P. Infrastructure

Rosemary Stevens joins the author in a last round of history — social insurance and the Blues are sung — Medicare, utilization review and DRG's identified as Important Changes — investor-owned hospitals and HMO's tapped — Charles Sabel returns to discuss guiding rules, tacit norms and fixed costs — Adrian Gropper enters — Adrian's notion of infrastructure dissected.

The following two chapters make frequent reference to two of the interviews with Adrian Gropper. The first interview recorded in November of 1998 and the second in March of 1999.

1. In healthcare, infrastructure is the product. So argues Rosemary Steven's book In Sickness and in Wealth [Stevens89], which tells the story of Healthcare from the New Deal onwards as the story of the struggle to fairly distribute access to an infrastructure of medical technology. The national medical enterprise she traces is one of massive concentration of resources in the infrastructure of healthcare— developed during the height of corporate administrative capitalism, under assumptions of a non-mobile population centered in cities, economic security centered in life-long careers and research and construction funding from some of the most generous federal institutions in the history of America (NIH and Hill-Burton, among others). The infrastructure that developed, therefore, has sat for years like concrete at the bottom of an economy that now insists on having water everywhere.

2. Stevens book updates a less convincing, often read earlier work by Paul Starr, The Social Transformation of American Medicine. Stevens book focusses on the twentieth century, and as a result of a focus on the relations of practitioners, organizations, institutions and technology, tells a much different story. Whereas Paul Starr's book narrates the history of healthcare as two long, uninterrupted narratives of medical authority and corporate power, Stevens story is a more subtle narration of the mechanisms of healthcare's bureaucracy as it has developed, and the strategic and technical relationships of government, professional societies, regulatory agencies, legislation, and technologies in the hospital system as it has evolved over the course of the 20th century.

3. The details presented in this chapter are drawn from Starr's book because I have identified them as either important political economic changes, or good examples of such changes. I find her argument that the infrastructure is the product compelling less because I believe her narrative, or trust her sources, but more because it resonates with the ethnographic questions I have concerning my informants attacks on the current healthcare system. Steven's book has been critiqued for it's weak organization and her conclusions on the potential role of the voluntary hospital [1]. It's chapters on the Progressive Era organization of healthcare (chapters 3 and 4) have been supplemented by an excellent article on the function of "cooperation" (as word and concept) in organizing medicine at the time [2]. And the details of the relationship between healthcare and the government are given in much clearer and more plunderable detail [3]

4. Regardless of the texture of Steven's argument, the book serves well to specify some of the details of the development of healthcare infrastructure and organization. There is much macro-economic and historical speculation in healthcare, especially when it comes to business plans and funding and purchase decisions; discerning which of these narratives of the present are connected to recognizable changes in the past, and which use imagined changes as ideological justification for present decisions requires a detour through this history. As in the case of telecommunications and software development, progress and stagnation are often the most palpable motivators in healthcare. A sense of the inevitable is essential for motivation (I can't count how often someone has said "It's just going to be that way," or a similar version of same), and the actual vagaries of history are rarely exceptional enough to affect this, but neither should they be allowed to be sufficient.

Detour -->

5. Medicine organized in the early twentieth century. Or so it appears, with the growth of huge technological hospitals, the powerful professional consolidation of the AMA and AHA, the new practices of Fordism and Taylorism, and "cooperative medical practice." Donald Madison's article [Madison96], however, suggest that in the Progressive era "cooperation" was used as a motivating ideological tool for certain kinds of organizational structures. "Cooperation" it appears, actually hid "competition" of a particular sort. At the same time that wider progressive reforms led to the growth of professional and labor unions, "cooperative" medical association, according to Madison, stymied the actual organizational structure of cooperation that would lead to group practices in favor of strengthening competitive individualism. Hospitals, in this era therefore mimicked the bureaucratic corporation, becoming larger, more impersonal [4] at the same time that they suffered in trying to control the power and professional autonomy of competitive individualistic practitioners. The demand for the "integration" of the hospital begins here. This left early hospitals beholden to a variety of conventions that demanded different and potentially contradictory organizational structures: the local autonomy of private physicians, the national standards and accreditations demands of organizations like the AHA and the AMA, and some mix of tacit moral frames, including variously, charity, hygiene, religious values and spiritual uplift, and the "cultural" values of scientific public health, germ theory, preventive health care, diagnostic technology, occupational safety, and various knots of productivity and health.

