Cutting expenses: It stands to reason that in an age of triage, changes will have to be made in budgeting for Medicare (for anyone) and Medicaid (for the indigent), and some services now available will have to be rationed. Short of scrapping our current health care system completely and starting over with a bold new system of national health care, modifications to the current system must be made. The problem is: How can we police those changes so that fairness to all citizens is protected? Both political parties, Republicans and Democrats alike, know that some kind of limitation will have to be imposed on these two services, and although the word triage is rarely spoken, that’s what the argument is about. And the subject is so vital to each party that the heated debate on medical costs has been at the forefront of the many disputed issues that have several times caused the government to shut down almost completely for weeks at a time, without any solution’s having been reached. And the impasse could continue right through the rest of 1996 and dominate the presidential election in November. Health care is a major problem for our federal and state governments. Cutting expenses is obligatory if the system is to be saved, but it would be dangerous and unacceptable if billions of dollars were to be cut from Medicare services to the middle class and even more from the Medicaid services to the poor. This would be especially repugnant if the billions thus saved were used to provide the upper classes with a tax cut they do not need. That proposal seems so immoral that our nation should scornfully reject it, yet it is being seriously proposed.
In recent years a promising innovation in health care has begun to proliferate, the HMO (health maintenance organization), a sample of which can be located anywhere in the United States from small town to major city. It consists of a group of doctors and nurses—often assembled and managed by an outside corporation—who practice as a unit and offer to their communities a wide mix of medical services, but not procedures as difficult as heart transplants or brain surgery. For such cases they reach out to specialists in their area or in the nearest city.
The important word in the name is maintenance, the job of keeping you well. To enroll in an HMO the patient signs a contract in advance, paying a modest entry fee whether or not a doctor’s services are needed at that moment. In most HMOs the patient is restricted to a choice among the doctors participating in his particular group. Any patient may, of course, consult with the doctor who had previously served as his family physician and pay him on the side for his help. But the experience of the ideal HMO is that the patient who signs up selects a doctor within the group who is found to be satisfactory.
By themselves the HMOs would not be a dominating force in the system, but they are backed up by guidance from a remarkable institution, Milliman & Robertson, a Seattle-based consulting firm specializing in medical economics. Milliman, roaring ahead in a field others had overlooked, quickly established itself as the arbiter not only of medical costs, about which it was an expert, but also of medical practice, about which it was formerly barely eligible to have an opinion. HMOs, insurance companies and hospitals seek guidance from Milliman on the most vital parts of their financial management. Because Milliman is not afraid to identify errors in medical practices and to issue guidelines to correct them, it has made itself the guru of triage.
Milliman’s pronouncements, published as guides for the saving of money, are being accepted as law by insurance companies, HMOs and hospitals. In The New York Times Allen R. Myerson cited some of Milliman’s edicts that have been widely adopted for patients under sixty-five without complications:
—You can’t stay in the hospital for more than one day after a normal childbirth, or two days after a Caesarean. (This is being widely contested.)
—You can’t stay in the hospital for more than three days for most strokes, even if you can’t walk out.
—You can’t have a coronary bypass unless the strongest drugs have failed to cure your chest pains.
Other consultants advise against hasty operations on the back, the prostate and the heart, and recommend that insurance companies cut back on the number of hysterectomies they allow.
The chief at Milliman and the authority in charge of the guidelines is Dr. Richard L. Doyle, a big, bearlike doctor, aged fifty-seven, with broad experience. He charges $395 an hour for individual counseling to hospitals and the like and his clients say: ‘Worth every penny. He makes you do things you ought to have thought of by yourself.’
His directives seem to be clear-cut and in some cases brutally frank: Cut costs. Rationalize your procedures. Submit everything to close rational inspection. Cut out the frills. Make every medical process justify itself. Cut costs. He is adamant that patients stay out of hospitals as much as possible, and when they do have to go in, they should get out in a hurry.
The Milliman guides seem to work best on patients under the age of sixty-five; older patients have more complex problems and require more individualized care. Doctors with long experience to justify their more cautious behavior fight against the Milliman rules, but the hardest blow falls on hospitals, whose daily basic costs have exploded to an average of nearly two thousand dollars a day per patient. Wide enforcement of the Milliman rules by insurance companies will force many smaller hospitals to close, a result that many leaders in the health professions would applaud.
What we are witnessing is triage on a grand scale, but today’s economic pressures and our unwillingness to pay the costs for national health care make its imposition inescapable. There are, however, certain illnesses that do not come under Milliman rules. Patients with total failure of the kidneys, which as recently as 1970 proved fatal, can now be kept alive with better than 95 percent certainty. This is possible through a miraculous system called dialysis, funded for everyone by Medicare, in which waste products are removed from the blood and excess fluid from the body. This wonder treatment saves thousands of lives a year, and costly though it is, Milliman rules do not apply to it. You cannot shorten the time the patient must spend on the dialysis machine; it demands three hours a day, three times a week. Dialysis is an example of what can and should be done at the national level.
