National health care lags behind other industrialized nations

Eds. Note: This is the fourth in a four-part series.

By Lana McGraw Boldt

Texan Dee Dee Dodd did not have health insurance, a situation she shares with almost a quarter of the state's population. But Dodd has diabetes. Without health insurance, her only recourse was the emergency room. In one 18-month-period of failing health she accumulated more than $191,000 in unpaid bills. At that point the Seton Family of Hospitals decided that it would be less expensive if they just provided her with regular primary care. They'd learned that by helping patients take care of themselves the hospital actually saves money. And the patients have a new life.

In the trenches

In the face of a national health crisis, health care providers are on the front line. They are the physicians who treat, prescribe and care.

They are the nurse practitioners, osteopaths, chiropractors and others who listen and educate, heal and comfort the sick. They are hospitals who are entrusted with birth, life and death every minute of every day. And they are all struggling.

"It should be public policy, written in law, that all Americans have affordable access to health care" wrote the Citizen's Health Care Working Group in September. The charter for the group was written by Democratic Senator Ron Wyden of Oregon and Republican Senator Orin Hatch of Utah, who declared it "a fresh approach."

After listening to views of more than 7,000 people at community meetings in 37 states and consulting health experts, the panel reported that Congress should take immediate steps to guarantee all Americans access to affordable health care by 2012.

According to Census Bureau figures 39.7 million Americans were uninsured in 1993. By 2005 that number of uninsured had increased to 46.6 million. More than half of family bankruptcies filed every year in the U.S. are directly related to medical expenses. A study reported in 2005 issue of Health Affairs, shows that 75 percent of those bankruptcies are filed by people with health insurance.

Most agree there is a health care crisis. The debate is whether solutions should be market-driven or patient-driven.

David Gratzer, senior fellow at the Manhattan Institute for Policy Research, maintains that "Congress needs to administer a strong dose of capitalism" to overcome the nation's health care ills. In the Washington Post's Think Tank Town he writes, "We must choose market reforms." He touts competition in health care, recommending the removal of regulations that reduce competition and innovation, expansion of health savings accounts legislation, giving federally mandated money to states to distribute and reducing prescription drug prices by trimming the size and scope of the FDA.

Paperwork over practice

Although most don't propose such comprehensive and market-based solutions, most providers recognize that today much more of their time must be devoted to the business of medicine instead of the practice of medicine. In an Oct. 15, 2006, story from the Boston Globe, Dr. Francis Rockett, former president of the Massachusetts Medical Society said that "There's no question that medicine is now looked upon as a business, much like a regulated utility."

Many hospitals have turned to the business template, forming corporate groups or separate corporations for the business-end of hospital functions.

Even though medicine can mean big business, this does not always work to the patients' advantage. A 2002 study published in the Canadian Medical Association Journal compared mortality rates in private for-profit and non-profit hospitals in the United States. Research of 38 million adult patients in 26,000 U.S. hospitals showed that the death rate in for-profit hospitals was higher than in non-profit hospitals. For-profit patients have a 2 percent higher chance of dying in the hospital or within 30 days of discharge. The study attributed the increased death rate to "the corners that for-profit hospitals must cut in order to achieve a profit margin for investors, as well as pay the high salaries for administrators."

Not everyone suffers under the current health care system. Medical consumers who through employment insurance have health care or those with large wealth who don't have to worry about financial disaster due to loss of health are not affected. The remaining 46 million uninsured and tens of millions of underinsured know that financial disaster is just one misstep, one germ, one mutating cell away. These people know first-hand that the market approach to medicine does not work for them and others like them. Competition between producers of commodities may work for washing machines or cars, but the theory falls apart when applied to health care.

When profit is the goal, the business of medicine is not immune to Enron-style ethical challenges. A report by the Department of Health and Human Services details the results of lawsuits filed on behalf of the Federal government under the False Claims Act. It reveals a multitude of health care fraud cases by retrieving funds paid by federal health care programs as a result of fraud, waste and abuse, both criminal and civil. These include overcharging by hospitals and other Medicare providers, involving everything from kickbacks to overpricing and the illegal marketing of pharmaceuticals.

Health practices and the law

The Washington Post reported in June 2005 on one corporation charged under this act. HealthSouth Corporation paid $100 million to settle allegations of fraud, false claims for patient services, accounting fraud and billing for unallowable costs such as lavish entertainment and travel for administrators, all charged against federal health care programs. The SEC originally charged HealthSouth CEO Richard Scrushy with a $1.4 billion accounting fraud. His civil trial is set for April 2007. He has been ordered to repay HealthSouth Corp. $47.8 million in bonuses paid to him. Fifteen HealthSouth executives have already pleaded guilty to fraud.

Another False Claims Act lawsuit alleged Healthcare Financial Advisors in California helped hospital clients seek reimbursement for non-allowable costs and prepare double cost reports, one inflated for Medicare and one for internal use only. Many of these cases were brought by whistleblowers, employees appalled by corruption and enticed by financial reward from successful claims. Since 1997, the program has returned over $8.85 billion to the Medicare Trust Fund.

