Carolyn E. Fiorillo
"The millions of uninsured Americans and the spiraling cost of health care received progressively more attention through the last half of the 1980's. But what finally pushed health care reform to the top of the national agenda, many believe, was the discontent of the middle class. Middle class families with sick children were being priced out of group insurance, even plans offered by large companies; others were stuck in dead-end jobs because 'pre-existing medical conditions" prevented them from getting insurance from a new employer; and still others lost medical coverage when they were laid off during the economic recession that began in mid-1990. (1)
"Medicaid, the state and federal health care program for the poor, has never lived up to its promise to eliminate the country's two-tiered system of health care. Medicaid income restrictions are so tight that the program covers less than half the poor, defined as those Americans who fall under the federal poverty level. Most of the working poor were and still are excluded from Medicaid and are thus uninsured, although some of their children are being progressively added to the program under reforms that began in the late 1980's. Those who manage to get Medicaid have struggled to find decent doctors. Medicaid pays physicians well below the rates of commercial insurers, and doctors perceive the poor as 'difficult' patients, sometimes with reason. Poor patients' ailments are made worse by delays in getting care, and they show up at doctors' offices with more of what one physician calls 'sociomos', social problems that range from not having a ride to the doctor's office, to drug addiction, to homelessness, to the despair that accompanies miserable life circumstances. As for the physicians who do practice in poor neighborhoods, they may be there only because they are not good enough to work anywhere else. Poor families usually have no way of knowing whether local doctors are up to snuff, even when they have been disciplined by state medical regulators. (2)
"While Medicaid recipients are exceedingly vulnerable to the vagaries of state and federal budgetsbenefits are cut when times are tight or whole categories of people are eliminated from the programMedicare is an entitlement program that covers most Americans who are older than 65 and certain disabled people. Because Medicare is an entitlement, the federal government cannot cut people from the program willy-nilly. Payments to doctors and hospitals can be reduced, however, and they have been, though Medicare still pays much better than Medicaid, and its lower rates have not seriously curtailed the elderly's access to doctors and hospitals. What bedevils the poor...is Medicare's gaps. It does not pay for medication, for transportation, for many basics that may sound wholly affordable to those with generous pensions or insurance to supplement Medicare. But such essentials strap the poor, who often end up going without. (3)
Millions of Americans find themselves in the position of needing health insurance, but not knowing which kind will best fit their needs. "New health plans offering some form of 'managed care' beckon to workers and retirees alike. These plans are frequently known as health maintenance organizations (HMO's) or preferred provider organizations (PPO's). Not only are such plans cheaper than traditional insurance, they offer reduced paperwork and assurances that they can guard members against overtreatment. The advantages sound irresistible. But the choice isn't that simple. Managed care plans save money by limiting patients' choices and by installing overseers who restrain what doctors can do. Those restrictions can lead to painful breakdowns in medical care just when patients need help the most." (3A)
"The trillion dollars that Americans spend on health care should be more than enough to provide all our people all the care they need. An equal amount would be enough to provide care for 750 million Britons, 620 million Japanese or 500 million Germans. But in the American way of health, a trillion dollars isn't sufficient to treat 260 million Americans. Instead we waste some $250 billion. We are buying billions in bureaucratic waste. America spends some $200 billion on administrative costs borne by private insurers, Medicare, and Medicaid, as well as the doctors, nurses, hospitals and nursing homestheir secretaries, assistants, and accountantswho handle the paperwork created by four billion insurance claims each year." (4)
"Hospital 'dumping' is repeated 250,000 times a year in the United States, when hospitals turn away sick and injured people or women in labor, due to lack of medical insurance or inability to pay their bill. There is no justification for emergency rooms to refuse treatment to the poor. Hospitals that wish to make money in a community have a responsibility to help care for all its sick and injured. And that community has a responsibility to help that hospital meet the expense of patients who cannot pay. The decision to treat a patient should be a medical decision based on moral and ethical principles, not on an economic decision based on profit. " (5)
Dr. David Hilfiker, who practices in Washington, D.C., states, "Private medicine is abandoning the poor....There are, of course, many complex factors that have precipitated (this). The urbanization and anonymity of the poor, the increasingly technological nature of medicine, and the bureaucratic capriciousness of public medical assistanceall these serve to make private physicians feel less responsible for the medical needs of those who cannot afford the going rate. But the cause that is most obvious to the lay public is singularly invisible to the medical community: Medicine is less and less rooted in service and more and more based in money. With many wonderful exceptions all over the country, American physicians as a whole have been turned away from the ideals of service by an idolatry of money. Physicians are too seldom servants and too often entrepreneurs. A profitable practice has become primary." (6)
"More than 23,000 Americans await a suitable cadaveric kidney, fewer than 8,000 receive transplants each year (originally published in JAMA 270, No. 11, Sept. 15, 1993). Approximately one-third of end-stage renal disease (ESRD) patients are African American, but blacks are less likely than whites to receive a transplant, with almost double the waiting time. Allocation is done by a federally-mandated system based on HLA matching. This puts potential black recipients at a disadvantage, especially with the critical shortage of transplantable kidneys. Minority populations (American Indians, African Americans and Hispanics) are at increased risk of developing ESRD relative to whites, with blacks having the highest incidence. Black ESRD patients are less likely to have a relative who can donate a kidney and also may have socio-economic reasons for being unable to travel to a transplant center in a timely fashion. There is also a shortage of black donors. Nationally, blacks make up 12% of the population, 8% of the donors, but 34% of those with ESRD." (7)
According to data from the UCLA Transplant Registry, HLA matching may not be a significant factor for black recipients, as the matching has no consistently documented benefit on graft survival. The estimated five-year average cost of a transplant (including return to dialysis in the event of graft failure) is $98,300 for a black recipient and $90,700 for a white recipient. Unfortunately, blacks have a lower rate of success, which leads to the ethically unacceptable practice of higher transplant allocation to whites." (8)