No easy remedy for our ailing health care system

Steve Heilig

Thursday, May 17, 2007

Sick

The Untold Story of America's Health Care Crisis and the People Who Pay the Price

By Jonathan Cohn

HARPERCOLLINS; 302 PAGES; $25.95

Health care has rather suddenly become, at least in political terms, sexy. Traditionally a "third rail" of policymaking that few dare touch, elected and aspiring officials at all levels are now proposing remedies to the chronic issues of the cost, quality, and, especially, lack of access to care. Not since the Clintons' well-intended but spectacularly sabotaged and unsuccessful 1994 attempt at sweeping reform has the issue been so prominently discussed.

The dilemma is vast and vastly complex. About one in six Americans -- about 45 million -- lack health insurance at any one point in time. Not having such insurance has been shown to be dangerous in terms of delayed and poorer quality of care. Medical costs are now the leading cause of personal bankruptcy even for those supposedly insured. Most insurance is provided via employers, who increasingly find the cost unaffordable. Retirement health plans, both private and public, are projected to run out of money given current trends. Technological advances promise ever more expensive options for saving life and improving health, and with an aging population and growing epidemics of diabetes, obesity and other yet unforeseen maladies, we're going to need all the help we can get.

Jonathan Cohn, a senior editor of the New Republic, sets his sights high in seeking to cover the sweeping story of the evolution of the modern American health care system or "non-system," as many would have it. "Sick" is no weighty tome full of academic analysis, though; it is a relatively concise, readable, human-centered tale of woe, money, bureaucracy, medical science and good intentions, in roughly that order of prominence.

One strength of "Sick" is that Cohn illustrates his factual and historical information with real-life stories, albeit invariably sad ones. There are far too many from which to choose, but consider Steven and Elizabeth Hilsabeck of Texas, whose son was born with cerebral palsy; physical therapy is indicated to help people with this incurable condition, but the family's "managed care" insurers suddenly stop paying for it. A clerk informs them wrongly that they are only covered for 60 visits per lifetime; and then asks them, idiotically, "When is he getting over the cerebral palsy?" The couple considers divorce just so Elizabeth might become poor enough to qualify for Medicaid. Instead, they sell their home and move into a cramped trailer to afford care for their kids. Other unfortunate people profiled here wind up in other trailers, and some of their lives end with suicide, brought on by the despair of never getting the care they need.

Again, there are countless such stories, including those in this book from all over the nation, but -- and this is perhaps one real point of the book -- even the insured often struggle with hassles, obstruction, misinformation, and worse from their "partners" in the health insurance industry. Cohn details how health insurance has evolved from well-meaning nonprofit efforts to large profitable companies and "managed care" in the 1990s, and how each step has brought more complaints. As a journalist remarked upon hearing a viewing audience respond with applause to an (HMO)-bashing scene in the 1997 film "As Good as It Gets": "I was clapping too. All of us, by now, have learned to hate an HMO."

Angry parents, patients and physicians began fighting back, with both lawsuits and legislation, but by the 2000 presidential election, "anxiety over the affordability of health insurance displaced the managed care backlash on the health policy agenda." And that is the driving issue -- expensive care and insurance -- or lack thereof that drives the debate to this day.

The underlying dynamic, of course, is that so much of the health care industry remains a for-profit business. Even the founding figure of managed care, Dr. Paul Elwood, came to lament it: "The idea was to have health care organizations compete on price and quality. The form it took, driven by employers, is competition on price alone." Or, as Cohn observes, "When they're not dealing with large groups of employees, insurers have no desire to protect those who most need protection." In effect, Cohn concludes, "managed care hadn't so much altered the evolution of American health insurance as reinforced it, moving toward a system that left the most medically vulnerable at even greater risk than before."

Cohn strives to be fair, though, explaining the side of those charged with controlling costs as well. But it's hard to reconcile a $500 million payout to HMO chiefs with the suffering even some "insured" people endure or don't. And now even managed care is less viable than ever; Cohn notes that public and private insurance is faltering, and safety-net charitable clinics and emergency rooms and public hospitals, themselves an endangered species, are strained to the breaking point.

"Sooner or later, something was going to give," he writes. So, with this depressing diagnosis, what is the cure? Reforms under Presidents Bill Clinton and Bush are seen here to be largely failures in the former or giveaways to powerful insurance and pharmaceutical interests in the latter. There has been little progress since then, and while the pharmaceutical industry now spends more on marketing than research, major insurers are fined for "routinely" canceling policies of sick people who actually need care, and the ranks of the uninsured keep growing.

The last major systemic reform was in 1965, when Medicare and Medicaid were started for care of the elderly and/or poor. Those programs have been targeted for funding cuts ever since. Now, every Democratic presidential candidate is pledging, or even promising, some sort of universal health care access, and even some more conservative politicians are joining the call. Cohn concludes that a universal health system similar to those found in many other modern nations would be an improvement, if not a panacea. Since most Americans believe they have adequate access to care and like their doctors, entrenched interests may still stave off any such drastic remedy. But at some point, when the issue becomes painfully if not tragically personal for enough of us, the status quo may no longer hold true. And then, perhaps, our national health care picture may not be quite so "Sick."

Steve Heilig is on the staffs of the San Francisco Medical Society, the Collaborative on Health and the Environment and California Pacific Medical Center.

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/05/17/DDGC1PRG1I1.DTL