New York. -- That mind-bending mire of health care plans being cooked up by various Democrats, Republicans and others differ most fundamentally in their definition of Who's Evil. For example:
* Hillary and Bill Plan: Drug companies are Evil Incarnate; insurance companies are Satan's minions; doctors are being corrupted by all that filthy money they're getting, and it's up to us to save them from it.
* Wall Street Journal Plan: Government is evil; taxation crushes the soul; price controls = Stalinism.
* There's-No-Health-Care-Crisis Plan: Sick people are evil.
All these plans will fail, of course, because of their petty lack of vision, their failure to grasp the greater truth: We are all evil -- desperate, greedy, heartless, lazy, whining jerks, from the doctor acquaintance of mine who complained that having to listen to his patients was the worst part of the job, to the drug companies trying to explain why we should be happy to pay seven times as much as Canadians or Europeans for the same drugs, to everyone who thinks that spending 14 percent of GNP on health care is just unacceptable but would kill anyone who tried to stop them from getting a heart-lung-liver transplant at the age of 68 if they needed it. (I include myself in this last group, by the way.)
To work, a health care plan must be based on Universal Evil. Here is my proposal, broken down by villain:
Doctors. Brainwashing, sleep deprivation, instilling a disrespect for human life: These are the training tactics for the Symbionese Liberation Army, and apparently also for your average pediatrician. The humanity is sucked out of doctors early. They spend their college years actually attending classes, their early twenties playing with corpses, and their late twenties learning that, unlike playing golf well or driving to Fort Lauderdale, treating emergency-room patients doesn't require having had any sleep the night before. In most cases the character that emerges from this process is deeply scary. Trained assassins probably feel intimidated when they go to the doctor.
So what do we do about it? Well, as much fun as it might be, we can't just force them to take less money. They're dangerously un-empathetic as it is; I don't want to be around when they get really ticked off. Besides, it will never work. Picture this: You or someone you love is sick. You can either wait your turn to get health care as good as everyone else's, or you can (legally or illegally) get better or faster care by paying a doctor more. Which do you do? This is a country of people who in their hearts believe they deserve every good thing their money can buy. So just forget about capping doctor's fees.
(By the way, I make absolutely no pretense of knowing whether the Clintons' health-care plan requires this, or what it says at all. From my extensive reading of other people's commentary, I conclude that the plan is either: (a) Anyone straying from the government-imposed HMO and its controlled prices will be shot on sight; or (b) Everyone gets to see any doctor he'd like for any reason at all for free for ever and ever.)
The only rational thing to do with doctors is to make more of them, and to make them more humanely. We need more medical schools, and we need them to encourage more general practitioners (without putting limits on the number of specialists). We could also benefit from training nurses to take on a lot more responsibility. Doctors who had more competition -- and who weren't tortured as residents -- might actually start treating their patients like human beings.
Don't worry about lowering our standards by creating more medical schools. As it is, we have lots of doctors who were trained in other countries. If we can license doctors from all over the planet, I don't think a few more from New Jersey will kill us.
Insurance Companies. Let's say you're in a business where (1) people pay you thousands and thousands of dollars years before they need your services; (2) when they do need your services, they're weak and vulnerable, and (3) even if you're absurdly bad at what you do, by the time your customers realize this they're sick and can't change companies. How good a job would you do?
Like nuclear power, the insurance business is one of those pinnacle-of-human-cleverness/ unimaginable-nightmare sort of things, and, like nukes, it has to be regulated to the hilt if it's going to do anybody any good. The industry has been heavily regulated for ages, and it seems that, after years of perfecting ways to avoid paying out to sick people under current regulations, the industry needs a new challenge.
Community rating, portability, new rules on pre-existing conditions: Almost everyone agrees that these changes are necessary. In fact, the really unfortunate thing about this health-care-plan morass is that these changes, which are the ones most important to most Americans, probably could have been enacted on their own months ago. Instead, these essential reforms are being held hostage while we fight over how to solve every single problem in the health-care universe all at once.
Drug Companies. Here's my chance to share the one thing I remember from my economics class. With most things, as the price goes up the demand goes down. You might like corn flakes now, but at $20 a box you wouldn't. On the other hand, if people needed corn flakes to stay alive, the demand would stay basically the same even when the price went up. Any for-profit business wants to charge whatever the market will bear; it's just that, when life or health is at stake, the market will bear a whole hell of a lot.
There's not much to be done about this. Drugs aren't corn flakes; they take millions of dollars and years of research to develop, they are protected by patents for only a limited time, and while I'm sure those fine scientists take satisfaction in the good they are doing mankind, our gratitude doesn't pay the rent.
But the wild disparities in drug prices between countries is annoying. Either drug companies can make a profit selling their products at a fraction of what we in the United States are being charged, in which case we're being hosed, or other countries are keeping the prices artificially low, in which case we are subsidizing the health care in those countries. I suggest we follow the lead of certain New York City electronics discounters, and arrange to import our drugs from whatever country sells them most cheaply.
All of Us. (1) We never want to die. (2) We never want to get sick. (3) When we do get sick, we want to take advantage of every conceivable medical technique that could possibly help us, (4) immediately, and (5) for free. And (6) we don't want higher taxes.
As a fan of science fiction, I see nothing wrong with aspiring to live forever. And I see nothing wrong with spending a big ol' hunk of our GNP on the attempt -- what would you rather spend the money on, anyway? But we need to direct the funds to where we want them most. The only way I know to accomplish this is through real personal choice -- that is, personal choice that involves personal money.
No one should be completely priced out of a yearly check-up or catastrophic health care, but beyond that lots of different kinds of coverage should be available for lots of different amounts of money. The person who wants to see his own doctor at no additional cost every time he has a cold, or the person who wants his Primal Scream therapy covered, should be free to have it as long as he's willing to pay more than someone enduring a high deductible or an impersonal HMO. Otherwise we are going to squander our resources on a lot of stuff we don't really need.
The one nice thing about this Universal Evil Health Care Plan is that it will unite all the warring factions -- in opposition to it. All that recognition of human nature and imposition of personal responsibility is bound to put everyone in a bad mood. I personally don't like the part about paying more for better-than-basic coverage, and I just wrote it.
Still, the beauty of our incredibly ineffectual legislative process is that, after everyone takes a whack at the Clinton plan for their own selfish reasons, something much like the above might result. If so, we'll be devilishly lucky.
Joan I. Greco writes for public television and teaches at Brooklyn Law School.