TOM MURRAY: We have over 43 million people without any health insurance.

GRACE HIXON: You shouldn’t have to send someone home from the hospital that’s not fully recovered.

KATHY D’AMICO: There’s nobody to go to, so say, "This is unfair."

NONI GILBERT: Let’s say in six months you’re allowed thirty procedures, well this is the thirty-first!

HAAVI MORREIM: We’re in this incredibly turbulent time when we are upending medicine, just upending it.

NARRATOR: The crisis is being felt in every part of our society. There are simple, small steps that we can take to alleviate some of this suffering. And there are larger challenges that we as a nation will have to address in the 21^st century. The answer to these challenges can be found in the lives of ordinary Americans, and in the values they share.

NARRATOR: Just thirty miles from the glittering skyline of New York City, are the old working-class mill towns of northern New Jersey. People in these communities have seen the same radical changes in healthcare that have been felt by Americans everywhere.

MARA GILBERT: When they first said, "You have leukemia," I just thought, "Oh, okay, whatever." Like, "This will get cured." And then when they started telling me that I have to do the chemotherapy and my hair would fall out and I'd have to stay out of school, and I started to realize how serious it really was.

NONI GILBERT: The insurance nightmares began right away, because here's an insurance company that you've always thought is going to, ahm, take care of everything. And they don't. For instance, the chemotherapy goes directly into a catheter in her chest. The catheter had a kink in it, had a little twist in it. So that had to come out. Then they had to put it back in. "Oh, that's too many procedures. Wait a minute. You just put it in, then you took it out, and now you're putting it back in the next day. Denied."

NARRATOR: The Gilberts get their health insurance through an HMO, or health maintenance organization. Like all managed care organizations, HMOs promise to hold down rising costs by controlling the healthcare process at every stage. The Gilbert’s HMO required referrals from Mara’s primary care physician for each procedure of her two-and-a-half year treatment. Even emergencies had to be approved.

DR. KAMALAKAR: If Mara was at home and had a high fever, we'd tell the family they should call us immediately. Whether it is the day or night, weekend, doesn't matter because infections, unless they're caught very early, can be life-threatening with these children who are receiving intensive chemo. At those hours, now it is very difficult for the family to get a referral or even to think about referral, you know, getting a referral from the primary care physician.

DAVID GILBERT: Pre-certifications for any procedure, ah, even though it had been called in by the hospital in advance, was sometimes still denied and had to be haggled about on the phone, at the hospital before the procedure could be started.

NARRATOR: At one point, Mara was in imminent danger from a blood clot near the heart. As she lay in a hospital bed, her family anxiously waited for the insurer’s permission to proceed.

MARA GILBERT: I didn't really know that the insurance was part of the problem. I just thought that the hospital was slow and it was all the fault of the doctor. I didn't really know that the bills were screwed up and that the insurance company wasn't doing what it was supposed to.

NONI GILBERT: I must say it's the last thing you want to share with a sick child, ah, someone that has no hair and is cold and is sick and has got tubes coming in and out of them. "Oh, guess what, dear. The insurance denied this procedure."

DANCE TEACHER: Five-six-seven-eight, with turn.

NARRATOR: The treatment of childhood leukemia is one the success stories of modern medicine. Mara is making a full recovery. (Background Action Going On). But for the Gilberts, the insurance nightmare goes on.

NONI GILBERT: We just found out recently. We bought a used car, nothing spectacular, and went to our credit union to get a loan. They said, ahm, "You're a D rating." I said, "What does that mean?" They said, "Well, there's A, B, C, D, and E. E is the worst. You're one above the worst." I said, "Why?" They said, "Here, let me show you." And there were the unpaid hospital bills. They're for spinal taps. They're for chest X-rays. They're for putting the catheter in and out of this child's chest. They're not bills in dispute. They're not procedures in dispute. They simply haven't paid them.

NARRATOR: The Gilberts’ story is not unusual. Delays in payment, delays in care are common complaints.

DAVID EDDY: I think it is possible to agree on certain principles. We should not require prior approval for things that are good faith emergencies on the part of the family. And I do believe it would be in everyone’s interest, the patient’s interest, the insurer’s interest, the managed care company’s interest, to have a very easy system for expressing grievances, like an ombudsman program. A place where the family can go and get an impartial party to look at the circumstance and determine who is in the right, what the merits of the case are, and to address and problems should they exist.

