Arnold Relman's Proposals for U.S. Health Care System Reform

Arnold Seymour Relman (1923-2014) was an American physician, medical researcher (in acid-base and electrolyte balance, nephrology, and renal physiology), medical school professor, editor, writer, and health care system reformer. He was born in Queens, N.Y., the younger of two children. His sister, Muriel (Relman Straetz), graduated from Smith College, the University of Rochester School of Medicine, and the Columbia Psychoanalytic Institute, and became a psychiatrist. His father, Simon Relman, was a businessman, and was also an avid reader who inspired his son to study philosophy.¹  Arnold's mother, Muriel (Mallach) Relman, was a cellist who nicknamed him “Buddy,” and he thus became known to his friends and family as “Bud.”² He attended Cornell University (graduating at the age of 19 in 1943 with a degree in philosophy), and graduated with a medical degree from the Columbia University College of Physicians and Surgeons at the age of 22 in 1946. He became assistant professor of medicine at Boston University School of Medicine (from 1951-1961), and then professor of medicine at Boston University (from 1961-1968,) and professor of medicine at the University of Pennsylvania (from 1968-1977), before becoming professor of medicine at Harvard Medical School and senior physician at the Brigham and Women’s Hospital in Boston (from 1977-1993). He served as editor of The Journal of Clinical Investigation from 1962-1967, and as editor of The New England Journal of Medicine from 1977-1991. In 1991 he became editor-in-chief emeritus of The New England Journal of Medicine (NEJM), and professor of medicine and social medicine at the Harvard Medical School. In 1993, he became professor emeritus of medicine and social medicine at the Harvard Medical School.  

      In 1953, he married his first wife, Harriet Morse Vitkin, with whom he had three children. Their marriage ended in divorce 40 years later.³ In 2009, he married his second wife, Dr. Marcia Angell, his colleague at the NEJM, who, after joining the editorial staff in 1979, became executive editor in 1988, and then interim editor-in-chief from 1999-2000. (She was the first woman to serve as editor-in-chief of the NEJM.)

      He was the recipient of many honorary degrees, including degrees from the Medical College of Wisconsin, Union University, the Medical College of Ohio, the City University of New York, Brown University, the State University of New York, and Temple University.

      He published numerous scientific articles, textbook chapters, journal editorials, and magazine articles, and he co-edited, with Franz J. Ingelfinger and Maxwell Finland, in 1966 and 1974, Volumes I and II of Controversy in Internal Medicine, which discussed the controversies surrounding the diagnosis and treatment of a variety of medical disorders.  His book, A Second Opinion: A Plan for Universal Coverage Serving Patients Over Profit, was published in 2007. He died in Cambridge, Mass., from complications of malignant melanoma, on his 91^st birthday, June 17, 2014.

      Dr. Jerome Kassirer, a nephrologist, bioethicist, editor, and writer who succeeded him as editor-in-chief of the NEJM, described him as “one of the foremost public policy thinkers in American medicine.”⁴   

      Dr. Marcia Angell, a medical pathologist, bioethicist, editor, writer, and health care policy analyst, described him as “a towering figure in American medicine.”⁵ In an article entitled “On Arnold Relman (1923- 2014),” (published in The New York Review of Books, Aug. 14, 2014), she explained that “under his leadership, the NEJM’s standing as the world’s most prestigious medical journal grew, and it became a source not just of new research results, but of thoughtful analyses of important ethical and policy issues in medicine.”⁶ She also explained that his dominant concern was that the American health care system was increasingly becoming a profit-driven industry, driven by market forces rather than patient needs, and that his proposals for health care reform were therefore twofold: (1) a single-payer public insurance system, with no investor-owned private insurance companies, and (2) a non-profit health care delivery system, consisting of multispeciality physician groups paid by salary within a set budget.⁷

      In a ground-breaking article entitled “The New Medical-Industrial Complex” (in the NEJM, Oct. 23, 1980), Relman warned of the rise of the “medical industrial complex,” a network of private corporations analogous to the “military-industrial complex.” The medical-industrial complex includes private hospitals, nursing homes, diagnostic laboratories, home-care services, dialysis units, emergency and urgent care services, ambulatory surgery centers, and other private for-profit corporations engaged in the business of health care. Other private for-profit health care corporations include pharmaceutical companies, medical equipment companies, and medical supply companies (although Relman in 1980 did not yet regard them as constituting a potential threat to the future of the American health care system). Relman says that although the arguments for allowing the free market to operate in order to improve the efficiency and quality of health care include the argument that private for-profit corporations may have a greater incentive to control costs than public or governmental nonprofit institutions, there is actually no evidence that the medical-industrial complex is capable of lowering the cost and improving the efficiency of health care.

