Please check your bill

While carrying his infant son, my friend Harvey slipped on tile and broke his wrist. He had an outpatient, non-emergency, one hour surgery in the nice hospital down the hill. After he got his bill, he called their business office to see when they'd be delivering his table.

"What table?" they asked.

"On my bill," he said, "you've listed $700 for a table. At that price, I figure it's mine."

"Oh, that's just the charge for your use of the operating room table."

Harvey pointed out that the hospital bill for $6,950 also included a charge for use of the operating room. "Doesn't that room always come with a table?"

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Of course, the anesthesiologist and the surgeon billed Harvey separately. But soon he got another bill from an unknown assistant surgeon--his primary surgeon said he'd needed help. Harvey's insurance company said no backup was needed for so routine a procedure, and refused to reimburse him.

Harvey's insurance type (more important than blood type or actual malady) is the traditional fee-for-service. But another insurance type, managed care groups, is proliferating. In order to sustain their revenues as these groups negotiate better deals, medical providers are billing their fee-for-service patients aggressively. (Hence the operating table surcharge and the back-scratching assistant surgeon.)

The United States is the world leader in percentage of gross domestic product spent on health care. We spend about 50 percent more than other industrial nations and get less access, less security, less satisfaction, and poorer health.

Because American voters have started focusing on this basic discrepancy, the health care industry has said that it wants reform, too, darnit. And as professionals they can save us from amateurish mistakes. We should know that government-imposed cost controls will lead to scarcity, rationing, and black markets. Entrepreneurs will flee the field, depriving us of tomorrow's wonder cures.

To warn citizens about the dangers of federal intervention, the health lobbies have hired our leading senators and representatives. Big health contributors have increased their donations to Congress 41 percent since Clinton's election.

The five biggest insurance companies tried to cut their own deal with the president. In exchange for his blessing their control of managed care, they promised not to fight universal coverage and limited cost controls. Enter Rep. Jim Cooper, D-Tenn., on behalf of small insurance companies and all the other medical players. His reform of Clinton's reform would eliminate cost caps and allow all businesses with more than 100 employees to shape their own plans. Essentially it would preserve the status quo, along with cherry-picking of patients. The majority of the uninsured would remain so. (Not coincidentally, this past year Cooper received more contributions from the health care industry than any other representative and all but one senator.)

The alternative to the Clinton and Cooper plans is a Canadian-style single-payer plan in which the insurance middleman is cut out. When Hillary Clinton granted a rare audience to single-payer advocates, she challenged them with a question: What political forces do you see in the country that could counteract the $300 billion-a-year insurance industry?

They answered: Polls show that 70 percent of Americans would support single payer if the president led them.

From the national bully pulpit Clinton could easily have explained single payer: how the administrative savings are enough to cover everyone currently uninsured; how patients could choose their own doctors. Opposition would have been ferocious, but Clinton could have peeled off many physicians who realize they're becoming corporate employees in a downsizing era.

Of course, with single payer we'd have to make some group decisions (via our elected representatives) to contain medical inflation. Likely to go would be last-minute procedures that do little to prolong the quality or duration of life. We would also shift some resources from costly acute interventions to preventive care. If individuals didn't trust the public realm with these choices, they could buy supplemental insurance, like that available in Australia, France, and Germany.

The specter of group decisions, however, may suppress single payer this time around. Americans are optimistic by nature. We feel we can cut a better deal alone. We're not sure we want to be lumped in with our neighbors, let alone the uninsured whom we secretly blame for their fate. Such misgivings allow the powerful to exploit our fear of change with scare stories and misinformation, even though the evidence shows that every other industrialized nation has successfully directed medical investments and regulated payments.

Clinton's flawed plan has one significant reform: Insurance companies will no longer be able to exclude those with pre-existing medical conditions. But we must demand that in the pending legislation access be immediate, coverage comprehensive, insurance premiums capped, a national health care budget established, and states allowed to create their own single-payer systems. Without such minimal guarantees, the new national Health Security bill will be as fraudulent as the one sent to my friend Harvey.