Letters to the Editor
Image credits: Mark Hooper; Marc Yankus; David H. Wells/Aurora Photos
David Goldhill’s disclaimer in “How American Health Care Killed My Father” (September Atlantic) that his observations may be nothing new to industry insiders is probably true. However, in my 25-year career in health-care operations, I have never before encountered so comprehensive, succinct, and compelling an assessment of the tangled mess that is American health care. I immediately forwarded the link to my congressman, and to 300 of my closest friends. Bravo for his hard work and insight. I can’t imagine a more powerful memorial to his tragically departed father than this spectacular article.
Brandon Hull
Princeton, N.J.
David Goldhill’s article was brilliant, timely, accurate, spot-on—and irrelevant. Why? Not because of the doctors or the insurance companies or the hospitals or all the other interest groups, but because Americans want more insurance, not less. Goldhill advocates self-insurance for all but catastrophic care, which makes perfect financial sense. However, most Americans are busy buying more and more insurance for smaller and smaller calamities. If people are not willing to self-insure for iPod repairs, what are the chances they will self-insure for colonoscopies? I would say zero, which is frustrating and depressing. Here Goldhill has provided a clear way to cut health-care costs, and there is no chance of its happening.
Mike Morse
Kensington, Md.
Throughout history, when societies have found that a service was needed for the common good, that service was created, and people chose to tax themselves to provide it. Armies, fire departments, water systems, police departments—all were created and paid for as the need arose. It makes no more sense to expect only those who can afford health care to have it than it would to make sure you have a valid credit card before dialing the fire department. The fact that the U.S. is the only industrialized country that has not figured this out speaks not only to our current obsession with the “consumerism” that David Goldhill bases his plan upon, but also to the tainted origin of our employer-based system of health care.
In World War II, the government enacted wage controls in an effort to ease the country through a demanding economic time. Corporations, to seduce the most-talented workers away from their current jobs, circumvented the intent of Congress by providing health insurance as a “benefit,” thus offering essentially a higher wage without technically breaking the law. From this wartime finagling was born the employer-based private health-insurance system we are saddled with today.
Studies have shown that a true single-payer system (aka “Medicare for All”) would cost about as much as the current total expenditure for health care in this country. Unfortunately, any Band-Aid-type solution, such as the public option, that still supports and encourages the already proven failure of private health insurance will undoubtedly lead us further down the road toward medical bankruptcy.
Mike Mahoney
Sandpoint, Idaho
As a physician working in a tertiary-care hospital treating the sickest of our population, I agree wholeheartedly with David Goldhill that our current health-care system has many flaws and needs a massive overhaul. But I disagree that moving toward a consumer-based model is the solution, because health care is not a consumer-based commodity. Purchasing health care is not like buying a house or a car, because the complexity of medical decision-making cannot be summarized in a few easily digestible sentences. There are usually no right or wrong answers in medicine, but different options, each with its own risks and benefits, which would be difficult to quantify in monetary terms. Good health care is not compatible with a purely business model, because the easiest way for insurance companies or hospitals to make money is to avoid people who are sick.
The solution is to create not a consumer-based system but rather a patient-based system, where patients have primary responsibility for taking care of their health. Studies have shown that preventative measures such as weight loss and smoking cessation have a much greater impact on overall mortality than any expensive medications needed down the line. Allowing patients more awareness of and accountability for where their health-care dollars are going is a step in the right direction—but a system where patients are responsible for the funding, decision-making, and monitoring of health care seems chaotic and would place a large burden upon those who are sick.
Preeti Rout, M.D.
Boston, Mass.
David Goldhill’s suggestion that major medical expenses—“including much end-of-life care”—be paid for out of personal savings and credit, while catastrophic insurance be limited to “massive, unpredictable expenses,” sets the stage for a new and contentious administrative nightmare: How would we decide whether end-of-life care was catastrophic or not? Would the $636,687.75 bill for Mr. Goldhill’s father, who spent his last five weeks in a hospital, be subject to a savings-and-credit charge, or be covered by insurance? A $600,000 bill would be catastrophic for almost everyone, regardless of treatment classification.