      According to Relman, health care is different from other commodities that are bought and sold in the marketplace.⁸ One reason is that many people consider health care to be a public rather than private good. “Pubic funds pay for most of the research needed to develop new [medical] treatments and new medical-care technology. [Public funds] also reimburse the charges for health-care services.”⁹

      Another reason that health care is different from other commodities is that when people are sick, they may not be in a position to be selective consumers with regard to the cost of the services they receive. Getting the best care available may be of much greater priority to them than getting the least expensive care. Thus, the usual laws of supply and demand do not operate with regard to the cost of health care services.¹⁰

      Another reason that health care is different from other commodities is that physicians are expected to put the interests of their patients before their own financial self-interests. Physicians and other care providers are expected to make decisions on the basis of what is medically best for patients, rather than on the basis of what is most economically profitable for themselves.

      A danger of the increasing commercialization of health care is that physicians who make decisions regarding proper utilization of heath care services may have an economic incentive to provide more services in order to receive greater reimbursement from insurance companies and third-party payers. Another danger of commercialization is that the practice of “cherry picking” patients in order to provide the most profitable services to the best-paying patients and avoid providing services to the least profitable patients (such as uninsured patients, poor patients, and patients with complex and chronic illnesses) becomes more pronounced.¹¹ Another danger of commercialization is that the profit-making sector tends to emphasize expensive procedures and technology over personally-centered care.¹²

      Relman therefore advocates greater public accountability and increased regulation of the private health care industry.¹³ He also recommends that physicians separate themselves from any involvement in the medical-industrial complex (including financial interests in private hospitals and nursing homes, diagnostic laboratories, radiology centers, dialysis units, ambulatory surgery centers, and other for-profit health care services).

      In an article entitled “What Market Values Are Doing to Medicine,” (published in The Atlantic Monthly, March 1992), Relman notes that some defenders of fee-for-service medicine regard health care as a commodity to be bought and sold like other commodities, such as food, clothing, and housing. But he argues that doctors who are paid on a fee-for-service basis are expected to act in their patients’ best interests, and not simply in their own financial self-interest. Medical care is not a mere commodity; it is a social good.¹⁴ If physicians have economic incentives to provide more costly services and to make greater use of more costly technology, then market forces may encourage the expansion of less cost-effective care options and the overutilization of services.¹⁵ Private hospitals may also be influenced by market forces to avoid or limit service to the poor and uninsured. “Paying patients will get more care than they need, and poor patients will get less,” says Relman.¹⁶ He concludes that “greater reliance on group practice and more emphasis on medical insurance that prepays providers at a fixed annual rate” are the two best methods of solving the economic problems of health care, because they “put physicians in the most favorable position to act as prudent advocates for their patients, rather than as entrepreneurial vendors of services.”¹⁷

      In an article entitled “Restructuring the U.S. Health Care System,” (in Issues in Science and Technology, Summer 2003), Relman explains that in the 1990’s, the health insurance industry was able to generate tremendous profits by utilizing such strategies as denials of payment for hospitalizations and services deemed not medically necessary by the insurer.¹⁸ Publicly funded expenditures were also limited by the government’s method of reimbursing hospitals according to a fixed-fee schedule determined by patients’ diagnosis related groups (DRGs):

“Rather than paying fees for each hospital day and for individual procedures, the government would pay a set amount for treating a patient with a given diagnosis. Hospitals were thus given powerful incentives to shorten stays and to cut corners in the use of resources for inpatient care. At the same time, they encouraged physicians to conduct diagnostic and therapeutic procedures in ambulatory facilities that were exempt from DRG-based restrictions on reimbursement.”¹⁹

      Relman notes that the failure of such measures to control health care costs and to guarantee affordable care for everyone has led some policy analysts to propose a universal not-for-profit single-payer system of health insurance, funded either entirely through taxes or through a combination of taxes, employer contributions, and individual contributions. Such an insurance system would eliminate or reduce the number of private insurers who now receive a steadily increasing proportion of health care payments.

