Moral Malpractice

America's health care system is in dire straits. Proper medical care has long been denied to the poor in this country, and now the middle class can't afford it either. Most proposed reforms would be mere Band-Aids unless the public--and especially the religious community--demands wholescale change.

Born prematurely to a 16-year-old mother who had received inadequate prenatal care, Lisa spent the first weeks of her life in a hospital intensive care unit. When she was finally sent home to her young mother's apartment in a Nashville housing project, Lisa still had breathing difficulties. Arrangements were made for her to sleep with an apnea monitor, a device that would sound an alarm if she stopped breathing.

One day, Lisa's mother answered a knock on her door to find a man standing there who was from the medical supply corporation that had furnished the apnea monitor. It turned out that he was the company's "repo" man whose job was to take back medical equipment from patients whose lease or installment purchase payments had fallen behind. The Medicaid program, which pays for health services for some of America's poor, had missed a payment on Lisa's monitor.

Lisa's mother pleaded with the repo man not to confiscate the apnea monitor. The device had already saved the child's life on several occasions, and the young mother was terrified. If she could just have some more time, she was sure that she could find out what the problem was and get Medicaid to resume its payments. But the repo man was firm, explaining that he had a job to do. The monitor was returned to the supply company.

Lisa's mother tried to stay awake, but of course could not do so indefinitely. That same night Lisa stopped breathing. By the time she reached the hospital, she was dead.

TERRY TAKEWELL was a 24-year-old construction worker who had suffered from diabetes since childhood. Like most construction workers, his job carried with it no health benefits, and with his medical record, Terry could not buy an individual health insurance policy at any price. During recurrent diabetic crises, Terry built up a large bill at Methodist Hospital in Somerville, Tennessee, where he lived.

One afternoon a neighbor in the trailer park where Terry lived came over to visit him after work. She found him quite ill and called an ambulance. A physician examined him, found him to be suffering from a diabetic condition known as acute ketoacidosis, and ordered him admitted immediately to Methodist Hospital.

Terry had been in the hospital less than an hour when word reached the acting administrator that he had been admitted. Alarmed at the prospect of the young man incurring another bill that he would be unable to pay, the hospital official personally went to Terry's hospital room, lifted him under the arms, and dragged him out of the building, leaving him propped under a tree in the hospital parking lot. His neighbor found him there a short time later, clad only in pants and a T-shirt.

Indignant, she called the hospital, which confirmed that he could not receive care because he had failed to pay his earlier bills. The neighbor took Terry back home to his trailer, laid him on his couch, and tried to make him as comfortable as she could. That's where he was found, dead, the following morning.

The shopping mall ethic of American health care

WHAT THESE STORIES have in common is that each is the inevitable consequence of treating health care, like CD players or designer jeans, as simply another commodity for sale. Those who can afford it get it (sometimes even when it is not necessary). Those who can't, don't. As one hospital-chain executive observed when questioned about his corporation's denial of treatment to a dying cancer patient, "General Motors isn't expected to give away cars. Grocery stores don't give away food. Why should anyone expect us to give away care to someone who can't pay for it?"

The French call it capitalisme sauvage. "Barbaric" is the less elegant term that other free market countries apply to the United States' peculiar institution of commercialized medicine. In other industrialized nations, access to basic care is a right of citizenship, much like a free public education or fire protection.

Citizens from such nations are intrigued by individual feats of medical virtuosity performed in the United States, but they are appalled at the moral dimension of a system that so unapologetically rations health care on the basis of wealth. How, they ask, can a civilized society make face-lifts available upon demand to the affluent while lifesaving care is withheld from the poor? Why are American advertising agencies paid hundreds of millions of dollars to market health services while millions of our children lack even basic immunizations? Other countries reject our entrepreneurial approach to medical care for what it is: Social Darwinism in its starkest form.

At home, however, moral sensibilities are curiously dulled. While the term "health care crisis" is becoming a cliche, it is largely devoid of moral content. Business leaders use the phrase when complaining about the spiraling cost of employee health benefits. Doctors use it when complaining about rising malpractice insurance premiums. Hospital investors refer to a "crisis" when complaining of government efforts to curb inflation in the Medicare and Medicaid programs.

But American religious leaders have just begun to characterize our country's health care system as being in a state of moral crisis.

Cradle to grave: Symptoms of a moral crisis

OUR INFANT MORTALITY rate, which the World Health Organization recognizes as perhaps the most accurate single index of how well a nation attends to the health needs of its people, is worse than that of 14 other nations. This poor standing is largely a function of economic deprivation and a legacy of racism.

