U. S. Health Care: A State of Emergency --
Introduction of Pamphlet: "Ban the HMOs!"

by Marcia Merry Baker

Printed in the American Almanac, January, 2000.

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U.S. government officials, such as Treasury Secretary Larry Summers, like to repeat over and over--especially after a stock market plunge--that ``The fundamentals of the economy are sound.''

If the fundamentals are so sound, how come America can no longer afford the high-quality health care it once had? Why are once-conquered diseases on the rebound? If the fundamentals are so sound, how come HMOs routinely deny or delay needed medical treatments, in order to save money and cut costs? If the fundamentals are so sound, how come you or your relative might die for want of medical treatment, because your local hospital has been downsized for ``cost containment''? If the fundamentals are so sound, how come you receive primary care from medical ``stand-ins,'' because the hospital can't afford to pay living wages to nurses or doctors?

Currently, millions of Americans are without access to adequate health care, because they either have no health insurance, are enrolled in a managed-care plan that denies or delays medical care on the basis of cost, or (even if they are financially able to pay for whatever medical care they need), their local communities lack the adequate facilities through which to deliver the care. Consequently, millions of Americans are sickened, injured, or die, as a result of a lack of adequate medical care.

Meanwhile, as we have shown elsewhere in this document, the HMOs suck millions of dollars out of the health system, for Wall Street mega-profits.

But say, ``Change it,'' and you hear the reply, ``But we can't afford it.'' In fact, if we can't afford today, what we once afforded in previous times, it shows that the fundamentals are not sound at all.

The dimensions of the medical and health-care crisis in the United States today make the point. The increasing morbidity and mortality rates occurring across a range of many different diseases, locations, and sub-groupings in the population, add up to a pattern of illness and death constituting a state of emergency.

Don't wait until you hear the announcement on the TV nightly news, ``Today, the U.S. national life expectancy started going down.'' Look around you right now, and do something.

- Poverty Spreading -

First, consider generally the health implications of increasing impoverishment and lack of medical care for millions of Americans. Even by the official--that is, understated--categorization of who lives in poverty, 13.3% of the total population, or 35.8 million Americans, do, as of 1997. This figure was about 12% in 1975, and it has worsened steadily. Of all American children under the age of 6, an estimated 23%, or 5.5 million, live in poverty.

For whole groups of people, if you are poor and sick, you die. For example, a 1995 study showed that the death rate for homeless men on the streets of Boston, New York, and other major U.S. cities was up to 50% higher than in Toronto, where there is still care provided (even if limited).

The poor are most likely to have no medical care insurance coverage, and those with the least recourse, when it comes to medical care, are young adults between the ages of 18 and 24, Hispanic-Americans (35% uninsured), the less educated, part-time workers, and the foreign-born.

Look at Texas, the gateway to the North American Free Trade Agreement-generated maquiladoras. Of all young people up to age 18, some 27%, or 1.502 million, are poor, and almost all of these lack any medical coverage.

- Lacking Insurance -

Overall, the number and percentage of Americans lacking any health insurance is rising. For 1998, some 44.3 million Americans had no health insurance of any kind, which is 16.3% of the population. One-half of the full-time working poor are in this category. In addition, another 30 million or more are estimated to be underinsured, or inadequately insured, because that is the likely number at risk of facing out-of-pocket expenses (co-payments, deductibles, etc.) exceeding 10% of family income, if they face serious injury or illness. These categories combined, mean that at least 75 million people are not insured or are underinsured--nearly one-third of all Americans.

For those households possessing insurance coverage, and with the means to cover deductibles and other costs, many are hit hard by ``managed''-care decisions to deny, delay, or charge for treatment, to the point of increased incidence of illness and deaths among whole categories of people--the disabled, elderly, mental health patients, dialysis cases, and so on.

This trend is even more pronounced in recent months, as many HMOs go bankrupt (having lived out the lifespan of the mode of financial gouging they could maintain--limiting care, underpaying care-providers, and charging higher premiums, in order to pay high private profits). There are widespread situations like that of New Jersey's HIP program, which went bankrupt in 1998, leaving its 200,000 clients scrambling to buy their own drugs, and provide treatment, including everything from chemotherapy to hospital linens.

- Youth -

Look at a few basic vital statistics of the United States, as of the mid-1990s.

For young black men (ages 15 to 24), the death rates (deaths per 100,000 of the total population within the group) are the following: 157.6 for ``homicide and legal interventions,'' 20.6 for suicide, in contrast to 6.8 for heart disease, and 5.4 for cancers.

For infant mortality (deaths per 1,000 live births of the specified group or location) the rate of death in, for example, Washington, D.C., is 19.6, in contrast to around 5 deaths per 1,000 in 1995 in Germany, France, Scandinavia, Australia, and many other countries.

