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Washington Perspective
113
NEWS & COMMENT
Washington Perspective Fickle
politics of health-care discontent
In this
early stage of the Presidential campaign, the one is certainty that the voters want something done about the rising costs and narrowing accessibility of health care. But what do the voters want done? At what cost? And with how much interference in health-care arrangements that the great majority deem satisfactory? Democrat Harris Wofford’s surprising victory in last autumn’s Senate election in Pennsylvania revealed political paydirt in declaiming against the failings of the health-care system (Nov 23, p 1322). Wofford, however, fired from a safe distance, denouncing the system without prescribing specific remedies. The latest reading of the public mind on health politics-a Washington Post/ ABC poll conducted in December-creates a challenge for even the most dextrous election strategist. The returns, based on a nationwide telephone survey of 1512 adults, suggest a daunting melange of attitudes: a high degree of personal satisfaction with the existing health-care system, rising anxiety about costs and durability of health coverage, but absence of a majority for any of the basic fiscal and administrative remedies currently on the political stage. It is doubtful that the very poor, who are the most aggrieved victims of health care American style, were as telephonically accessible to the pollsters as more fortunate citizens. But voting is sparse among the very poor, and their views on mending the health system are not a potent factor in politics. About three-quarters of the poll respondents reported themselves "satisfied" with both the quality and availability of their health care. With only 10-11 % declaring themselves "not satisfied at all", there is no evidence of raging discontent with treatment or existing access. However, the poll reveals substantial concerns about ability to pay for health care in the future, an anxiety that is fed by the recurring waves of layoffs in major industries, where health insurance is a sacred benefit of employment. 57% expressed confidence that, in the event of serious need, "my major health-care costs would be taken care of’. But 68% feared that "health-care costs I may have in the future will not be taken care of’. Among the remedies offered in the poll, none received a majority. A mere 32 % favoured the most talked-of proposal for assuring universal insurance coverage: the so-called play-or-pay scheme under which employers would provide insurance for their workers or pay into a pool that would cover the uninsured. Only 20% said they would "maintain the current system of private insurance, Medicaid and Medicare"-another revelation of grave discontent unattached to any particular solution. The largest bloc, 44%, favoured a drastic departure from the existing fee-for-service anarchy-a "national health-care plan run
by the government, financed by the taxpayers". Even allowing for the vagueness of that description, it is noteworthy that a system "run by the government" is the least-discussed choice in the health-care debate. Other polls on health care-it is a major topic on the survey circuit-reveal a similar gap between discontent and remedies. Last June, for example, 69% in a Wall Street Journal/NBC poll said they favoured the best health care for everyone, even if a tax increase were required to pay for it. But the samaritan spirit wilted when the responders were asked whether they would personally abide higher taxes of insurance premiums to provide health care for the needy48% said no; 47% said yes. A virulent anti-tax mood has spread across the political landscape, raising great perils for anyone basing health-care reform on higher taxes. In view of the unsettled state of public opinion-to the extent that it can be accurately plumbed by pollsterscaution is the principal theme on the part of the President, while some ideas are sprouting in the crowded field of Democrats who want to succeed him. Senator Bob Kerrey of Nebraska has heroically introduced legislation that would provide universal health care, financed by a payroll tax and higher taxes on the rich. It is too early to assess the electorate’s response, but none of his fellow Presidential aspirants is following him down that route. Former Senator Paul Tsongas favours the "play or pay" method. There’s a tax there, too, but it’s not as obvious. Governor Bill Clinton says that, with existing expenditures, universal coverage could be financed by strict cost controls and a crackdown on defrauding of Medicare and Medicaid, which is known to be a lucrative industry. The other Democratic candidates agree that reform is urgently needed but are less specific about correctives. The President has publicly frowned on mandating insurance as a condition of employment, saying it would burden many firms in difficult economic times. A panel he appointed nearly three years ago to solve the health-care problem was recently reported to be so split by disagreements that it could not endorse any comprehensive measure. It did suggest a plan to establish a nationwide system of school-based health clinics for children, but beyond that it called for relying on the states to experiment with better ways of financing and delivering health care. While the President was on the far Pacific side of the world, the White House leaked reports that his next budget would address the health-care issue by providing a$2000 tax credit for personal payment of health-insurance premiums. That would reduce the bite on many taxpayers, and would help those so poor that they would receive a cash payment in lieu of a tax reduction. But a tax credit unaccompanied by cost controls would add lift to an already soaring medical inflation. And the reports of the tax credit made no mention of restraints on prices or utilisation. The latest financial accounting of our lusty health industry probably would have been dismissed as medical-
114
science fiction a decade ago, but it passed with little notice in last year’s closing days. According to the Commerce Department, the nation’s health spending in 1991 reached $738 billion, or about 13 % of the gross national product. It’s expected to rise to 14% of GNP this year-even with approximately 35 million persons uninsured and therefore only marginal customers in the system. The share of national wealth is a bit distorted by a soggy GNP and a fast-rising rate of health-care spending, which stood at a mere 7 3% of GNP in 1970. But there’s no doubt that health care is the last big growth industry in the American economy. The Commerce Department says that hospital employment increased by 409 000 between 1988 and 1990, while employment in doctors’ offices rose by 200 000. Much of the increase is attributed to managing the paperwork generated by some 1500 separate health-insurance organisations. The General Accounting Office tells Congress to expect that health care will consume over 16% of the GNP by the end of the decade. Hopes persist that politics can surely find a way out of this morass. But those hopes go back to the long-ago days when health-care costs took 8% and then 10% of the GNP. The difficulty now is that the health-care industry is a major power in economics and politics, and is not inclined to come under strict controls. Perhaps most important of all, the American people, by a wide majority, pronounce themselves satisfied with their health care, even if they are worn with worry about the costs. The task facing politics is to devise a miracle that can accommodate a gold-plated system on an austere
budget. Daniel S.
