The issue of triage today is complicated with many facets both rational and emotional. Let us imagine that we are members of a medical committee, meeting to consider how we would vote in two different situations. A hospital has one donor heart but two claimants who could use it. The first is a twenty-two-year-old mother with three children and a husband able to pay for the operation. The other is a seventy-seven-year-old with funds too skimpy to pay for a heart transplant. The choice seems too easy for our committee to discuss at length. The young mother gets the heart.
But now let’s suppose the seventy-seven-year-old man is Albert Einstein, still working on his masterly explanation of the universe, while the young mother is an alcoholic who tests HIV positive and whose three children have inherited from her both the virus that causes AIDS and the negative effects of an alcohol addiction they acquired in the womb. Again, the committee requires only a few minutes to decide that Einstein gets the heart.
But triage decisions are usually not so simple. In a more realistic case, both the claimants are the same age, both are sterling citizens and both can pay for the operation. Now the choice requires an agonizing decision. Whichever way the committee votes may be justifiable but is nevertheless devastating for the loser.
I happen to know something about the procedures of triage because recently I chanced to see a confidential report on how best to use a healthy kidney that an automobile accident had supplied. The question was ‘Which of our patients can profit most from this kidney?’ Opposite my name were the notes ‘Too old. Too many other medical problems.’ In my case the decision was the right one. Other similar types of judgments are being made daily covering all sorts of medical problems. In the cases of transplanted organs, the deciding factors may be clear even if the solution isn’t, but many of today’s triage decisions in other less dramatic situations are based on the much more subtle factor of greed.
The United States is fast becoming a nation practicing triage on a grand scale. Unfortunately, greed rather than legitimate medical necessity has too often become the driving force behind triage. The share of our gross national product that we are currently willing to devote to medical services is being stretched to the limit. This means that such care as our nation is willing to pay for must be rationed financially; we can perform only so many costly operations in the hospitals, and we can provide only so many recuperative facilities and nursing homes. Our insurance companies believe that to protect their profits they should pay for only the most necessary (to them, not to the patients) operations and for limited specialized care. Hospitals, many of them profit-seeking corporations, charge fantastic rates for one day’s occupancy of a bed, two thousand dollars being typical in some areas, and the costs of the advanced medical technology are astronomical. A huge number of our citizens cannot afford today’s very expensive private health insurance and must receive their medical care in the emergency room of the local hospital. Much of the medical care for the indigent—say, the bottom fourth of the entire population—has to be paid for by government funds, and the costs to the taxpayer are becoming exorbitant.
Employers, both large corporations and small businesses, are deciding that, with the skyrocketing costs of medical care, the costs of adequate group health insurance now cut too deeply into corporate profits and are requiring their employees either to contribute to their health care costs or to join an HMO. The crisis is exacerbated by the fact that those who receive any kind of health care benefits from their employers cannot carry that insurance with them if they have to change jobs; we are the only major nation in the world that allows such a miscarriage of simple justice.
Any careful observer of America’s health care system is perplexed as to why such an admirable collection of health experts, supported by one of the richest nations on earth, cannot provide all its citizens with an insurance system they can afford and with medical care through something like Medicare, now available only to elderly citizens over age sixty-five. Currently those under age sixty-five in the middle class are caught in the gap between the wealthy, who are able to pay high medical costs, and the very poor, who receive some assistance through Medicaid. Our nation’s failure to solve the problem of this gap is one of the mysteries of American life, especially when both the major political parties agree that steps must be taken to solve it. The reason for the failure is the rampant greed that pervades the medical profession, the insurance companies, the various types of medical corporations and the character of the individual taxpayer.
I have been obliged to study American medical practice because my wife and I had five cancers to deal with, and I had a massive heart attack, a quintuple bypass, the insertion of an electronic heart monitor, the insertion of a new hip and extended treatment for kidney failure. In Pennsylvania, New York, Florida and Texas, my wife and I had superb medical care. We saw American medical practice at its technical best.
But when it came to paying for the doctors and the hospitals, we found ourselves in a jungle so insane that we could not even guess who might have been sufficiently addled to have devised it. The experience gave us an inkling of the tremendous waste in our medical system. We both had Medicare, and my wife had private insurance as well, but the government system was as confusing as that of the private company. Both seemed to be vying for a prize to see which could have the stupidest book-keeping system and the most lost records. It was a draw.
Repeatedly I would receive itemized bills from doctors and hospitals involved in some treatment. I would pay them promptly, only to be told by the doctors that I should not have paid so quickly: ‘Wait till you get your check from Medicare and then reimburse us for our services.’ The next doctor would have a different system: ‘Ignore my bill. We get reimbursed by Medicare for the portion they’ll authorize, and then we bill you for the difference.’ Other doctors and other Medicare offices had their own tricky systems; all seemed to be honest but inept.
