You say managed, I say mangled,
let's call the whole thing off?

"Torture by H.M.O." "Managed Health Care's Future Looks Frightening." "Your Health or Your HMOs?" "The Scary New World of Health Care." These are only a few recent examples of passionate editorial tirades against managed care. News stories aren't much more positive: Typical headlines include "Backlash Against HMOs," "Elderly, Poor Patients Don't Fare As Well in HMO," "States Crack Down on HMOs' Abuse of Power," "HMO Tells Physicians to Cut Back Specialists," and "How Your HMO Could Hurt You."1

We have been bombarded with horror stories -- many accurate -- about plans that kick patients out of the hospital the day after childbirth or a mastectomy. The evils of health maintenance organizations are now fodder even for the entertainment industry; in several "ER" episodes, a doctor has been unable to deliver the care he thinks best because the big bad HMO is holding down costs. Says David Rothman, director of Columbia's Center for the Study of Society and Medicine and author of the just-released Beginnings Count: The Technological Imperative in American Health Care (NY: Oxford, 1997), "I'd be hard pressed to think of any medical innovation that has been greeted with this much hostility."

In a time when newspapers are desperately in need of advertising dollars, and their coverage of most corporations tends to be about as critical as a press release, the HMO horror stories provide welcome reassurance that muckraking is alive and well. But do they create a fair picture of managed care?

Scholars are divided on this, as on every other question related to health care in America. Barron Lerner of Columbia's College of Physicians & Surgeons and the School of Public Health -- physician, medical historian, ethicist, and assistant professor of medicine -- thinks the coverage has been "reasonably balanced, once you get past misleading terms like 'drive-through mastectomy.'" Lerner also points out that the scandal stories have been useful, spurring legislation in many states to improve HMO regulation.

On the other hand, "there are cases for managed care," Rothman argues, "and they are never made." The U.S. health care system, despite being -- with some 40 million uninsured -- less accessible than that of any other developed nation, is also far more expensive. Managed care has the potential to curb the overtreatment that Rothman claims is jacking up those costs. "What the coverage emphasizes is that the physician has a financial incentive to do less." But, he wonders, "why wasn't anybody worried about incentives to do more?" In bringing down costs, Rothman argues, managed care could improve the long-term prospects for -- get ready for a phrase you may not have heard in a while -- national health insurance.

The raging backlash against HMOs heated up in early 1996, when Harvard physician David Himmelstein spoke out against gag clauses (the stipulations in doctors' contracts not to make referrals outside their plans or not to tell patients negative things about the plan) on "Donahue" -- and was promptly dropped from U.S. Healthcare. His dismissal sparked hundreds of sympathetic articles and editorials. Himmelstein is, with Dr. Steffie Woolhandler, co-founder of the Boston-based Physicians for a National Health Program (PNHP). Unsurprisingly, he's gotten a lot more press attention for criticizing HMOs than for his years of advocating a Canadian-style health plan.

Groups like PNHP are hoping to use the widespread dissatisfaction with corporate-run health care to build support for single-payer health insurance. But you wouldn't know it from reading most newspapers; single-payer -- indeed, any alternative to managed care -- is generally left out of the conversation. Often, Lerner observes, the coverage implies that things were just fine before managed care came along, when most care was on a fee-for-service basis. But in fact, health care was then pretty much as it is now: too costly and not accessible enough. Lerner says, "It is pretty much out of the question to go back to fee-for-service."

Today's nostalgia for the fee-for-service system is a symptom of a common media ailment: amnesia. In the early 90s, the press was critical of the state of American health care and supportive of reform efforts. In September of 1991, Minneapolis's Star-Tribune ran a three-part series called "Health Care is In Crisis"; such coverage was typical. But what were favorite remedies of editorialists back then? A two-part New York Times editorial (Dec. 2 and 3, 1992) spelled out the consensus -- "The Answer: Managed Care." Now it's hard to remember what the question was.

It's even unclear whether fee-for-service and HMOs differ in the quality of care. Rothman and Lerner agree that the research is inconclusive, but Rothman says, "So far, you can't show substantive differences between fee-for-service and managed care." Some kinds of managed care plans perform better than others, adds Lerner, but he's observed that the coverage tends to lump all HMOs together without distinguishing between them. Such blanket coverage leaves it unclear whether the system can be improved.

In a sense, the media coverage of health care resembles its coverage of countless other issues: anecdotes about the problems of individuals, overshadowing larger questions about what's good for society. "From the perspective of the individual," Rothman points out, "there are problems with managed care. Its benefits are in the aggregate. The press takes the side of the individual." The big question is: How are we going to contain costs and provide universal access to care? Will managed care help us do that? Rothman says maybe. PHNP says no. And the national media have barely entered the conversation.

Related links...

  • The HMO Page

  • Physicians Who Care, national anti-HMO organization

  • "HMOs---The Death Of Medical Ethics," Physicians Who Care newsletter

  • "The HMO backlash," CNN, November 5, 1997

  • Managed Care On-Line news menu

  • Atul Gawande, "Of Course You Don't Like Your HMO," Slate, October 24, 1997

  • Sally McLain, "Managed (or Mangled?) Care: Impressions and Experiences," P&S Journal: Winter 1997

  • U.S. News and World Report guide to top HMOs

  • U.S. News 1997 HMO rankings, October 13, 1997

  • Fight Managed Care! (advocacy site)

    1. Headlines, respectively, are from The New York Times, 3/15/96; Sun-Sentinel (Fort Lauderdale), 1/1/96; Wilmington Star-News, 1/1/96; Chicago Tribune, 12/21/95; Time, 4/14/97; Chicago Sun-Times, 10/6/96; Chicago Tribune, 4/15/96; Sun-Sentinel, 5/31/97; and U.S. News & World Report, 1/15/96.

    LIZA FEATHERSTONE is a free-lance journalist whose work has appeared in The Nation, Salon, Columbia Journalism Review, and other publications.

    Illustration credit: Debra Solomon

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