Our Health-Care Disgrace

By Barbara Ehrenreich

National health insurance is an idea whose time has come . . . and gone . . . and come again, sounding a little more querulous with each return, like any good intention that has been put off much too long. It was once, way back in the 1930s, a brisk, young, up-and-coming idea. By the late '60s, when Richard Nixon first declared a health-care "crisis," it was already beginning to sound a little middle-aged and weary. Today, with the health-care situation moving rapidly beyond crisis to near catastrophe, the age-old and obvious solution has the tone of a desperate whine: Why can't we have national health insurance -- like just about everybody else in the civilized world, please?

Health-care costs have nearly doubled since 1980, to become the leading cause of personal and small-business bankruptcy. Collectively we spend $600 billion a year on medical care, or 11% of GNP -- a higher percentage than any other nation devotes to health. But the U.S. health system may be one of the few instances of social pathology that truly deserve to be compared to cancer. < It grows uncontrollably -- in terms of dollars -- but seems to become more dysfunctional with every metastatic leap.

For a thumbnail index of failure, consider the number of people left out in the cold. Despite per capita medical expenditures that dwarf those of socialized systems, 37 million Americans have no health insurance at all. For the uninsured and the underinsured -- who amount to 28% of the population -- a diagnostic work-up can mean a missed car payment; a child's sore throat, an empty dinner table.

Even among those fortunate enough to be insured, the leading side effect of illness is often financial doom. Consider the elderly, whose federally sponsored insurance program, Medicare, inspires so much drooling and sharpening of knives at budget time. Even with Medicare, older Americans are forced to spend more than 15% of their income for medical care annually. And since nursing-home care is virtually uncovered, the elderly are pushed to degrading extremes -- like divorcing a beloved spouse -- in order to qualify for help through a long-term debilitating illness. Or, as more than one public figure has suggested, they can shuffle off prematurely to their reward.

We can't go on like this. Our infant-mortality rate is higher than Singapore's; our life expectancy is lower than Cubans'. As many as 50% of inner-city infants and toddlers go unimmunized. In the face of AIDS, our first major epidemic since polio, we are nearly helpless. Our city hospitals are overflowing with victims of tuberculosis, poverty, AIDS, old age and exposure. Our rural areas don't have this problem; they have fewer and fewer hospitals or, increasingly, less medical personnel of any kind.

But everyone knows that the system is broken beyond repair. According to the New England Journal of Medicine, 3 out of 4 Americans favor a government- financed national health-care program. The AFL-CIO is campaigning vigorously for national health care, and Big Business, terrified by the skyrocketing cost of employee health benefits, seems ready to go along. Even in the medical profession -- the ancient redoubt of free-enterprise traditionalists -- a majority now favor national health insurance.

So what stands in the way? There's still the American Medical Association, of course, which has yet to catch up to its physician constituency. But the interest group that arguably has the most to lose is the health-insurance industry, which spends more than $1 million a year to forestall any thoroughgoing government action. And why not? The insurance industry already enjoys a richly rewarding, gruesomely parasitic relationship to the public health domain. In broad schematic outline, it goes like this:

For decades the private insurers have fanned the crisis by blithely reimbursing the fees of greedy practitioners and expansionary hospitals. Then, as costs rise, the private insurers seek to shed the poorest and the sickest customers, who get priced out or summarily dropped. For some companies, a serious and costly illness is a good enough reason to cancel a policy. Others refuse to insure anybody who might be gay and hence, actuarially speaking, might get AIDS.

So over the years, government has moved in to pick up the rejects: first the elderly, then the extremely poor. Since the rejects are of course the most expensive to insure, government is soon faced with a budget nightmare. Draconian cost-control measures follow. But because government can only attempt to control the costs of its own programs, the providers of care simply shift their costs onto the bills of privately insured patients. Faced with ever rising costs, the private insurers become more determined to shed the poorest and the sickest . . . and so the cycle goes.

The technical term for this kind of arrangement is lemon socialism: the private sector gets the profitable share of the market, and the public sector gets what's left. The problem with this particular lemon is that it tends to sour us on the possibility of real reform. Even those who crave a national program covering everyone are wont to throw up their hands in despair: Nothing works! It's so complex! Maybe in 100 years!

It's time to cut the life-support system leading to the hungry maw of the insurance industry. The insurance companies can't have it both ways: they can't refuse to insure the poor, the old and the sick while simultaneously campaigning to prevent a government program to cover everyone alike. The very meaning of insurance is risk sharing -- the well throwing in their lot with the sick, the young with the old, the affluent with the down-and-out. If private enterprise won't do the job, then let private enterprise get out of the way.

With the largest-ever consensus behind it, national health care's time is surely here at last. Otherwise, let us bow our heads together and recite the old Episcopal prayer: "We have left undone those things which we ought to have done . . . and there is no health in us."