WASHINGTON — Washington. The denial of medical care for lack of money is no rarity in America. But cash-on-the-barrel for treatment is so repugnant to the American dream that it's hushed up or regarded as an aberration when awful cases come to public attention. As a result, the cruel failings of the health system have long been obscured by old, though increasingly tattered, myths of egalitarianism.
But now, a massive, unprecedented study of hospital records has quantified the obvious: Patients who can pay are hospitalized sooner, get more care and are less likely to die. Patients who can't pay are admitted in sicker condition, get less care and are more likely to die. The study found that ''The actual in-hospital death rate was 1.2 to 3.2 times higher among uninsured patients'' for 11 of 16 serious health problems.
Money means care. It's as simple as that. In proper academic fashion, the findings of the study are strewn with statistical qualifications, cautions and a call for more research. But the inescapable conclusion of the inquiry is that ''an individual's condition on admission, use of resources during hospitalization and likelihood of in-hospital death vary depending on whether the individual has health insurance. ''Approximately 35 million Americans do not have health insurance.''
The study, reported by Georgetown University and Johns Hopkins University researchers in the Journal of the American Medical Association, looked at a nationwide sample of nearly 600,000 patients hospitalized in 1987. The focus was on condition at time of admission, the treatments given, deaths in hospital -- and insured or uninsured. The study was by far the biggest of its kind in terms of the number of patients and medical conditions reviewed.
Using a severity-of-sickness measure known as the Risk-Adjusted Mortality Index, the researchers found that the uninsured ''were more likely to be admitted for a condition that has a higher risk of death . . . and appeared to be in more urgent need of care.'' The implication is that their medical needs were untended until hospitalization became unavoidable. A sure sign of medical urgency among the uninsured patients was their higher frequency of weekend admissions, the least popular time for doctors, hospital staff and patients who have a choice.
Though the uninsured were generally sicker upon admission, the report notes, their average length of stay was 12 to 38 percent shorter for a major group of illnesses. Thus, they were admitted ++ later and pushed out sooner. They were 75 percent less likely to receive knee replacements and 29 percent less likely to receive coronary-bypass grafts. Another revealing discovery was that normal findings on tissue biopsies were 50 percent higher among the insured than among the uninsured. That suggests a pattern of routine screenings for those who can pay, while the uninsured are more likely to be biopsied only in response to suspicious symptoms.
The unavoidable conclusion is that in medicine, as elsewhere, money opens doors and produces benefits that are otherwise unavailable. The harshness of this reality clashes with deeply rooted social and cultural values. The charitable tradition has historically held an important place in the economics of medicine, and it still endures. But with the arrival of costly technology as the basis of modern medical practice, charity has been unable to keep up with the costs.
In other countries, governments long ago stepped in and provided the financial underpinnings needed to finance health care for all, though it usually turned out to be skimpy by the standard of the best of American health care. Nonetheless, all had access to whatever was available.
The United States, however, has not gone beyond an underfinanced patchwork of health-care assistance that's limited to the very poor and the elderly, with all others required to fend for themselves. The result, according to the American Medical Association, is ''a two-tiered structure that provides one level of care for the uninsured and one level for everyone else.'' The shameful outcome of that division can be found in the grisly statistics of those who can pay and those who cannot.
Daniel S. Greenberg writes a column on science and technology.