Published on Sunday, February 13, 2000 in the Seattle Times
A Call To Action: New Direction For Nation's Health Care
by Kathleen O'Connor
Doctors are unionizing, surgeons are leaving Regence Blue Shield and now, you can pay extra money to Virginia Mason to buy time we all used to have with our doctors.
Vice President Al Gore and Sen. Bill Bradley are duking it out on who has the best health-care plan, who they are going to cover, and what it costs.
In Olympia, insurers, consumers, employers and elected officials are duking it out over individual insurance policies. This war of words is only going to get worse. Why? Because, simply put, we do not have a health-care system. We have armed camps. Here are six core facts that contribute to this divisive climate.
Fact No. 1: Health care is America's Balkans
Health care oozes intrigue and shifting alliances. The adage "the enemy of my enemy is my friend" is probably the best way to understand "the system."
Today, doctors and hospitals have a wary alliance against insurers and government programs that cut rates, but they compete for money on other fronts with equipment and services.
Nearly everyone now is fingering the pharmaceutical industry for its profits and costs. But, hardly anyone is looking at whether or not drug costs reduce other costs, such as hospitalizations. Most insurers cannot do a cost benefit analysis because patients are either not in their system long enough to measure the impact or they cannot get access to the medical records in myriad physician offices. Or both.
Employers are relatively predictable wild cards. When the economy is good or the labor market tight, they heap benefits to get and keep employees. During recessions, they cry foul and blame insurers, doctors, hospitals and consumers for rising costs.
The public-health system has specific goals and objectives to promote the health of communities, track epidemics, treat low-income clients (sometimes), and assure our food, restaurants and water are clean. Commercial health insurers and most employers virtually ignore the public health-care system.
We have Medicaid for people with incomes below the poverty level. We have Medicare, for those over 65 or disabled, but it basically only covers hospital costs, some nursing home costs and some home health care. Private Medicare supplemental insurance covers what Medicare does not - doctor visits and sometimes prescription drugs and other costs. Congress decides what Medicare covers. Medicaid is shared by the states and the feds.
Governments often think hospitals, doctors, pharmaceutical companies and insurers are unscrupulously greedy. Their key weapons are rate reductions and reams of regulations.
We have community and neighborhood clinics that serve low-income patients who might not have public or private insurance. They are also largely ignored by insurers and employers. Insurers sell benefits to employers and individuals. Premiums are based on what actuaries tell them about the health patterns of certain groups of people, based on their age, gender and size of groups and sometimes, occupation.
Like bookies setting odds, actuaries determine the risk - the odds of illness and diseases in these groups - and put a price on it. The smaller the group, usually the higher the cost. This is, in large part, what the fight boils down to over individual policies: who is in whose risk pool.
Insurance premiums have not been covering costs, so rates are rising again. But, even platinum companies like Harvard Pilgrim Community Health are in financial receivership.
And then, the big guns: self-insured employers who are essentially their own insurance companies. Accountable to virtually no one, they offer what they want in the way they want to offer it. Because they are not insurance companies, they do not have to pay state premium taxes the commercial insurers pay. They are also immune from any state legislation on what is in health benefits, such as mammograms, mental health or other so-called "mandated benefits."
Half of all people with insurance through their employer work in these companies.
Consumers? They fit in here somewhere, but now are like refugees simply trying to dodge the cross-fire. They are often vilified as the reason costs are so high, because they don't take care of themselves, use other people's money (employer's) to pay for services and expect doctors to take every last ditch, heroic measure.
Because we do not have a system of care, no incentives exist to work together. When one group gets money, others don't. Each group is pitted against each other for its own economic survival.
Fact No. 2: A shoddy return on a big investment
We pay more for health care than any other country. In return, we have lower life expectancy for men and women, higher maternal and infant death rates and lower rates of childhood immunization than Japan, Germany, Britain, Italy, Canada or France. We remain the only nation in the economic Group of Seven that does not cover all its residents. We spend more than $1 trillion per year for health care, or nearly 14 percent of our gross domestic product.
Fact No. 3: Health care is not undergoing rapid changes
The only real major changes have been technological, scientific, medical and pharmaceutical/biomedical. In 1932, the Committee on the Cost of Medical Care said U.S. health-care costs were so high because we had too many infectious diseases, too many medical specialists, a disease-oriented system of care vs. prevention and lacked a community-focused health system - all this before wonder drugs and antibiotics, which offered the first cures for diseases.
Now, we have infectious diseases resistant to those drugs, nearly 80 percent of our doctors are specialists and we still do not have a community-focused health system.
We really still have a disease-based system parading in a "prevention" mask. Our "managed care" and "prevention" programs are basically only early diagnosis and screening. If prevention is done, it is largely through some hospitals, community clinics and the public-health system. Most insurers shun prevention programs because they are costly and long term. The average consumer is in a health plan about three years.
