Is This Where We Want to Go?

Abstract

Las Vegas is a microcosm for what a community loses when, the market controls health care. As curious as it sounds, a lot of communities in America wish they looked like Las Vegas. As garish a place as it has become, Las Vegas is doing what people expect from America. A city in the desert that didn't exist at the turn of the century, Las Vegas is alive with opportunity. It has 90,000 hotel rooms and more are being built every day. More than 50 percent of the city's 1,040,688 residents have lived there ten years or less. Las Vegas has grown 33 percent since 1990 and will probably increase its population another 300,000 by the end of the century. The city's emergence as a major urban powerhouse coincides with another profound transformation in American society. Both private employers and government, who pay for the bulk of health care in this country, have demonstrated in recent years a growing disgust with escalating health care costs. Even before President Clinton attempted to reform the system in 1993, a price revolution in health care had been unleashed by payers. They demanded lower prices, and new market mechanisms were put in place that have been delivering just that. And after the collapse of the President's reform effort, the market revolution has become a bullet that no one can stop even if they were inclined to try. Las Vegas serves as a useful model for those trying to understand how these new mechanisms will play out nationwide. Las Vegas, as a city of the future, is having the health care system of the future grafted on tO it. Health care in Las Vegas is overwhelmingly a commodity that is sold as a product unabashedly expected to deliver a profit for those who control the delivery system. Clark County, which contains Las Vegas, has seven community hospitals and five are owned and operated by for-profit health care companies. These are some of the most profitable hospitals for the chains that own them. A not-for-profit Catholic hospital, St. Rose Dominican, has entered into an alliance with for-profit Columbia/HCA Health Care Corporation, the national hospital behemoth that owns the largest hospital in Las Vegas. The city, running strikingly counter to national trends, is actually adding hospital beds. Elsewhere in the health care delivery system the investor-owned model is dominant as well. Of the thirteen managed care companies doing business in Las Vegas, not one is a not-for-profit. What one finds in Las Vegas, despite the dynamism of its economy and its attractiveness to legions of newcomers, is a health care system that doesn't work very well for a lot of people. The system fails both the insured and uninsured. In the case of the latter, the city has an inadequate and tenuous safety net in place to care for them. For both groups the market has been unable to justify investing in their long-term health through aggressive prevention strategies. Las Vegas is a microcosm for what a community loses when the market controls the health care system. And it should be an object lesson for what the country stands to lose as well. While gambling may not be the principal new face of American economic life, Las Vegas is very much in step with the rest of the country relative to the kinds of jobs it's creating. Almost 254,000 are in service-related areas. And as is being found in other parts of the country, service-sector employers in Las Vegas are notoriously stingy in providing benefits. So even though the unemployment rate in Las Vegas is below the national average, and despite the aggressive efforts of organized labor, the city still has a staggeringly high rate of people without health insurance, the aggressive efforts of organized labor not withstanding. Nevada is a great paradox. It is one of the wealthiest states in the United States yet also has one of the country's highest levels of uninsured. Many of the states who share this distinction are Sunbelt states, including Arizona, Texas, and New Mexico, other states held out as models of the new American economy. …