What Is Reform in Health Care

hat Iq Rpfnvm in Hoalth Paro' physicians argue that they need the «■licit 19 nciunil III ncdllll wdre. possibly dubious tests to protect against lvin L.Schorr malpractice suits. Obviously, these incentives run up the cost of medical care (not to mention This is a time of great national trouble, perwork. Three qualities of the coladd to the inconvenience and risk of Our economy is in recession, and all lage—the competitive insurance sysreceiving medical care), and the gov the difficulties we worry about—povtern, physician reimbursement, and ernment has been trying to regulate erty, unemployment, homelessness, adhospital competition—are at the heart these practices without notable suc diction, delinquency—are accentuated, of our difficulties. cess. Not as visible an effect as rising In health care, people who thought cost is the deteriorating relationship they were protected are dumped out of ^ .... T ox between physicians and patients; pa coverage because they lose their jobs, Competltlve InSurance System tients feel pushed around and think and others discover that benefits they In a competitive insurance system, that physicians are more interested in need have been shaved. So 30 million the best way for an insurance company money than in them. Doctors are dis to 40 million Americans have no health to make money is to avoid insuring turbed about this, and at least some care coverage, and many more have those most likely to make claims. The complain that although the talk heard such poor insurance that a serious illinsurance company makes its guesses among colleagues in hospital corridors ness would bankrupt them. We in the based on the applicant's age and other was once about medical issues, it is United States pay twice as much for factors. Eitheritdeclinestocoverpeople now about how to keep doctors'income medical care as the average citizen of who are regarded as having high risk— up in the face ofwhat physicians see as other industrialized countries, and we the very ones who are going to need to a conspiracy by insurance companies, feel worse. Compared with other inbe insured—or it sets rates so high that employers, and the government to re dustrialized nations, we have a mediopeople voluntarily go uninsured. This duce their income, ere average life expectancy, a high practice is given a name—"underwrit death rate among youths, and high ing"—so that it will appear to be prow .. , r .... n i i vj • i ,i ,i i i. AO spiral competiti n infant mortality. fessional rather than simply rapacious. Perhaps a crisis that stretches on for At the same time, insurance compaFor items such as food, rent, and 20 years loses its right to be called that, nies develop practices that keep costs automobiles, the consumer compares Still, our national health care situadown even with respect to people they products and chooses the best product tion deteriorates steadily, with costs are insuring. People who are really for the lowest price. Theoretically, at rising stubbornly even as coverage and sick get dropped from coverage. Paleast, this drives prices down. With patient care decline. There is this to tients are shifted from one set of physirespect to health care, however, many say for a crisis: Sometimes in a crisis cians to another in the search for patients judge physicians by bedside we dismiss tinkering and shrug off the cheaper care. Such practice is now manner or other qualities irrelevant catchwords that would mollify and called "managed care," again to give a to competence and outcome. The truth delude us, and we make the fundagloss of professionalism and innovais that physicians and hospitals are mental changes that are necessary. tion to distressing behavior. marketed, but in the Ronald Reagan It is in this context—that we have or George Bush or Alan Greenspan come to a time when we will take steps , , sense, there is little competition that that are proportional to the difficulPhyS1Cian Reimbursement affects price. ties—that this article is prepared. BeMost payment to doctors is based on With respect to hospitals, it is well fore saying what we need to do, the the number of times they see patients understood that competition leads to problem must be identified. and the procedures they use. With this higher prices (Schorr, 1986). Why? system, doctors make more money if Because hospitals compete for pa The Problem 0y S8e someone twice for 10 minutes tients by buying high-technology ii. t i, i rather than once for 20 minutes and if equipment and by bidding for well We have a fragmented system that they order a variety of tests and proceknown physicians, was put together like a collage: a Blue dures, no matter how marginally use Cross here, a health maintenance orful. It is tempting to physicians to play What To Do ganization there, and controls to keep out these advantages, especially when the hospitals in line over there. Such a it is only the government or an insurer In addition to a quality health care system produces gaps in coverage, proand not the patient who is paying, system, the nation needs universal hibitively rising costs, and endless paWhen challenged on this practice, many access and control of costs. So well are