Our Health Care System Need Not Be a Labyrinth

The state forfeiture later this week to the federal Treasury of more than a half-billion unspent dollars meant to insure poor children shows the problems with timid and incremental efforts to expand health coverage. What’s needed is an overhaul of the indecipherable patchwork of insurance programs to create a single, seamless and sensible system. Medicine does not have to be this chaotic and this unfair.

California is one of 40 states that likely will lose the federal funds that were set aside by Congress in 1997 through the Children’s Health Insurance Program, or CHIP. Nationally, 45% of the $4.2 billion has gone unused, but not for a lack of need. There are about 2 million uninsured children in California, and only 330,000 have been enrolled in California’s CHIP program, called Healthy Families. California will return more than any other state and more than a quarter of all moneys.

The state deserves much blame for bureaucratic roadblocks, including at one time a 28-page application form that now has been cut down to four pages. Only recently were states allowed to include parents of eligible children, and California has yet to apply for permission. California also could have applied for expanded eligibility for children and enhanced benefits, as well exploring other federal waiver opportunities earlier.

The larger problem, however, is that we do not have one health care system, but myriad systems, which create an ineffective and incomprehensible morass for anyone to try to figure out. For the insured, the alphabet soup of HMO, POS, PPO and what they can cover and do not is increasingly fraught with confusion. For the uninsured, the boutique incremental insurance programs are highly selective. An older child in a family may qualify for Healthy Families, but the infant would have to go on Medi-Cal. A child may qualify for Healthy Families, but her parents may not qualify for any assistance, leaving the family saddled with bills when the breadwinner cannot work. If a family qualifies for Medi-Cal, they are not able to receive Healthy Families, which has less of a welfare stigma associated with it. Coordinating care for different family members who have different providers becomes very burdensome for families with few resources.

Patients with inadequate or no coverage often are not diagnosed and treated at the earliest opportunity--when it is most effective for the patient and least expensive for the system. Instead, these patients are typically seen in the emergency room after their diseases have progressed to the point where treatment is not as effective and very expensive.

Ironically, when it is medically too late is precisely when the patient may be able to access government programs. A middle-class cancer patient would have to sell her home to pay for life-saving treatment that no government program will cover. But that patient can access government programs once she is on her death bed, beyond saving. At this point, hospital bills can run far higher than the cost of the initial cure.

My octogenarian neighbor simply cannot understand how California can relinquish the CHIP funds. It is no easier to describe to him why an uninsured patient with kidney problems who cannot afford treatment must wait until end-stage renal disease develops before the government will help, rather than getting it at the initial sign of trouble.

Selective health care insurance systems must be replaced with a systemwide overhaul that guarantees every patient coverage for medically necessary treatment at all times, so that patients are kept healthier and taxpayers are saved the cost of preventable medical tragedies.

Such a seamless system could be financed by eliminating the overhead costs and profits of today’s private insurers and HMOs, which can total 20 cents to 30 cents of every premium dollar. A study released by the California Nurses Assn. and the Labor Party (in the U.S.) found that for the same cost as Americans pay today, a new full-coverage health care system can be developed that cuts out the private corporations and puts health care dollars back with private doctors and hospitals to provide treatment. A payroll tax would finance the system, but employers actually would pay, on average, less than they do now.

The increasing discontent with HMO payment and control systems has made California ripe for revamping its health care system. If a few large employers joined with a coalition of doctors, nurses, hospitals and patients, there would be a new health care system in California that is far more rational, compassionate and cost-effective.