A coroner's report
Roller, Christopher F.
4 HEALTH-CARE REFORM A CORONER'S REPORT MAYBE THERE'S A LIFE AFTER DEATH "Who would you trust your health with—an M.B.A. or an M.D.?" asked an "educational" advertisement placed in...
...The etiologies of health-care reform's demise are as varied as those of the diseases (high costs and poor access) it was intended to cure...
...health-care financing and delivery, and with limited success...
...or the notion of someone like me arbitrating a value for the act—$ 100...
...State-appointed commissions in Vermont and Montana dutifully included evaluations of single-payer plans in their recommendations to their state legislatures...
...These are the situations and alternatives we settle for when the private sector gets stuck making public policy...
...According to Citizen Action, the effect was to cow congressional members and confuse the public, reducing everybody's appetite for new initiatives, especially those which ran counter to the endemic suspicion of "big government...
...President Bill Clinton grossly underestimated the public's resistance to change, and aggravated it with a technocratic, complex plan drawn up in isolation from the many stake-holders...
...1,000,000...
...Equity is not a growth concept in the United States (the number of people living below the poverty line is at a thirty-year high, and income discrepancies continue to grow...
...This 4 percent increase over last year comes in a period of economic growth...
...As I pored over this mindnumbing construct, code by code, one procedure's description bludgeoned its way through my stupor: "Resuscitation of a Newborn" it was called...
...Try articulating the value of the procedure to the parents if the child lives...
...In the wake of the demise of federal health-care reform, this rhetorical query came back to haunt me in my work for a health maintenance organization...
...Health-care consumption will continue to be supply-driven, fueled by a ceaseless array of diagnostic, treatment, and pharmaceutical options...
...and even the ones that do don't contribute to congressional campaigns...
...Finally, states, feeling the financial burden of the uninsured, will continue to shape pay policies...
...Representatives of the status quo—such as the pharmaceutical, health insurance, medical equipment, and health-care provider industries—unfettered by campaign finance reform or anything so arcane as a sense of civility—threw mountains of invective and money at anything smacking of substantial change...
...The unequal distribution of health-care resources in the United States is a fundamental injustice...
...The proposition has generated strong praise from some corners for its guarantees of access, but criticism from others for its administrative complexities, state bureaucracy, and vaguely defined benefit package, which may or may not include abortion...
...If the private sector has limited powerto control costs, it feels no obligation to increase access to health care and will probably exacerbate the problem...
...It was the crux of the Clinton plan) will limit cost increases...
...I could not decide which was more absurd, the system which forces a physician to codify, annotate, and then charge others for a compassionate, albeit technically sophisticated, response to a helpless individual in great need...
...Incremental strategies need not be anathema...
...Networks of hospitals, physicians, and other providers will contract with insurance companies to provide and help "manage" care for employers...
...Single-payer advocates have focused their efforts at the state level...
...Despite this gloomy forecast, incremental reform will be the watchwords for any effort by the next Congress...
...CHRISTOPHER F. koller Christopher F. Koller lives in Buffalo, New York, where he works for a health-maintenance organization...
...The adage held true: the poor do not vote...
...How admirable is the high quality health care this nation boasts of if one in six people cannot obtain it...
...The most significant potential impact for single-payer advocates will be in California, where Proposition 186, a comprehensive single-payer initiative, will be included on the November 8 ballot...
...the nonvoting poor will be joined by newly uninsured and underinsured, disenfranchised members of the middle class...
...no adult should forgo necessary antibiotic therapy...
...The most aggressive will attempt to expand Medicaid access, as Oregon and Tennessee have, to include uninsured populations...
...demand for generalist primary-care physicians is increasing at the expense of higher-priced specialists...
...MBAs, alas, will continue to thrive, but probably not conquer in such a world—reviewing fee schedules, negotiating contracts, and wringing out savings...
...I had helped develop a new fee schedule for the HMO, a compilation of 8,000 standardized procedures performed by physicians, each paired with what we would consider a reasonable fee (that is, low enough to save money, but not so low as to alienate participating physicians, with whom we contract to provide care to our members...
...asked an "educational" advertisement placed in numerous highprofile newspapers last summer by a physicians' organization...
...The private sector, in which we have placed our fealty, will address only the cost problems in U.S...
