Governmental Medicine - a fait accompli

by Del Meyer, MD

The Jan/Feb/Mar1992 issue of Common Cause (Vol 18, No 1, pg 8 ff) states that the democratic Harris Wofford's victory over former Attorney General Richard Thornburgh last fall was attributed to his five TV advertisements on health care which stated "if criminals have a right to a lawyer, sick Americans should have a right to see a doctor." Post election polls indicated one of three votes for Wofford was cast solely for his position on health care. Paul Begola, his campaign manager stated, "This issue is strong enough to turn goat spit into gasoline."

There are few things hotter than burning gasoline. This would lead us to believe that our profession and the delivery of our service will be one of the major issues in politics in the foreseeable future.

Contrary to popular belief, health care is already one of the most socialized sectors of our society. Our medical schools are heavily subsidized by our federal and state tax dollars. We then have student loans to pay for the tuition and other costs subsidized by our federal tax dollars. Our hospitals are greatly controlled by governmental regulatory agencies and their reimbursements are, in large part, controlled by the medicare and medicaid systems. Our fees are, in large part, also controlled by medicare and medicaid federal/state systems. And increasingly our private plans are being geared to the governmental plans. With all this governmental involvement, the problem seems to be getting worse.

The popular perception is that more government intervention will solve the apparent problem of allowing those 35 million Americans who don't have health insurance greater access to us and the product we provide and the service we sell. And reduce the overall costs! It also appears that many physicians agree, cooperate, and even become the bureaucracy that polices the rest of us.

A study done by Drs. John Goodman and Gerald Musgrave of the Dallas-based National Center for Policy Analysis would lead us to the opposite conclusion. In their "Twenty Myths About National Health Insurance" (see Williams in Sacramento Union, February 2, 1991) they itemize a reversal of the socialized trend in a number of countries.

They point out that the British government introduced market-based reforms in health care in 1989. New Zealand government signaled its intent to end 40 years of socialized medicine by providing tax incentives to purchase private insurance. Sweden has already introduced "managed competition" into its nationalized health plan. Chile has given its citizens financial incentives to opt out of its socialized health insurance.

They also point out that Canada at any point in time has 250,000 patients on a waiting list for surgery with the result of more Canadians coming to the USA for health care. Ontario in 1990 paid $214 million for its citizens to receive treatment in the US. The MRI waits have gone up to 16 months. (Don't we sometimes obtain these on the same day?)

Drs. Goodman and Musgrave referred to above conclude that if health care is made free at the point of consumption, rationing by waiting is inevitable.

I've had some personal experience which brought their observations into focus. When I attended the Pan American Chest meetings in Lima, Peru, I arranged a tour of Peru's largest public hospital with 800 beds. The chest surgeon presented me a patient with what appeared to be an obstructive pneumonia in a heavy smoker at an age that endobronchial neoplasm would be the first diagnosis. I asked for the bronchoscopic findings, he said that they didn't have a bronchoscope. They had requested one in their budget for seven years and it was always denied. When asked by whom, he retorted, "by the politicians in the government." (At that time all 10 hospitals in the Sacramento area including the 20-bed Community Hospital had fiberoptic bronchoscopes.) He stated that he would probably do a thoracotomy to determine the diagnosis. The tour through the x-ray department revealed seven x-ray units. That day, only one x-ray unit was functioning. The surgeon stated that the most he had ever seen in an operational state was three of the seven. The tour through the CCU revealed new monitoring equipment that was non-functional. It was made in Eastern Europe. When asked why non-functional equipment was purchased, the physician explained that Peru exported anchovies to Eastern Europe and the minister of trade made the decision as to what to buy in exchange.

My guide, a pediatrician, summarized his country’s philosophy of health care. He stated that his country could not afford what Americans were use to. All routine care has to wait. It would not be uncommon for an elective herniorrhaphy to have to wait at least five and perhaps ten years. Life processes and perhaps even death would intervene and thus save the government "all that expense."

All this has led me to realize that what frequently is missed is that full-coverage health insurance is also free at consumption. Full-coverage health insurance will then also lead to rationing. Rationing means a large expense of our time is not reimbursable. It changes the physician from being the patient's advocate to the patient's adversary and the insurance company's advocate. And if the insurance company (or HMO, IPA, PPO, USG, or GOK) pays the entire fee, we will eventually be totally controlled by the carriers, whether private insurance or government. And we will then have gone from one of the most respected professions in the world, to near the bottom, along with car salesmen and congressmen.

Let us make sure that, in every plan we propose or support, the patient pays some part at the time of consumption, such as 10% of the hospital bill, or 20% of the surgery center bill, or 50% of the office/outpatient bill. Only then will the patient be his own utilization reviewer and cost container and we can get back to practicing medicine without using the next patient’s consultation time to obtain authorization for the prior patient’s treatment plan.