Ethical Foundations of Health System Reform

Abstract

To the Editor. —There are several reasons that I am not reassured by Drs Brock and Daniels' 1 discussion of the ethical basis for President Clinton's health care plan. First, having worked in the Indian Health Service, I am familiar with how government budgetary restraints can interfere with patient care. Right now, if a utilization clerk denies payment for medical care, physicians and hospitals usually ignore the clerk's decision and do it anyway, keeping themselves solvent by overcharging other patients. In President Clinton's plan, we will all be working for the government/ health care alliances. The pressure to conform will be severe. Since nonalliance health care would be forbidden, we may be unable to ignore the clerk's decision and may be unable to give care until the appeal is heard, by which time, of course, some patients will no longer need the care. Second, there is an underlying public distrust