Also, Mr. Goldhill’s suggestion that under a consumer-centered system we’d likely see a new breed of “health-care agent,” paid for by consumers and responsible for steering them to the best medical option when health problems occur, overlooks the fact that these agents would quickly become subject to energetic sales pitches by every profit-oriented hospital, medical group, and insurance company around. As long as profit remains the driving force, health care will remain a commodity instead of a human right.
Howard Bluth
Baltimore, Md.
David Goldhill’s proposal to place the patient in the role of direct consumer is a compelling economic idea, but it carries with it certain ethical perils for physicians. When a third party pays the bill, the physician has a layer of insulation between the financial component on one side, and the care component—the physician and the patient—on the other. With patients as payers, however, physicians become de facto salesmen, having to navigate a conflict-of-interest minefield every time they propose treatment options. This sort of arrangement would undoubtedly degrade the fiduciary doctor-patient relationship.
Ian G. Dorward, M.D.
St. Louis, Mo.
As an emergency physician 20 years deep into practice, I have witnessed the battle over spiraling costs firsthand. When the topic of electronic medical records comes up, what you tend to hear is how they increase efficiency, enhance data sharing, and reduce medical errors, leading to improved care at a lower cost. It sounds so good that the government has mandated that hospitals move to EMRs in order to receive future Medicare reimbursements. What isn’t mentioned is how the data first gets into the record. At my hospital, it gets there when I type it—one finger at a time. Hospital administrators, having shelled out $25million or more for the implementation of EMRs, are not about to allocate additional funds for transcription, especially to a busy emergency department already seen as a money loser.
During a typical eight-hour shift, I spend about five hours performing basic data entry. The EMR has dropped my efficiency by 30percent. Another unintended consequence is that the number of medical errors on my part, far from declining, has gone up exponentially. Computer screens list all the patients in the department, and it is extraordinarily easy during a busy shift to simply click the wrong box. It happens daily.
Robert Clare, M.D.
Virginia Beach, Va.
As a pediatrician, although I know my patients are “owned” by insurance entities, I still ignore this evil as best I can and treat them as my own clients. If David Goldhill seeks incentives to reduce waste and cost, here are two wee ideas. Find a way to remove the constant fear of lawsuits from medical decision-making; defensive medicine drives excessive testing and treatment. And recognize that after five, seven, or more years of grueling training plus the ultimate responsibility for human lives, primary-care doctors, especially, should not be awarded less than half of what our free-market society pays lawyers and low-level CEOs.
F. Ralph Berberich, M.D.
Berkeley, Calif.
David Goldhill replies:
I’m happy that my article has stimulated so much discussion. Regarding my proposal to shift health-spending resources and responsibilities to consumers, several readers have contended that we consumers lack the knowledge to make wise or perfect decisions. Of course that’s true, but even in our current system, patients are required to make most decisions on care. Doctors advise us, insurance companies can restrict us, but neither can force us to have treatments we don’t accept and order. By shifting resources to the consumer—and putting the government more in the role of consumer advocate/protector—we would give patients better access to necessary information.
Others believe it is unrealistic to expect consumers to shop around for health-care services when they have an urgent medical need. I agree, but such behavior is not essential to the success of a consumer-centered system. Think about most of the products and services we buy: few of us are active, price-comparing, quality-grading consumers. But some of us are, and that puts pressure on vendors across the board to improve the value of their wares. (We all benefit from the low prices at Wal-Mart, whether or not we shop there.) Price transparency would be an essential part of consumer-based reform, and competition among providers for the most discerning patients would drive lower prices and better service for everyone.
Some respondents are concerned that in my proposed system, consumers would be unable to afford basic care uncovered by catastrophic insurance. But that shouldn’t be a problem as long as we move gradually toward this system—decreasing both the coverage offered by insurance (including Medicare) and the premiums we pay. Eliminating employers’ share of insurance premiums, Medicare taxes and premiums, and the support for Medicare and Medicaid out of general tax revenues would free up vast financial resources. For example, current government spending on Medicaid and Medicare would fund catastrophic premiums plus a $2,500 annual health account for 100million people—a true safety net. In the end, I favor relying more on consumers/patients because I believe government, employers, and insurers have all clearly failed to control costs and maintain quality. And I believe that at $2.5trillion a year, we already spend enough money that a market-disciplined system would meet everyone’s health-care needs, and many of our health-care wants.
