© Davidson Loehr
21 October 2007
First UU Church of Austin
4700 Grover Ave., Austin, TX 78756
www.austinuu.org
SERMON: Honest Health Care
This morning, I want to engage in the unlikely activity of theological reflection on our country’s health care system and the gods we’re serving with it.
What that means is that when we’re serving worthwhile gods – by which I mean high ideals – they help us create more whole and integrated lives and a more compassionate society. And there’s hardly anywhere this is more pertinent than in healthcare.
Taking medicine seriously as an art and a science in Western civilization goes back to Hippocrates, the ancient Greek doctor who was a contemporary of Socrates. He was also thought of as a descendant of Asclepius, the Greek god of medicine.
When you find the Greeks tracing something back to the gods like that, it usually means They’re talking about some aspects of character, or a quality of ideals, that transcends and often commands us in the same way that ideas like truth, beauty, justice and goodness transcend and need to command us – or the way that anger, envy and power can command us. The Greeks were clear that not all gods are good – They’re just powerful and always with us. And you can find this in the ancient Hippocratic Oath, where he talks about living and working for the benefit of the sick, and he says, “I will keep them from harm and injustice. I will keep them from harm and injustice.” Those are high ideals. And when you are around a physician who serves the idea of keeping you from harm and injustice, You’re probably in much better hands than you are in with Allstate.
In the 1960s, a modern version of the Hippocratic oath was written, which is still used in many medical schools today. Here are some lines from it. Listen to how high it is aiming, and you’ll hear what gods, what ideals, are being served in this:
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
(Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University.)
This is a very moving oath. It is a religious oath, in the spirit of Hippocrates, making a vow to protect the sick from harm and injustice. I suspect that nearly every physician who took this oath at their medical school was both moved and inspired by it.
Now many of us may not think the current state of health care reflects these high ideals, and many physicians don’t either. But I want to see why. I want to see what happened to the gods once served, and see what took their place, what is being served now, and how it has changed even the way we think and talk about health care in the U.S. Only a fool would try to do this in 20 minutes, so let’s get started.
Up until the 1930s, most patients paid for almost all health care services out of their own pockets. (Maggie Mahar, Money-Driven Medicine, p. 7) Doctors completely controlled which treatments and medications were given to patients, and at their best they were guided by the kind of ideals embodied in the spirit of Hippocrates. Hospitals were never – and were not meant to be – profitable, any more than libraries or public schools are meant to be profitable. We paid for them through our taxes, as places where our physicians could work, care for us, and help keep us from harm and injustice.
After WWII, employers began paying health coverage for their workers, and things began to change. Insurance companies got into the game in a big way, and this expanded health care.
But once insurance companies paid most of the bills in the late 1960s, few patients, doctors or hospitals cared as much about what it cost. (p. 16)
Costs soared. From 1960 to 1970 the nation’s health care bill rose from $27 billion to $73 billion (p. 17). By 1980, it had more than tripled, to $257 billion (p. 22). In the next ten years it nearly tripled again, to $700 billion. And by 2006 it had tripled again, to over $2 trillion (p. 46), almost 75 times the cost in 1960.
The costs are now out of reach for about fifty million Americans, and not just the poor. About a third of the uninsured families in our country earn over $50,000 a year (p. xiv).
In a 2002 report Care Without Coverage the Institute of Medicine says overall, uninsured adults face a “25% greater risk of dying.” That translates into about 18,000 extra deaths among Americans under the age of 65 each year – about the same number as die of diabetes or stroke. (pp. 201-202)
How did it happen? The short answer is that for our healthcare system, the Hippocratic oath was replaced by the business model, which began to take over in 1982. From then on, the goal was no longer better health, but “the rate of return on investments.” (p. 25)
The contradiction that lies at the heart of the idea of “corporate medicine” is that as health care has become a growth industry, “the pressure is to increase total health-care expenditures, not to reduce them.” (NEJM editor Marcia Angell). Like all business, health care businesses want more customers, not fewer – but only if they can pay. (p. 28) This is not about making us a healthier nation, or doing much preventive health care, because preventive health care doesn’t return a profit in the short run.
