The Health Care Struggle

...ROUND THREE The Health Care Struggle BY WALTER R GORDON "It's an unreal situation," said the official of an aging hospital in Baltimore's inner city "If we go on like this, it means disaster m five years or less Absolute disaster," he stressed, voicing a lament that can be heard in hospitals across the land Middle-class patients have moved to the suburbs, leaving behind a growing concentration of the poor, the young and the old—the groups that need the most medical care but can least afford it Rich contributors who once financed charity wards have disappeared, and now instead there is Medicare and Medicaid But the red tape is endless, the payments are delayed for months, sometimes years, and the scope of the programs has been increasingly restricted If the old facilities are costly to run, the fancy new equipment that has gripped the imaginations of doctors and patients is even more costly to buy And salaries of nurses, aids, orderlies have risen 40 per cent or more in a few short years All this is part of the "massive crisis" in health care (with the ghetto the loser) that President Nixon has predicted will develop in the next three to five years It is also part of the reason the Administration last summer prophesied "a breakdown in the delivery of health care unless immediate concerted action is taken by government and the private sector " But despite the available evidence, some rather simplistic diagnoses of the crisis have been made from time to time For instance, it is not due merely to the absence of national health insurance, as Senator Edward M Kennedy occasionally has appeared to suggest, Medicaid and Medicare have shown that increasing the demand for health services without altering the supply is a sure road to disaster Nor does it result solely from the inability of the poor to pay, as the American Medical Association (ama) asserted in proposing its Medicredit scheme, since the middle class is affected too Building more hospitals will not solve the problem either, because maldistribution of facilities keeps one-fifth of the nation's 800,000 general purpose beds empty all the time And the situation will not be helped much simply by adding more doctors to those 313,000 now licensed (one-third of whom are administrators or researchers), or training more dentists and nurses (half a million of whom are inactive) Increasing only a few thousand trained personnel a year, in Walter R Gordon is Washington Bureau Chief of the Baltimore Sun fact, would require enormous resources applied over a very long time Besides, there are a dozen countries with better health care than the United States, and most of them have fewer medical personnel in relation to population Finally it is not just a question of spending more money The over $60 billion spent on health care in the United States last year was a greater percentage of the Gross National Product than the health expenditure of any other country in the world Yet former Secretary of Health, Education and Welfare (hew) Wilbur J Cohen said m a year-old report that the nation ranks 16th in life expectancy at birth, 28th in age-adjusted death rates for heart disease among men, 13th m rates of ulcers, diabetes, cirrhosis of the liver, and hypertension without heart involvement, 15th in infant mortality, and sixth in maternal mortality Heading most informed observers' lists of what is wrong with American medicine is the health care "system" itself John W Gardner, chairman of the Urban Coalition and Cohen's predecessor at hew, calls it a "nonsystem", a Princeton University authority dismisses it as "a figure of speech", and a recent survey concluded that "our present system of medical care is not a system at all A related thesis shared by high Administration officials and medical professionals is that the problem is not too little money, too few doctors, antiquated hospitals, or even uncooperative medical societies It is, rather, a disorganization and fragmentation of medical services so great as to be tantamount to chaos Of course, all of those other things, so frequently mentioned, particularly money, may certainly be contributing factors Gardner once told the following anecdote "A friend of mine said recently, 'I have great skepticism as to what can be done with money,' and I told him it was matched by my skepticism as to what can be done without money " Although the "nonsystem" has been around a long time, what has abruptly brought it to general attention is the issue of costs Under the impact of new Federal health programs, inflation, increasing affluence, and spreading knowledge of the benefits derived from high-quality medicine, the need for health services has soared Disorganization and maldistribution, however, have prevented physicians and hospitals from responding by expanding the availability of medical care, and the growing demand for a constant supply has meant exorbitant price rises The elements of a solution have been widely discussed, though rarely as a package until recent months One suggestion calls for the use of paramedical personnel, such as medical corpsmen returning from Vietnam, to relieve doctors of many routine functions Another would take advantage of the distributive mechanisms of Medicare, Medicaid, Blue Cross-Blue Shield, and private insurance companies to alter medical care patterns In the case of the two Federal programs, the law would have to be amended to eliminate the current flat prohibition against doing precisely this A third approach would emphasize preventive medicine at the expense of traditional treatment, at the same time trying to relieve the load on hospitals by stressing outpatient services An idea imported from Vietnam would give isolated rural areas helicopters instead of small, inefficient hospitals The difficulty here is that while 85 per cent of Americans under 65 have some hospital insurance, only about one-third have any coverage for ambulatory attention And only a handful of insurance plans, most notably that of the Kaiser Foundation in California and the Health Insurance Plan of New York (hip), include preventive care Thus present financial incentives encourage doctors and patients alike to do nothing until sickness appears, and then to overuse hospital facilities This has resulted in a rash of unnecessary surgery According to an investigation team from the Columbia University School of Public Health, one-third of the hysterectomies it observed were unjustified Even a spokesman for the ama has denounced the increase m tonsillectomies paid for by Medicaid as "verging on the scandalous " Other aspects of a new medical system would be