participation in the political process, is through meaningless tests and uncomfortable proce- a right, and, as such, should not be treated like a mar- dures. The salaries of administrative executives are exorbitant - in some cases, in the millions. The sala- ries of specialists continue to rise at a higher rate than A career in medicine has become very much an inflation (the norm for surgeons is over US$300,000), individualized profession. Your own needs - family, whereas those of primary care and family doctors re- lifestyle, and status - come first; those of the patients come next. Personal achievements are emphasized Cost can be reduced dramatically by controlling over social responsibility. Future health professionals duplication and redundancy. A fair and just tax sys- need to be made aware in the course of their educa- tem in which those with the highest incomes pay the tion that they have an obligation and responsibility to highest rates can take the burden from the small busi- serve as an agent of society, sponsored by society, to ness employer and spread costs around more equita- the society (21). This moral commitment does not mean that they have to forego their personal and pri- vate life. A sense of satisfaction and achievement in one's work compliments one's satisfaction in life (22, Since all of the technology and highly-trained 23). As Freud said, Lieben und arbeiten, "to love and professionals are housed in the large academic health care centers, the patient has to go there to get that kind of health care (3). These institutions function as Lessons to be Learned
independent citadels of power and self-sufficiency.
They operate primarily from a "supply-side" perspec- tive: since they are driven by new knowledge and A fee-for-service, private system excludes peo- technology, their resulting need is to find patients to ple, especially the most vulnerable, from needed fit the interests and technical capabilities of the spe- health care. Even with the best intentions, the most cialists and the equipment and services of the medical competent physicians will be drawn to a practice Eckenfels: U.S. Policy for Vulnerability Reduction where they can make more money. Inevitably, this there were some negative reactions as well. The cre- leads to a multileveled system, with those who can ation of new vaccines has been a financial windfall pay in and those who cannot out. The best guarantee for the pharmaceutical industry, one the greatest is to make sure that all health professionals are ade- profit-making enterprises in the world (27). Along quately paid. To reach the people who live in more with Viagra and other comfort medications, this con- isolated areas or in the poorest sections of the cities, it cern has become their highest priority while at the is necessary to make sure that the resources - person- same time one out of five children is not being immu- nel, equipment, and materials - are distributed suffi- nized. This is another example of what happens when ciently with special attention paid to the neediest market forces dictate what constitutes health care.
Since that horrendous atrocity five months ago, close to 1.8 million workers have lost their jobs (28). For them and their families, this also includes a loss of The public health system needs to be reinforced health insurance. In other words, almost 2 million with respect to immunization of children, the control people are joining the ranks of the uninsured.
of infectious diseases, and the monitoring of the phys- ical environment. In addition, public health agencies If there is one major lesson to be learned from all need the legal and political authority to take action of this it is that we are all vulnerable - even those of when the situation warrants it. Primary prevention us in the richest and most powerful country in the should be integrated throughout the system with ma- world. If we are all vulnerable, then as Dostoevsky jor campaigns directed at children when it comes to says, "We are all responsible for all." smoking and drugs. Also public health practitioners must teach each patient the importance of a healthy References
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