Health-Care System Will Continue to Die--Until More Feel the Pain : Sickness: The uninsured and underinsured have fewer options as government budgets are squeezed--and nobody seems to care.

California’s and Los Angeles County’s health-care systems are dying before our eyes, the victim of a chronic illness that threatens medical care for millions.

The poor, the middle class and the elderly all share the burden of a faltering health-care system. More than 25% of Los Angeles County’s non-elderly population are uninsured. Statewide, the uninsured population has grown by 50%, to 5.8 million, in the last 10 years. Tens of thousands more have too little health insurance to pay for catastrophic illness. Still others cannot buy any insurance because of their pre-existing health conditions.

Most of the uninsured and underinsured have nowhere to turn but to overcrowded and underfunded county hospitals and clinics or to the emergency rooms of private hospitals. But even these dwindling options are increasingly at risk.

Los Angeles County’s emergency-room trauma system has been imperiled for years, with one hospital after another dropping out because of the high costs associated with treating the uninsured. Over the last 10 years, the share of the county budget devoted to the Department of Health Services has dwindled, from 16.8% to 9.9%. Expected cuts in this year’s health-care budget were put off in the hope that a November ballot measure raising alcohol taxes would pass. The revenue would be used to bring health-care spending more in line with need. If the measure loses, further cuts in the system will have to be made.

Health care for the privately insured is not immune from similar problems. Indeed, the same difficulties undermining the public system are present in the private one. Employers, reeling from escalating health-insurance costs of 15% or more each year, are cutting back employee coverage. For many small firms, health insurance costs amount to more than 10% of their employee salaries.

Nor are the elderly protected. Despite Medicare, the elderly now spend 18.2% of their income on out-of-pocket medical costs. Lack of coverage for prescription drugs and long-term care make Medicare recipients extremely vulnerable to the escalating costs of serious illness.

How could a medical system that costs so much have become so inadequate? Why is the infant-mortality rate rising? Measles causing disease, even death? More and more middle-class Americans denied health insurance? The AIDS epidemic spreading unchecked in poor, minority communities? The mentally ill hallucinating on our streets? What happened to the best health-care system in the world?

Twenty-five years ago, with the passage of Medicare and Medicaid (Medi-Cal in California), we thought the problem of providing health-care coverage to all Americans was licked. Medicare would take care of the elderly, Medicaid the poor, private health insurance the working population.

All seemed well. Medicare picked up the elderly’s acute-care bills. Medicaid gave millions of poor people access to hospital and physician care. Private insurance expanded to protect more and more working Americans.

Yet both the public and private health insurance systems were inherently flawed--they were unable to control costs. Medicare costs billions more than was projected--currently $81.2 billion, up from $3.4 billion in 1966. Private insurance costs went up as much or more than Medicare during the 1980s. In 1988, national health spending was $539.9 billion, 117% greater than the sum spent in 1980. That’s $2,124 for every man, woman and child living in the United States. During the 1980s, we spent more money to provide less care to fewer Americans.

Responding to ever rising and seemingly uncontrollable health-care costs, government, business and insurers began looking for ways to reduce expenditures. Needed services were cut; coverage was denied. Medi-Cal reimburses physicians so poorly that few will provide care to needy mothers and children. Private insurance, meanwhile, looks for almost any medical reason to deny coverage. Medicare’s efforts to control costs have led to seemingly random denials of needed care.

Today, we have the worst of both worlds--continued health-care inflation combined with huge cuts in private and public health-care coverage.

As with our dependence on foreign oil, throughout the 1980s pundits warned that the day of reckoning was near. But Americans haven’t heeded the warnings. While polls show that 89% believe that the health-care system needs “fundamental reform” and 61% prefer Canada’s system to America’s, the will for change seems weak. To be sure, Americans complain about health-care costs. But most--at least those with insurance--remain generally content with the medical care they receive. A February, 1990, Los Angeles Times poll, for example, found that 90% of Americans were satisfied with their personal health care, and therein lies the problem.

So long as the majority of Americans are not personally affected, so long as they have access to doctors and hospitals, even if that access gradually shrinks, they will not recognize the danger signs around them. No-tax politicians will continue to be elected. Budget-deficit phobia will keep reform proposals at bay.

More and more, business will be asked to pay for health insurance--without passing along the added costs. The latest plan would give the business community three years to provide health coverage for its uninsured workers.

Yet California business is increasingly unwilling and unable to afford the health-care bill. Moreover, pilot projects in a number of states--including Massachusetts, Michigan and Oregon--to provide subsidized health insurance or tax credits to encourage small businesses to buy health insurance have not been successful. Nor can the added health insurance costs simply be shifted to workers, many of whom already pay more than they can afford.

Expansion of private health insurance is no answer, either. Private health insurance no longer provides a mechanism to spread the risk of illness between the well and ill; it weeds out the least healthy instead.

There is a way out, of course. Whenever problems are too large for individuals and communities to handle, whenever they feel threatened, Americans turn to government. Only government can guarantee the right to health care. Only government has the revenue-raising power to finance a state or national health insurance.

Sadly, until more Americans know what it is like to be ill and not have the money to take care of themselves, until they are unable to obtain immunizations for their children because of overcrowded public facilities, until they see a family member or friend impoverished by health-care costs--until then our health-care system will continue to die a slow, lingering death.