Wednesday, July 4, 2001

We need a strong patient's bill of rights now

Back in 1988, fresh from Germany and a few days into my pediatric residency at Rhode Island Hospital, Providence, Rhode Island, I converged with dozens of other residents to the benefits office to select a health insurance plan, one of three offered by my employer.

A bit wary about of what I have heard of U.S. health insurance, I asked for a brochure about the most extensive (and expensive) plan, hoping that would cover me well enough. I was handed out a folder with an appealing, artsy pamphlet on glossy paper with lots of pictures of warm and gentle-looking physicians and nurses, stately offices and happy-looking families.

I took it home and brooded for hours over its 50 or so pages, but in the end I still could not get a grasp as to the full extent of my coverage. I remember, besides a lengthy and very disconcerting chapter on exclusions, there was one data that caught my particular attention: "Lifetime insurance limit $1 million," it said on the very top of a summary sheet. I couldn't believe it. I did not plan having children right then but I knew that the cost of care per year of a sick premie with all sorts of complications may easily pass the $1 million mark.

That's it; one year of care for a sick premie would cut us off from health insurance. The next day I dropped in again at the benefits office requesting clarification. The lady looked at me bewildered and said, "You are the very first who ever asked me that question." She had no comment on that data but at least agreed I had a good point. Unbelievable, I thought then.

Unbelievable, I still think today, 13 years later. The most expensive and sophisticated health care system in the world with, by far, the greatest overhead in international comparison (about 30 cents to the dollar) accomplishes only rank 24 among the nations of the world in healthy life expectancy (rank 1,2,3 Japan, Australia, France; Rank 12 Canada; Rank 14 UK; 19 European nations ahead of the United States, [1] WHO data 2000); rank 4 in Infant Mortality (together with Belgium, Denmark, Ireland, Italy, Luxemburg, Slovenia, Spain, UK, New Zealand) (rank 1 Japan; rank 2 Germany, Iceland, Norway, Sweden, Singapore; rank 3 Australia, Austria, Canada, Czech Republic, Finland, France, Netherlands, Switzerland; 10 European nations ahead of the United States, [2] WHO data 1999); rank 9 in Maternal Mortality (together with Netherlands) (rank 1 Iceland, Luxemburg; rank 2 Cyprus, rank 3 Canada, Norway, Switzerland; 13 European nations ahead of the U.S, [3] WHO data 1999).

A sample of actual data is shown in the table below, a comparison between the U.S., Cuba, Mexico, Canada and Japan of three basic health indicators:

U.S. Cuba Mexico Canada Japan

Overall Life Expectancy in years

70.0 68.4 65.0 72.0 74.5

Infant Mortality

7/1000 9/1000 31/1000 6/1000 4/1000

Maternal Mortality

12/100,000 95/100,000 110/100,000 6/100,000 18/100,000

Of course, all these data permit only a very limited glimpse into the complex relationship between a country's GNP and the health of its population. To associate a nation's economic productivity with its physical and mental health is not an easy task, fraught with a myriad of confounding factors. Still, the U.S. could do better but not under its current system of a raw, free-wheeling capitalism which has no scruples walking over bodies to squeeze out one more penny of profit.

It's no secret, the horrendous income gap in the U.S., the by far greatest of any Western democracy, is intimately related to all other gaps: in access to, and quality of, health care; in educational standards; in justice. If you have money in this country you can buy everything science, technology and commerce may possibly offer.

In fact, with money even killers may go free as long as they can afford hiring the cream of the legal profession. Without money, people get sporadic care if any or have to sell their homes to pay their hospital bills; send their children to schools devoid of resources, taught by untrained teachers, under roofs that leak; many a people have languished for decades in U.S. prisons, even on death row, convicted of crimes their have never committed, "defended" by lawyer who slept through their most crucial day in court.