The business model is about profit, not protecting the sick from harm or injustice – in spite of the best efforts of our best doctors. In 2002 drugmakers spent over $91 million to hire a legion of lobbyists – more than one for every congressperson. The next year lawmakers passed Medicare legislation pledging that the government would never attempt to negotiate lower drug prices. By 2005, the drug industry had spent $800 million on lobbying in just seven years (p. 52). Of course, we end up paying for this through obscene drug prices. They don’t do this for our health, but for their profit. The dynamics are those of a vampire.
Is the business model working?
No. As hospitals merge and are acquired, a lot of people make a lot of money on the rise in their stock prices. But as they get larger, hospitals don’t lower their prices to us consumers; they raise them. Consolidating makes them more powerful, not more charitable. Why do they charge more and more? Because they can. And under the rules of corporations in America, if they can increase profit, they must (p. 289). There are legal cases going back to at least 1916 showing corporations being successfully sued by their stockholders for failing to maximize profit. Healthcare corporations operate under the same constraints.
But it isn’t working, for them or for us. In 2004, the Wall Street Journal reported that General Motors was paying out $5 billion a year for employee health care benefits – or roughly $1,400 for each vehicle that it manufactured. This is a major reason why GM’s profit per vehicle made in North America came to just $178. Chrysler and Ford both lost money on every vehicle that they turned out that year. By contrast, Japanese auto maker Nissan showed a profit of $2,402 per vehicle, while Toyota made $1,742. (p. xv)
“Japan, like most industrialized nations, has national health insurance,” the Wall Street Journal said in 2004. And while providing coverage for all of its citizens, Japan ‘spends about half as much on health care as a percentage of GDP, yet has a higher life expectancy at birth and a lower infant mortality rate.” (p. xv)
A 2003 study published in Annals of Internal Medicine says “Higher spending did not result in higher quality care, lower mortality, better function outcomes, or greater patient satisfaction.” (p. 162) “At the top level, outcomes are worse. This is a frightening finding.” (Dr. Donald Berwisk, cofounder of the Institute for Healthcare Improvement, 2003 – p. 162) So we’ll look into the dark side of our health care for a few minutes.
Medicare claims data from 1998-2001, for example, shows Texas to be the state spending the second-highest amount per capita (just under an average of $8,000, second only to Louisiana), and having the 3rd lowest quality of health care in the US (Mississippi and Louisiana) (p. 166) When You’re only ahead of Mississippi and Louisiana, that’s not good.
The best available evidence suggests that up to one out of every three health care dollars is squandered on unnecessary tests, unproven procedures, and overpriced drugs and devices that too often are no better than the less expensive products that they have replaced. (p. xviii) That means that the best available evidence says that last year we squandered about $650 billion dollars – money that we’re all paying for, through higher taxes and insurance premiums.
Let’s ask some more blunt, rude questions. We have billions of dollars of very high-tech diagnostic machines. Have they made a significant difference? This is one of the more upsetting things I’ve read. When patients die in the hospital, autopsies reveal major misdiagnoses were made about 40 percent of the time, according to three studies done in 1998 and 1999. And in about one-third of those cases the patient would have been expected to live if proper treatment had been administered. So in spite of all our expensive modern diagnostic imaging techniques, autopsy studies say that medical misdiagnosis of terminally ill patients has not improved since at least 1938. (p. 189)
So we not only get the diagnosis wrong in two out of five of our patients who die, but we have also failed to improve over time. This sounds preposterous, so to test it, a group of Harvard doctors did a major study to see if it could possibly be true. They went back into their hospital records to see how often autopsies picked up missed diagnoses in 1960 and 1970, before the advent of CT ultrasound nuclear scanning and other technologies, and then they checked the records for 1980, after those technologies became popular. To their dismay, “the researchers found no improvement. Regardless of the decade, physicians missed a quarter of fatal infections, a third of heart attacks and almost two-thirds of pulmonary emboli in their patients who died” (p. 190). Some of this is just saying that medicine is as flawed as any other human endeavor. But it’s not the picture we’re used to.
Data from the National Cancer Institute talk about what they call PSA blood testing in men for prostate cancer. While screening has led to a dramatic rise in the number of new cases of prostate cancer that are detected, as of the fall of 2005 there was still no evidence that the screening has led to fewer deaths. (p. 230) People just know they have prostate cancer longer.
