In December, I collected quotes from my Trinity students’ final papers and published them as Fontenotes No. 113: Voices of Tomorrow and a Message of Hope. These emerging health care administration leaders fill me with optimism that we will ultimately have the effective, efficient, caring, and equitable medical delivery system we all seek.
I was delighted to get an essay in response from a reader I’ve never met. Ronald L. Campbell, BS, MHA, LFACHE, ACP graduated from Trinity 28 years before I started my tenure as the adjunct health law professor. His perspective on the status of American healthcare after 50+ successful years as an executive is thoughtful and thought-provoking, academic, and poignant.
Whether you are a healthcare professional or concerned about medicine in America as a patient and community member, I believe you will appreciate Ron’s words. I expect many of you will disagree with portions of the essay; I do not ascribe to all he says. (It is also important to stipulate that neither Ron nor myself speak on behalf of, or as agents of, Trinity University.)
The year Ron graduated (1969), the first temporary artificial heart was transplanted. Non-invasive fetal heart monitoring wasn’t possible until 1973; the MRI wasn’t invented until 1979. (medical history resource) We conquered diseases and expanded not only lives- but also the quality of those extended years. And yet- as Ron so eloquently describes- the most critical patient we haven’t healed is our system itself.
With appreciation for the generosity of my new friend and colleague Ron Campbell, here are his contemplations.
A Glance Back and A Quick Look Ahead
Public Health Advocate
In January 1966, I matriculated at Trinity University as part of the first class of students in the Master of Hospital Administration program and graduated with an MHA in 1969.
In the ensuing 50+ years, I provided executive leadership with hospitals, nursing homes, home health care agencies, group physician practices, medical foundations, a statewide hospital association, and a state health department; in government, military, corporate-for-profit and not-for-profit organizations; planning, construction, opening and operation of new hospitals and clinics; acquisitions, mergers, and bankruptcy reorganization; consulting, including evaluating the private hospital system in South Africa; and currently in retirement as a public heath advocate and as co-host of Politics and Poetry podcast, www.politicsandpoetry.org.
The ink was still drying on the Federal Register in the Trinity library as I read and learned about the Social Security Amendments of 1965, Title XVIII and Title XIX, (note from Sarah: This is the legislation that created Medicare and Medicaid) enacted by Congress and signed into law by President Johnson. At the time, I had no idea of the extent and impact this legislation would have in the healthcare industry during my career—but it was huge and shaped the destiny of the healthcare in America.
However, only a few CPAs and physicians immediately understood the impact and how partnering/contracting with the government would practically guarantee sustaining huge profits from providing healthcare, even as the government guaranteed the payment of costs plus profit. The highly successful emergence of hospital corporations and other provider corporations ensued, and hundreds of insurance companies began providing healthcare insurance, much of it through employer benefits.
During my residency at a Texas county-owned hospital district, we began implementing a charge/billing system for the first time in a previously 100% tax-supported charity hospital. Since then and until now, I have experienced firsthand the steady decline of non-profit community hospitals in favor of for-profit companies amidst the administrative challenges leading healthcare providers face in delivering healthcare, with patients’ quality care and services as the paramount priorities, through FFS, HMO, PPO, POS, PBM, ERISA, ACA, etc. In the struggles among quality, services and price/profit, profit won, and profit continues to win. Support for not-for-profit healthcare and public health lost.
For all the talk about changing our healthcare system, it is extremely difficult to bring those visions to reality because healthcare is truly a complex adaptive system; because healthcare is reserved to the states, in part because the United States Constitution does not set forth an explicit right to healthcare; and because there are 50 different state Insurance Commissioners, regulating insurance plans, including prescription drug plans and pricing. The insurance companies and the big Pharma manufacturing industries are now the driving and controlling forces in our healthcare system. Their strategy of “divide and conquer” has been extremely successful and extremely profitable; and keeping the real cost/price obscured has also been equally successful and profitable.
Who lives, who dies, and who pays? It all depends primarily on whether one has comprehensive health insurance or not and/or on the short-term quarterly earnings targets for the shareholders. The ethical dilemmas confronting the healthcare executive are daily challenges in determining what happens in answering these questions.
Why is it usually considered okay to subsidize healthcare of employer-sponsored health insurance plans (with tax incentives for the employer and the employee), and why is it too often not okay to similarly subsidize healthcare of the unemployed and indigent population?
Our country has a highly profitable healthcare industry in which millions of people enjoy good but very expensive healthcare and at the same time, millions have inadequate or no healthcare. In a country as wealthy as ours, I believe we can/should enable healthcare as a right for everyone, and we all should enjoy the same healthcare that is afforded our congressional leaders. It’s important to understand how all the parts of our healthcare industry work in delivering healthcare; but it’s also important to understand the politics of our healthcare industry.
I believe the price/cost of healthcare (especially for individual plans) is egregious and ultimately unsustainable unless restrained and restructured. I also believe that everyone has a right to healthcare, but that right is not yet enabled. Our country did not ratify equal rights for women and is still engaged in the struggle for racial equal rights. Hopefully, one day the outcome will be equal rights for all; and perhaps then we can all work together for equal healthcare for all.
If our democratic republic survives and our government begins to look more like all our population with equality for all its citizens, maybe the ideal of healthcare for all can be realized.
The pandemic has impacted hundreds of thousands of people showing clearly who lives, who dies and who pays. Without safe, healthy workplaces and safe, healthy schools, our economy shuts down. Public health of everyone is crucial and fundamental to a thriving economy.
I still look to the future even though the past is ever present wherever we look. In the future, I believe genomic medicine and the integration of technology seems likely to have the most transformative impact on both the healthcare economy and on personal health and therein lies our best chances for a new and better day in healthcare.
My generation did not fail, but neither did we fully succeed. Nevertheless, I am optimistic and hopeful that as our next generation of students graduate and begin their careers, they will maintain the integrity of their ideals and bring a dedicated enlightened advocacy and focus in support of public health and of equal healthcare as a right for all. Surely some will emerge as stateswomen and statesmen who, with their knowledge of healthcare and political savvy, will provide the leadership to bring the vision of healthcare for all.
My thanks again to Ron for this and all his many contributions to health care over 50 years-
Sarah Fontenot, J.D., B.S.N., C.S.P, and Adjunct Professor, Trinity University is a popular speaker who brings clarity to health care legal and policy issues. Her twice-monthly newsletter “Fontenotes” provides clear information about today’s healthcare system. Click here to subscribe.