One of the goals, and pleasures, of my Gap Year is to read and reflect. I recently finished Ike’s Bluff by Evan Thomas, a 484-page look at Eisenhower’s presidency seen through the lens of his nuclear weapons policy which he never fully articulated. Now what does that have to do with healthcare reform?
Bear with me. It was Eisenhower’s 1961 Farewell Address that crystallized my thoughts about the Medical-Industrial Complex. With that in mind, I invite you to accompany me as I parse the words of Ike’s most famous speech, delivered over half a century ago, and explain how it foreshadows our current healthcare crisis.
Of course, Eisenhower did not rail against the Medical-Industrial Complex in his speech. The term didn’t exist and wasn’t used until a decade later. It was inspired by President Nixon’s 1971 National Cancer Act, commonly referred to as the War on Cancer.
In his Farewell Address, which he spent two years writing, Ike laid out his concerns about the Military-Industrial Complex that had grown up around him. He fought this growth throughout his presidency as the arms industry created new weaponry which begged to be used and the Defense Department grew exponentially while simultaneously seeking justification for its existence. At the same time, the news media was hammering away at the “missile gap” favoring the Russians and thereby stirring the fears of the populace and Congress.
While he was in the White House he knew that he could control these vast interests. With his departure he was uncertain that the next President would be able to do so. In the book, Thomas writes that the Iron Triangle (the contemporary term for the incestuous relationship of Congressional-Industrial-Military interests) “drove the defense budget ever higher, whether the increases strengthened national security or not.” (Italics are mine.) Ike shortened the term to Military-Industrial Complex in his speech, omitting the word Congress “out of respect for the other branch of government,” writes Thomas.
Ike suggested that the Iron Triangle not only increased the risk of additional conflicts but also institutionalized a level of spending that would mortgage our grandchildren’s futures.
Ike’s speech eloquently foreshadows what has come to pass: unchecked cost without measurable benefit
I believe that Ike’s speech merits more detailed parsing with the Medical-Industrial Complex in mind and our children’s future at stake. Why? Because unchecked cost without measurable benefit is unjustifiable and potentially destructive and because his speech eloquently foreshadows what has come to pass.
I should say that I am not the first to note the parallel between the Military-Industrial Complex and the Medical-Industrial Complex. My intent is to go deeper into the comparison and to make the key point above.
In parsing Ike’s speech there is no need for us to maintain comity with Congress. Whenever Medical-Industrial Complex appears we should think, at least, of the three-sided Iron Triangle. As a more apt metaphor, we should envision the Octagonal Constrictor Knot of (1) health care providers and (2) health care systems (Medical); (3) pharmaceutical companies, (4) medical technology companies and (5) insurance companies (Industrial); (6) government regulators and (7) government payers, i.e. Medicare/Medicaid (Congressional); and (8) the entity of “ tainted research” spread unevenly over all.
You can read Ike’s 1961 Farewell Address in full here.
Below, for your convenience, I have copied paragraph IV, the pertinent section of the original speech. Following this is my adaptation for today’s healthcare crisis.
Excerpt From Ike’s 1961 Farewell Address
Our military organization today bears little relation to that known by any of my predecessors in peacetime, or indeed by the fighting men of World War II or Korea.
Until the latest of our world conflicts, the United States had no armaments industry. American makers of plowshares could, with time and as required, make swords as well. But now we can no longer risk emergency improvisation of national defense; we have been compelled to create a permanent armaments industry of vast proportions. Added to this, three and a half million men and women are directly engaged in the defense establishment. We annually spend on military security more than the net income of all United States corporations.
This conjunction of an immense military establishment and a large arms industry is new in the American experience. The total influence – economic, political, even spiritual – is felt in every city, every State house, every office of the Federal government. We recognize the imperative need for this development. Yet we must not fail to comprehend its grave implications. Our toil, resources and livelihood are all involved; so is the very structure of our society.
In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.
We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted. Only an alert and knowledgeable citizenry can compel the proper meshing of the huge industrial and military machinery of defense with our peaceful methods and goals, so that security and liberty may prosper together.
Akin to, and largely responsible for the sweeping changes in our industrial-military posture, has been the technological revolution during recent decades.
In this revolution, research has become central; it also becomes more formalized, complex, and costly. A steadily increasing share is conducted for, by, or at the direction of, the Federal government.
Today, the solitary inventor, tinkering in his shop, has been overshadowed by task forces of scientists in laboratories and testing fields. In the same fashion, the free university, historically the fountainhead of free ideas and scientific discovery, has experienced a revolution in the conduct of research. Partly because of the huge costs involved, a government contract becomes virtually a substitute for intellectual curiosity. For every old blackboard there are now hundreds of new electronic computers.
The prospect of domination of the nation’s scholars by Federal employment, project allocations, and the power of money is ever present and is gravely to be regarded.
Yet, in holding scientific research and discovery in respect, as we should, we must also be alert to the equal and opposite danger that public policy could itself become the captive of a scientific technological elite.
It is the task of statesmanship to mold, to balance, and to integrate these and other forces, new and old, within the principles of our democratic system — ever aiming toward the supreme goals of our free society.
