It has been wisely said that if you can keep your head when all about you are losing theirs, it is quite possible you have not grasped the situation. Or, as Simon Weil more simply put it, "Anyone who isn't confused today, simply isn't thinking straight."[1]
That's the way it is trying to understand health care in the year 2000. Since autumn I have been working with our Health Care Task Force attempting to figure out what's right with it, what's wrong with it and what we can do to maximize the former and minimize the latter. While I will provide some factual context for health care issues, my primary goal is to ask: Is health care a commodity? Is everything for sale? Or, is health care a human right?
In his State of the Union address of January 11, 1944, President Franklin Delano Roosevelt advocated a Bill of Economic Rights including "the right to adequate medical care and the opportunity to achieve and enjoy good health." The United Nations 1948 Declaration of Human Rights includes health care as a basic human right. It is quite clear, however, that the United States does not subscribe to that principle. Why do I say that?
The facts are clear. Over 44 million Americans have no health care insurance (1 in 7 are children). These citizens rely instead on the kindness of strangers: doctors who treat charity cases, hospital emergency rooms or simply on not seeking the care they need. Millions more are underinsured. Medicare and Medicaid have suffered cutbacks. We now spend more on pharmaceuticals than on primary care. Health care is more a business than a social service. We stand alone among the industrial democracies in not recognizing health care as a human right.
We were warned that enactment of the Clinton Health plan of 1993 would lead to increasing health care costs and a bureaucratic mess. We have been warned that a single-payer system would be ever more expensive and disrupt the doctor-patient relationship. The irony is that these dire events have indeed transpired, despite the defeat of the Clinton health plan - which deserved it - and despite failure to even discuss a single-payer national health plan - which has never been given a hearing. Instead we have relied on the magic of the competitive marketplace, but Health Maintenance Organizations, HMO's, have not turned out to be our salvation. While researching HMO's on the Internet I came across a satirical critique which, however hyperbolic, suggests some of our health care problems.
Question: What does HMO stand for?
Answer: Horrible Medical Organization.
Question: Do all diagnostic procedures require pre-certification?
Answer: No. Only those you need.
Question: I just joined a new HMO. How difficult will it be to choose the doctor I want?
Answer: Just slightly more difficult than choosing your parents.
Question: What are preexisting conditions?
Answer: This is a phrase used by the grammatically challenged when they want to talk about existing conditions. Unfortunately, we appear to be pre-stuck with it.
Question: Well, can I get coverage for my preexisting conditions?
Answer: Certainly, as long as they don't require any treatment.
Question: What happens if I want to try alternative forms of medicine?
Answer: You'll need to find alternative forms of payment.
Question: What should I do if I'm away from home and I get sick.?
Answer: You really shouldn't do that. You'll have a hard time seeing your primary care physician. It's best to wait until you return, and then get sick.
The Rochester area has one of the nation's highest rates of HMO penetration. These are non-profit for now, though profit-making HMO's are on the health horizon, and most people aren't happy about it. Wasn't it just a few years ago that Rochester was a much-praised model of a regional health care system delivering high quality care at reasonable price? What happened?
In 1992 when President Clinton famously cited Rochester as a model for health care, its premiums were 33% below the national average. As of 1997 they were only 6% below and moving toward the average. In 1992 Rochester had a collaborative model with a global budget for all hospitals avoiding duplication and enacting efficiencies. Now we have three competing systems: StongHealth (Strong and Highland hospitals), ViaHealth (General and Genesee hospitals) and Unity (St. Mary's and Park Ridge hospitals). Many believe StrongHealth alone with survive, and some believe StrongHealth wants it that way.
Indicative of what is happening is a story told to me by a doctor friend. He attended a meeting of medical personnel addressed by a local hospital administrator. He was taken by the rhetoric of the official who talked not so much of patient care and service delivery as of the bottom line, of market share and "winning" in the competition for patients. He apparently sounded more like the CEO of a Dow Jones or NASDAQ company than a health care executive.
