By John C. Baldwin and C. Everett Koop
Thursday, May 6, 1999
The crisis in American health care is real and
getting worse. A record 16 percent of Americans now
have no health insurance -- a grave situation
that will not be solved by conventional business models. Indeed, the movement
over the past few years to turn health care into a "business" through health
maintenance organizations and other stratagems has not worked to the satisfaction
of most Americans.
Frustrated, legislators across the political spectrum
pursue the notion that legislative tinkering
will solve the problems. But since the derailment
of President Clinton's health reform plan in his first term -- and particularly
since the elections of 1994 -- the country has slipped or been lulled into
a false
sense of confidence that the real and worsening
crisis in American health care can somehow be solved by implementation
of "reforms" based on such euphemistic concepts as "gatekeepers," "pathways,"
"preexisting conditions," "risk pools" and other impediments to access
-- all disguised as tools of efficient management.
To be sure, health care costs have risen too rapidly
in the past 20 years. Highly paid providers and
administrators and exceedingly profitable health
care corporations have played a role, though their contributions to rising
costs have been less important than the effects of an aging
population and the continual introduction of
new technologies. But we must not abrogate our
responsibility to make difficult choices in the
vain hope that a "free market," profit-based system somehow will solve
the problem for us without our doing anything.
If health care were a business, it would be a
strange one indeed -- one in which many sectors of the
"market" could never be profitable. People with
AIDS, most children with congenital, chronic or catastrophic illness, poor
people, old people and most truly sick people could never pay enough to
make caring for them profitable.
Over the past few years, nevertheless, we have
often heard that "health care is like any other
product; you buy what you can afford." Most proponents
of this idea quickly add that of course "basic" health care should be provided.
But what does this mean? Suppose two children, one in an uninsured family
and one in a well-insured one, both developed leukemia, a treatable and
often curable illness. What is the basic level of care each child is entitled
to?
HMO executives properly emphasize that their responsibility
is to shareholders. That
responsibility is defined in terms of profit
and stock price. The volume and market-share considerations in this "business"
require aggressive pricing. Sustained profits, in turn, require aggressive
cost-cutting. This results, inevitably, in restriction of access and withholding
of care.
Both these things may well be necessary to improve
efficiency and cut costs. But do we really want
to relegate such decisions to analysts within
the health care industry, or should we assert the public interest in these
crucial
ethical, societal and medical issues?
We nod our heads when we are told that the percentage
of our GNP spent on health care is "too
high" and that inefficiency, the "fat" in the
system, results in its providing less effective care than is available
in other industrialized nations that spend a lesser percentage. But this
argument is specious. The American biomedical research endeavor, supported
in the main by the taxpayers, has led the world for more than 30 years
and continues to do so. Attendance at any medical scientific meeting anywhere
in the world confirms this hegemony and affirms the enormous respect the
rest of the world has for American medicine.
Our system is not a failure. The dramatic decline
in deaths from heart disease is salient evidence
for the phenomenal success of technologically
advanced American medical care for those who can afford it. Our problem
is a failure of distribution, a failure to extend care to all of those
who need it and a failure to recognize the importance of applying scientific
rigor to the problems of broad-based health care delivery. If state-of-the-art
American medicine were offered to our citizens in a
comprehensive way, our levels of public health
would be unexcelled.
Like education (also, in important ways, not a
business), the public health is a national
investment and a crucial one. Could we justify
a "privatized" educational system that denied access to slower learners
unable to pay -- i.e., the children who need help the most? When you consider
that we spend more on leisure than on health care (22 percent more just
on recreation, restaurant meals, tobacco and foreign travel), is the percentage
of the GNP we spend on health care really so
inappropriate?
The failure in distribution of health care is
the product of our tacit acquiescence in the notion
that health care access rightly depends on ability
to pay. This idea has become, for many, a point of philosophical and ideological
zeal.
It is long past time we acknowledged that broad-based
access to health care will be an exceedingly
expensive proposition. We must rid ourselves
of the delusion that it is a business, like any other business.
The problem can be fixed. Forming a public consensus
on this matter is a mighty and politically
perilous challenge, requiring leadership and
the courage to state that adequate health care is an appropriate goal for
this country and a vital national investment. These are, indeed, treacherous
waters. Can we get away from the cliches about
"socialized medicine" and the hackneyed references
to overly bureaucratized, centralized, inefficient
postwar European health systems?
As world leaders in science, business and organizational
management, we are capable of something
new. We should maintain our commitment to the
advancement of biomedical science for the public good and couple it with
the management skills that have created our vibrant, competitive economy,
and apply both in creating a national policy of investment in health.
John C. Baldwin is vice president for health affairs
at Dartmouth College and dean of its medical
school. C. Everett Koop is senior scholar at
the Koop Institute there and a former U.S. surgeon general.
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