January 4, 2008
POINT, COUNTERPOINT
Universal health care and health care coverage expansion are expected to take center stage in state legislatures over the next year or two. Plans to expand health care coverage or create universal health care are being implemented in Massachusetts and San Francisco, being discussed in California, and at the top of Albany's to-do list. (The growing demand in various states for sane health care policy hasn't been lost on the'08 presidential candidates, either).
Housing Works is committed to pushing forward with universal health care initiatives at the state and federal level, expanding health care accessibility to people living with HIV and people at risk for HIV, and to fighting for coverage expansion that will get affordable high quality care to largest number of people possible. There are vigorous and respectful disagreements between health care advocates about the best way to expanding health care coverage—almost everyone is agreed that a single player universal health care system would be the most efficient and effective solution, but almost everyone also acknowledges the immense political difficulties that stand in the way of single payer.
Two highly respected health care advocates who lead advocacy groups with whom Housing Works has collaborated productively have two different perspectives on health care expansion. We want Update readers to hear from both.
Click here for David Jones' perspective. David Jones is the president of the Community Service Society of New York, a 150-year-old nonprofit focused on fighting poverty and improving the lives of low income working new Yorkers.
Click here for Mark Dunlea's perspective. Mark Dunlea is the associate director of the Hunger Action Network of New York State, a leading statewide antipoverty and healthcare organization.
Universal health care can be realized
By David Jones
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Jones favors sliding scale premiums with coverage available to all, through individual, family, business, or union plans. |
Working families in New York, like those throughout the country, are struggling to get the health care they need at a price they can afford. In New York, 2.5 million adults—including 415,000 children—have no coverage at all.
Millions more find it difficult to pay for their exorbitant employer-based insurance cost-sharing, expensive premiums, and onerous co-pays and deductibles.
The agency I head, the Community Service Society, has worked with and for low- and moderate-income New York families for more than 150 years, and our recent polling and research shows that health care and drug costs are the No. 1 personal worry of low-income New Yorkers.
Many of the people we've surveyed delay or postpone getting needed care, creating health hazards for themselves and the public and pushing up costs when they are forced to seek treatment in hospital emergency rooms.
In the absence of national leadership on the issue of the uninsured, governors and state legislatures throughout the nation are grasping for ideas about how to handle this ever-growing crisis.
Here in New York, Gov. Eliot Spitzer has held a series of forums across the state, the last of which was on Long Island last week, to gather ideas and proposals toward instituting universal health care for New Yorkers. The governor is looking for ideas that will form building blocks toward achieving universal health coverage for all New Yorkers.
At Wednesday's hearing, the Community Service Society contributed our plan to the dialogue. Titled "Cornerstone for Coverage," the CSS proposal would be an important building block toward universal health care in our state: it would offer affordable, high quality and comprehensive health care to all New Yorkers.
Our plan builds on the success of the popular Child Health Plus program, using the maximum purchasing power of state government to keep down costs while allowing moderate- and low-income New Yorkers to afford high quality insurance.
We propose an affordable sliding scale of premiums, based on working family's earnings. Health care coverage would available to all, through individual, family, business, or union coverage. And care would be comprehensive, meeting the needs of young people, families, seniors, and people with disabilities alike.
The idea is to allow all New Yorkers to access high quality health care at an affordable price. Our plan builds on New York's record of leadership on health care, which has been a foundation for progress in national health policy over the past two decades. Our Child Health Plus program was the first of its kind, leading the way to the States Children's Health Plan program adopted across the country.
We expanded health care coverage to low-income working parents and individuals with Family Health Plus. We established programs that have led the way to providing drug coverage to the elderly and comprehensive care for people with AIDS throughout the country.
These achievements serve as a strong foundation for the goal of universal health care for New York. Other respected organizations and leaders will offer their own proposals over the coming months, including an exciting and ambitious program by State Assembly Health Committee Chairman Richard Gottfried.
Like Gottfried, we believe that universal health care must be really universal—not a program where some must opt out because of unaffordable costs, as is the case in Massachusetts. All good plans must have three components if they are to meet the pressing needs of New York's working families.
It must be affordable to all. It must have comprehensive benefits. And it must be accessible to everyone. Real universal health care for all New Yorkers is within our reach. Our leaders in Albany—Republicans and Democrats in the legislature, and Spitzer—can accomplish this important goal and continue our state's national leadership on health care. And, more importantly, they will provide real solutions to the health care crisis facing millions of New Yorkers.
Can Incrementalism Be the Path to Universal Health Care?
By Mark Dunlea
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Dunlea says single payer is the only way to go. |
Unfortunately, the Spitzer administration, along with many health care reformers, continually assert, without providing any evidence, that the best way to universal health care is a series of incremental steps that build upon existing programs to bring targeted populations of the uninsured into the "health care" system.
