Curing All Our Nation's Ill

AS AMERICA'S WEALTHY spend millions of dollars on unneeded medical care, as the stinging inadequacies of our health care system go uncorrected by milquetoast politicans, The poor ponder their choice: death by anecdote or by the numbers.

By anecdote: a local hospital refused to admit a pregnant woman because she lacked health insurance. She was in labor at the time.

By numbers: The United States spent $671 billion on health care in 1990, twice as much as in 1982. Twelve percent of our GNP goes to health care, more than any other nation on earth. At the current rate of increase, it will consume 37 percent of our GNP in 2030.

The problems of the American health care system are so huge and terrible, it is almost incomprehensible. Everything that is right with the system is going wrong. And everything that is wrong is getting worse. No one thing is responsible for the collapse of the system; no simple repair will fix it.

To save us from spiraling costs, apalling waste and needless suffering, America needs a complete overhaul of its unequal and ineffective health care system.

IT'S HARD to locate an ugly core to the American health care crisis: There are too many problems--administrative waste, lack of preventive care, misapplied technology--and they all seem to cause each other, creating a viscious uncontrollable cycle. But the current discussion of health care difficulties focuses on two primary problems: the plight of the uninsured and the skyrocketing cost of medical insurance.

An incredible number of Americans, 37 million of them, have no health insurance. They are poor, but not poor enough to qualify for Medicaid. They are not old or disabled, so they don't get Medicare. And for the 85 percent of them who are employed, or whose parents or spouses are employed, their firms are too small to provide any health coverage.

At the same time, the costs of medical coverage for those who are insured are going through the roof. Private companies that generally provide health insurance for employees are facing higher and higher premiums, which they pass on to their workers. Workers, in turn, get angry and worried about their ever more threatened ability to afford medical care.

BUT THESE are just the most obvious signs of crisis; the real calamities involve the meeting of these insurance problems and our actual health care system.

The first place insurance meets, or fails to meet, medical care is in preventive medicine. We don't have any.

Since our health care system is so fragmented, no single authority looks out for the national health. The federal government doesn't play a central role in public health, so it can't impose universal preventive medicine, even though spending a few dollars up front would save huge amounts later.

The uninsured have found that the best way to avoid paying for medical care is not getting any. Children go without vaccines, and then catch diseases that may cripple them for life. Pregnant women don't get prenatal care, and then bear expensive, unhealthy, premature babies. Women don't get mammograms, and die of treatable cancer.

When uninsured people do get sick, they let it linger, and get sicker and sicker, until they have to go to the emergency room and wait for hours behind the gunshot victims. Had they gone to the doctor a week earlier for a five-minute visit they couldn't afford, they would have stopped the illness in its tracks. Instead, they use emergency rooms for primary care, and help destroy already overburdened innercity hospitals.

The 37 million suffer, effectively rationed out of health care by an invisible hand at the beck and call of the crusading army of Blue Crosses and Blue Shields.

ANOTHER OUTCOME of the collision between insurance and care is excessive technology. Since medical procedures cost patients nothing up front and little later, there is no incentive for the insured to skimp on technology. Doctors want to maximize their fees by maximizing care, and they also fear malpractice suits for missing a diagnosis. As a result, they order as many tests as they can. Patients don't pay, so they want to get the most care they can. Insurance costs went through the roof, but we didn't care because we didn't have to pay up front.

The elderly are all-too-witting pawns in this game of beggar--thy-young-neighbor doctoring. The old get older, consume more and more health care resources, and get older and older and seemingly never die. Politicans don't have the guts to confront the AARP's millions of votes, so the elderly continue to monopolize dollars through high-tech efforts to push the envelope of life expectancy. Medicare (read: your income taxes) pays a lot, co-insurance is cheap, so the old, like the insured, don't care.

Unfortunately, excessive care doesn't mean better care. In her book Medicine and Culture, Lynn Payer compared medical treatments in America, England, West Germany and France and found that American doctors are far more aggressive in prescribing and treating and testing and operating than their European counterparts. Sad to say, though, we are not healthier, and American medical care is no more effective than that of the less intrusive nations.

And for those without insurance, all the money the hospital has thrown into expensive technology is less than useless. It means--pure and simple--less money going to basic care for the needy.

The final place insurance crashes into care is in administration. We have many, many layers of billing for care. The government bills one way for Medicare, another for Medicaid, a third for veterans' benefits. Getting private insurers to pay for a medical procedure throws a Kafkaesque billing system into action. Bills run endlessly between hospital, insurer, doctor and patient.

According to the New England Journal of Medicine, the American health care system may waste as much as $100 billion annually on administrative costs.

The results of the system's scathing inequality, excess and waste are socially devastating.

Yes, our old people are living longer and longer, sustained by billions of dollars in drugs and billions more in ludicrous life-prolonging surgery. But our inner city hospitals are collapsing. Our infant mortality rate is shocking (the highest in the industrialized world). We are witnessing a revival of epidemics--not just AIDS, but measles, whooping cough and tuberculosis, diseases we thought were defeated, broken by the onward march of civilization.

We are approaching the point where most Americans, not just 37 million unlucky ones, won't be able to afford to be sick or get well.

INSTEAD OF TALKING about ideas, George Bush likes talking about paradigms. Here is another one for him to chew on.

Americans believe that police protection, fire protection, elementary and secondary education, and roads are public goods: The government has to provide them or we scream and yell. Before we can make any fundamental change in our health care system, we must acknowledge, decades behind the rest of the industrialized world, that health care is a public good, too.

