COLUMN: The Ballad of Hillary and Charlene

From Bertie Bregman's "On Call," Fall '94 From Bertie Bregman's "On Call," Fall '94Stop Insurance Company Greed!" "Malpractice Reform!" "Stop Killing Primary Care Doctors!" Like most of you, I imagine, I understand the health care crisis about as well as I understand the S&L; crisis, or Iran Contra. It's not that I don't try. After all, I am asked for my opinion about health reform whenever anyone discovers I'm a medical student. I would love to sound intelligent for once, instead of steering the conversation to my real policy interests: Lorena Bobbitt, the Menendez brothers and Tonya Harding. But put an article about health care reform in front of me, and my eyes glaze over. Single payer plans, regional alliances, insurance premiums, HMO's, rationing, it all becomes a blur. So I went to hear Hillary in the hope that she would straighten me out. In the chitchat preceding Hillary's appearance on stage, I discovered that the woman sitting next to me worked for an insurance company. I'll call her Charlene. I told Charlene that I was a medical student and beat her to the punch: what did she think about health reform? She looked so dismayed at the question that I took pity on her (actually, it was more a selfish hope that my good deed would come back to me one day) and allowed her to change the subject to Michael Crichton's latest pitiful excuse for a novel. Finally Hillary stepped to the podium. The forum was organized like a town meeting, with two microphones in the aisles for questions from the audience. It was a health care crowd -- doctors, students, researchers, a few parents of pediatric patients (CHOP sponsored the event) -- and Hillary played it like a pro. With style, charm, and wit, she allayed fears about the future, explained elements of the Health Security Act in simple English, and rabble-roused against lawyers, drug companies, and most of all ... well, let me put it like this: What's black and blue and whimpers in the corner? Give up? The insurance industry in Hillary's wake. A doctor at CHOP set the stage with the first question. Some of us are with you all the way, he said, and we hate the campaign to discredit your plan with sleazy advertising. What can we do to help? Was he a plant? We may never know, but Hillary took the ball and ran with it. The first thing you can do is what you're doing now, she said, -- speak up. Let people know that we do have a health care crisis in this country! Not only for the 38.2 million Americans who are uninsured, a list that is growing by one hundred thousand each month, but for those who are chained to their jobs because of fears of losing their coverage. For those whose premiums will skyrocket when they become ill. And for the insured too, who pay more than they should. Because although we have the finest doctors, nurses, and hospitals in the world we also have the stupidest way of financing health care in the world! Cheers, applause. She took a breath and honed in on her prey: The insurance companies are running things! They are in charge. They pick and choose who to insure. They force group practices and hospitals to hire four administrators per physician to handle the vast load of paper work. They steal time and resources away from patient care. They must be stopped! Cheers, applause, scattered whistles. I felt bad for Charlene, who I noticed didn't clap, so I restricted myself to a demure hoot of approval. For Charlene's sake, I hoped that Hillary would lay off insurance companies, and for a while she did. A woman whose child has Cystic Fibrosis worried that the new system would discourage pharmaceutical companies from discovering "miracle drugs." In fact, one popular criticism of the Clinton plan is that price controls on drugs will inhibit research and innovation. Hillary had a three-pronged response. First, she said, the plan calls for more medical research on the federal level. Second, prescription drugs will be covered by the plan representing a $15 billion pharmaceutical industry windfall (I didn't quite follow that one -- if price controls force companies to sell drugs at a loss, who cares whose paying?) Third, American pharmaceutical companies are raking it in! They charge two, ten, fifteen times as much at home as they do abroad. They cry poverty but refuse to let anyone peek at their books. She told a story about a doctor who discovered that a compound used in sheep agriculture could help treat colon cancer. He excitedly brought this news to the drug company, which promptly packaged the compound for human use. Only now, instead of a pill you could buy for four cents at a feed store, the new pill cost four dollars at the pharmacy. More cheers and applause. I looked encouragingly at Charlene. She smiled wanly and gave a little clap. An Osteopathic medical student timidly approached the mike and asked about malpractice. He hoped this didn't sound selfish, but he and his friends were worried about the cost of malpractice insurance, and intimidated by the predatory nature of the legal system. What would Hillary do about that? Selfish? Don't be ridiculous, she replied. Malpractice suits raise the price of health care in two ways: directly, from the price of malpractice insurance; and indirectly, from the cost of unnecessary laboratory tests performed for fear of lawsuits. The solution? Require alternative dispute resolution before an arbitration board, with qualified experts deciding the merits of a case before allowing it to go to court (sounds unconstitutional to me, but what the hell -- you go girl!) Work with M.D.'s to set up practice guidelines to insulate physicians from lawsuits. Enlist doctors to help police themselves and keep the bad apples out of the orchard. And, last but not least (drum roll please) ... limit attorney's fees for malpractice suits! Cheers, applause, howls of glee. Charlene caught the spirit and smiled broadly. I patted her encouragingly on the shoulder. She reminded me of the rabbits at the "pets or meat" stall in Roger and Me, Michael Moore's docu-comedy about the decline of Flint, MI. The proprietress would caress a rabbit into a blissful stupor, and then ... thwack ... down came the cleaver, and off came its little head. Sure enough, the next question came from a parent who said she'd spent years learning how to navigate the paperwork surrounding the care of her chronically ill child. Would a new system mean piles of new forms and documents? I felt Charlene stiffen to my right. Paperwork, Hillary mused. Do you know why you have so much paperwork to fill out? Do you know why everything is so confusing and convoluted and wasteful? Exactly! Insurance companies! And she slammed the insurance industry once again. For the rest of the forum the onslaught continued. A woman asked about universal coverage and Hillary told a story about the parents of two children with Cystic Fibrosis. They went from agent to agent, trying to find insurance for their children. Agent after agent turned them away, until one finally said: "You just don't get it, do you? We don't insure burning houses, and that's what your children are. Burning houses." At one point, Hillary exclaimed: "Real Americans are sick and tired of being at the whim of some insurance company bureaucrat!" The look on Charlene's face almost broke my heart. I leaned over and whispered reassuringly that whatever Hillary said, I knew insurance company employees were real Americans too. I walked her out and sympathized. It must have been hard to sit through all that. She said that when her friends heard she was going to see Hillary Clinton, they offered her tomatoes to throw at the stage. I told her they should have given her a valium to take along too. Well, at least we know that doctors won't change, she laughed, whatever damn system we get. Bertie Bregman is a second-year medical student from New York City. On Call appears alternate Wednesdays.