The Health Care Mess: Foreword and Preface



The restructuring of health care in America is the most important debate of the nineties. Every citizen, regardless of age or social status, will be affected by changes that are sure to evolve from the endless disputations on the subject in settings ranging from high school to the halls of Congress.

The American Health Security Act of 1993 as proposed by the Clinton Administration calls for an enormity of social change unexceeded even by the New Deal. There is no disputing the value of some of the benefits this plan purports to offer, such as improving health care, simplifying paper work and administrative complexity, measures to increase the supply of primary care physicians, and correction of injustices in the medical liability system through tort reform.

More ominous is the prospect of increased federal bureaucracy (which has a dismal record for efficiency and cost savings) and expanded cradle-to-grave benefits with no credible means of paying form this largesse. Infinity of care cannot be achieved with finite resources. Instead of reducing the cost of health care the plan as presented would greatly increase costs.

Robert Bear Smith, a physician with 22 years of practice experience, outlines the wrongs that led us to the dilemma, which he calls the “mess” of the health care system. Many societal sectors are incriminated to varying degrees in having brought about current health exigencies.

Some increased costs are necessary offerings on the altar of progress: an ever increasing age of the population and expansive technology advances. In other areas, Dr. Smith describes where the government, the insurance, hospital and legal industries, health care supply and pharmaceutical companies, physicians and the public have all contributed to the “:mess.” Corrective reforms are suggested for these various players.

Dr. Smith makes interesting observations and his “treatment” deserves consideration.

John W. Hollowell, M.D.

Past President,

The Medical Society of Virginia.

October 1993



The Past & The Present

For 22 years, as a practicing physician in the United States, I have watched the increasing deterioration of our health care system.  I see everyone having more and more difficulty affording health care.  This country has increased spending in health care each year.  The total annual health care costs were 666 billion dollars in 1990, 738 billion in 1991, and 817 billion in 1992.  The costs represent nearly 15% of the Gross National Product (GNP) of this country.  The cost is so huge that it affects the cost of living for everyone.

With the skyrocketing health care costs, we still have 35 million people in this nation either are unable to afford basic insurance or are simply uninsured.  Being uninsured creates a serious problem when those people need health care in critical situations.  Hospitals might refuse to provide facilities for them (see p.63) even if physicians are willing to care for them free of charge.  Meanwhile, we can not allow the costs to continue to rise.  We have to stop the increase or at least to slow it down.  But so far nobody has done anything effectively.  It is very discouraging to find that every offered “solution” has always increased the costs.  Now the Clinton Administration is already talking about spending up to 150 billion dollars more to reform the ill-fated health care system.  Their reform may be even worse than letting the current system run at its own pace.

The public does not realize that it, too, is one of the key players in this health care nightmare.  The public has to understand that there is no free lunch in this world.  Someone always has to pay.  The public cannot demand more services with better equipment and technology without paying for them.  Your insurance payments to hospitals and physicians are coming from your insurance premiums.  The payments are not someone else’s money.  The payments are your hard earned cash.  Therefore, the public has to watch carefully and actively participate in the reform.  Always keep in mind that you get what you pay for.

I am firmly convinced that you and I can figure out a way to have a good health care system for all in this country.  However, you and I have to take a while to understand the problems from every aspect, to analyze them, and to find the best solutions for them.  Without reasonable solutions to every problem in the health care system, which includes patients, physicians, the hospital industry (including nursing care facilities), the insurance industry, the health care supply industry (including the pharmaceutical industry), government regulations, and medical legal involvement, the powerful factions will always corrupt each other and benefit themselves at others’ expense.  They have led this country’s health care system into a chaotic situation.  They have created the MESS of the American health care system!

In Corporate America nothing works without money.  Therefore, everyone rushes to collect money whenever and however he can.  Anyone can start a business to earn a living and to make a profit, whether the business is ethical or not.  People, armed with intelligence and business management skills, have never missed opportunities to make money.   It was inevitable that they would not spare the health care system.

