Posts Tagged 'rationing'

It’s 2003 and healthcare’s in crisis. Are workers and business in this together?

The following is a leaflet distributed at the American Public Health Association convention in the fall of 2003, six years ago.  It seems  pretty relevant today, given the current health reform legislation, with its emphasis on cost reduction for business and government, its incentives to make us pay more for less healthcare while securing sustained profits for insurers, drug companies and hospital chains, and its reliance on cuts to Medicare to fund the whole plan.


Obviously, healthcare is in crisis, but really there are two parallel health care crises.

For us, patients and providers, the health crisis is: 43 million uninsured, “patient driven” insurance that shifts costs to patients through high co-pays and inadequate benefits, a safety-net in tatters, a critical shortage of health workers, a hospital system rife with dangerous mistakes, and the worst health indicators in the industrialized world.  It’s clear to us that something must be done.

Business has a completely different health crisis: falling HMO and health insurance profits, rising and uncontrollable health costs, strikes and near-strikes over cuts in employee coverage, millions of ageing baby boomers with expensive diseases on the horizon, an uncertain recovery, huge federal and state budget deficits, and costly open-ended war ahead.  From their viewpoint, too, something must be done.

We need high-quality, comprehensive, single-tier, universal, government-financed healthcare.  Business needs to lower its operating costs as much as possible. We believe these are conflicting imperatives, which do not point to the same solutions.

Obviously, a huge segment of the corporate world wants to keep health insurance and high-priced drugs as part of the health delivery system because it’s a profitable commodity.  That sector is busy planning multi-tier “universal health coverage” where the uninsured get vouchers to buy new stripped-down health plans that could be profitable.  This plan was advocated in a recent NY Times Op-Ed piece (11-18-03), a SF Chronicle interview with Kaiser’s CEO (11-16-03), and is a plan proposed by California Blue Shield, which has hired hundreds of workers to handle anticipated new policy holders.

But what about the rest of the corporate world, businesses whose profits are reduced by bloated healthcare profits?  Could they help get single payer?  Some single-payer advocates say cracks are forming in the wall of corporate resistance. High costs and strikes are making some think twice about single payer. There are even policy-makers who worry that the dominance of the health and drug industries weakens the manufacturing sector, which could compromise national defense in time of major war.  Does all this make those businesses our ally?

We think not. For this sector of the economy, workers’ healthcare is a cost of doing business, like maintaining the machinery. Business will try to reduce health costs whether they are paid as direct benefits or as taxes under single payer.  They certainly have tried to reduce other tax-supported health programs like Medicare and Medicaid.  It should not stretch the imagination to foresee how business could turn the intense centralization of universal single-payer health care to their own advantage, and make it a mechanism for severe rationing of healthcare.  For example, the stripped-down “basic coverage” schemes that the insurance industry is presently designing for the uninsured will require standardization and government approval.  Once that happens, business will push to have “basic coverage” be the standard for patients under single payer.

For years, business hasn’t given a damn about people not having medical insurance.  Since the early 1980s they’ve laid tens of millions of us off, cut millions of current workers and retirees off medical benefits, and made their coverage so expensive that millions cannot afford it even when it is offered.  So you’ve got to suspect something is fishy when they start being so concerned about whether we have medical insurance.  We saw what happened when they were concerned with seniors not having prescription coverage.  They bundled in a plan to dismantle Medicare!

Our healthcare should be neither a commodity nor a cost of doing business.  This is a period of tremendous collision of people’s needs and aspirations versus corporate needs and demands.  The movement to end this disgraceful situation will involve a tremendous fight.   As Quentin Young said, getting good healthcare will be as big a struggle as civil rights.   Civil rights, Medicare, and Medicaid were all won by people who worked, their families, and people who would have worked if they could.  Their actions on the job, in their schools, organizations, churches, in the streets, and in the military challenged the US’s ability to govern and made the government produce the “Great Society” programs.  Although many of these gains have been erased in the intervening forty years, millions of lives were improved and the struggle remains as an inspiration and example of what is needed for deep reform of society.

We deserve nothing less than high-quality, comprehensive, single-tier, universal,  government-financed healthcare.  We have to be clear on what it will take to get it and who our allies are.