At the time President Clinton tried to introduce more justice and humanity into U.S. health care, I remember his opponents and their business buddies made every effort to slander the Canadian health care system and make it appear like the worst choice of all. But look how impressive Canada's performance is in the health care sector! My American friends, please don't get mad at me but I have to tell you the truth: Compared to other countries' standard social benefits package, health care included but not restricted to, yours is rather pitiful.

The spin doctors of U.S. corporate interest groups successfully dumbfounded you for the past two generations or even longer, boasting the world's most cost-effective health care system when it is not. 45 million Americans have no health insurance at all; much of the rest depends on plans with all sorts of exclusions and restrictions. Only the very rich get comprehensive, high-standard care.

Besides worries about health care many of you work longer hours for the same income today than 10 or 20 years ago. For decades West and Central European workers have enjoyed not only comprehensive, inclusive, affordable health insurance, and a 50 percent employer co-pay to social security, they have also enjoyed six weeks of paid vacation for at least the past 20 years.

Here your bosses and their friends from the health insurance lobby including the American Association of Health Plans and the Health Insurance Association of America and the major business groups, including the United States Chamber of Commerce, the Business Roundtable and the National Federation of Independent Business, warn you'll lose your job if health insurance premiums rise by 4.2 percent under the Kennedy-Edwards-McCain Patients' Bill of Rights proposal.

What nonsense! My American friends, when will you finally wake up and realize for how many years American business has lied to you or told you half-truths? Did you ever ponder what will happen with your coverage some day in a not-too-far-away future when the progress in stem cell research and medical genetics translates to effective life-prolonging medical therapy? Only the well off will be able to benefit the ultimate in medical care. Most of you will be cut out of those benefits.

Of cause, there is no flawless system anywhere in the world. All human nature has achieved in its 2-million-year history is a "baby culture, really, a primitive culture," not one of the "highly evolved cultures of the universe" (Neal Donald Walsch, "Conversations with God").

Yet the least we are called upon to do is making a serious effort to distribute health and wealth with greater justice. Eighty percent of Americans count themselves to one Christian denomination or another; it is to them whom I say: "Live the Bible, don't just read the Bible." Love thy brother and let every man, woman and child enjoy the benefits of cost-effective and affordable health care.

Let me finish with a physician's letter to the editor posted in the June 21 New York Times on the Web: "The argument that a patients' bill of rights should not be passed because countless frivolous lawsuits would result underscores the lack of sensitivity about patients, their health and their rights. When a patient is deprived of care, resulting in a reduction of health, a shortening of life or even death, a company should be held responsible just as if it had manufactured a bad product. There is no difference!

"This law should be passed even if there are an infinite number of lawsuits. Maybe health care could then be turned back to the people who were running it before managed care. They did it with a sensitivity, hope and caring that does not exist today." (Norman Alessi, M.D., professor of psychiatry at the University of Michigan, Ann Arbor, Mich.)

Needless to say, the wave of lawsuits predicted by the opponents of a strong patients' bill of rights is a mere phantom: "The right to sue a health maintenance organization for unlimited damages has been in effect in California since Jan. 1. Not a single lawsuit has been filed, but according to the first data from the state's HMO regulator, HMOs appear to be deferring more to patients' requests for treatment. The threat of lawsuits, not actual litigation, has helped the HMOs understand that both the demand for lawyers and the supply of large damage awards are within their control." (Jamie Court, executive director, Foundation for Taxpayer and Consumer Rights, Santa Monica, Calif.)

I invite you all to sit back and consider for a moment my arguments. Then contact your senators (Max Cleland, 202-224-3521, fax 202-224-0072; Zell Miller, 202-224-3643, fax 202-228-2090), your representatives, and the Senate and House majority and minority leaders and demand that America finally be allowed to join the chorus of other progressive nations who offer their citizens a cost-effective, high-quality, dedicated health care system. Encourage our political representatives to listen, for a change, to their own conscience and not to the siren calls of their campaign contributors.

Günther Rückl, M.D., Ph.D.



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