Health Care for All--With Limits : To Avert a System Collapse, We Must Define a Basic Package
There is no question that the emergency medical-services system in Los Angeles is collapsing. Ask paramedics, and they will tell you how hard it is to find an open emergency department during peak hours, or when there’s an outbreak of the flu. Talk to emergency physicians, and they will tell you that their departments are frequently overwhelmed by incoming patients for whom they can not find specialists or hospital beds. Ask the hospital administrators, who collectively subsidized the care of the poor by $402 million in Los Angeles County in 1988.
Our trauma-center system, with 9 of 23 centers closed, is no longer a system. Now our basic emergency system--much more fundamental than specialized trauma care--is failing.
The reason for the collapse is financial. More than one-quarter of the local population is uninsured and we have large numbers of illegal immigrants. The cost of health care is so high and rising so fast that insurance companies and employers are reducing benefits and denying payment for legitimate services as a means of controlling costs. Judging by their actions, the governor and other politicians have decided that they will pay no more for health care, regardless of the consequences. Politicians apparently have concluded that if spending more than 11% of the gross national product won’t provide an acceptable standard of care in this country, then committing a larger share is unlikely to do so. In sum, government, private insurance and employers have put a cap on health-care expenditures.
In this situation there are two threats to the public: one short-term and direct and the other indirect, and in the long run more dangerous.
The short-term danger is that individuals, including the well-to-do and hard-working, will die needlessly despite their health insurance because the system will have collapsed for lack of financing. The county hospitals will be choked with poor people. Sufficient numbers of private hospitals will have closed or abolished their emergency services so that even those who have money will not be able to get care soon enough to save their lives.
The more insidious threat is that such a grave collapse would prove to be the incentive for an ill-considered ballot initiative which, while attempting to meet the real needs of the 26% who are uninsured, will destroy our health-care system for the 74% who are covered. One has only to look at our recent history to see ballot initiatives that dealt simplistically with critical and complex issues. The Jarvis and Gann tax and spending-limit initiatives, the fight over insurance reform and the AIDS quarantine initiative are good examples of key issues that were oversimplified for the ballot and then obscured by competing advertising agencies. To subject our health-care system, whatever its shortcomings, to such treatment would be stupid and tragic.
What we need instead is to develop a social consensus that will permit health-care delivery to all within a specified cost or cap. To do that we must abandon the notion that we can provide all health-care services to people regardless of their ability to pay. Instead, we must define a basic health-care package that we can afford to offer everyone. Then we need the political and moral courage to explicitly acknowledge that we will not “do everything possible” for everyone.
This must be done on the basis of a social consensus because physicians, by their training and beliefs, will not withhold services that might save a life. I will do for my patients what I would do for a member of my family. I do not want to bear individually the burden of deciding who gets what care and who is denied. The public needs to be involved in deciding the total budget and should be advised by the medical profession on which interventions are cost-effective and which are not.
Diagnostic and treatment options will have to be ranked by priority by the medical profession within a fixed budget, and when the budget has been exceeded, it should be mutually understood that further treatment will not be funded. As examples of how this might work, liver and bone- marrow transplants may benefit too few to be publicly financed, and hair transplants would most certainly not be paid for in the basic package. On the other hand, prenatal care, childhood immunizations and hypertension screenings are known to be cost- effective and most certainly would be funded. Such a system may seem hard-nosed, but it is kinder and more decent than our present system in which basic care is not defined and large numbers of persons get no care at all.
Working within a budget makes more sense than refusing to do so and thus bankrupting government and threatening the entire health-care system. We are, in fact, rationing health care today. Los Angeles County has 4,363 licensed beds, but staffs only 2,928 of those beds, while turning away the poor. That is a form of rationing not subject to medical review.
The Los Angeles County Board of Supervisors, in cooperation with the state Legislature, should assemble a panel of respected and knowledgeable persons in business, government and medicine to specifically address the issue of health-care costs and uncompensated care. We must deal with this problem promptly and dispassionately, before the collapse of our present system provokes an intemperate and irrational response that would then be indelibly incorporated into the state Constitution as a result of a ballot initiative and an ad campaign.
