why the US needs a national health program
by Ana Malinow, MD
Dr. Malinow is a member of Physicians for a National Health Program and serves on the Steering Committee of the Harris County Green Party. She practices in an emergency center in Houston.

Robert is in Room 3. He is a 5-year-old boy, full of promise. He has asthma, like too many African-American children. Both of his parents work, yet he has no medical insurance, no regular doctor. When he starts to cough in the middle of the night, when it hurts to breathe, Mom drives him to the nearest emergency room. They had asthma medication at home, but Mom says they ran out and couldn't afford to buy more.
Penny, in Room 5, has had a runny nose all 18 months of her life. She goes to day care while Mom works. Dad holds down two jobs. No one has medical insurance. Sometimes her parents pay out of pocket for a doctor close to home; when they're short of cash, they bring Penny to the emergency room. I diagnose Penny with an upper-respiratory-tract infection and try to spend some time educating the parents about the common cold. They will get a bill for this, probably for $150.

Robert and Penny are among the more than 1 million children in Texas who have no medical insurance. They are the medically homeless, dragged to the nearest "free" emergency room for non-emergencies. A stranger will treat their symptoms but never know them. Parents will be expected to foot the astronomical bill. This is how we treat young Texans without insurance - 25 percent of our children.

The American health-care system is failing. It denies access to many in need; it is expensive, inefficient, wasteful and bureaucratic. It has become a cruel joke we play on our people when they are most vulnerable. It is in need of its own strong medicine. The time has come to change the direction of American medicine by developing a comprehensive national health program.

For more than 100 years, the United States has consistently rejected programs that guarantee health care as a right and promoted those that treat health care as a privilege. Cowardice in leadership has doomed us to a system of private insurance for those who can afford it and public welfare services for those who cannot. The exception is Medicare, embodying our insistence, despite strong opposition from the American Medical Association and Republicans, on covering hospital costs for our elderly.

Meanwhile, after the Clinton administration's botched attempt at universal health-care coverage, our managed-care (aka mangled-care) system leaves 44 million Americans uninsured. Of these 44 million, only 5 percent are unemployed. Fifty percent are employed; 20 percent are students over 18, homemakers, disabled or early retirees; and 25 percent are children. These are the children I see daily in the emergency center.

The problem is not that our government isn't spending enough money. Public spending per capita for health is greater in the United States than total spending per capita in other nations. The United States spends $4,270 per capita while Germany, our closest competitor, spends $2,400 and Sweden $1,820. Fourteen percent of our gross national product goes to health care; in Canada the figure is 9 percent, in Sweden 8.6 percent. Yet for all our spending, our health lags behind that of other industrialized countries. Life expectancy is lower and infant mortality is higher in the United States than in any other industrialized country. In Sweden, where universal health care has been in effect since 1962, patients over 16 years of age pay $9 per day for hospitalization; the maximum individual expense for hospital and physician services is approximately $108 per year; and the maximum individual expense for prescription drugs is $156 per year.

Can you imagine paying $9 a day for hospitalization? Under managed care, HMO overhead and profits have skyrocketed while care, access and satisfaction have plummeted. At Cigna, overhead and profit accounted for 33 percent of the premium, at Aetna, 25 percent. Cigna's chief executive officer was paid $69.2 million (including stock options) in 1998; compensation for the CEO of Warner Lambert totaled $303 million (that's not a typographical error).

It's hard to believe this money couldn't be better used to help Robert and Penny, along with 44 million other uninsured, not to mention millions who are underinsured and lack prescription-drug coverage. Insuring every uninsured person in America would cost about $12 billion per year, Physicians for a National Health Program estimates. But taking that step would save $67 billion per year: $40 billion in hospital and physician administrative costs plus $27 billion in insurance administration and profits. A national health program would produce a net savings of $55 billion per year.

So it would save us all money if Rosa, who is waiting in Room 2, had insurance. Rosa is 4. She has mental retardation and seizures, is fed through a tube and is confined to a wheelchair. She has frequent infections that require lengthy hospitalizations. But when it comes to insurance, her most serious problem is her place of birth: Mexico.

In Room 10, I notice that Brenda is behind on her immunizations. Brenda, who seems to have some language delay, hasn't had a regular doctor since the family lost Medicaid. Her mother has jumped through hoops trying to get her benefits reinstated. Streamlined procedures, as provided by recently passed Senate Bill 43, are good, but they're a Band-Aid on a burst aorta.

Americans do not need more patchwork health insurance, a kinder, gentler Medicaid. America needs a national health program. A program that covers everyone, from cradle to grave, providing all needed care without co-payments. A single, public payer with simplified reimbursement, not investor-owned HMOs or hospitals. Improved health planning and public accountability for quality and cost, with minimal bureaucracy.

Brenda looks at me from her mother's lap. She is 2, and not about to be too friendly with a stranger. She doesn't need a stranger in the middle of the night looking into her ear or listening to her heart. She needs a regular doctor who knows her, who will immunize her on time and talk to her mother about injury prevention and about reading to her at bedtime.

Like every patient I'll see today, like every child and adult in America, she needs health insurance.