Infant mortality rates for blacks are twice as high as those for whites. In fact, an African-American infant is less likely to survive to her first birthday than a child born in any of 28 other countries, including Cuba, Singapore, and Bulgaria. While a number of social pathologies associated with poverty help account for these grim statistics, the single most important factor is the lack of mothers' access to early, comprehensive prenatal care.

Congress and the states have moved in recent years to broaden access by liberalizing eligibility requirements for the Medicaid program. However, in a context of commercialized medical care, these steps have had only limited effect: Doctors and hospitals have often spurned Medicaid mothers because tightly regulated Medicaid rates make them less financially attractive as patients than those who are privately insured.

Thirty-seven million Americans have no health insurance, and the number continues to grow as health care hyperinflation pushes the cost of insurance beyond the reach of more and more individuals and employers. Another group of at least equal size is officially classified as underinsured, meaning that the insurance they do have is inadequate for their most basic health care needs.

In a society that conditions access to care on one's ability to pay for it, the consequences of being inadequately insured can be grave. While Terry Takewell's death illustrates that point, others die every day in the United States under less dramatic circumstances because they, too, lack adequate health insurance. The American Cancer Society has noted that the cancer survival rates among the uninsured are markedly lower than those with adequate health coverage, and for obvious reasons. People who know they cannot afford health care will not seek it in the early stages of cancer when it might be treated successfully. Others die, unremarked, of strokes simply because they did not have the money or insurance to pay for hypertension medication.

No age group is spared. The elderly, at least, have partial public health coverage under the Medicare program. Yet they, too, pay a high price to sustain a health care system in which profits take priority over patients. Nowhere is the toll on the elderly more evident than in nursing homes.

Nursing home lobbyists have effectively resisted the redirection of government subsidies away from their business and into programs that would provide health personnel to assist in the care of frail patients at home. The result: Many of the elderly and disabled are needlessly consigned to the loneliness and despair of institutionalization.

The myth is that they are abandoned by uncaring relatives. The reality is that they are victims of a national health policy that subordinates their humanity to the business interests of nursing home entrepreneurs.

Trickle-up economics

EVEN APART FROM its direct toll in physical suffering and death, America's commercialized health care system makes demands on our conscience for another reason: The system operates as a huge mechanism for the redistribution of wealth to the most affluent segment of society from those of lesser means. For more than two decades, health care costs have inflated twice as fast as personal income. The health care business continues to corner an ever growing share of the society's resources; health costs accounted for 11.6 percent of gross national product in 1989, up from 5 percent in 1960.

This "trickle-up" phenomenon is at the expense of other sectors of the economy, and especially those lower income individuals without adequate insurance to insulate them from the health cost spiral. Indeed, doctor and hospital bills are now a leading cause of personal bankruptcy in the United States.

At the opposite end of the income transfer system, the average physician earned approximately $155,800 in 1989. Security analysts report that in 1990, the mutual funds that outperformed all others were those which invested exclusively in health care stocks.

Economic injustice is perpetuated within the health care industry as well. Not all health care providers benefit from the redistribution of wealth wrought by the commercial health care system. Much of actual hospital care, and the great majority of nursing home care, is provided by aides who are disproportionately women and people of color. Their work is physically demanding and emotionally draining. It is also critically important.

Yet these workers typically earn little more than minimum wage. Hospitals and nursing homes, including those that are church affiliated, lobby vociferously against increases in the minimum wage, precisely because it would affect so many of their employees. Ironically, many of these corporations do not provide health insurance for aides or their dependents.

Ethics and the bottom line

CERTAINLY ONE REASON that moral alarm was so late in coming from much of the religious community is a factor not unique to this issue: There are no evils so invisible as those we have lived with all our lives, and none so intractable as the ones we cannot see. Commercialized health care has been with us so long that we tend to regard it as part of the natural order of things. Our oblivion has been cultivated by those who profit from the current system and who regularly decry as "socialized medicine" any suggestion of a need for health care reform.

There is another reason why until recently many church leaders have said so little on this subject. American religious organizations have a heavy investment, both financial and political, in the status quo. All of the major religious groups have strong ties to hospitals or nursing homes. In some cases the religious orders or denominations own the facilities. In other facilities, the ties are more nominal. In either case, the religious bodies have traditionally taken pride in what they have seen as their "health ministry." The churches have naturally accepted the leadership of their affiliated health care administrators on matters relating to health policy.

In today's commercialized medical marketplace, such deference on moral matters is no longer safe, if it ever was. Religious hospitals were founded a century ago as acts of true charity, providing havens where the poor could go to die in the consolation of their faith. Today they are large, complex financial institutions whose administrators command six-figure salaries. These days, nominally charitable hospitals must, and do, respect the dictates of the marketplace.

