Health care’s don’t ask, don’t tell policy

BOSTON—To celebrate national health care week, I took my mother to the hospital. She was in at 9 a.m., out at 2 p.m. She went in with a cataract and came out with a patch. Total cost to Medicare: $3,000.

This was not a medical horror story. Nor was it, anymore, a medical miracle tale. Cataract surgery is one of yesterday’s miracles and today’s routine blessing. This is your everyday, good-news-bad-news report about medical care and cost.

I have no idea how much of the $3,000 will go to cover the costs of treating the uninsured, how much will pay for paperwork overkill, for drug company profits, for overbuilding. They don’t break down the bill this way. Indeed, they didn’t give us a bill. In the wonderful world of third-party payments, there seems to be a don’t-ask-don’t-tell policy.

But I do know that a generation ago, my mother might have gone blind. And I know that two days after the surgery, when President Clinton went on television—which she could already see better than before—he was struggling with the question of how to keep the good and reduce the bad—share the benefits of medicine and control the costs.

In a speech that was both fervent and persuasive, sprinkled with folk wisdom and toughness, Clinton took on the biggest social policy issue of our era. The word of the night was security. The moral issue was health care security for everyone. And the language, the common currency in which this will be discussed, is literally currency: money.

By now even the most innumerate of us has memorized two figures, $1 trillion—the annual cost of health care—and 37 million—the number of uninsured. By now even the apolitical among us are aware that there is a down and dirty debate ahead.

The argument is being waged on the turf of medicine economics, not medical ethics. But there is a question even more basic than the six principles that Clinton ticked off: What is it that we want from the health care system?

Do we expect medicine to fix our broken legs, protect our children against measles, remove our parents’ cataracts? Or do we expect medicine to the max: transplants for 85-year-olds, CAT scans for every back pain, hi-tech treatments for the terminal?

On the same day as Clinton’s speech, there was a study in the Journal of the American Medical Association raising doubts about money spent on heart attack victims with virtually no chance of survival. “Virtually” is the pivotal word.

On the same day, in one hospital in Philadelphia, Angela Lakeburg, the remaining Siamese twin survives with a gastrointestinal tube and a ventilator. In another in the same city, a 92-year-old woman who came in with pneumonia remains there on a respirator. Across the country some 10,000 people in permanent comas are subsisting at untold cost.

To raise these matters is to risk being branded with the dreaded “R” word: rationing. But these are just some of the choices we face. Not choices in the way Clinton used the word—the choices we want to have—but choices we will eventually have to make.

When her father was dying, Hillary Clinton,”the talented navigator” of health reform, asked aloud, “When does life start? When does life end? Who makes those decisions?” But there was barely a mention about such ethical dilemmas in the president’s speech. Barely a mention about our expectations of medical care.

The money to fund this health care plan is to come from waste, fraud, inefficiency, profiteering. Surely, the edifices built by insurance companies, the salaries of hospital corporate CEOs, the profit margins of drug companies, the administrative mess, all bear witness to the bloat.

But as psychiatrist Willard Gaylin has written, there are “deeper and more challenging reasons for escalating health costs: our unbridled appetite for health care and our continuing expansion of the definition of what constitutes health.”

It’s easy to understand why these issues are being skirted. The health care debate could sink if it were weighed down any further. First on the list of moral question is health security for all Americans. The focus is on the people who cannot get and cannot pay for the flu shot and the eye surgery.

Like ethicist Art Caplan, I regard “rationing as a somber last resort, not the convenient option of first resort.” But even Caplan says that the savings will at best buy us time, time in which we must wrestle with our real expectations and demands about health care.

At the end of the speech, the president warned, “Responsibility in our health care system isn’t just about them. It’s about you. It’s about me. It’s about each of us.” This body-and-soul-searching has just begun.