This Noble Land (16 page)

T
riage
is a French word stemming from the root
trier
, meaning
to sort.
It was used originally in battlefield hospitals when the triage officer picked those wounded soldiers with the best chances of profiting from immediate medical care. Today triage is a word driving medical practice in the United States. Triage-type decisions are being made as to which type of patient is worthy of advanced medical care and which type has to be allowed to die. Triage-type decisions are being made as to what medical specialists a patient may see, what medical procedures and tests the insurance companies will pay for, and how many days a patient may remain in the hospital. Costs rather than needs are too often the determining factor for triage decisions.

The issue of triage today is complicated with many facets both rational and emotional. Let us imagine that we are members of a medical committee, meeting to consider how we would vote in two different situations. A hospital has one donor heart but two claimants who could use it. The first is a twenty-two-year-old mother with three children and a husband able to pay for the operation. The other is a seventy-seven-year-old with funds too skimpy to pay for a heart transplant. The choice seems too easy for our committee to discuss at length. The young mother gets the heart.

But now let’s suppose the seventy-seven-year-old man is Albert Einstein, still working on his masterly explanation of the universe, while the young mother is an alcoholic who tests HIV positive and whose three children have inherited from her both the virus that causes AIDS and the negative effects of an alcohol addiction they acquired in the womb. Again, the committee requires only a few minutes to decide that Einstein gets the heart.

But triage decisions are usually not so simple. In a more realistic case, both the claimants are the same age, both are sterling citizens and both can pay for the operation. Now the choice requires an agonizing decision. Whichever way the committee votes may be justifiable but is nevertheless devastating for the loser.

I happen to know something about the procedures of triage because recently I chanced to see a confidential report on how best to use a healthy kidney that an automobile accident had supplied. The question was ‘Which of our patients can profit most from this kidney?’ Opposite my name were the notes ‘Too old. Too many other medical problems.’ In my case the decision was the right one. Other similar types of judgments are being made daily covering all sorts of medical problems. In the cases of transplanted organs, the deciding factors may be clear even if the solution isn’t, but many of today’s triage decisions in other less dramatic situations are based on the much more subtle factor of greed.

The United States is fast becoming a nation practicing triage on a grand scale. Unfortunately, greed rather than legitimate medical necessity has too often become the driving force behind triage. The share of our gross national product that we are currently willing to devote to medical services is being stretched to the limit. This means that such care as our nation is willing to pay for must be rationed financially; we can perform only so many
costly operations in the hospitals, and we can provide only so many recuperative facilities and nursing homes. Our insurance companies believe that to protect their profits they should pay for only the most necessary (to
them
, not to the patients) operations and for limited specialized care. Hospitals, many of them profit-seeking corporations, charge fantastic rates for one day’s occupancy of a bed, two thousand dollars being typical in some areas, and the costs of the advanced medical technology are astronomical. A huge number of our citizens cannot afford today’s very expensive private health insurance and must receive their medical care in the emergency room of the local hospital. Much of the medical care for the indigent—say, the bottom fourth of the entire population—has to be paid for by government funds, and the costs to the taxpayer are becoming exorbitant.

Employers, both large corporations and small businesses, are deciding that, with the skyrocketing costs of medical care, the costs of adequate group health insurance now cut too deeply into corporate profits and are requiring their employees either to contribute to their health care costs or to join an HMO. The crisis is exacerbated by the fact that those who receive any kind of health care benefits from their employers cannot carry that insurance with them if they have to change jobs; we are the only major nation in the world that allows such a miscarriage of simple justice.

Any careful observer of America’s health care system is perplexed as to why such an admirable collection of health experts, supported by one of the richest nations on earth, cannot provide
all
its citizens with an insurance system they can afford and with medical care through something like Medicare, now available only to elderly citizens over age sixty-five. Currently those under age sixty-five in the middle class are caught in the gap between the wealthy, who are able to pay high medical costs, and the very
poor, who receive some assistance through Medicaid. Our nation’s failure to solve the problem of this gap is one of the mysteries of American life, especially when both the major political parties agree that steps must be taken to solve it. The reason for the failure is the rampant greed that pervades the medical profession, the insurance companies, the various types of medical corporations and the character of the individual taxpayer.

I have been obliged to study American medical practice because my wife and I had five cancers to deal with, and I had a massive heart attack, a quintuple bypass, the insertion of an electronic heart monitor, the insertion of a new hip and extended treatment for kidney failure. In Pennsylvania, New York, Florida and Texas, my wife and I had superb medical care. We saw American medical practice at its technical best.