Nothing better illustrates the clash between ethical values and financial constraints than the phenomenon of "patient dumping." "Dumping" is the term applied to hospitals' practice of turning away patients who lack insurance and money. It has been illegal for a number of years for hospitals to dump "emergency patients," technically defined in most instances as those who are faced with loss of life or limb within 24 hours if left untreated.

Even emergency patients, however, receive little real protection from the anti-dumping laws, for laws are no match for the imperatives of a hospital's bottom line. A study published in 1987 in the Journal of the American Medical Association estimated that 250,000 emergency patients are dumped from our hospitals each year in violation of the law. As competitors in the medical marketplace, hospital administrators must weigh the certain losses associated with treating an uninsured patient against the remote contingency of being fined for a violation of the law. A policy of dumping the uninsured is, therefore, a supremely rational one, dictated by the rules by which our country has chosen to organize and finance health care.

With regard to dumping, as in most other areas of operation, religious facilities are frequently indistinguishable from their secular, for-profit competitors. Dr. Arthur Kellermann, medical director of the emergency department at the city hospital in Memphis, made this point graphically at recent hearings on the failure of federal anti-dumping laws to curb such abuses. Upending a garbage bag full of plastic patient identification bracelets, he explained that they had been removed from patients who had made their way to his hospital's emergency room after being dumped from other hospitals in the area, in spite of their dangerously unstable condition. The jumble of bracelets bespoke a sad ecumenism, as Dr. Kellermann explained, "This color is from Baptist Hospital, these are from Methodist, and those are from St. Francis."

Religious organizations also operate nursing homes. The care they provide tends to be of better quality than the shockingly poor norms set by the for-profit chains which dominate the industry. Unfortunately, the religiously affiliated nursing homes also tend to be racially exclusive. The exclusivity of these tax-exempt institutions is a product of high financial barriers to admission. Their nominally charitable services thus remain inaccessible to the poor (who are disproportionately people of color). In the parlance of commercial health care, these religious facilities "market" to upscale patients who also happen to be large contributors and therefore more influential within the church community.

Yet these elitist facilities also accept Medicaid subsidies intended for the benefit of the poor. Rather than using these funds to open their facilities to the needy, many religious institutions simply use the subsidies to offset losses they would otherwise incur on those more-affluent patients who happen to outlive their financial resources.

Church-affiliated health providers tend to act like their explicitly commercial competitors, not only in their treatment--or refusal of treatment--of the poor, but also in their political behavior. Religious organizations in both the hospital and nursing home industries are generally loyal dues-paying members of industry lobbying groups that vigorously oppose systemic reform.

Thus hospitals that were originally chartered to serve the poor and vulnerable now give financial support to hospital industry lobbying campaigns to block laws against patient dumping. Church nursing homes that provide humane care themselves support, through their membership in nursing home trade associations, industry efforts to blunt regulation of substandard care.

In fact, church-related facilities often enjoy a prominence in such trade groups that is out of proportion to their numbers. Other, less savory medical entrepreneurs find it useful to let religious institutions represent their industry before the public. There is little evidence to indicate that most churches are aware of, much less troubled by, their indirect support for such lobbying activities.

To be sure, there are still religious activities worthy of the title "health ministry." But the more authentic ones tend to be low-budget, small-scale enterprises: AIDS hospices, clinics for the homeless, and the like. And while some church bodies, such as the Catholic Health Association and the Interreligious Health Care Access Campaign (see "Finding a Cure for Our 'National Disgrace,'" page 14), have adopted health policy positions supporting access to care for all, the health care institutions affiliated with them continue to march to the tune of the marketplace. Where churches have waded into the mainstream of the commercial health care system, they have almost invariably been co-opted.

Finding our moral voice

THE CRISIS WILL get worse before it gets better. Families USA Foundation and Citizens Action, two Washington, D.C.-based advocacy organizations, project that health spending per person will more than double by the end of the decade. As a consequence, more and more of the middle class will fall into the ranks of the uninsured. The number of public hospitals that serve the uninsured will continue to dwindle. Under pressure of rising health costs, states will continue to cut back their Medicaid programs (as more than 30 of them are already proposing to do this year).

It seems unlikely that change, when it does come, will mean significant reform. Many of the policy proposals now in vogue are expected to save employers and government money by further restricting the public's access to care. Few are questioning the basic American premise that health care be organized primarily for the purpose of producing wealth for those who sell it.

As long as that premise goes unchallenged, policy makers will continue to regard as hopelessly expensive any proposal to extend health care coverage to all Americans. And why shouldn't they? If health costs are already bankrupting us, what would happen if we tried to care for tens of millions now excluded from the system?

