Editorials
COMMONWEAL Getting well he litany is familiar—and familiarly depressing. More than 35 million Americans are without health insurance, those who have insurance find themselves paying more for...
...Commonweal 27 March 1992: 5...
...Yet, it has proven difficult, if not impossible, to persuade American voters that the poor deserve, as a matter of justice, a decent roof over their heads or a job that might enable them to pay for that roof...
...Even George Bush has a plan—sort of...
...But that's just the beginning...
...In the meantime, the first step is to recognize that a healthcare system, like the extension of voting rights to black Americans in the 1960s, should be an expression of the enduring American belief that "all men are created equal, and endowed by their Creator with a right to life, liberty, and the pursuit of happiness...
...Both are reasonable suggestions...
...Yet our steadfast adherence to individualist prerogatives—each patient ideally entitled to all possible treatments—may deprive us of the moral resources needed to resolve a problem that requires broad-based sacrifices...
...Individuals are free to supplement the primary package through added insurance coverage, but basic enrollment is compulsory...
...Health-care reform is in every presidential candidate's platform...
...Without that sense of common values, the just allocation of limited resources is impossible...
...Worse, in our present open-ended, fee-for-service system, doctors have little incentive to manage costs...
...Government could contract exclusively with HMOs and industry could be prodded to do the same if the present tax exemption for health benefits stipulated that managed-care systems be used...
...This practice, known as "experience rating," should be prohibited...
...Most other developed nations offer universal coverage while spending less than 9 percent of GNP...
...How can a high and responsible level of care be maintained and excesses reduced in the day-to-day practice of medicine...
...The imposition of standard fees for medical procedures should be part of such a plan...
...Joel Rappeport's heroic 4: 27 March 1992 Commonweal and miraculous battle to save young Patrick Hough from WiskottAldrich syndrome to see the very paradox Callahan describes...
...The nation's health bills are going to increase inexorably as our population ages and as more high-tech interventions against chronic illness become available (Christopher Koller, p. 9...
...The obstacles—cultural, professional, and bureaucratic—to health-care reform are daunting, as the several in-depth (and, we hope, balanced) articles in this issue suggest...
...Yet, for American society to continue to do nothing will only bring greater inequities and turmoil...
...Daniel Callahan has argued that the health-care system will not respond to managerial reforms and that the efficiencies now being trumpeted will prove illusory...
...Yet many who have studied the ongoing health-care crisis are skeptical about the chance for reform...
...More than 35 million Americans are without health insurance, those who have insurance find themselves paying more for less coverage while catastrophic illness or long-term care for the elderly can threaten any family with bankruptcy...
...Some uniform, perhaps electronic, system of record-keeping and accounting is surely possible...
...There is much to be said, after all, for the venerable American tendency to muddle through such irreconcilable conflicts...
...The electorate generally prefers to live with the pain and inequities it knows rather than experiment with those it doesn't...
...Clients pay a set yearly fee for medical services and doctors are on salary...
...Perhaps some adaptation of the Canadian insurance system (Jordan Bishop, p. 6), in which the federal government mandates and monitors a basic benefit package but administering the program is left up to each province, is the best hope for achieving universal coverage...
...It has been paid by the millions of Americans denied any decent medical care at all...
...Nor has Congress forgotten the stinging rebuke suffered when its 1988 effort to graft coverage for catastrophic illness onto Medicare was reversed by the shrill lobbying of mostly affluent senior citizens...
...American government was constituted to protect that claim to life, and surely life's continuation in the face of illness should not turn on the accidents of wealth and privilege...
...In the unassailable pursuit of health and cure, do we not increasingly risk sacrificing many other human values...
...If our personal desire is to live longer, and medicine can manifestly accomplish that, who can say no...
...The same polls that show Americans eager for national health insurance show them unwilling to pay a dollar more in taxes to fund it...
...Indeed, all the financial as well as moral incentives encourage overtreatment...
...No one knows if we as a nation will be able to turn away from the promises of absolute self-determination that modern medicine so dramatically embodies...
...leads the world in health-care spending and boasts of the most sophisticated technologies, Americans do not live longer nor are we measurably healthier than citizens of other industrial nations...
...Restricting individual choice is not easy...
