How Shall We Then Heal?

C. Everett Koop not only distinguished himself in 8 years of service as Surgeon General of the United States, but served for 33 years as one of the nation’s most innovative pediatric surgeons. He spoke with CHRISTIANITY TODAY managing editor David Neff about U.S. health-care policies.

Is the magnitude of our health-care crisis as big as the media have portrayed it to be?

I think it’s at least that big. First of all, we have a failure in the delivery of health care to upward of 33 to 37 million of our citizens, which is 12 to 15 percent of our population. These people are either uninsured or underinsured or seasonally insured, and there is ample evidence to show that the lack of insurance and the seriousness of health problems go together.

The second problem is that we have a seriously deteriorated doctor-patient relationship. Neither side trusts the other, leading to a situation where doctor and patient see each other as potential legal adversaries. That sparks the profession to practice defensive medicine and to pay exorbitant malpractice-insurance premiums to protect themselves. Just those things alone are enough to make the present situation intolerable.

How should the U.S. attack these problems—through expanded tax-supported entitlement programs or through private-sector employers funding private insurance, or a combination of both?

The first thing the government has to do is deal with poverty. Poverty is at the base of almost all the problems that I see in health, whether they are in Appalachia or a Chicago ghetto.

There is a tremendous clamor every place I go. I hear it in the halls of Congress. I hear it from business. I hear it from labor, doctors, and patients: We need to restructure the health-care system. And I agree with that. But it cannot be patched up with Band-Aids any longer. It has to be done from top to bottom. And it won’t work to enact a national health service, because those types of government-supported programs are based upon a system of planned scarcity, which ultimately leads to a deterioration in health care. It starts with a lack of innovation and is felt first in research and then in patient care. Then the bureaucracy becomes further separated from the sensitivity of patients, and we end up with rationing and standing in line for health care. Americans do not stand in line well for anything.

Yet people in the United Kingdom are used to standing in line for things.

The infatuation with any other country’s health-care system is based more upon a dissatisfaction with our own than it is with a true understanding of any other system. Nobody really wants the UK system, because it’s bankrupt and everybody is moving in another direction. Mrs. Thatcher is trying to kill it. But people are very enthusiastic about the Canadian system, which is just a few years behind. But it has changed a lot in the last three years, and people there are becoming disenchanted. So I don’t think we should try to copy those models.

What do you make of the American College of Physicians’ statement, which was tantamount to recommending that we eventually adopt some form of socialized medicine?

I think they haven’t looked at it thoroughly, because wherever there is truly socialized medicine, what I just described eventually happens.

Are you more favorable toward the Oregon proposal to quantify the value of each medical procedure and then limit their spending on medical entitlements for only the most valued procedures?

The first thing that’s wrong with the Oregon plan is that it discriminates against the poor. You can have anything you want in Oregon as long as you have money, but if you’re poor, you can’t have much. That means that if you are poor, you can’t have an organ transplant in Oregon. But if you live in Washington, Washington Medicaid will pay for you to go to Oregon for the transplant, because Oregon is the national liver-transplant center. That seems to me to be extraordinarily unfair.

Do you think we need legislation that limits physician liability and encourages a freer and less-expensive approach to medical practice?

I think we have to have it. It’s very difficult to get because Congress is made up of so many lawyers that they’re not likely to act against their brothers with such legislation. But I think there are several things that could be done. The tort system has to be rearranged so that exorbitant awards are not made on the basis of pain and suffering. Second, the contingency fee must be eliminated [the practice in which lawyers take cases with no money up front, but in hopes of a percentage of a settlement or damages; the practice clogs the courts and plagues insurance companies with suits that are unlikely to be won, but that are often cheaper to settle out of court than actually to defend before the bench]. And finally, if a doctor wishes to devote himself to a charitable enterprise—to the care for patients who do not pay him in any way—he should be exempt from malpractice-insurance liability premiums.

Malpractice does indeed exist, but most of today’s lawsuits are for maloccurrence, not malpractice. I’ll use myself as an example. I’m 73. If I had my gall bladder operated on tonight and I had a myocardial infarct on the table and died, it would be what we used to call “an act of God.” You expect it to happen to a certain number of people who are 73 and undergo that kind of stress. But now the tendency is to blame someone. Was the anesthesia too deep or too light? Did they not give me the proper premedication? Was the surgeon slow or fast? We expect today’s health-care system to be perfect, but it can’t be, because people are not carburetors.

Do we also need a new approach to physician compensation that emphasizes time and energy spent in patient contact?

A lot of people are opting for that as a solution. As I do polls of my own among medical students and young doctors around the country, it doesn’t interest them in any way unless you eliminate the stupendous debt that they leave medical school with. Few Americans realize that young doctors leave medical school $50 thousand to $150 thousand in debt. Such a huge debt leads many of those young men and women to change their specialty so they can pay that off sooner. And although they don’t set out to be dishonest in any way, they soon become more likely to perform procedures that are not absolutely necessary. One solution would be to find some way to compensate physicians for providing free or reduced-price service for those who cannot afford it—perhaps by reducing their medical school debt whenever they donate their services.

Prescriptions for a Sick System

At both the state and federal levels, legislators are proposing strong medicine to cure our sick-unto-death health-care system. Here are some of the programs being considered.

