NYT - May 26, 2007 - Op-Ed Columnist

A Katrina Health Care System

By ATUL GAWANDE
This is my fourth week as a guest columnist. Let’s take a look at the health care news that’s transpired in that time.

First, DaimlerChrylser sold off 80 percent of its Chrysler division for three pebbles and a piece of string. O.K., the cash payment was actually $1.35 billion. But for an 82-year-old company that built more than two million cars and trucks last year, took in $47 billion in revenue, and owns 64 million square feet of factory real estate in North America alone, that’s almost nothing. Yet analysts say that it was a great deal for Daimler. Why? Because the buyer, Cerberus Capital Management, agreed to absorb Chrysler’s $18 billion in health and pension liability costs.

Stop and think about this for a minute. The deal meant that the costs of our job-based health insurance system — costs adding $1,500 to each car Chrysler builds here, but almost nothing to those built in Canada or Europe — have so broken the automaker’s ability to compete that giving it away became the smartest thing Daimler could do. Chrysler’s mistake was to hang around long enough to collect retirees and an older-than-average work force. As a result, it now has less market value than Men’s Wearhouse, Hasbro, the Cheesecake Factory, NutriSystem, Foot Locker and Pottery Barn. Oprah is worth more than Chrysler. This is not good.

Meanwhile, officials at West Jefferson Medical Center outside New Orleans reported that the number of indigent patients admitted there has tripled since Hurricane Katrina. The uninsured are now 30 percent of their emergency room patients. Officials in Houston hospitals are reporting similar numbers. Conditions seem worse rather than better. Katrina caused a vicious spiral. Large numbers of people lost their jobs and, with them, their health coverage. Charity Hospital, the one state-funded hospital in New Orleans, closed. The few open hospital emergency rooms in the area have had to handle the load, but it’s put the hospitals in financial crisis. Four hundred physicians filed a lawsuit against the state seeking payment for uncompensated care, and massive numbers of doctors and nurses have left the area.

In Washington, a conference held by the American College of Emergency Physicians revealed that New Orleans may have it worst, but emergency rooms everywhere are drowning in patients. Mandated to care for the uninsured, they are increasingly unprofitable. So although the influx of patients has grown, 500 emergency rooms have closed in the last decade. The result: 91 percent report overcrowding — meaning wait times for the acutely ill of more than an hour or waiting rooms filled more than six hours per day. Almost half report this occurring daily.

A few days later, the Commonwealth Fund released one of the most detailed studies ever done comparing care in the United States, Australia, Canada, Germany, New Zealand and Britain. We’ve known for awhile that health care here is more expensive than anywhere and that our life expectancy is somehow shorter. But the particulars were the surprise.

On the good side, the study found that once we get into a doctor’s office, American patients are as likely as patients anywhere to get the right care, especially for prevention. Only Germans have a shorter wait for surgery when it’s needed. And 85 percent of Americans are happy with the care they get.

But we also proved to be the least likely to have a regular doctor — and starkly less likely to have had the same doctor for five years. We have the hardest time finding care on nights or weekends outside of an E.R. And we are the most likely (after Canadians) to wait six days or more for an appointment when we need medical attention. Half of Americans also reported forgoing medical care because of cost in the last two years, twice the proportion elsewhere.

None of this news, however, did more than lift a few eyebrows. So this is the picture of American health care you get after watching for a few weeks: it’s full of holes, it’s slowly bankrupting us and we’re kind of used to it.

That leaves two possibilities: (1) We’ve given up on the country; or (2) we’re just waiting for someone else to be in charge.

I’m pulling for No. 2.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.