In fact, America's unique institution of commercialized medicine is far more expensive and less efficient than that of other industrialized nations that provide care to all citizens. Dollars presently wasted on a bloated health care industry are ample, if redirected, to meet the needs of people now being denied care.

For example, an estimated 20 percent of total U.S. health spending goes into administrative overhead associated with the marketing of thousands of different types of insurance policies, and the costly claims-processing apparatus necessary to cope with such complexity. Hospital bills are inflated by the cost of maintaining thousands of vacant beds--more than one third of the nation's supply--even as competing hospitals continue to build costly new facilities in an effort to "capture better market share."

Thus real health reform is financially feasible. There are enough resources to address the needs of the entire society. But reform will not be politically viable until the nation finds its moral voice. Only when the complicity of the American religious community ends and enough people condemn the moral bankruptcy of the current system will it be possible to achieve a just alternative. Until then the poor or merely unlucky will continue to suffer and die needlessly, victims of America's profitable but uncaring system of health care.

Editors' note: Finding a cure for our "national disgrace"

President Bush contends that the U.S. health care system provides "the best quality health care in the world," and some see his health care "reform" proposal as little more than a means to block any meaningful attempts at comprehensive change. Religious leaders, in contrast, have called the present system a moral outrage and a national disgrace--and have launched a campaign to overhaul the structure of American medicine.

The "Interreligious Health Care Access Campaign" was launched in January by 15 national and 30 state religious bodies after two years studying the health care crisis and developing a 12-point document of working principles. Most major mainline Protestant denominations have backed the campaign. The U.S. Catholic bishops issued their own set of criteria in a 1981 pastoral letter, calling health care a basic human right and calling for comprehensive reform of the health care delivery system.

Three factors suggest that this is an opportune time for proponents of health care reform: 1) the election of Sen. Harris Wofford in Pennsylvania under the rallying cry of the right to medical care; 2) the growing anxiety of the middle class, already squeezed by the recession, over access to affordable health care; and 3) health care reform has become a central issue in the presidential campaign.

Genuine reform has some powerful opponents. Any movement toward national health insurance will be strongly opposed by the health insurance industry, some medical personnel, and others who profit from the current system--all heavy contributors to political campaign coffers.

--The Editors

Sidebar: How to Know Reform When we See it

Health reform proposals abound. Even opponents of change are floating their own proposals to confuse the issue and obscure true reforms. In fact, the sheer number of alternative plans now on the table poses a major obstacle to progress, with many politicians claiming they are stymied by the lack of any clear consensus.

While the details of implementation are sometimes arcane, the major health policy choices facing Americans are straightforward enough. True reform can be distinguished by its adherence to several essential principles.

Universality. Basic health coverage should be extended to all. Some proposals would merely reduce, not eliminate, the number of uninsured. For example, so-called "pay-or-play" schemes, which require employers to insure their workers ("play") or pay additional taxes to cover their care under a public program, often shortchange the unemployed.

Some plans fail the test of universality because they would consign the poor and otherwise uninsured to a health program distinct from that of the general population, thereby relegating them to inferior care and marking them for discrimination by health care providers. Single-payer systems such as Canada's achieve universality by extending the same coverage, with identical benefits, to each individual.

Affordability. Effective cost controls are imperative. At one level that means that individuals must be protected from personal liability for major health expenses. For example, many otherwise sound reform packages omit coverage of long-term care in nursing homes. Others leave out prescription drugs. Such omissions would leave many without the means to obtain such care on their own. Out-of-pocket expenses imposed on individuals should be held to a minimum and restricted to payment for amenities such as private hospital rooms or cosmetic surgery.

At a national level, the system must be capable of curbing health cost inflation. Otherwise, long-term political support will erode as the taxes needed to sustain the system rise faster than personal incomes. The most successful approaches to controlling costs have involved the setting of overall health budgets by publicly accountable authorities as in the Canadian model.

Accountability. A reformed health care system should be accountable to the public. Responsible authorities must be more than passive purchasers of care, as is the case with the existing Medicare and Medicaid programs. They must have the means, as well as the responsibility, to shape the delivery of care in order to ensure its quality and responsiveness to patients.

Payments to providers should incorporate financial incentives that reward quality care. Proposals that build on the present patchwork of private insurance and the public Medicare and Medicaid programs would perpetuate many of the perverse incentives of the current system, which neglects primary and preventive care and encourages overuse of high-tech, invasive medicine.

Political Feasibility. Some of the least satisfactory proposals now circulating are offered by political leaders who recognize their inadequacy but believe that more meaningful improvements are not politically achievable. This limitation, though important, is subject to rapid change. As voters become more discerning and demand true reform, change that is now considered unrealistic will come within our reach.

Gordon Bonnyman was a legal aid attorney in Nashville, Tennessee, when this article appeared.