CT Institute: Emergency

Christians respond to the health-care crisis.

Alert Americans have known for several years that the U.S. is on the brink of a health-care crisis. But on April 26 of this year, any doubts should have been eradicated: the nation’s second-largest medical society, the 68,000-member American College of Physicians, went on record, calling for sweeping reform of the health-care system—including a nationally funded health program in some form. The professional organization for specialists in internal medicine thus broke ranks with the larger American Medical Association and the profession’s 30-year tradition of trying to keep a great gulf fixed between the government and the doctor’s office.

What could so shake this segment of the medical establishment that it did everything but endorse “socialized medicine”? No one factor accounts for the phenomenon, but a quick look at American health care shows that the doctor’s white coat is frayed, worn, stained, patched, and darned at so many points that more patchwork is not the answer. Americans—both consumers and medical professionals—are shopping for a new look.

Here are the main threadbare points on our present system:

• Emergency rooms have become the family doctor for the nation’s poor. For example, the emergency room at Bellevue Hospital on Manhattan’s Lower East Side looks like a bus station waiting room. But because Bellevue is already full, those people could wait there for two days or more.

The scene at Bellevue, typical of urban hospitals, is so bad because the number of health-care centers has been cut back. One survey of ten poor communities with 1.5 million people found just 22 full-time doctors below retirement age willing to take Medicaid patients. A shortage of primary care encourages patients to wait until they are seriously ill before seeking medical care—and then they go straight to the hospital.

Hospitals are restricted by a 1986 law from refusing to treat poor patients. But when the vast majority of those who seek help at a hospital’s emergency room are not privately insured, the institution cannot cover its own costs. With Medicaid rates too low to pay the hospital’s own bills, it is good business sense to close the emergency room. It is bad health-care sense, however. Not the poor only, but the affluent as well suffer when there is no emergency room in the immediate vicinity. Longer ambulance rides mean more untimely deaths for rich and poor alike.

• Lack of insurance keeps the threat of medical bills or no treatment at all hanging over 37 million Americans. Another 50 million have inadequate insurance.

Because health-insurance costs are rising much faster than the cost of living (about 20 percent per year, according to one estimate), many employers are being priced out of the group-insurance market. They either cut benefits or place the burden of insurance back on the employee.

Hawaii, the only state that requires employers to provide health insurance, is an exception to this picture. After over a decade with 95 percent of the state’s population having access to health care, the practice of preventive medicine and the availability of good treatment has brought health insurance premiums to a point 25 to 30 percent below the rates charged on the mainland.

• Race and social class predict poor public-health statistics better than any other variable. This is probably because those who can afford health insurance tend to get preventive care and, when they are sick, can see a physician more easily. In Chicago, for example, poor persons using that city’s public clinics must wait an average of 68 days for an appointment. Some have waited as long as 181 days. By the time 68 days have elapsed, a simple cold or case of the flu can become an otherwise preventable disaster requiring expensive hospitalization.

• Epidemics—AIDS, drug abuse, and mental illness—account for much of the overload in urban emergency rooms. These same factors affect public-health statistics. When a study showed District of Columbia infant mortality rates at 23.2 deaths per 1,000—more than twice the national average—officials pointed to a rash of cocaine babies. In addition, once-dormant diseases—such as tuberculosis—are reappearing on the American scene due to poor hygiene in substandard housing.

• A litigation-happy society, in which too many frivolous and nuisance lawsuits are filed, has caused medical costs to surge upward. Often insurance companies find it cheaper to settle a case out of court than to fight a winnable case.

In the five years between 1981 and 1986, professional liability claims per hundred doctors nearly tripled (from 3.2 per 100 physicians to 9.2 claims per 100), and between 1980 and 1987, the average jury award more than quadrupled (from about $400,000 to $1.76 million). As a result, professional liability insurance—rising at about 22 percent per year—has become one of the fastest-growing factors in a physician’s overhead. Doctors, who face a growing likelihood of having to defend themselves in court some day, practice “defensive medicine,” ordering laboratory tests and medications that their intuitions may tell them are unnecessary, but that, should something go wrong, would be evidence of the care with which they practice.

• Health-care administration also has been increasing. Due to the requirements of both government agencies and insurance companies, paperwork has multiplied. Total health administrative costs have been estimated at about 22 percent of all health-care spending in the U.S. And the average medical claim requires an hour of staff time at the doctor’s office to prepare forms for Medicare, Blue Shield, or other insurers—much longer than your physician probably spends examining you.

• High-tech innovations have transformed American health care. From helicopter “ambulances” equipped for the treatment of trauma to sophisticated scanners that can allow a physician to study a clear image of any diseased organ without invasive surgery, the frontiers of medical effectiveness have been pushed back.

But these innovations are not cheap. A typical magnetic resonance imager can cost $2 million. So when a patient with serious headaches needs her brain examined, the bill for 60 minutes of machine use can run just under $1,000.

The U.S. health system can now provide much more intense and complete medical care than we can pay for. But do we want less?

• Physician incomes are a sensitive subject, not often discussed. Everyone agrees doctors have to pay for long, expensive educations. Nevertheless, the median earnings of physicians increased an average of 6.9 percent per year between 1981 and 1988—a period when consumer prices rose an average of 4.6 percent annually and overall wages and salaries only 4.5 percent.

Not all doctors are nightly killing the fatted calf. Certain specialties—such as heart surgery or neurosurgery—earn at the high end of the scale, but general practitioners and pediatricians (the foot soldiers of medical practice) earn far less.

Nevertheless, the overall rise in physician incomes has played its part in the rising cost of health care.

Thanks to these factors and others, many experts are predicting that two out of every five U.S. hospitals will close during the nineties, largely due to shrinking revenues and the increasing burden of unreimbursed care. In a time like this, Christians have a duty to examine the issues and bring biblical values to bear on the way society shapes the solutions.

When infants die and young adults suffer for lack of proper access to medical care, our prophetic sense of justice should feel at least a twinge of outrage.

As Christian citizens, we must be the outspoken social conscience of the nation. And as giving members of Christ’s church, we must be his hands in the nonmedical ways that can bring comfort and a sense of belonging to those for whom the system doesn’t work. Perhaps, then, someday Jesus will say to us, “I was sick, and you visited me.”

By David Neff.

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