Health care at home

While health care in the 21st Century is often reflected in the sleek glass-fronted offices of corporate medicine, its antithesis harkens to an earlier time. The American Academy of Home Care Physicians reports members in 38 states, all of whom make house calls. (All AAHCP members in the state of Oregon are in the Portland area.) These are physicians who, armed with their black bags and laptops, make house calls to care for chronically ill, bed-bound patients, many of whom are elderly.

Constance Row, executive director of The Home Care Physicians group, based in Edgewood, Md., estimates that there are some 1,000 house-call practices nationally.

"For a long time, there's been an unmet need to serve the bed-bound elderly," Row said, "and our beginning efforts, while still small, are making a difference in chronic-care coverage."

For four years Dr. David M. Wahl of Melrose, Massachusetts, has had a home-based practice. He visits about eight patients a day. He says his income is not what it was when he was seeing 30-40 patients a day in a family practice office in Saugus, Mass.

"But I like being my own boss — I answer my own phone — and trying to help those who really need help," he said.

The New York Times reported on Oct. 25, that the Seton Family of Hospitals in Texas is not the only hospital that did the math and found it's cheaper to provide free preventive care than it is to absorb the high cost of repeated emergencies.

New York's public system, the Health and Hospitals Corporation, has assigned almost a quarter million uninsured patients to personal primary care doctors.

"For most preventive efforts there is an upfront expense," said Alan D. Aviles, president of the corporation. "But over the long term it saves money." Denver's public system, Denver Health, has 41,000 patients enrolled in its clinic. They calculate that every dollar spent on prenatal care for uninsured women, saves more than $7 in newborn and child care.

An ounce of prevention ...

Education and prevention is crucial to the success of any health plan. Every health care provider interviewed for this article said that individual responsibility is key to any plan. The concensus is that eople must take responsibility for their own health, starting with exercise. Other advise includes losing weight if needed, don't use alcohol to excess and don't smoke. Senator Bates, speaking as Dr. Bates, adds, "We estimate that 70 percent of what people go to see their doctor about is the result of those four things."

Beginning in the 1930s Canada and the U.S. had very similar populations, health care costs and statistics with virtually identical mortality rates calculated along income lines. Their health care was equally similar to that in the U.S. However, in 1971 when Canada's Medicare was fully applied, Canadian death rates suddenly plummeted.

Now in Canada there is no relation between income inequality and mortality. Not so in the U.S., where among the poorest people even a 1 percent increase in income results in a mortality decline of nearly 22 out of 100,000. Today, U.S. statistics rank Canada's infant mortality rate 23rd out of 225 countries, on a level with Denmark and Australia. The U.S. ranks 43rd (below Taiwan and Cuba) on a level with Croatia and Lithuania. The United States is the only nation in the 30 top industrialized nations without a national health care program.

Even worse, the United States spends far more on health care than any comparable country. A recent study from the University of California San Francisco estimates that the United States would save over $161 billion every year in paperwork alone if it switched to a singlepayer system like Canada's.

Although some states are not waiting for the federal government to solve the health care crisis, the hard truth is that until we have a federal response, there will likely continue to be vast inequity in health care with a resultant financial tragedy for increasing numbers of Americans.

Possibility of change

The Center for Responsive Politics reports a notable increase in health insurance/HMO federal campaign contributions between 1992 and 2002, an increase of 164 percent for Democrats and 642 percent for Republicans. Contributions from pharmaceutical manufacturers increased by 79 percent for Democrats and 594 percent for Republicans over the same period. Fifty-one of Bush fundraisers who raised at least $100,000-$200,000 for the president's campaigns are employed by the health care industry.

The 220 House members who voted for the 2003 Medicare drug bill received on average two times the campaign cash from pharmaceutical manufacturers as those who voted against it. Pharmaceutical manufacturing invested $46,964,230 in campaign contributions between 1999 and 2004, 23 percent of that to Democrats and 77 percent to Republicans. The 108th Congressional Senate had the highest lifetime contributions from Pharmaceuticals with the five highest recipients having a total between them of over $2.25 million dollars. In order they were Orin Hatch (R-Utah), Arlen Specter (R-PA), Chris Dodd (D-CT), Rick Santorum (R-PA) and Joe Lieberman (D/I- CT).

Oregon 2004 campaign contributions from health care related industries totaled over $8.5 million. Pharmaceuticals and health products contributions amounted to $728,506. Health services contributed $475,815 to Oregon campaigns. Hospitals and nursing homes contributed $3,858,453. And health professionals contributed $3,409,456 to 2004 campaign financing in Oregon.

Colorado State Representative Morgan Carroll said in the Rocky Mountain News that she believes that "health care has been hijacked by a 'jihad' of insurance and hospital special interests and only substantial government intervention will right those wrongs."

November's elections carried ballot measures in several states addressing some kind of campaign finance reform. A diverse collection of people and organizations proposed, support and are actively campaigning for them.

On the October 2006, the PBS program NOW asked why the California Nurses Association was campaigning for a campaign finance reform ballot measure? Executive Director Rose Ann DeMoro summed it up.

"We have a declining democracy and Ground Zero is the health of patients. Nurses see it first. Our health takes place in a political and economic environment. That's why we need a systemic change in the political process in order to have a change in our lives. It's critical. It's urgent. We can't wait."

Carolann Hennen and Tammy Achurra contributed to this report.