Concerned members of APHA

Unbiased studies dispute Obama, say more healthcare gives better outcomes

The Obama administration and health policy analysts advocating strong cost containment talk about how much money the nation wastes on needless tests and futile procedures, particularly in Medicare. They particularly cite hospitals that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.  Their data comes from a decades-long study, the Dartmouth Atlas of Health Care.  But Dartmouth’s approach counts only the patients who die,so the patients who who respond to additional care are not counted. Indeed a study of heart failure patients, both living and dead, showed the hospital that spent the most had one-third fewer deaths after six months of an initial hospital stay.  This rush for “efficiency” could result in rationing.  Also see Crusading Professor Challenges Dartmouth Atlas On Claims Of Wasteful Health Care Spending.

New York Times, December 23, 2009

Months to Live – U.C.L.A. Medical Center at Heart of End-of-Life Debate

Weighing Medical Costs of End-of-Life Care

A successful outcome

Dr. Tamara Horwich with Salah Putrus, right, and his brother-in-law, Fouad Abdulla. A change of drugs helped Mr. Putrus avoid a heart transplant.

LOS ANGELES — The Ronald Reagan U.C.L.A. Medical Center, one of the nation’s most highly regarded academic hospitals, has earned a reputation as a place where doctors will go to virtually any length and expense to try to save a patient’s life.“If you come into this hospital, we’re not going to let you die,” said Dr. David T. Feinberg, the hospital system’s chief executive.

Yet that ethos has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

Take the case of Salah Putrus, who at age 71 had a long history of heart failure.

After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was referred to U.C.L.A. this year to be evaluated for a heart transplant.

Some other medical centers might have considered Mr. Putrus too old for the surgery. But U.C.L.A.’s attitude was “let’s see what we can do for him,” said his physician there, Dr. Tamara Horwich.

Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues “did every test.” They changed his medicines to reduce the amount of water he was retaining. They even removed some teeth that could be a potential source of infection.

His condition improved so much that more than six months later, Mr. Putrus has remained out of the hospital and is no longer considered in active need of a transplant.

Because Dartmouth’s analysis focuses solely on patients who have died, a case like Mr. Putrus’s would not show up in its data. That is why critics say Dartmouth’s approach takes an overly pessimistic view of medicine: if you consider only the patients who die, there is really no way to know whether it makes sense to spend more on one case than another.

According to Dartmouth, Medicare pays about $50,000 during a patient’s last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

“One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical,” Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. “We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.”

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final year of life account for about a quarter of the program’s total spending.

Under the House health care legislation pending in Congress, the Institute of Medicine would conduct a study of the regional variations in Medicare spending to try to determine how to reward hospitals like Mayo for providing more cost-effective care. Hospitals identified as high-cost centers might even be penalized, perhaps receiving lower payments from the government. The Senate bill calls only for studies of Medicare spending variations, so it will be up to House-Senate negotiators to resolve the matter in the final legislation.

That prospect worries Dr. Rosenthal and his U.C.L.A. colleagues, who say that unless the distinction can be clearly drawn between excellence and excess in medical care, efforts to cut wasteful spending could be little more than blunt rationing.

“There’s a real risk of doing harm here — real harm,” he said.

Indeed, U.C.L.A. and five other big California medical centers recently published their own research results with a striking conclusion: for heart failure patients, the hospitals that spend the most seem to save the most lives.

Testing the Thesis

Dr. Rosenthal remembers a pivotal meeting back in 2005 when he and officials at the other California hospitals met with Dartmouth researchers to discuss their findings.

“We were inspired,” Dr. Rosenthal recalled, saying he found himself agreeing with much of the criticism aimed at his institution for its aggressive approach.

The Dartmouth analysis prompted Dr. Rosenthal to seek further data. He collaborated with colleagues at U.C.L.A. and four other medical centers affiliated with the University of California system, as well as Cedars-Sinai Medical Center in Los Angeles, to design a study of why some hospitals spent so much more on dying patients than others and what they got from their efforts.

To focus their analysis, the researchers chose to look only at a single category of patients: elderly people with heart failure. The dead would be counted, as Dartmouth does, but so would the living.