6. This did not prevent hospitals from growing remarkably in size and complexity during this period, however. Until the thirties, the AMA had managed to resist any government intervention in Healthcare (Madison, p.479), but as with all industries during the creation of the regulatory state, such autonomy would be short lived. It is at this time that the issue of equalizing access to medical technology, according to Stevens, led to the creation of the Blues.

"The resulting Blue Cross plans were a major organizational innovation of the 1930s. By protecting workers against the high cost of hospital technology, the plans improved hospital access government (compulsory) health insurance for everyone. They provided voluntary hospitals with needed income, and they gave large employers the opportunity to support or guarantee services for employees who might otherwise seek "socialist" solutions (i.e. a governmental scheme)" (Stevens, 172).

7. Out of the Blue Cross/Blue Shield model, developed a national quasi-public healthcare funding infrastructure, differing markedly by state, but providing a model mechanism by which all subsequent schemes for funding healthcare would be measured. This success in the 1930s, alongside the hard-won successes of New Deal Progressives for the Social Security Administration and the expansion of the regulatory-administrative state is often narrated as one in a long series of defeats in the struggle for compulsory social insurance— specifically, government guaranteed health insurance. But the distance between success and defeat is ideology, and the opposition by physicians groups, employers, politicians to socialized medicine was opposition largely in name. As Stevens suggests, the resulting system, while sacrificing a state-imposed equality, and state-run hospitals (as in the case of the NHS in England) sought equality of opportunity, as in all things American. During the following forty years, despite its manifest inequalities, the schemes gained an image and a share of both public and private money that rivals the largest state-owned schemes, whether in healthcare or elsewhere.

8. The famous Hill-Burton Act of 1946 is a concrete example of the expansion of healthcare under this regime. A partnership between the U.S. government and the "voluntary" hospital system [5], overseen by a Federal Hospital Council, Hill Burton provided states with incentives to expand the national medical infrastructure with a small degree of national planning, but great freedom in the control exercised regionally (hence, among other more persistent histories, a medical system with vastly different quality across regional areas). Hill Burton (like the VA, also reformed during this period) rewarded an industrial model of organization in the hospital, in which hospitals became horizontally integrated centers offering a wide range of services to a constituent population (Stevens, 216ff). Though Hill-Burton outran itself by the early 60's, there is no denying that such a scheme, along with the far more successful invention of the NIH and its funding of research hospitals, constituted an occasioning of governmental responsibility to the quasi-public healthcare system. The AHA and the AMA, continued to play a role in attempting to standardize and control healthcare, and are examples of professionally-related corporatist regulatory bodies more akin to Labor Unions than they are often given credit for [6], even as today's doctors, angered by HMO's, consider precisely the possibility of unionizing.

9. Beginning in the early 1960s, healthcare entered a kind of self-diagnosed permanent crisis. [7] Just about every other statement on the state of healthcare, or every proposal for reform, has begun with some version of the phrase: "Healthcare is in crisis." From this period on, beginning with the medicare/medicaid legislation of Johnson's Great Society, the government has taken a much more activist role in attempting to organize healthcare— even if this has meant deliberately designing initiatives to incent private organizations to improve the financial aspects of healthcare. Debates over the possibility of voluntary planning on the part of hospitals and schemes for institutional competition have created a system of enormous diversity and complexity. The 1960's and early 70's also saw the reorganization of healthcare around a university-based regionalism (including the solidification of the primary/secondary/tertiary care distinctions) that was in no small part driven by the enormous prestige of academic medical research, the available funds in NIH and the NCI (after Nixon's War on Cancer). The DeBakey Commission reports on heart disease and stroke are one clear example of this particular form of expansion in medicine, based more on the possibility of distributing expensive technology to those who need it, than on the possibility of guaranteeing a minimum of care to everyone (Stevens, 284ff). Medicare and Medicaid stepped in to provide such a basis.

10. As Stevens puts it "Medicare gave hospitals a license to spend." (284) Medicare and Medicaid were cost-plus systems that represented a form of healthcare present nowhere else in the world. Hospitals and doctors were given incentives to spend extravagantly by the system, and the history of fraudulent billing and over-compensation that it created has yet to be told. But this history of medicare is no less striking than its success in bringing private insurers and federal bureaucracy together to provide care (even if not quite universal) to the elderly and the poor. The system of utilization review that would have curbed the growth of expenditures was, according to Stevens, seldom obeyed, despite its statutory mandate in the Medicare legislation. The struggle over the autonomous authority of doctors decisions that a utilization review committee represents is one of the most poignant of the last thirty years, and forms the basis for much of the anti-managed-care rhetoric that doctors and nurses engage in today in discussions of, for instance, "order-entry," (the equivalent of real-time utilization review, and representing, for most doctors, the ultimate form of control over their autonomy).

