More Implications of the September 11 Tragedy for a National movement for Universal
Health Care
(Back to Beginning of Thread)
Still A Long Way to Go
by Jonathan Oberlander, Ph.D., Assistant Professor of Social Medicine, University of North Carolina - Chapel Hill
Jeffrey Gordon's suggestion that in the aftermath of September 11 there is a potential opportunity to pass a Medicare for All program seems quite improbable to me. It is far to early to judge the political implications of what happened as well as the military campaign ahead. I agree that with Dr. Gordon that the development of a communitarian national ethos is one possible outcome. But there is a long way from this to adoption of Medicare for All.
The political reality after September 11 is still that you have a president opposed to universal health insurance, a Congress without much appetite for health reform, and most importantly a Republican party fervently opposed to Medicare as a model for public insurance. Moreover, with higher inflation rates, American businesses are less likely to pressure the GOP to pass national health insurance than they are to drop coverage. If momentum does develop to expand health coverage in response to economic woes, it is much more likely to come in the form of the already-on-the-table tax credits or extending CHIP, than Medicare for All or single payer. The most ambitious goal for reformers would be to expand the scope of these instruments; pushing for Medicare for All is simply not feasible for the moment.
"The Whole Enchilada"
by Martin Donohoe, MD, Senior Scholar, Center for Ethics in Health Care, Oregon Health and Science University
Major social changes in the US have come about through radical changes, not piecemeal. Otherwise, in the US we would have outlawed slavery but only say for Africans from certain nations or only for first and second generation African-Americans; or we would have given women the vote, but only women making over a certain amount of money or those with a college education; or we would have outlawed child labor but only for kids working in the mines (granted I realize that child labor still exists in the US, particularly in agriculture). I say we need visionary policymakers and ethicists who will go for the whole enchilada - a single payer system, and that physicians and patients say, "For God's sake, it is about time.
Foremost in mind: "What is Best for the
American Patient" by Dr. Don McCanne.
The response to Jeoffry Gordon's call for a shift in strategy might be summarized best by Arthur Caplan's statement, "Fifty years of waiting for a national health system has left tens of millions with nothing... Let's get the damn thing done already."
While there is no consensus on the models for reform, there is universal agreement that we must accomplish reform now.
The urgent issue is that we must go to the negotiating tables IMMEDIATELY. We need to lay down on the table the fundamental issues of health policy - coverage, equity, affordability, access, cost containment, adverse selection, portability, continuity, etc., etc. Then we can hash out the policy applications that will address these issues.
If health care as a profession is to remain attractive to some of our more gifted individuals, we will need to compensate them adequately, and we can do this by establishing collective negotiating rights for providers. And restoring the traditional physician-patient relationship will meet the ego needs of physicians. This can be done by eliminating the micromanagement of the middleman money managers, and replacing them with quality improvement programs based on assessment of applications of evidence-based medicine.
All special interests have real concerns that must be addressed. Instead of attempting to achieve compromises that inevitably result in mediocrity, we should be looking for the strengths that the special interests bring, and weave them into our system, while rejecting the weaknesses that would compromise reform.
Let's all move immediately to the negotiating tables. Let's put down on the table the real issues that need to be addressed with real policy science. Let's bring ALL of the special interests to the table. Let's begin with only one rule: Advocates of each position are mandated to keep foremost in mind at all times what is best for the American patient. If we create a model that is best for the patient, it will be the model that is best for any special interests that have a rightful place at the table. Those that don't belong there will rapidly reveal themselves to the rest of us.
There is far more than enough genius amongst the recipients of this message to initiate this process. Who volunteers as the convener?
Terrorism Reveals Our Common Needs that Only Health Care Reform Can Fix
by Bob Griss, Director of the Center on Disability and Health, Washington, DC
The objective opportunity is there for the emergence of National Health Insurance as Dr.Gordon reveals, but it is not a sure thing as Professors Marmor and Oberlander remind us.