Health care businessmen are a special breed of business people.  They do not necessarily have any knowledge about taking care of health problems.  They do not even understand why the medical profession has to emphasize a code of ethics.  They only want to make profits by monopolizing the running of the entire health care system, gaining financial control, and taking advantage of you when you are sick.  They are determined to get every penny that they can.  They show no compassion if you can not afford health care.

Medicine is traditionally a profession with compassion, love and self-sacrifice.  Our society historically has respected physicians because of their devotion to helping their fellow citizens.  Good physicians practiced medicine according to the Hippocratic Oath.  In caring for their patients, they made self-sacrifices in lifestyle and freedom.  They deserved respect and reasonable compensation from their patients for their work.  Physicians trusted their patients to understand their efforts and to appreciate their quality of care.  Physicians never believed that anyone might harbor ill intentions toward them.   The physicians’ belief in the goodness of human nature, combined with their disinterest or lack of knowledge in politics and finance, has also allowed the health care system in this nation to deteriorate.

You may have watched an old movie portraying a story about a doctor making a house call in a small beautiful, peaceful town in this country.  You might have also seen the doctor providing his best care to a poor patient without asking him if he had money to pay his bill.   The doctor might have even given this poor patient some money to buy food.  Of course, this doctor did not own a gold mine for him to afford to do such a humanitarian act.  He was able to do it because most of his patients in town paid him reasonably well, and he did not have to worry about any possible shortcomings financially.  Most people in that society were paying the doctor for the poor, just as we do today.  Interestingly, they could afford health care then, but with spiraling costs we can not afford health care today.

In China, old traditions in medical practice were impressive.  They demonstrated love among people and the best of human nature.  A practicing physician in a community knew almost everyone in that area.  The physician did not have to post a fee schedule on the wall in his office.  However, every patient knew the reasonable fee for each visit.  It is Chinese tradition to use the color red for good luck.  So, patients enclosed their gratitude or fee in red paper or an envelope to their physician.  The physician just thanked the patient when he received his fee.  The physician did not check the enclosed gratitude or fee until the end of his office hours.  Assuming the customary fee was 5 dollars for each visit then, most patients would give the doctor about that amount.  However, patients from some wealthier families would give the doctor twice or three times or even more than the customary fee, partly because they appreciated the doctor’s service and partly because they knew that the doctor needed their support to help poor patients.  When a poor, sick patient came to visit the doctor at his office, he might have managed to get a loan or to sell some of his personal belongings to get money for the fee.  The fee could be very little, say, one dollar.  Again, it was wrapped in red paper and given to the doctor at the end of the visit.  The doctor knew that his patient was very poor financially.  He accepted the gratitude and opened it under his desk immediately.  He held the red wrapping paper in one of his hands before his patient and thanked him for it.  Meanwhile, the money was enclosed in the other hand.  Without checking the amount of the fee, the doctor gave the money back to his patient and asked him to use it for dispensing his prescription.  It was a wonderful picture of the best love of mankind.  If the old Chinese traditional medical practice could afford medical care to all people then, why can we not afford medical care for all people today?

In the Orient, physicians would do everything to save their patients’ lives.  At times, with a simple verbal consent from the patients or the patients’ families, they used some medications and modalities, without final proof of effectiveness, in cases of terminal illness.  When the patients recovered, the doctors were thanked dearly.  But when the patients died in spite of the treatments, physicians were thanked by the patients’ families anyway for their unreserved effort and excellent care.  It was the patients’ families’ feeling that the illness simply took its own course, regardless of the best effort made by the doctors.  With that kind of public attitude toward physicians, it helped physicians to practice the best medicine they could without adding unnecessary costs in liability insurance.   Why could the Orientals have excellent health care at affordable costs while we have reduced health care benefits with skyrocketing costs?

It is necessary for you and me to be objective and open-minded while we discuss a major issue, which affects every one in this country.  Sometime in this discussion, I may touch your sore spots and may make you hate to continue our discussion, but the gravity of this health care issue should carry more weight than anything else in your daily life.  To restore a long lasting and sound health care system which every one can afford now and in the future, one has to set his selfishness aside and work together with others toward this goal— affordable and quality health care for all Americans.

Robert Bear Smith, M.D.

September 1993

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