Incrementalists argue that the public opinion polls showing overwhelming public support—not just for a comprehensive government universal health care financing system but also for radical reform—are misleading. They contend that if one digs deeper, one finds that those with health insurance ("those who actually vote") would rather keep the shrinking (and often already inadequate) coverage they have than see the entire system changed. They murmur that it is not "politically feasible" for our leaders to stand up to the power of the private health insurance industry and big Pharma. They redefine the public's desire for choice in doctors to hospitals to instead be choice among which insurance company to contract with. They confuse access to comprehensive health care with expanding health insurance.
Yet the experience in the various states that have tried a variety of "incremental approaches" objectively shows that it will not work. "Bold, new experiments in moving our state to universal health care" have invariably withered away over time, often in only a few years.
For instance, the media coverage over the new "universal" health care system in Massachusetts generally failed to mention similar pronouncements from Governor Dukakis two decades previously that fell apart in a few years. Because Massachusetts expanded its subsidies for insurance premiums for low-income people, over 160,000 of those eligible signed up this year. But only 7% of the nearly 250,000 who must buy unsubsidized insurance—or face a fine of $2,000 in 2008—purchased private health insurance this year. Thus the plan will end its first year at least $147 million over budget, with Massachusetts preparing to cut payments to doctors and hospitals and ramp up out-of-pocket costs for patients. And nearly 500,000 in Massachusetts remain uninsured. Yet the leading Democratic Presidential contenders now embrace Massachusetts' mandate for individual purchase of health insurance.
Maine's patchwork approach to universal health care—the Dirigo plan—is not working. Nor have the plans in Vermont, Minnesota, Washington and Oregon Tennessee's noteworthy TennCare program to help the poor and uninsured is in the process of being dismantled. New York has added targeted programs such as Child Health Plus and Family Health Plus yet more than 5 million New Yorkers annually lack health insurance.
This fall Vermont launched "Catamount Health," a plan to cover all Vermonters by subsidizing private health insurance from MVP and Blue Cross Blue Shield with a combination of tobacco tax money, Medicaid money and new taxes on employers who don't offer health insurance. But as the plan takes its first steps, the inadequate insurance for those who have it, with soaring co-pays, huge deductibles and unaffordable prescription drugs has put the crisis in health care back into the legislative agenda for 2008, front and center.
In contrast, the experiences in the rest of the industrial world provide ample evidence that a comprehensive approach to universal health care will succeed. Not only do the other major industrial countries spend far less on health care than we do, they cover everyone with better health outcomes, even though we have among the best medical professionals, infrastructure and equipment in the world.
Incremental approaches evade the fundamental problems that are causing the ongoing crisis in our health care system. Real change requires addressing the entire structure of financing—in which employer-based private health insurance dominates. Without facing this, the problem of costs cannot be solved.
Most of the money spent on health care in New York comes from government (federal and state) spending, yet private health insurance dominates the system. As Governor Spitzer has pointed out, New York's system of health care financing is often not directly tied to the services being provided, its complexity and irrationality a result of the backroom deal making at the State Capitol.
Incremental approaches have done little to nothing to control costs, while adding more people to the system, thus causing more financial strain on both the government and private sectors, especially in bad economic times. The various stakeholders such as hospitals and insurance companies often actually extract more resources as a result of the political negotiations over expanding access to health care (i.e., ok, you can cover more people but we need to extract higher payments in exchange).
Costs increase over time as health care costs in general continue to rise above the rate of inflation and more people utilize the new programs. Thus states find that they simply cannot afford incremental improvement, and so they must manage an incremental retreat. They end up pushing the costs of the health crisis problem back onto individuals by raising premiums, co-pays and deductibles, through roadblocks to limit participation in government programs and by whittling away at health services.
Perhaps the most fundamental difference between the US and the rest of the industrial world is that we allow health care to be treated as a commodity that is bought and sold on the open market, with the profit motive as a major factor. Access to health care is often based on the ability to pay rather than on need. The profit motive propels the US towards a "sick care" system, even though it is more expensive to cure people once they are ill rather than keeping them healthy. Incremental approaches fail to address these basic problems.
By definition, incremental approaches fall far short of universal coverage.
The incremental approach also mistakenly often defines "universal" as everyone having access to health insurance, when what we need is a system that offers comprehensive care to all. Having everyone "in" one system provides a variety of ways to save costs, both within and without the health care system (e.g., reduction in costs impacted by health care such as workers' comp and automobile insurance.)
Take for instance computerized medical records, something that everyone agrees we need. In a fragmented for-profit system individual "players" such as HMOs won't make such common-sense investments since the immediate bottom line, not the long-term interests of the patient or society, prevail. In contrast, a true universal health care system will need to build in incentives for the use of computerized records, in order to allow medical providers demonstrate their efforts to keep the population healthy and to systematically address areas of high cost such as chronic illnesses.