prepaid group practice, national health insurance, and Federal incentives to eliminate duplication, fragmentation and maldistribution of medical services Government and private insurers could also use incentives to repay efficiency, following the practice of the ancient Chinese, who paid doctors not to treat sickness but to keep patients well The Kaiser plan uses a variant of this arrangement All ot its doctors are on salaries and work in large clinics, if through efficient administration the plan is able to operate at a cost less than total revenues, the savings are passed on to doctors in the form of bonuses As a rule, preventive medicine is cheaper than treating sickness after it develops, ambulatory care is cheaper than hospitalization, efficiency is cheaper than inefficiency Clearly, the proper incentives are built into the Kaiser system, and the 2 million subscribers in California, Oregon and Colorado seem to like the results A variety of smaller, somewhat less successful plans have been functioning in New York, Detroit and elsewhere In all, about 8 million people are covered by prepaid group plans Health officials in the Nixon Administration look upon such schemes with favor but have been unable to win approval for the means to encourage them The same has been true of a number of health programs which could have achieved significant changes at relatively modest cost Indeed, the influence of one key health official, Dr Roger O Ege-berg, hew's Assistant Secretary for Health and Scientific Affairs, has sunk so low that a recent prepared statement he delivered before a congressional committee included a paragraph he had not written, did not agree with, refused to endorse, and even declined to read aloud Nevertheless, it appeared in texts distributed to committee members and the press (The unuttered paragraph said he wanted no money for an experimental medical training program He wanted the money, but the White House and Budget Bureau did not ) In the past, most of the controversy over health reform has centered on national insurance The ama's stand against President Truman's protection plan two decades ago has been equaled in lobbying history only by that same organization's 1965 fight against Medicare —each cost $1 million officially, and far more unofficially Today the ama is at it again Anticipating Round Three m the health care battle, it spent an estimated $5 million on the 1968 elections, and has now launched its own Medicredit plan to give the poor and the lower middle class tax credits for insurance premiums There was even a top secret meeting last month between ama officials and their arch rivals of the Committee for National Health Insurance A coalition of 100 liberal leaders, including four senators, the committee is headed by Walter Reuther, president of the United Auto Workers, and has had its insurance proposal introduced in both houses of Congress The February meeting was scheduled at Reuther's initiative to seek some possible compromise common ground, a purpose in which it largely, though not entirely, failed The Medicredit plan, the meeting and a variety of statements by ama officials indicate the organization, representing slightly over half of all U S doctors, senses impending change and is concentrating more on controlling its direction than on halting it entirely For example, Dr Gerald Norman, president of the ama, recently made the startling admission that only 60 per cent of Americans receive good medical care "Serving the other 40 per cent will be the next big thrust in medicine," he said It is hard to see how this is going to be accomplished without some kind of national health insurance Many liberal groups have long been in favor of national health insurance as an equitable way of providing entirely for the medical services required by the poor and the lower middle class Now that medical expenses are affecting the pocketbook of the middle class, enthusiasm for some sort of plan would seem to be nearly irresistible Virtually every Administration official who has commented on the subject has admitted as much hew Secretary Robert H Finch, Dr Egeberg, Daniel P Moynihan, the President's Urban Affairs Counselor, Walter McNerney, who heads an Administration task force looking into health insurance and other medical problems, and Surgeon General Jesse L Stemfeld Four congressional committees, moreover, are now studying various aspects of the health crisis, and all are expected at least to touch on the matter Even the National Governors Conference, three-fifths Repubhcan, came out for national insurance last year by a wide margin, causing President Nixon, who flatly opposed this approach during the 1968 campaign, to waver Still, the dominant feeling that emerges from conversations with physicians and hospital administrators, congressional aides and hew officials is that the present Administration will not be the one to launch national health insurance-or, for that matter, any of the other major innovations that the President's own health officials agree will be absolutely essential during the 1970s The Nixon economics has built a series of roadblocks m the path of domestic programs, and they have prevented any substantial health proposals from emerging The fiscal 1971 budget calls for more health funds for Medicare and Medicaid, which are already established and therefore largely uncontrollable, about $30 million more for five high-priority research projects, and an additional few million for pilot programs Some long-range reforms have also been mcluded in the first set ot recommendations to emerge from the McNerney task force A number of hew officials have evinced public unhappiness with the pace of action Dr Egeberg has done so in a roundabout way, and the Surgeon General has taken a similar course Recently, in the midst of a "personal statement" before a congressional committee, Stemfeld said national health insurance is inevitable, and will in fact be accomplished before the end of the decade He repeatedly asserted that steps to prepare for it, including the launching of experimental programs, should be taken at once by the Congress and the Administration There is no evidence, however, that the White House is prepared to follow his lead, the President's mam thrust is clearly to hold down costs as much as possible by tightening up Medicare and Medicaid operations When hew Undersecretary John G Veneman was asked to reconcile Administration rhetoric about the health crisis with its handful of comparatively minor proposals, he replied "The statements were made merely to call attention to the problem They were not meant to solve them...