For the American Medical Association, the preferred word to diagnose the situation in malpractices insurance is "crisis." Objection! replies the American Bar Association: "While there are problems in the medical professional liability area, we question whether they are, in fact, of crisis proportions."
The square-off between the doctors and the lawyers occurred before the House subcommittee on health and the environment. Each organization had statistics, selected facts and assorted grabbers to prove that its case was sound and the other's unsound.
Another inconclusive hearing might have yawned its way into the long sleep of nonreform, except that time was given to a witness who spoke about the effect of malpractice insurance on people's lives. The scaled-down message of Dr. David Smith of Brownsville, Tex., is that while lobbyists and politicians are playing word games on whether we have a "crisis" or a "problem," the citizens he is caring for are dying and suffering from preventable neglect.
Smith, 32, board certified, married to a physician and a member of the National Health Service Corps, is the medical director of the Brownsville community health center. More than 26,000 citizens -- a number that is about one-fourth of the local population -- have been registered as patients. Brownsville, at the geographic bottom of Texas, is also in the lowermost economic regions as the nation's third-poorest metropolitan area. At the last census, average income was $4,100. Medicaid covers 26 percent of Texas' poor people, with the national average at 46 percent. More than half the center's patients suffer intestinal parasites. Anemia and tuberculosis are common. Cases of leprosy and brucellosis have shown up. Brownsville is a border town but less than 3 percent of the patient visits are those of illegal aliens. As many as 40 percent of the center's patients have gone south because the costs are lower.
At times, Smith feels as though he is called on to practice First World medicine in Third World conditions. One of those times came last summer. A 1,000 percent increase in liability-insurance rates in two years -- from $30,000 for the center's 14 doctors to $300,000 -- meant the forced closing of the center's maternity site. For six weeks, no services were available. Smith believes that "the closure may have directly -- and certainly indirectly -- proved tragic for three infants."
The deaths came about because the mothers lacked the money to pay -- up front -- the costs for a hospital delivery. Smith told the subcommittee that "patients are required by local hospitals to provide large deposits prior to obtaining both obstetrical and nonobstetrical care, of up to $3,500. Most cannot afford this and are frightened away, the 'fear factor.' Many refuse to go to the local hospitals because of this 'fear factor,' and people have died needlessly."
Smith documented the stories of three mothers who could not deliver their babies because either the maternity center was closed or they could not afford the deposit required for a hospital admission. The center was reopened after six weeks because the $300,000 for liability insurance was taken out of the federal grant that supports the operation. The money now going for insurance means less or no health care for the patients.
As with many young physicians, Smith has enough money worries without the extra one of insurance rates. He and his wife owe $35,000 in college and med-school debts. They pay $400 a month and have reduced the total by $5,000. Smith earns $50,000 a year, a low salary by medical standards and lower still when put in the context of an 85-hour work week. None of that bothers him. Smith has a social conscience, one that would be deadened with a routine middle-class practice where his skills could make money but not a difference. He didn't go into medicine to get rich and bored and, assuredly, he didn't move to Brownsville to set up a glamor practice.
A graduate of Cornell and the University of Cincinnati medical school, Smith works at one of the nation's 600 community and migrant health centers. Most of the 6 million people served by them are poor, uninsured and on the far fringes of the health-care system. All they have are advocates and friends like David Smith who believe, with refreshing idealism, that their skills and lives belong to the whole community. According to the National Association of Community Health Centers, American medicine keeps attracting the David Smiths: "Between 1974 and 1983 health centers increased the population they served by more than 300 percent, even though their grant funding levels grew by only 65 percent."
At the hearings on liability insurance, the battling giants -- the AMA and ABA -- were united on one front: Neither's testimony referred to doctors in the community health centers or to the poor who, as usual, are feeling it first and hardest. The lobbies defended the already well defended, themselves.