Health care and community obligations - social responsibility - The State of Health Care in America - Column

Daniel Callahan is president of The Hastings Center and the author, most recently, of The Troubled Dream of Life: In Search of a Peaceful Death.

I confess to being a closet Europhile. When I go to Europe I can't help admiring Europeans' ability to keep the homeless to a minimum, to control the use of guns and crime, to provide good public transportation, to support the poor in some dignity--and to give every citizen a decent basic package of health care. There is an ethos of solidarity and mutual responsibility for one's fellow citizens in Europe that is admirable. And it works at a cost we should envy.

Can we ever develop a similar sense of responsibility in the United States? We seem to have turned our back for the time being on universal health care, choosing instead to follow the yellow brick road of managed care. Where the Europeans have long taken it for granted that good health care for all is as necessary as good police, fire and defense protection for all, we have historically chosen to put health care outside of that inner ring of core social entitlements. Or perhaps more accurately, to put it half in and half out, conceding the necessity to have some kind of public safety net to help the most needy.

That safety net has become tattered. While managed care grows rapidly so also does the number of those with no health insurance, now estimated to be as high as 42 million. There is something encouraging, discouraging, puzzling and intriguing about the turn to managed care.

The encouraging part is that it seems to be working well at the moment to contain costs--even if it leads to many angry physicians and muttering patients. While there has been here and there some evidence of a diminishment of the quality of care, for the most part that has not happened. The discouraging part is that it seems also to be leading to a decline in public health services, to a diminished role for the federal government, to the balkanization of health care services and to an increase in the number of uninsured. The puzzling part is that, seemingly unaware of it, those Americans who are part of managed care systems are living within exactly the kind of closed, single-payer, cost-capped programs of a kind so indignantly rejected for a national, universal health care plan. The intriguing part is whether, as managed care grows, it can find the resources of will and interest to worry about those not covered by managed care programs or otherwise provided with employer health care.

That last point should be of special concern. Will it be possible for those working with managed care programs to develop and implement a sense of responsibility for those outside of their programs for the health and well-being of the nation as a whole? There is, on the face of it, little to encourage that development. The need to keep managed care programs competitive, to provide good care of high quality at an acceptable cost, can be all-absorbing. Given that situation, there is a limit to how much time, energy and money can be devoted to the needs of the larger community. It is a system, in short, inadvertently designed to make certain that those who run it keep their eyes narrowly focused on the bottom line of their programs and the satisfaction only of their stockholders, providers and consumers. It is thus perfectly understandable that there should be a thin sense of social responsibility for the common good. It is hard enough to guarantee the smaller good of one's own program.

Nonetheless, it is imperative that those who manage employer-based health care programs or managed care organizations develop a drive for social responsibility. Why is this necessary? First, they are by virtue of their occupations in a good position to know the health needs of the communities they serve, the medical skills necessary to meet those needs, and the capacities and potentialities of the hospitals, clinics and nursing homes in the community. They have knowledge, and this is an imperative first step in acting responsibly.

Second, they should well know that the general needs of the uninsured, or underinsured, often end up on their doorstep, even if indirectly. The poor and uninsured will in fact use the services of the local hospitals, increasing their costs. Their medical and attendant social problems will, moreover, affect the welfare and social services of their region, pushing up their taxes. In short, the uninsured will have an effect upon everyone, even those who try to live behind the walls of managed care.

Third, I believe there is a simple duty on the part of everyone to help create a better society--not just for oneself but for everyone. While our American individualism has been a source of strength and economic growth, it does not cope well with needy human beings. Sick people require help, and those who are poor or near poor need it more than the rest of us. They are more at risk for accidents and disease, and less able to cope with them when they strike.

We have set up a large number of private enclaves in housing, allowing the well-off to live in comfort and security. That is nice if you are on the inside, but not so nice on the outside. We are gradually doing the same thing with health care. A large number of us do well inside our protected health care systems, but many of our fellow citizens--probably not our immediate neighbors--do poorly. They are as much at constant risk of economic destruction from poor health as physical destruction.

What can be done to counter this trend? A minimal start would be for each and every organization providing health care--employers and managed care organizations in particular--to establish units within their organizations that are responsible for monitoring the health of their surrounding communities. They should have the job of keeping track of public health trends, the number and characteristics of the uninsured and federal and state developments that will have an impact on the uninsured.

A further step would be to appoint some people as organization representatives to work with state and federal authorities in developing programs for the poor and uninsured. If, as is likely, Medicaid is taken care of by block grants to the states, then health care organizations should remain in close touch with those officials who will be managing the programs.

Perhaps I am being too hopeful and too idealistic with one more suggestion, but let me try it anyway. Every managed care organization and every employer offering health care to its employees should put aside some money to pay for efforts to improve health care for the uninsured. Enough money to help educate their own constituency about the needs of the community. Enough money to collect the necessary data to pinpoint those needs. Enough money to ensure good liaison with pertinent government agencies. Enough money, in short, to be a real presence in discussions and debates about the needs of the uninsured.

Middle-class Americans have found it hard to imagine that the fate of their own health care might be tied up with the fate of health care for the uninsured. It is easy to understand why, since it was never obvious to most people that the rising costs of their own insurance had anything to do with the costs Of caring for the poor. But of course the connection was always there in the cost-shifting that took place, with the cost of care for the poor being shifted to those who took care of the more affluent. That connection will be even harder to see now because, in fact, much of that earlier cost-shifting is now coming to an end. The poor are really out on a limb as public hospitals and clinics close and cost-shifting is eliminated. It will take not only a great act of the imagination, but a new burst of responsibility, to understand that no country can be a decent country that denies good health care to a large portion of its citizens. If the federal government is increasingly being pushed out of health care, and if state government is unlikely to pick up the slack, that leaves one and only one candidate to pick up the pieces: those who now direct or work with the burgeoning managed care industry. There is no one else to do it.

COPYRIGHT 1996 A Thomson Healthcare Company
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