Basic Health Benefits for All Americans Act (BHB)

Aim: Introduced by Sen. Edward Kennedy (D-Mass.) and Rep. Henry Waxman (D-Calif.); would provide health-care coverage for all U.S. citizens by the year 2000.

Advantages: By channeling most coverage through employer-based insurance, BHB avoids creating a large, centralized, bureaucratic state monopoly; provides additional protection for small businesses by offering subsidies.

Disadvantages: By increasing labor costs (equal to a 16 percent increase in the minimum wage), it may reduce employment; does not address flaws in the present system.

Funding: Employers to provide access to a minimum package of health insurance for all working Americans; combined federal-state program to provide comparable health benefits for uninsured Americans; because of budget deficit, the public portion would be phased in gradually. Value of the employment-based insurance purchased as a result of BHB: about $33 billion; net cost: about $18 billion.

The Comprehensive and Uniform Remedy for the Health Care System Act of 1989, Part I (CURE)

Aims: Introduced by Sen. Orrin Hatch (R-Utah); would be geared to improve the health of mothers and their babies; remove barriers to affordable health insurance; improve health-care quality and medical liability reform; reduce health-care costs through prevention and public-awareness programs; and improve the trauma-care system. Medicaid would be expanded and returned to its original purpose of providing health care to the economically disadvantaged.

Advantage: Attacks specific areas in need of reform rather than simply providing more funds for present system.

Disadvantage: Increased federal taxation.

Funding: $8 billion additional tax revenue.

Should we, both as a society and as the church, encourage people who are clearly near the end of life to view dying as an honorable and acceptable choice rather than something always to be avoided through high-tech life support?

We have to be very careful how we approach this, because a positive view of death can be mistaken for euthanasia, assisted suicide, and other things that don’t belong in the Christian community. But I do think Americans lose sight of the fact that they have to die of something. And we must recognize that sometimes the best thing that a reasonable physician can do in an elderly person’s terminal illness is to step back and let nature take its course. That is not euthanasia, although some ardent prolife groups would confuse it with that and demonstrate outside a hospital where it might be practiced. That’s wrong.

You are known for pioneering in experimental pediatric surgeries. Under most proposed solutions to the health-care crisis, what would have happened in those cases?

Many of the proposed solutions to the high cost of medical care call for a cutback in research and high-tech procedures. Under such a climate, most of the babies I operated on would never have been saved.

What can we do to ensure that necessary research and experimental surgery will continue?

We need to recognize the difference between doing outlandish things that only affect one or two people and doing things that can benefit hundreds, thousands, or sometimes millions of people. And then we should focus our research on those kinds of problems and be just as discriminating in our treatment of newborns as we are in our treatment of the elderly. It doesn’t help anyone to maintain a child for six months who has a condition that will render him incapable of ever doing anything just to say we saved another baby that was born at 1.5 pounds. That’s not killing a Baby Doe, and it’s not in any way being unethical. Generally, neonatal physicians know how to make those decisions; it’s people looking over their shoulders telling them to try harder that brings us to some of our dilemmas.

Denominations—Catholics, Adventists, Evangelical Covenant, Lutherans—have traditionally been involved in running hospitals. Is it now no longer economically feasible for churches to be in the hospital business?

Inasmuch as hospitals were once considered either hospices or places for acute care where a lot of the service was provided by church members as a form of ministry, that doesn’t exist anymore. So the cost of running the business of a hospital is the same no matter who runs it. With all the changes in the hospital industry, I don’t think the church necessarily has to get involved in that. But I think the church can be a partner in the overall health-care picture by doing those things that always seemed to fall on the Christian church before the days of entitlements.

Universal Health Insurance for Ohio (UHIO)

Aims: Introduced by Rep. Robert F. Hagan (R-Ohio), modeled after the Canadian system; offers comprehensive health care for all Ohio citizens; eliminates unnecessary administrative costs through a single, universal system of health insurance for all necessary services without out-of-pocket expenditures.

Advantages: Wider choice of doctors; almost no insurance paperwork; universal coverage.

Disadvantages: Increased taxation; restricted flexibility in choice of medical providers: A person enrolled in a practice reimbursed on a per-patient basis would be allowed to change providers no more often than once a year.

Funding: Funded by an 8 percent payroll tax and an equivalent tax on the self-employed, a 1 percent wage tax on employees, a 2 percent tax on interest and dividends, and a 10 percent sales tax on alcohol and tobacco.

The Oregon Basic Health Services Act

Aim: To guarantee access to basic health care for all Oregonians and provide economic incentives to providers for employing those services and procedures that are effective and appropriate in preference to those that are marginal or unproven.

Prioritizes health services using criteria based on social values and according to the degree of benefit each service or procedure can be expected to have on the health of the entire population being served.

Additional legislation would encourage small businesses that have not previously offered health-care benefits to provide such benefits; would spread the cost of providing health care to the uninsured or uninsurable to as broad a base as possible.

Advantages: Reduces the practice of “defensive medicine” (unnecessary tests and procedures to avoid potential lawsuits) by providing a “liability shield” for providers; contains costs by not paying for procedures ranked low on the priority list; would not reduce Medicaid coverage for the aged, disabled, the blind, and wards of the state.

Disadvantages: Allows reduction in benefit packages; may have serious effects on some people who now receive Medicaid by ranking prevention of illness and early detection much higher than operations that may prolong the life of somebody who is profoundly ill.

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