Portal de Periódicos da CAPES

Poor Relations: Connecting Waste, Need, And Health SpendingPoverty And The Myths Of Health Care Reform By Cooper Richard “Buz” Baltimore (MD) : Johns Hopkins University Press , 2016 304 pp., $35.00

2017; Project HOPE; Volume: 36; Issue: 2 Linguagem: Inglês

10.1377/hlthaff.2016.1555

2694-233X

William M. Sage,

Healthcare Systems and Challenges

Book Review Health AffairsVol. 36, No. 2: The Work/Health Relationship Poor Relations: Connecting Waste, Need, And Health SpendingWilliam M. Sage Affiliations William M. Sage ( [email protected] ) is the James R. Dougherty Chair for Faculty Excellence at the University of Texas School of Law and a professor in the Department of Surgery and Perioperative Care at the Dell Medical School, both in Austin. PUBLISHED:February 2017Free Accesshttps://doi.org/10.1377/hlthaff.2016.1555AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSCosts and spendingResearchersPopulationsCancerPhysician shortagesPhysiciansMedicareSystems of care More than forty years before Saturday Night Live parodied presidential candidates Donald Trump and Hillary Clinton, the show’s inaugural season featured faux advertising for “New Shimmer”—a mysterious creamy aerosol that original cast member Gilda Radner praises as a floor wax but that Dan Aykroyd, playing her husband, claims to enjoy as a dessert topping. Their staged argument is resolved by pitchman Chevy Chase, who cheerfully declares New Shimmer to be both a floor wax and a dessert topping. Richard “Buz” Cooper, who died shortly before the publication of this fine first book (the capstone to an illustrious career in academic medicine), shared something with Radner in addition to their untimely passing from cancer. He and Radner’s widower, comedian Gene Wilder—whom the world also lost in 2016—attended high school together in Milwaukee, Wisconsin, in the early 1950s. As Wilder built his acting career, Cooper trained in medicine, specializing in hematology. He founded the Abramson Cancer Center at the University of Pennsylvania, returned to Milwaukee to become dean of the Medical College of Wisconsin, and ended his career back in Philadelphia at the University of Pennsylvania’s Leonard Davis Institute of Health Economics.Poverty and the Myths of Health Care Reform was born of controversy. Cooper spent much of his professional life studying the health care workforce and in the 1990s correctly predicted a looming shortage of physicians, including specialists, when other authorities projected a surplus. By asserting the value to society of training more specialists, Cooper’s analysis eventually came into conflict with research from the Dartmouth Institute for Health Policy and Clinical Practice, publishers of the Dartmouth Atlas database, which mainly attributed unwarranted geographic variation in medical costs to the profligacy of excessive specialization. Where Cooper saw quality, the Dartmouth Atlas researchers saw waste and harm. Cooper’s standing disagreement with those researchers, some of it aired in the pages of Health Affairs, is his book’s raison d’être. In the book, Cooper draws on local and regional demographic patterns—some long-standing, others evolving—to argue that poverty rather than specialist oversupply is the principal driver of geographically variable spending. The book opens with a ride on New York City’s legendary “A” train as it leaves the Bronx, bends around Manhattan, and races on to Brooklyn—and it documents an inverse relationship between the socioeconomic status of each neighborhood along the train’s route and the hospital spending the neighborhood generates. The book takes similar journeys through Milwaukee, Los Angeles, Boston, and New Haven, Connecticut (differences between the last two cities constituting, to Cooper, the creation myth of the Dartmouth faith), and for each location argues persuasively that the demographics of poverty, not “supplier-induced demand,” accounts for differences in health care spending. Cooper is less successful at shedding light on larger regional variations in US costs and care; the book offers a “brief cultural history of the eight nations” into which he divides the United States that is long on generalization and cultural stereotype but short on scholarly and empirical support.Although not as entertaining as the Radner-Aykroyd debate over the uses of New Shimmer—and, sadly, not as good-natured—Cooper’s re-engagement with his Dartmouth adversaries convinced me that Chevy Chase had the right idea after all. Like New Shimmer, health care spending is both a floor wax and a dessert topping. It is a floor wax when it restores luster to the foundation of human potential—relieving suffering that is often associated with poverty and what we now call the social determinants of health. It is a dessert topping when it adorns an enticing (but often unhealthy) indulgence—and becomes a symbol of professional gluttony instead of the satisfaction of patient need.Once one accepts that a combination of social and professional determinants drives health care expenditures, Cooper’s book offers surprising insights. One is the difference between Medicare spending, which largely reflects high utilization and the demographics of aging, and private spending, which is more a function of price than of volume. Another is the historical trend of spending on richer compared to poorer patients. According to Cooper, the amount spent on health care for the poor was only 60 percent of that spent for the rich in the late 1960s but grew to 150 percent by 2010, with the crossover point in the mid-1980s. Only a small amount of that shift reflects population aging or the epidemic of chronic disease. More is attributable to the passage and expansion of Medicare and Medicaid (including their prohibition on racial discrimination).In other words, US health care in the post-Medicare era is a major redistributor of society’s resources from the rich to the poor. (This is most true year-by-year—over a lifetime, the higher mortality associated with poverty reduces the progressivity of redistribution). Taxpayers willingly support rescue services for the poor and elderly, and they trust physicians to spend their money ethically and competently. It is equally clear, however, that redistributing resources through health care is grossly inefficient: Services are expensively produced yet often ineffective, prevention is neglected, social problems are medicalized but not solved, and—once the health care system has taken its generous cut—fewer public funds remain available to support basic social services that might have a greater impact at a substantially lower cost.Ironically, acting on Cooper’s belief that one must relieve poverty to decrease medical spending therefore depends on the health care system’s being just as wasteful as the Dartmouth researchers (and many others) have asserted—not a myth at all. There might be both logical and empirical flaws in the Dartmouth approach, but, in my opinion, no other corpus of health services research has done as much to open US policy makers’ minds to the possibility of building a health care system that is not only cheaper and more accessible, but better as well. Breaking away from a hospital-centric model, tempering physician control, paying for outcomes instead of inputs, and moving care upstream into communities can free up billions of dollars to invest in education, health, and economic opportunity. Cooper himself acknowledged this potential in his strong support for the nursing profession. Building solidarity to both redesign medical care and shift public resources to social services that can more effectively relieve poverty and confer opportunity should be our national project. Cooper gets the last word against the Dartmouth crowd in this valuable, posthumously published book, but I hope that scholars and policy makers will take note of the important synergies that underlie their dueling perspectives. Cooper indeed offers a poor explanation for why health care spending is inconsistent as well as excessive, but his argument would be a poor excuse for failing to reduce it. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 February 2017 Information Project HOPE—The People-to-People Health Foundation, Inc. PDF download