Care Goes To Those Who Pay

Daniel S. Greenberg

October 29, 1990|By Daniel S. Greenberg

WASHINGTON — Washington.

FROM THE CRUSHING cost of thousands of dollars a year for the AIDS drug AZT, to public appeals to pay for a dying child's liver transplant, America is repeatedly reminded of an egalitarian truth that it is reluctant to face: Money matters in obtaining medical treatment.

It shouldn't be that way, according to the warming myth of health care as a right available to all, regardless of ability to pay. But an abundance of personal tales and press accounts show that the charitable tradition in health care survives only in tatters, if at all. Systematic research confirms the link between money and medicine.

A recent study of 38,000 heart patients in Massachusetts found that those with extensive private-insurance coverage were far more likely to be given costly treatments than those with limited coverage or none at all. The researchers, writing in the Journal of the American Medical Association, reported that the odds for receiving X-ray examination of the blood vessels was 80 percent higher for privately insured patients than for the uninsured.

In obtaining bypass grafting and angioplasty -- the roto-rooter-style clearance of clogged blood vessels -- the odds favored the privately insured. Since the blood vessels of the insured and uninsured are similar, it may reasonably be concluded that cash on the barrel played a role in determining treatment.

This finding brings up nasty implications, because of the skimping payment practices of the country's two biggest health-insurance systems, the all-federal Medicare for the elderly and the federal-state Medicaid for the very poor. Providing coverage for some 55 million patients, the two programs have responded to the problem of ever- rising health-care costs by cutting back on the amounts they will pay for hospital and physician services.

Under Medicare, physicians have traditionally been reimbursed at 80 percent of their usual rates. In San Francisco, Medicaid pays an average of 33 percent of Blue Cross-Blue Shield rates for most AIDS-related services, according to American Medical News, a publication of the American Medical Association. The comparable figure for New York is reported to be 15 percent. And in both cities, as well as in others hit hard by AIDS, hospitals are sinking under the financial strain, thus bringing new urgency to the issue of availability and quality of care under spartan reimbursement levels.

The fiscal burdens imposed on the health industry by thin or non-existent insurance used to be quietly attended to by cost-shifting, i.e., boosting the bills of the well-insured to cover the costs of less-fortunate patients.

That accounting tactic supplemented the payments of the poorly insured and helped finance care for an estimated 31 million persons with no insurance coverage at all. But with employers rebelling against runaway premiums for insuring their workers, the cost-shifting tactic is less and less tolerated.

Among politicians and policy makers concerned with medical economics, the great fear has always been ever-rising costs and the impact on taxes.

Little attention was paid to the related problem of eroding quality of care. One reason, of course, was that it was hidden away among the poor. But on-going medical inflation in a period of economic stagnation is bringing the quality and cost linkage into the open, and into the ranks of the middle class.

The myth persists that top-quality medical care is a right, even in the absence of political agreement on how to pay for it. Reality is battering that myth as never before.

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