Both political parties are finally paying attention to the complaints of doctors and patients alike that managed care is keeping sick people from getting necessary medical care. But patients' rights legislation, though overdue, does not address the system's more fundamental flaws.
Because the United States lacks a universal system, Americans fail to spend enough money on prevention. So, despite our spending nearly 14 percent of our national income on health care, we have average life expectancies about five years lower than Europeans or Japanese, even though those countries spend less than 10 percent of GDP on health.
Moreover, as our population ages, it becomes more and more expensive to treat. This is a dilemma everywhere, whether health insurance is private or social. And as science keeps inventing new ways to prolong life and health, it becomes economically impossible for the society to give every patient every possible treatment.
It is hard to admit, but some form of rationing necessarily operates in every society. Here are some aspects of rationing, American style: Failing to insure some 43 million Americans is a form of rationing. Devising payment systems that financially reward HMO doctors for restricting access to specialists and tests and hospital admissions is rationing. Limiting prescription drugs covered by insurance is also rationing. Not having enough nurses leads to rationing of care on hospital wards. And the fact that well-off people can pay out of pocket for medical services not covered by insurance is the most fundamental form of rationing.
Of course, countries with universal health systems also have rationing. The issue is more politicized in such countries because government is explicitly responsible. Here, it's hard to know exactly whom to blame if your HMO bribes your doctor to keep you from seeing a specialist.
In Canada, some elective surgery is not covered or provided only after long waits (try telling someone who needs a hip replacement that this is elective.) In Britain, many standard cancer therapies are not covered by the National Health Service. But the rationing that operates in the British system is not the result of socialized medicine. It is, rather, the result of successive Tory governments thinking they could provide decent medical care by spending as little as 6 percent of GDP, a percentage that's only now being slowly increased under the first Labor government in two decades.
Whether a system is private or social, 6 percent of GDP doesn't buy adequate care. Twelve percent does just fine. But interestingly enough, because their universal systems are so much more efficient, countries that spend far less than we do actually buy better health care. That's because the most effective route to good general health is via basic public health measures. Such measures include universal sanitation, universal vaccination for preventable diseases, prenatal and baby care, screening for conditions that can benefit from early treatment, and universal annual checkups, as well as public education on factors that affect health, such as diet, exercise, and lifestyle. Even poorer nations, which spend far less than we do, have better longevity statistics because a universal system naturally invests relatively more in public health.
Britain, despite its threadbare system of medical treatment, covers everyone. So it actually has an average life expectancy (at birth) of about 78 years, compared with 75 years in the United States. Other countries with universal systems that spend 9 or 10 percent of GDP have life expectancies over 80 years.
Though we think of health care as mainly medical, it is really primarily social. High-quality care for acute diseases adds only the last few months or years to life expectancy. Paradoxically, that's why the rationing of treatments that so justifiably annoys doctors and patients is not yet depressing our mortality statistics.
It is unconscionable that managed care systems are second-guessing doctors, particularly for treatments that are standard rather than experimental. But if we want to spend our available dollars more efficiently, the first thing we need is a universal system. Such a system would be both more cost-effective and more accountable.
Even with universal coverage, there will be limits on how much society decides to pay for health. Every experimental treatment won't be covered. But we can surely afford both prevention and standard treatment for all. Moreover, any rationing should be explicit, not covert, and never based on the patient's private purse. Most Americans would vote for such a system if they had the choice. It would be nice if our political leaders offered it.
Robert Kuttner is co-editor of The American Prospect. His column appears regularly in the Globe.
© Copyright 2000 Globe Newspaper Company.