NONI GILBERT: The chart that I was handed when I first started working that said, "If you get sick we’re gonna pay this, and we’re gonna respond quickly, and we’re a wonderful company that has you cradled in our arms, and whatever happens we’ll take care of it," that, that would be nice, just do it. The payment shouldn’t take a year.

NARRATOR: Managed care has caused a revolution in the economics of our healthcare system.

MARCIA ANGELL: In the old days, when doctors were paid fee-for-service, the doctors and the patients were kings. The insurance companies reimbursed whatever the doctors charged, no questions were asked, and so they began to do too much, and that gave rise to the incredible healthcare inflation that we began to see in the ‘70s.

NARRATOR: During the 1970s, we saw dramatic advances in medical technology. As doctors began using these new techniques, healthcare costs rose rapidly. Employers started to complain about rising insurance premiums. Some even dropped health coverage for their workers. In the 1980s, in an effort to hold down premiums, insurance companies began to offer managed care plans. Today, most Americans who have health insurance are enrolled in managed care,

TELEPHONE VOICE: The referral has been added to the system. Referral number zero, zero, zero, zero, zero, zero, zero, one.

NARRATOR: Managed care has successfully held down insurance premiums for millions of Americans. (Background Action)

NARRATOR: Competition between insurers is fierce. In the search to cut costs, some are adopting a system of reimbursement called capitation, in which doctors are paid a fixed amount per month per patient

DR. NAPOLI: A lot of physicians joke and they call it "decapitation." It’s just the dehumanizing of medicine. I would get a dollar amount, whether I saw you or not, whether you were in the intensive care unit or I never saw you, I would get the same dollar amount (Background Action). And it's a very, very small amount of money. I would get paid ten to twelve dollars per month to take care of you. For a hundred-and-forty-four dollars a year? Come on, the guy who pumps gas in your car probably gets paid at a better rate than that.

MARCIA ANGELL: There are financial incentives directly affecting doctors now, that put them at odds, put their interests at odds, with the best interests of their patients. Now to me this is unethical, it’s an unethical system. And it puts ethical doctors in a terrific quandary. They have to play mind games with themselves; they have to convince themselves that this chest x-ray that they would like to get, maybe isn’t necessary.

(Background Action).

NARRATOR: Many doctors feel that managed care threatens the traditional values of medicine.

DR. NAPOLI: When I first started out in medicine and you came to me as a patient, I was your advocate. I was the patient's advocate. With managed care and capitation, I'm no longer your advocate. I'm now the insurance company's advocate. They tell me what to do and then I do it. And I can't represent you. I can't -- I can't take care of somebody if I'm not -- I'm not on their side. So it's a -- it's a -- it's kind of really twisted medicine around.

(Background Action)

NARRATOR: In America’s hospitals, like Newark’s Beth Israel Medical Center, doctors also confront the moral dilemmas raised by managed care. (Background Action)

DR. BRIEF: This hospital loses approximately 80 thousand dollars a month on denial days by managed care companies. Why must we send an 80-year-old patient out on the street the night after a big operation, and they deny the social aspects of why the patient needs to stay another day or two, because his 80-year-old wife can’t take care of him at home. That’s not a reas- you put that on the chart they’ll deny the day, they don’t accept social reasons.

DAVID EDDY: I think in general HMOs have gotten a bad rap. We have to remember that they were brought in because they were the best hope for solving a critically important problem, which was the rising cost of health care and questionable quality of health care. HMOs have the promise of both controlling cost and improving quality.

E. HAAVI MORREIM: Once you draw limits, you have to actually enforce them. That's -- everybody, I think, agrees that we need to draw limits and, "You betcha'. No, we can not as a society afford everything for everybody." But our problem is -- you know, it's kind of that rule of rescue thing. As soon as we find an actual person being deprived of something that might help and probably won't hurt, it's very hard for us to say, "No, you can't have it. Yeah, it would help and, no, you still can't have that." We really can't do that very easily, and one of the things that we have created in terms of creating managed care, in a sense we've kind of created out own ogre so we can stick pins in it even while it's doing something that we need for it to do.

DR. NAPOLI: I want to be very clear about the fact that it's not just the HMO's fault. And I -- and I can't say enough to that end. Their dealing with the same problems that the patients that can't afford their medications are dealing with. They're dealing with the same problems that I, as a physician from a -- from a small business point of view, am dealing with. They have a business to run. And so they do have to put some kind of constraints on. It's that the costs are escalating so rapidly with new treatment modalities, new medications.

