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P&S Journal

P&S Journal: Spring 1994, Vol.14, No.2
Health Care Reform: Responses and Proposed Alternatives
Letter to the Editor:

We can achieve universal health care of high quality without increasing taxes, rationing, forfeiting hi-tech care or giving up our choice of doctors. This can be done with a combination of reforms which eliminate wasteful administrative costs, unwanted, unneeded and unproven treatments, spurious and outlandish litigations, and fraudulent, unethical and incompetent business and professional practices. But in dollar amounts-the chief present concern-each of these is less important than the lack of universal, comprehensive prevention of illnesses and injuries, due largely to poor personal health habits and to a lesser extent institutional irresponsibility for health matters. At least $150 billion is spent each year for treating preventable illnesses and injuries and if indirect costs-social, occupational, familial-are included, the total may easily be double this amount.
Most of the causes of preventable disorders are well known and some are illegal. Regrettably, the lion's share of the health care costs of these are paid by health abiding individuals. This clearly is unethical and undemocratic. Tobacco usage, which accounts for about 1/5th of preventable disorders, causes are $30 billion per year of avoidable health care costs. Other risky and unhealthy behaviors and activities include substance abuse-including alcohol-moving vehicular violations, certain recreational activities, careless and incompetent practices by health professionals and failure of individuals to obtain timely wellness checkups. The latter omission greatly increases the likelihood that insidious and covert conditions, including cancer, heart, blood vessel and emotional disorders and faulty life style remain undetected and thus untreated until they become entrenched and more difficult and expensive to treat.
Although many unhealthy habits have been well documented for decades, many individuals including health educators, health professionals and generally well informed individuals continue to abuse their health, and at times, those of others. There is a practical, ethical solution: the imposition of health impact charges. These are analogous to environmental impact charges which protect the health of the environment. Health impact charges can be collected by existing bureaucratic methods. The ultimate health care costs of tobacco usage for example, would be defrayed if cigarettes carried a $4.50 to $5 per pack health impact charge which already is the case in some European counties. With health impact charges in place, there would be no reason to tax cigarettes or refer to them as 'sin' taxes since the impact charge would pay for the health care services that ultimately are needed. The revenue collected from all sources of health impact charges-circa over $125 billion per year-could easily pay for effective, universal programs of prevention as well as a large portion of the health cares costs of those who are uninsured or underinsured. And, additionally, even with only a 30 percent reduction on preventable disorders which had been stimulated by health impact charges and programs of comprehensive and integrated prevention, total health care costs would be reduced substantially. Further, an important ethical goal would be achieved: health abusers would reimburse the health care system for the service they should not have required.
While managed care and competition, and cost shifting and sharing may improve some aspects of our health care system, the more frequent use of physician extenders, alternative delivery systems, and the implementation of practice guidelines and technology assessment are important keys for a long term solution. But maximally stimulating personal responsibility for wellness will inevitably remain a main player.
Americans need not give up their choice of doctors as a part of a package to establish fiscal stability for their health care system, but they must participate wholeheartedly in all aspects of prevention programs to minimize preventable illness and injuries.
Hans G. Keitel'44
Sarasota, Fla.


copyright ©, Columbia-Presbyterian Medical Center

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