Thoreau's advice for the health-care system

January 11, 1996|By Robert Whitcomb

PROVIDENCE, R.I. -- So many things in the U.S. medical ''system'' would be so much better if they were much simpler.

Take, for instance, a ''single-payer'' plan in which the government would shove the paper-producing and (in some cases) profit-dominated managed-care outfits out the window. Most medical decisions would again be made within the patient-doctor relationship.

Unfortunately, the economic sector that profits mightily from the present wasteful and bureaucratic system, led by lobbyists for managed-care health plans, are fearsome foes of anything that would cut them out of the loot.

So, as something of a compromise, why not try Medical Savings Accounts and an expanded network of U.S. Public Health Service clinics?

An MSA allows individuals and/or their employers to buy a high-deductible health-insurance policy to cover catastrophic emergencies and to set up a tax-exempt savings account to tap for ordinary medical expenses, such as seeing the doctor for a bad cold. Because patients can keep the unspent funds, they have every incentive to watch where their money goes. Consumers would have wide choice in choosing their own physicians, hospitals and so forth, and MSAs would give incentives to consumers to be careful in their purchases.

Medical propaganda

Don't believe the propaganda put out by managed-care lobbyists that MSAs would raise overall health-care spending.

People are remarkably prudent when it comes to spending their own money; this has been proved where (as at Dominion Resources of Virginia) the medical-account option has been offered to employees.

But what about people who have little or no money? Well, for them an expanded Medicaid system and the establishment of many more U.S. Public Health Service clinics are good moral and practical approaches.

Rather than use layers of processors, let the federal government send cash vouchers to everyone below a certain income for daily medical expenses, while also providing a catastrophic health plan. And make these payments truly cover the medical overhead. As Nobel economics laureate Milton Friedman once said: ''The trouble with poor people is that they have no money; why not just give them some money?''

New federal scholarships to medical-school students who contract to enter the Public Health Service after getting their degree should also be part of any streamlined plan for the poor.

Presumably most of these young doctors would be primary-care physicians, but let's let medical need and the market decide that, not economic planners. Indeed, one of the best things about MSAs is that they militate against the distortions of medical and economic reality that accompany managed care and some government payment systems.

Foreign physicians

Anyway, we may well need more primary-care physicians now. But who knows future needs? Yet witness the effort by Congress, the administration and the managed-care lobby to slash the number of foreign physicians granted visas with the proviso that they practice primary care in low-income places.

Bad idea!

Unless there are plans afoot to arrest U.S. doctors at gunpoint and order them to work in inner cities, Appalachia and so on, why not let foreign doctors respond to these humanitarian needs? After all, they meet the assumed demand for more primary-care physicians, since that's what they generally end up being to their impoverished patients.

For that matter, maybe it's a grossly misguided guess that the nation really does need many more primary-care physicians, or that the United States may have 100,000 more physicians than it needs by the year 2000.

Look at the demographics. Won't the vast cohort of aging Baby Boomers need more specialists? Gerontologists and cardiologists come to mind first. (Or will all start calling themselves primary-care doctors?)

And won't we need more specialists to handle the increasingly complex technology and equipment?

Maybe, maybe not. But do we want government officials and managed-care executives to make these determinations? Why not let the patients go where they feel they should go, and let them decide?

Moral imperatives

A system based on Medical Savings Accounts, direct government payments to the poor and public health clinics would better reflect moral imperatives and economic realities.

This beats funneling people through cut-rate managed care, much of the revenue of which goes to individuals quite detached from the direct provision of medical services.

On November 26, the New York Times profiled a young osteopath, Jean Miller, who waved goodbye to the managed-care revolution and set up her own practice. Managed care ''was too regimented, and I'm too much of a maverick,'' she says.

She dislikes managed care's focus on cost of treatment and advance approvals for specific treatments.

'Highly motivated'

So she and a financial adviser set up a corporation in which Dr. Miller and four other individuals (a business manager, a clerk, a receptionist and a medical assistant) are full-time employees.

''The patients I'm looking for are highly motivated,'' the family practitioner told the Times. She sees her practice as a ''partnership -- the patient and doctor work together to find out what works best.''

MSAs and direct cash payments to the poor for medical care would open up large opportunities for other Dr. Millers, and would improve the overall quality of medical care to boot. Best, they would allow medicine to move in ways commensurate with needs. As Thoreau said: ''Simplify, simplify.''

Robert Whitcomb is editorial-page editor of the Providence Journal-Bulletin and consulting editor of Primary Care Weekly.

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