We never protested the handling of our many cases, but preposterous tangles kept driving us to despair. I was most angered when, two years after I was sure I had paid everyone, I received a lawyer’s letter warning me that if I did not pay his client’s bill, which was now two years overdue, he would sue me in court for payment and inform the credit agencies of my delinquency Upon checking, we found that indeed I had already paid the bill. The snafu that most angered my wife came when a kindly Medicare secretary told her they were sorry to hear that I had died. My wife could not convince them otherwise, and the system, having been defrauded by families who kept deaths secret to protect their relief checks, demanded from us a notarized assurance from our doctor and our bank that I was still living and that I had appeared in person in the notary’s office to verify that fact.
If our experience with America’s system of providing medical care was typical—and we heard of worse cases—the nation’s insurance and medical bureaucracies are wasting billions of dollars on repetitive paperwork alone. With this type of waste, and with waste involving fraud, we citizens are legitimately angered by the unnecessary expenditure of our insurance, medical and tax dollars.
One of the truly serious matters that require immediate attention is the imminent danger of bankruptcy that threatens the entire Medicare and Medicaid system. Reliable predictions are that by the year 2002 there will be no more money in the Medicare fund unless sensible rectifications are made at once. This disaster will occur just as the baby boomers of the postwar 1950s are becoming eligible for payments from Medicare. Radical revision of the system is necessary, and Congress will have to act.
Apart from the Medicare agency, which has generally treated me well and generously, and apart from the technical proficiency, our medical system functions so poorly in many respects that it is a blot on our democracy. Its primary weakness—that it is not available to everyone at an affordable cost—would be easily corrected if we had the determination to act. Our deficiencies are not due to lack of knowledge; we know what we need to know. Nor do they represent the victory of o
ne political party over another; all parties know the weaknesses that need to be repaired and have the desire to make things better. Nor is it a lack of medical knowledge; our training hospitals, our research laboratories and the qualifications of our physicians are unmatched. So what is lacking? We simply lack the resolution necessary to tackle the complexities of our health system and its obvious failure to serve the nation with maximum efficiency.
In the aftermath of the 1992 presidential election when Governor Bill Clinton of Arkansas was sworn in as president, I was relieved by his proposal to tackle seriously our nation’s health problems. But I was shaken some weeks later when it became apparent that he would be installing his wife, Hillary, as manager of his medical program. It wasn’t that I feared she might not be up to the task of being in effect a co-president in dealing with medical affairs, because she was a brilliant graduate of Wellesley College and Yale University Law School and a prime mover in Arkansas politics and social reform. I knew a good deal about her and assured my friends that she had an excellent chance of being our next Eleanor Roosevelt. The danger I saw was that our reactionary senators, congressmen, other political leaders and both men and women in the news media would not accept her and would be poised to vilify her whenever she gave them an opening because of some unwise statement or action. Within a few months her enemies had indeed nullified her effectiveness and discounted whatever good ideas she put forward.
But I did not anticipate the extent of the venom and the cleverness with which the insurance industry launched its television campaign against everything she proposed. Its Harry and Louise ads were as persuasive as any I have ever seen. This middle-class couple were so sincerely, so deeply worried about the health of the nation—and so eager to leave all decisions to the insurance people—that they made any allegiance to Mrs. Clinton’s proposals seem unpatriotic. With a series of some five or six ads, each more manipulative than the ones before, they neutralized not only Mrs. Clinton but also the president. Any health plan the Clintons proposed would be dead on arrival. Their reforms never had a chance. They were not even voted on; they died aborning.
What is there in our national character that makes us incapable of tackling a relatively simple job like organizing and running an affordable national health system for all our citizens? Like so much of American life, the roots of this characteristic go back to colonial days, when, almost as an act of faith, the frontier family was supposed to stand by itself and look to its own members to safeguard the family. With doctors unavailable or in short supply, the frontier settlements usually had to struggle along for some years before medical services became available to their new communities.
When a doctor finally appeared in their midst, he was idolized and granted an exalted position that he may not have deserved. It was in this period that doctors came to occupy a position of power in community life. In my boyhood village doctors were trusted deities—so much so that I still feel that way about the doctors who treat me now.
At some point in the postwar period, American doctors became concerned about political threats to their incomes, and they declared war on any liberals who might pass legislation that would in any way curtail their unrestricted control over the fees charged for their services. In a campaign about which I can speak from personal experience they were joined by other workers in the health care field and by the insurance companies fearful of any type of regulatory controls. When I ran for Congress in 1962, word spread through the medical community that doctors could give my opponent, who despised any federal program in medicine, contributions of as much as $999 without the recipient’s having to report the gift publicly. When the election was over, the local newspapers printed the lists of doctors who had each given my opponent the $999. The earlier report of nondisclosure had been an error, but the end result was that everyone knew that I was for public medical care and the doctors and my opponent were not.
