Campaign Issues

By TED GUP

Sophocles wrote of an archer named Philoctetes, who was bitten by a serpent and whose wound would not heal. His countrymen were so discomforted by his injury and his anguished cries that they marooned the war hero on a desolate island. That is one way to deal with the suffering: remove them from sight. There are many like Philoctetes in America, citizens cast out from public consciousness because their medical problems seem too painful or costly to face. Among them: 37 million Americans who have no health insurance, a million young women too poor to provide adequate prenatal care for their unborn children, countless drug addicts turned away from treatment centers for lack of room, 73,000 victims of AIDS denied protection from discrimination.

Some policy analysts argue that, with an estimated $150 billion deficit this year, the U.S. cannot afford to tend to such people. But the truest index of a society is how it provides for its most vulnerable members. At stake is America's self-respect, the sense of community that binds it together, and its standing in the community of civilized nations.

The next President should make a priority of health, particularly the fair distribution of health services. With the notable exception of Surgeon General C. Everett Koop's commitment, this Administration has often gone no further in health care than bromides. Candidates George Bush and Michael Dukakis declare that health care is high on their agendas, but neither one has offered a comprehensive approach to the issue.

This year's enactment of catastrophic health insurance, the most dramatic expansion of Medicare since its inception, demonstrated that Washington can still respond creatively to a problem without busting the budget. There is a rightful consensus that expansion of the nation's health-care system must largely pay for itself; catastrophic health insurance will be paid for by premiums from those who stand to benefit. The program shows what commitment and ingenuity can produce, with the right leadership.

The first step in medical reform must be cost containment. Americans spent half a trillion public and private dollars on health care last year. Costs are skyrocketing at a yearly rate of 8.5%, more than double that of inflation and faster than in any other segment of the federal budget. By 1990 health-care costs will consume more than 12% of the nation's GNP, further draining resources from defense, education and other vital federal programs. President Bush or President Dukakis will be greeted his first year in office with a Medicare bill of $101 billion. By the end of his first term, it will be $164 billion. By the end of his second term, a dizzying $250 billion.

But often this pile of medical money has not bought better care or increased access. Instead, it has fueled a profoundly wasteful and inefficient system. "Thirty percent of what we do in health care is of no apparent benefit," says Marion Ein Lewin, of the National Academy of Sciences' Institute of Medicine. A Rand Corp. review of carotid endarterectomies, operations aimed at clearing blocked neck arteries, found nearly a third of the procedures "inappropriate." Similar questions have been raised about heart bypass operations and pacemakers. The next Administration must put a premium on value and coordinate a nationwide re-examination of diagnostic and surgical procedures to curtail the exorbitant, unnecessary or inferior.

Some physicians' incomes could also do with a little liposuction. The average thoracic surgeon last year earned $350,000 in gross income from Medicare billings -- seven times the amount taken in from that source by family doctors. Physicians' gross income from Medicare cases went up 16.3% last year alone. Employees of private industry saw a rise of less than 4% during that same period. Congress should weigh such numbers as it considers revising Medicare fee schedules. Nor are the patients blameless: Americans must come to learn that more expensive machines and elaborate procedures are not always better and that their demands for risk-free care risk pricing medicine beyond everyone's reach.

Cost containment alone won't cure the medical system. New sources of revenue must be found. Begin by doubling the federal excise tax on cigarettes. In recent years smoking has been recognized for what it is: an addiction and a health threat, often even to bystanders. This Administration championed "zero tolerance" and urged Americans to "Just say no" to other drugs. Let the next Administration commit itself to leading the U.S. away from its single most deadly habit. Cigarettes kill an estimated 300,000 Americans annually. That is 15% of the deaths in the country, far more than are caused by heroin, cocaine or other illegal drugs that have aroused such concern. Nonsmokers -- more than two-thirds of the population -- subsidize cigarettes through increased Medicare and Medicaid payments to provide care for victims, as well as through stiffer private insurance premiums that reflect smokers' high rates of heart disease, cancer and emphysema. The congressional Office of Technology Assessment estimates that the health and lost-productivity costs of smoking total $65 billion a year.

Federal excise taxes on cigarettes are about 16 cents a pack. For every additional penny levied on the 29 billion packs smoked yearly, the Government would raise $290 million. Doubling the tax -- call it a user fee -- would yield an additional $4.6 billion that could be earmarked for health care. That revenue would be only half the benefit. Kenneth E. Warner, a professor at the University of Michigan's School of Public Health, estimates that doubling the cigarette tax would cut the population of teenage smokers by 17%, protecting more than 800,000 young Americans from cigarettes. Governments at all levels should also push for further restrictions on smoking. Airplanes were a first step. Hospitals could be a next step, then perhaps schools.

