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NEWS & COMMENT

Washington PerspectiveHealth-care discontent wins an election

"If criminals have the right to a lawyer, I think workingAmericans should have the right to a doctor." On that pithyif illogical campaign theme, Harris Wofford, theDemocratic candidate, was elected to the US Senate inPennsylvania on Nov 5.As a result of Wofford’s victory, rated impossible just a

few months ago, health economics and equity are assuredprime time in Congress and in the year-long run-up to thepresidential election. Whether beneficial changes will beachieved in the newly attentive atmosphere is anothermatter. Political and popular unanimity exist on the need forbringing in the nation’s medically excluded millions,assuring continuity of insurance coverage, and restrainingcosts-goals not easily harmonised. But there is no

consensus on the means to get there. Wofford himself was

safely vague on the fine details.What is certain, however, is that political instincts have

been intensely aroused by the unexpected triumph thatfollowed Wofford’s invocation of the health issue. Even

George Bush has signed on as a health-care reformer,asserting that the message from Pennsylvania is to "try tohelp people with health care". Having done close to nothingon that front since coming to office, the President

vaporously pledged that he will now pay attention to thematter. Elsewhere, though, public dialogue resounds withnew and reissued master plans for remaking the Americanhealth-care system.A former college president with no elective experience

and little public recognition, Wofford, the state Secretary ofLabor and Industry, was appointed to the Senate byPennsylvania’s Democratic governor to fill the seat formerlyheld by John Heinz, a Republican who died in an airplanecrash in April. Last June, victory seemed assured for hisRepublican opponent, former Governor Richard

Thornburgh, long a popular figure in Pennsylvania politics.Most recently, Thornburgh had served as Attorney Generalin the Reagan and Bush administrations. His performance inthat post was derided in Congress and the press as ineffectiveand he was generally regarded as having poor command ofthe vast law-enforcement bureaucracy he headed as chief ofthe Justice Department. When the Senate seat opened,Thornburgh left his unhappy place in the President’scabinet for what was expected to be a shoo-in election in hisfriendly home state.

Waiting in ambush was Wofford, not only armed with thesurprise weapon of the health-care issue but also benefitingfrom the anti-incumbency spirit churning American

politics. Thornburgh, fresh from three years of serviceunder President Bush, was tarred by Wofford as an insiderwho exemplified the failings of Washington. In June,

Thornburgh led in the polls by 67-20. When the votes werecounted, underdog Wofford had won by a landslide, 55-45.In a post-election poll, the health issue was identified as amajor concern by 64% of Wofford’s voters and 39% ofThornburgh’s.On many occasions before the election, George Bush had

been not merely indifferent but scornful toward complaintsthat he was aloof from our tortuous domestic affairs infavour of less disputatious matters on the world scene.Immediately after Wofford’s victory, Bush postponed a tripto Asia and Australia, long planned for the end ofNovember. The President attributed his revised travel plansto his high sense of duty, citing deep concerns aboutdomestic matters and, in particular, the perils of leaving thecapital with spendthrift Democrats in control of the

Congress. They, of course, have been in command ofCapitol Hill throughout the President’s three years of

frequent flying.What happens next in health-care politics is far from

clear. The problems most distressing to the voters are thecontinually rising costs of health insurance and uncertaintiesabout the durability of coverage. Health insurance formerlywas regarded as a standard benefit of employment inmedium and large companies. But with annual increases of20-30% in insurance premiums burdening recession-bound firms, many are either insisting on cost-sharing byemployees or they want to shed the responsibility altogether.Health benefits have become the major sore point in labournegotiations.

Meanwhile, major segments of the insurance industryhave adopted and refined the tactic of selection to avoidhigh-risk enrollees in their benefit programmes.The world’smost celebrated HIV-positive case, Magic Johnson, learnedof his infection from an insurance examination. The middle

class, menaced if not hit by the recession, finds its securitythreatened by the realisation that those who need health carethe most may find insurance coverage is either limited orunavailable. Loss of employment is often accompanied byloss of insurance. And employment is no guarantee ofinsurance. Among the approximately 35 million personswithout any health insurance, some 20 million are in familieswith a full-time worker.Embodied in various proposals and legislative formulas,

the most widely supported remedy for health-care reformwould require all employers to provide health insurance fortheir workers or pay into a pool to finance care for theuninsured. Many major employers favour that arrangementbecause it would spare them from the hidden cost shiftingunder which the insured are "taxed" to help pay the hospitalbills of the uninsured. But in the business community,sentiments have not coalesced on any one particularformulation for coverage. And there has been relatively littlediscussion of how costs would be constrained when millionsof more insured customers are added to the medical market.

