The Corporatization of American Health Care: The Rise of Corporate Hegemony and the Loss of Professional Autonomy

321 Pages·2021·3.426 MB·English

by  J. Warren Salmon, Stephen L. Thompson

J. Warren Salmon
Stephen L. Thompson
The Corporatization
of American Health
Care
The Rise of Corporate Hegemony and
the Loss of Professional Autonomy
The Corporatization of American Health Care
J. Warren Salmon • Stephen L. Thompson
The Corporatization of
American Health Care
The Rise of Corporate Hegemony
and the Loss of Professional Autonomy
J. Warren Salmon Stephen L. Thompson
School of Public Health College of Professional Studies
University of Illinois
and Advancement
Chicago, IL
National Louis University
USA
Chicago, IL
USA
ISBN 978-3-030-60666-4 ISBN 978-3-030-60667-1 (eBook)
https://doi.org/10.1007/978-3-030-60667-1
© Springer Nature Switzerland AG 2021
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
This book is dedicated to the memory of
Karen H. Thompson (1947–2016) and Dr.
Bernard H. Baum (1926–2008).
Preface
The American healthcare system frequently has been called a “non-system”; yet we
clearly interpret it very much as a coherent system—it is a system designed, much
the same way as other businesses in America are organized, for private profit-
making and return on investment.
We have relied heavily upon news sources as academic writing lags on current
topics of concern. At times, we may generalize, or seem abstract, in presenting
points, since we have absorbed an immense amount of knowledge to be sorted out,
synthesized, and presented over the past history of 150 years. Much of what we
focus upon contains numerous moving targets, changing weekly, often hidden or
obscured from the public’s attention. With the onset of the global pandemic caused
by the COVID-19 virus, the blatant weaknesses in our healthcare structure and with
the populations, not historically well served by the current system, have been laid
bare. The power structure and its tendencies for greed have been exposed with lower
socioeconomic communities and confined populations in nursing homes, prisons,
and detention camps particularly hard hit by this virus. The resultant economic
calamities caused by the preventive “stay-at-home orders” imposed by state govern-
ments also have created much harm (Nicola et al., 2020).
The approach of our book has been somewhat selective. There is admittedly
much more to make it complete, despite our extensive referencing. In the healthcare
system and outside of it, there needs much more detailed analysis of what we have
attempted to focus upon. Trump exclaimed, “Nobody knew healthcare could be so
complicated.” Well, we did understand how complicated our system is and still do
marvel at its complexity, even as we only begin to ponder the difficult reform
road ahead.
In our opinion, doctors are so key in the direction for reforming our healthcare
system, surely along with other health practitioners and scientists. Physicians often
determine the course of treatment and still have relative power in the system if they
choose to exert it in new and different ways for progressive directions. The roles and
relationships among health professionals can mediate in both the clinical realm as
well as for political action for the public’s health. Gaining renewed trust in the pro-
fessions by the public will be necessary to give them authority to perform and to
vii
viii Preface
maintain a relatively decent degree of professional autonomy and respect. First and
foremost, this comes with competent technical performance and a dedication to
both patients and populations. New resource allocations will hopefully not be too
abrupt; progress may go slowly even as difficulties are delineated and confronted.
An analogy may be that the protests in the summer of 2020 asking for changes in
policing are quite challenging, but clearly very needed. Popular sentiments on both
sets of issues must be listened to and understood so that the health system evolves
new responsibilities for the profession. We encourage the profession to live up to its
capacity and potentials.
So much confusion remains within the medical profession to interpret the ongo-
ing changes in medical practice. Much has been brought on by increasing adminis-
trative control and reductions in professional prerogatives. In the 1850s, Marx made
the point that today remains critical: Production thus produces consumption (Marx,
1857). When we examine modern medicine, it is important to note that true public
health needs are hidden by mere medical care utilization, which in the United States
has historically been individually centered, episodic, end-staged, highly tertiary
care-based, technologically reliant, curative-oriented, with little prevention, and
very, very costly, so thus profitable.
The lack of a public health focus is quite sad in that modern social epidemiology
demonstrates that people do get sick in predictable and preventable ways depending
on what socioeconomic status they possess. The waste of financial resources as well
as years of productive lives lost due to a shortsighted market-based approach to
healthcare is beyond tragic. We attempt to explain how and why this is happening to
address the policy question of who benefits by continuing to increase the reach of
such a flawed profit-based system.
