Paradoxes of U.S. Health Care System Have Complex Social Origins

Special Issue of ASA journal explores 100-year evolution and future of American health care delivery and related public policy

by Donald W. Light, University of Medicine & Dentistry of New Jersey*

The American health care delivery system is one of the most complex “non-systems” in the industrialized world, but its unique strengths and weaknesses originate less from the demands of medical necessity and economic efficiency than from embedded vested interests, many of which are examined in depth in a special end-of-2004 “Extra Issue” of ASA’s Journal of Health and Social Behavior (JHSB). [See accompanying sidebar.] Generously sponsored by the Robert Wood Johnson Foundation, and co-edited by Ivy Bourgeault of McMaster University, this issue delves into the sociological origins of our nation’s highly commercialized health-delivery “system” and analyzes fundamental institutional dynamics that must be addressed by any realistic reform efforts.

Odd Mix

American health care is an odd mix of many disparate players with sometimes contradictory goals. For example, it features competing hospitals, physician groups, labs, and other services each trying to maximize revenues and profits; consumers (sometimes known as patients) being bombarded with warnings and inducements to purchase more care, drugs, and tests; managed care plans trying to control costs while generating a profit; voluntary, competitive health insurance for defraying the high costs of medicine; and public programs attempting to fill the more egregious health care gaps for Americans. Policy leaders worry about the rising number of uninsured (about 43 million and increasing by about 3,000 each day), families who suffer medical-expense-induced bankruptcies, and businesses that are made less competitive in international markets because of high health insurance costs they incur on behalf of employees.

100 Years in the Making

What’s to be done? Leading sociologists do not have easy answers, but part of the impetus for this special JHSB issue was to have sociologists offer key relevant insights and fact-grounded overviews. For example, early forms of competitive, cost-effective managed care arose about 100 years ago, according to the centennial history that is the opening feature article in the special issue. And organized medicine took great offense and mounted a multi-prong campaign to stop the development of managed care and to build a regulatory fortress that would protect physician autonomy. “No middlemen” was the American Medical Association’s (AMA) driving theme. Professional medicine dominated for decades and developed its ideal type of health care: private, clinically and financially autonomous, hospital and specialty based, and voluntary. But what I call the “ironies of success” became increasingly evident, first by the 1920s and sharply by the 1960s: a paucity of public health and primary care; upward spiraling costs and elaboration of subspecialty services; large proportions of unnecessary tests, operations, hospitalizations, and prescriptions; medical impoverishment for millions—a particularly American form of poverty. Professionalism (the new movement today to rescue the profession from itself ) has yet to recognize its own institutional and clinical consequences.

“Countervailing powers” is a concept used by several authors in the journal issue’s 10 feature essays; this is a sociological transposition of John Kenneth Galbraith’s economic term. As the organizational payers of the bills, governments and employers constituted one countervailing power to providers, as did insurers when the latter’s agents arose after the 1940s. Patients, as special interest groups and as consumers, are a fourth. During the era of professional dominance, the AMA and state societies designed insurance to be a passive middleman, recruited governments to protect them from unwanted forms of competition, and fostered strong allegiances with patients.

Professional Autonomy

But when Congress and employers got serious about holding down costs and questioning the value of services, institutional transformations began to happen. Insurers and Congress developed a growing number of ways to monitor and manage care. Larry Casalino, a practicing physician and sociologist, analyzes in his JHSB article how the medical profession was handed the unfamiliar tasks of both controlling costs and improving the quality of care for patient panels by health plans that claimed jurisdiction over clinical care. Consumers would not stand for these efforts to develop cost-effective, rationalized care, and David Mechanic’s essay analyzes the backlash that now leaves payers stymied. The clash between countervailing powers has manifested itself in developing clinical practice guidelines, though professional organizations have ended up developing most of them. In their essay, Stefan Timmermans and Emily Kolker examine the implications for professional power and document a more complex picture in which professional autonomy is still quite prevalent.

Awkward Misalignments

Such awkward misalignments between values, regulations, and concepts of reality—the three pillars of health care’s institutional framework—worry Carol Caronna in her incisive analytical essay about what policymakers are facing today as the countervailing powers battle it out. Martin Kitchener’s and Charlene Harrington’s article examines the institutional dynamics that have transformed nursing homes and home health care into for-profit industries. Universal health coverage is one of the victims, as Jill Quadagno explains in her original analysis of why the United States is uniquely unable to assure its citizens that health care is a right—and also that getting paid is a right of doctors and nurses for doing their work. One can see how the misalignment of values, regulations and cognitions complements the analysis of countervailing powers. These problems of misalignments and lack of consensus are the key policy challenges for improving the U.S. health care system.

Addressing the excesses of professional dominance by turning health care over to for-profit companies has been a tragic mistake in my view. When quarterly profits depend on lowering costs, patients can become victims, and cost-shifting creates the illusion of progress. Exporting U.S.-style corporate-based health care has grown as profit margins here narrow, spreading our self-created tragedy to other countries by selling the promise of “managed care” to well-squired foreign leaders as the modern way to manage their health care systems. A team led by Howard Waitzkin, also a physician-sociologist, documents the results in their JHSB essay. But the biggest new market is the medicalization to overcome normal variation (e.g., being too short, shy, anxious, grumpy, old, or sexually unsatisfied). Peter Conrad, with co-author Valerie Leiter, extends his distinguished series by showing how corporate medicalization has eclipsed earlier professional medicalization in raising expectations of perfect health. Why shouldn’t you be your perfect self all the time?