I agree with the readers who point out that my—or any other truly fundamental—reforms won’t happen in this political environment. Until the large number of Americans who claim satisfaction with their current insurance realize how much it actually costs them, true reform is unlikely. But even then, we’ll need to give up our hope for a quick fix, a magic bullet. It’s taken more than half a century to create this mess, and it will take at least a generation to replace it. Whatever we put in its place must be both financially sustainable and flexible enough to allow for the new benefits that ever-innovative health care can provide.
I was really enjoying Caitlin Flanagan’s article “Sex and the Married Man” (September Atlantic), right up until the part where she offends every reader who doesn’t have children with the sentence “I was years away from having a child of my own, and until you’ve done that you’re just guessing about love, gesturing toward it, assuming that it’s the right name for a feeling you’ve had.”
If Flanagan wants to assert that your child-free readers don’t understand, empathize with, or experience the full spectrum of the parent-child bond, that’s fair. If she herself never really knew love until she became a parent, that’s unfortunate, but only she can judge her own experiences. But frankly, this sentence, this attitude, is patronizing and insulting. As a child-free adult, I have plenty of disposable income, and I’m not interested in spending it on publications that insult me for not truly understanding the bonds of love because I am free of the bondage of parenthood.
Lisa Sanford
Sherman Oaks, Calif.
Kevin Maney’s article on tech giants (“What Scares Google,” September Atlantic) fails to mention Apple Inc. Before the rise and fall of Google can be considered, Apple’s role as a longtime contender and current industry leader must be understood.
Apple for a long time played the punchy underdog, keeping the previous Goliaths on their toes. Apple was the first real challenge to IBM’s might, with its Apple II and Macintosh computers. As Microsoft took hold of the market in the ’90s, Apple found itself unable to break the stride of this new giant. Honing its branding and innovation, Apple unleashed the iMac in 1998. Subsequent strikes from the iPod and iPhone left Apple ready to sunder the enemy. Vista was Microsoft’s final attempt to quell Apple, but it proved ineffectual.
Google’s strong Web presence and its developing computer and smart-phone operating systems, Chrome OS and Android, respectively, make the company a formidable opponent. With neither Apple nor Google faltering, the conclusion of this struggle remains to be seen.
Joseph Conran
Alexandria, Va.
Kevin Maney replies:
From everything I know, Apple, although terrific at what it does best, has never been a threat to the core business of IBM or of Google. And it challenged Microsoft’s core business only in the earliest days of the personal computer, when Apple was actually the dominant company.
As someone who has lived and studied in Kandy, Sri Lanka, I began Robert D. Kaplan’s article “Buddha’s Savage Peace” (September Atlantic) with excitement. Kaplan accurately summarizes the effect that ancient Sri Lankan history has had on the ethnic conflict there. However, by speaking of “a quarter century of civil war between ethnic Sinhalese Buddhists and Hindu Tamils,” he miscasts the conflict as religious as well as ethnic in nature. Although Buddhism has been central to the consolidation of the Sinhalese identity in this conflict, Hinduism has had almost nothing to do with the Tamil approach. Ethnic Tamils include vast numbers of both Christians and Muslims, as well as the “up-country” Tamils who were brought in by the British to harvest tea. These religious identities are not without significance, but they were of little import within the Liberation Tigers of Tamil Eelam. Unlike their Sinhalese counterparts, the Tamil Tigers used no religion (not even Hinduism) to attract new recruits. “Recruits” were too often stolen from families, particularly from the eastern province.
More disturbing yet was how Kaplan missed the opportunity to consider the lessons we might learn from the history of Sri Lanka: how a peaceful Buddhist country plagued for decades by civil war chose a military solution over a diplomatic one; how the oppressed Tamil minority has been terrorized by its own “resistance movement” (the LTTE); and how Sri Lanka is attempting to deal with the prejudice, hatred, and psychological damage wrought by a decades-old conflict that is now ostensibly over. Whereas few Sinhalese live in the Tamil-dominated north and east of the island, ethnic Tamils and Tamil-speaking peoples live among the Sinhalese all over the island. The importance of this post-war window for real reconciliation cannot be overstated.
Ted Frisbie
Carbondale, Colo.
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