For Hispanic U.S. children, rates of morbidity are running needlessly high for whooping cough (pertussis), measles, and other preventable childhood diseases, as the Hispanic population has the highest percentage (37%) of families uncovered by any health insurance. In Denver, California, Texas, and similar locations, a major public health threat of contagions is now present.

In California, 1.7 million children go without health insurance. In some areas of Los Angeles, only 30% of pre-school youngsters have been immunized. In Orange County, California, 37,000 youngsters have no immunization at all. The families are in fear that seeking health care will jeopardize their immigration status. In one colonia in El Paso, Texas, 25% of all children under age 7 had hepatitis A.

Specifically, the 1996 Welfare Reform Act contravened the standing 1960s Medicaid law (health care for the poor), and ordered legal immigrants to wait five years before being eligible. Whole epidemics and permanent disabilities are now traceable to this law and way of thinking.

- Diseases -

Tuberculosis rates are rising rapidly globally, and the disease is present in the United States and poised for epidemic expansion. After the significant decline in TB cases during the Hill-Burton period, TB became resurgent in the 1980s under the deteriorated economic conditions of the ``managed-care'' era, with the epicenter being New York City. The national TB incidence rate increased by 20% from 1985 to 1992, led by the outbreak of 20,000 cases in New York. Special efforts reduced that immediate outbreak, but now the preconditions for renewed threat are even worse. In Los Angeles and elsewhere, there is a significant presence among the homeless of ``primary TB,'' i.e., newly acquired, not merely reactivated. Multi-drug-resistant tuberculosis (MDR-TB) is spreading.

Closely connected is the killer disease AIDS. Of the people infected with TB in the age group 25 to 44 years, 21% have HIV, the AIDS virus. In 1979, the first 11 cases of AIDS were identified; now there are hundreds of thousands. In 1987, in New York City alone, there were an estimated 500,000 residents infected with the HIV virus. In 1989, some 62% of homeless people tested in New York City were HIV-positive. Two hospitals in the South Bronx reported that 23% of their Emergency Room patients were HIV-positive.

Add to these, the prevalence of hepatitis C, and other public health threats, and the lack of action to expand public health care and medical treatment is dramatic.

As yet, there has been no national mobilization of research, treatment facilities, and public health programs undertaken.

- Prisoners -

The imprisoned population in the United States, now pushing 2 million people, lives under conditions directly leading to increased illness and death rates. The rate of HIV infection among prisoners is six times higher than the national rate. During 1995-96, there have been several outbreaks of TB in prisons in California and Texas. The rate of hepatitis C is relatively high, yet deliberately not treated. In Virginia, for example, an estimated 30% of the prison population is afflicted with the potentially deadly disease, in contrast to 2% of the general population. A significant proportion of the 4 million Americans estimated to have hepatitis C, are in the prison system at some time, but most states do not even test for it, and only California, Virginia, and Rhode Island treat prisoners known to have the disease. Prison guards and employees are routinely vaccinated for hepatitis C.

- Mental Illness -

Over the 1980s to the present, most HMO plans cut back on the number and type of mental health treatment services formerly covered by fee-for-service, or other means. This was accomplished through outright cuts, and through pressure on the medical staff and facilities involved. Suicides have resulted. In January 1996, the general situation was summed up by Mary Hurtig, director of the Southeastern Pennsylvania Mental Health Association: ``A major profit center for health plans has been mental health. For example, I know of one large HMO that gets $35 per month for mental health treatment for its members who qualify for Medicaid. But they subcontract their mental health care to a managed-care firm at a rate of $14 per month. The result is that some vulnerable, very ill people, are getting badly hurt by arbitrary denial of care.''

- Hospitals Are Disappearing -

Instead of a build-up of ratios of key diagnostic, staff, facilities, and public health treatment capabilities per thousand of the population, we are seeing the takedown of the U.S. health-care delivery system. Both the accessibility, and the quantity, of beds per thousand people are dropping, as shown in the graph. Over the last 20 years of managed-care outlook, the total number of U.S. hospitals dropped by over 1,200, and the number of licensed hospital beds (equipped to standards), fell from around 1.5 million, down to only 853,000 (1998). By managed-care experts, this was called ``restructuring'' and eliminating ``over-supply.'' Similarly, the absolute number of nurses and the patient-nurse ratio--the foundation of hospitals--have dropped. The number and ratio of public health and specialty clinics and staff, in proportion to the population, has likewise gone down.