Hospital costs in Rochester are rising faster than the national average - 6% to 4%. There is duplication of services - for example in birthing centers. Our insurance rates are going up in double digit leaps and bounds. Hospitals are buying some doctor's practices from other hospitals while some doctors are fired. It sounds like the meat-market in the National Football League.
Rochester has moved from community rating - where the whole population was in the patient pool and everyone paid roughly the same relatively low premiums - to experience rating - where companies can engage in what is charitably called "cherry-picking" - recruiting the healthiest group of people to keep costs down - leaving the sickest people for someone else. Some observers believe we are engaged in a health care arms race. Doctors are given incentives to provide as little care as possible - to save money.
The major factor in this rapid transition was the action of Eastman Kodak which withdrew from the community-rated system by offering a self-funded insurance plan as its basic, no-cost health care benefit. As City Newspaper's columnist Joan Collins Lambert put it, "Kodak had broken the all-for-one, one-for-all approach to health care in favor of an each-man-for-himself philosophy."[2]
Rene Reixach, a lawyer specializing in health care, said Rochester had been so successful because "The ethos of this town has been: There are community goods that ought to be supported. (But now) Business leadership in this community - and Kodak is certainly in the forefront - concluded that there ought to be a more competitive health care system. You know, 'Competition is good, and we ought to have more of it.' And that's become the standard business mantra." "Why not let the market decide?" he was asked. "Because historically, when you have an unfettered market in health care, you just end up with enormous duplication and expense. Each facility or entrepreneurial provider . . . says, 'Gee, this is an opportunity. I want one of these.' But the result of that is you end up with one of everything. In Grand Rapids, Michigan, they had three hospitals, and each one had a helicopter. Grand Rapids isn't that big a place." He also cites the competition between F. F. Thompson Hospital in Canandaigua and the Clifton Springs Hospital, which are 12 miles apart, each acquiring expensive radiation oncology services, an illustration of health care Balkanization.
What is more, while welfare rolls decrease, many still-eligible people fail to apply for Medicaid coverage. They mistakenly believe that if they lose welfare they automatically lose Medicaid. Medicaid application forms have gone from 2 to 12 pages and many administrators, I am told, actively discourage applicants. New York State's Child Health Plus and the newly enacted Family Health Plus, which goes into effect on January 1, 2001, cover only a fraction of the working poor. We are left with a patchwork of inadequate plans and an administrative nightmare.
Rene Reixach and Sandra Parker, Executive Director of the Industrial Management Council, among others, believe we should return to the successful system we enjoyed in the early 1990's. Ironically, in this age of privatization, Reixach believes we had "the closest thing to the Canadian system of health care you would ever have found in America."[3]
When asked "How do the Canadians do it?" Reixach replied, "They have a different culture. People don't jaywalk in Canada. If there's a stop-light, you're supposed to stop and wait for it to turn. We don't believe that."[4] While our Declaration of Independence touts "life, liberty and the pursuit of happiness," a very individualistic goal, Canada's founding document affirms a communal emphasis on "peace, order and good government."
I confess my own preference for a Canadian Medicare type plan which provides substantial federal financing and criteria with provincial management. I believe it meets our three basic health care crises head on:
1. Cost: As the General Accounting Office once put it, "if the United States were to shift to a system of universal coverage and a single payer, as in Canada, the savings in administrative costs would be more than enough to offset the expense of universal coverage."[5] The Canadian system expends .1% of Gross Domestic Product in administration; our expenditure is 10 times as great, 1%. And nearly every other industrialized democracy has better health outcomes while spending on average 9% of GDP on health, while we spend 14%. What is wrong with them that they don't emulate us?
2. Coverage: While 44 million Americans have no health coverage, all Canadians are covered. Many basic needs in our country go unmet - many plans, including Medicare, for example, make no provision for increasingly expensive prescription drugs.
3. Care: doctors complain that their medical decisions are being second-guessed by non-medically trained administrators in insurance plans. In Canada the doctor-patient relationship is a primary principle. U. S. doctors once feared assault from the governmental left; now they fear intrusion from the private sector right.