What has evolved with the offered commodified form of services does not truly
reflect a patient’s, nor a population’s, health and well-being. The definition of health
has been argued and debated over time as modern medicine has been significantly
critiqued. We wish readers to ponder a newer broader concept of the public’s health
as they examine our writing: the sustenance of well-being of the entire population
apart from the clinical condition of a single individual patient’s designated utiliza-
tion of services. In the recent past, healthcare organizations have engaged in
increased efforts in population health, but what that often means is extending the
current system out into the ambulatory sphere for purposes of extending their brand
and creating greater opportunities for profit-making in the face of declining inpa-
tient revenues. Very few of these efforts are intended to actually do much about the
population’s well-being as it relates to the environments people live in, the endemic
health conditions in their neighborhoods, poor infrastructure, schools and services,
and general hopelessness.
Since the 1970s, corporate healthcare has been reorganizing the production of
health services, yielding new production techniques, producing many new products
and services, and reaping bountiful operating margins. While most of these entities
operate as so-called not-for-profit due to their historic origins, many operate as
though their prime directive is to generate surplus value rather than objective
improvements in community health. All of this is changing the relationships between
Preface ix
patients and health professionals. Through these processes, different expectations
and new needs have arisen so that these processes also create additional services
that production attempts to satisfy; nevertheless, these new services may not be
what is necessary to advance true public health. In short, the market attempts to
satisfy patients’ needs of those who can afford to pursue such perceived enhance-
ments by providing them with whatever service they may require while neglecting
those who actually need medical oversight of more mundane and lesser profitable
problems and who also possess limited ability to pay for much of anything.
Clearly, the means to satisfy health needs are constantly changing. Availability of
new technologies multiplies medical production possibilities and further offers
commoditized versions of what is to be consumed, usually with explosive costs. For
example, the pharmaceutical industry has come up with a plethora of drugs to
address adverse drug reactions created by other drugs. They advertise them directly
to consumers to have them create demands upon their physicians to prescribe them
with the latest medication for whatever they perceive ails them. Production requires
many people to buy into the system without questioning what we as a population are
getting out of the deal in terms of improved health status (O’Connor, 1974).
If we are to journey as a nation toward a more rational, effective, and humane
system of healthcare that sustains and improves the health of the entire population,
we need positive contributions to the development of health professional awareness
to resist the very corporate financial relationships being foisted upon them. Most
analyses of modern medicine have taken narrow, specialist, and mechanical views,
uncritical of the existing social order: the very social order that the COVID-19 pan-
demic has exploited and laid bare. Tendencies to alter such perspectives require
human efforts against the dominant interests that constrain varying professional and
consumer behaviors. There are connections between economic, social, cultural, and
political life that make it difficult for the average health professional to grasp.
Traditional health professional education fails miserably in preparing practitioners
for practice under the emerging conditions. Coupled with our nation’s limited sense
of history, this creates little clarity in health policy and its implementation.
One of us (Salmon) taught medical students as a community medicine faculty
member in the 1970s, when the organization, financing, and delivery of care was
being introduced into curricula. Rapid advances in science and technology squeezed
out such non-clinical courses in most medical colleges. Today, few curricula ade-
quately prepare most health professional graduates for the complexity of the emerg-
ing healthcare delivery system, though admonition for utilization management and
cost control lectures have worked their way into becoming common.
Fifty years ago, liberal faculty efforts sought to reduce “medical mystification”
over patients’ bodies, disease processes, and treatments chiefly to aid patients’
understanding for getting better. Inklings of such educational efforts are here again
today, but under the guise of patient engagement for containment of utilization and
cost reduction. More academicians are calling for new emphases on population
health, spurred forward by the COVID-19 awareness (Nash, 2020).
Today, consumers and professionals both face a highly complicated, constantly
changing healthcare system. A growing “administrative obfuscation” makes it
x Preface
difficult to grasp insurance concepts, making it far more difficult to ascertain federal
policy and rapid marketplace changes, and to comprehend the bases in most mana-
gerial decision-making over directions. The rapidly evolving system is manifested
most profoundly in the loss of professional autonomy; its effects are seen every day
in terms of physicians and nurses adhering to corporate treatment protocols, while
at the same time losing the ability to utilize the professional judgment and expertise
gained through their education and training. The growing burnout has much to do
with these changes and the internal conflicts, which are inherent.
This book’s chapters represent our ongoing assessment from different angles, so
what may appear to be redundancy is actually designed to reinforce the points. We
have reviewed and assembled a massive bibliography of literature relying upon aca-
demic experts who came before us as mentors in public health. We have also fol-
lowed many journalists who have become authorities on various topics, particularly
in the information technology sector. Publishing guidelines have restricted the use
of their insights using their own words as quotes, so we paraphrase and reference
with respect and appreciation as we strive to synthesize their contributions into our
analysis here. It makes for much to take in by the readers. We often delve into higher
levels of generalization in places to draw analogies to reveal how the healthcare
system reflects the larger American political economy.
