RUST COMMENTARY: LITTLE ROCK EDITORIAL SHEDS SOME LIGHT ON IMPACT OF HMOs

One of my disciplines as owner of some newspapers in Arkansas is to read some Arkansas newspapers. They're more critical of the Bill and Hillary Clinton they know than most newspapers.

Also this long editorial in the Aug. 22 issue of the Arkansas Democrat-Gazette in Little Rock is a needed bit of information for the national, state and local health debate:

HMO-phobia: Fear and loathing on the health-care trail

Dadgum that Howard Kurtz. The media critic at the Washington Post had to go and act like a journalist -- and, in the process, ruin the fun for everybody who's made a hobby of bashing managed care. And we mean everybody -- from presidents to reporters to late-night comics.

Mr. Kurtz threw water on the day's hottest outrage. Which goes something like this: HMOs bad. Must fix.

He did it by checking the facts. Instead of relying on stories that begin, "Joe Patient's ordinary checkup turned into his worst nightmare when ...". Howard Kurtz noticed something: Too much of the HMO bashing was based on anecdotal evidence. Further, a lot of the more popular stories, including one whopper the president wore out, couldn't be checked out because of confidentiality laws. Meanwhile, less-inciting numbers got buried, if reported at all. For example:

* According to a study by KPMG Peat Marwick, inflation in health-care premiums fell from 10.8 percent a year to 0.5 percent between 1992 and 1996 -- the same period in which enrollment in managed-care programs zoomed.

* Another study sponsored by the American Association of Health Plans found that HMOs have saved the health-care industry between $24 billion and $37 billion since 1996. Before the proliferation of HMOs, health expenses were rising at a rate of about 11 percent a year.

* A fact-filled little magazine called American Demographics reports that in 1996 some 12.8 million families did not get the health care they wanted. Why? Money. Almost 60 percent said they couldn't afford it. Only 20 percent blamed their insurance companies for being unwilling to pay for some procedures. Even fewer blamed the big, bad HMOs.

* As a percentage of Gross Domestic Product, Americans spend almost twice as much on doctors, drugs and high-tech procedures as Europeans -- with no noticeable difference. We don't live any longer, or any healthier.

* An editorial in the Economist figured that "a typical American earning $25,000 a year and receiving $2,000 worth of health insurance from his company would have to pay an extra $500 if he tried to buy the insurance himself."

* There have been some major changes in health care: a growing number of managed-care programs, new laws aimed at making insurance more readily available for children and to workers who change jobs, a general industrywide cost cutting ... yet the number of uninsured Americans continues to rise. A report the other day in the New York Times estimates that the number of Americans without insurance increased by a million a year. That's the big problem, but without the proliferation of managed-care programs, the numbers might be even bigger.

What conclusion can we draw from these various and sundry factoids? The following: (a) It's not as easy as some of us thought, or hoped it would be, to blame all our health-care problems on HMOs. (b) On the contrary, costs are down thanks largely to managed care. (c) Don't look now, but we may never find the perfect health-care system in our market-driven economy but only the best possible. (d) All of which is why some rabble-rousers prefer anecdotes over hard data.

Still, perception being pseudo-reality, not just in politics but now in health care, Americans as a whole seem downright angry about the HMO revolution. Maybe it's because we've been goaded into it by the lobbyists and some of the more shameless pols. Or maybe it's because the real horror stories are real horror stories. As one-sided and overblown as are some of the unsubstantiated anecdotes, there's no denying that real people do have real problems in managed care. Health care may always have its horror stories no matter who administers it. After all, health care is often about life or death.

Managed care does have its irritants. For example, many of us in some HMO plans can't see the doctor we want. We worry about emergency-room care. And about getting the right treatment. About all the red tape. About our share of the bills. All of these are legitimate concerns. And great fodder for demagogues. The line can be thin between a patients' bill of rights and a campaign's bill of fare.

Candidates may not get as much mileage out of explaining how the market has corrected itself, and has done so without a lot of help from Washington. The truth can be dull. But, what th' heck, note this anyway from the Economist:

"As recently as 1990 over 90 percent of Americans with jobs that provided health coverage still received traditional, fee-for-service insurance: if they fell ill, they went to the doctor, and passed the cost on to the insurer. The more consultations, tests and operations the doctors performed, the more they earned. This gave them an incentive to order batteries of unnecessary tests, over-prescribe pills to the point where drug-resistant bacteria flourished, and perform invasive surgery when doing nothing might have been more prudent. Medical costs soared, with insurance premiums rising 13.6 percent a year between 1988 and 1992. Doctors bought BMWs, and employers found it increasingly hard to pay for their workers' health coverage."

Then came the managed-care revolution, lower medical costs, and the resulting fury that things aren't perfect.

Since we're compiling data, did you know that, at last count, only 3 percent of insured Americans pay for their own care in the form of and old-fashioned, unmanaged, pay-for-service plan? No wonder, as William F. Buckley Jr. puts it, the ideal of health care in America has come to be defined this way: Somebody else picks up most of the tab. "All you need to do," writes Mr. Buckley, "is report to the doctor, or hospital, and care is taken of you."

Part of the blame for this attitude falls on the HMOs. The managed-care patient has come to expect $10 doctor visits and $5 prescriptions. While we have few qualms about paying 250 bucks for some needed work on the family car, the same amount for health care shocks and even angers.

Why? Because health care is seen as a kind of constitutional right, instead of a service or a commodity. Therein lies the confusion -- and a popular notion just waiting to be exploited. So we get legislation like the bill from House Democrats to let patients sue the HMOs first and ask questions later. We get legislation like the bill from House Republicans that requires hospital stays after certain procedures -- thus taking a medical decision out of the hands of profit-minded insurers and putting it into the hands of vote-hungry politicians. As if that were an improvement. It's more like shifting the responsibility from Scylla to Charybdis. As a result, we get meddlin' from all sides and solutions from none. So some of us wonder: Do we even need a solution? Beware: It could turn out to be Clinton-Care redux.

What worries most about all this talk of patients' bill of rights is that we might end up where we were: with runaway medical costs. We'd all like to see an even playing field between physicians who charge fee-for-service and HMOs. But the whole idea of treating medical services as a right seems unrealistic -- because it is. It's not a right but a purchase. Do we really want to encourage folks to order anything and everything, as if they're lining up at an open bar? That way lies high costs for everybody, including you, Gentle Patient."

~Gary Rust is president of Rust Communications, which owns the Southeast Missourian and other newspapers.