This Noble Land (17 page)

What is there in our national character that makes us incapable of tackling a relatively simple job like organizing and running an affordable national health system for all our citizens? Like so much of American life, the roots of this characteristic go back to colonial days, when, almost as an act of faith, the frontier family was supposed to stand by itself and look to its own members to safeguard the family. With doctors unavailable or in short supply, the frontier settlements usually had to struggle along for some years before medical services became available to their new communities.

When a doctor finally appeared in their midst, he was idolized and granted an exalted position that he may not have deserved. It was in this period that doctors came to occupy a position of power in community life. In my boyhood village doctors were trusted deities—so much so that I still feel that way about the doctors who treat me now.

At some point in the postwar period, American doctors became concerned about political threats to their incomes, and they declared war on any liberals who might pass legislation that
would in any way curtail their unrestricted control over the fees charged for their services. In a campaign about which I can speak from personal experience they were joined by other workers in the health care field and by the insurance companies fearful of any type of regulatory controls. When I ran for Congress in 1962, word spread through the medical community that doctors could give my opponent, who despised any federal program in medicine, contributions of as much as $999 without the recipient’s having to report the gift publicly. When the election was over, the local newspapers printed the lists of doctors who had each given my opponent the $999. The earlier report of nondisclosure had been an error, but the end result was that everyone knew that I was for public medical care and the doctors and my opponent were not.

Not surprisingly, American doctors have developed a hatred for the medical-system experimentation in Canada, where a relatively sound national medical program has been installed and flourishes. It resembles the great programs in European countries like Great Britain, Denmark and Sweden, and is in no sense radical. But the American doctors, terrified by what they saw happening in Canada, where the doctors no longer had unrestricted control over their fees, launched a program of vilification against everything the Canadian medical system accomplished. This was the period when any Canadian who had the slightest grudge against his national system could come south of the border and be assured of heavy newspaper coverage when he declared the Canadian system did not work and should be junked. In fact some 90 percent of Canadians liked their system and compared it more than favorably with ours.

The American Medical Association adopted, with equal success, the policy that had served the National Rifle Association so well. If any critic pointed out that every advanced country in the
world except ours had a national health and insurance policy that worked, while we lagged behind, AMA apologists for our inferior system shouted that our system was better because we were a different kind of people who had a system that suited us perfectly—we had nothing to learn from Europe, whose people were effete and not as advanced as we were. The NRA has used the same argument when anyone points out that our murder rate from handguns is four hundred or five hundred times greater than the rates of civilized foreign nations: ‘We’re a different people with a unique history, so there’s nothing to be gained in comparing us with what are essentially backward foreign countries.’

The sad part about our refusal to establish a sensible national program for health care is that we already have in place all the components required for such a system—components of the very highest caliber. From extended experience with doctors, hospitals, insurance companies and collateral medical agencies, I make the following evaluations:

Personnel:
Our specialists, general practitioners and nurses are equal to the best in the world and, in many important specialties, superior. So they would be able to service any kind of delivery system we elected to install.

Hospitals:
The ones in which I have been a patient have been superior, and for the most part the rest are excellent, but we appear to have so many superfluous ones that any less than excellent hospitals should probably be closed down.

Retirement centers:
After I had seriously inspected some two dozen of the top installations, I reached two conclusions: living conditions, including exercise rooms and recreational areas, were excellent, but the health care facilities, so glibly advertised when attracting new clients, were almost always nonexistent. Much fakery is evident in this aspect of health care. You live in the
beautiful condominium, but you are left on your own to find in the nearby town what turns out to be very ordinary health care.

Delivery systems:
If a family has an income of more than eighty thousand dollars a year, its members can enjoy the best medical care in the world. Medicare is a precious boon even to such families, although they could probably exist without it, except in cases of catastrophic illness or injury.

Emergency care:
People at the bottom of the economic ladder face a brutal task when trying to obtain adequate medical care. Persons without medical insurance use the emergency rooms for minor medical problems because they have nowhere else to go. No-charge emergency rooms are crowded, rushed and sparsely staffed. The waiting period is often intolerable. Other nations do better.

Nursing homes:
They are almost universally deplorable. The health care they provide is often a farce, and anyone who can should avoid entry to such dead-end operations. There must be the occasional nursing home that does a respectable job, but I have never found it.

Transportation:
Because transportation, especially the private automobile, is presumed to be easily available to all, home care from a physician or a nurse is usually unavailable. And if the family does not have a car, or if the one they do have is preempted by the breadwinner, the lack of transportation is itself a major medical problem. We do not handle this well.

Lack of universal care:
We are the only major nation I know that does not provide its citizens with the assurance of universal health care. This deficiency is a scandal of which we should be ashamed.

Lack of lifetime insurance:
Most major nations provide health insurance to all citizens, with the promise that it will follow them like a protective umbrella wherever they have to move in changing
jobs. We should provide the same, but we lag far behind the other major nations in this respect. We have not been allowed to provide lifetime insurance because of the cupidity of the insurance companies, who fear government regulation and want to keep the monopoly for themselves, and the avarice of some doctors, who support and defend the insurance people. The insurance companies must continue to be involved in a new system guaranteeing lifetime insurance, and they must, of course, be allowed to make a reasonable profit, but they cannot be allowed to control the system. Private medical insurance can continue to be available for those who can afford not to trust a national system to meet all of their medical requirements.