A man on dialysis asked me: ‘Suppose Milliman or Congress decides to cut the number of dialysis machines by two thirds. Will the congressmen who vote for such an action agree to serve on their hometown triage committees: “You can have one of the chairs. Unfortunately you can’t, so you must die”? I doubt it. Hard facts would supersede Milliman cost cutting.’
Fortunately, there are not many diseases like total kidney failure, so Milliman procedures have a possibility of reducing our national medical bills by an almost unbelievable amount, and I expect them to be adopted throughout the nation. At one time I was inclined toward recommending that HMOs expand their coverage in America, and for a while I thought I might join one. But when I announced this publicly I was greeted with loud protest and a recitation of several dozen horror stories. In fairness I must share a sampling.
The thoughtful doctor: When this doctor heard me speak favorably of HMOs he grew choleric: ‘They’re making robots of us doctors. Medical decisions of the gravest kind are being imposed by secretaries on the telephone. I had a woman patient with a severe complication that only an on-site examination and diagnosis could treat. I explained this, but the secretary with no medical training whatever told me: “Rules are, Doctor, that she gets one day in the hospital, and that’s it.” If I wanted to keep her for two more days, I could do it at my own expense or hers.’
The highly trained specialist in an exotic field: ‘I’m embarrassed to say this, but there are not many of us in all America who are expert in this area of medicine. But when I advocated a somewhat unusual treatment for a patient with an advanced case, the girl on the telephone said: “Doctor, you know that’s not authorized. Insurance does not cover that and your appeal is rejected.” I was powerless, and I’m the expert with years of training, overruled by a telephone operator.’
A typical patient. ‘I’ve paid my entry fee and been on the ro
lls for seven months and have not yet been able to schedule a meeting with my primary health care provider. I have a feeling we’re being treated like cattle.’
A typical family physician of superb reputation: ‘I’ve been forbidden to recommend to any of my patients that they consult with a specialist in some field in which I’m adequate but not really well informed. To save pennies they invite serious setbacks that will cost thousands.’
Because of this constant drumbeat of criticism, I have become wary of placing too much power in the incestuous relationship of insurance companies and HMOs as a solution to our medical problems. Are the Milliman rules turning doctors into robots? Or are the protests of the doctors merely self-serving laments for the simpler—and more profitable—doctor—patient relationship of yesteryear? Are those days not doomed by the computer, which can handle diagnosis so ably, and by the Milliman rules, which show the health care profession how to save money? After painful attention to what is best for the country, I must vote against the HMOs as dictatorial, self-aggrandizing and indifferent to the welfare of the patient. Their abuse of doctors disqualifies them, and I see them now as a clever mask to perpetuate the tyranny of the insurance companies. The persuasive grain of truth in the otherwise absurd Harry and Louise advertising blitz was that we do fear having the medical decisions, so crucial to our very lives, being made by HMO secretaries and telephone operators rather than by doctors. There must be a better way.
But just as I am awakening to the dangers of the HMOs I learn that Congress is thinking seriously of using them as the basis of our national health care system. They and the insurance companies will dictate to patients, doctors and nurses how they shall operate. Saving money will become the rule in American health. I must protest against this unwise and brutal decision. The insurance companies’ profit margins cannot be the driving force behind what is and what is not adequate medical care, and neither should the profit margins of organizations such as the HMOs be the decisive factor. The motive for our medical care system has to be the health of our citizens rather than the health of a financial statement.
One test of any health care system is how it functions in a disaster or reacts to the sudden onset of a plague or an epidemic. In 1995, when the government building in Oklahoma City was destroyed by a massive bomb explosion, the health agencies of the area responded instantly and with the most admirable precision to save the lives of those few who survived. Praise was heaped upon the doctors who reacted so spontaneously to the call for help. Special accolades went to the medical team that dug deep into the rubble, which might have fallen on them at any moment, where they worked in darkness to amputate the leg of a woman trapped under a heavy slab of concrete that could not be moved. We have grown to expect doctors and nurses to do their best under the most perilous circumstances, which, as in the case of Oklahoma City, they invariably do.
But I am less impressed by our national response to plagues. These are unexpected eruptions of some unfamiliar death-dealing affliction like the spread of leprosy in Old Testament times, or the outbreak of the ancient plague in the London of 1665, or the strange attack of cholera among those journeying westward on the Oregon Trail in the 1840s, or the deadly pandemic outbreak of influenza in 1917. In the United States our medical system is currently engaged in fighting two modern plagues, and the battle reports are not encouraging.
AIDS: One of the perplexities facing health care administrators is: ‘How should HIV-positive patients who can be expected to contract full-blown AIDS with its threat of early death be treated?’ AIDS must be handled as an epidemic that strikes across our entire population. That it has been associated in the media with homosexual behavior is only partly accurate; AIDS is also attacking the general population. (Indeed, the rates of increased cases are greatest among heterosexual young women.) We shoúld fund research to identify and distribute cures to halt the HIV infection but also provide hospices in which AIDS-afflicted people can die with dignity.