One example is the concept of “development and underdevelopment,” where
growth gets fetishized in corporate advancement. Yet, such a process is always
accompanied by underdevelopment of a segment: one side grows, the other side
diminishes usually in terms of what procedures have the best payer reimbursement.
Whiteis and Salmon (1990) utilized this contribution by the economist Andre
Gunder Frank (1967) in establishing this dynamic of development/underdevelop-
ment of the proprietary health system growth across the 1970s and 1980s, amidst
the neglect and decline of public sector providers and certain “not-for-profit” hospi-
tals. Much of this wide disparity resulted from dynamics in the medical market-
place, but it was promulgated by the then health policy decisions—and still
continues to be!
The role of large corporations and powerful interests behind US healthcare and
its distortion of the healthcare system are a unifying focus of this book. We maintain
there is a clear relationship between production growth and the development of new
kinds of social organization in the health sector (Dreitzel, 1968). Now, most main-
stream observers rarely stray from the conventional and dominant perspective that
tends to support existing relations and hovers at micro levels of analysis. Thus, the
overall system gets little critique except for managerial rationalist tinkering in terms
of minor incremental corrections, usually for its legitimation; the overall structure is
assumed to stay intact, its directions and priorities are assumed to be immutable.
Nevertheless, the apparent contradictions in American healthcare are becoming
so evident to many more Americans these days: profits over people with widening
inequalities persisting and with the coronavirus exacerbating. This social reality is
increasing a fresh pondering of why things are the way they are, how they got that
way, and what should be done to avoid a continuation of decline.
Preface xi
We encourage other scholars and analysts to probe the downsides of corporate
health and help propose routes to find reasonable resolutions in a reform direction.
In short, there needs to be a re-examination of the American healthcare system that
has been created and ask the questions, “Is this the best we can do?” and “Is this
what the American public really wants and needs?”
Health policy academics have little to say to engage the broader American pub-
lic, many of whom seem to “get it” with their own personal critiques given their
mounting dissatisfaction long before the academic journals delineate problems.
Businesspersons, politicians, bureaucrats, and many professionals too often fail to
perceive the consumer/patient perspective, though efforts by healthcare marketers
are surely trying of late. Of course, these groups have a greater ability to control and
regulate health policies, but rarely do you see them choosing to compromise their
position when it runs counter to their vested interests.
As public health professionals, we seek a different and more holistic assessment
of human beings and their health in their daily, family, community, and work lives.
We see this at the collective level of groups of people; in fact, the entire population
in the social and ecological environments in which we all function. The experts,
specialists, and researchers usually work on individuals as separate unrelated enti-
ties in bits and pieces, not globally in their assessments of health. Notwithstanding,
the pandemic may be leading to a paradigm shift in public health as a younger gen-
eration of basic and clinical scientists forge a new outlook for addressing disease
patterns.
Chicago, IL, USA J. Warren Salmon
Chicago, IL, USA Stephen L. Thompson
References
Dreitzel, H. P. (1968). Die Gesellshcaftlichen Leiden und das Leiden and der Gesellschaft. Eine
Pathologie des Alltagslebens, Stuttgart, Perfect Paperback.
Frank, A. G. (1967). Capitalism and underdevelopment in Latin America: Historical studies in
Chile and Brazil. Monthly Review Press. Available via DIALOG. https://monthlyreview.org/
product/capitalism_and_underdevelopment_in_latin_america/. Accessed 12 June 2020.
Marx, K. (1857). Introduction to a contribution to the critique of political economy. Marxists.
Available via DIALOG. https://www.marxists.org/archive/marx/works/1857/grundrisse/ch01.
htm. Accessed 12 June 2020.
Nash, D. (2020). We need a retooled post-COVID-19 curriculum to emphasize the role of popula-
tion health. Modern Healthcare. Available via DIALOG. https://www.modernhealthcare.com/
opinion-editorial/medical-schools-should-emphasize-population-health-post-covid. Accessed
3 June 2020.
Nicola, M., Alsafi, Z., Sohrabi, C., Kerwan, A., Al-Jabir, A., Iosifidis, C., & Agha, R. (2020).
The socio-economic implications of the Coronavirus and COVID-19 pandemic: A review.
NCBI. Available via DIALOG. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162753/.
Accessed 12 June 2020.