Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, October 3, 1993 TAG: 9312100279
SECTION: EDITORIAL PAGE: D3 EDITION: METRO
SOURCE: ANNE PHELAN-ADAMS, M.D.
DATELINE: LENGTH: Long
We need to improve our health-care delivery system. We need to control costs. People need health-care security throughout their lives. We can and must properly immunize all our children. Indeed, violence is a disgraceful drain on our health-care resources.
In fact, the only thing I outright disagreed with was his opening statement that our health-care system was "broken." It is not. The United States delivers the best health care in the world.
True, there are major problems with our health-care system, but a greater problem is that too many people are outside it: the uninsured and underinsured, and those disenfranchised by ignorance, immobility or cultural and language barriers.
When the speech was over, however, I realized agreeing with it was meaningless, because the president left so much unsaid.
This isn't surprising. Consistently, those at the helm have maneuvered around the discussion of some very large obstacles to health-care reform. That night was no exception. I wouldn't expect anyone to touch on every issue in a single hour, but the omissions were glaring:
Burgeoning medical technology, the major cause of health-care inflation, to which Clinton barely alluded.
Think about it. In 1901, how much money could anyone spend on health care? Did we have magnetic resonance imaging? "Outrageously" expensive antibiotics? Coronary-artery bypasses? Trauma centers? Liver transplants?
Granted, technology has conquered certain diseases (exit: polio) and could have saved money that way, but others have taken their place (enter: AIDS).
When Blue Cross/Blue Shield came into being in the late '50s to early '60s, it was a pooled-risk insurer that protected people against unpredictable, catastrophic losses from unpredictable, catastrophic illnesses and injuries.
This is why insurance companies have traditionally reimbursed procedures and hospital care above preventive care. Did they, or anyone else, predict that it might cost $60,000 to treat a common condition like angina? Or that people would expect reimbursement for routine matters like pap smears? For that matter, had pap smears even been invented at that time?
Demographics, a major issue also sidestepped in the official health-care debate.
We not only have an aging population (and God love 'em, I hope to be part of this group someday) with fewer working adults to financially support them, but a generally frailer elderly population as well. Once upon a time, you'd have to be pretty spry to reach the ripe old age of 90; now, with the aid of modern medicine, you can be pretty debilitated and still hang in. How can the health- care system possibly deal with this trend and cap Medicare expenditures at the same time?
In addition, our health-care system has had to contend with a significant influx of immigrants (I watch with great interest how West Germany's and Great Britain's health-care systems fare with this), and a rising tide of highly concentrated and costly inner-city problems as well.
Malpractice, the third big ball that our health-care experts are dodging.
The evasion is understandable, given the concentration of lawyers in politics. Nonetheless, trying to second-guess a lawyer while practicing medicine is expensive in money, time and its effect on the patient-physician relationship.
It's also a travesty that so many people with compensable injuries never get a dime, and so many others receive monetary awards way out of proportion to their economic damages. The only consistent winner is the legal profession.
The tort system is broken. Where is the debate on mediation, arbitration and dispute resolution in the health-care reform agenda?
Medical training, a factor that hasn't even been hinted at.
Physicians trained in the second half of this century have been taught to use all the medical technology at our hands. Most of us don't know how not to use it, and, further, we feel a moral obligation to provide all of our patients the best that medicine can offer, even for a marginal gain. Rationing health care on the basis of cost goes contrary to our training and values.
If they are to practice medicine more cost-effectively, physicians must have the opportunity to learn to practice medicine more economically, the authority to refuse to provide futile care, and the freedom to withhold unnecessary tests and procedures without fear of legal reprisal.
Yet I've heard nothing in this debate about changing medical education, little about encouraging medical students to go into primary care, and even less about the use of outcomes-based research into which treatments are truly beneficial. On the other hand, I've heard a lot about how health-care rationing, which is essentially what "cost-effective medicine" is, violates the Americans With Disabilities Act.
Last, but not least, people's expectations for health care.
We think we can smoke, drink, drive intoxicated, have sex with anyone or anything, ride motorcycles without helmets and grow roots on our rear ends, and then run to the doctor to fix it when it gets broke. Self-inflicted illness and injury cost society an enormous amount of money, time and energy.
And rather than turning to the Great Books, our family or religion for help with the age-old dilemma of human frailty and mortality, we turn to our doctors to keep us alive forever. People don't want doctors to play God; they want doctors to be God.
Although President Clinton's lush idea of a "basic" benefit package is sheer whimsy, I agree, in principle, with his goals. However, I don't see how employer mandates, tax-trading tactics, arbitrary spending caps and "health care to the lowest bidder" will give us decent, secure and humane health care.
Treating only the symptoms (oops, we gave too many Medicare dollars to doctors last year; let's cap off their heads!) will not cure the disease. I learned this in medical school. We must address the underlying causes of the health-care crisis in order to cure it.
\ Anne Phelan-Adams, M.D. is university physician/health educator at Radford University, and a board-certified family physician.
by CNB