378. "Critics of 'Boutique' Doctor Care Miss the Point." USA Today (January 24, 2002) p 15A.

For $ 600 to $ 5,000 a year above what their insurance already pays, patients at these "boutique" practices receive a battery of extra services from their doctors: 24/7 availability (some even give out their cellphone numbers); hand-holding during major consultations with specialists; leisurely office visits free from the usual rush.

The doctors get something more than money in return: By greatly curtailing the size of their practices, they can get to know their patients better and enjoy a return to old-fashioned medicine.

The trend reflects the growing dissatisfaction of patients with their medical services. And the source of that dissatisfaction? Managed care's price controls, which got us into the pickle we find ourselves in now. But the dam has broken. Those who can afford it have found a way to make their purchasing power work around the imposed system -- and the critics are up in arms.

The naysayers label the new premiums "concierge care for the rich" and "wealthy health." In a typical comment, Dr. John D. Goodson, an associate professor of medicine at Harvard Medical School, wrote in The Boston Globe that "change is inevitable, but a change toward elitism in the delivery of health care is pernicious. It undermines the most fundamental commitments of our profession." He urged his fellow physicians to "stand firmly and resolutely opposed to the entrepreneurial and self-serving practices of some of our colleagues."

Many Americans are offended when someone openly introduces a two-class system into one of our human-service areas, including schools. But once we get off our idealistic horses, we quickly recognize -- or at least ought to -- several basic facts:

* Neither America nor any other country has ever been egalitarian. Those that tried -- the Soviet Union, Cuba, North Korea -- had to rely on the massive use of force. Even then, the class system persisted, health care included.

* We never had anything approaching egalitarian health-care service. Those who are better off live in parts of cities where the best-trained doctors practice, while those in the inner city (or the hinterland) often have to settle for physicians trained in lesser schools or overseas.

* Given that we are a democracy, it is impossible to curtail a vital service year in and year out and expect the politically active middle class, to which most Americans belong, to lie low.

* Above all, those who care about the disadvantaged are barking up the wrong tree when they spend their ire on those who buy extra health care for their families. The No. 1 issue that disadvantaged Americans face is not that someone else who is better off is getting to use his or her hard-earned or inherited dough to buy extra care. The huge issue facing these poorer citizens is that they have no access to health insurance at all.

The situation here is akin to what happens in other areas of our life: Our No. 1 employment problem is not that some people are paid more than others, but that millions cannot find jobs. Our most urgent housing problem is not that some people buy mansions and summer houses, but that we have people who cannot afford even marginally adequate housing.

The fact that we have heard a thousand times that we have more than 38 million persons who are not covered by any form of health insurance, that we are the only civilized nation in the world that keeps millions of people wholly uncovered, does not reduce the importance of this issue.

People who care about the disadvantaged may wish to argue that a special tax should be imposed on premium care, with the proceeds dedicated to covering the uninsured, or that each boutique doctor also be required to take on a number of disadvantaged people -- or, best, they may increase the pressure on our elected officials to finally enact national health insurance.

But just griping about those who break out of the HMO straitjackets is an unproductive and misdirected outlet for the critics' well-justified concerns about elementary social justice in health care.

Amitai Etzioni, a professor at George Washington University, is the author of The Spirit of Community and a member of USA TODAY's board of contributors.

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