11. Utilization review aside, the particularly sharp increase in healthcare costs during the sixties and seventies is often also attributed to the explosion of diagnostic technologies and expensive and commonly needed procedures (e.g. coronary artery bypasses). Whatever the reasons, the cost, and however they are measured, the result has been a continued experimentation with forms of financing, reimbursement, and most importantly techniques of utilization review and outcomes measurement. Rhetorically, hospitals have been trapped in the crisis-speak of, on the one hand, increasing profit-maximization goals, corporatization and the sacrifice of patient care, and, on the other, ridiculed as some outmoded system of charity, asleep to the hard realities of distribution and inequality.

12. In the late 60's a new type of organization appeared: the investor-owned hospital chain (Stevens 297ff). Such chains of proprietary hospitals gave the healthcare industry a familiar corporate face, behind which the techniques of financial and capital management could be pursued in order to provide an additional alternative source of revenue to the reimbursement streams from insurance companies and Medicare. But this appearance by no means signified the end of government intervention in healthcare, but rather the opposite, in the form of a proliferation of agencies, legislation, and legal decisions in a desperate attempt to wrest healthcare from its perpetual crisis. Not-for-profit healthcare systems also appeared during this period, further complicating a scene all too easily polarized into laissez-faire free-market proposals and varieties of government regulation. HMO's first made an appearance in this context, as did legislation that aimed less at regulating existing business than planning the growth and distribution of healthcare— projects such as the comprehensive health planning agencies (CHP) (Stevens 306ff) and the certificate of need (CON) system that would effectively limit direct private capital expenditure towards areas that need it, or more likely, away from areas that didn't, and later the Health Services Agencies (HSAs) which replaced the CHPs.

13. In the early 1980's, standardization in medicine began to reach the public policy levels in the specific form of DRGs (Disease Related Groups) which were designed to make the government, as Stevens puts it "a more prudent purchaser of Medicare services." (Stevens, 323ff) Standardization in this instance, rests on an emerging capacity to control the statistical data associated with patients with some greater degree of flexibility. Hence, it appears possible to determine which diseases are associated with the highest costs, statistically, and mandate a schedule of reimbursement based on those statistics. Here we come one step closer to the kind of "Learning by Monitoring" that Sabel describes: given standards, hospitals can compare the amount spent, the hospital stay, mortality and morbidity, and just about any other statistic that can be measured and tabulated. But in the eighties and early nineties, as we will see, this meant that everyone designed or bought their own computerized accounting and patient record systems, since it was less the system, than the statistics that mattered [8]. While DRG's per se may not have been the most successful incentive or control on reimbursement, they represent what is today a status quo in healthcare: the statistical representation of disease. DRG's expand in two direction, toward the patient and towards the institution. Patients, such as Joe Dumit's sufferers (New Biomental Disorders), learn new subjectivities of disease, learn to first test positive for a disease, and only then to "have" it (In Dumit's studies, sufferers learn quickly that the medical system orders itself around classifiable diseases, and despite all subjective ministrations to the contrary, no doctor will diagnose a disease that is not standardized, not reimbursable, or not measurable). The development of personal and social movement based techniques for the navigation of such an environment are an instance of reflexive modernity [9]— a modernity responding to its own successes, but in a manner that is not planned by a central authority (though one purpose in unloading all the details of the growth of the regulatory state is to suggest that in America, modernity was always reflexive, just a bit less responsive). The other direction is the institutional direction: the reorganization of workflows, the specialization of practice groups, and in the furthest case, in the business school language of Regina Herzlinger: towards focused factories. This is "Learning by Monitoring" applied to the healthcare industry.

