TCS Daily

Judicious Generosity

By Sydney Smith - December 10, 2002 12:00 AM

It's easy this time of year to get carried away with the spirit of giving, to exceed the bounds of our generosity, to give more than we have to give. And not just for our lesser brethren, but every friend, neighbor, and relation, regardless of worthiness.

The same spirit has lately infected our politicians and pundits when it comes to health care. Former Vice President Al Gore wants us to adopt a socialist system, along the lines of Canada and other former British colonies, but he would call it a "national health insurance program," so as not to frighten us. The Institute of Medicine, the arm of the National Academy of Science that advises the federal government on matters medical,
recommends expanding our current corporate-socialist system, with the help of federal grants and incentives to states and employers. Both would have the government play Lady Bountiful, showering us all equally with its beneficence, from the poorest street urchin to the wealthiest Palm Beach matron.

There's no denying that our system needs to be revamped. Many of the elderly are forced to go to Canada for affordable drugs, forty one million Americans have no health insurance at all, medical debts are responsible for fifty percent of personal bankruptcy cases, and those who do have insurance are finding it less and less affordable. We have at our fingertips the best that modern medicine has to offer, yet we increasingly haven't the means to pay for it. But expanding Medicare and Medicaid to include every citizen, regardless of need, isn't the answer.

Look at Medicare. When it started in 1967, it was a wonderful program. People who could never before afford to go to the doctor could finally have their cancer, heart disease, high blood pressure, and diabetes diagnosed. They got needed treatment, their lives improved, and they lived longer. But the problem with chronic disease is that there is no cure. Living longer requires more treatment. More treatment requires more spending. The cost of Medicare ballooned to ten times more than any of its proponents ever predicted. Unwilling to take the politically distasteful step of cutting benefits to voters, Congress instead took steps to cut their payments to providers. They enacted Byzantine rules for collecting payments, the transgression of which not only results in loss of payment, but in accusations of fraud and severe financial penalties. When the budget is really tight, they cut payments without lifting any of the administrative burdens. It's no surprise, then, that physicians are increasingly frustrated with the system. Forty-two percent of physicians polled recently by the AMA say they will opt out of Medicare next year if reimbursement declines yet again, as planned.

There's no reason to think that expanding federally funded health care benefits to everyone would improve this situation, but there's every reason to expect that doing so would make it worse. In 2001, Medicare and Medicaid spending took up 19% of the federal budget, more than we spent on defense. Imagine how much higher that would be if everyone, regardless of income or age, were included. Imagine how much more onerous the government's role would be as it tried to rein in that cost. A single-payer system may make it more difficult for physicians to opt out and still practice medicine, but that only means that more would opt out of practicing medicine altogether. Universal coverage is useless if there's no one willing to provide the care. Don't believe it would happen?
It's already happened in Canada and England, where they've had to resort to importing doctors and nurses from abroad.

There are better alternatives. More and more employers are experimenting with consumer-driven insurance that gives employees a substantial say in how they spend their health care dollars. These plans provide an incentive for patients to choose treatment options wisely, and for doctors to honestly acknowledge the margin of benefits, as well as the costs, of their treatment recommendations. Health insurance companies are spearheading an effort to make affordable, basic plans available to everyone in an attempt to head off government intervention. These are steps in the right direction.

An even bigger step in the right direction would be to offer insurance directly to the consumer, by-passing the employer altogether. Much of what's wrong with our current system is that health insurance is linked so strongly to employment. This may have worked fine in the stable corporate culture of the 1950's, but in today's fluid job market, it makes no sense to tie health care insurance inextricably to employment. We would all profit by divorcing the two. Insurance companies would improve their risk pools and their customer base by offering affordable, basic insurance plans to individuals rather than limiting themselves to comprehensive health benefits for corporations. The self-employed could find affordable insurance. The unemployed wouldn't risk losing theirs. And maybe, just maybe, our runaway costs would be contained by introducing financial responsibility to the doctor-patient relationship.

Few would argue that we should eliminate Medicaid and Medicare. A good and just nation would not deny basic medical care to the poorest of its citizens. But neither would a wise nation squander all of its wealth on one private good for everyone. The solution to our current woes is not unlimited generosity, but judicious generosity. To act otherwise is to risk gaining heaven at the cost of losing earth.

The author is a family physician who has been in private practice since 1991. She is board certified by the American Board of Family Practice, and is a Fellow of the American Academy of Family Practice. She is the publisher of MedPundit.



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