“Compassion in the Service of Money” is the provocative title of a book review that has caught my attention. Writing in the current issue of The Gerontologist, a professional journal in the field of aging, James Callahan discusses the American health care system, with a special focus on the needs of older citizens. As his title suggests, he feels highly critical of it.

In one hard-hitting paragraph, he summarizes what is wrong with the system. It is “extremely expensive as measured as a percent of GNP; inefficient as measured by resources wasted on administration, billing, and marketing; unjust as measured by the number of citizens uninsured; corrupt as documented by valid government and private sector reports; questionable in quality as measured by tens of thousands of unnecessary deaths documented by the Institute of Medicine; and fallible in satisfying the needs of long-term caregivers.”

Reading these words impelled me to seek out Jim Callahan, the Newton resident who wrote them. I wanted to discover what prompted this blast from a person long known to me, and to a wide public, as mild mannered and low-key; I wanted to find out what prompted this blast.  

It is hard to imagine an indictment so sweeping as this one. In a single sentence Callahan brands the American health care system as expensive, inefficient, unjust, corrupt, of dubious quality, and, when it comes to caregivers, fallible.

Of all these accusations, the one that I judge most devastating is corruption. For a delivery system that is so huge and complex, there may be some excuses for its other faults. But for corruption, it is hard to find any extenuating circumstances.

In his own career, Jim Callahan has seen up close instances of “fraudulent billing, nonexistent patients, Medicaid mills, bundling and unbundling rates to the providers’ advantage, exploitive nursing home real estate deals, split prescriptions, provider excuses,” among other misdeeds.

No wonder that Jim Callahan now says about some of his experience: “It made me a firm believer in original sin.”

What makes his charges so shattering is that the author is no armchair theorist or negative observer, but a practical leader who has had a long and distinguished career in the field of human services. He has held top positions at several of the public agencies that serve Massachusetts residents.

Among these agencies are the Medicaid program, with the largest budget, and the Mental Health department, with the largest number of employees of any state office. In addition, he became Secretary of the Department of Elder Affairs in the first Dukakis administration, after having been director of two state hospitals at the same time.

In these positions, he did not simply skillfully manage large and complex agencies, but he also made it a point to have personal contact with the people he served. Among them, he still recalls a 22-year old woman suffering from cancer who could not get coverage for treatment, and patients he encountered in his visits to all of the state’s mental hospitals.

In addition to practical know-how about managing public agencies, Jim also brought strong academic credentials to his various roles. With a Ph.D. from the Heller School at Brandeis, and several research projects that focused on the delivery of human services in his résumé, this public servant understands the way systems work or don’t work.

“I’ve been at all levels of this thing; I have a good idea of how things work,” he says, modestly understating the case.

Now retired, this high-level administrator recently shared with me his doubts about a health care system that resists all efforts to control it. He compares it to Godzilla in the Japanese movie who, out of anybody’s control, keeps on growing larger.

It would be reassuring to report that Callahan feels optimistic about fixing the system.  He doesn’t. One is confronted, as he views it, with this formidable combination:  socialism in the delivery of services and capitalism in their support. And when you try to change it, a wide variety of interest groups get involved.

In a crunch, generalized systems almost unfailingly prove weaker than specialized ones. And, given the American bias toward the market culture and reliance upon the private sector, public authority will find it hard to devise an effective approach to reform.

Nor does he think the American public can do much to change the system. “We as citizens lack the intellectual, political, and moral resources to create a good health care system,” he says with regret.

You have to get citizens to act in their own interests, as he writes in the published review. And that’s not going to happen until they “stop listening to the cleverly designed disinformation campaign of private sector solutions, free enterprise, and competitive markets.”

Callahan concludes his review with a plaintive question: “Who will lead?” He does not know the answer. If he does not, one wonders who does.

Richard Griffin