      In a long article entitled “The Health of Nations” (in The New Republic, March 7, 2005), Relman explains that managed care insurance plans have also attempted to control costs by requiring patients to select primary care physicians from among a panel of doctors approved by their particular insurance plan. Patients must obtain referrals to specialists from their primary care physicians in order for their care to be approved by the plan. Denials of payment may be made for services provided by specialists who are not under contract with the plan. The government has also contracted with managed care organizations (MCOs) and health maintenance organizations (HMOs) to control costs for its Medicaid and Medicare beneficiaries. Cost-controlling efforts by private and public insurers have included “case management” and "disease management" approaches, whereby patients are given advice and counseling by nurses in order to facilitate their compliance with treatment and help them avoid unnecessary emergency department and inpatient hospital care.²⁰

      However, we now have an increasingly fragmented health care system that makes greater use of specialized outpatient services, with an increasing proportion of payments going to specialists for outpatient technological services, and a decreasing proportion of payments going to primary care physicians who provide continuity and integration of care.²¹ In 2005, total U.S. health care spending was approximately $2 trillion, representing 16 percent of national GDP. (According to the Centers for Medicare and Medicaid Services, total U.S. health care spending in 2016 was approximately $3.4 trillion, an average of $10,000 per person, and was projected to increase annually by 5.8 percent, rising from 17.8 percent of GDP in 2015 to 19.9 percent by 2025.²²) According to Relman, this rate of inflation will eventually become unsustainable, and neither the government nor private employers will be able to keep up with rising health care costs.

      Relman concludes that

“First, since we cannot rely on the free play of markets to control costs or guarantee universal coverage, we should establish a tax-supported national budget for the delivery of a defined and comprehensive set of essential services to all citizens at a price we can afford. Employers should pay an appropriate part of the tax for their employees. These services should include both acute and long-term care, and they should be exclusively reimbursed through a single-payer national insurance plan, with other elective and non-essential services paid out of pocket or through privately purchased insurance. No services covered by the national plan should also be covered by private insurance plans, but the latter could insure services, such as "aesthetic" plastic surgery and private hospital rooms, that would not be covered by the national plan. There should be no billing by providers and no piecework payment in the single-payer plan, thus eliminating the huge business costs and the colossal hassle of the present billing and payment systems in multiple public and private insurance plans.

"Second, not-for-profit, prepaid multi-specialty groups of physicians should provide all necessary medical care on the approved list of insured services. The physicians in the groups should be paid salaries from a pool of money that would be a defined percentage of the total patient income received by the group from the central payer. The groups should be privately managed but publicly accountable for the quality of their services, and they should be expected to use standardized information technology that could be integrated into a national data system. They should be indemnified against losses due to adverse selection or other costs beyond their control, assisted with start-up and technology expenses, and exempted from antitrust restrictions. They should compete for patients on the basis of the quality of their services. All groups should be open to all citizens, although the number of members for a given-sized group should be regulated to ensure an appropriate ratio of doctors to patients.

"Third, patients should be free to choose their own physician group and to switch membership at specified intervals, but everyone must be included in the national plan and belong to a group--including politicians. (Lawmakers are unlikely to neglect the needs of a health care system that provides care for themselves and their families.) Physicians should be free to join any group that wanted them and to change their affiliation, but they should not provide services outside the national system that are covered by the latter.

"Fourth, all health care facilities (whether privately or publicly owned) that provide services covered by the central insurance plan should be not-for-profit, and should compete on the basis of national quality standards for patients referred by the physicians in the medical practice groups. Facilities should be paid, and monitored for their performance, by the central plan. They should have no financial alliances with the physicians or the management of the medical groups. Teaching facilities should be separately funded by the national plan and be paid for their extra

costs, including education. Budgets in all facilities should include salaries for full- and part-time clinicians providing essential services.