Several years ago, (2001) the Institute of Medicine shocked the medical world by showing that it can take 15 to 20 years for new scientific knowledge to percolate down into everyday medical practice. (243)
Why don’t doctors know everything? One reason is that there are now about 23,000 medical journals published each year. Nobody can be entirely current (p. 243). Without a comprehensive, shared online database of best practices and patients” records – like several other countries have had for years – our doctors can’t be as well informed as they want and need to be.
So we pay too much, see a third of it squandered, and don’t get world-class health care anyway. The business model for running health care is failing miserably, no matter how much profit some people made from it for awhile.
What do the spokespeople for the business model of health care say to this? Do they talk about the money squandered on far more tests and procedures than are needed? No. Do they talk about the stunningly high prices of drugs in this country – far higher than anywhere else in the world – or the fact that drug companies have spent nearly a billion dollars buying congresspeople to make sure we won’t control their greed? No, they don’t talk about that. Or that a huge part of the squandered money each year comes from too many hospitals duplicating expensive equipment, ordering money-making tests that aren’t needed, and spending tens or hundreds of millions of dollars competing against each other?
No, they don’t talk about that. What they tend to talk about is how it’s our fault. It’s the fault of people who want all kinds of medical care done for them, especially when They’re old. In fact, this is the bias that looks like it will be behind nearly all of the questions that I and three other ministers will be asked in a few hours, in the panel discussion on end-of-life care, which they have titled “When is enough enough?” The draft questions we saw at a lunch meeting on Thursday were asking us to find theological arguments to convince people they shouldn’t be so greedy for so much health care, and remind them of the biblical injunction to humility. I think the arrogance of this is almost as repulsive as the pathological greed behind it.
(The panel discussion actually went very well. Though the questions were often coming from a profit motive and trying to blame patients, the four panelists all got to point it out – to the satisfaction or delight of the audience of about 250.)
Sure, the system is broken, but you don’t try to fix it on the backs of the most vulnerable patients. (p. 204)
In 2006, meanwhile, drugmakers and device makers took in well over $300 billion – or about 15% of the nation’s health care dollars (p. 285). And another 18,000 people died because they were uninsured.
What do we need to do? Well, far more than I am aware of. It’s a discussion that will have to involve a lot of people from a lot of areas. But I feel pretty sure about two things we need to do.
The first is once more to empower the doctors to determine what care patients need, rather than hospitals or insurance companies. Neither insurance companies nor healthcare corporations have either the expertise or the right allegiance to make health care decisions. We need to control drug prices and regulate drug company advertising directly to customers. Famous cases like Phen-Fen, Vioxx and pacemakers the manufacturers knew to be faulty and deadly, as well as spending nearly a billion dollars to buy congress. People have shown they will eagerly do us harm and injustice if there’s enough money to be made.
What does honest religion say about this today? The same thing its best voices have said for a couple thousand years. The prophet Amos lived three hundred years before Hippocrates. Here’s some of what he said about the ideals being served by the priests and politicians of his time:
“They sell the righteous for silver, and the needy for a pair of shoes; they trample the head of the poor into the dust and push the afflicted out of the way.” (Amos 2:6-7)
Or as Hippocrates might have said, they do harm and injustice to them because they can turn a profit.
How far we have fallen, it seems, from the oath to help keep the sick from harm and injustice!
We could and should talk at long length about this, but not this morning. We will be showing a special screening of Michael Moore’s movie “Sicko” on Friday November 2nd in our social hall, which I recommend if you haven’t seen it.
But for now, I want to close with an adaptation of part of the modern Hippocratic oath I read at the start:
We will remember that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
We will remember that we do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. Our responsibility includes these related problems, if we are to care adequately for the sick.
We will prevent disease whenever we can, for prevention is preferable to cure.
We will remember that we are members of society, with special obligations to all our fellow human beings, those sound of mind and body as well as the infirm.
Above all, we will help protect the sick from harm and injustice. This we swear by all the gods worth serving.
———————–
Confession:
Health care is a huge subject and I don’t know a lot about it. In order to get enough data to find some of the larger patterns in the U.S. healthcare system, I’ve mostly trusted just one book, in addition to whatever I already knew about it. That book is the 2005 book by Maggie Mahar, Money-Driven Medicine. The book was recommended by another author I trust, and her earlier book Bull! on the stock market received strong positive reviews from the likes of the Wall Street Journal and Warren Buffet, so I decided to trust her research. All page numbers refer to her book.
