by S. Todd Stolp MD
©September 2008
There are reasons to believe that our health care system was designed by Dr. Seuss. It is not as though some feather-tufted creature in striped socks woke up one day and deliberately organized a system with convoluted billing procedures and hopelessly tedious eligibility requirements. No. The system is a product of an uncountable series of decisions made by conscientious people – legislators, insurance companies, doctors, nurses, employers, administrators, technicians, investors and (yes) patients – that contributed a galaxy of modifications to a system which was originally fairly straightforward: sick people were provided with care in exchange for money. So what were the major curves and intersections in the road that brought us to “Whoville?”
In 1900 there was very little protection for people who became ill to help them continue to provide for their families while simultaneously covering the costs of health care. Granted, at that time there was minimal cost for such things as “Thunderclap Hot Springs Injection: World Famous Remedy for Gonorrhea and Gleet,” but neither was there much benefit to the patient for such snake oil.
It was not entirely a benevolent act when, at the turn of the century, employers developed the novel idea of “disability insurance.” The idea was to offer your employees some financial assistance when they became ill so they could cover the costs of health care and continue to feed their families…and, of course, return to their factory jobs more quickly. Diseases such as tuberculosis were widespread and it was to the advantage of employers to have a healthy work force. This was the foundation for the employer-based health insurance system we have today.
In 1945 an organization called Kaiser Permanente was established to provide not only financial assistance to employees of the Henry J. Kaiser Company, but to actually provide doctors and clinics. Several similar experiments had been explored in the 1930s, but it was during the construction of the Grand Coulee Dam in Washington that the notion took hold. This was the beginning of the Health Maintenance Organization, or “HMO.”
Prior to 1965 most care for people without the economic means to pay for their care was provided as a charity, both by hospitals and physicians. However, there was no way to guarantee to the poor that they would be able to find a source for such services. Health care was becoming more expensive and effective. Therefore the Social Security Act was passed and Medicaid (or MediCal in California) and Medicare were born.
Unfortunately, there were few controls to the cost of care to MediCal and Medicare recipients, so that government expenditures went rapidly through the roof. In 1970 health care represented 7% of the Gross Domestic Product (GDP). In 1980 that increased to 8.8% of the GDP. In an effort to enlist the assistance of private industry to control health care costs, the HMO Act was passed in 1973. It was expected that the insurance industry would be able to more efficiently deliver health care.
Expenses continued to skyrocket. The Managed Care Act was passed in 1982, extending additional leverage to health insurance programs to control costs. This provided the recipe for an alphabet soup of organizations who were interested in skimming the cream from the well-financed health care system: PPOs, HMOs, MCOs and others that are not appropriate for a family website. Unfortunately, by 1990, 12% of the GDP was going into health care and today, in 2008, health care represents 16% of the GDP. Insurance companies thrive.
It was inevitable in such a system that gaps in health care delivery would occur where providing health care was difficult and unprofitable. In response to such gaps, legislators developed individual programs to assist people who fell into the chasm. MediCal and CMSP for the unemployed. CHDP for well-child care. AIM for pregnant mothers. FPACT for adolescents needing family planning services. CDP for women needing mammography and Pap smears, etc… At last count, there are twenty seven different government-operated programs to delivery health care to those who are not served by the meager generosity of the insurance industry, each public program with it’s own forms, eligibility requirements, administrators, infrastructure, trained staff, computers, and budget. Welcome to “Whoville.”
It is time for a Universal Health Care system. The problem is not that the government is somehow intrinsically inefficient, but rather that our current health care model has become obsolete. A single health care program for all Americans would render the bewildering array of band-aid programs unnecessary, providing more dollars for direct patient care. Such a step might even simplify the management of a state budget.
In fact, it turns out that the good Dr. Seuss did focus his satirical wit on the health care industry in his book, You’re Only Old Once: “You are in pretty good shape for the shape you are in!”