What to Do about Health Care

To the Editors:

Paul Krugman and Robin Wells [“The Health Care Crisis and What to Do About It,” NYR, March 23] have written a lucid and insightful analysis of the US health care crisis, but they make a surprising omission. They say the main source of high US costs “is probably the unique degree to which the US system relies on private rather than public health insurance.” And so, they conclude that the way to fix the system is to “shift from private insurance to public insurance, and greater government involvement in the provision of health care.” What they seem to ignore, however, is that over the past few decades the private health care delivery system, like the private insurance system, has been converted into a huge commercialized market which in many parts is heavily influenced—if not dominated—by competing investor-owned firms. The “monetarization” of health care (a term used by the late Eli Ginzberg) changed it from a largely not-for-profit, community-oriented social system into an industry, and this has affected the behavior of all providers—hospitals, doctors, and others.

Investor-owned businesses constantly seek to expand their revenues. Yes, expensive new technology and new procedures, more specialists, and an aging population are all part of the problem. But much of the impetus to expand the use of health resources surely comes from the fact that there is a lot of money to be made and the expectations of investors and physicians are high.

Krugman and Wells are right that we will have to reform the delivery system as well as the insurance system and that powerful vested economic interests will have to be confronted. They should understand, however, that private insurance companies and the pharmaceutical industry are not the only vested interests who will resist. All those investors who have an equity interest in a vast variety of for-profit health care businesses and all those medical specialists whose high income depends on the fee-for-service reimbursement of expensive technology and complex procedures will also have to become convinced that change is necessary before we can make it to the promised land.

Arnold S. Relman, M.D.
Professor Emeritus of Medicine and of Social Medicine
Harvard Medical School
Boston, Massachusetts