Health headaches, Carter to Covid
By John Marshall
On August 3, a New York Times reporter said her first article on covid treatment costs in America was about $3,900 in charges to a man and his three-year-old daughter. “Since then, my colleagues and I have written about $2,315 coronavirus tests and $401,886 bills for treatment. We’ve discovered that the price of a coronaviruis test can vary by 2,700 percent within the same emergency room.”
In the civilized world, testing and treatment costs are not a threat to the sick; people don’t worry whether they can afford to see a doctor or pay the bill. Universal, affordable health care has been the norm for decades throughout Europe, Canada, the Caribbean, Central and South America, the Pacific Rim and much of Asia.
The issue in America is a global embarrassment, painting us as little more than a feudal health care backwater – cruel, discriminatory, suppressive, expensive. Basic health care is out of reach for many Americans. Covid magnifies the fault.
In 1977, President Jimmy Carter proposed a nine percent lid on increases in hospital fees. The idea struck home – not only in hospitals but also to every person who needed one.
Criticism was general. The American Medical Association and American Hospital Association said the plan could curtail patient care. Labor leaders said the president’s proposal didn’t go far enough. Consumer groups said hospitals already cost too much. Congress was underwhelmed (as it still is) when the subject of health care surfaced.
All this was long before the Affordable Care Act, with its provision to expand Medicaid, and before the politics of health insurance turned vicious. But the Carter proposal foretold distress for health care in America: that the cost of an appendicitis or a busted leg could mean bankruptcy for a middle income family without insurance, or the right kind of insurance.
At the time of Carter’s bracing proposal (mild by today’s standards) we considered controversy to be beneficial, particularly when it concerned our health. We thought we were on the brink of national control of health care, not because anyone in or out of government particularly wanted it, but simply because no one in or out of government had figured how to maintain the nation’s health care in the face of ever-growing expenses.
We know by now that health care is not in the free enterprise system. Patients who need help seldom can shop around for the best bargain. They have no control over what doctors or hospitals charge them, and they cannot decide for themselves how much care they should buy.
On the other side of the picture, there is little incentive to dampen the price fever. Third parties – insurance firms or the government – are paying more and more bills, which effectively reduces free market restraints on pricing. Physicians themselves have little motive to jump into the price picture; they know the pocketbook of their patients won’t be directly affected.
Medical malpractice suits, not the headliners they were, have been another reason we didn’t have the normal caution about costs. Damage claims had prompted both physicians and hospitals to go the full route in treatment, where in other times they would have been more conservative in tests and procedures.
There were other concerns with Carter’s proposal. Local hospital officials worried that it would curtail our growth potential and rule out new patients needing care; consumers worried that a nine percent rise may not be a ceiling, but a floor; and there were worries about the efficiency of hospital accountants, their techniques to permit easy juggling around price lids.
Notes from that era ring familiar: The plans to stop unnecessary surgery, for insurance companies to get more involved in holding the line, the need for greater use of out-patient facilities, more emphasis on the need for people to take better care of themselves.
The Carter plan went nowhere.
It was obvious then, as now, that we had two choices: get costs within practical limits ourselves, or the government will take charge.
The government took charge – sort of. The Affordable Care Act of 2010 became effective in 2014. It sought to cobble an effective plan for American health care with two prime objectives: subsidized, comprehensive insurance for those who could not otherwise afford it and no exclusion for a “pre-existing condition”; and federally subsidized Medicaid expansion for states that opted in.
Since then, the Trump Administration and congressional Republicans have worked tirelessly to corrode the Act, and last month asked the Supreme Court to kill it. In its place, nothing.
Forty years ago we at least had some rational discussion. Today we slide backward into legislative malpractice. We can spend trillions of dollars for high-end tax cuts, more trillions for wars in the Middle East, and billions for border fences, but we can’t assure reliable, affordable health care in America.