Medically Downsizing the Poor
Next year we face a highly contentious and complex health care debate in Sacramento and in California counties as we confront the reorganization of the public and private health care systems, Medi-Cal, welfare and immigrant benefits.
The debate will center on money: who’s entitled to what and how much. The language will be obscure, hard to follow, and for many the issues may seem remote. We should pay attention. Underlying the politics and jargon are two central concepts that will profoundly affect the future for us all: the standard of care and the basis upon which we will receive or be denied care.
In years past, we had one standard for all, “the community standard,” which prevailed in the doctor’s office or the hospital. It didn’t matter if you were admitted to a private or public hospital. The medical staff was often the same in both places and was held to the same standard. Services were determined by patients’ medical needs.
Today we have no single standard. The poor can spend hours or days waiting in an emergency room at a county hospital. Poor patients suffer needless complications when transferred from a private hospital to a county facility. Patients with a bad HMO may spend weeks or months waiting for “gatekeepers” to allow access to a specialist, or have needed simple tests delayed or withheld with disastrous results. Medi-Cal policies today routinely make patients endure repeated gallbladder attacks before “authorizing” removal when any practicing physician knows surgery is necessary.
By contrast, the rich get what they want, when they please. Our standards of care are multiple and economically determined.
We have institutionalized and codified inequality. In 1992, as part of the budget battle, the governor signed legislation that explicitly relieved counties of their obligation to meet the prevailing community standard--and specified no new standard to replace it. The same law went on to weaken public notice and hearing provisions that would enable debate.
The state is not above breaking its own laws if it thinks it can save money on health care. For several years, and intensively over the past three years, the state has been pushing Medi-Cal patients into managed-care HMOs. There’s nothing inherently wrong with that, but the way it has occurred is unseemly.
Particularly illuminating is the setting of “capitation” rates--the rate paid per group member each month. The usual method of setting the rate is to look at the age, gender and health characteristics of the population to be covered, predict what its health care needs will be, calculate the cost per person of meeting those needs and pay that on a monthly basis. Insurance companies regularly bet their survival on that calculation. It is so standard that Section 14301 of the Welfare and Institutions Code specifies this methodology and requires that the state do the same.
The state has complied with the law for nearly 20 years. The capitation rate for Medi-Cal in Los Angeles has been $102. That compares with $120 to $130 for private HMOs in Los Angeles and for Medi-Cal equivalent HMOs in Arizona ($107), Oregon ($118) and Washington ($114). The “new methodology” used by California today results in a capitation rate for Medi-Cal in Los Angeles of less than $75.
Many believe that this rate is based not upon patient needs, but rather on what the state is willing to pay. It will not support a decent standard of care, regardless of who provides it.
These are just a few of many possible examples. True, the poor and uninsured are unpopular and politically weak. Some in government think that health care for the poor is just another entitlement program, one that encourages indolence and irresponsibility.
There are sound reasons for all Californians to be concerned about the outcome of the changes ahead.
The first is based in principle. Americans have long held that we are all created equal. We believe in legal, social and political equality and the dignity of the individual. To alter access to basic life-saving services now, without an explicit public debate, is to invite social unrest.
The second reason is based in self-interest. If we accept the idea that the standards of care are economically determined, there is no lower limit to the quality of care we can receive. If we accept a lower standard of care for the poor, the threat extends to all as employers, insurers, government and HMOs discover that there is no medical standard, only an economic standard: the price the buyer is willing to pay.
