The true test of health reform

Arthur Caplan & Steve Miles

June 09, 1993|By Arthur Caplan & Steve Miles

YOU WILL know when Hillary Clinton's long-awaite health-care reform plan is released by the flood of crocodile tears pouring from every suite in the insurance industry. You will hear a lot of yammering about the importance of preserving as much as possible the trillion-dollar Rube Goldberg machine that is our current health-care system.

Don't believe it.

Complexity and bureaucracy are essential if those now making a good living from the current system are to continue to do so. The only way to increase access, lower costs and give you peace of mind about your insurance coverage is to make the system simpler.

The major reason our health-care system costs so much while covering so few is that it is built on a number of assumptions about Americans that are no longer true. The true test of health reform is whether the administration and Congress can give you a system that is in sync with the needs of a 21st-century nation. Here are the four crucial tests you should use in sorting through the tidal wave of verbiage about Hillary's health-care plan:

* Does the plan link health insurance to your job?

The American family no longer depends upon a breadwinner dad who has a lifetime career with one company. Many jobs, especially in the service economy, last less than a year.

Millions of households depend on several wage earners, part-time work and moonlighting.

When your health insurance is linked to your job, coverage is a game of musical chairs. Which employer pays, Mom's or Dad's? Which employer contributes for covering the kids, his or hers? What if the kids' parents aren't married? Job-based insurance offers third-party payers lots of opportunities to make a buck mining the fine print and ducking liability through the manipulation of red tape about how to handle joint coverage, overlapping coverage, part-time workers or subcontractors.

Employment-based health insurance is confusing, costly and inefficient. The more it is in evidence in health reform, the more wary you should be.

* Does reform presuppose that you will stay married for a lifetime?

Family-based insurance lets insurers tell Americans what their families must look like. Who holds a family policy, the old dad or the new mom, the parent with money or the one with child custody? What about kids in foster care? Family-based insurance makes kids' insurance depend on deadbeat dads. Linking insurance to the traditional family structure means a system that cannot deal with the complexities of unmarried partners, interstate marriage, single moms, adoption, surrogacy and the like. If you need to be in a family to get insurance under the president's proposed reform, you need a better plan.

* Does the reform plan assume that you are a homebody?

America needs a health-care system that can keep up with migrant farm workers, interstate truckers, college students, retirees and frequent fliers. These days, a Minnesotan can get pneumonia harvesting wheat in Iowa, back pain unloading computers in Arkansas, a broken leg skiing in Wyoming, a hip replaced while wintering in Florida, an anxiety attack while at the beach on Maryland's Eastern Shore or have an asthma attack during summer study in Vermont.

Everyone needs a personal physician, but health-care reform must do more. It must provide coverage that goes where we go. If coverage is not portable, it does not go far enough.

* Does the plan create accountability?

Under our current system, nobody is accountable for universal health care. Insurers and businesses have made dodging sick people the ultimate form of cost control. America has a generation of kids who need life-long special education and who will never be as economically productive as they might have been because no one is responsible for making sure pregnant women have access to prenatal care.

Insurers use discrimination based on age, gender, genes, jobs and addresses to avoid people who need care. Businesses use buyouts, reorganizations, personnel policies and obscure federal laws to avoid insuring employees or retirees who thought they had a promise of health care. States are trading business climate for health care, lowering taxes by decreasing state assistance for people who cannot get (or afford) private insurance.

Enough of the Clinton plan has leaked out to make it clear that states will get the responsibility for ensuring coverage. But these leaks also suggest that large and perhaps midsize corporations may stay outside of state health-care coverage, that each state will be able to decide how to organize health-care delivery and that insurers and HMOs will be encouraged, not mandated, to enroll and adequately service people in hard-to-serve areas. Flexibility is a good thing in health care. But setting general goals is no substitute for accountability.

Health-care reform is the crucial test of this administration. It is an administration that says it wants to lead America into the next millennia. That vision must extend to health care. We can no longer afford a health-care system built on 19th-century views of who we are, where we work and how we live. Health reform must fit the needs of our children, not our grandparents.

Arthur Caplan and Steve Miles both served on the Clinton Health Care Reform Task Force. They are both at the Center for Biomedical Ethics at the University of Minnesota in Minneapolis.

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