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Following the Pennsylvania election, a major assemblageof business and labour organisations, the National

Leadership Coalition for Health Care Reform, endorsed aplan centred on employer-financed insurance with firmfederal controls on utilisation and spending. But one of thelargest members, the American Telephone and TelegraphCompany, withdrew from the coalition on the grounds thatit was opposed to mandatory requirements. The NationalFederation of Independent Businesses, which claims

500 000 member companies, denounced the proposal asunfair to small companies.The irony about political discontent with the health-care

system is that all plausible remedies call for more publicspending. But the other message from the Nov 5 electionwas that the voters are against higher taxes. In New Jersey,for example, a tax-raising Democratic legislative majoritywas voted out, while voters in Missouri rejected a taxincrease earmarked for education. And public debate onhealth, which is just beginning, is yet to address the complexissues of restraints on utilisation as the only possible meansof holding down cost increases.An appropriate footnote to the dilemma of American

health-care politics is contained in a press release issuedshortly after the recent election day. It states: "Two out ofthree Americans say they would like to live 100 years and anequal number believe that scientists will cure majorlife-threatening diseases in their lifetimes, according to anationwide survey released today by the non-profit Alliancefor Aging Research".

Daniel S. Greenberg

Round the World

Soviet Union: Crumbling edifice of medicalresearch

The Ministry of Health of the USSR is no more. It

disappeared last week, together with around eighty otherAll-Union ministries and government departments, leavingthe future of medical education and medical researchuncertain.

Officially, health care and medical research will notbecome the responsibility of the successor republics.However, the economic collapse of the former Union meansthat all republics are pressed for money. Even the hugeRussian Republic, which inherits most of the resources andassets of the former Union, sees no way to support its

existing network of hospitals and research facilities. In ruraland provincial districts the situation is particularlydifficult-and was so even before the break-up of the Union.Around Sverdlovsk (now Ekaterinburg), for example, amysterious neurological condition known as Sverdlovsksyndrome (or, more colloquially, "stomping foot") hasattacked vegetable-harvesters for the past three years, butthe local health authorities have been unable to afford the

necessary research to track it to its source.What makes the situation more tragic is the waste of

money over the past two decades. Dr Zhores Medvedev, aformer dissident, who has just retired after 18 years at theNational Institute for Medical Research in London, lastweek gave a retiring lecture in the Institute describing arecent visit to his native Russia.

During the 1970s, he said, enormous sums of money-and in particular, hard currency from Soviet oil exports-were wasted on building huge "prestige facilities". Doctorsand scientists in high favour competed to build themselvespalatial institutes, equipped with sports centres and winter-gardens. One such, which has its own Olympic-sizedswimming-pool, was the Institute of Biochemistry, built inthe form of a 12-unit DNA molecule, with the "hydrogen-bonds" providing the corridors, in which everything, downto the very taps, was imported. Breshnev’s personalphysician, Dr Yevgenii Chasov, built himself a hugecardiological clinic, and Dr Nickolay Blokhin, president ofthe Academy of Medical Sciences, built an enormous cancerinstitute and hospital. There was even a special (and untilrecently, top secret) marble-clad necropsy facility in thewoods near Moscow, devoted solely to the remains of topparty officials.

Now, Dr Medvedev says, all these facilities stand idle forlack of money. Their western equipment is useless withoutspare parts and reagents, which they cannot buy. Even DrBlokhin’s hospital lacks basics such as dialysis membranes,disposable needles, and insulin. And there is no money at allfor subscriptions to foreign medical journals.

Furthermore, the break-up of the Union means the loss ofsome major facilities from the network of the formerAll-Union Academy of Medical Sciences. All republics,including Russia, have "nationalised" the assets on theirterritories. The All-Union Academy itself will become, in allprobability, a Russian Academy of Medicine-but it willlose direct control over, for example, its gerontology andradiology institutes in Ukraine, and its epidemiology centrein Uzbekistan. Doubtless the staff of these institutions will

eventually work out some informal contracts on the sharingand transfer of data-if, that is, the institutes survive. Foralready the republics are finding it difficult, Dr Medvedevsaid, to meet the payrolls and maintenance bills for thefacilities they acquired so happily three months ago. AndGeorgia, in particular, has more than its scientists and theirsupport staff to feed and house. It has also acquired theAll-Union Centre of Primates, which supplied animals toresearch laboratories. But, Dr Medvedev said, the

Georgians have no resources to feed the animals, and there isconsiderable doubt as to how long the centre can continue.

London Vera Rich

Germany: Abortion ways and means

During the past few weeks one recurring topic of debate inthe media has been whether the abortion pill RU 486(’Mifepristone’) should be introduced to the Germanmarket. The subject has of course been hotly debated inother countries, but in Germany it is complicated by beinginextricably linked with discussion about a new abortion lawfor the reunited country. At present different laws apply tothe West and the East. In West Germany abortion is legalonly within the first three months if a doctor has found amedical, criminal, or psychosocial reason for it. In East

Germany abortion on demand is legal in the first threemonths. The German unity treaty stipulated that a

nationwide law must be installed by the end of 1992.But a new law is not yet in sight. So far the various political

parties have produced several drafts: whereas theConservatives favour an even stricter or a slightly modified