Greenberg
Round the World India, Pakistan: Community psychiatry India and Pakistan
the British compare the progress in providing community based services in two developing countries that have adopted somewhat different approaches to the challenge posed by the WHO programme on extending mental health services to primary-care settings.
A visit
to
(sponsored by
Council) provided an opportunity to
India One of the first successful community mental health programmes based in primary care was evaluated in India at Chandigarh. Since then trainers have been trained at national centres such as Bangalore and Ranchi, and workshops have been held for psychiatrists in the various states.’ The seventh mental health plan (1984) found services in the community still grossly deficient in certain states. The recommendation was to establish a "modest, viable, and effective programme in each of the states rather than to plan for a wider coverage".2 Sad to say, only seven comprehensive community programmes have been set up, and these are in only four states. Even when the target is achieved the great majority of the population will be without an adequate mental health service, so the greater part of the task still lies ahead. The National Institute for Menial Health and Neurosciences (NIMHANS), at Bangalore, produces training manuals for these programmes and has conducted the most careful and exhaustive evaluations of mental health
problems.3 Its Manual of Psychotherapy for Medical Officers is the first attempt to teach psychotherapeutic skills to the doctors who must provide the basic medical services across the developing world. NIMHANS has pioneered a comprehensive mental illness service in the district of Bellary, which is in a remote rural area in the State of Karnataka and has a population of 1 -9 million. Training has been given to all the primary care physicians and multipurpose care workers who worked in the district, and sensitisation courses have been held for the public health doctors who are responsible for all government medical services in each area. Back-up services are provided by a NIMHANS-trained psychiatrist who works in tandem with a social worker, and the programme works throughout the district. The new service is targeted on epilepsy, mental handicap, psychosis, neurosis, and drug-related problems, and has been especially successful in identifying cases of the first two of these conditions. However, both public health administrative doctors and the medical officers who provide the services are regularly rotated to other posts in the State of Karnataka outside the programme, and are replaced by untrained personnel. Although such rotations are typically justified by administrative convenience, junior doctors spoke of having to bribe officials if they were to be allowed to stay in one place. During my visit most of the primary care physicians interviewed had been rotated into the district recently, and were going to need training. The Sisyphean task of
continually providing more training seems quite daunting. Mental health also has to compete with other public health programmes-such as those for leprosy, malaria, immunisation, and family planning-for use of the jeep without which the back-up service comes to a halt. In India, as in England, private hospitals are now opening, offering a very superior service for those few who are able to pay for it. At Bangalore neurosurgeons at NIMHANS are leaving their poorly paid government jobs to work in the new hospitals, leaving government-funded facilities even more impoverished than they were before. Pakistan The community mental health programme in Pakistan got off to a flying start owing to the conjunction of a President with a genuine interest in services for the mentally ill, and an indefatigable professor of psychiatry.’ The programme has fortunately survived the passing of the President. During my visit the Director General of the federal Ministry of Health convened a 4-day training course to be attended by every public health doctor in the Punjab, a state that contains a substantial proportion of the population. These medical administrators were shown how the mental health programme near the capital city works, and agreed to find resources to start the programme from their own budgets when they got home. The programme has expanded to include training courses for faith healers, as well as continuing to provide training for medical officers, administrators, and multipurpose care workers and health visitors. Refresher courses are now offered from time to time. Preventive programmes have been inaugurated, including an attack on iodine deficiencies, provision of spectacles for children, and rehabilitation of those with chronic psychotic illness. A start has been made in implementing the programme in all the other states as well, although progress has not been so fast. The school programme continues to be successful, and has spread widely across the country.
