Extending Health Care security to seniors, kids and the vulnerable

By William R. "Bill" Orton

We are entering a "post-HMO" world, where the future of health care needs new definitions. We must make some big decisions, so that seniors, children, families and our most vulnerable citizens can be confident that they are protected.

In the generation after World War II, there came to be a medical culture focused around hospitals as a primary health care service unit. Large hospital flourished as they became the center of expensive services and technology. Patients who had conditions that previously could not be treated or where treatment was too costly or inefficient suddenly found that regular journeys to the hospital prolonged life.

These advances in treatment were accompanied by tremendous growth in the insurance industry, which started to concentrate its attention on the process by which decisions affecting the bottom line were made.

When pharmaceutical drugs emerged as a true competitor to the hospital, there began a slow decline in the economic power of great hospitals. People who previously had to spend hours and days getting treatment for chronic conditions could, miraculously, take a pill to control their symptoms. These drugs became very expensive, but, on the whole, often cut the costs significantly for care, as people were no longer admitted to hospital.

Thus rose the concept of the HMO. Begun by Henry Kaiser, as a service for his steel workers, the concept of a medical staff that had to clear decisions with a cost controlling team was not new. But as insurance shifted its sights to the HMO model as the way to control the bottom line, this became the way that most people received health care.

There's always someone to say no. There's often a doctor who says, with frustration, "there's nothing I can do."

And now, as HMOs have competed brutally against one another, we are seeing great death throes within the industry. There have been mergers, consolidations and squeeze-outs. Costs have risen, owing very much to the reliance upon expensive drugs.

And so we must ask, what comes next?

How can we be sure that the concepts of "capitation" and "authorizations" and the idea that doctors have simply become workers within a company will still hold up in ten years?

I don't think they will.

• I think it's time that we begin a grand debate on what path the state should follow to make sure that children all have the chance to see a doctor.

• I think it's time that we explore how best to provide health care security for our seniors and disabled, so that we are not held hostage to an HMO world, where fewer and fewer companies are able to bargain for higher and higher costs and deliver less and less service.

• The debate cannot be entirely among the insiders, for while there must be experts ready to lead and guide debate, this is a societal discussion. Everyone must be a part of this.

It was state legislation that outlined the "paradigm" of the HMO. It is time now to see what next needs to be crafted. We need to be ahead of the curve on this one. Too much is at stake to leave it to chance.