MUSIC

NARRATOR: New medicines offer us new hope. Drugs are becoming more specialized, and more effective. When a drug is more specialized, the cost of development is divided between fewer patients, and the price per patient goes up. The high cost of these new drugs creates dilemmas for many American families.

DOTTIE MARETTO: Dr. Napoli has always said if I ever needed samples for my husband, to ask and as long as he has them, he will give it to him. But I feel -- I get to the point where I feel like I'm begging and I don't like to do that.

VAL MARETTO: I have diabetes. That's my main problem. I've had bypasses on both legs. I had toes removed on both legs. And I'm on insulin plus Resalin. (Background Action)

DOTTIE MARETTO: I -- I -- I don't know -- I think it's outrageous. I don't know what it costs them to make a drug, but I just can't see where some of these things cost so much money. Now he has heart medication that he takes that's $6 a bottle and it's helping his heart, but the diabetes medication that he takes is like $300 a bottle.

MARCIA ANGELL: You can get the same drug in Canada for far less than that drug costs in this country because the Canadian government insists on having some regulation of what they’ll pay for it. The same is true of Europe, they will not pay what the drug companies ask, they say ‘we’ll pay only so much.’ And the drug companies make up for that by charging Americans more.

UWE REINHARDT: There’s two things you could do, you could raise prices to the Canadians, of course they could turn around and say ‘well, then we’ll buy Swiss or Japanese drugs,’ right, they — they have that power. Or you could lower prices here but then you would have to have government get into the act of setting drug prices and I know of absolutely no one who has the stomach for that, ‘cause you know, where would you set these prices? And then if you set them too low, you definitely could impair the R & D capacity of this wonderful industry.

(Background Action)

DR. NAPOLI: There are a number of pharmaceutical companies that have programs for people that can’t afford their medications, but because Val worked all his life, he has a little money in the bank, he has a home that he owns, that automatically disqualifies him. The prescription plan that is part of his managed care insurance program is very limited. It covers about, I think his is about $300 a year worth of medications.

MUSIC

NARRATOR: The combined cost of Val and Dottie Maretto’s medication is $14,000 per year.

DOTTIE MARETTO: Right now, sometimes we do share drugs 'cause I can't get the samples or it's just too costly and he'll share my drugs or we'll go halvsies on it or, you know, whatever we can do. He's gone as far as a month without medication, right?

VAL MARETTO: Yeah.

DOTTIE MARETTO : For the diabetes.

DR. NAPOLI: When Val is not able to take his medication, he may lose a leg, he may go blind. And the - the sad thing is, he knows it, ‘cause I’ve told him but he just — he can’t afford the medication.

UWE REINHARDT: Let me give you some numbers on pharmaceutical spending. As a percent of Gross National Product, it's one percent. Only one percent, as we speak, of GDP goes for prescription drugs. It's about eight to nine percent of total health spending. Only eight to nine percent is drugs. So these are not big numbers. The point of these numbers is to say, can America afford drug therapy? Yes, not a problem. What is unaffordable is that a family with a chronically ill person, somebody with depression, they can not afford -- or an elderly person. We have 12 to 15 million elderly who have no insurance for drugs at all. So the problem is how do we share the wonders of this industry so that everyone can partake? And that is a task for Congress, obviously, they need to grapple with it.

NARRATOR: Over the last fifty years, Congress has repeatedly wrestled with the problem of how to deliver the hope of modern medicine to all Americans. In 1946, President Harry Truman thought he had the solution. He proposed a plan which would guarantee healthcare to every citizen. But many believed that the compulsory, government-backed system, which Truman offered, was alien to the American way. Senator Taft called the plan, "Socialism. Right out of the Soviet constitution." In the years following World War II, Americans came to rely on employer-provided, private health insurance.

ROSEMARY STEVENS: We’ve really believed that the majority of the population could be covered through private health insurance. National health policy has been to try and put in governmental programs which assist the private sector to cover the whole population.

NARRATOR: By the 1960s, it was clear there were shortcomings in the private insurance system. It didn’t cover the poor or the elderly.

NARRATOR: In 1965, President Lyndon Johnson came to Harry’s Truman’s home town Independence, Missouri, to sign two historic pieces of legislation. The Medicaid bill boosted federal aid to state medical programs for the indigent. Johnson also signed the Medicare bill.

