填空题 The question of health care reform again wafts about the corridors of power in Washington. The revolutionary spirit of Thomas Jefferson is invoked with the language of a Patients' Bill of Rights. Life and liberty are again at stake, threatened by the tyrannical Chief Efficiency Officers of the managed care empires.
16. ______
Sadly, the answer is "no." Harry lost his management position three years ago in a downsizing applauded by Wall Street. He now works two jobs at $9 per hour and has no health benefits. Louise has metastatic breast cancer. They've re-mortgaged their house to pay her medical bills. They have no time for pointless political posturing.
In 1993 the Clinton administration undertook an honest effort at health reform. It was flawed in many ways. But it was inspired by a genuine moral vision that a just and caring society ought to assure all of its citizens the right to health care.
The defining moral features of the plan were:
· Universality (no one would be uninsured).
· Nearly equal access (a thick package of health benefits would be guaranteed to all; no segregation of the poor in dilapidated health plans).
· No discrimination against the chronically ill (health plans could reject no one for pre-existing conditions).
· Choice among health plans for virtually all (contrary to the Harry and Louise commercials).
Cost control through managed competition (health plans would have to compete by improving quality and efficiency, not by dumping costly patients with the most serious health needs).
The sad fact about the two proposals now before the U.S. Senate is that not a single one of the six moral goals above are advanced even minimally by either. Meanwhile, the ranks of the uninsured have grown by 7 million in the past six years during the most prosperous period we have ever enjoyed as a nation.
17. ______
These proposals are really just consumer protection bills, and there's nothing ignoble about that. The unmanaged competition among health plans that characterizes today's market has proven to be a real threat to the well-being of many less healthy middle class paytients.
But for the uninsured who are merely "patients" -the sick and poor -what good is a right to sue for denied health benefits when you have no right to benefits to begin with?
Speaking of which, what benefits do middle class patients in managed care plans have a right to? The answer to this question is a lot murkier than you may think.
The technical answer usually given is that they're entitled to "all medically necessary care." But in 1994, the Clinton Health Reform Task Force spent days trying to attach a precise meaning to that phrase, and the phrase is again crucial to the Senate bills.
Medical experts can surely tell us what care is medically necessary. And if medical care is really necessary (if some essential function or life itself may be lost without access to that care), then that seems to make a moral claim as well. That is, wouldn't it be indecent, unjust and lacking in compassion to deny sick and vulnerable persons access to care like that?
The concept of "medically necessary care" is supposed to be the rational foundation for a middle class right to sue a provider when such care is denied. But if the middle class hopes to invoke this kind of moral argument to protect their own rights, then the very same argument requires that they put in place policies that would also guarantee the uninsured access to all medically necessary care.
18. ______
The Clinton administration is making the same mistake in this current bill that I believe was the fatal flaw in the earlier reform effort. That is, it believes some combination of experts and bureaucrats and organizational or legal wizardry can achieve health care reform, either wholesale or by increments.
But I would contend that what we are faced with is fundamentally a moral problem: What does it mean to be a just and caring society when we have only limited resources to meet virtually unlimited needs? This moral problem can only be addressed through a national process of democratic deliberation aimed at explicitly deciding the difficult tradeoffs we're willing to make.
19. ______
A concluding example of the kind of thing we'd be discussing: In the past several months, researchers have perfected something called a left ventricular assist device. This device strengthens the part of the heart that is failing when patients are in congestive heart failure. Such patients are faced with death in a year or two. With the device, they may gain an extra year or two of life.
The cost of the procedure to implant it is between $100,000 and $140,000. There are potentially 200,000 patients each year in the United States who could use the device, most of them on Medicare. If we did that many open heart surgeries, we would add $20 billion to $28 billion per year to the cost of health care in the United States, mostly in the Medicare program, where we are presently deciding whether to add a prescription drug benefit.
20. ______

A. Both bills are misleadingly titled. A more honest name would be a "Bill of Rights for Mostly Healthy Middle Class'Paytients'".
B. Private-sector insurers are more concerned with the so-called "medically necessary", for their health programs are more profit-oriented than providing health care for patients.
C. Is this "medically necessary" care? Is it more important, morally speaking, to add this new device or a drug benefit to the Medicare program or to provide a good basic package of health benefits to the uninsured? I wonder what Harry and Louise would have to say about that.
D. We have to decide for ourselves what we regard as medically necessary care-care that our moral ideals would require we guarantee to all. No experts can give this answer to us.
E. If the middle class is unwilling to accept the logic of this moral argument, then the consequence is that managed care bureaucrats alone have the right to decide what they will or will not regard as medically necessary.
F. Can we hope thatTV ad stars Harry and Louise will once again summon reserves of political courage and organize legions of patients to mount the ramparts against (this time) the corporate forces of death and denial?