Healthcare for sale.

IN AUGUST 2004 a Houston, Texas, man with fatal liver cancer received a transplant as a consequence of a national advertising campaign that documented his plight and requested families to specifically designate him as the recipient of any available liver. Although organ donors or their families can specify recipients (which is unusual and generally occurs only within families), the individual's initiative violated the spirit of the Uniform Anatomical Gift Act, which proscribes the buying and selling of organs. No money was exchanged, however, so the transaction was legal. But the intent of the law is to make medical considerations the sole criteria for organ distribution, and the considerable resource expenditure involved in procuring the precious liver in this case was an end run that legislators hadn't foreseen.

In the commentary section of the September 1, 2004, Chicago Tribune, three bioethicists describe the mostly egalitarian nature of the U.S. system for distributing livers for transplant. Noting the loophole in the law that allowed the Houston man to essentially purchase his "new" liver, they call for tightening the law governing organ donation.

At first glance it's hard to argue with this policy of fairness. But this viewpoint flies in the face of the direction in which U.S. healthcare has been evolving for the last ten or fifteen years. Medical care has become a big business and it increasingly functions in a way that is based on the principles of the marketplace. This means that people can access healthcare services in proportion to their ability to pay for them. And, since the cost of healthcare is skyrocketing, an increasing number of Americans can't afford it.

This dreary fact is played out in the medical marketplace daily. In an effort to safeguard their precarious bottom lines, healthcare providers avoid patients who can't pay or who have inadequate insurance. Hospitals, for instance, though obligated by law to treat all patients in emergency situations, are quick to transfer indigent or uninsured patients to public hospitals as soon as the patients are stabilized. Furthermore, many physicians refuse to see Medicaid insured patients because the poor reimbursement they receive doesn't cover expenses. Even the number of physicians who accept Medicare is decreasing.

The meteoric rise in the cost of medical insurance is a subtler competitive force that makes healthcare hard to obtain for low wage earners. Premiums have increased almost 25 percent in the last two years alone. To remain competitive in their respective industries, employers increase employee contributions to health benefits and purchase plans with ever larger deductibles and co-pays. Especially among small businesses, the number of employers who offer any kind of health insurance is declining. Only 63 percent of businesses with two hundred or fewer employees currently offer health benefits, down from 68 percent in 2001. Even when health insurance is offered as a benefit, an increasing number of workers find the employee contribution prohibitive.

The price of prescription drugs also cuts people out of the medical marketplace. One reason for the extraordinary expense of drugs is the aggressive marketing practices of the pharmaceutical industry. It spends more than 10 percent of its budget on advertising alone, accounting for at least $17 billion of healthcare costs in the United States and inflating the cost of crucial medications to the point that many patients can't afford them.

There are many more examples of common marketplace practices that help explain why people are unable to get adequate healthcare. In its embrace of marketplace principles, the healthcare industry is working like any other in a marketplace economy: its goods and services go to those who can afford them.

In this light, the Houston man's successful campaign to get a liver conforms to the rules of engagement that have become the norm in the peculiarly American game of procuring medical services. Americans accept the notion of winners and losers in the acquisition of most goods and services. Accordingly, as healthcare costs continue their staggering rise, fewer Americans will be able to access even mainstream medical help, much less something as exotic as a liver transplant. If a liver or any other scarce resource goes to the highest bidder, then healthcare is working just like any other American capitalistic venture.

The bioethicists who feel that the Houston man "cut in the ling" have an alternative concept of how to deal with precious healthcare resources. They end their commentary by saying that "faced with scarcity ... the right thing to do is what is right for all, not right for one." Most developed nations endorse this philosophy and back it up with a social welfare system that provides basic care for all. The United States stands nearly alone in treating healthcare like any other commodity.

Dr. Whalen is a freelance medical writer who can be reached at [e-mail].