By Philip J. Hilts
N.Y. Times News Service
WASHINGTON _ The American
health care system is the most expensive
in the world, but for those not in its
mainstream, the care it offers is among
the most unsatisfactory. Americans pay
$700 billion a year for health care but 34
million of them remain uninsured. Life
expectancy in the United States is shorter
than in 15 other nations, and infant
mortality is worse than in 22 other
Many believe this is a system in crisis,
a crisis marked by sharp contrasts drawn
mostly along class lines but permeating
every segment of society. Now, after
decades of fruitless debate, it has
inspired a sense of urgency.
In Congress, there have been more
than a dozen proposals to revamp the
system. And last week the medical
establishment, through its leading pro-
fessional publication, the Journal of the
American Medical Association, trum-
peted its concern and called for action.
While these and other advocates have
produced a bewildering diversity of
overhaul plans, they agree on at least a
couple of things:
Reforming health care is essentially
a political problem.
It will be difficult to solve without
leadership from the White House, which
so far has had little to say on the issue.
A main concern of reformers is that
patients' medical needs play so small a
role in determining levels of care and
reimbursement. Ron Pollack, executive
director of Families U.S.A., a non-profit
health reform group, tells of a Maryland
couple with full health insurance that has
been bankrupted by their son's ailment.
A star soccer player by day, the boy
suffers near suffocation every night
because of a nerve disorder.
The family's policy, as most policies
do, has an upper limit on some expenses,
and theirs _ $100,000 per dependent _
was exceeded when the boy was 11
months old. He is now 10 years old; his
family is $600,000 in debt.
For the public, fear is growing. In any
two-year period there are 34 million
people without health insurance. But the
number who lose their insurance at least
temporarily is nearly double that many,
For businesses, tension is rising.
Companies watch as health care spend-
ing devours ever larger portions of their
profits. In the 1960s, businesses spent
between 4 percent and 8 percent of each
dollar of profits on health care. In 1990,
it was 25 percent to 50 percent and
For labor, anger mounts. The Service
Employees International Union reports
that the proportion of workers involved
in health-care related strikes rose from
18 percent of all strikers in 1986 to 78
percent in 1989.
Enter the doctors. Last week, the
American Medical Association _ a
group usually seen as fiercely opposed to
all social reform in medicine _ shed its
inhibitions. The Journal of the American
Medical Association and all of its nine
attendant journals were devoted to calls
for health care reform. There were no
fewer than 13 separate proposed solu-
The new leadership at the physicians'
group made strong statements of new-
found fervor for reform.
"The AMA's old style was to react
and be against things," said C. John
Tupper, president of the association.
"But there has been a philosophical
change in our house of delegates (the
group's policy-making body).
"We will be out front where the
action is. We'll stop being just selfish
and only thinking of our own welfare. If
we start taking good care of our patients,
they will take care of us.
"I think we will see health care
reform high on the list of both presiden-
tial candidates in the next election."
But on the Potomac, when there is too
much interest in a subject a political
paralysis can result. In Congress there
have been no fewer than 14 proposals to
revamp the national system. At the
White House, there have been no major
proposals, as political specialists wait for
the right conservative proposal and the
right moment _ just before or just after
the election _ to put it forward. …