"Fifth, the health care system should be overseen by a National Health Care Agency, which should be a public-private hybrid resembling the Federal Reserve System. It should be independently responsible for managing its budget and establishing administrative policy, but should report to a congressional oversight committee and to the public. It is essential that the plan be sufficiently independent of congressional and administration management to be protected from political manipulation and annual budgetary struggles.”²³

     

      Relman also explains that most proposals for a single-payer insurance system lack any plan for changing the health care delivery system, and thus do not solve the problem of rising health care costs.

      In an article entitled “Medical Professionalism in a Commercialized Health Care Market” (in the Journal of the American Medical Association, Dec. 12, 2007), he warns of the danger posed to medical professionalism by the growing commercialization of the health care system. He says that although some physicians may regard their medical practice as in some respects a business,

“the essence of medicine is so different from that of ordinary business that… [the two] are inherently at odds. Business concepts of good management may be useful in medical practice, but only to a degree. The fundamental ethos of medical practice contrasts sharply with that of ordinary commerce, and market principles do not apply to the relationship between physician and patient.”²⁴

The ethical responsibilities of physicians require them to put the needs of their patients ahead of their own personal financial interests, and to avoid economic conflicts of interest that would undermine public trust in the medical profession.

      In an article entitled “The Health Reform We Need & Are Not Getting” (in The New York Review of Books, July 2, 2009), Relman acknowledges that health care system reform faces opposition from those with ideological objections to “big government,” who balk at proposals that would fundamentally transform the for-profit health care industry into a single-payer non-profit insurance and delivery system. One reason for higher health care costs in the U.S. than in other developed countries is that the U.S. has a higher proportion of medical specialists who rely more for their livelihood on performing expensive technical procedures than do primary care physicians.²⁵ Another reason is that “there are greater financial incentives in the U.S. to use technology, since health care insurers pay doctors and clinical facilities most of what they charge for such services.”²⁶ Another reason is that the great majority of private health insurers today are investor-owned businesses that have increased the commercialization of the health care industry through such practices as marketing and advertising. Investor ownership of insurance plans has resulted in increased health care costs. “Profits and management expenses take at least 10 to 20 percent of the premiums charged by investor-owned plans, including the costs of selecting those they will insure, whereas the overhead costs of Medicare—a government-run insurance plan covering everyone sixty-five and older—are about 3 percent. When private insurance companies provide coverage for Medicare patients (as in the Medicare Advantage plans), they cost the US government about 13 percent more than standard Medicare coverage.”²⁷

      Relman explains that the health proposals made by President Obama in his budget message of February 2009 emphasized the need to reduce the costs and increase the affordability of health care. According to Obama’s fiscal 2010 budget, health insurance coverage should be made available to all. People should have a choice of health plans and physicians. To reduce health care costs, high administrative expenses should be eliminated, along with unnecessary tests, unnecessary services, and other inefficiencies. People should not be locked into their jobs just to secure health coverage, and no one should be denied coverage because of pre-existing medical conditions. Greater use should be made of electronic medical records in order to prevent medical errors and improve health care quality. Greater use should be made of data comparing the effectiveness of specific medical treatments. Greater investment should be made in preventive measures and wellness intervention.²⁸

     Relman says that while these proposals were laudable, there is little evidence that they would actually have produced any substantial savings in health care expenditures. They did not address the main causes of rising health care costs, and they did not “recognize as a major problem the fragmented, entrepreneurial organization of a medical care system that is dominated by specialists and deficient in primary care doctors.”²⁹

      The solution, says Relman, would be

“a single public payer that guaranteed comprehensive health care for all, funded by a progressive tax whose proceeds would be dedicated to medical care. This insurance and funding plan would be combined with a delivery system, overseen by a public agency but managed entirely on a not-for-profit basis by privately organized doctors and hospitals. The delivery of care and the use of health resources would be the responsibility of organized multispecialty groups of salaried physicians and other health professionals, which would include adequate numbers of primary care doctors.”³⁰

He admits, however, that

“Neither my proposal, nor… any other plan that starts with the elimination of private employment-based insurance and depends largely on public funding stands much of a chance of being enacted now. It would be too great a change, and it would threaten insurance companies and other powerful vested interests that influence Congress. The same is true of any major reorganization of medical care that phases out fee-for-service practice in favor of nonprofit multispecialty groups of salaried physicians and dampens the commercial fire that has converted US medical care into an ever-expanding profit-seeking industry.”³¹

Not until health care expenditures become absolutely intolerable will major health care reform become politically possible.³²

      In an article entitled “Health Care: The Disquieting Truth” (published in The New York Review of Books, Sept. 30, 2010), Relman argues that after the passage of the Affordable Care Act (ACA) in March 2010, there was little reason to think that it would actually control health care costs, because it failed to change the dependence of the U.S. health care system on private, for-profit insurance plans.

