- The Washington Times - Sunday, November 24, 2002

The threatened reneging of some industries to cover retired employees with health insurance, and the loss of employer-based coverage due to rising unemployment, are only the latest blows to a health care system whose brain waves are flattening. Indeed, columnist David Broder hardly overstated the case when he recently concluded, "The American system of medicine is threatened with meltdown."
"The health of the people is really the foundation upon which all their happiness and all their powers as a state depend." This expression of a nation's strength voiced a century and a half ago by the brilliant British statesman, Benjamin Disraeli, is perhaps even more apropos today. For modern medicine has probably done more to mitigate the misery and suffering that plagues so much of mankind than all economic theories, political ideologies and religious persuasions combined. The triumphs of modern medicine are marred, however, by the failure of medical socioeconomics to keep pace with the remarkable progress of medical science and technology. A resultant double standard of health care has evolved in our country.
Most Americans are medically well-insured and have ready access to a health-care system that has appreciably lengthened life expectancy and dramatically improved its quality. But many Americans do not fully share these health benefits, largely because they are medically uninsured and have limited access to the health-care system. That the medically uninsured have poorer health outcomes than the fully insured has been well documented. Indeed, there are wards in our nation's capital whose health statistics are more akin to those of a Third World country than of a world superpower.
The socioeconomic problem has its roots in the unanticipated nature of accidents and disease. The answer to preventing a medical calamity from becoming a financial catastrophe is budgeting in advance through insurance, as we do for a possible auto accident or fire in the home. But unique among Western industrialized societies, we do not provide coverage of our entire citizenry through either private or public medical insurance.
It was with high hopes, therefore, that we elected a president in 1992 who had made universal health insurance (UHI) the centerpiece of his pre-election campaign. UHI was initially endorsed by such influential voices as the American Medical Association, American Hospital Association, American Nurses Association, American Association of Retired Persons (AARP), League of Women Voters, corporate America and labor unions. With public polls also indicating overwhelming support. Bill Clinton apparently had a sure winner.
What followed, however, was an incredibly inept White House performance. The president appointed the first lady (those were the two-for-one days) and Ira Magaziner, a troubleshooter from industry, to midwife UHI through Congress. Neither had a track record of health-care expertise, and it soon became apparent they were in over their heads. Instead of narrowly focusing on UHI, they attempted to remake the entire health care system during one session of Congress.
The Health Security Act that emerged was an indigestible 1,400-page tome of tenuous assumptions, untested theories, top-heavy bureaucracies and government intrusion into medical education, training and practice. This mishmash could not compete with an insurance industry-sponsored $19 million "Harry and Louise" TV blitz that, without rebuttal from the White House team, confused the public by equating national health insurance (e.g., Medicare) with socialized "government medicine." The bill never even came to a vote.
Mr. Clinton's vision of UHI came a cropper mainly because he erred in his choice of messengers to deliver his message. With the demise of UHI, senior White House adviser George Stephanopoulos acknowledged that "we bit off more than we could chew" and the recruiting Hillary Clinton to pilot the program was "a mistake."
Thus, for the second time in the last century UHI was scuttled, in large measure, due to the poor judgment of a single individual. During World War I, the then-progressive AMA introduced a series of resolutions promoting universal national insurance, but the idea was derailed by Samuel Gompers, the powerful head of the American Federation of Labor, who denounced the plan as "paternalistic" and who was more interested in swelling union ranks by offering union-based health insurance.
But our health-care problems are not melting away; rather, they are approaching a crisis. After a temporary reduction of the medically uninsured during the prosperous mid-1990s, their number has again risen to 41 million. Health insurance premiums remained stable during this period as the HMOs ratcheted down prices paid to health-care providers (the cost of any service or community can, of course, be lowered if the buyer sets the price, whether buying apples or appendectomies), but their savings have been wrung out of the system, and health-insurance premiums are again sharply escalating at double digit figures annually.
Moreover, access to the system is declining as many doctors have stopped accepting Medicaid and Medicare patients because of unrealistic reimbursement rates; most hospitals are losing money, a nursing shortage is growing and prescription drug prices are soaring.
Health-care reforms are in order and should start with building the long overdue basic foundation of an optimum system UHI to ensure that the richest and most powerful nation on the planet provides what the populations of other industrialized societies have enjoyed for decades the assurance that economic considerations are not paramount at the time of illness or accident.
With the foundation in place, other building blocks can be added as our resources permit. But further fine-tuning of our health care system must compete with other pressing domestic problems and accept the principle that compromise and temporary solutions are the handmaidens of persuasion in a democracy.
But the mandatory aspect of UHI cannot be compromised. For a small business insuring its employees for health care cannot compete with a rival electing not to adopt such insurance. The playing field is only leveled when a deli raising the price of a salami sandwich to cover the added overhead of insurance is assured that its competitor down the street mandatorily meets the same insurance obligation.
Regardless of whether UHI is implemented by Medicare-like public insurance or by an expansion of current employer-based private insurance, health-care costs will continue to spiral upward. The reasons are threefold:
(1) The population is rapidly aging, and health care costs of the elderly are 4 times higher than for those under 65.
(2) Increased demand as the media saturates the public with announcements of the latest medical breakthroughs.
(3) Staggering growth of medical technology. Fully 50 percent of the knowledge needed to practice modern medicine didn't even exist 15 years ago.
We can do nothing about the first; demand will only increase in the information age and no one is advocating a moratorium on medical advances certainly not arthritics for whom life has depth as well as length, and who opt for a $20,000 hip prosthesis to replace a $10 bottle of aspirin and a cane.
The good news is that the cost of instituting UHI will be lower than commonly assumed probably less than one-tenth the ultimate cost of September 11 and the war on terror. The millions of uninsured are not dying on the streets. They are obviously receiving care somewhere emergency rooms, public hospitals and clinics, through charitable organizations or uncompensated care at private facilities with the costs shifted to the privately insured through higher premiums.
The future for universal health insurance is bleak; the issue has never been on President Bush's agenda. Indeed, during his governorship, 24.5 percent of the Texas population was uninsured for health care the highest incidence of the 50 states.
Our society must soon decide, however, if our under-funded health care system is worthy of further expenditures to avert a health care crisis. It may be helpful to remember Thomas Jefferson's words, "Without health there is no happiness."

Alex Gerber, M.D., a clinical professor of surgery, emeritus at the University of Southern California, formerly was a health-care consultant to the White House and the Federal Department of Health and Human Services.


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