14. But recall that in the case of the (automotive) example that Sabel describes, the proximate cause of such monitoring is the reduction of fixed costs in order to increase efficiency in the design and innovation of a product (car). In healthcare, however, as long as the source of revenue is the deep pockets of medicare, or a rich fee-for-service insurance industry, there is no primary incentive to reduce infrastructure. On the contrary, there is incentive only to expand, since the funding source has such complete control over the kinds of treatments and diagnoses it will fund, and as long as reimbursement is not indemnified. But the entire healthcare industry — and this was inevitable at the point that medicare was reformed in the early eighties to curb the worst excesses of the cost-plus medicare system — has became the unwilling subject of a series of experiments in the gamut of fee-for service, indemnity, and capitation plans. During the last fifteen years of experimentation in reimbursement schemes, the industry has been flooded by all manner of management and business school students and theories that promise to implement cost-saving, cost-cutting, revenue-generating, revenue-enhancing techniques. Riffing off of the concept of the DRG and the increasing availability of disease statistics, a new generation of healthcare measurement has resulted in a new generation of healthcare crises: shortening hospital stays (in some cases, such as various surgical procedures, this is a success, but others, like pregnancy, it has ended up requiring legislation), refusals of services of all kind, the health maintenance organization telephone purgatory, and an entire new industry devoted to the measurement (quantification?) of quality. It is not clear that healthcare will reach quite the stage of efficiency that Sabel describes in the automotive industry— either because medicine abhors efficiency or because the legislative interference is so severe in healthcare— but it wont be for want of trying. Various techniques, such as evidence-based medicine, have emerged as examples of a certain kind of pragmatic, constantly revised medical practice, while the promises for a vastly improved medicine based solely on information flows is ever more common in the wake of the internet.

15. All of this depends, according to Sabel, on the pragmatic course between "guiding rules" and "tacit norms." What organizes industries, according to most social theory, is the division of labor, organically evolved in most cases, to create some combination of tacit norms of skill-based association, and/or guiding rules of corporate organization— unions, craft-guilds, professional societies, corporations. In order to understand this development, Sabel turns to pragmatism, in particular pragmatism as a philosophy of language that understands the relation between theoretical conception and practical knowledge as a recapitulation of language as a (the) common standard. That is to say, language is shared and commonly understood, but not so well specified that instances of misinterpretation don't challenge speakers to improvise and extend language. Pragmatism spells out this experience as one of everyday navigation of the self, and Sabel applies this to the development of learning by monitoring [10]. In this version of the division of labor, learning, or apprenticeship proceeds by reference to a constantly changing background of goals and demands.

16. If we keep in mind that the principal goal of these new organizational forms is the recovery of fixed costs (the principle goal of reorganization, that is, but it is difficult to assert that healthcare has a principle goal in anything), and that in healthcare those fixed costs— the infrastructure— are in fact the product (e.g. the access to diagnostic technologies, surgical procedures, and doctors as a kind of information infrastructure)— then it should be more apparent just what the internet represents as a possible infrastructure— and this is precisely the interest for Amicas. The focus on standardization should not signal a kind of simplistic recognition that standards and classificatory schemes do not capture reality completely [11], but rather that the evolution of forms is precisely a response to this— and pragmatism may in fact be the best mode of understanding the tension between a standardized classificatory medical industry and the role of discretion on the part of doctors, nurses, and administrators in nudging the system towards workability.

17. The internet, then, represents an alternative infrastructure, and this is apparent from discussions with Adrian Gropper and Sean Doyle, as well as by observing a painful recognition of this fact in the Partners Telemedicine Center. Moreover, the opposition of 'guiding rules' to 'tacit knowledge' also finds its sublation in the internet— specifically in the creation of internet standards according to an open process of monitoring whose motto, remember, is "no kings, no priests, just rough consensus and running code" and whose tag line is "it works." Such a measure of certainty is fundamentally a pragmatic one— and that it developed out of the institutions and communities of science is not surprising (cf. Lyotard on language gaming in science, introduction). Medical care stands to gain from such an infrastructural inversion (to borrow again from Geof Bowker), but only in specific and deliberate ways, not merely by virtue of the inversion itself.

The Internet Vision of PACS

18. Despite his education and career in the world of healthcare and hospitals, Adrian leans Amicas incessantly towards the "non-healthcare-specific." This fact could indicate a dissatisfaction with the practice of medicine (Adrian has an MD, but never practiced medicine), or more likely a love-affair with the cleverness of engineering and a fascination with machines, materials or media (Adrian was an undergraduate at MIT). Absent indication, it is good reason to be confused about the nature of the work that Amicas engages in. But more than simply being non-healthcare specific, Adrian's Amicas would be non-industry-specific, a tool for any trade, swiss army software. But this has less to do with ambition, and more to do with a sharp sense of the transformation of "infrastructure" by the internet.

19. In fine engineering fashion then, Adrian achieves clarity by dividing the world (i.e. healthcare) into "three natural players": "the people who are collecting the bits— modality vendors; the people who put terminals on desktops— which you can think of as application software vendors, and then there's everybody else who's basically infrastructure." This triad is not objectively firm, but serves the purpose of clarification for Adrian's arguments about the role of his company and the structure of the economy and the internet.

