The great health-care reform

Robert Reno

August 27, 1993|By Robert Reno

IN THE 18th century, many health care reformers embraced the Brunonian theory by which it was thought there were only two diseases, sthenic and asthenic, treatable with either stimulants or sedatives.

In the 19th century, they discovered germs, which got blamed for everything. Health care reform was primarily concerned with their eradication.

The early 20th century marked the ascent of the surgeon. Reform involved cleaning up operating theaters and making doctors wash their hands. Millions of questionable appendectomies and tonsillectomies later, we have moved from the age of the operation to the age of the unnecessary operation.

One way or another, we have managed to raise the life expectancy of Americans from 54 years in 1920 to a little over 75 today. The body of medical knowledge has become so enormous that the mere delivery of known treatments, let alone those waiting to be discovered, threatens to bankrupt the nation. So does the cost of maintaining larger and larger numbers of people deep into their dotage even as farm animals have higher rates of immunization than the children of America's poor.

Given the extent of this mess, the discovery of a comprehensive "cure" would seem to rank with those of Lister and Pasteur. Yet the interesting thing about the health care plan slowly emerging from the Clinton administration is how very little it has to do with medicine.

Man's age-old war on disease has been reduced to proposals to tax nicotine addicts and dipsomaniacs to cover improvements in long-term care for the elderly. It is bogged down in fights over whether people's employment has anything inherently to do with their health care, subsidies for small businesses but not for large businesses, prescription drug subsidies for low-income Medicare recipients not eligible for Medicaid, the absorption of workers' compensation into the regular insurance system and the deductibility of health care premiums paid by self-employed individuals. The plan proposes to attack "overutilization" of the present system while at the same time attacking underutilization and to preserve competition by "managing" it.

By comparison, Pasteur's milestone experiments with chicken cholera, which moved medicine a century forward, were simple and straightforward.

As more details of President Clinton's health care program were tentatively revealed last week, what was striking was the degree of complexity the politicians seem willing to go to to avoid the simplest solution which is, of course, a single-payer, Canadian-style system. Judging by the conciliatory noises coming from Bob Dole and some congressional Republicans, the Clinton plan seems to have at least half a chance of passage in some recognizable form. This is a great tribute to Hillary Rodham Clinton and its other framers. Whether it will successfully reform the health care system is another matter entirely. It is an experiment whose time has clearly come. Let us hope it has not also passed.

Robert Reno is a columnist for Newsday.

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