NEWSREEL: The new bill expands the thirty-year-old social security program to provide hospital care, nursing home care, home nursing service and outpatient treatment for those over sixty-five.

NARRATOR: He credited former President Harry Truman with planting the seeds for Medicare twenty years earlier. By and large, Medicare has been a success story for America’s senior citizens. But more than thirty years after its inception, some think Medicare is out of step with modern medicine. Tommy Giardina had a heart transplant nine years ago under Medicare.

TOM GIARDINA: Tarawa was a mile long and 1500 yards wide, but they were so well fortified that it took about three days to conquer that little island. There was only one Japanese that we took prisoner. But at the (unintell). you didn't have a chance.

PINKY GIARDINA: Here’s his Purple Heart. "For military merit," it says.

TOM GIARDINA: We had a misfire, a hangin' fire. So now the show -- you know, when the mortar, it looks like a stove pipe.

TOM GIARDINA: I had my heart transplant in '91. Medicare paid me for, ah, my, ah, operation on my heart and, ah, also paid for one year of my medication. And after that one year, I was on my own to get, ah, medication. So, naturally, I -- I tried to get it through the VA. And, ah, I was refused.

PINKY GIARDINA: And it is a very expensive medication. About, what, 13 -- $13,000 to $15,000 a year it would come to if you have to pay for everything.

THOMAS MURRAY: There are lots of bizarre inconsistencies in American health care, but one of the strangest is what we do with organ transplants, say heart transplants. We may pay to have the transplant done and then we'll pay for a brief period, one year, maybe up to five years, for the drugs that are absolutely necessary to keep that transplant going. Our body tries to reject the transplanted organ as a foreign object all the time. So you have to keep taking immunosuppressant drugs to keep that organ alive. Ahm, if we bought a fancy new car and didn't maintain it and then the car's engine blew up after a year, that would be really stupid, but to put in a new organ, which costs at least as much as that fancy car, and then not to take care of it with the drugs that are absolutely needed to keep it going is not just crazy, but, it seems to me, morally perverse.

MARCIA ANGELL: Medicare was designed to pay for everything. But in those days, there weren't very many good drugs. Now we have wonderful drugs, but that's not covered by Medicare simply by historical accident, because in 1966 we didn't have a lot of good drugs. So yes Medicare pays for heart transplantation, but it doesn’t pay for drugs. I think we ought to go back and look at the benefits covered by Medicare.

NARRATOR: Tommy Giardina suffers from another historical accident. Veterans Administration hospitals are federally funded, but states interpret the guidelines in different ways. In some states, the VA has decided to pay for drugs for transplant patients, but not in New Jersey.

TOM GIARDINA: From what I gather, some fellows in the outfit, they were gettin' medication from VA hospitals in Virginia or, ah, Pittsburgh or Brooklyn. Now if them other places can dish out Sandimmune, I -- I can't see why we can't. I didn't fight for just Jersey. When I fought, I fought for the whole United States.

MUSIC

TOM MURRAY: We Americans are very good at denying the connection between our most deeply held ethical values and our public policies. We need to connect those in the realm of healthcare. We’ve always tended to focus our concern about healthcare, and healthcare insurance, on what goes on in the doctor’s office and what goes on in the hospital. In fact, there’s always been a considerable amount of care that goes on afterwards, goes on at home. What’s happened in the past decade has been an increasing off-loading of care, sometimes very complicated and demanding card from the hospital to the home.

MUSIC

TOM MURRAY: We've tried to get people out sicker and quicker. That's the saying. And then the care falls largely on the family.

GRACE HIXON: My mom is on oxygen 24 hours a day. She went into the hospital in October for renal failure. From that, she got pneumonia. From the pneumonia, she had a heart attack and open heart surgery. When she came from the hospital, because of the trach, she has to be suctioned for, ah, phlegm build-up that builds up in -- in her air passage and, ahm, the hos-- the insurance company just said, you know, "It's time to go and you're just out of here."

NARRATOR: Many senior citizens like Carrie White have switched from traditional Medicare to Medicare HMOs. These privately-run programs offer an attractive drug package, and smaller co-pays. When Carrie became seriously ill, she discovered unforseen trade-offs.