The incremental approach often underestimates the number of uninsured and the problems they face. Every one has heard there are 47 million uninsured in America but few realize that the Census Bureau defines that number by those who lack insurance for the entire year. Perhaps twice as many go without health insurance for some time during any one-year. Thus it is impossible for a program that expands subsidies for private insurance to offer true health security to those who unexpectedly find themselves uninsured.
Further, those who are uninsured but live in medically under-served areas may finally find a way to pay for health care, for instance under New York's Family Health Plus, but that fact by itself will not necessarily bring health care facilities or providers any closer to their door. And they may remain unable to find doctors in their communities willing to accept the reimbursement rates provided (e.g., Medicaid for certain services such as dental care.)
Then there is the problem of people who have inadequate insurance. A 2003 Commonwealth study estimated that 16 million adults have inadequate insurance. In September 2007 Consumer Reports found that 29 percent of people with health insurance have coverage so meager they often avoid necessary medical care because of costs, that 43 percent of people with insurance feel unprepared to cope with a costly medical emergency, and that 20 percent were so dissatisfied with their HMO or PPO that they hoped to switch plans.
Worse, most people don't realize they have inadequate insurance until they need it. Private insurance companies increase their profits by denying services to those they insure. As a result, high health care bills now account for a majority of bankruptcy filings, yet 3 out of 4 such individuals had health insurance when they become ill.
Thus at least a third of the American population suffers from a lack of adequate health insurance.
Incremental efforts, by definition, fail to offer comprehensive health solutions. We need a plan for health care that will provide all necessary medical care. This means emergency, primary and preventive care, necessary specialty care including prenatal care, acute hospital care, rehabilitative services, home care, nursing home care, dental care, mental health care, eye care. Look at nursing home care. Medicaid is in crisis, entangling our nursing homes and our county governments. Incremental expansions may be much more likely to exacerbate than to alleviate such problems.
Most experts who study health care admit that a single payer Medicare-for-all-style program does best at achieving the goals of providing quality, affordable health care to all. Single payer means one entity pays all bills but it doesn't run the delivery system (e.g., doctors, hospitals). Single payer proposals, by eliminating the cost and bureaucracy of private health insurance, manage to bring everyone in while actually saving costs. Single payer has been rated best by every state that has undertaking the comprehensive cost-benefit analyses of universal health care that New York is presently starting. The single payer proposals are almost always the only ones that meet the goal of actually bringing the entire population into the health care system (i.e., universal coverage.)
Yet many elected officials and health care reformers contend that single payer is not politically feasible, largely due to the opposition of special interests starting with the private health insurance companies that would no longer be needed. Many argue that the massive amounts of money spent by the insurance industry to defeat the Clinton health care plan in 1994, highlighted by their Harry and Louise ads, shows that they can't be defeated. This argument however ignores that Clinton explicitly rejected a single payer approach, deciding instead to try to buy the support of the various stakeholders by throwing money at them in her proposal. The result was so complex and convoluted that many single payer advocates agreed that it should be defeated. The lesson arguably is not that a single payer proposal has no chance but rather that half-baked, flawed incremental approaches are doomed to failure.
Proponents of incrementalism tend to avoid the reality that the special interests oppose many of their proposals anyway, since most involve a reduction of their market share and funding. So right from the start incrementalists have weakened the impact of potential reforms without receiving any concessions in return from the major opponents. Incrementalists accommodate rather than resolve the fundamentally negative impact of private health insurance on health care delivery; indeed, the "reforms" that have been enacted have invariably strengthened rather than curtailed private insurance companies. Incrementalism unfortunately also undercuts the momentum for more comprehensive, effective reforms.
Others argue that moving to a single payer system—despite its positive impacts across the board on issues such as cost, coverage, access, choice, etc.—would be too disruptive, starting with the hospitals, doctors and insurance companies. More "time" is needed to allow everyone to "adjust" to the new reality. However, little evidence has been presented to back up this assertion.
It should be noted that a number of industrial countries do have multipayer systems. What they don't have is our system of private health insurance, where doctors are forced to navigate a maze of companies, many of them for profit, with their own rules and paperwork. As much as a third of every health care dollar touched by private insurance firms goes to pay for their existence, paperwork and profit. In America, despite the fact that more than 60% of health care costs are now paid directly for by the government (e.g., Medicare and Medicaid), we allow private health insurance to dictate much of the terms of the health care system. In all other industrial countries, the health care system is determined through their system of representative democracy. If private insurance is allowed, it plays a minor supplemental role, operating under strict rules determined by the government, with no role for profit.
The chorus of calls for incremental reform has fallen badly out of tune with respect to what the people of New York want for their health care system and hopelessly out of tempo with what people need for their personal health and security. When Governor Spitzer weighs the evidence he will find that only a single payer system can provide affordable, comprehensive health care for all New Yorkers.