But when it came to paying for the doctors and the hospitals, we found ourselves in a jungle so insane that we could not even guess who might have been sufficiently addled to have devised it. The experience gave us an inkling of the tremendous waste in our medical system. We both had Medicare, and my wife had private insurance as well, but the government system was as confusing as that of the private company. Both seemed to be vying for a prize to see which could have the stupidest book-keeping system and the most lost records. It was a draw.

Repeatedly I would receive itemized bills from doctors and hospitals involved in some treatment. I would pay them promptly, only to be told by the doctors that I should not have paid so quickly: ‘Wait till you get your check from Medicare and then reimburse us for our services.’ The next doctor would have a different system: ‘Ignore my bill. We get reimbursed by Medicare for the portion they’ll authorize, and then we bill you for the difference.’ Other doctors and other Medicare offices had their own tricky systems; all seemed to be honest but inept.

We never protested the handling of our many cases, but preposterous tangles kept driving us to despair. I was most angered when, two years after I was sure I had paid everyone, I received a lawyer’s letter warning me that if I did not pay his client’s bill, which was now two years overdue, he would sue me in court for payment and inform the credit agencies of my delinquency Upon checking, we found that indeed I had already paid the bill. The snafu that most angered my wife came when a kindly Medicare secretary told her they were sorry to hear that I had died. My wife could not convince them otherwise, and the system, having been defrauded by families who kept deaths secret to protect their relief checks, demanded from us a notarized assurance from our doctor and our bank that I was still living and that I had appeared in person in the notary’s office to verify that fact.

If our experience with America’s system of providing medical care was typical—and we heard of worse cases—the nation’s insurance and medical bureaucracies are wasting billions of dollars on repetitive paperwork alone. With this type of waste, and with waste involving fraud, we citizens are legitimately angered by the unnecessary expenditure of our insurance, medical and tax dollars.

One of the truly serious matters that require immediate attention is the imminent danger of bankruptcy that threatens the entire Medicare and Medicaid system. Reliable predictions are that by the year 2002 there will be no more money in the Medicare fund unless sensible rectifications are made at once. This disaster will occur just as the baby boomers of the postwar 1950s are becoming eligible for payments from Medicare. Radical revision of the system is necessary, and Congress will have to act.

Apart from the Medicare agency, which has generally treated me well and generously, and apart from the technical proficiency,
our medical system functions so poorly in many respects that it is a blot on our democracy. Its primary weakness—that it is not available to everyone at an affordable cost—would be easily corrected if we had the determination to act. Our deficiencies are not due to lack of knowledge; we know what we need to know. Nor do they represent the victory of one political party over another; all parties know the weaknesses that need to be repaired and have the desire to make things better. Nor is it a lack of medical knowledge; our training hospitals, our research laboratories and the qualifications of our physicians are unmatched. So what is lacking? We simply lack the resolution necessary to tackle the complexities of our health system and its obvious failure to serve the nation with maximum efficiency.

In the aftermath of the 1992 presidential election when Governor Bill Clinton of Arkansas was sworn in as president, I was relieved by his proposal to tackle seriously our nation’s health problems. But I was shaken some weeks later when it became apparent that he would be installing his wife, Hillary, as manager of his medical program. It wasn’t that I feared she might not be up to the task of being in effect a co-president in dealing with medical affairs, because she was a brilliant graduate of Wellesley College and Yale University Law School and a prime mover in Arkansas politics and social reform. I knew a good deal about her and assured my friends that she had an excellent chance of being our next Eleanor Roosevelt. The danger I saw was that our reactionary senators, congressmen, other political leaders and both men and women in the news media would not accept her and would be poised to vilify her whenever she gave them an opening because of some unwise statement or action. Within a few months her enemies had indeed nullified her effectiveness and discounted whatever good ideas she put forward.

But I did not anticipate the extent of the venom and the cleverness with which the insurance industry launched its television campaign against everything she proposed. Its Harry and Louise ads were as persuasive as any I have ever seen. This middle-class couple were so sincerely, so deeply worried about the health of the nation—and so eager to leave all decisions to the insurance people—that they made any allegiance to Mrs. Clinton’s proposals seem unpatriotic. With a series of some five or six ads, each more manipulative than the ones before, they neutralized not only Mrs. Clinton but also the president. Any health plan the Clintons proposed would be dead on arrival. Their reforms never had a chance. They were not even voted on; they died aborning.