What they found seemed to contradict the Dartmouth thesis. The hospital that spent the most on heart failure patients had one-third fewer deaths after six months of an initial hospital stay.

The researchers did not disclose which of the six hospitals had the best results. But for the doctors involved, the implications were clear: spending more can sometimes save lives.

“It doesn’t look like it is all waste,” said Dr. Michael K. Ong, a U.C.L.A. internist and health policy researcher who was one of the authors of the study, which was recently published in the peer-reviewed medical journal Circulation: Cardiovascular Quality and Outcomes.

Another of the authors was Dr. Michael A. Gropper, a critical care specialist at the University of California, San Francisco. The Dartmouth research has consistently portrayed his hospital as much more cost-effective in end-of-life care than U.C.L.A. But the California study gave Dr. Gropper a new perspective. “There’s no doubt that additional investments may be worthwhile,” he said.

Some other experts take a similar view.

“If you only look at the failures, you miss the benefit,” said Dr. Peter Bach, an epidemiologist at Memorial Sloan-Kettering Cancer Center in Manhattan, who has examined the medical histories of cancer patients who have died, including women with early-stage breast cancer.

“No one in their right mind would tell you not to treat these women,” he said, “even though some of them will die.”

The California researchers say they also found much less variation among the six hospitals than the Dartmouth data would indicate after they took account of significant differences among the patients the hospitals treat, including the many patients who come to U.C.L.A. for a transplant, who are, by definition, extraordinarily sick.

Over all, the California researchers found that the variation in spending among the six hospitals was significantly less than the level reported by Dartmouth. When looking at all patients hospitalized for heart failure, for example, the variation in use of resources was 27 to 44 percent lower than when they looked at only the patients who died. And that corresponded with a separate, informal analysis of Medicare spending by the Congressional Budget Office, which after adjusting for the severity of illness in patients and differences in prices among regions, found less striking variations in spending.

A report from the Medicare Payment Advisory Commission released this month also found less variation.

Dr. Rosenthal, who argues that there are also fundamental socioeconomic differences between patients in the poorer sections of Los Angeles and those in the Mayo Clinic’s small and solidly middle-class hometown of Rochester, Minn., was co-author of an op-ed article in The Los Angeles Times last summer making that case. “Health care costs are significantly higher in areas of poverty,” he wrote.

The Dartmouth researchers tend to dismiss such counterarguments, saying their conclusion — higher spending does not necessarily buy better patient outcomes — is backed by decades of research. While more spending may have yielded benefits among these six hospitals, a Dartmouth official said, hospitals generally have not shown they deliver better results when they provide more care.

Still, Dr. Elliott S. Fisher, one of the lead investigators at the Dartmouth Atlas Project, acknowledged that the California researchers’ analysis might be better able than Dartmouth’s to identify cases in which more intensive care might prove beneficial. “Sometimes more medical care is better,” he said, “but the question is when.”

He says he believes that cost-effective hospitals with good medical outcomes should be financially rewarded for their efforts and results. But he says that public policy aimed primarily at penalizing high spenders would not be the solution. “Simply reducing their prices,” he said, “won’t fix anything.”

‘Hail Mary Pass’

Just how hard it is to determine who will most benefit from expensive care is clear in the case of George Klidaras, a 49-year-old stay-at-home father of two who arrived by ambulance late at night in mid-June in need of a heart transplant.

His age might have made him a good candidate for the procedure. And so might his overall state of health. He was lucidly answering doctors’ questions when he arrived. And although he had suffered a stroke in his early 40s and had a chronic heart condition, as recently as March, Mr. Klidaras had been living a relatively normal life.

By the time Mr. Klidaras arrived at U.C.L.A., though, his heart had weakened significantly. In the preceding weeks he had already received a pacemaker and defibrillator, and his local cardiologist decided it was time to ask U.C.L.A. — a highly regarded transplant center and regional magnet for cases beyond the skill of many other hospitals — to tackle his case.

Coming to U.C.L.A. “was our Hail Mary pass,” said his wife, Andra, a postal worker.

Mr. Klidaras’s lungs were damaged from a pulmonary embolism, and he had a high white-blood-cell count — a possible sign of infection. So the first order of business was to try to determine the source of infection so he would be well enough to undergo surgery.