...A denial of the limits of the possible in effecting cures is thus a central part of the ideology of scientific medicine," Callahan writes in What Kind of Life (Simon & Schuster...
...Insurance companies also need to be publicly accountable...
...The effort to extend insurance coverage to all Americans should build upon the employer-based and payroll-tax-funded group insurance system we now have...
...Even if savings can be wrung out of the current chaotic and inefficient system, extending decent medical care to 35 million people will inevitably increase costs...
...Not the failures, but the very success of modern medicine—its palpable promise to "cure" all illness—drives our insatiable desire for ever-expanding medical care...
...we are a country of great moral and cultural diversity, and blurring our antagonisms is a time-tested way of preserving the peace and protecting individual dignity...
...Competition now encourages insurers to pool only the healthiest clients, limiting risk and thus enabling them to offer lower premiums...
...One has only to read Madeline Marget's story ("The Need to Preserve Hope," p. 12) of Dr...
...Given the primacy Americans assign to individual freedom of choice, Callahan continues, there is no way to curtail the demand and therefore the cost of modern medicine...
...All nationalized systems impose some form of "global budgeting," which caps spending and results in some form of rationing, either in access to the most innovative medical technology (as in Canada) or in access to specific therapies (in Britain dialysis is not available for men over fifty-five...
...Meanwhile, health-care costs continue to spiral out of control: The $600 billion Americans spend annually represents more than 12 percent of GNP...
...Most important, however, is to put economic incentives in place that will curtail unwarranted treatment generally...
...Until recently, insurance companies gave doctors and patients a blank check, and we have used it profligately...
...For example, enormous savings are thought to be readily available in two areas: curtailing administrative paperwork and restructuring malpractice laws to reduce high malpractice premiums and to reduce the practice of "defensive medicine...
...Treatment for identical conditions varies from city to city, and according to the preferences of the local medical community...
...Health should be placed in its proper relation among other social goods...
...Managed care or prepaid group practice, best exemplified by health maintenance organizations (HMOs), is one way to bring fair-minded discipline to medical care...
...Callahan's stark critique is revelatory...
...To reduce defensive medicine, which accounts for an estimated 20 percent of medical costs, C. Everett Koop, the former surgeon general, has proposed a ceiling on awards for pain-and-suffering and binding arbitration to resolve questions of Commonweal 27 March 1992: 3 accountability...
...Private insurance companies should be free to compete—this will help lower costs—but health insurance must be regulated by the government to insure equity and universal coverage...
...Although the U.S...
...Americans loathe the idea of explicit rationing, and for understandable reasons...
...The task of convincing voters that the poor should have medical care at a level roughly equivalent to other Americans seems forbidding indeed...
...A consensus for reform may be emerging...
...Making explicit choices is difficult, but consider: rationing already exists throughout the United States, where the poor are excluded from routine medical care...
...COMMONWEAL Getting well he litany is familiar—and familiarly depressing...
...Many people in highrisk groups can no longer afford the exorbitant premiums asked...
...Callahan urges us to turn away from such a self-defeating quest in order to guarantee a basic level of health to all while reorienting the practice of medicine to the reasonable rather than the heroic care of the dying...
...But a medical ethos that refuses to recognize limits imposes a cost...
...Witness the effort in Oregon, which wants to extend a minimal level of health care to all the poor by denying some of them certain procedures (kidney transplants for alcoholics, or treatment of premature babies weighing less than 1.1 pounds...
...Given the size and diversity of needs in the U.S., a system of "regulated pluralism" rather than Canada's "single-payer" insurance model may be the best solution...
...As a good deal of research has shown, it is decisions by health providers themselves, not the logic of any objective measurement of outcomes, that determine the type of medical treatment patients are likely to receive...
...Once insurers pooled a broad spectrum of clients, spreading the risk across society as a whole...
...Much work needs to be done, and religious communities that have preserved a sense of moral authority in which individual sacrifice is given a meaning in relation to a larger good may be the best place to start...
...Worse, our hospital emergency rooms are flooded with needy and uninsured patients while even large corporations, finding a crippling percentage of revenues allocated to insurance premiums, are looking for relief...
Vol. 119 • March 1992 • No. 6