KATHY D’AMICO: She was having a low grade temperature, low grade fever. She had fluid in her lungs. She was barely walking. She was having large amounts of secretions. She was having mucous plugs and the insurance company was then, on the 18th, giving us a reduced rate to keep her in this hospital. They, at that point, felt that it was time for her to leave the hospital and go to an alternative setting.

GRACE HIXON: She falls in that in between range in income and so there's really not much care that can be given to her except from family and friends. My daughter and her three children live here. My son lives here and we take turns. If I have to go out, they help. My sister comes during the day and stay with her. Ah, she drops her off at dialysis and I pick her up in the evening.

KATHY D’AMICO: Grace really wanted the help Carrie, but Grace also needed to earn a living. And with many of my families up on the geriatric floor, many of the families in our community, they have to work in order to survive. So the patients are often left at home by themselves trying to manage.

GRACE HIXON: If she had kept regular Medicare, she would have been able to at least get six weeks of service if the visiting nurse deemed it so, at least six weeks of home health aide service would have been here. And because of the HMO and them having to okay everything, they’re saying, "No, she doesn’t need it."

GRACE HIXON: Once before she was ill, and that was about probably 30 years ago. Until '72, she's been fine. She's been doing for herself, taking care of herself, cooking, driving.

CARRIE WHITE: It’s really kind of hard for me to look to somebody else because I’m so used to doing for myself.

NARRATOR: Medicaid would pay for Carrie to go to a nursing home, but she would have to surrender the few thousand dollars she has saved. And she would lose her own rented apartment, which she hopes to return to someday.

ROSEMARY STEVENS: Families are always going to have to carry some responsibility for people in those families who are sick, (Background Action) but we could do a much better job on sustaining families who are under great stress. That may mean more home care for some people, respite services so a care taker, can -- can get out, go to a movie, go shopping. As family policy, we've really ignored the burden on families with a seriously ill, ah, individual. (Background Action)

TOM MURRAY: What is it that we really care most about when it comes to healthcare. I think you’ll find a concern for ministering to genuine needs, you’ll find a concern for giving families’ opportunities to have good lives and some medical, emotional and financial security. You’ll also find a concern for individual liberty, Americans like to be able to choose their doctor, they like to be able to choose which plan or hospital they go to. You’ll have a balancing of these values, and it won’t be easy you because there’ll be trade-offs that will have to be made at the margins.

PRESIDENT NIXON: Forty-five years ago, my oldest brother contracted tuberculosis. In those days we did not have the new methods of treatment which handle tuberculosis very effectively and very quickly.

NARRATOR: Throughout his presidency, Richard Nixon pushed for healthcare reform.

NIXON: There are still too many Americans who lack health insurance protection. Let me give you some of the numbers, you probably know them, but it’s good for the national audience to hear them. One out of every ten Americans has no coverage at all, either public or private. I believe that comprehensive health insurance is an idea whose time has come. I believe that some kind of program will be enacted in the year 1974.

NARRATOR: Six months later, in the face of the Watergate scandal, Richard Nixon resigned. Since then, the number of uninsured Americans had doubled, and continues to rise at a rate of one million each year.

NARRATOR: This extraordinary rise is due in part to the unraveling of our employer-based insurance system.

CHARLIE NIELSEN: I've been working here for 42 years. When I first started workin' here, we had Blue Cross/Blue Shield insurance. You could go to any doctor, any hospital. It didn't matter. You just presented your card and everything was paid for. Through the years, everything has changed. You can't afford total coverage anymore, no matter where you go, I don't care who it is, how big a company, because everybody is downsizing.

THOMAS MURRAY: Almost all Americans who have private health insurance have it through their employer. That's an historical accident. In the 1940s, during the Second World War, wage and price controls were placed on American employers. And in order to compete for employees, they could offer health benefits. In those days it was -- it was cheap.

ROSEMARY STEVENS: I think the employer-based insurance system is falling apart. The market has changed. We've got a lot of small businesses who find it difficult to afford health insurance.

RICHARD BING: We originally started out paying a hundred percent for the employee and their family. We've gone to a scheme where the employee pays 25 percent of the premium cost and we pay the rest. Health benefits were climbing at such a rate where some of my competitors just dropped 'em and they hire, ah, I’d say, part-time employees.

ROSEMARY STEVENS: We've got a lot of people doing contract work, temporary work, several part-time jobs. And at the same time, the cost of insurance has reached such a pitch that some employers have been cutting back on their employee -- on their employee benefits. So the -- I don't think the -- the -- the employment-based system is sustainable.