The flurry of activity in the intensive care unit was “overwhelming,” Ms. Klidaras recalled. Her husband saw a dizzying array of specialists, including an infectious disease doctor and a dermatologist after he developed a rash. “They gave him every antibiotic and every test,” she said.

Mr. Klidaras spent nearly five weeks in the intensive care unit, at a cost of about $10,000 a day and a total cost in the neighborhood of $300,000. And the doctors never could stabilize his condition enough for the transplant surgery.

After the doctors told Ms. Klidaras there was nothing more they could do, she told them not to resuscitate him if his heart stopped beating on its own. He died July 20.

“Until the last week, I believed he was going to make it,” Mrs. Klidaras said. “I wanted them to do everything they could to save him.”

Someone giving the strictest of reading to the Dartmouth doctrine might argue that, given the outcome, the effort devoted to the Klidaras case was a futile expenditure of time and money.

Family Struggles

For U.C.L.A.’s doctors, deciding when enough is enough is not ultimately their call. Even when they recommend against a patient’s getting another procedure or test, it may be the patients and families who cannot let go.

When doctors, patients and families have trouble agreeing when to stop medical treatment, the person typically called in is Dr. Neil S. Wenger, a practicing physician who also serves as director of the U.C.L.A. Health System Ethics Center.

“For someone to die who is in the clutches of medical care, decisions have to be made,” Dr. Wenger said. “Otherwise, you don’t get to die a reasonable death.”

The decisions may include turning off life-prolonging technologies that were put in place when there was still hope — the dialysis machine to keep the kidneys functioning, the ventilator for the lungs — but now may be the only thing keeping the patient alive.

Dr. Wenger often sees difficult family dynamics. He spent more than an hour recently counseling the relatives of a woman with a traumatic head injury who was unlikely to ever regain consciousness. When a family member suggested stopping treatment, a sibling protested, saying, “You’re killing my sister.” Such intense emotions are “extremely common,” Dr. Wenger said.

Doctors, too, often have trouble letting go.

Many acknowledge that the current payment system encourages more care, because it rewards doctors for providing additional tests and procedures — not for spending the hours sometimes necessary to guide patients and families through the long, difficult process of deciding when to stop.

“The more tubes you put in, the more you get paid,” said Dr. Patrick T. Dowling, chairman of the department of family medicine at U.C.L.A.

But the bigger challenge may be changing the “we’re not going to let you die” culture at places like U.C.L.A.

Doctors at other leading medical centers, like the one at the University of California, San Francisco, say one big difference among institutions is how doctors and nurses talk with patients and families about their choices.

“It’s a cultural thing,” said Dr. Gropper. He says the doctors and nurses at the San Francisco medical center take the time to keep talking with patients’ families and even other doctors when they seem reluctant to end treatments. “You chip away at them,” he said.

At U.C.L.A., such palliative care — treatment devised to relieve pain and make patients more comfortable, particularly at the end of life — was essentially an afterthought until just a few years ago, when an internal task force recommended that the hospital add it to its many other specialties. The hospital now has a formal unit devoted to palliative care and is building up its expertise in the field. Residents, in training to be doctors, are being taught how better to discuss these issues with patients and their families.

Some doctors are resistant, particularly those with patients who had hoped for a transplant but were removed from the list when it became clear they had no realistic chance of recovery.

Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient two years ago who got a liver transplant but developed serious complications afterward and remained in the hospital for a year. “He had never, ever been told that he would have to live with a ventilator and dialysis,” Dr. Ferrell said. “He was never told that this is as good as it’s going to get.”

Dr. Ferrell talked with the patient about whether he might want to leave the intensive-care unit to go home and receive hospice care. But when the surgeon overseeing the case found out, he was furious.

“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr. Ferrell. “Don’t ever come back.”

The patient chose to leave.

But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the value of what he is trying to do.

“We’re not the bad guys,” he said. “We offer options.”

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A Past Campaign to Persuade Doctors to Ration Health Care

It’s clear now that business and government want healthcare “reform” to control costs, not provide everyone with comprehensive, affordable healthcare.