NEWS & COMMENT
Washington Perspective Fickle
politics of health-care discontent
In this
early stage of the Presidential campaign, the one is certainty that the voters want something done about the rising costs and narrowing accessibility of health care. But what do the voters want done? At what cost? And with how much interference in health-care arrangements that the great majority deem satisfactory? Democrat Harris Wofford’s surprising victory in last autumn’s Senate election in Pennsylvania revealed political paydirt in declaiming against the failings of the health-care system (Nov 23, p 1322). Wofford, however, fired from a safe distance, denouncing the system without prescribing specific remedies. The latest reading of the public mind on health politics-a Washington Post/ ABC poll conducted in December-creates a challenge for even the most dextrous election strategist. The returns, based on a nationwide telephone survey of 1512 adults, suggest a daunting melange of attitudes: a high degree of personal satisfaction with the existing health-care system, rising anxiety about costs and durability of health coverage, but absence of a majority for any of the basic fiscal and administrative remedies currently on the political stage. It is doubtful that the very poor, who are the most aggrieved victims of health care American style, were as telephonically accessible to the pollsters as more fortunate citizens. But voting is sparse among the very poor, and their views on mending the health system are not a potent factor in politics. About three-quarters of the poll respondents reported themselves "satisfied" with both the quality and availability of their health care. With only 10-11 % declaring themselves "not satisfied at all", there is no evidence of raging discontent with treatment or existing access. However, the poll reveals substantial concerns about ability to pay for health care in the future, an anxiety that is fed by the recurring waves of layoffs in major industries, where health insurance is a sacred benefit of employment. 57% expressed confidence that, in the event of serious need, "my major health-care costs would be taken care of’. But 68% feared that "health-care costs I may have in the future will not be taken care of’. Among the remedies offered in the poll, none received a majority. A mere 32 % favoured the most talked-of proposal for assuring universal insurance coverage: the so-called play-or-pay scheme under which employers would provide insurance for their workers or pay into a pool that would cover the uninsured. Only 20% said they would "maintain the current system of private insurance, Medicaid and Medicare"-another revelation of grave discontent unattached to any particular solution. The largest bloc, 44%, favoured a drastic departure from the existing fee-for-service anarchy-a "national health-care plan run
by the government, financed by the taxpayers". Even allowing for the vagueness of that description, it is noteworthy that a system "run by the government" is the least-discussed choice in the health-care debate. Other polls on health care-it is a major topic on the survey circuit-reveal a similar gap between discontent and remedies. Last June, for example, 69% in a Wall Street Journal/NBC poll said they favoured the best health care for everyone, even if a tax increase were required to pay for it. But the samaritan spirit wilted when the responders were asked whether they would personally abide higher taxes of insurance premiums to provide health care for the needy48% said no; 47% said yes. A virulent anti-tax mood has spread across the political landscape, raising great perils for anyone basing health-care reform on higher taxes. In view of the unsettled state of public opinion-to the extent that it can be accurately plumbed by pollsterscaution is the principal theme on the part of the President, while some ideas are sprouting in the crowded field of Democrats who want to succeed him. Senator Bob Kerrey of Nebraska has heroically introduced legislation that would provide universal health care, financed by a payroll tax and higher taxes on the rich. It is too early to assess the electorate’s response, but none of his fellow Presidential aspirants is following him down that route. Former Senator Paul Tsongas favours the "play or pay" method. There’s a tax there, too, but it’s not as obvious. Governor Bill Clinton says that, with existing expenditures, universal coverage could be financed by strict cost controls and a crackdown on defrauding of Medicare and Medicaid, which is known to be a lucrative industry. The other Democratic candidates agree that reform is urgently needed but are less specific about correctives. The President has publicly frowned on mandating insurance as a condition of employment, saying it would burden many firms in difficult economic times. A panel he appointed nearly three years ago to solve the health-care problem was recently reported to be so split by disagreements that it could not endorse any comprehensive measure. It did suggest a plan to establish a nationwide system of school-based health clinics for children, but beyond that it called for relying on the states to experiment with better ways of financing and delivering health care. While the President was on the far Pacific side of the world, the White House leaked reports that his next budget would address the health-care issue by providing a$2000 tax credit for personal payment of health-insurance premiums. That would reduce the bite on many taxpayers, and would help those so poor that they would receive a cash payment in lieu of a tax reduction. But a tax credit unaccompanied by cost controls would add lift to an already soaring medical inflation. And the reports of the tax credit made no mention of restraints on prices or utilisation. The latest financial accounting of our lusty health industry probably would have been dismissed as medical-
114
science fiction a decade ago, but it passed with little notice in last year’s closing days. According to the Commerce Department, the nation’s health spending in 1991 reached $738 billion, or about 13 % of the gross national product. It’s expected to rise to 14% of GNP this year-even with approximately 35 million persons uninsured and therefore only marginal customers in the system. The share of national wealth is a bit distorted by a soggy GNP and a fast-rising rate of health-care spending, which stood at a mere 7 3% of GNP in 1970. But there’s no doubt that health care is the last big growth industry in the American economy. The Commerce Department says that hospital employment increased by 409 000 between 1988 and 1990, while employment in doctors’ offices rose by 200 000. Much of the increase is attributed to managing the paperwork generated by some 1500 separate health-insurance organisations. The General Accounting Office tells Congress to expect that health care will consume over 16% of the GNP by the end of the decade. Hopes persist that politics can surely find a way out of this morass. But those hopes go back to the long-ago days when health-care costs took 8% and then 10% of the GNP. The difficulty now is that the health-care industry is a major power in economics and politics, and is not inclined to come under strict controls. Perhaps most important of all, the American people, by a wide majority, pronounce themselves satisfied with their health care, even if they are worn with worry about the costs. The task facing politics is to devise a miracle that can accommodate a gold-plated system on an austere
budget. Daniel S.