What we need, and fast, is reform. Reform does not just mean cutting costs, or standardizing billing. It means changing the structure of America's health care system, root and branch. Any reform must accomplish three things. It must cut administrative costs. It must increase the use of preventive medicine. And it must cover the uninsured.

Any proposal for radical health care reform immediately runs into serious political problems.

The first is a tragic misperception. Politicians are afraid that Americans perceive reform as another case of handing stuff out to the poor. The politicians are wrong. All Americans--poor, rich and everyone in between--have begun to realize that health care, in the form of higher premiums, is killing them, too.

The second problem is that any major health care reform will cost lots and lots of money, and will require massive new taxes. Never mind that those new taxes will be the same money we are already spending on health care, Americans just don't believe the government can provide services as efficiently as the private sector.

This may not, in fact, be true. A number of studies suggest that Medicare is more efficient than private insurers in administrative costs.

Health care reform runs into another problem even when everyone agrees it is necessary--a lack of vision. Politicians, as well as most policy advisors, tend to see only two possible kinds of reform.

Conservatives, not surprisingly, tend to advocate a quasi-market solution. The absence of thinking in the White House and the abundance of knee-jerk free marketeers there means that the only suggestion we will get out of Bush is a reluctant agreement to a gap-filling insurance system for those 37 million uninsured.

This kind of public/private partnership would require employers to provide insurance and let the federal government pick up everyone else. Like the old Massachusetts plan, small employers would be allowed to buy into a government-sponsored insurance plan that reduces their costs and lets them comply with the law. Even the American Medical Association, that bastion of greedhead doctors, has come out in favor of this kind of reform.

The great advantage of this system is that it makes a lot of smoke while it does absolutely nothing to help correct the systemic rot. Nothing keeps hospitals from being walk-in clinics. Nothing reverses our increasing infant mortality rate. And most important, nothing cuts the skyrocketing insurance costs.

The second option is a nationalized, standardized, state-based, universal health care program similar to Canada's. Such a program would slash administrative costs by centralizing administration within the government. Of course it would cover the uninsured and encourage preventive medicine.

A Canadian-style socialization would be, in a perfect world, a very good idea. But in a world with a powerful Republican party, it is an utter impossibility. (Oddly enough, corporate America will probably back the more radical plan--companies are paying so much for health care that anything that shifts costs from them would be an improvement.)

The wealthy will yell about "socialization" and how that means rationing, and how rationing is a death sentence for old people who need transplants, dialysis and other expensive treatments. Of course, the wealthy will not yell about the rationing which is taking place right now, where the rich live in a medicalized paradise and the poor die in a third-world hell.

THERE IS, however, a way around the legislative bottleneck of the Washington loop. Out in the boonies, innovative states and locales are doing the impossible: They are doing more with less. Here is where America, if it chooses to, will find its medical salvation.

In western Ohio, a radical plan is taking shape. To renew your Medicaid eligibility, you must sign up for a state-sponsored Health Maintenance Organization (HMO). Then you choose a primary care physician. This keeps people out of emergency rooms with anything less than an emergency. The huge reduction in emergency room visits improves the quality of emergency room care for everyone.

And due to the dedication of the people involved, the HMO includes 99 percent of all doctors in the area. That means that the welfare HMO is the best HMO in the region--public or private.

In addition, the Ohio plan includes an aggressive prenatal program. If an expectant mother goes to her prenatal visits she gets free merchandise from a department store. The plan increase birth weights, reduces premie costs and lowers infant mortality. It is the best of public/private partnerships imaginable, and it works because the administrators and the business community want it to.

Finally, the savings have been so great that the organization was able to hire fulltime several people on general relief to be drivers. They drive people without transportation to their doctor visits. They also drive mobile clinics, staffed by doctors and nurses, who run blood pressure checks, give vaccinations, mammograms and bring health care into areas where there has been none.

Such successful systems are bound to proliferate. For a political entrepreneur, they could be models not only for Medicaid, but for a revolution in system of health care administration.

If such a plan were nationalized, states would be required to pick two or three of the biggest HMOs in their borders and grant them a collective monopoly. Employers would stop buying insurance, Medicare and Medicaid would wither away, and everyone would sign up for one of the new plans, funded through tax dollars and administered through the HMOs.

Insurance companies which are not selected to administer state programs will go out of business. It will be, for all intents and purposes, a high-tech, high-flexibility nationalization.

This idea of a government-regulated private oligopoly system has the strength to be the compromise legislators eventually settle on.

Here, though, a partnership is between different levels of government is crucial. The federal government would fund vaccination programs, fund and administer an institution concerned with epidemics and set minimum standards. Those standards would mandate that state plans cover routine doctor visits and provide for a massive shift toward preventive care.

To save money there will, of course, be trade-offs. Heart transplants that cost hundreds of thousands of dollars, extend the lives of almost no one, and take away valuable resources from vastly more beneficial, if banal, activities like prenatal care, will be cut. Rationing will become an open element of the system. But the rationing will move away from its nasty classism toward a more rational ageism.

The brashness of open rationing is not entirely nasty. We have to realize that a longer life expectancy is not a universal good, that we would be a vastly healthier society if we tried to prevent suffering at the beginning of life than extend it at the end.

For those who have, America is the greatest place to be ill, and for those who don't, it is the worst. Usually, that's the end of the story, and we accept the triump of self-interest improperly understood. But this time, we actually have a chance to do something, and it could be a triumph of politics.

Instead of talking about ideas, George Bush likes paradigms. Here is another one for him to chew on...

We are nearing the point where most Americans won't be able to afford to be sick or get well.

...a nationalized system of health care, funded by tax dollars and provided through the HMOs.