Yet business and government are unwilling to do the real things that could control costs:  (1)  eliminate private insurance with its profit, administrative and marketing costs, and costs to medical providers,  (2) put doctors on salaries, so they’re no longer private businesses with incentives to either over-treat us or under-treat us, and (3) require the government to control drug prices.   Without these tools for cost control, what’s left but rationing?  And if $500 billion in savings in  Medicare are to supposed to finance half the cost of healthcare “reform”  over the next ten years, how can medical care for older people NOT be rationed?

Obama’s insistence that deep structural reform is needed for so-called “entitlement” programs (Medicare, Medicaid, and Social Security) gives no re-assurance.  These programs have been under attack by liberals and conservatives alike because their funding automatically increases with the expanding senior population.  The Brookings Institute, closely allied with Obama, is particularly vehement about this.

Given these troubling trends, it would be useful to examine earlier periods when there was a push for medical rationing,  to see what it would look like.  The following paper was written in the mid 1990s, a period with similarities to the period we’re entering.  Working families were suffering from a jobless recovery but the financial sector was doing fine.  Business-friendly healthcare reform had failed, and a major push was underway to reduce costs by limiting services.  What emerges is that business and government had collaborated for years to produce a climate favorable to rationing in the medical profession.

“Given the competition for markets with foreign firms, US corporations can no longer afford to leave health care politics to the usual participants– professors, bureaucrats, physicians, and hospitals. Whether or not a hospital cost control bill is passed, or is passed but found inadequate, the big corporations are here to stay. They will work for federal and state attempts to control costs, preferably keeping the impetus in the private sector, but controlling costs by all means, at all costs.”  (1977)

“Only when society is fully able to come to grips with death and dying is it likely that policies and  procedures for decisions not to treat will not only will be formulated, but will also be followed.  This period is likely to be hastened as financial constraints force the issue.”  (1983)

“Yet it will be a hard pill for many Americans to swallow — the idea of doing with less so that big business can have more.  …  Nothing that this nation or any other nation has done in modern history compares to the selling job that now must be done to make people accept the new reality.   And there are grave doubts about whether the job can be done at all.  Historian Arnold Toynbee, filled with years of compassion, laments that democracy will be unable to cope with approaching economic problems — and that totalitarianism will take its place.”   (1975)

The Twenty-Year Campaign to Take Away Our Health care

Michael Lyon, January 23, 1996

Newspaper headlines have echoed ATT’s plan to lay off 40,000 mostly white-collar, college-educated workers over the next three years. ATT had already laid off 100,000 in the last dozen years. Since 1980, the top 500 corporations destroyed 4.5 million jobs, 600,000 in the past year alone.  35% of us receive poverty-level wages or less ($14,000 for family of four). Stagnation of workers’ 1995 wages and benefits is the worst since 1981.

Besides cutting back our jobs, benefits, and hourly wages, corporations and banks are cutting our “social wages”: education, housing, welfare, and particularly health care. From a corporate perspective, keeping an idle workforce healthy makes no more sense than doing maintenance on  abandoned machinery.    This paper outlines a twenty-year campaign in the health care field to persuade doctors   to go along with abolishing health care as we know it. The US economy cannot provide healthcare for its people.

  • The US has the worst infant mortality, highest percentage of low-birthweight babies, shortest male life-span, second-shortest female life-span, and second-lowest visits-to-doctors-per-person of all industrialized countries.
  • 41 million of us across the country have no health coverage.  40% of jobs have no health benefits, including one of three health care workers. Of the 1.2 million jobs created from January to June ‘93, 60% were part time, and virtually all had few or no benefits.  An additional 29 million people with private insurance are underinsured in the event of a catastrophic illness.”
  • Most people without medical insurance have jobs. The GAO says of the 9.3 million children lacking health insurance during 1993, 89% had at least one parent working full time.   4/5 of the 2.6 million medically uninsured in Los Angeles either have jobs or are dependents of someone with a job.
  • Over 100,000 people die yearly in the US from lack of health insurance, 11 per hour.  Medicaid covers only about 47 percent of the poverty population.  Over one third of Mexican Americans under age 65 lack health insurance. Congressional Medicaid/Medi-Cal cuts will produce an additional 9 million uninsured.  Two million adults on Medicaid were denied care in the first half of 1992, because of low fees that many states pay.  86 hospitals, in 22 states, were cited by the federal government for denying treatment to emergency patients for non-medical reasons.