In New York City as of 1988, when the TB and HIV incidence data soared, the number of public clinics for TB in the city had declined from 24 in the 1960s, to eight! The staff of the New York Bureau of TB Control had been reduced by two-thirds since the 1960s. The city's public health system was overwhelmed, as between 1985 and 1992, the number of cases of TB tripled, and the multi-drug-resistant rate doubled, to 23% of all cases. In Harlem, the TB incidence rate was 222 per 100,000 population, a percentage higher than many Third World countries at the time. An out-of-state response team had to be mobilized to help deal with the situation, as if it were a surprise.

Nevertheless, along with cutting hospital services, the TB treatment capabilities in New York and elsewhere are again being drastically scaled back. The National Tuberculosis Center budget has been cut back. The New York City TB control budget was cut 30% last year; Massachusetts' was cut by 10%. In the Southern states, Georgia's TB control budget was cut 10% last year; and Florida's by 5%.

Even ``ordinary,'' to-be-expected community illnesses, such as the flu, now overwhelm the U.S. health-care system. During the annual influenza season, which hit the United States ``early'' in January 2000, the stripped-down hospital base in the major Middle Atlantic and Northeast states could not take the load. In the region of Washington, D.C. itself, there was an emergency situation in Maryland and Virginia. At least 12 hospitals, of 26 in the suburban Washington/Baltimore region, were on red alert as of Jan. 6, which means that they had no more critical-care beds, and their in-patient operations were overwhelmed. What happens when this repeats itself, at the same time as potential casualty victims from a rail accident (now a frequent occurrence), or a sudden TB or AIDS caseload show up?

The U.S. hospital system has been marginalized far below national health security levels for many years. The only reason there is not a greater appearance of overload in hospitals is that people are going untreated and dying. For example, in many counties now, pneumonia (treatable) is on the rise as a cause of mortality, because people have no means to get health care, and are still staggering to work just for expense money for food and housing.

The criminal insanity of cutting treatment facilities is underscored by the prevalence and spread of HIV/AIDS and tuberculosis, but also by many other obvious public health threats, including hepatitis C (and other liver disease variants, particularly in the ``NAFTA'' Hepatitis Belt on the USA/Mexico border), venereal disease, insect-vectored illness (West Nile fever, dengue, etc.), and so on.

- Veterans Care -

The fact that the cheating on care and elimination of medical services is deliberate, is nowhere more obvious than by the treatment of military veterans, and their beneficiaries, who number over 8 million people. In recent years, the move was made to herd veterans into ``managed-care'' plans, to ``ration'' and restrict the treatment available to them. This also involved attempting to herd them into the shrinking number of community hospitals and clinics outside the free-standing national Veterans Administration system, which is being drastically downsized.

As of the mid-1990s, the V.A. medical system operated 172 hospitals, 128 nursing homes, and more than 350 outpatient clinics in the United States. Under the Conservative Revolution movement, moves were made to: 1) drastically reduce this resource base; and 2) open up the vets' government medical payments flows to go outside the V.A. system, as an ``income stream'' for private managed-care-era HMOs, and private facilities. The ``Tri-care'' plan was proposed to cheat and chisel through a military managed-care program.

The Veterans Administration expected to treat 2.9 million patients in fiscal 1997, but the argument was made by the ``managed-care'' advocates that vets are aging, and need only nursing homes, not a V.A. hospital system. Two reports commissioned by Congress put forward this view--one in 1996 by the General Accounting Office; one in 1997 by the private accounting firm Price Waterhouse.

V.A. hospitals are being phased out. Over the 10-year period 1986 to 1996, the number of hospital beds in the V.A. system dropped 35%, to under 60,000. Some more beds were added to nursing homes, to care for World War II veterans, but construction for new or refurbished facilities was cut. The only new medical center on the books in the '90s was in Brevard County, Florida.

In September 1997, the Department of Veterans Affairs cancelled the construction of a new 243-bed hospital facility on Travis Air Force Base (east of San Francisco). (The new hospital was to replace a V.A. 359-bed facility in Martinez, near San Francisco, which closed in 1991 as the result of earthquake damage.) An estimated 440,000 veterans in Northern California had been expected to get treatment at the new hospital. Now the beds aren't there.

This just shows that veterans are being dumped onto the shrinking public hospital system, and made subject to ``managed-care'' orders to cut care. Moreover, the national V.A. medical care system itself, though much reduced, is a national asset, whose facilities should be reactivated, not deactivated, as part of rebuilding and upgrading regional care systems that have been ravaged during the HMO decades. People in the National Association of Uniformed Services, and collaborators, have tried to mobilize a fight-back against the takedown of the veterans' military full-care medical system, for its own sake, and in light of the need for building up resources to deal with resurgent and new diseases, and standby medical facilities.

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The preceding article is a rough version of the article that appeared in The American Almanac. It is made available here with the permission of The New Federalist Newspaper. Any use of, or quotations from, this article must attribute them to The New Federalist, and The American Almanac

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