[End of excerpt. Other versions of Eisenhower’s Farewell Address including his speaking notes.]
Now, please read my modification of this section of Ike’s speech. You will note that I have added parenthetical phrases to expand on the semantic substitutions. I hope you will read my adaptation with Eisenhower’s gravitas in mind.
Harrington’s Adaptation of Ike’s Farewell Address
Our health care system today bears little relation to that known by any doctors or patients prior to 1940 when a simple country doctor and a small hospital supplied adequate care to most citizens.
Until the middle of the last century the United States had no health care industry. American physicians could care for most illnesses they saw then, and with time and as required, they could slowly advance medical technology and the acquisition of new skills.
But we can no longer risk emergency improvisation of health care (improvisation leads to mistakes and patient safety must be paramount); we have been compelled to create a permanent health care industry (health care delivery systems, insurance companies, pharmaceutical companies, medical appliance companies, government agencies, regulatory agencies and research organizations) of vast proportions.
Added to this, tens of millions of men and women are directly engaged in the health care establishment. We annually spend 18 percent of our GDP on health care (the U.S. is number one in the world for health care expenditures but number 36 in developed countries for health care outcomes).
This conjunction of immense health care delivery systems and a large medical supply industry is new in the American experience. The total influence – economic, political, even spiritual (we defer to the false comfort of technical support at the end-of-life rather than the spiritual comfort of understanding and acceptance) – is felt in every home, every city, every Statehouse, every office of the Federal government.
We recognize the imperative need for this development (advanced medical care is complex and does require large systems). Yet we must not fail to comprehend its grave implications. Our toil, resources and livelihood are all involved; so is the very structure of our society (too much advanced care wastes money, saps resources, undermines our future and robs us of our humanity).
In the councils of government down through the doctor patient relationship, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the medical-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist (as long as the powerful lobbyists for the pharmaceutical, insurance and medical technology industries manipulate our lawmakers, our researchers, our physicians and our advertising).
We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted. Only an alert and knowledgeable citizenry can compel the proper meshing of the huge industrial and medical machinery of health care with our peaceful methods and goals, so that security liberty and wellness may prosper together.
Akin to, and largely responsible for, the sweeping change in our industrial-medical posture has been the technological revolution during recent decades.
In this revolution, “research” and the resultant technology have become central; it also becomes more formalized, complex and costly (both in terms of dollars and human capital as the research is tainted by commercial interests leading to dishonest results and, therefore, wasted treatments). A steadily decreasing share is conducted for, by, or at the direction of, the Federal government (which might otherwise act as a constraint on research driven largely by financial gain).
Today, the solitary practitioner, delivering care in his office, has been overshadowed by task forces of scientists in laboratories followed by their PR machines promoting expensive and unproductive care. In the same fashion, the free university, historically the fountainhead of free ideas and scientific discovery, has experienced a revolution in the commercialization of research.
Partly because of the huge cost involved, a government contract becomes virtually a substitute for intellectual curiosity. For every old paper chart there are now thousands of screens of electronic medical records (and with the push of a button the EMRs replicate records inducing physician/reviewer fatigue but satisfying regulatory requirements for reimbursements for care that may or may not have been delivered).
The prospect of domination of the nation’s medical scholars and physicians by Federal and commercial employment, project allocations and the power of money is ever present and is gravely to be regarded.
Yet, in holding scientific research and discovery in respect, as we should, we must also be alert to the equal and opposite danger that public policy could itself become the captive of a scientific-pharmaceutical-technological-insurance administration and “free-marketer” commercial elite.
It is the task of physician leaders and statesmen to mold, to balance, and to integrate these and other forces, new and old, within the principles of our democratic system—ever aiming toward the supreme goals of our free society.
– End of adaptation by SPH
“We have met the enemy and he is us”
The quote is from Walt Kelly’s long-running cartoon strip, Pogo.
How can we, as citizens, potential patients and health care providers regain control of this situation? An educated citizenry and an enlightened, humanistic physician corps would be a first step. A second step would be to amplify and focus the outrage we should feel at the commercial excesses of all parties.
That is my intent in this and future posts. I will be highlighting various excesses which frequently approach and occasionally breech criminal activities, and I will explain how damaging they can be. I look forward to your feedback and comments.
What a powerful well thought out reflection. Your gap year is being well spent. Kudos to you
Superb. Now you need to start a chain of examples based on your personal experience and observations from what happened around you. It will help, in my opinion, if you can point at least in the general direction of fixes to the problems you identify.
Wow! Great job. This is a vital topic–important to every citizen–and this post deserves broader circulation. I encourage you to continue your exploration.
Roger, thanks hugely. Your encouragement for the blog means a lot!
You are so correct to make this analogy. Please continue to educate the American public since it is the consumer who holds the power to decrease costs and improve the health of the nation. JTH
A nice treatment of an obvious scam which is the medical industrial complex. If you are employed by a corporation then you are in good shape because the net cost of medical care is reasonable with large corporation insurance.
But if not then you are screwed. As a small business or private individual you first pay an outrageous insurance premium and then if you ever need service you make a co-payment or have a deductible which equals the actual value of the service provided. It definitely chases people into corporate jobs.