An unhealthy business


WE USED TO have health care, but now we have managed care.

"Managed care" is another way of saying "the health business."

Health has become a big business. Really big.

Corporate hospital chains are suddenly flourishing on Wall Street. Drug stocks always have.

The health-insurance branch of the insurance industry is constantly bobbing and weaving to dump off old, sickness-prone customers and snap up young, robust ones.

"Old, sickness-prone" means "a drag on profits," while "young, robust" means "My, how the money rolls in!"

The care provided by managed care is managed by insurance companies. They do the job by managing the doctors.

How? Doctors who don't shape up don't get the money from the insurance companies, which control more and more of it.

Naturally this causes a power struggle between doctors and insurance companies. But it is probably too late for the doctors.

For instance, the insurance companies have been insisting that mothers and infants be put out of the hospital after one day. Baby doctors say this puts profit ahead of sound medical practice.

In Maryland the doctors have won a small victory. There the state legislature favors a two-day hospital stay.

Victory or not, it is evidence of the insurance industry's dominating power that the state legislature must be bugled in like the cavalry to win an extra day for motherhood.

The rise of the health maintenance organization, or HMO, is a major piece of the story of how health came to be the health business.

HMOs organize participating doctors into cooperative sub-units of large profit-oriented corporate enterprises. A report by Robert Pear in the New York Times now discloses that more and more HMOs are refusing to pay for treatment their customers receive in hospital emergency rooms.

Sound business principles are at issue. The charm of HMOs is their power, supposedly, to hold down constantly rising costs for businesses that provide health coverage for their employees. The HMO people say allowing the customers unlimited access to hospital emergency rooms would put those costs out of control.

Cost containment or health care -- which comes first? Hospital people told Mr. Pear that cost containment as practiced by HMOs in this instance "discourages patients from seeking urgently needed medical care."

Meanwhile, back at the dump, more people are constantly joining the "uninsured" rolls. This is said to mean ever-increasing medical costs for everybody as the uninsured present themselves, late in the case and often hopelessly ill, at their nearest hospitals.

Who pays then?

Much admired though downsizing and lean-and-meanness may be just now, the Kevorkian solution is probably almost as repellent to most Americans as a tax increase.

This can only mean that the ever-rising bill for the ever-rising numbers of uninsured will be sent to hospitals and saintly doctors, who will struggle to pay them by padding their charges on the insured.

Which of course will press the industry for even more cost containment, more leanness-and-meanness, more downsizing, for ever-shorter hospital stays, ever-fewer trips to the melodrama of the E.R. when those chest pains strike in the wee hours.

The tax will be hidden, but it is inescapable and must be paid.

Did Harry and Louise tell us about this? If so, I missed it. If they had, doctors' enthusiasm for killing the Clinton health care bill might not have run so high. Not that there was much in that bill to stir anyone's enthusiasm.

Even the president's was so low that he tossed it to the Congress saying, "Do what you will." And what that dreary, pre-Gingrich Congress did was what it almost invariably did when facing heavy problems: nothing.

The president abandoned his bill, the Democrats abandoned the president and connived with the Republicans to treat the health-care matter as if it were a matter of caring for the insurance industry. And here we are: water six feet high and rising, and everybody out to lunch in New Hampshire.

Russell Baker is a New York Times columnist.

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