20. The first group, modality vendors, is easily imagined for Adrian. "Collecting bits" is an elemental technoscientific activity. It involves optics, signal processing, radiation physics, materials science, etc. X-rays, CT scanners, MRI, Ultrasound, Nuclear Medicine (the list seems to grow and shrink with the cycles of research) are "modalities." The modality vendors therefore includes anyone who designs and sells these devices (the most visible of which are large organizations such as GE and Siemens).

21. The second group, application software vendors, is much less clear. Here is concentrated the expertise of software engineers and applications programmers. In this instance, the word application is stressed, as one kind of software among others. It includes "the people who put terminals on desktops," which does not necessarily mean Dell, Hewlett-Packard, or IBM (obviously the distinctions are flimsy in the face of a corporation like IBM that has its fingers in everything), but rather companies like Microsoft, Peoplesoft, SAP, or with healthcare specificity in mind, HBOC-McKesson, Sunquest, Adac. The nature of the particular applications may also be more and less obvious— and this should become clear as Adrian discusses them— from the naturalized ubiquity of the "word processor" to, for example, a billing and eligibility program for a hospital and associated insurance firm.

22. The third group, the "everybody else," is infrastructure. The internet is Adrian's infrastructure. From this triad are excluded the people who once imagined themselves as infrastructure, specifically in radiology: film vendors, who "have no reason to exist." No reason because to allow a reason would concede the demand that the future be digital and that film and the waste that it represents be superceded. This exclusion does not necessarily deny the continued existence, diversification, or 'modernization' of film companies like Agfa, Kodak, or Poloraid. Film— the word 'film'— represents the workflow and the medium to be replaced, much in the same way as paper and "paperless" offices have been represented. "They [film vendors] might like to consider themselves infrastructure" precisely because they own the substructure of this workflow— film viewing cylinders, developers, light boxes, filing systems (i.e. glorified envelopes and file folders), and libraries and archives of film— an outdated, stony medium, installed in countless hospitals, clinics, and imaging centers around the world. Once the envy of every medical advance, X-ray films now represent only a sepia-tinted past. Words placed in the mouths of film vendors often sound like a parody of conservatism, atavism, or stasis (the protection of a market at the expense of technological innovation). But film vendors are not nostalgic monsters of a pre-modern era, they too have modernized, created the PACS industry and have replaced the film workflow with a digital version— Film viewing workstations, digital X-ray scanners, Digital and optical disk storage archives and in-hospital radiology networks. But this is still the same, in Adrian's version. This is simply a recreation of the film workflow in digital form, it doesn't change anything: it still brings the doctor to the data, Adrian wants to bring the data to the doctor. So infrastructure today is something else: "Microsoft selling [Windows] NT, Dell selling computers, or AT&T selling internet access." Again, the non-healthcare-specific nature of this infrastructure is stressed: "infrastructure as I am defining it has this characteristic of not being image or radiology specific, or healthcare specific for that matter."

23. The central and most important fact of this image of infrastructure is that it therefore "lends itself to the impact of standards beyond healthcare." Without standards there are only limited and specific solutions, with no possibility for scale. Standards jettison polysemy, but ramify polyvalence. A standard cannot be many things to many people, but, as Sean Doyle says, "the great thing about standards is that there are so many to choose from." Standards— in particular, internet standards— are what allow Adrian's image of Amicas to exceed its industry-specific origins. The infrastructure he speaks of is the infrastructure of the internet as it penetrates every industry, every activity, every organizational form (cf. Adrian's DI article). Recall that there are competing standards in question here. First, the networks the film vendors install, until recently, were local area networks not connected to the internet, using proprietary protocols (or perhaps in some cases TCP without being connected to the internet) of various sorts to transmit images. Amicas is all internet. Second, the DICOM standard for imaging is essential to Amicas for transmitting images (both because the radiology field demands that there be a rigorous standard for diagnostic technology, but more importantly, because it allows Amicas to communicate directly with the scanners, all of which are built to use DICOM), but it falls short of the potential the internet holds for image management. From Amicas' standpoint it should concern itself with standards for the "modality" and leave the rest to infrastructure and application software people.

24. Adrian's triad quickly undistinguishes itself— what matters is the data, not the package, and therefore the distinction between the application software and the infrastructure folds. This is how Adrian gets from radiology to nonspecificity.

