By Gregg Gonsalves
The Nation, February 16, 2023
The injustices at the heart of the American health care system are clear to anyone with eyes and common sense. So is the need for dramatic reform of that system. Yet the status quo in American medicine is well-defended, and little real change has been forthcoming. One could even make the case that the situation has gotten appreciably worse over the past few decades.
But, at long last, there are signs that something might be changing from within the system itself. More and more physicians are rejecting the forces of self-interest and conservatism within their field and joining the emerging grassroots movements that are trying to revolutionize American medicine and safeguard the public health institutions that so many people rely on.
In early February, my friend and colleague Eric Reinhart wrote a piece in The New York Times on physician burnout. What made it unique was that Reinhart didn’t focus on the issues that such articles usually tackle, like grueling hours or the added burdens of the pandemic Instead, he went deeper, to the very fundamentals of American medicine—specifically, its unending quest for profit.
Reinhart’s column touches on all of the most rapacious aspects of US health care: the predatory billing of patients; deliberate cutbacks in staffing to cut costs, while hospitals rake in record profits; the way the system defines health according to what it can charge people for. He also talks about the complicity of the medical profession, which for decades has, as he writes, “[defended] health care as a business venture” because doctors believed that “if health care were made a public service, we would lose our professional autonomy and make less money.”
But Reinhart goes further than a diagnosis. He presents a treatment plan: “Regardless of whether we act through unions or other means, the fact remains that until doctors join together to call for a fundamental reorganization of our medical system, our work ‌won’t do what ‌we were promised it would do, nor will it prioritize the people we claim to prioritize.”
Reinhart’s cry in the wilderness—albeit in the pages of one of our nation’s leading newspapers—could not be more timely, or more reflective of a new generation of health care workers who are unwilling to accept the status quo—and are organizing to overturn it.
But Reinhart wasn’t the only person raising the alarm this month about the remorseless venality of American health care. Only a week or so before his piece, another commentary was published in the Journal of the American Medical Association, “Salve Lucrum: The Existential Threat of Greed in US Health Care,” by Dr. Don Berwick. Unlike Reinhart, Berwick is a pillar of the medical establishment: a former administrator of the Centers for Medicare and Medicaid Services under President Obama, and a former CEO of the Institute for Healthcare Improvement. In recent years, though, he has shifted his interests into the political realm, where he seems to have found a voice unconstrained by the conventions of academic life.
Berwick comes to the same conclusions as his junior counterpart: “The glorification of profit, salve lucrum, is harming both care and health.” Like Reinhart, he calls for health care professionals to get “noisy” about the “unchecked greed” in American medicine, to challenge the complicity of their professional organizations, the hospitals, and other institutions for which they work, and take the fight to Congress.
However, one research article from early February, in the Journal of General Internal Medicine, takes Drs. Reinhart and Berwick’s challenge one step further. In it, Drs. Suhas Gondi, Sanjay Kishore, and J. Michael McWilliams turn a spotlight on the top 20-ranked hospitals in the United States, according to U.S. News and World Report, in an article rather blandly titled “Professional Backgrounds of Board Members at Top-Ranked US Hospitals.”
If you want to know how greed drives American health care, you probably should ask questions about who’s in charge of the way things work. After all, as the proverb goes, a fish rots from the head. The trio’s findings are striking: “At top-ranked US hospitals, the most common professional background for board members is finance, far exceeding representation from physicians, nurses, and other health care workers. Over half (~56%) of board members are from finance or business, while a small minority (~15%) have clinical training or are from the health services sector.”
The authors are modest about their conclusions, but suggest that the prioritization of financial success over the needs of health care workers, patients, and communities—the same ones that Reinhart and Berwick detail—may have its roots in this financialization of the leadership of American medicine. We should all be grateful to these five physicians for breaking the professional code of silence and speaking out against what is happening in their profession, and even more grateful for the nurses, physicians, and other health care workers organizing for something better.
But having more honest conversations about these problems isn’t important just for health care workers. It’s crucial to understanding why our system is so uniquely dreadful compared to most of our peers.
Here’s one statistic: According to a new report the United States spends more on health care than any other nation per capita, yet we have terrible health outcomes. As I have said here before, we’re heading towards 64th in life expectancy in global rankings by 2040, with many countries far poorer than we are leaping ahead of us.
Here’s another statistic: Despite all of that money, American medical care can only be credited with a tiny percentage of health outcomes. That’s right: According to the National Academy of Medicine, “Medical care is estimated to account for only 10-20 percent of the modifiable contributors to healthy outcomes for a population. The other 80 to 90 percent are sometimes broadly called the SDoH [social determinants of health]: health-related behaviors, socioeconomic factors, and environmental factors.” In other words, there are endless dollars swimming around in the health care system, but almost none of them are actually dealing with the structural inequalities—poverty, racism, sexism, environmental degradation, and so on—that are the true drivers of so many medical problems in this country.
Ten years ago, my Yale colleague Elizabeth Bradley, now president of Vassar College, along with Lauren Taylor, published a book, The American Health Care Paradox: Why Spending More Is Getting Us Less. Bradley and Taylor compare the US to other rich countries in the book and something not-unexpected emerges: What makes us different from other nations in terms of health care outcomes is not how much we spend on medical care but how much we spend on social protections.
If we want to remedy the sorry state of health in America, we have to address racism and boost social programs to get at the root causes of what ails us. We have to deal with the 80–90 percent of our survival that is not connected to clinical care. (You can hear the heads of Republicans, conservative Democrats, and centrist pundits exploding now.) And we have to resist the growing trend towards the medicalization of public health, in which every public health issue gets reconfigured as a clinical problem to solve, and the social and economic factors that drive so many of our health outcomes get kicked to the curb again and again in favor of a pill (or other lucrative medical intervention) to prescribe.
As medicine seeks ever-greater financial gains, public health, which requires investment rather than extraction of profits, stands squarely out of step with the times. And ever since the early 20th century, medicine has been trying for a hostile takeover of the field, as I’ve written about before. In The New Public Health, from 1913, Dr. Hibbert Hill wrote: “The old public health was concerned with the environment; the new is concerned with the individual. The old sought the sources of infectious disease in the surroundings of man; the new finds them in man himself.” You can draw a straight line from those words to the physicians and others who have been talking about individualized risk, individualized choice, and “you do you” as the preferred strategy of dealing with this pandemic for several years now. You can also find echoes in the oft-repeated White House mantra when it comes to vaccines and treatments—“we have the tools”—even as the administration prepares to surrender all of us to the private market for these interventions. The undermining of public health as a common good since 2020 is just more of the same, but in hyperdrive, with the predatory instinct of a financialized modern American medicine here to kill what it cannot absorb and compromise.
So, as Drs. Reinhart, Berwick, Gondi, Kishore, and McWilliams warn, American medicine is broken, surrendered to high finance and the extraction of profit as a primary goal. The institution is hell-bent on dragging down public health in its greed. There is a fight for the soul of American medicine happening now, and it is tied to the survival of public health in America. It’s not about Covid. It’s about so much more. And we should pay attention. More than that, we need to organize. Together. Now. And doctors, nurses, and other health care workers have to lead this fight, because the struggle we face starts at the heart of American medicine. Those of us in public health will need to join them too; they cannot do it alone. But this is a collective struggle that will take all of us, even if we do not work in these fields. Our lives are indeed at stake.
Nation public health correspondent Gregg Gonsalves is the codirector of the Global Health Justice Partnership and an associate professor of epidemiology at the Yale School of Public Health.
