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 91st
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/.