Tobacco: Two aspects of our health program are so perverse they defy rational explanation. Since 1964, when the famous report of the surgeon general launched an attack on the health hazards of cigarette smoking, our federal government has aggressively campaigned against tobacco. Advertisements for cigarettes could not appear on television. Packages in which cigarettes were sold had to carry a government warning that they were hazardous to one’s health. Taxes were piled on cigarettes, and laws were passed forbidding people to smoke in public places. Millions of families posted PLEASE DO NOT SMOKE signs in their homes, and many public buildings such as libraries, hospitals and entire colleges and universities became nonsmoking areas. In addition, scientists were remorseless with their barrage of studies that proved to the satisfaction of the general public that cigarette smoke by itself was carcinogenic if the nonsmoker inhaled enough secondhand smoke. Millions of two-pack-a-day smokers quit.
But while this government campaign was gaining new converts every month, our Congress was nullifying the effort by kowtowing to a powerful group of southern senators and congressmen who demanded that the government continue to protect the tobacco industry; the law even paid southern farmers subsidies to cultivate and market their tobacco crops. This bifurcated policy—condemn cigarettes but subsidize farmers to keep on producing huge surpluses—left many Americans bewildered, for they saw that they were paying twice for the cigarette: once when it was produced with a subsidy and a second time when hundreds of thousands of men and women contracted lung cancer and emphysema, leaving behind massive medical bills that often had to be paid from government funds.
The insanity of our tobacco policy was exacerbated when we exported our tobacco abroad and made it attractive for foreign governments to import our cigarettes and to endanger their own people. This three-pronged policy—condemn the cigarette at home, do everything to diminish its use within the United States, but pay farmers a subsidy so that their tobacco can be both marketed at home and shipped abroad to other nations—is a social crime with international reverberations.
This behavior on our part of forcing tobacco on other nations is reminiscent of the opium conflict of 1839–42, in which a powerless China sought to halt a nefarious opium traffic that was enervating her people but was defied by Great Britain, which earned a huge profit from the opium trade. Britain initiated what is known as the Opium War, and was joined by other European nations. The result was the imposition of duty-free ports along the China coast inhabited and controlled by foreign powers. The United States participated in this shameful incident, and opium continued to be forced upon the Chinese.
I shall not belabor the analogy except to point out that for the last one hundred fifty years foreign historians have condemned Great Britain for her reimposition of the opium traffic upon a nation that did not want it.
To summarize, the components of a world-class medical system are already in place in the United States. What has been lacking so far is a firm resolve to pay the costs of welding the pieces together into a workable pattern that will meet the nation’s needs. I doubt that this can be achieved if we allow the insurance companies with their special interests to dictate what form that system will take.
I find it intolerable that our political leaders, those in charge of our plan of taxation, should propose a solution that would leave an enormous minority at the bottom of our economic ladder without reliable care or the insurance backing to acquire it. Other civilized countries have national systems of medical care to benefit all citizens, but the citizens are taxed to pay for it. Americans must be brought to realize both that medical facilities must be made available to all and they will be taxed to pay for them.
I consider health care to be one of the four most important issues on the national agenda. Not in order of priority they are: race relations, getting money to the dispossessed, education and health care. For me, improved race relations are a philosophical-moral imperative; helping the people at the bottom of the ladder is an economic necessity; education is vital if we
are to continue to compete in world markets; health is a matter of life and death for all of us.
Recommendations
1. Our national health care system must be made rational and all participants must bear their share of the costs.
2. It must include care and insurance for all citizens.
3. Medicare and Medicaid should be continued, but savings must be made in each agency.
4. The horrible mess of government paperwork in the health care field, especially in Medicare, should be simplified.
5. If changes currently proposed are implemented, doctors could become like schoolteachers: everyone will acknowledge the important role they play but will be reluctant to pay them a respectable wage. We must not let this happen. Multimillionaires, no. Decently paid public servants, yes.
6. The nation seems destined to move toward an HMO system. But before that happens, the current dictatorial tendencies of HMOs must be curbed.
7. We must stop subsidizing tobacco, restrict its use here at home, and cease our export of it to other lands. In the year 2030 our country might well be cited in some international court for such near-criminal behavior.
Macho is a Spanish adjective meaning ‘male.’ It would be improper to say: ‘He has macho,’ for the noun is machismo. To say ‘He has machismo’ would be proper usage, but in contemporary English the word macho has come to mean excessive or posturing male characteristics. The United States as a nation of active people has veered, I believe, toward a macho image of itself, and this is having an effect on many aspects of society. Macho ambitions explain, for example, why football has superseded baseball as our national pastime and why control of guns seems an impossibility. Among the deplorable effects of machismo in America are the complete degradation of many of our legitimate sporting programs, the ever-increasing numbers of children murdered by handguns, the rise of vicious militia organizations, the proliferation of vitriolic and dangerous radio and TV talk shows, and the depictions of violence in motion pictures that make violence appear to be a norm in life.
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