NARRATOR: During the 1990s, the fastest-growing segment of the uninsured was the working poor.

BRUCE C. VLADECK: This is as good as the labor market gets in the United States. What is scary about the current phenomenon is that this is really the first time since people have been keeping the numbers on this since the end of the second world war when the number of uninsured people has increased when unemployment is low. That is what is really scary about the present situation.

THOMAS MURRAY : If you as an American want to buy health care insurance, the worst situation to be in is to be unemployed, self-employed, or to work for a small employer. In those cases you're going to have to look for the most expensive and difficult to find forms of health care coverage.

UWE REINHARDT: It's much, much cheaper to enroll 10,000 General Motors employees. The administrative cost per enrollee is trivial. But when it has to be done one by one, something like 30 to 40 percent of your premium just goes for administration. And that is what makes it in a way a double whammy for the low-income working stiff who doesn't have employer-provided insurance. They pay this huge overhead, but it isn't that the insurance company is gouging. It costs that much to do.

BRUCE VLADECK: Take the simplest example, and people I don’t think adequately understand the economics, but take someone who makes ten dollars an hour, which is not quite twice the minimum wage, whose gross salary, therefore, is something on the order of 22,000, $23, 0000 a year, before payroll taxes, before commuting costs, before many local taxes they have to pay. Um, in the Northeast, a half-way decent family health insurance policy can run anywhere from 5 to $7,000 dollars a year, and that’s not the Cadillac policy, that’s the Chevrolet policy. Well, you can’t expect folks who are -- who are just getting by to be able to afford health insurance, nor, I think, can you expect their employers to pay what is in effect a 35 percent surtax on their wages to provide them with health insurance, The fact is, that employment even at a multiple of the minimum wage in the United States these days is not enough to provide a family with a reasonable standard of living if the family has to pay for its own health care, it’s just , the arithmetic doesn’t compute.

PRESIDENT CLINTON: This health care system of ours is badly broken. And it is time to fix it.

NARRATOR: 1n 1993, President Clinton proposed a comprehensive overhaul of healthcare.

PRESIDENT CLINTON: So let us agree on this, whatever else we disagree on. Before this Congress finishes its work next year, you will pass and I will sign legislation to guarantee this security to every citizen of this country.

HARRY& LOUISE COMMERCIAL: The government may force us to pick from a few health care plans designed by government bureaucrats. Having choices we don’t like is no choice at all.

NARRATOR: Intense lobbying from the health care industry, led by private insurers, helped derail the Clinton Plan. Less ambitious proposals to cover only the working poor were also abandoned.

GAIL WILENSKY: There wasn't a willingness to say, "Even if we should do more, let's at least make sure we do this," because it had been, as far as I can remember, the first time that both political parties were on record as saying, "There should be a minimum benefit package for at least the very poorest." To my mind, it was just shameful that we let that period slip away.

TOM MURRAY: We have over 43 million people without any health insurance, we have over 80 million people either without insurance entirely or with inadequate insurance. It’s nearly a third of the country.

ALICIA FACCHINO: Where’s my chair honey?

ALICIA FACCHINO: I've had MS for ten years. And my kind is like progressive. So I just get worse. I really can't do anything. I don't leave my house. You know, it's hard for me to get out. There's steps in the back. My kids, they're young and they really help me. But it's hard for them. Noelle, she turned two when they said I had MS.

NOELLE FACCHINO: And he's little Mr. Taste Everybody's Food.

ALICIA FACCHINO: He was four months old, my son.

ANTHONY FACCHINO: That's just what kids are supposed to do. I mean they gotta take care of their parents.

ALICIA FACCHINO: They grew up with it, so they didn't get to do all kinds of normal things like kids normally would go and do. I think my son I did take to nursery school and then I couldn't drive. I couldn't even drive around.

ALICIA FACCHINO : That might be ...

ANTHONY FACCHINO: This is my mom and ...(overlap) get outta the house.

ALICIA FACCHINO: It wasn't really a marriage. He was just always taking care of me. And he still has to come in. I do have to be cathetered -- like I think three times now. And he'll do it like before he goes to work and after work and he's gotta check on the kids. So he's in and out, but he -- he doesn't live here. So, you know, it just -- it just got to that point. (Background Action)

NOELLE FACCHINO: I cook most of the meals and do laundry. I do like vacuuming and just stuff like that that normally she would do that I have to because she can't.

