Mismanaged Care

The New York Times, April 8, 2007

By Sally Satel

SICK: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price. By Jonathan Cohn. 302 pp. HarperCollins Publishers. $25.95.

The timing of this book is perfect. An epidemic of anxiety over the cost of health care has catapulted reform back onto the national agenda, and states from California to Massachusetts are now experimenting with universal coverage. It also promises to be a key issue in the 2008 election.

In “Sick,” Jonathan Cohn, a senior editor at The New Republic, lucidly shows how America’s system for financing medical care helps determine who gets proper medical attention — and who doesn’t. He tells this story through the experiences of ordinary people, like Cynthia Kline, a 55-year-old teacher in Cambridge, Mass., who suffered chest pain one afternoon and knew from prior experience that she was having a heart attack. She phoned 911, and when the paramedics arrived, Kline told them to take her to Mount Auburn Hospital, a nearby facility known for its intensive cardiac care unit. But since the emergency room there was full, the paramedics sped her to another facility, even closer than the first, only to discover, as Kline herself evidently suspected, that she needed an emergency catheterization — a procedure the staff at the second hospital was not able to perform. Two and a half hours after dialing 911, Cynthia Kline was dead.

This true-life story, at once disturbing and illuminating, encapsulates the larger drama of a failing system. “Overcrowding in E.R.’s, according to most experts, is actually a symptom of other systemic problems now plaguing medical care,” Cohn writes, “from the downsizing of less profitable hospital services such as psychiatric wards … to the swelling ranks of people without health insurance, whose untreated chronic conditions are more likely to become serious medical crises.”

“Sick” is an account of the author’s listening tour, which took him across the country. In Austin, he met a young mother whose managed-care provider refused to cover physical therapy for her developmentally disabled toddler. In Deltona, Fla., there was a self-employed woman with diabetes who fell prey to an insurance scam. In Chicago, a former nun living in poverty told Cohn how she tried but failed to obtain charity care at a Catholic hospital.

By the end of Cohn’s narrative we’ve run the gamut of woes: the hopeless fragmentation of the mental heath system; staggering medical debt; the dependence on job-based insurance; frayed social safety nets; lousy (or no) guarantees of preventive care; selective access to medications. Lack of insurance is a meaningful problem, too, especially for the mentally ill. But since 80 percent of all emergency room visits in 2004 were made by people who had at least some form of coverage, the problem can’t be pinned solely on insurance.

The hand-picked subjects in “Sick” don’t reflect the full range of causes for so much poor health in this country, many of them rooted in inertia: not watching one’s diet or exercising, drinking to excess, smoking. Cohn’s victims are in almost every instance hardworking, conscientious people blocked at every turn by a dysfunctional system. Thus, even as he vividly brings them to life, Cohn cautions that their stories “are not so much representative as indicative,” meant to show the perils faced by people “when their need for medical care overwhelms their ability to pay for it.” But “Sick” is much more than a meticulously drawn and moving compilation of crises. It is also an edifying primer on how we got here. To fine effect, the author weaves summaries of health care history into the case studies. He traces the developmental arcs of key institutions, like private insurance, employer-linked insurance, managed care, religious hospitals and corporate health care. We see Blue Cross and the first prepaid group practice in the bloom of their youth when idealism was high and implementation relatively straightforward. They flourish for a while but then decline under the weight of a troubled manufacturing economy, bottom-line imperatives of corporate health care, the rising cost of medical technologies and changing definitions of what constitutes basic benefits.

Cohn also reminds us that efforts to enact a national health policy have been a staple of presidential politics in the past century. In the 1930s Franklin D. Roosevelt wanted to pursue a universal health insurance plan (as Theodore Roosevelt had done during his failed presidential bid in 1912, although Cohn doesn’t mention it) but feared opposition from the American Medical Association and from state medical societies. Harry S. Truman had the same idea, only to meet resistance from union leaders concerned that members’ benefits would decrease under a national system. A quarter-century later, President Nixon proposed an employer mandate to insure workers, and in the early 1990s we lived through the drama (and trauma) of President Clinton’s thwarted reform effort.

“Sick” does not offer a prescription for our ailing health care system, but it does include a closing chapter on what to do. Here the argument turns tendentious. Critics of universal coverage, Cohn writes, often traffic in alarmist tales “about rationing and waiting lines, followed by a horror story from Britain or Canada.” Those complaints are “wildly exaggerated” and also unfair, he says, because the problem is not the result of universal health care but “of universal health care on the cheap.” But Cohn is himself being unfair when he sweepingly denounces “the principles of modern conservatism” for being “conspicuously short on … comfort or hope.” In truth, there is nothing inherently pessimistic in choice, self-reliance or limited bureaucracy — the values that underlie a market-based proposal like the one introduced by Senator Ron Wyden, an Oregon Democrat. In this plan, employers would no longer provide insurance and would instead convert those costs into a bigger paycheck, enabling workers to buy private insurance from providers who would then be forced to compete for business by offering better plans. (Wyden’s proposal also offers subsidies for the unemployed.)

Cohn prefers the French health care system, calling it the “showcase for what universal health care can achieve.” His brief description does indeed make the French model, which is largely single-payer, look attractive. But since we are not given enough details — an inevitable feature of a book that devotes only a fraction of its content to solutions — the reader is left to take the author at his word.

Nor does Cohn fully consider fundamental questions. For example, can a health care market ever function like a regular market? Is it wiser to upend the entire system or concentrate on creating conditions that free the states to innovate on their own? Should we make private markets work better, or increase government involvement?

It’s a pity that Cohn doesn’t adequately address these questions, because they are critical to the issue of health care reform — particularly for Americans, who historically have had a deep-seated aversion to centralization (as Truman found even among powerful unions).

In any event, meaningful changes in health care, at least at the federal level, will surely follow the incrementalism that marked policy changes in the Clinton years. Of course, incrementalism, too, can lead to a health care revolution. And Cohn’s important book may bring us closer to that day.

Sally Satel, a physician, is a resident scholar at the American Enterprise Institute and co-author of “One Nation Under Therapy.”