Doctors’ incomes:
One of the most difficult alterations to make in our system will be the question: What is a just salary for the doctor, especially in days when budgets have to be rationalized? All signs point to two changes. Across the board, doctors’ fee-for-service incomes will be under fire. Those with strong reputations, particularly the specialists in exotic fields, will be able to practice individually and will retain their yearly incomes of many hundreds of thousands of dollars. But the majority of their fellows will probably be forced to practice as members of group plans, under fee limits such as those imposed by Medicare. Doctors’ incomes will be diminished, but I hope that equitable salary categories can be established; doctors
do
deserve good compensation for their skills, and we do not want to see our towns and cities filled with doctors who feel they have been cheated. Nevertheless, doctors will have to give up the idea of becoming millionaires on the backs of the taxpayers.

Cutting expenses:
It stands to reason that in an age of triage, changes will have to be made in budgeting for Medicare (for anyone) and Medicaid (for the indigent), and some services now available will have to be rationed. Short of scrapping our current
health care system completely and starting over with a bold new system of national health care, modifications to the current system
must
be made. The problem is: How can we police those changes so that fairness to all citizens is protected? Both political parties, Republicans and Democrats alike, know that some kind of limitation will have to be imposed on these two services, and although the word
triage
is rarely spoken, that’s what the argument is about. And the subject is so vital to each party that the heated debate on medical costs has been at the forefront of the many disputed issues that have several times caused the government to shut down almost completely for weeks at a time, without any solution’s having been reached. And the impasse could continue right through the rest of 1996 and dominate the presidential election in November. Health care is a major problem for our federal and state governments. Cutting expenses is obligatory if the system is to be saved, but it would be dangerous and unacceptable if billions of dollars were to be cut from Medicare services to the middle class and even more from the Medicaid services to the poor. This would be especially repugnant if the billions thus saved were used to provide the upper classes with a tax cut they do not need. That proposal seems so immoral that our nation should scornfully reject it, yet it is being seriously proposed.

I
n recent years a promising innovation in health care has begun to proliferate, the HMO (health maintenance organization), a sample of which can be located anywhere in the United States from small town to major city. It consists of a group of doctors and nurses—often assembled and managed by an outside corporation—who practice as a unit and offer to their communities a wide mix of medical services, but not procedures as difficult as
heart transplants or brain surgery. For such cases they reach out to specialists in their area or in the nearest city.

The important word in the name is
maintenance
, the job of keeping you well. To enroll in an HMO the patient signs a contract in advance, paying a modest entry fee whether or not a doctor’s services are needed at that moment. In most HMOs the patient is restricted to a choice among the doctors participating in his particular group. Any patient may, of course, consult with the doctor who had previously served as his family physician and pay him on the side for his help. But the experience of the ideal HMO is that the patient who signs up selects a doctor within the group who is found to be satisfactory.

By themselves the HMOs would not be a dominating force in the system, but they are backed up by guidance from a remarkable institution, Milliman & Robertson, a Seattle-based consulting firm specializing in medical economics. Milliman, roaring ahead in a field others had overlooked, quickly established itself as the arbiter not only of medical costs, about which it was an expert, but also of medical practice, about which it was formerly barely eligible to have an opinion. HMOs, insurance companies and hospitals seek guidance from Milliman on the most vital parts of their financial management. Because Milliman is not afraid to identify errors in medical practices and to issue guidelines to correct them, it has made itself the guru of triage.

Milliman’s pronouncements, published as guides for the saving of money, are being accepted as law by insurance companies, HMOs and hospitals. In
The New York Times
Allen R. Myerson cited some of Milliman’s edicts that have been widely adopted for patients under sixty-five without complications:

—You can’t stay in the hospital for more than one day after a normal childbirth, or two days after a Caesarean. (This is being widely contested.)

—You can’t stay in the hospital for more than three days for most strokes, even if you can’t walk out.

—You can’t have a coronary bypass unless the strongest drugs have failed to cure your chest pains.

Other consultants advise against hasty operations on the back, the prostate and the heart, and recommend that insurance companies cut back on the number of hysterectomies they allow.

The chief at Milliman and the authority in charge of the guidelines is Dr. Richard L. Doyle, a big, bearlike doctor, aged fifty-seven, with broad experience. He charges $395 an hour for individual counseling to hospitals and the like and his clients say: ‘Worth every penny. He makes you do things you ought to have thought of by yourself.’

His directives seem to be clear-cut and in some cases brutally frank: Cut costs. Rationalize your procedures. Submit everything to close rational inspection. Cut out the frills. Make every medical process justify itself. Cut costs. He is adamant that patients stay out of hospitals as much as possible, and when they do have to go in, they should get out in a hurry.

The Milliman guides seem to work best on patients under the age of sixty-five; older patients have more complex problems and require more individualized care. Doctors with long experience to justify their more cautious behavior fight against the Milliman rules, but the hardest blow falls on hospitals, whose daily basic costs have exploded to an average of nearly two thousand dollars a day per patient. Wide enforcement of the Milliman rules by insurance companies will force many smaller hospitals to close, a result that many leaders in the health professions would applaud.

What we are witnessing is triage on a grand scale, but today’s economic pressures and our unwillingness to pay the costs for national health care make its imposition inescapable. There are, however, certain illnesses that do not come under Milliman rules.
Patients with total failure of the kidneys, which as recently as 1970 proved fatal, can now be kept alive with better than 95 percent certainty. This is possible through a miraculous system called
dialysis
, funded for everyone by Medicare, in which waste products are removed from the blood and excess fluid from the body. This wonder treatment saves thousands of lives a year, and costly though it is, Milliman rules do not apply to it. You cannot shorten the time the patient must spend on the dialysis machine; it demands three hours a day, three times a week. Dialysis is an example of what can and should be done at the national level.