The State Of Medical Care, 1984


FEW PEOPLE ARE as well qualified to assess the U.S. medical scene as David E. Rogers. Formerly chairman of the Department of Medicine at Vanderbilt University and then dean of the Johns Hopkins University School of Medicine and medical director of Johns Hopkins Hospital, he has since 1972 been president of the Robert Wood Johnson Foundation. The foundation was established on a modest basis in 1936 by Robert Wood Johnson, head of the pharmaceutical concern of Johnson & Johnson. Today, with assets exceeding a billion dollars, it is among the largest of foundations in the United States. From his office in Princeton, New Jersey, Dr. Rogers continually monitors the status of the number and geographical distribution of doctors, the huge cost of medical care, the training of medical professionals, and the role of the hospital; and from the foundation has come an array of programs and studies designed to benefit the health of Americans. Dr. Rogers—who is the son of the noted psychologist Carl R. Rogers—also keeps in close personal touch with medical practice by donning the traditional white coat for several weeks each year to make rounds as a visiting consultant at the New York Hospital-Cornell Medical Center, where he was originally trained as an internist more than thirty years ago.

How good is U.S. medical care today?

Our health is better than it has ever been before. There has been astonishing progress in just the past fifteen years. For a couple of decades before that, life expectancy had not increased much, but starting in 1968, the American death rate began to drop, and by 1980 the expectation of life at birth had grown by three and a half years. Infant and maternal death rates have plummeted, and death rates for black newborns have dropped an unbelievable 41 percent.

What brought this about?

It’s mainly the result, I think, of programs that were put into effect in the mid-1960s. Greatly expanded private health insurance programs coupled with Medicare, Medicaid, the neighborhood health centers, and the whole range of Great Society programs. Back then we realized that although we had some powerful technologies at our command, we were not delivering them to the American people on an equitable basis. Many people were badly underserved, especially the poor, the blacks, and the Hispanics. The programs worked. We’ve made remarkable progress in moving these people into the mainstream of American health care, so that now poor people are seeing doctors as often as others are, black people are seeing doctors as often as whites are, and people generally are healthier. Ten of the fifteen major killers of Americans are on the decrease, even in an aging population. The country has done a superb job. I only wish that our success was better known.

How so?

Because there is a danger that many of these programs will be dismantled, which could be tragic. To deal with our economic problems, we are cutting back sharply on social expenditures. In the medical care sector this could be tricky. For example, for several years we’ve been dropping people from the Medicaid rolls, which could be expensive in both human and economic terms. I think that’s penny wise and pound foolish.

The maximum duration of human life probably has not changed much in 100,000 years: it averages eighty-six years.

But it’s easy to see why the politicians got worried about the expense. We’ve all been reading about how the cost of Medicare and Medicaid has escalated. What happened?

Something quite unanticipated took place. The way the legislation was originally structured, Medicaid was targeted primarily for younger people, poverty-level mothers with dependent children and the like. What the legislators did not foresee was the drain put on the system by oldsters, for whom Medicaid was a payment of last resort. Many older people who found themselves destitute because of health catastrophes ended up in nursing homes. Medicaid was the only program that could help them. In a number of states as much as half of all Medicaid funds are now going to support older people in nursing homes. Just the other day I was talking with someone whose primary concern is the welfare of children, and I asked him what he felt was the major problem for them. Without hesitation he said, “The elderly.” He meant that ‘many of the dollars that we had thought would be going for the nurture of our youngsters were being gobbled up in the care of the aged—and this could hurt the youngsters.

Sometimes it does indeed appear that we are being brought face to face with the repercussions of all the medical progress of recent decades; people are not dying the way they used to. They live a lot longer, and therefore we now have to spend money to care for them.