Consumer Interest and Health Reform: The Logic of Withdrawal from Managed Competition

We will talk about truth-in-mending--mending broken bones, broken budgets, and broken bargains. Mending our ailing health system is, according to a Harris poll, the number one issue on consumers' minds. At Cook County Hospital, I have encountered mothers who will not let their kids go out and play, lest they break a bone for which they had no health insurance coverage. I took a cab to the airport in Chicago yesterday. When I told the cab driver I needed to stop at Cook County Hospital he said, "I hate Cook County Hospital. You go to the Emergency Room early in the morning and don't get out till late at night." While coming as no surprise (I began working at Cook County in the Emergency Room as a volunteer 25 years ago) such comments nonetheless always strike a painful chord; a reminder of shortcomings that are hard not to take personally. The cab driver told me he now goes to a private hospital and uses a false name to avoid being billed. I have met mothers who have to go to court to get legal custody of their own children: they delivered their babies under a false name using a neighbor's Medicaid card. In my clinic, the General Medical Clinic, there are over 10,000 people on the waiting list, all sick people with medical problems referred from our emergency room (and contributing to the delays there). We hear stories about supposed waiting lists in Canada for high tech procedures. In the United States, we ration primary care. Mending broken bones and helping to heal diseased bodies--what I was trained as a physician to do, in theory the simplest and most straightforward of tasks--has turned out to be a much more complex and challenging job than I was prepared for in medical school. What a physician quickly learns, once he or she tries to apply medical skills to effectively impact patients' and populations' health, is that the interrelationships among medicine and the social science disciplines represented in this room ultimately have more influence on our citizens' health than 99 percent of what was learned in medical school. This realization has led me down a variety of paths that you as consumer advocates and academics have cleared for us to meet and travel together. And for that reason, it is with a great deal of honor and trepidation that I speak on subjects highly relevant to my day-to-day work, but subjects for which my expertise is inferior to many in this audience. Broken budgets refer to the crushing burden of health care costs on governments especially the states (their leading and fastest growing costs), corporations (whose expenses for health costs in 1965 equaled only 14 percent of their profits, whereas 1990 health expenses exceeded total profits) (Himmelstein and Woolhandler 1994, 41), and most importantly consumers for whom health bills are an important cause of personal bankruptcies, poor credit ratings, and financial hardships. The average household now spends ten percent of its household income on out-of-pocket health expenses, up from 6.6 percent in 1965. For seniors this portion approaches 20 percent, rising to the same level as before Medicare was enacted (Himmelstein and Woolhandler 1994, 35). The broken bargains are the failed promises of our political leaders to bring about meaningful and effective national health reform, to accurately weigh and portray the alternatives, and to give leadership toward optimal solutions. The broken promise I fear is again being repeated in Washington, unless we can educate and activate consumers, and thereby break the political gridlock that appears to block real reform this year. MENDING OUR AILING HEALTH SYSTEM How should we mend our ailing health system? The simplest approach for a consumer might be to turn to Consumer Reports for the answer. And it's right here in last month's issue (Karpatkin 1994). I hope they won't sue me for citing what Rhoda Karpatkin CU President rates/advocates as our best buy--"the single-payer plan co-sponsored by 98 members of Congress. …