Greenberg
Round the World India, Pakistan: Community psychiatry India and Pakistan
the British compare the progress in providing community based services in two developing countries that have adopted somewhat different approaches to the challenge posed by the WHO programme on extending mental health services to primary-care settings.
A visit
to
(sponsored by
Council) provided an opportunity to
India One of the first successful community mental health programmes based in primary care was evaluated in India at Chandigarh. Since then trainers have been trained at national centres such as Bangalore and Ranchi, and workshops have been held for psychiatrists in the various states.’ The seventh mental health plan (1984) found services in the community still grossly deficient in certain states. The recommendation was to establish a "modest, viable, and effective programme in each of the states rather than to plan for a wider coverage".2 Sad to say, only seven comprehensive community programmes have been set up, and these are in only four states. Even when the target is achieved the great majority of the population will be without an adequate mental health service, so the greater part of the task still lies ahead. The National Institute for Menial Health and Neurosciences (NIMHANS), at Bangalore, produces training manuals for these programmes and has conducted the most careful and exhaustive evaluations of mental health
problems.3 Its Manual of Psychotherapy for Medical Officers is the first attempt to teach psychotherapeutic skills to the doctors who must provide the basic medical services across the developing world. NIMHANS has pioneered a comprehensive mental illness service in the district of Bellary, which is in a remote rural area in the State of Karnataka and has a population of 1 -9 million. Training has been given to all the primary care physicians and multipurpose care workers who worked in the district, and sensitisation courses have been held for the public health doctors who are responsible for all government medical services in each area. Back-up services are provided by a NIMHANS-trained psychiatrist who works in tandem with a social worker, and the programme works throughout the district. The new service is targeted on epilepsy, mental handicap, psychosis, neurosis, and drug-related problems, and has been especially successful in identifying cases of the first two of these conditions. However, both public health administrative doctors and the medical officers who provide the services are regularly rotated to other posts in the State of Karnataka outside the programme, and are replaced by untrained personnel. Although such rotations are typically justified by administrative convenience, junior doctors spoke of having to bribe officials if they were to be allowed to stay in one place. During my visit most of the primary care physicians interviewed had been rotated into the district recently, and were going to need training. The Sisyphean task of
continually providing more training seems quite daunting. Mental health also has to compete with other public health programmes-such as those for leprosy, malaria, immunisation, and family planning-for use of the jeep without which the back-up service comes to a halt. In India, as in England, private hospitals are now opening, offering a very superior service for those few who are able to pay for it. At Bangalore neurosurgeons at NIMHANS are leaving their poorly paid government jobs to work in the new hospitals, leaving government-funded facilities even more impoverished than they were before. Pakistan The community mental health programme in Pakistan got off to a flying start owing to the conjunction of a President with a genuine interest in services for the mentally ill, and an indefatigable professor of psychiatry.’ The programme has fortunately survived the passing of the President. During my visit the Director General of the federal Ministry of Health convened a 4-day training course to be attended by every public health doctor in the Punjab, a state that contains a substantial proportion of the population. These medical administrators were shown how the mental health programme near the capital city works, and agreed to find resources to start the programme from their own budgets when they got home. The programme has expanded to include training courses for faith healers, as well as continuing to provide training for medical officers, administrators, and multipurpose care workers and health visitors. Refresher courses are now offered from time to time. Preventive programmes have been inaugurated, including an attack on iodine deficiencies, provision of spectacles for children, and rehabilitation of those with chronic psychotic illness. A start has been made in implementing the programme in all the other states as well, although progress has not been so fast. The school programme continues to be successful, and has spread widely across the country.