In the face of all this, corporations, government, and the health industry are saying that too much health care is being delivered.  In particular, they are taking measures to reduce delivery of healthcare by reducing the number of  doctors. The Pew Health Professions Commission has just recommended closing one fifth of the nation’s medical schools in the next ten years, and tightening immigration laws to ensure that foreign medical students leave after completing training. The report predicts that by the year 2000,  half of all hospitals and 60% of beds will close and there will be surpluses of 100,000 to 150,000 doctors, 200,000 to 300,000 nurses and 40,000 pharmacists. (Pages 36-40 of the report) The San Francisco-based Pew Commission includes former government officials, medical educators including University of California San Francisco  (UCSF), public health professionals and insurance company executives. The commission is headed by Richard Lamm, former governor of Colorado, who became notorious for speeches in 1984 declaring that old people had the duty to die and free up scarce  national reresources.  (NY Times, 11-17-1995,  SF Examiner, 11-17-1995)

How is it possible that we have gone from a country where it was taken for granted that adequate medical care was available to anyone to a country where most people do not have even adequate health care? It is important to realize that corporate and governmental forces have spent almost two decades preparing the ideological groundwork for taking away our healthcare, particularly among doctors. Taking medical care from the poor, minorities, and Medicaid patients first was a integral part of this message. As far back as 1977, a leading hospital management magazine wrote:

“Given the competition for markets with foreign firms, US corporations can no longer afford to leave health care politics to the usual participants– professors, bureaucrats, physicians, and hospitals. Whether or not a hospital cost control bill is passed, or is passed but found inadequate, the big corporations are here to stay. They will work for federal and state attempts to control costs, preferably keeping the impetus in the private sector, but controlling costs by all means, at all costs. ” (Hospital Progress, 12-1977 p 49-50).

A 1978, a UCSF staff conference on cost-containment, “The Ailing Health Care System,” was addressed by a UCSF Associate Professor of Bioethics. “Bioethics,” as a discipline, arose parallel to the cost-containment movement in response to “ethical” problems of denying patients care for economic reasons. The Bioethics Professor said:

“The Hippocratic Oath declares  ‘Into whatever houses I enter, I will come to help the sick.’ The oath did not oblige the Greek physician to enter every house where there was sickness. Today we may ask whether some houses cannot be entered because it is not cost effective to do so. … Are cost considerations permissible when clinical decisions are being made in view of the social costs? How can we apply the principles to broad social policy?” (The Ailing Health Care System, Western Journal of Medicine, 6-1978)

One should note that in the period from 1980-1992. when medical cost containment became triumphant, and the Bioethicists balanced people’s medical care against “diminishing national resources,” tax changes increased the income of the richest 1% of the country by 74%. (NY Times, 4-17-95) The University of California SF (UCSF) organized a Cost Containment Conference in 1980. The organizer stated “the culprit in the high cost of medical care is our current inability to make and enforce decisions about what medical services we need and can afford.”

  • At the same conference, a speaker said medical costs were too high because there were too many doctors providing healthcare. He suggested cutting medical school admissions by 1/5 and eliminating foreign post-graduate MDs.
  • Another speaker at the conference described a 3-year program at UCSF to discourage residents from ordering SMA6 blood tests, clotting times, stat orders, X-rays, vital signs, weights, fluid Intake-and-Output tracking, and medicines administered four times daily. He advised doctors not to worry about malpractice suits, because residents were not legally liable. When asked why the residents were being trained, and not the attending doctors, he explained that there is private health care, used by the wealthy, where decisions are made by attending doctors, and there is public health care, used by the poor, where decisions are made by the residents. Therefore, it is the residents who need to be taught cost-containment.

