Chapter 4: End of Mandate

This Chapter goes over the history of American medicine in the 1970's. Starr states that there were three different political "Revelations" that occurred through this decade. The following will summarize key points of the 1970's by way of these three revelations.

The First Revelation: Crisis
As a result of the expansion and increase in the medical field throughout the 1960's, the 1970
s was faced with a need to cap ongoing expansion that was now resulting in high costs and depletion of resources. Politicians in the early 1970's recognized these problems and openly stated that American medicine was now in a state of "crisis." A possibility for national health insurance reappeared as both conservatives and liberals began to believe that such a plan could resolve the "crisis of money."

There were several reasons behind rising health costs

• government share of health costs had increased
• rising health costs of Medicare and Medicaid -- as research& technology increased, more money was needed to provide the "best" services to patients, which they had come to expect
  
• fee for service reimbursements allowed doctors and hospitals to charge high prices for services, requiring employers to pick up the difference for their workers and the government for the poor

These problems are summarized by Starr, "Patients want the best medical services available. Providers know that the more services they give and the more complex the services are, the more they earn and the more they are likely to please their clients." This idea led to overuse of services, over prescribing of services, etc. that led to unneeded costs. Furthermore, over expansion of services was not the only problem that stemmed from this ideology. "The incentives that favored hospital care promoted neglect of ambulatory and preventive health services." Furthermore, there was less money available for the public sector (voluntary hospitals, etc.)

Rising costs led many to be wary of physicians and other medical professionals. There was a sort of "revolt' against medical professionals. Major changes occurred:

• Patient's rights were created via the the Patient's Bill of Rights and the individual creation of other rights "in health care," such as right to refuse treatment, were created.
• Women's rebellion against modern medical professionals.
  
• The most radical change was when women began to take medicine "back into their own hands" -- alternative abortion clinics were started, midwives popularized, etc
• Return of Alternative Medicine

And, most importantly, for the first time, the doctor was now seen as a "villain."

This new revolutionary thought that went doubted medical professionals' credibility along with the recognition that high medical costs needed to be tamed led to a dire need for government intervention.

The beginning of the 1970's was also characterized by a series of legislation geared towards regulating medical control. The main things created were: government HMO's, National Health Planning, and PSRO's. There were all agencies created to control costs.

Another major try to regulate medicine were two different plans for a national insurance plan. One was created by President Nixon and his administration and one was backed by Senator Kennedy. However, neither actually came to be.

The Second Revelation: Therapeutic Nihilism
The series of legislation halted in the mid 1970's when the U.S. was faced with recession and inflation. The U.S. government found itself herded in by the multitude of legislation it had just passed in just four short years. Despite the legislation, which was passed in part to help control costs, the recession disabled the government from passing any further reforms in fear of depleting national funds. Additionally, government officials realized that further legislation would continue to eat up more and more time. Not only does the legislation, itself, take an "inexorable" amount of time to bring into reality, but there was also a growing pattern of litigation following any government legislation. In short, the U.S. no longer had the time or money to continue bringing about new legislation as it had in the first half of the 1970's.

The government agreed to bring about an HMO project in hopes of controlling costs as an experiment. In the final version of the legislation, the new plan called for "low subsidies and high requirements" of the HMO's. These requirements proved damaging. Employers were hesitant to use HMO plans because they were "uncertai[n] about which plans would qualify under the statutes." Also, "neither the capital nor the management skill swere readily available" to put HMO plans into place. Thus, in the end, this plan failed, just like other health care reform at the time.

These failures led to severe down of the medical system in the U.S. As Starr states, "the 19th century doctrine of therapeutic nihilism-- that existing drugs and therapies were useless-- was revived in a new form. Now the net effectiveness of the medical system as a whole was called into question." The American public saw that an inordinate amount of money was being spent on medicine -- research, legislation, etc. -- but little differences were made. There were now doubts about whether we really need medicine. Many stated that, while modern medicine had been good before this time, the population was now so healthy that medicine would no longer effect mortality rates. Critics now wanted to put "greater emphasis on changing unhealthy individual behavior."

Thus, there was a severe shift in thinking where, in general, Americans believed there was now a need for cost control. For the first time, both Right and left wing politicians agreed with this notion. Once again, there were different proposals for a national health insurance plan (one from President Carter and another from Senator Kennedy); however, both proposals were unsuccessful, being deemed implausible and/or too expensive.

Fortunately, some of the programs set up in the early 1970's, now proved fruitful in the late 1970's. The new planning programs that had been put in place were helping cost control. The HMO's began to do well; although they were not as successful as the Nixon administration had hoped. "Reform had succeeded in many original aims to improve access to health services." However, the tides were still turning and politicians were "on the defensive, while health care providers denounced the excesses , duplication, and irrationality of government." The industry was now "criticizing the inefficiency of reform."

Despite the heightened recognition about "the irrationality of [the health care] system, the financial insecurity it created, and its effects on the use of primary and preventive health services," no concrete health care reform or solutions were successfully put into effect in the late 1970's.

The Third Revelation
By the late 1970's, there was a final shift in thought -- "the problems of health care in America could be cured by relying on competition and incentives, if only the government's role was reduced to a minimum." When Reagan took office, he wanted to immediately "abolish the HSAs and PSROs, to consolidate federal health programs, and to "cap federal support for Medicaid." Despite this ambitious plan, there was still opposition for physicians and hospitals. These parties welcomed less regulation from the government, but did not want to see cutbacks on their federal funding. Due to such opposition, the Reagan administration backed away from their "competetive approach."

In the end...
Thus, we see that there were three clear revelations throughout the 1970's. In the beginning, there was a need to quickly slow down progression of medicine that had been so popularin the 1960's. Then, recession and inflation in the mid 1970's led to a halt of legislation that ensued earlier in the decade. Finally, towards the end of the decade, America finally realised the need for severe cost containment of medicine. However, no legislation was able to be passed due to impeding factors.

Another general theme throughout the decade was a clear distrust for medicine. It began as individuals began to question doctor's and their motivation for working. In the beginning of the decade, patients insisted on finding ways to "protect" themselves from doctors, which gave way to the "Patient's Bill of Rights" and other rights in health care. After this, there came a general distrust for the entire field of medicine. Americans questioned whether we really needed medicine to protect our health anymore. I believe this embellished way of thinking stemmed from a momentary panic when Americans were struck by the large amounts of money the medical field was eating away. Finally, perhaps there was a return to a somewhat more clear-minded way of thinking in the late 1970's, as government officials began to focus on how to contain exceeding medical costs.

Either way, it is interesting to see what happened when, for perhaps the first time in American history, doctors and medical professions were not hailed as national heroes. Medicine was put on the defensive. Past strategies of simply campaigning against or sabotaging legislation or movements that impeded their self "autonomy" did not work anymore. Doctors were now, or so it seems, willing to compromise as they too noted the excess present in medicine.

Another interesting first was how, in just a short time, the government used three different strategies to control medical costs. I don't think I've seen such hurried strategies in this entire book. Three different presidential administrations (Nixon, Carter, and Reagan) all had different ideas on how to control excess in medicine and each at least tried to pass its own legislation early in the presidency.

Obama and 2009
My final point brings me to the Obama administration. Like the 1970's, this presidential administration, too, is working to quickly pass health care reform. One of the main reasons is to curb unprecedented costs in medicine. I am very interested to see how this reform will turn out.