World

Mismanaged care

July 20 1998
World

Mismanaged care

July 20 1998

Mismanaged care

UNITED STATES

Paul Ruskin admits it: he’s obsessed. “I’m compelled to keep fighting,” he says. “Sometimes I wish I could stop.” For a few hours every week for almost three years, through icy winter days and the sweaty heat of a Maryland summer, Ruskin, 53, has paced outside a hospital run by the health insurance company he believes bungled his wife’s medical care, leaving her with permanently impaired vision. “Kaiser misdiagnosed my wife’s brain tumor for four years—why?” reads the yellow placard he carries.

It has been a lonely fight. The company, Kaiser Permanente, is one of the biggest private health insurers in the United States, and it denies that it mishandled care for Ruskin’s wife of 33 years, Jill. “It’s David against Goliath,” he says as he marches up and down. These days, though, Ruskin’s complaints are being echoed across the land. Americans are increasingly angry about the restrictions on medical treatment imposed by so-called managed-care organizations like Kaiser. Crucial decisions about health care, goes the common refrain, are being taken out of the hands of doctors and turned over to insurance company accountants. Politicians, their eyes fixed on November’s midterm elections, have jumped on the issue. Democrats and Republicans alike are pushing legislation to enforce “patients’ rights” against hard-hearted insurers. In one TV

ad that sums up the new mood, a Democratic candidate for governor of Georgia, Roy Barnes, fires off this line: “If you can choose who changes the oil in your car, you should be able to choose who delivers your baby.”

The last time health care topped the U.S.

ANDREW PHILLIPS

IN WASHINGTON

political agenda was 1993, when President Bill Clinton proposed a massive program to give more Americans access to medical insurance. Health costs were soaring and millions of Americans could not afford care. The insurance industry successfully portrayed so-called Clintoncare as a manoeuvre by government bureaucrats to take choice away from patients. A $22-million industry ad campaign featuring Harry and Louise, a fictional middle-class couple, aired those anxieties. “They choose,” mused Harry, and Louise responded: “We lose.” Clinton’s plan died in 1994.

This year’s version of Harry and Louise is Carol, the waitress portrayed by actress Helen Hunt in the movie As Good as It Gets. Carol’s son suffers from asthma, and when she learns that her health maintenance organization, or HMO, has denied him proper care, she lets loose a string of epithets that had U.S. movie audiences cheering. Politicians noticed, and acted accordingly. Clinton announced his support

Americans are angry about their health care

for a patients’ rights bill in his state of the union address last January. Republicans, traditionally skeptical of government fixes and reliant on campaign funds from the health industry, were slower to react. But in late June, they, too, took up the cause. Both parties support giving patients more information about their health plans, greater ability to appeal when they are denied care, and guaranteed access to emergency rooms. The Democrats, though, would go further, and allow patients to sue health plans for improperly denying them treatment.

What changed between 1993 and now? Even though Clinton’s plan was defeated, the reasons that inspired it remained. Health costs were rising far faster than inflation. They ate up some 13 per cent of the U.S. economy in 1992, and Washington forecast a rise to 18 per cent by 2000. Employers, who pay most of the cost of Americans’ medical care, were determined to reverse the trend. They transferred more and more of their employees from traditional coverage, where doctors simply bill insurance companies for treatment, to managed-care plans like HMOs, which usually receive a fixed annual fee for each patient they cover. However, patients often must go to doctors chosen by the insurance company, and there are far stricter rules on what kind of treatment is allowed. Some 160 million Americans are now covered by managed care, compared with just 90 million as recently as 1990.

The move worked. In 1996, the growth in health-care spending hit a 37-year low. U.S. doctors’ earnings stagnated, at an average of $280,000 a year. Health care still consumes about 13 per cent of U.S. economic output—far higher than the 9.6 per cent in Canada and the highest in the industrialized world, but considerably lower than had been projected. But the human cost mounted. Middleclass families who once feared that government bureaucrats might micro-manage their health care were now finding that insurance company bureaucrats were doing the same thing. “HMO horror stories” became a staple of political discourse.

Robert Raible, a health-care activist in Washington, has compiled more than 200 such cases. They include a California man who was discharged from hospital four days after receiving a heart transplant because his HMO would not pay for addi-

tional hospital care; he soon died. An HMO in Atlanta told a mother to take her six-month-old son with a high fever to one of its clinics 60 km away rather than to a closer hospital; by the time he arrived, he was in cardiac arrest. And a newborn baby in New York City died after he was discharged from hospital after the one day mandated by his parents’ HMO—even though his mother voiced concern about his health.

Paul Ruskin’s tale is similar. He says his wife, who is 54, went to the doctor assigned to her by Kaiser Permanente in 1987, after an optometrist became concerned about pressure building in her eye. She was diagnosed with glaucoma, and was treated with eyedrops for four years. Eventually, as her vision deteriorated, Jill Ruskin sought treatment elsewhere and a new doctor used a CAT scan to discover that she had a slowgrowing benign tumor in her brain. It was removed in 1993. She recovered sufficiently to continue her job as an accountant at a nursing home in suburban Washington, but suffers from impaired vision. Paul Ruskin believes that Kaiser failed to perform a CAT scan or refer Jill to other specialists because its doctors are given financial incentives to limit treatment—something the company denies. He got nowhere in trying to get a settlement out of Kaiser, so he began picketing. “They’ll never see the end of this case,” he vows.

The irony is that many health-care reformers have advocated managed care as a way of improving Americans’ health. Instead of rewarding doctors only when they patch up sick people, went the argument, managed-care companies have an incentive to keep their patients healthy through prevention programs. Even the anti-HMO diatribe in As Good as It Gets, though entertaining, may be misleading: HMOs have actually pioneered programs to keep childhood asthma under control. And independent experts rate Kaiser Permanente as one of the best HMOs.

But the populist appeal of attacking managed care is irresistible for many politicians. Clinton’s 1993 health-care plan focused on the 37 million Americans who had no medical insurance. That number has jumped to 41 million since then, but the anti-HMO campaign targets the anxieties of the middle-class majority who have insurance, but worry they may still be denied the care they need. ‘This is an everybody issue,” says Democratic political consultant Doc Sweitzer, who has crafted TV ads for congressional candidates aiming to win in November by bashing insurance companies. The industry, though, is not taking it lying down. In true American political fashion, its response has been quick: a multimillion-dollar TV campaign of its own. □