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January 15, 1999
By Rodrigo Muņoz, M.D.
APA President
From April to December of last year, the National Museum of American History sponsored the exhibition "Between a Rock and a Hard Place: A History of American Sweatshops, 1820-Present."
Though defined in many ways, a sweatshop generally refers to a workplace where relatively unskilled workers toil long hours for meager pay in unhealthy and unsafe conditions. Does this definition ring a bell?
The term was first used in the 19th century to describe conditions in some parts of the tailoring trade, but the same conditions existed in other industries as well.
What forces produce sweatshops? Some have postulated that a sweatshop may emerge every time unprotected workers fall under the control of greedy entrepreneurs. There is general agreement that avarice and opportunism, "competitive pressures," exploitation of government regulations, misguided business practices, and plain discrimination generate sweatshops.
The exhibit showed the evolution of sweatshops starting with the poorly compensated seamstresses who were barely surviving on 16-hour workdays between 1820 and 1880. Between 1880 and 1920 immigrants converted small apartments into contract shops that doubled as living quarters. Fierce competition kept wages down and hours up. An entrepreneur without social scruples will always find defenseless workers for his sweatshop. This situation is reminiscent of conditions applied to medical care by for-profit HMOs one century later.
Sweatshops declined but did not disappear during World War II and the decade afterward, only to increase again in the 1960s. As recently as 1995, police officers raided a fenced compound of seven apartments in El Monte, Calif., where they arrested eight operators of a clandestine garment sweatshop and freed 72 illegal Thai immigrants forced to work in virtual captivity.
Sweatshop conditions have become a reality in recent years in American medicine-greedy entrepreneurs and employers allied together, protection from litigation arising from harmful decisions because of an ERISA exemption, inappropriate dependency on nonmedical "providers" whose fees are lower, forbidding physicians to discuss with their patients treatments not covered by their health plan, use of vague "medical necessity" criteria to deny care, removal of potentially costly patients from medical plans.Exploitation of physicians and patients alike is common. Physicians are expected to go along with managed care's dictates or else suffer financially by being dropped from provider panels. Patients have been reduced to "lives" and counted as industrial properties. They have been robbed of their right to make their own health care decisions.
The odious experiment in managed care has been a failure. Its two purported aims of keeping costs down and increasing quality of care have not been realized. Today costs are once again sharply increasing, and physicians and patients are learning how to use the courts and new legislation to achieve quality.
As Wall Street joins Main Street in forecasting the demise of sweatshop strategies in medicine, physicians are using the experience to organize and regain their leadership. Physician-sponsored networks will lead the evolution toward systems designed, controlled, and directed by physicians to serve our patients.
The task at hand is daunting:
Having gotten to know many APA members as I travel to district branches and attend various meetings throughout the country, I believe we are up to the task.
Antohony D'Agostino, M.D., an Illinois Psychiatric Society Assembly Delegate and vice chair of the APA Managed Care Committee, will sponsor a meeting on physician-sponsored networks in Chicago on March 12. Dr. D'Agostino can be reached at (847) 437-5500, ext.4679.