ANTHONY FACCHINO: (Laughter) I usually have to clean a lot and vacuum, but pretty much I don't cook or do laundry. I just like do the garbage.

NOELLE FACCHINO: When she falls and stuff, we're stuck like getting her up, 'cause like even when our father was here, he threw his back out tryin' to help her. So even then we were stuck getting her. And she's a lot bigger than us, so it's hard.

ALICIA FACCHINO : I know there's people that if I had to call, they would help me. But most of the time it's just me and them, (Laughs) me and the kids.

NARRATOR: Just weeks before, Alicia Facchino had developed a life-threatening infection. Because she is uninsured, her only recourse is the emergency room at her local hospital.

DR. PAREDES: When we saw Alicia in the emergency room, her symptoms had actually gotten much worse. Multiple Sclerosis is -- is a chronic disease and, ah, you know, each time as the years pass, ah, the exacerbations may get worse. Her disease may progress even more. She may need more, ah, medical assistance. Ah, she may become physically unable to even do the -- even ambulate on her wheel-- on the wheelchair.

ALICIA FACCHINO : I'm on the beta seron, which was the first drug they approved, and they have a foundation and I applied to that and they accepted me 'cause I have no insurance. So that's how I'm getting that medicine. So ...

NOELLE FACCHINO: I have to give her that, because her hands are too shaky to give it to herself. So that's another thing I have to do. And you have to mix it and then put it in the needle and bring it and like gives her the shot. A nurse came and taught us how. And like she takes a lot of pills and stuff and I set them up for her every day. (Background Action)

NARRATOR: Alicia has been reluctant to apply for Medicaid. To quality, she must prove herself totally indigent.

BRUCE C. VLADECK: What it means is that when people really have very serious medical problems, you put them through an excruciating -- I mean the rule is, you know, again back to the Elizabethan Poor Law, it has to be so unpleasant and undesirable to get public assistance that only people who are truly desperate will seek it. That's the guiding principle. It's pretty horrible in this day and age, but that's still the basis on which our eligibility, ah, decisions are made. (Background Action)

NOELLE FACCHINO: Even if she can't get better, like with the Medicaid, if we can get that, the medicine is really expensive. And then someone to come here and help her, maybe like they could do the laundry or something, because I have a lot of homework. (Background Action)

THOMAS MURRAY : Chronic illness may exhaust the family physically, emotionally, and financially. People may find themselves unable to afford help from outside, unable even to afford the medications that they desperately need. This just doesn't seem like the response of a humane country. I think we're a better -- Americans are a better people than that. We -- we can find ways to meet the genuine deep needs of -- of our fellow citizens who -- who simply need our care and compassion.

MORREIM: We really do need to cover those other 44 and-a-half million people, who have not been brought on board yet, it really is important, and not just because it’s the decent thing to do in an affluent society, but also because that many people without good access to healthcare creates economic quirkiness in the marketplace, a lot of strange economic dynamics when you have that many people who don’t have access to health care, and everybody else is scrambling to try and avoid being hit with the bills indirectly.

NARRATOR: America’s uninsured are putting an unbearable strain on our nation’s hospitals. In many states, emergency rooms are required by law to treat the uninsured.

DEL MAURO: If you look at the Saint Barnabas healthcare system and the amount of charity care that we deliver, um, in 1998 the shortfall on the charity care reimbursement was approximately 24 million dollars, in 1999, the shortfall was approximately 38 million dollars.

NARRATOR: Advances in medical technology are pushing healthcare costs upward at twice the rate of inflation. Rising costs and lowered revenues are driving the industry into crisis.

EDDY; If you talk to hospitals they’ll tell you, "Not only have we reduced costs to the bone, so to speak, but we’re about to go out of business." Many of the so-called for-profit managed care organizations didn’t make a profit at all, they functioned at a loss. Physicians are accepting lower and lower salaries. Very, very few parts of the healthcare economy, if you will, are doing well.

NAPOLI: Many physicians are struggling, many are leaving medicine and going to other fields (Background Action). The biggest HMO in the state right now, many physicians have just said, "I know you’re the biggest and I know you represent 53 percent of the patients in the county, but I can’t keep my door open if I continue to accept your limited reimbursement." (Background Action).