And rationing? Canadians do have to wait for certain specialized treatments. But as Robert Kuttner puts it in Everything for Sale, "The real issue is whether it is rationing based on private purse or on medical need. A system that coddles wealthy patients with minor ailments but cannot find money for universal vaccinations is, of course, rationing."[6]
But most critical is the moral error of making health care a commodity, subject primarily to market forces. Let me share three brief case studies and ask in each case if they can be responsibly resolved by a market solution.
"'Margaret' is a married woman with two children who has worked all her adult life. Neither she nor her husband is in jobs that offer benefits, but their income is several dollars over the Medicaid limit. Her health care was hit-or-miss until two years ago when she came to St. Joseph's Neighborhood Center, one of only two health care providers in the Rochester area specifically serving the uninsured and underinsured. Initially Margaret was diagnosed with diabetes and hypertension, conditions that are dangerous and expensive to treat. With the neighborhood center's help, her health is stable, but she must constantly make financial choices between her health care and her family's well-being. Why is her life threatened in this way?"
"'Mark' is a chemist who was laid off. He did not find a job in his field before his health benefits ran out. He has several medical conditions, including depression, requiring medications. His only option, without acquiring overwhelming medical bills, is the neighborhood center. While he is grateful for the professional care and assistance, finding himself so vulnerable so quickly is a frightening experience."[7]
"Henry," 83, suffered repeated attacks of pneumonia, which at that age can be fatal. The doctors said his immune system wasn't making the right antibody to fight the infections and recommended he take a drug - intravenous serum immunoglobulin. Fine, he said - until he heard the price: $2,500 a month for several months, possibly for the rest of his life. Forget it, he said.
Ability to pay wasn't the issue. Henry had private health insurance in addition to Medicare. The issue was whether the drug was worth it. He felt the marginal benefit it offered to someone his age did not justify the substantial cost, and it would not be right for anyone - not him, not his insurance company and not his fellow taxpayers -to pay.
As it happened Henry's system healed itself and he got well; today he's 86. He had taken an unnecessary risk and won, but he had also raised a central health care question our society has avoided: How much are we willing to pay for the medical technology that we are so adept at developing?[8]
I submit resolving these problems by the blind forces of the market does not work. There are issues here far deeper than profit and efficiency. Fairness and justice are at stake.
In his classic work in social ethics Harvard philosopher John Rawls suggested the "original position" exercise in making ethical judgments. Imagine we are at the creation of a new society. We live behind a "veil of ignorance." We don't know how we will fare. We are as likely to be the worst off as the best off. Would we wish the worst off, and we might be among them, to have a basic human right to health care whether or not they can afford it? I believe - and hope - we would.
One cannot prove that right logically; one can base it on the "inherent worth and dignity of every person." One can base it upon mutual obligation in a Beloved Community. Rights cannot be bought and sold in the market place. Society is not a vending machine that delivers anything for the mere insertion of coins. Otherwise, we may again be accused of knowing the price of everything and the value of nothing. Human rights are not denominated in dollars. Health care is not a commodity to be bought and sold; without it, other rights are meaningless.
An example of community responsibility. "When a Canadian man was handed an invoice showing the cost of his care after he was discharged from the hospital it was a news event covered throughout Canada. The 'bill' for $2,269 - covering a two-day stay in a Toronto hospital for investigation of an irregular heart beat - was stamped "Do not remit. Paid on your behalf by the citizens of Canada."[9]
Can we ever bring that sense of community solidarity into our national conscience? Will we ever believe that health care is a human right? I like to think that some day I will be able to read on my doctor's bill, or my hospital bill, on my medical bill - paid for by the citizens of the United States because they are a community; because they care; because they believe all of us are part of the "independent web of all existence of which we are a part."
As Vaclav Havel of The Czech Republic wrote: "We still don't know how to put morality ahead of politics, science and economics. We are still incapable of understanding that the only genuine backbone of all our actions - if they are to be moral - is responsibility. Responsibility to something higher than my family, my country, my company, my success. Responsibility to the order of Being, where all our actions are indelibly recorded and where, and only where, they will be properly judged."[10]
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