Clearly, private insurers would prefer that Congress rely on COBRA continuation policies and CHIP expansions instead of creating a right to health care for everyone. But COBRA continuation does not guarantee adequate coverage, nor does it provide the leverage for cost containment or an information system that facilitates quality assurance in our fragmented health care system.
Now is the time to publicize the advantages of National Health Insurance at the national and state levels to all of the interest groups while:
(1) Employers lay off many of their workers as the economic recession deepens, and shift their rising health insurance premiums to their remaining employees;
(2) States seek to cut benefits and increase cost-sharing in their Medicaid programs which CMS (formerly HCFA) has enabled them to do through the recently imposed HIFA waiver and the even more pernicious gutting of consumer protections in Medicaid managed care by gutting the regulations designed to safeguard the needs of the most vulnerable Medicaid recipients with disabilities; and
(3) Medicare leaves a growing number of seniors and persons with disabilities without outpatient prescription drug coverage as drug profits continue to soar driving up health care prices throughout our health care system while drug companies continue to use their lobbying power to oppose the cost containment mechanisms that Medicare uses for all other health care providers.
Bioethicist Art Caplan correctly understood that terrorism has obliterated the distinction between soldiers and civilians making it imperative that all residents have access to medically necessary health care.
Meanwhile, Representative Jan Schakowsky (D-IL) stands poised to introduce a legislative mechanism called "First Things First Act" that would roll back the tax cut for the wealthiest Americans until various social objectives are achieved to ensure the unity and productivity of our nation.
Instead of arguing whether a Republican-dominated White House and House of Representatives would ever enact a right to health care, the challenge to health care reformers is to publicize the advantages that National Health Insurance could offer to all stakeholders in society, and mobilize support from mainstream advocacy groups like AARP, labor unions, employers, religious groups, and health care providers to get behind a political strategy like "First Things First" that could pave the way for "National Health Insurance".
Convene a closed door meeting of
experts to hash out a workable road to universal health
care by Dr. Donald Light
Jeoffry Gordon and Art Caplan have, with somewhat different agendas, articulated well the special opportunity and need to address the long-standing, inherent inadequacies in "our lousy health care system." Bob Griss has added still more reasons why this effort would be timely. While I agree with Jon Oberlander about the obstacles, the way around them, I think, is to get major stakeholders to sign on to a basic principle, to "simply state that every American will have access to [needed health] care." Art is right to keep it vague, and from my international experience, the mistake would be for us experts to figure out just how. The only way around the serious obstacles that Oberlander describes is to get this basic consensus and then ask, "OK, how would you like to do it?" Then, let the small employers, the large employers, the health insurance companies, the for-profit health plans and hospitals, the public hospitals and health centers and the non-profit ones start working on an answer.
It won't be easy, and one needs a neutral, prominent strong convener. Let Art Caplan and the Center for Bioethics be the
convener. Bring together a hand-picked group of leaders from across the industry and sectors, close the doors, and have a sustained meeting on how to do it. Of course, it will take several such 2 or 3-day meetings. And if a plan of consensus arises, there will be subsequent back-sliding and the need to shore it up while widening the circle.
A real danger is that one group of us experts or another will oppose anything they come up with. If they go for universalizing Medicare, our experts will tell them five reasons why they're doing it the wrong way, while the powerful pro-market coalition will tell them government-run programs always fail. If they go for a Karen Davis mix (quite interesting), nearly every faction of experts will pick apart one part or another. Advocates of a national health care program (at least, as they envision Britain's
NHI) will oppose almost anything the major stakeholders come up with. Maybe this means that in the meantime, we should have a parallel meeting to see if experts and advocates for universal health care can agree on a plan!