NARRATOR: The danger of this crisis of finance and morale is that good medicine itself may be at risk. Cut the drug payments and you cut drug research. Cut the hospital payments and specialists will become hard to find. Cut the doctors enough, and there will be fewer good doctors. If we want to continue with the high standard of medicine in America, we may have to be willing to spend more. Currently we spend 15 percent of the GDP, or Gross Domestic Product, on healthcare.

GLIED: It’s funny when you look at historical documents, people were complaining about the share of healthcare in the GDP when it was 5 percent. They said it would be unsustainable if it hit 10 percent, and you know we’re going, we’re chugging along very strongly at 15 percent, and the economy doesn’t seem to be suffering for it. It doesn’t really matter what share of the GDP we spend on healthcare, just like it doesn’t matter how much we spend on movies. We could spend 80 percent of the GDP on movies and that would just mean we were a wealthy society that liked to watch movies and there’s nothing ethically, morally or economically wrong with that.

WILENSKY: I think we will always spend substantially more relative to our GNP than other countries, and as a wealthy, industrialized country, there isn’t any reason why we ought not to allow ourselves to do that. The question that we ought to ask is whether or not we think we’re getting our money’s worth.

NARRATOR: We could spend more, we could also agree to spend more wisely on administration.

REINHARDT: We burn much more money on administration than any other country. I personally consider that really the scandal of this system, the enormous amount of administrative expense which, I believe, much of it is waste.

NAPOLI: The biggest HMO in the area right now, 22 percent of every healthcare dollar that you pay to them for your health insurance, 22 cents of that goes to operating expenses and profit margin. And I think it’s a generally held concept that you need approximately 6 percent, or 6 cents out of every healthcare dollar, to actually make the system run. So there’s, there’s lots of room for reducing costs.

EDDY: Some treatments might increase cure rates by 80 percent for a few thousand dollars, those are extremely high value. But there are other treatments out there,that might provide a tiny little benefit, or no benefit at all, or just a small chance of a benefit. For example, there are some treatments for bone loss that in fact decrease a woman’s chance of having a hip fracture by about one out of ten thousand or one out of thirty thousand. So at one end of the spectrum you’ve got very beneficial and very valuable things, at the other end of the spectrum you’ve got things that provide a tiny amount of benefit. Right now, we don’t do a very good job of distinguishing between them, we try and deliver all of them. But clearly if we want to control healthcare costs, if we want to use people’s money wisely, we have to make those distinctions much better than we have in the past.

NARRATOR: The most urgent need in American healthcare today is finding a way to deliver care to the rising number uninsured.

WILENSKY: We ought to be making sure that people, particularly the lowest income among us, have basic coverage. This doesn’t necessarily mean that it has to be government-funded, but we ought to make sure of that. I am less concerned about multi-tiers as long as what we’re providing for the lowest income is acceptable to us as a country.

REINHARDT: I personally say let us have a two-tier system, let’s accept it, and let us focus on the bottom tier and say let us make it good enough so that as Americans we could be proud of it. I think that could be done. That would probably be based around managed care, it would have HMOs.

NARRATOR: In the healthcare debate today, the key to success seems to be in resolving the conflict between those who think private insurance should run healthcare, and those who think the job ought to be done by government.

ANGELL: We could say look, a decent society provides certain things for its citizens and healthcare is one of those things. Some people get sick expensively and some people are well all their lives and then drop dead one day and they cost the system nothing. But we share it all and we say we’re all in this together. We could go in that direction and probably begin by, while we still are in a time of prosperity, extending Medicare, decade by decade, instead of over 65, going over 55, and maybe working up from children, toward the middle, and then we would have a single-payer system.

MUSIC

WILENSKY: It’s important to remember that we are a very big and diverse country with very different attitudes towards social responsibility and government responsibility. And if we ignore that when we’re trying to resolve these very difficult social issues, the chances are they aren’t going to get resolved.

NARRATOR: As we move into a new century, our healthcare system will undoubtedly change. What is not clear, is whether these inevitable changes will reflect our ideals and values, or whether our healthcare system will continue to fail millions of Americans.

STEVENS: History has shown that we can be very inventive, we can move fast as a culture, as a nation. How we’re going to do this is currently up for grabs so this is an exciting period, it’s a very alarming period, but I believe we can create a better healthcare system, and have to.

END OF PROGRAM