In Reply: Although Dr. Stone believes otherwise, I submit that what American lawmakers think of medical care is at least ambiguous. By holding employers responsible for paying for most of it as a benefit, they have implicitly identified health care as a product, the affordability of which is tied to profit margins and competition in the global economy. Few if any politicians advocate switching the fiscal burden to the federal tax base, which is where it should belong if the American public viewed health care as an entitlement.
Even when health care is considered to be an entitlement (as in Britain), the costs of providing it have escalated to the point where denial of benefits, rationing, and capitation have become inevitable. Prescriptions, eyeglasses, dental care, and some hearing aids are no longer free. For non-life-threatening conditions, there are often long waiting lists. Fund holding, a form of capitation, has been introduced into primary care.
The contemporary relevance of an article published in 1963 to understanding the ethics of today's marketplace is highly questionable. In mid-century, health care consisted largely of panaceas, placebos, inexpensive natural remedies, and compassion. Today it involves magnetic resonance imaging, organ transplants, and expensive manufactured cures. In addition, we have a population of increasing longevity with fantasies of immortality.
America does have the best health care in the world because it is the most affluent and spends more of its gross national product on health care than any other nation. Paradoxically, it has designed a health care product that an increasing segment of the population cannot afford. The ethical imperative today is to find a fair way of rationing finite resources. Corporate America opted for managed care, but it is only the messenger—an intermediary between who pays and who consumes. Shooting the messenger will not solve the basic issue of affordability or equitable distribution.
In the kaleidoscope of American ingenuity, only the state of Oregon has produced a plan that balances the burden of illness and the cost of treating it with what the public can afford or is willing to pay. We should translate that thinking to the federal level and administer it with a public corporation composed of both providers and consumers, but with a majority of consumers.
I recently retired from medicine after 30 years as an academic psychiatrist and three years as the medical director of a small managed care company (my salary was the same in both jobs). It is my unpaid opinion that managed care and its accrediting agencies have done more to educate patients, implement quality improvement, and set up appeal mechanisms in the last ten years than organized medicine did in the past half century.