In the early 80’s, mainstream medical journals  carried statements like:

“Persons will be recognized as in need of, and then denied, benefits that the medical care provision system is capable of providing. … These decisions (to withhold treatment) are likely to be made when any of the following conditions are met: (1) the treatment is determined to be futile, (2) the patient declines treatment, (3) the quality of the patient’s life is unacceptable, or (4) the cost of providing care is too great. … Only when society is fully able to come to grips with death and dying is it likely that policies and  procedures for decisions not to treat will not only will be formulated, but will also be followed.  This period is likely to be hastened as financial constraints force the issue. (Health Care Technology and the Inevitability of Resource Allocation and Rationing Decisions, Journal of the American Medical Association 4-22-1983 p 2208)

This period also saw the beginning of a large-scale campaign in medical journals warning the medical community of the economic dangers of an aging population with disabilities, chronic diseases, and expectations of receiving complete medical care.

“The longer people live, the greater the likelihood that they will exhibit chronic disease, have subsequent disability, make use of new and expensive medical technology, and ultimately fall into the category of high-cost users of medical care. Fully 85.2% (of the civilian population) indicated that they were limited in or unable to carry on major activities, affecting their ability to work or manage a household. … The total cost of illness should reflect not only actual medical treatment costs but (also) the costs of services and other benefits the person receives because of his illness.” (Health Care Technology and the Inevitability of Resource Allocation and Rationing Decisions, Journal of the American Medical Association, 4-15-83, p. 2047)

There was also a campaign in the popular press and medical journals questioning whether dialysis patients had a right to treatment because of the cost. (Philadelphia Bulletin, 1-21-81) In the SFGH Dialysis center, doctors had to explicitly state that black patients were not drug addicts and Latin patients were not undocumented in order to get them renal dialysis. (Personal communication from former director of unit) The Indian Health Service barred dialysis for reservation Indians in southern Arizona if they were approaching end-stage renal failure, cutting 20 Indians off and saving $500,000. There was also a flood of articles in medical journals on cost-effectiveness analysis, and articles justifying withholding medical treatment. Some examples:

  • In 1980, the Secretary of Health and Human Services announced that new health technologies must be evaluated not only on the basis of their medical efficacy and safety, but also on the basis of their “social consequences” before financing their wide distribution. (Health Care Technology and the Inevitability of Resource Allocation and Rationing Decisions, Journal of the American Medical Association, 4-15-83, p. 2047)
  • A cost-benefit analyses showing that care of very low birthweight babies is not economically warranted, based on the expected lifetime earnings of the infant. (“Economic evaluation of neonatal intensive care of very-low-birth-weight infants”, New England Journal of Medicine 308:1330-1337, 1983. )
  • A UCSF Health Policy Program conference report on neonatal resuscitation stated: “Resuscitation criteria should be established with full awareness of the economic and medical implications of providing this care. Estimates should be made of the financial cost to society of prolonging life, at a humane level, depending upon the condition at birth.” (Pediatrics, 6-6-1975, p 756)
  • A survey was published of patient deaths in Seattle extended care facilities, demonstrating that doctors were willing to withhold antibiotics to 40% of patients with fever, the majority of whom died.  “Physicians have been accused of prolonging life at any cost. However, surveys of health professionals have found that many (50 to 70 per cent) are disposed to withdraw or withhold life-prolonging treatment.”  The question of whether the patient expressed a desire to continue living is never even mentioned in the article. (“Nontreatment of Fever in Extended-Care Facilities, New England Journal of Medicine, 5-31-1979, p 1246)
  • A UCSF Health Policy Program published a paper analyzing factors affecting survival of patients with hospital bills over $4,000. The paper suggested that patients with cancer, patients with medical as opposed to surgical service, patients over 64 years of age, and patients with hospital bills over $10,000 have poor survival and are a bad investment. (Journal of the American Medical Association, 4-10-81, p. 1466)

So although it seems like our health care is being taken away with breathtaking rapidity, the truth is that the policymakers and academics have been working for at least fifteen years preparing the groundwork for this assault on us. What do they have planned for the next fifteen years? It’s no exaggeration to say that the next fifteen years will probably bring us closer to the idea that persons without economic value do not deserve health care, reminiscent of Nazi Germany’s rhetoric denying care to the “useless eaters.”