Insurers fear other insurers will reap the benefit of their up-front financial investment. They also fear promoting prevention programs for diabetes or asthma. If too many people sign up, it will increase their costs and their premiums, making them less competitive.
The changes we see are payment fads. These fads drive up our costs because we keep changing courses and adding rules and regulations.
Fact No. 4: Rates, regulation and body parts
Because no vision exists for what a system should do, we substitute cost control for policy directions.
Because our public and private health insurance stem from a disease/fix-it model, we resort to legislation to get coverage for prevention or early diagnosis programs. Groups lobby for mammograms, prostate screenings, alcoholism or mental-health programs, or lobby against "drive-by deliveries."
This body-part approach only serves to pit employers and insurers against consumers and providers and breeds further entrenchment, animosity and distrust. It also diverts attention from what could be done to serve employer, patient, insurer and provider or how to inject responsibility and accountability into a system of care.
Fact No. 5: We use health benefits as wages
We are the only country that uses health benefits as employee compensation. During wage/price freezes after World War II and during the 1970s, employers gave health benefits when they could not give raises. Like giving employees tickets to a ball game - the employees may not have wanted to go, much less buy tickets - but now that they have them, they will use them. The message in this approach is: use it.
Greater use means greater costs. Others nations in the Group of Seven believe it is to their benefit to have a healthy, productive work force and society. Modern health insurance started in Germany before World War I so German companies would have healthy, and therefore, more productive workers.
We nearly adopted that model, but war erupted.
Fact No. 6: Health policy - sound bites not vision
Any discussion about change rapidly arouses the two most visceral ideological camps: single payer vs. medical savings accounts. Any attempt at change, no matter how incremental, is lost in the noise of these two extremes.
Because the spaces between these two camps are littered with special interests - consumer groups, employers, insurers, pharmaceutical manufacturers, hospitals and doctors - no easy way exists to make substantive change.
Addressing one group's solution only serves to alienate one or more of the others. To keep them at bay, and get elected, candidates are often reduced to sound bites they think their voting and donating constituencies will understand.
Seniors vote more than other groups and are well-organized, so we hear much about Medicare. Medicare does not cover prescription drugs, so most candidates will now try to despair of pharmaceutical and insurance costs, without being so extreme as to alienate those affections and cash contributions.
Fifteen years ago, candidates flogged "money-grubbing hospitals," next came "wealthy, overcharging doctors." Villains simply change with the times.
We have a crisis in terms of availability, cost and quality of nursing-home care for our elderly, but it is not as glamorous as rising drug costs or as prone to sound bites. We debate solutions, arguing whose approach is right or wrong. Sound bites, like stereotypes, contain a modicum of truth, but are barriers to a rational public discussion of what we should expect from a system, how we can organize it and how best to pay for it.
We need to talk
We need to start from scratch.
We are doing the wrong thing. We have been trying to Rube Goldberg something that is impossible to fix. You can't fix something if you don't know what it is supposed to do.
Just as wars are too important to be left to generals, health care is too important to be left to the industry or government. We need people to decide what a health-care system should do for us and our families and to determine the results we want in our cities, our states and our nation.
We have never done this - as a community, a state or a nation. We need new words, new ideas and new directions. Right now, we are stuck tinkering with dead languages. Tinkering hasn't worked. It will not work.
All politics is local and all health care is local. Workable solutions must come from where we live and work. How things work in Omak and Yakima differ profoundly from how things work in Seattle or Spokane.
We need to share our ideas with each other in our places of worship, workplaces, reading groups, or civic clubs and organizations. We need to hold citizen forums.
If we take off our official hats and ditch our official language, we will find more in common than we imagined - for ourselves, our partners, our children, our parents, our loved ones. We don't need any more task forces that only ask us to respond to another set of tinkers. We need to talk about what health means to our families, our communities, how to get it and then be invested in those changes.
Money must come last. Only after we have decided on what we want can we design ways to pay for it. We have all the pieces. We should pay for it as we do now: employer, consumer, insurer and government. France, Germany and Japan do this. Like us, they have private insurance, public insurance and self-insurance, public-health and community clinics and private hospitals and doctors. They are organized, not socialized.
We'll need a plan to get from here to there. Businesses create strategic plans to reach their goals, but only after they have a vision and mission.
Radical? Certainly. But, so is the Internet. Will this work? Nothing else has - not rate-cutting, not Medicaid, not Medicare, not the marketplace, not the fad of managed care, not even a Patient's Bill of Rights.
But, without a system defined by communities, we will remain Balkanized and be held hostage to intractable groups and the latest cost-control fad.
So, let's start talking. Now.
Kathleen O'Connor is a Seattle health-care industry analyst, consultant and writer with more than 20 years' experience with many sectors of the health-care industry.
Copyright © 2000 The Seattle Times Company