Aside from this recommendation, the first thing that advocates for universal health care need to do is to persuade the small employers, that fierce lobbying group that did serious damage to the Clinton proposal. On one hand, they are hurting the most (or not participating), they feel they have the most to lose, and they are the source of most workers without the partial, flawed voluntary health insurance that other employers offer. On the other hand, you can't win without understanding their issues, taking in their value and
language, and responding effectively. If we can persuade them that universal health insurance is a good deal for them, the large employers will be no problem, and together they constitute the clientele of the insurance industry, their agents and the health benefits industry.
The Need for a Broad Movement
by Mark Hannay, Director, Metro New York Health Care for All Campaign
Don's suggestion of moving right to the negotiating table is a fine idea, except that it presumes that we are being invited, that there's a chair for us there, and that the
conveners of the table care about and want to hear what we have to say re: health care. Unfortunately, at the current point in time the political reality is that none of the above is true.
We are going to have to force ourselves to the table, and the only way to force them to extend an invitation to us is if we create enough political noise and clout that they cannot afford to ignore us. What this means is that one of our very first steps MUST be to *build a broad movement*, centered around the demand for action in this area, centered around a set of principles which embodies but does not lay out a specific policy formulation on which many heretofore disparate forces can agree. I invite all to the UHCAN conference next month in Baltimore to join us in that renewing that objective. Full info
about UHCAN meeting.
NOTE: that as we previously
have discussed, UHCAN supports an incremental approach towards UHC or
believes this is a possible road towards UHC, while EINO does not. We do
believe that Dr. Light is correct about the broad movement that is needed.
Curiously much of the broad movement which is correctly called for by Dr. Light
has been growing already, and with a lot of dedicated effort, in the state
grassroots movements for non-incremental Universal Health Care. We in
no way oppose efforts made to pressure legislators or agencies in Washington for
Federal recognition of the right to health care. We see, however, no
reason to ignore the work in so many states towards statewide UHC and the
recognition of this right.
We submit that it be kept in mind that the right to universal primary and
secondary education was fought in the states (and adopted in a majority) long
before the federal government could be budged towards recognizing the
"right to education".
Further, regarding the following opinion from Ken Frisof along with Don
McCanne's comment. While we agree in the importance of unity on the issue
of UHC. We have to be clear about what UHC is and how it can be achieved.
EINO strongly advises against diverting any of the resources available to the
UHC movement into efforts that are more fairly characterized as incremental
reforms. Read about why we warn against
this.
Fortunately for us, there is already a legislative vehicle that allows us to organize around this approach. House Concurrent Resolution 99, or as we are now calling it, "The Health Care Access Resolution" [HCAR] was the first joint work product of the Congressional Universal Health Care Task Force, founded in 2000 by Congressman Conyers. The Resolution was crafted by Members of Congress and their legislative aides. It lists 14
attributes or principles of quality health care for all. It intentionally does not offer a policy prescription, but rather directs "Congress to enact legislation by October 2004 that provides access to comprehensive health care for all Americans."
The first draft of a general flyer for the educational and advocacy campaign around HCAR was made ready for the Jobs with Justice National Conference on September 7-9. After a pause to reflect on the implications of the terrorist tragedy, the activists in UHCAN and other organizations working on the campaign are once more moving ahead, mindful of the changed circumstances. A new version of the general flyer, soliciting organizational endorsements and activity around HCAR is being prepared for the meetings in Atlanta later this month.
The renewed popular recognition of the vital role of government in promoting well-being is a valuable opening for the forces for health care justice and equity. HCAR provides a vehicle through which we can reach out to the organizations and politicians of mainstream America and seek endorsement and cosponsorship of our core principles.
If you would like to participate, please e-mail your contact information to uhcan@uhcan.org.
UHCAN will e-mail material once the revised version is available, in the last week of October.
A description of House Concurrent Resolution 99 is available.
Don McCanne comments: There are many individuals and organizations dedicated to health care equity, and there are even more ideas floating out there on the preferred agenda for reform. But there is one agenda item that we must all place first and that is that we are going to have to agree to work together.
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