25. The first of the players Adrian mentions (the modality vendors, X-Ray, CT, CR, NMR etc.) must of necessity remain "healthcare specific," even if the nature of CT and MRI lends itself to myriad uses, from looking for tumors to reading cuneiform tablets encased in clay (which was the topic of a scientific paper presented at the RSNA that caught everyone's eye). Nothing in the development of an imaging modality is fundamentally changed by the internet (except, significantly for someone studying that industry, the method of developing an imaging technology— the "learning by monitoring" of that industry), and as such it is, and should remain the most essential part of healthcare— the diagnostic technology that produces a steady data stream [12].

26. Adrian's second and third groups are less obviously separate, however. When adrian speaks of application software, he toggles between existing medical information systems that try to be all things to all people (and we will elaborate on these below), and application software— such as Microsoft Word—that is not specific to any industry. Adrian imagines such application software as specific to healthcare only by the addition of specialized dictionaries or other such information respositories that can be added into a software tool, that is, tools whose content is drawn primarily from medical expertise rather than primarily from software engineering. Adrian challenges:

"Do you think that there is a PeopleSoft for car manufacturers that is different from Peoplesoft for lawyers? No... Do you think that digital dictation systems from IBM are going to remain healthcare-specific, or will it just be that within a year, the med-speak for radiology is simply a new dictionary that costs $69.95. I challenge you to think of one example of a large scale software supplier, whether they be Oracle, PeopleSoft, SAS, that to corporate america, that you can say 'Oh, yeah, these guys are in the insurance business..."

27. Such examples of application software are not dependent on the internet for their non-specificity. They are tools that can be used across industries (across the division of labor?) for tasks that have been specified to the extent that only minor changes (changes the user can make) in order to specify them. These tools are already present in Healthcare (Partners, for instance uses Microsoft Windows and Office products, and Peoplesoft Accounting tools). But what about the tools for radiology, must they be developed specifically for radiology? Not if one imagines the world alongside Adrian with application software designed unto an infrastructure. The distinctions that Adrian relies on are meant to clarify his position, to him and to me. They toggle description and desire, because healthcare's traditionalism biases it towards a mixture of old and new, a temporal pragmatism of adulation in progress and constant braking against the same. They split an experienced fact, Adrian as observer of the healthcare industry, and imagined value, internet infrastructure as solution to the problem of information flow in healthcare. Observed healthcare, however, is filled with a lingering industry of healthcare and radiology information systems (HIS and RIS) companies. For Adrian's distinction to work, these companies must stay as they are, missing the internet boat, and doomed to an infrastructural model, a hospital, that recedes as fast into the past as the internet arrives on the horizon. Adrian's tripartite distinction is only as accurate as it is particular. Thus the second category splits into companies heading in opposite directions: Amicas towards the future, HIS and RIS vendors towards the past, doomed to diminishing returns in a non-growth sector of a forgotten economy.

28. The quasi-religious fervor of internet zealots (of which Adrian is a measured exampled) is based on the assumption that the impact of the internet has been under-appreciated, not over-hyped. This encompassing change is Adrian's non-healthcare specific stick. With it he beats not only the dead horse of e-commerce (the internetification of any product or service), but also hurries along a dying form of healthcare organization— if healthcare's infrastructure cannot be transformed from within by the handbooks of re-engineering or the regulations of governments, then let it be replaced from the outside.

29. The stakes here are a transformation of both healthcare and 'the market' of which healthcare is slowly becoming a proper part. Pause though, and specify exactly what has happened to American healthcare. From its origins, healthcare has treated itself as a business, not only that, but a particularly moral business. God's business. The hospital is a creature of the corporate era, and against all disavowals, regardless of the moral mission, the voluntary ethic, the hospital has envied the corporation and formed itself in that image. The macroeconomic changes (a Welfare state slowly defunding itself, and occasioning other actors to fill in; an unregulated world of financial capital, mobile, but nonetheless illiquid; fast fading trust in government control, Keynsian welfare techniques, or planned incentive structures) within which healthcare has dwelt in crisis have also seen it undergo a startling number of experiments in funding, reimbursement, liability controls. These changes, by any given measure (and there are plenty, and often very specific), are both good and bad. On the one hand it is too simple to assert, in cynicism or resignation, that healthcare has sold out, and that ruthless corporations now profit on sickness; on the other it is still yet dangerous to assert some version of hard-nosed "I-told-you-so" business realism that would evacuate responsibility from incorrigible suffering. Things changed, stayed the same, asynchrony reigns.

Last Modified 11-Sep-99 9:01 PM ckelty@mit.edu

Go Back to the Start