...A highly partisan opposition, increasingly emboldened by polls showing wariness toward the Clinton plan, willingly adopted an obstructionist stance...
...In the future, absent major regulatory interventions, managed care will grow in strength...
...This system is already producing lower premium increases in highly competitive areas, with projections of zero to 4 percent annually in several Northeastern states...
...They certainly do not coordinate assaults on their representatives' offices with fax machines, as do the masters of single-interest pressure politics, lobbyists who wield disproportionate influence on Capitol Hill...
...These efforts will continue to be constrained by revenue limitations, the fear of provoking employers or industries to leave a region because of new tax burdens, and federal statutes such as ERISA (the employ5 ee benefits funding regulations) limiting the states' power over large employers...
...While positing little in the way of credible alternatives, Republican Senate minority leader Robert Dole and House minority whip Newt Gingrich et al played a stall game, counting on a more Republican Congress in 1995 to deliver moderate reforms for which they could take credit...
...At best, the result of these state initiatives will be a patchwork of efforts to increase access, resulting in the oft-quoted health economist Uwe Reinhardt's prediction of a three-tiered United States health-care system: fee-for-service practice with unlimited choice for the wealthy few, managed care for many, and an underfunded, largely segregated public system for the rest...
...The absence of campaign finance reform makes the practice of single-interest politics devastatingly easy...
...basic coverage for children and expectant mothers seems an obvious place to start...
...The number of uninsured in the United States, as estimated by the Census Bureau, now stands at 39.7 million, or 15.3 percent of the population...
...Is our federal government up to the task of health-care reform...
...The events of the past year indicate, however, that it is too important to leave solely in the hands of congressional members, M.D.s, or M.B.A.s...
...This was the legacy of the 103rd Congress, and it is a poor substitute for what might yet be...
...No child should go without immunizations...
...These companies' employees will accept limited provider choices and some treatment review for more comprehensive coverage and lower costs than traditional feefor-service indemnity plans...
...Such a world of managed care and private-sector resource allocation, however, is powerless against larger forces which drive much of our health-care needs and expenses...
...Competition between these alliances (does this sound familiar...
...And if it doesn't...
...Moreover, with proper oversight, the quality of care provided will not suffer appreciably compared to old-fashioned fee-for-service medicine...
...The need for fundamental restructuring will grow stronger...
...Ironically, prospects for reform may increase as time drags on...
...I paused...
...Any cost improvements accomplished by HMOs will produce more uninsured Americans...
...Finally, those most likely to be favorably affected by reform— those with poor access to health care—were not heard...
...10,000...
...neither considered it politically feasible...
...when health care is relegated to a commodity, best left to the market to allocate...
...Physicians and hospitals are experiencing sea changes in their roles and responsibilities as a result of these realities...
...What if they had to pay for it themselves...
...Many parts of the country will not have sufficiently large populations to support a competitive market...
...Finally, the public continues to vacillate between its wishes for a controlled, noninterventional end of life, and a steadfast refusal to accept anything resembling an untimely end...
...The issue of unequal access can only be addressed at the federal level, where resources exist to redistribute funds and define national standards of equity (for example, Medicare's standard benefits package) for citizens...
...An aging population will require more resources...
...Interests opposed to comprehensive reform donated $46 million for the period from January 1993 to July 1994...
...Chastened by the Clintons' failure and the brute force exercised this year by stake-holders in the current system, political leaders will look for ways to tinker with insurance reforms and, as they tend to say: Why fix what is not broken...
...But Congress has only postponed action on health-care reform, not buried it...
...Families who have members with pre-exisiting medical conditions, members of small, hardto-administer groups, and employees of businesses electing to reduce or drop coverage face greater risk of being shoved out of private-sector health care lest they reduce efficiency...
...Willard Gaylin, the physician and ethicist, maintains the only acceptable death in the eyes of many Americans is by heart attack at ninety years of age, in the arms of your lover, after beating your son in tennis...
...In the meantime, it is not entirely clear where leadership will arise on this issue...
...A significant proportion of those without insurance live above the poverty line...
...The larger political context will make reform difficult as well...
...A public wary of the federal government's ability to do anything but collect taxes and incur debt will look skeptically at any program to redistribute income and assure government services, Medicare, Social Security, and the Veterans Administration notwithstanding...
Vol. 121 • November 1994 • No. 19
