Just how bad is the state of health care in America? Well, consider two recent developments that shine a spotlight on a system that was already showing signs of severe distress, even before the Supreme Court decided to let HMOs off the legal hook. In Colorado the rich are paying what amount to bribes to make sure that they are at the head of the line when it comes to getting health care, and in Tennessee the poor are basically being told to get lost.
Denver was the setting a few weeks ago, when more than 100 physicians from around the United States attended the first meeting of the American Society of Concierge Medicine. Concierge medicine is a special, high-end form of medical care that guarantees that if you need treatment you will get it, without a hassle, seven days a week-but only for an extra fee. If you can pay amounts that range from $20 to thousands of dollars a month, you can guarantee that your phone calls will be promptly returned by your doctor and that you'll get special attention whenever you're admitted to a hospital.
Now, one might wonder why it is necessary to pay a bounty to get a doctor to call you back, especially if you are already paying through the nose to belong to a managed care plan. The answer is that under the watchful eye of managed care and insurance companies, the quality of care has gotten so awful that doctors sneeringly refer to it as "hamster care." Only those patients who pay more are going to get treated by the "concierge" doctors who get off the daily treadmill and practice good medicine, providing the sort of attention and service that our parents and grandparents took for granted.
Think that giving the rich special access to health care is unfair? Consider what is going on at the same time in Tennessee.
It is making over its state Medicaid program known as TennCare. If this program gets implemented, many of the poor, elderly, children and disabled in Tennessee who rely on Medicaid will be told simply to get over it. And other hard-pressed states may well follow suit.
Gov. Phil Bredesen, a former HMO entrepreneur, sees the challenge of health care for the poor in Tennessee in very stark terms. In a speech last February, the governor described the state Medicaid program as nothing more than an open checkbook that is continuously being raided by "doctors and hospitals and advocates" who "decide what is needed."
Well, who should be deciding what is needed for medical treatment if not doctors and hospitals and advocates? Not under TennCare, if the governor gets his way. Bureaucrats, not doctors, will pick how the poor get treated.
Historically, decisions about what drugs or treatments a patient received were chosen by a standard of care known as "medical necessity." Doctors determined what was medically necessary based on local standards of medical practice, and if they did not practice according to this standard they could be found guilty of malpractice. TennCare does away with the established standard and replaces it with a new one - "adequate care." If a bureaucrat in the Tennessee department of health thinks a low-cost drug or treatment, or even no treatment at all, is "adequate," then that is what TennCare will provide.
Under the new definition, preventive care and many pain medications will no longer be funded. And only generic drugs will be available to treat poor kids with life-threatening conditions such as cystic fibrosis, cancer or asthma, and no prescription antihistamines or gastric-acid reducers for anyone of any age. If you want to protest these inadequacies, you might be able to find a doctor willing to plead your case to a special state-established foundation.
No one wants to see any state dissolve in a sea of red ink. But how can any American stomach a public health care system that is so unfair to people who aren't rich? Surely there are less drastic steps a state like Tennessee could take that would let doctors decide what is appropriate care for children, the disabled, the chronically ill, pregnant women and the elderly poor.
Those now seeking public office must come up with something better than medicine prescribed by bureaucrats. Whatever solutions they arrive at, doctors must be in charge of our heath. That is something to remember when we enter the voting booth in the fall.
Arthur Caplan is chairman of the department of medical ethics and a professor of bioethics at the University of Pennsylvania.
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