"By mandating and subsidizing the purchase of private insurance for almost all those not eligible for such government programs as Medicare or Medicaid, the legislation...created a virtual monopoly for the private insurance industry. True, the law...[restricted] some of the industry's worst practices, such as denial of coverage because of preexisting conditions...[and] rescinding coverage because of expensive illness. However, it [imposed] no effective controls on the price [that] private insurers can charge for premiums.”³³

Relman also explains that 

“Before paying doctors and other providers of care, investor-owned health insurance companies now spend as much as 15 to 30 percent of their premiums to cover their many overhead costs, which include extravagant salaries and bonuses for top management, dividends for shareholders, and retained corporate profit…Because of its overhead, as well as the expense of billing and collecting it imposes on doctors and hospitals, the investor-owned for-profit insurance industry probably adds at least $150-200 billion to the annual cost of providing health coverage to the American population, as compared with government-run programs such as Medicare.”³⁴

Thus, the worst defect in the ACA was that it did not fundamentally change how medical care is organized, paid for, and delivered. Its major effect was simply to expand insurance coverage in a basically unchanged health care insurance and delivery system.³⁵

      In an article entitled “How Doctors Could Rescue Health Care” (in The New York Review of Books, Oct. 27, 2011), Relman says that one reason for Republican opposition in Congress to the Affordable Care Act (ACA) was that the “individual mandate” required that “all citizens not covered by public or private insurance plans be required to purchase private insurance or incur a tax penalty.”³⁶ However, the ACA did not replace—but in fact expanded—the investor-owned private health insurance industry, and it did not change the method of payment for most medical care, which is based on a fee-for-service system.³⁷ It also did nothing to reduce the fragmentation of medical care, which favors the use of specialty rather than primary care services.

      Relman notes that Republican alternatives to the ACA have included Representative Paul Ryan’s plan to privatize Medicare and change federal support of Medicaid by substituting fixed grants for the federal government’s current commitment to pay states a specified percentage of program expenditures. Under Ryan’s proposal,

‘the Medicare system covering most of the medical costs of elderly citizens would be gradually replaced by a federal voucher system. Starting in 2022, each new Medicare beneficiary would choose a private insurance plan and the government would give participants in the plan a voucher to help pay for coverage…However, actuarial experts predict a doubling of total Medicare costs within a decade; so Ryan’s proposed vouchers would fall far behind actual costs, and beneficiaries would have an increasing financial burden.³⁸

Relman also notes that

“As for Ryan’s proposal to reduce Medicaid expenditures by making fixed grants to states, the states would have considerable discretion in spending these grants, and their deficits would almost certainly force them to curtail Medicaid services in order to meet other budgetary needs. The grant idea, although favored by some state governors, has provoked wide opposition because it threatens the medical services needed by low-income citizens, and because Medicaid money now also supports nursing home care for the elderly.”³⁹

   

  Relman therefore argues that one way of controlling health care costs may be through the creation of not-for-profit multispecialty physician groups, in which physicians are paid annual salaries rather than on a fee-for-service basis, so that they don’t have a financial incentive to perform expensive procedures and provide unnecessary services. Group practices would be reimbursed for comprehensive care of patients on a per capita basis. Payment would be through a single public payer system supported by a universal, progressive, designated health care tax. In order to receive payment, “group practices would have to reimburse their physicians largely by salary. Regulations would require open enrollment of patients; [in order] to limit the risk of fixed payment for comprehensive care, groups would need public reinsurance or other financial guarantee to protect against the possibility that some patients might need expensive services.”⁴⁰

      In an article entitled “Obamacare: How It Should Be Fixed” (in The New York Review of Books, Aug. 15, 2013), Relman says that

“more than a few liberals think the ACA was fatally compromised by deals…[that President Obama] made with the private insurance, hospital, and pharmaceutical industries to get their support, particularly the sacrifice of a “public option”—insurance the government would sell if private companies refused or their plans were seen as excessively expensive. They believe it will ultimately fail because it did not basically change our dysfunctional system. It expands and improves private insurance coverage, but provides no effective controls of rising costs and no significant change in the way medical care is delivered. Many of the critics think we need major reform that replaces private insurance and employment-based coverage with a publicly funded single-payer system.

