The Health-Care Issue? Why, It’s an ‘Exigency’

OK, so maybe health care isn’t in crisis , (“a crucial or decisive point,” “American Heritage Dictionary,” third edition), as Hillary Rodham Clinton maintains--for example, re cently telling a physicians’ conven tion of “the unfair and in many ways cruel claim that there is no health-care crisis.” Probably the year 1994 will not be “crucial or decisive” for health care regardless of what Congress decides, since the medical system is guaranteed to clank and wheeze forward in some form.

Then again, health care is hardly just a problem (“a question to be considered, solved or answered”), as Sen. Bob Dole (R-Kan.) is insisting. How to choose your doctor is a problem. How to pay that doctor’s bills is far more than a problem.

Let’s test-drive other words recently applied to the subject. Health care can’t be an emergency (“a serious situation or occurrence that happens unexpectedly”), since its deficiencies have been apparent for some time; or a disaster (“an occurrence causing widespread destruction and distress”), since medical personnel solve rather than cause distress, at least usually, or a nightmare (“a dream arousing feelings of intense fear”), since health-care issues are annoyingly real.

Thus, I nominate this compromise label: the “health-care exigency.” Exigency means “the state or quality of requiring much effort or immediate action.” Surely, Republicans, Democrats, liberals, conservatives and even insurance-industry ad agencies can agree on that terminology.

No one can seriously contest that there exists a health-care exigency. Some 37 million Americans have no medical insurance. Perhaps you don’t care, since you do not number among the “medically indigent.” To the man, those like Dole and the conservative Republican strategist William Kristol, who insist everything is hunky-dory in the U.S. health-care system, are not among the uninsured. Their health plans are generous and fully paid-up--usually by somebody else.

The central reason many GOP politicians and strategists have shifted ground recently, from touting their own health-reform packages to denying any substantive legislation is required, is their realization that virtually the entire GOP constituency--the middle class and senior citizens--has good health insurance, either through employer-provided plans or Medicare. The group with the keenly felt problem--the 37 million uninsured--is mainly a Democratic constituency. So screw ‘em.

Yet, the existence of a vast block of Americans lacking health insurance has two deleterious effects on society generally, harming even those securely insured. This makes the lack of universal insurance not only the key issue in the health-care exigency--but an issue the majority of Americans ought to care about, if only for selfish reasons.

First, by some estimates, the existence of the class of medical indigents increases net health-care spending. People who don’t have any coverage--who can’t qualify for Medicaid because they are not under the poverty line, but whose jobs provide neither health benefits nor enough income to purchase insurance privately--usually neglect to get routine preventive care. This causes health conditions that might be corrected at low cost in the early stages to advance to serious illness--which is expensive to cure. Then middle-class taxpayers and insurance ratepayers get stuck with the bill for the expensive cure.

After the medically indigent become so ill they can’t stand it, they go to hospital emergency rooms--where, by federal law, anyone with an acute condition cannot be turned away. In emergency rooms, the medically indigent receive treatment far more expensive per visit than what they might have gotten in a doctor’s office. That treatment is then paid for with state funds, charity or, most often, by the markup on the bills of private-pay patients. If an uninsured person needs an operation or other extended care, he or she gets it, too--again at the expense either of the taxpayer or the private-pay patient.

The existence of 37 million Americans without health insurance harms even the securely insured majority in another important way. Practically everyone in the “medically indigent” class is working poor: people who hold jobs, not freeloaders. (Full-time labor at the minimum wage, about $9,000 annually, puts you above the income line for Medicaid in most states.) Most of the working poor have families to support. These people are poised at the boundary line between productivity and dependence, between pulling their own weight, or falling backward to become wards of the state.

It’s fair to expect people in the working-poor category to be responsible for their own housing, food and education--however difficult it may be. It’s preposterous to expect families earning $9,000 a year (about $7,000 after taxes) to be able to spare about $3,300 for medical insurance (the national average). By denying health insurance to the working poor, society makes it more likely they will fall backward toward dependence, rather than advance toward productivity. And each new dependent member of society costs middle-class taxpayers far more than is at issue in universal health coverage proposals.

Even the fractured-flickers system, by which the uninsured are denied low-cost preventive care, then once rushed to the emergency room have the most expensive treatments money can buy showered on them, no questions asked, pushes the working poor toward dependence. This is because the longer someone waits to have sickness treated, the lower the odds of a cure. Among the working poor are a significant proportion of people with disabling illnesses or degenerative conditions. Often the disabling part of the problem results from having waited, for financial reasons, till the rush-to-the-emergency-room moment is reached.

In this regard, it’s disquieting that opponents of the Clinton plan are now coalescing around a health-care exigency proposal offered by Democratic Rep. Jim Cooper of Tennessee. Cooper’s plan has several appealing aspects that would solve most health-insurance anxieties of the middle and upper classes. Under the Cooper plan, no one could lose benefits for changing jobs; no one could be denied coverage for having a “pre-existing condition”; insurers could not discriminate against the self-employed who work at home as consultants; lots of new price and performance data about doctors and hospitals would have to be published, helping the sharp-minded negotiate for better care. All these aspects of the Cooper proposal are desirable reforms.

But something essential is missing from the Cooper plan--there’s no universal coverage for the working poor. The middle class would be seen to. Society’s dependent class would still be protected, via a successor to Medicaid. And, of course, the upper class could have whatever it wants. But the working poor--those 37 million Americans for whom a major hospital bill is a greater trauma than the sickness itself--would get next to nothing. They’d get “access”--the legal right to buy a medical plan. And they’d get a somewhat vague, partial public subsidy for the price. But the bottom line is, under the Cooper plan, millions of Americans would still have no health insurance.

Perhaps the worst outcome of the health-care exigency would be that the middle and upper classes get the medical reforms they need, such as portable insurance plans, while the working poor get shafted. After the concerns of the middle class are addressed, the majority of Americans will no longer believe there’s a health-care crisis, problem, exigency--or anything else. But the group most in need will remain in need.

Right now, with support shifting to the Cooper plan, an outcome that serves only the middle class seems increasingly possible. Fixing what ails the majority on health care, while leaving the struggling to fend for themselves, would be a depressing outcome indeed.