  • A 34 year old Sacramento woman was denied a heart and lung transplant by Stanford and UC San Diego Hospitals because she has Downes Syndrome and mental retardation. She lives on her own, graduated from high school, and has a job. She is also a past president of Capitol People First, a Sacramento disabled rights group, and her work on behalf of those with Down’s syndrome and other disabilities has been widely recognized. Stanford Hospital rejected her without even a physical examination. (SF Examiner, 8/11/95) Due to widespread protest, this decision was recently reversed.
  • In the fall of 1994, the newsletter of the Los Angeles chapter of Mensa (an organization for people with high IQs) published an article calling for the sterilization of individuals with low IQs.

Once again, the ideological groundwork for the idea that economic factors should decide who lives and who dies has been prepared for at least a decade.

  • At Children’s Hospital of Oklahoma, secret “quality of life” experiments on children born with spina bifida were conducted between 1977 and 1982. 25 parents were advised by doctors not to have their babies treated; of these, 24 died. 36 parents were advised by doctors to have their babies fully treated; all 36 lived. The decision to advise for or against treatment was based on a formula devised by the doctors, involving the baby’s functionality, the parent’s financial resources and education, and how little public resources would have to be used for treatment and rehabilitation. The US Supreme Court refused to hear a lawsuit filed by the parents of children who were allowed to die. (Progressive, 10-94)
  • A prominent British neurologist wrote in 1975 that “no person with severe handicaps is likely to be able to earn his living in competitive employment, unless his IQ is at least 100.” He developed a set of rigid criteria to determine which newborns with spina bifida should receive aggressive therapy. These criteria include consideration of the infant’s “social condition.” (J Roy Coll Phys, 10:47, 1975)
  • A pediatrician writing on genetic disorders stated, “ the unchecked accumulation of undesirable genes constitutes a clear and present danger,” and criticized “the salvage of nature’s rejects.” (Ross Conference on Pediatric Research, 65:1, 1973)
  • In 1983, the Journal of the American Medical Association wrote about end-stage renal disease: “Once it is apparent that all who are in need cannot be treated, the question then becomes which of the potential recipients are going to derive the greatest benefits. … The preferred candidates were selected on the basis of a variety of criteria, e.g. age, medical suitability, mental acuity, family involvement, criminal record, economic status (income, net worth), availability of transportation, likelihood of vocational rehabilitation, (some other criteria) and educational background, occupation, and future potential.” (JAMA 4-22-1983) A committee was established in Seattle which established guidelines for eligibility for dialysis based on social worth criteria as well as medical criteria. (The Ailing Health Care System, Western Journal of Medicine, 6-1978)
  • In 1984 Governor Richard Lamm of Colorado declared in a series of speeches that old people had the DUTY to die and free up scarce resources. He described the old people as “leaves falling off a tree forming humus for other plants to grow up.” He said medical care that allows ill old people to live longer was ruining the nation’s economic health. (SF Chronicle, 3-29-1984)

Approximately 5,000 mentally deficient and physically deformed children were killed in Germany between 1939 and 1944 under Nazi euthanasia policies. At the Nuremberg trials of high-level Nazi doctors, various American doctors were brought in as observers and prosecutors. Later, they published articles on how the German medical system was transformed, so that it was willing to carry out the mass killing of disabled children, old people, and disabled adults.

  • Leo Alexander wrote: “It started with the attitude, basic in the euthanasia movement, that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself with the severely and chronically sick. Gradually the sphere was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted, and finally all non-Germans” (“Medical Science under dictatorship, New England Journal of Medicine 1949, 241, 39-47)
  • Alexander Ivy wrote: “In my opinion, medicine is doomed if it ever consents to take part or permits any member in good standing to take part in a program of euthanasia applied for socioeconomic purposes.” (New England Journal of Medicine, 139, 131-135, 1949)

In the mid 1970s the US rulers realized that their defeat in Vietnam had broken their stranglehold on the world’s economy, that there would be serious problems for US capitalists in the coming decades, and that they would have to greatly reduce the living standards of the US working class.    Business Week (10-12-1975) wrote,  “Yet it will be a hard pill for many Americans to swallow — the idea of doing with less so that big business can have more.  …  Nothing that this nation or any other nation has done in modern history compares to the selling job that now must be done to make people accept the new reality.   And there are grave doubts about whether the job can be done at all.  Historian Arnold Toynbee, filled with years of compassion, laments that democracy will be unable to cope with approaching economic problems — and that totalitarianism will take its place.”



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