MISSOURI WATCH: THE SILENT SICKNESS STRIKES MISSOURI

Even before the aborted attempt of a new president of the United States to enact health-care reforms, Missourians were offered numerous proposals to guarantee medical assistance at a price that was at least affordable to a vast majority of families. The plans, more often than not, were offered by officials who knew only too well that their chances for enactment were slim to none. And they were right.

Five years ago, few disputed the need for major changes in health care delivery. When Bill Clinton first proposed his 1993 Health Security Act, the nation was spending 14 percent of gross national product -- $800 billion -- on health care each year, more than one-quarter of it on administrative overhead and marketing by a patchwork of 1,500 insurance companies. Even while spending two to three times more than other Western industrialized nations, the U.S. came in close to last, alongside Portugal, in basic health indices such as child mortality. And as private employers slashed benefits, 38 million working Americans were left with no health insurance, a number that today has grown to 41 million.

Against this grim backdrop, the major question remaining is not whether to reform health care but what type of reform, carried out by whom?

It is perhaps asking too much to suggest that the way out of this puzzle wrapped in a conundrum should be provided by elected politicians. Few of this group have ever willingly involved themselves in uncovering creative plans to solve our state and national health problems. First of all, the subject is extremely complex and the challenge of making them simple is almost beyond the scope of political minds. Secondly, any plan that would resolve current problems will require a degree of sacrifice that most engaged in public policy would rather avoid, if only for the sake of personal popularity. It is certainly clear that those engaged in care delivery did not embrace the Clinton program, spending $50 million by way of corporate lobbies to depict the president's idea as one that would end a patient's freedom to choose a doctor, reduce access to care and create a death star of government bureaucracy.

The answer, in both Washington and Jefferson City, was to herd millions of patients into for-profit managed-care plans, which pay capped fees to doctors rather than pay for each service rendered. Capitalizing on this upheaval, health-care conglomerates launched a series of barely regulated mega-mergers and created private bureaucracies that are as good at denying care as governmental ones are bad at providing it.

While profit-driven medicine has at least temporarily slowed health-care inflation, the people receiving these services have been forming their own ideas, based on real-life experiences, and those who once though for-profit health care was satisfactory dropped 20 percent form March to October this year; by contrast, 47 percent of consumers think for-profit health care is a "bad thing," up fro 42 percent last March. Unless a White House-sponsored proposal is adopted in 1998, patients will continue to have no redress from this system, for the reality is that the real power still remains in the hands of employers, where care is less important than cost.

This fact is even more apparent in psychiatry. Several years ago, employers and states such as ours were desperate to reduce their mental health expenditures, which had skyrocketed to 10 percent of overall health costs. There was also recognition that when behavioral-health problems such as chemical dependency, major depression and anxiety were undertreated, workers' productivity diminished. Fearing a cost conflagration employers enlisted what are known as carve-out companies offering comprehensive mental health benefits at bargain-basement prices. The result, a complete separation between economic concerns and therapeutic standards, lays bare the worst excesses of the profit-driven drift. Too many Missouri patients today receive perilously substandard care, while costs are shifted indiscriminately back to taxpayers. It is no wonder so many trained psychiatrists are leaving their profession.

Mental health care has seen the most consolidation, and while the full force has yet to be felt in Missouri, there are ample signs that we will not have to wait long. If planned mergers go through, the nine behavioral-health companies that dominate today's market will soon collapse into seven. One such company, Magellan Health Services, Inc., now owns 90 percent of the country's psychiatric hospitals and two huge behavioral-health companies. If Magellan's planned purchases go through, it will soon be responsible for the mental health of 50 million Americans and Missourians. by contrast, the largest HMO controls only 14 million "covered lives."

The cost of all these acquisitions and purchase is horrendous and no one expects this will be borne by providers but by projected recipients. Health care costs grew by 8 percent last year, and while the cost to employers dropped by 1.6 percent, premiums to workers have continued to increase by as much as 21 percent a year at small companies.

Corporate mental health care has been downsized by ignoring long-term illnesses and decreasing the time spent on less serious complaints. Long-term treatment is now virtually forgotten as a remedy, with the corporate remedy calling for a doctor to treat at least six patients every 60 minutes. Not even podiatrists can move that quickly. Some patients are even being seen by physicians for no longer than three minutes each.

According to a recent survey of mental health professionals, one in five therapists is taking active steps to leave his profession because of changes brought about by huge behavioral-health conglomerates.

Will the last person leaving our mental hospitals please turn out the light?

~Jack Stapleton of Kennett is the editor of Missouri News and Editorial Service.