Catastrophic health care was only the first problem addressed in assisting the chronically ill who desperately need help in paying for nursing-home and home health care. As the population grays, those demands will grow. But paying for programs projected to cost $30 billion to $50 billion a year will take sizable increases in taxes on payrolls, gifts and estates. Moreover, ; Washington will need both compassion and political gumption to achieve so- called generational equity. The sometimes stentorian American Association of Retired Persons ably represents America's elderly, but it should not be allowed to drown out the softer voices calling for improved prenatal and infant care. U.S. infant mortality rates remain among the highest for all industrialized nations; 40,000 newborns will die this year. "Children don't vote, but they surely need a constituency," says Dr. William Roper, a pediatrician who is head of the Health Care Financing Administration.

Children also make up about one-third of the 37 million Americans who have no health insurance. Today the uninsured are sometimes dumped by hospital after hospital, forced to "crawl around like health-care beggars asking for some kindly doctor's or hospital's noblesse oblige," says Uwe Reinhardt, professor of political economy at Princeton University. Of the industrialized nations, only South Africa and the U.S have not made an effort to extend coverage to all their citizens. If compassion were not an argument for remedying that dreadful situation, economics might be. At present the costs of the uninsured are hidden and spread unevenly in the form of higher insurance premiums and general medical costs. Bad debts and uncompensated care totaled an estimated $8 billion last year.

In Massachusetts a new law signed by Dukakis will require employers to pay for health insurance, and the Governor has proposed a similar program on a national scale. The proposal is regressive, since the added costs threaten marginal businesses and might put the lowest-paid workers back on the street. Yet firms unable to bear the full brunt of expanded health benefits might participate in insurance pools, phase in their contributions and get some Government help. A larger difficulty is that while the Dukakis plan would offer relief to uninsured workers and their dependents -- about 22 million people -- it does nothing for the 15 million uninsured Americans who are without jobs. Dukakis skirts that problem with the quintessential Washington hedge: a task force.

Bush has singled out pregnant women and infants as a priority for health coverage, the costs to be paid by the rising tax revenues of an expanding economy. But for most of the uninsured, he offers only a vague suggestion that they "buy into Medicaid." With what? Even among the uninsured who work, about half earn less than $5 an hour. Their contribution to a Medicaid insurance fund would be either meaninglessly meager or unconscionably expensive.

Republicans have suggested that the Dukakis plan smacks of socialism. Ironically, it bears a striking resemblance to a plan put forward in February 1971 by a man seldom accused of being a liberal: Richard Nixon. The most equitable -- and therefore politically least feasible -- solution would be to launch a federal health-insurance program financed by premiums based on income. Do not look for any candidate running for office to suggest that one.

The passage last month of a $1 billion-plus AIDS bill has given a vital boost to research, testing, education and home health care for that incurable disease. But Ronald Reagan has refused to use his Executive power or persuasive skills to fight discrimination against AIDS victims, even though the presidential commission on AIDS recommended that he do so. Recent surveys indicate that 25% of Americans do not want to work beside an AIDS carrier. And 40% do not want someone with AIDS living in their neighborhoods. The Administration's silence on this issue has sanctioned prejudice and baseless fears that will drive AIDS carriers to conceal their condition, making the epidemic that much harder to combat. To their credit, both Bush and Dukakis have said they will support antidiscrimination legislation.

AIDS must be stopped at a key point of transmission: the insertion of a needle. "There has been a real discrepancy between the rhetoric of the war on drugs and the care available to intravenous drug users," says Dr. Robin Weiss, director for AIDS activity at the Institute of Medicine. Treatment centers would have to be expanded tenfold to accommodate the nation's drug abusers. At some centers, the waiting list is two years long. New York City last January had 29,400 methadone-maintenance treatment slots for an estimated 200,000 IV drug users.

That Government is limited in what it can do is less a matter of political philosophy than economic reality. But what family does not count the health of its members as its most precious asset? Either President Bush or President Dukakis would do well to remember Philoctetes the archer. After exiling him to that barren island for ten years, his countrymen learned they could not take Troy without his mighty bow. They were forced to return and rescue him from exile. It is time the U.S. does the same for those it has abandoned.