TIME: Almanac 1993/TIME Almanac 1993.iso/time/121090/1210640.000

Text File | 1992-08-28 | 6.2 KB | 131 lines

                                                                                ESSAY, Page 112

Our Health-Care Disgrace


By Barbara Ehrenreich


    National health insurance is an idea whose time has come .
. . and gone . . . and come again, sounding a little more
querulous with each return, like any good intention that has
been put off much too long. It was once, way back in the 1930s,
a brisk, young, up-and-coming idea. By the late '60s, when
Richard Nixon first declared a health-care "crisis," it was
already beginning to sound a little middle-aged and weary.
Today, with the health-care situation moving rapidly beyond
crisis to near catastrophe, the age-old and obvious solution has
the tone of a desperate whine: Why can't we have national
health insurance -- like just about everybody else in the
civilized world, please?

    Health-care costs have nearly doubled since 1980, to become
the leading cause of personal and small-business bankruptcy.
Collectively we spend $600 billion a year on medical care, or
11% of GNP -- a higher percentage than any other nation devotes
to health. But the U.S. health system may be one of the few
instances of social pathology that truly deserve to be compared
to cancer. It grows uncontrollably -- in terms of dollars --
but seems to become more dysfunctional with every metastatic
leap.

    For a thumbnail index of failure, consider the number of
people left out in the cold. Despite per capita medical
expenditures that dwarf those of socialized systems, 37 million
Americans have no health insurance at all. For the uninsured
and the underinsured -- who amount to 28% of the population --
a diagnostic work-up can mean a missed car payment; a child's
sore throat, an empty dinner table.

    Even among those fortunate enough to be insured, the leading
side effect of illness is often financial doom. Consider the
elderly, whose federally sponsored insurance program, Medicare,
inspires so much drooling and sharpening of knives at budget
time. Even with Medicare, older Americans are forced to spend
more than 15% of their income for medical care annually. And
since nursing-home care is virtually uncovered, the elderly are
pushed to degrading extremes -- like divorcing a beloved spouse
-- in order to qualify for help through a long-term
debilitating illness. Or, as more than one public figure has
suggested, they can shuffle off prematurely to their reward.

    We can't go on like this. Our infant-mortality rate is
higher than Singapore's; our life expectancy is lower than
Cubans'. As many as 50% of inner-city infants and toddlers go
un immunized. In the face of AIDS, our first major epidemic
since polio, we are nearly helpless. Our city hospitals are
overflowing with victims of tuberculosis, poverty, AIDS, old
age and exposure. Our rural areas don't have this problem; they
have fewer and fewer hospitals or, increasingly, less medical
personnel of any kind.

    But everyone knows that the system is broken beyond repair.
According to the New England Journal of Medicine, 3 out of 4
Americans favor a government-financed national health-care
program. The AFL-CIO is campaigning vigorously for national
health care, and Big Business, terrified by the skyrocketing
cost of employee health benefits, seems ready to go along. Even
in the medical profession -- the ancient redoubt of
free-enterprise traditionalists -- a majority now favor
national health insurance.

    So what stands in the way? There's still the American
Medical Association, of course, which has yet to catch up to
its physician constituency. But the interest group that
arguably has the most to lose is the health-insurance industry,
which spends more than $1 million a year to forestall any
thoroughgoing government action. And why not? The insurance
industry already enjoys a richly rewarding, gruesomely
parasitic relationship to the public health domain. In broad
schematic outline, it goes like this:

    For decades the private insurers have fanned the crisis by
blithely reimbursing the fees of greedy practitioners and
expansionary hospitals. Then, as costs rise, the private
insurers seek to shed the poorest and the sickest customers,
who get priced out or summarily dropped. For some companies,
a serious and costly illness is a good enough reason to cancel
a policy. Others refuse to insure anybody who might be gay and
hence, actuarially speaking, might get AIDS.

    So over the years, government has moved in to pick up the
rejects: first the elderly, then the extremely poor. Since the
rejects are of course the most expensive to insure, government
is soon faced with a budget nightmare. Draconian cost-control
measures follow. But because government can only attempt to
control the costs of its own programs, the providers of care
simply shift their costs onto the bills of privately insured
patients. Faced with ever rising costs, the private insurers
become more determined to shed the poorest and the sickest .
. . and so the cycle goes.

    The technical term for this kind of arrangement is lemon
socialism: the private sector gets the profitable share of the
market, and the public sector gets what's left. The problem
with this particular lemon is that it tends to sour us on the
possibility of real reform. Even those who crave a national
program covering everyone are wont to throw up their hands in
despair: Nothing works! It's so complex! Maybe in 100 years!

    It's time to cut the life-support system leading to the
hungry maw of the insurance industry. The insurance companies
can't have it both ways: they can't refuse to insure the poor,
the old and the sick while simultaneously campaigning to
prevent a government program to cover everyone alike. The very
meaning of insurance is risk sharing -- the well throwing in
their lot with the sick, the young with the old, the affluent
with the down-and-out. If private enterprise won't do the job,
then let private enterprise get out of the way.

    With the largest-ever consensus behind it, national health
care's time is surely here at last. Otherwise, let us bow our
heads together and recite the old Episcopal prayer: "We have
left undone those things which we ought to have done . . . and
there is no health in us."