American Medicine Heading for Collapse. . .

Bt Harvard's New Health Plan May Rescue Patient and Doctor

In response to the medical crisis, the government has unloaded its standard fiscal arsenal. Through programs like Medicaid, it has hoped that it could give people money and let them buy their health -- as easily as hungry people could buy a loaf of bread. But the money does no good when the medical care isn't available.

(This is the first in a two-part series. Today: the explosion coming in American health care; the plan Harvard has devised to head it off. Tomorrow: the Med School's scheme for helping the sick in Roxbury; the public's role in running the health plan; Harvard's role in shaping a national reform.)

AS AMERICA has slowly worked its way down he roster of internal needs that demand quick solution, one previously-overlooked trouble spot has worked its way up in priorities. The impending crisis in America medical care has become too blatant to ignore any longer.

Anyone who has spent time in a U.S. hospital recently knows part of the problem. The astounding increase in the cost of hospital care shows no sign of slowing down, and it makes the much bewailed "rise in the cost of living" look trivial by comparison. While the cost of staying alive in America has jumped some 21 per cent since 1960, the cost of staying alive in a hospital has zoomed up by nearly 125 per cent. Drugs an physician's services haven't quite kept pace, but they have both risen by about 45 per cent in the last ten years.

But this mushrooming cost is only the most visible part of the medical crisis syndrome. Taken in a long-term view, it is also the least disturbing part. Much of the rise in hospital cost comes from inevitable--and desirable--sources. The ceaseless stream of marvels that medical researchers produce certainly save more lives. But they also gobble more dollars in the process. And the other major component of the hospital cost increase--higher wages for cooks, janitors, and the other prosaic workers who help care for the patients -- helped solve another obvious social need. The semi-sweatshop laber practices of the 1950's hospitals had to end; unfortunately, ending them meant hiking hospital charges another step.


If this price rise were all American medicine had to cope with, the solution would be easy. But the cost is not the whole be problem. More disturbing than higher hospital bills is the fact that many people don't even have a chance to pay those higher bills. While American medicine has surged ahead in some areas, it has still lagged in one of its chronic trouble spots. The distribution system that is supposed to send medical benefits out to the public is hopelessly inadequate to its task.

THE CAUSES of the distribution breakdown aren't hard to trace. While the groups of Americans that live near sophisticated medical centers can tap the full bounty of medical technology, those trapped in isolated areas aren't able to share. The traditional social hierarchy operates in medical care, too: white Appalachians, black Alabamians, and slum dwellers of various tints all have disease and death rates high above the national average.

"It is sickening, pompous, and criminal," an unpopular speaker at an AMA convention in 1966 said, "To speak of the United States as having any kind of medical care when many people can get no care at all. Until we can give everyone some part of the product, we can take little comfort in the help we give a few people."

Faced with the pressing demand of healing its sick people, the Federal government has responded with a standard tactic. The government has unloaded the federal fiscal arsenal--through programs like Medicare and Medicaid--and hoped that the poor would be able to buy their health, much as hungry people could health, much as hungry people could use government money to buy a loaf of bread. The simplistic analysis, however, ignores the root disease of the medical system. The money can't do any good when the care is not available.

But by their wallowing fiscal deaths, Medicare and Medicaid may have made a valuable contribution. Many medical administrators regard Medicare as the final piece of argument needed in the case for a new system. As the government's programs have shown, money is futile unless coupled with long-range plans to improve distribution.

INTO THIS medical morass, the Harvard Medical School has stepped. Harvard's role as a healthy spawning ground for medical talent as well known. But the Med School's attempt to soothe the medical crisis has now involved it in a task more typical of the Business School. Led by Robert Ebert, dean of the school, and Jerome Pollack, an experienced medical administrator from New York, the Med School planners are working on a scheme that may offer American medicine a way out of its current welter of ills.

At first glance, the plan that Pollack and his Community Planning staff offer does not seem too revolutionary. It is called the Harvard Community Health Plan, and in essence it is just another kind of insurance system. People pay money into the plan; in return, they have their medical expenses covered.

But the similarities between the Community Health Plan and conventional insurance end at that simplistic level. The plan does retain the insurance ethic of prepayment for guaranteed benefits. But the new system the plan has devised for dispensing the benefits adds up to a totally different approach to mass medical care.

The "totally different approach" comes in several segments:

* The Health Plan's theory of "prepayment." Standard insurance systems eventually pay some medical costs--but only after the patient has paid by himself and applied for reimbursement. Once the Health Plan patient has paid his entry fee, he can get almost any medical service free at the health center;