A Call for Radical Surgery

By Anastasia Toufexis

If the U.S. health-care system were laid out on the operating table, its condition would be rated critical and worsening. Though the country has physicians with unsurpassed training, its health-care delivery is among the most expensive, least efficient and least equitable in the developed world. Of the industrialized nations, the U.S. ranks 17th in life expectancy and an appalling 20th in preventing infant mortality. Yet the prospect of a national health-insurance system, long advocated as a solution, alarms many doctors. They see it as an intrusion by Big Government into their professional lives -- and, perhaps more important, as a threat to their high incomes.

So it came as a shock last week when the American College of Physicians, the U.S.'s second largest medical society, called for comprehensive health-care reform that would include some form of national financing. The announcement, made in Chicago at the A.C.P.'s annual meeting, marks the first time that a doctors' group has backed an overhaul of American medical care. And it puts the 68,000-member group at direct odds with the powerful 300,000-member American Medical Association, which has been opposing sweeping change for at least 30 years. Says Dr. John Ball, the A.C.P.'s executive vice president: "We hope to produce some leadership for the medical community."

Somebody has to do it. Medical costs have soared from $75 billion in 1970 to $600 billion last year, gobbling up more than 10% of the gross national product. And while many citizens receive exemplary care, many others -- mostly poor women and children, and the unemployed -- do not. About 50 million Americans have inadequate medical insurance, and as many as 37 million have none at all.

Among the solutions offered by the A.M.A.: force more employers to provide health insurance, and expand Medicaid coverage for the poor. But the A.C.P. | labels such changes "tinkering," not reform -- helpful in the short run but inadequate to address the fundamental flaws in the system. In the 21-page position paper it issued last week, the group cites several such flaws, including wasteful administrative overhead that has burgeoned to 22% of medical expenses, and enormous malpractice awards that force doctors to buy expensive insurance and pass the cost on to patients. But the biggest problems, according to the A.C.P., are inadequate care for many Americans, and the "complex, confusing, costly, wasteful and intrusive" bureaucracy involved in paying for the care others get.

Instead of suggesting specific answers to these and other problems, the A.C.P. offers broad guidelines. Explains Ball: "One of the reasons we don't have solutions today is that we haven't got societal agreement on what kind of health system we need, want and can afford." Although the report does not say so explicitly, the Canadian health-care system, based on principles of accessibility, universality and public funding, is a model. The reason Canada was not mentioned, according to one official: its system is considered by some to be "socialized medicine," a buzz word that could torpedo the reform effort. Besides, says Ball, the Canadian model could not be wholly transplanted into the U.S. because, among other reasons, Canadians trust their government more than Americans do.

Still, the Canadian system has a good deal going for it. Citizens are issued a health card by the government, and they present it when they receive care. Doctors process claims much as retailers handle credit-card transactions. The government then pays the doctor with money that comes largely from taxes. "Once somebody's in the system," says Dr. Graham Pineo, an A.C.P. officer from Canada, "the payments flow regularly." Only a few services are excluded. Among them: private or semiprivate hospital rooms, drugs prescribed outside the hospital, eyeglasses and wheelchairs, and pre-employment and insurance examinations.

Provincial governments have ultimate control over hospital budgets and doctors' fees, but in return do not force physicians to justify every procedure and test, as U.S. doctors must do. And while there are occasional reports of long lines and insufficient bed space, Pineo says, "we feel everybody gets adequate service."

The A.M.A. predictably has pooh-poohed the A.C.P. statement. Says Dr. Raymond Scalettar, an A.M.A. trustee: "It contributes very little to the * debate. The American health-care system needs to be improved, but it works." That reaction may say as much about medical politics as about medical policy. Until recently the A.M.A. dominated the field. Now it is being challenged. Says Ball: "Other medical groups still believe in the politics of the past. That's when medicine could demand its way. The politics of the present and the future is when medicine and other elements of society sit down equally to solve a societal problem."

The A.C.P. is hoping to build a coalition of industry leaders, politicians, health-care-provider organizations and consumer groups that might build a consensus for dramatic change. The group is already working with AT&T and the United Auto Workers, and in recent weeks it has presented its proposals to the American Association of Retired Persons.

That is no substitute for leadership from the most effective lobby in the nation -- the White House -- but it looks as though the characteristically cautious Administration will not provide it. Health and Human Services Secretary Dr. Louis Sullivan told the A.C.P. last week that he found its proposal "thoughtful and thoroughgoing" but that "a simple national system will not meet the needs of such a diverse group of people."

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With reporting by Barbara Dolan/Chicago