Not surprisingly, American doctors have developed a hatred for the medical-system experimentation in Canada, where a relatively sound national medical program has been installed and flourishes. It resembles the great programs in European countries like Great Britain, Denmark and Sweden, and is in no sense radical. But the American doctors, terrified by what they saw happening in Canada, where the doctors no longer had unrestricted control over their fees, launched a program of vilification against everything the Canadian medical system accomplished. This was the period when any Canadian who had the slightest grudge against his national system could come south of the border and be assured of heavy newspaper coverage when he declared the Canadian system did not work and should be junked. In fact some 90 percent of Canadians liked their system and compared it more than favorably with ours.
The American Medical Association adopted, with equal success, the policy that had served the National Rifle Association so well. If any critic pointed out that every advanced country in the world except ours had a national health and insurance policy that worked, while we lagged behind, AMA apologists for our inferior system shouted that our system was better because we were a different kind of people who had a system that suited us perfectly—we had nothing to learn from Europe, whose people were effete and not as advanced as we were. The NRA has used the same argument when anyone points out that our murder rate from handguns is four hundred or five hundred times greater than the rates of civilized foreign nations: ‘We’re a different people with a unique history, so there’s nothing to be gained in comparing us with what are essentially backward foreign countries.’
The sad part about our refusal to establish a sensible national program for health care is that we already have in place all the components required for such a system—components of the very highest caliber. From extended experience with doctors, hospitals, insurance companies and collateral medical agencies, I make the following evaluations:
Personnel: Our specialists, general practitioners and nurses are equal to the best in the world and, in many important specialties, superior. So they would be able to service any kind of delivery system we elected to install.
Hospitals: The ones in which I have been a patient have been superior, and for the most part the rest are excellent, but we appear to have so many superfluous ones that any less than excellent hospitals should probably be closed down.
Retirement centers: After I had seriously inspected some two dozen of the top installations, I reached two conclusions: living conditions, including exercise rooms and recreational areas, were excellent, but the health care facilities, so glibly advertised when attracting new clients, were almost always nonexistent. Much fakery is evident in this aspect of health care. You live in the beautiful condominium, but you are left on your own to find in the nearby town what turns out to be very ordinary health care.
Delivery systems: If a family has an income of more than eighty thousand dollars a year, its members can enjoy the best medical care in the world. Medicare is a precious boon even to such families, although they could probably exist without it, except in cases of catastrophic illness or injury.
Emergency care: People at the bottom of the economic ladder face a brutal task when trying to obtain adequate medical care. Persons without medical insurance use the emergency rooms for minor medical problems because they have nowhere else to go. No-charge emergency rooms are crowded, rushed and sparsely staffed. The waiting period is often intolerable. Other nations do better.
Nursing homes: They are almost universally deplorable. The health care they provide is often a farce, and anyone who can should avoid entry to such dead-end operations. There must be the occasional nursing home that does a respectable job, but I have never found it.
Transportation: Because transportation, especially the private automobile, is presumed to be easily available to all, home care from a physician or a nurse is usually unavailable. And if the family does not have a car, or if the one they do have is preempted by the breadwinner, the lack of transportation is itself a major medical problem. We do not handle this
well.
Lack of universal care: We are the only major nation I know that does not provide its citizens with the assurance of universal health care. This deficiency is a scandal of which we should be ashamed.
Lack of lifetime insurance: Most major nations provide health insurance to all citizens, with the promise that it will follow them like a protective umbrella wherever they have to move in changing jobs. We should provide the same, but we lag far behind the other major nations in this respect. We have not been allowed to provide lifetime insurance because of the cupidity of the insurance companies, who fear government regulation and want to keep the monopoly for themselves, and the avarice of some doctors, who support and defend the insurance people. The insurance companies must continue to be involved in a new system guaranteeing lifetime insurance, and they must, of course, be allowed to make a reasonable profit, but they cannot be allowed to control the system. Private medical insurance can continue to be available for those who can afford not to trust a national system to meet all of their medical requirements.
Doctors’ incomes: One of the most difficult alterations to make in our system will be the question: What is a just salary for the doctor, especially in days when budgets have to be rationalized? All signs point to two changes. Across the board, doctors’ fee-for-service incomes will be under fire. Those with strong reputations, particularly the specialists in exotic fields, will be able to practice individually and will retain their yearly incomes of many hundreds of thousands of dollars. But the majority of their fellows will probably be forced to practice as members of group plans, under fee limits such as those imposed by Medicare. Doctors’ incomes will be diminished, but I hope that equitable salary categories can be established; doctors do deserve good compensation for their skills, and we do not want to see our towns and cities filled with doctors who feel they have been cheated. Nevertheless, doctors will have to give up the idea of becoming millionaires on the backs of the taxpayers.