      "Before the ACA was enacted, the president’s health care proposals were bitterly opposed by Republicans who said they violated two conservative principles: first, the familiar Reagan view that government involvement usually is the problem, not the solution; and second, an implied but rarely spoken belief that medical care is basically a special kind of business, and should conform to business practices. Republicans believe that the ACA flouts these principles by depending heavily on government regulation and interfering with free-market forces.

      "Republican opposition hardened even more after the legislation became law, culminating in a constitutional challenge before the Supreme Court. On June 28, 2012, the Court sustained by a 5–4 vote the contested major provision in the ACA that mandated insurance coverage. But by a 7–2 vote, the Court struck down the provision in the law that gave Congress the power to withhold federal Medicaid support from states refusing to expand their Medicaid program, which provides medical care for poor people. This decision made it financially feasible for states to opt out of the ACA’s provision requiring that the coverage of low-income patients be expanded. As of this writing, seven of them have done so. The Urban Institute estimates that this will deny insurance to nearly six million very poor people.”⁴¹

     According to the Kaiser Family Foundation, the Affordable Care Act (ACA), which expanded Medicaid coverage for many low-income Americans and also subsidized the purchase of insurance by many people through the establishment of new health insurance exchanges, decreased the number of uninsured people by nearly 13 million between 2013 and 2015. But by the end of 2015, nearly 29 million Americans under the age of 65 were still uninsured.⁴² According to the U.S. Census Bureau, the rate of uninsured adults below age 65 was about 13 percent (41 million people) in 2013, but decreased to about 9 percent (29 million people) in 2015.⁴³ However, many people who live in states that have decided not to expand Medicaid or who are ineligible for insurance subsidies are still unable to afford health insurance.

      Relman argues that “replacement of all public and private insurance and elimination of itemized bills with a public tax-funded system that simply paid medical groups per capita for comprehensive care would avoid much of the expense and many of the other problems with the current system.”⁴⁸

      In his last article, entitled “A Challenge to American Doctors” (in The New York Review of Books, August 14, 2014), published nearly two months after his death, Relman argues that “without leadership by physicians, it is unlikely that we will see any major change in the system for payment and organization of medical care within the next decade or two…and without such change…financial responsibility for health care coverage will increasingly fall on individuals, because neither government nor business employers will be able to afford the rising costs.”⁴⁷

      Now, more than ever, as the U.S. Senate and House of Representatives resume their efforts to draft new health care legislation, Relman’s evaluation of the problems of the U.S. health care system and his proposals for health care reform need to be thoughtfully considered.

FOOTNOTES

¹Douglas Martin, “Dr. Arnold Relman, 91, Journal Editor and Health System Critic, Dies,” The New York Times, June 21, 2014, online at https://www.nytimes.com/2014/06/22/us/dr-arnold-relman-outspoken-medical-editor-dies-at-91.html?mcubz=0&_r=0.

²Ibid.

³Bryan Marquard, “Dr. Arnold Relman, 91; ex-N.E. Journal of Medicine editor,” The Boston Globe, June 17, 2014, online at https://www.bostonglobe.com/metro/2014/06/17/arnold-relman-former-new-england-journal-medicine-editor-was-forceful-voice-health-care-debate/k4Flrz8z2xgWyilyMB555I/story.html.

⁴Jerome Kassirer, “A Tribute to Arnold S. Relman (1923-2014),” The Journal of Clinical Investigation (Oct. 1, 2014), 124 (10), 4152-4153, online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4191018/.

⁵Marcia Angell, “On Arnold Relman (1923-2014),” The New York Review of Books, August 14, 2014, Vol. 61, No. 13, online at http://www.nybooks.com/articles/2014/08/14/arnold-relman-1923-2014/.

⁶Ibid.

⁷Ibid.

⁸Arnold Relman, “The New Medical-Industrial Complex,” The New England Journal of Medicine, Vol. 303, No. 17, p. 966.

⁹Ibid., p. 966.

¹⁰Ibid., p. 966.

¹¹Ibid., p. 968.

¹²Ibid., p. 969.

¹³Ibid., p. 969.

¹⁴Arnold Relman, “What Market Values Are Doing to Medicine,” The Atlantic Monthly, March 1992, 269(3), pp. 98-106, online at https://www.theatlantic.com/past/docs/politics/healthca/relman.htm.

¹⁵Ibid.

¹⁶Ibid.

¹⁷Ibid.

¹⁸Arnold Relman, “Restructuring the U.S. Health Care System,” in Issues in Science and Technology, Volume XIX, Issue 4, Summer 2003, online at http://issues.org/19-4/relman/.

¹⁹Ibid.

²⁰Arnold Relman, “The Health of Nations,” The New Republic, March 7, 2005, online at http://issues.org/19-4/relman/.

²¹Ibid.

²²Centers for Medicaid & Medicare Services, “2016-2025 Projections of National Health Expenditures Data Released,” Feb. 15, 2017, online at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-02-15-2.html.

²³Relman, “The Health of Nations, The New Republic, March 7, 2005, online at https://newrepublic.com/article/68087/the-health-nations.

²⁴Relman, “Medical Professionalism in a Commercialized Health Care Market, Journal of the American Medical Association, Vol. 298, No. 22, Dec. 12, 2007, p. 2669.

²⁵Relman, “The Health Reform We Need & Are Not Getting,” The New York Review of Books, Vol. 56, No. 11, July 2, 2009, online at http://www.nybooks.com/articles/2009/07/02/the-health-reform-we-need-are-not-getting/.

²⁶Ibid.

²⁷Ibid.

²⁷Ibid.

²⁸Office of Management and Budget, “President Obama’s Fiscal 2010 Budget,” online at https://www.rila.org/news/pblccomments/Health%20Care%20Public%20Documents/WhiteHouseObamaPrioritiesforHealthReform.pdf.

²⁹Ibid.

³⁰Ibid.

³¹Ibid.

³²Ibid.

³³Relman, “Health Care: The Disquieting Truth,” The New York Review of Books, Vol. 57, No. 14, Sept. 30, 2010, online at http://www.nybooks.com/articles/2010/09/30/health-care-disquieting-truth/.

³⁴Ibid.

³⁵Ibid.

³⁶Relman, “How Doctors Could Rescue Health Care,” The New York Review of Books, Vol. 58, No. 16, Oct. 27, 2011, online at http://www.nybooks.com/articles/2011/10/27/how-doctors-could-rescue-health-care/.

³⁷Ibid.

³⁸Ibid.

³⁹Ibid.

⁴⁰Ibid.

⁴¹Relman, "Obamacare: How It Should be Fixed" (in The New York Review of Books, Vol. 60, No. 13, Aug. 15, 2013, online at http://www.nybooks.com/articles/2013/08/15/obamacare-how-it-should-be-fixed/.

⁴²The Henry J. Kaiser Family Foundation, “Key Facts about the Uninsured Population,” Sep. 29, 2016, online at http://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/.

⁴³Sara R. Collins, Munira Z. Gunja, and Sophie Beutel, “New U.S. Census Data Show the Number of Uninsured Americans Dropped by 4 Million, with Young Adults Making Big Gains,” To The Point: Quick Takes on Health Care Policy and Practice (Sept. 13, 2016), online at http://www.commonwealthfund.org/publications/blog/2016/sep/2015-census-data-insurance.

⁴⁶Relman, “Obamacare: How It Should be Fixed,” online at http://www.nybooks.com/articles/2013/08/15/obamacare-how-it-should-be-fixed/.

Relman, “A Challenge to American Doctors,” in The New York Review of Books, Vol. 16, No. 13, August 12, 2914, online at http://www.nybooks.com/articles/2014/08/14/challenge-american-doctors/.