Prof. Donald W. Light responds to Prof. Kevin Grumbach’s comments on cost
sharing:

Further Thoughts on “Cost Sharing”

American employers and policy makers are unique in their conviction that
cost sharing (by which I mean co-payments) will or do hold down rising
health care costs. As European experts note, the United States has had by
far the greatest amount of cost sharing for decades and by far the most
costly health care system with the poorest controls over its escalating
costs. For a realistic, evidence-based overview of the comparative
literature, I recommend Chapter 3 of European Health Care Reform: Analysis
of Current Strategies from WHO-Europe, Copenhagen 1997.

One basic reason co-pays have little effect, as Berk and Monheit have noted
in Health Affairs, is that patient-based decisions largely consist of
initial decisions to see a doctor or not and other similar decisions that
affect only a few percent of total costs. If one has a co-pay on more
serious and costly decisions, like hospitalization, it’s a punishment, not a
deterrent.

When Congress decided that senior citizens should pay for the first day of
hospitalization, what did they have in mind? -That patients whose doctors
think their problem is serious enough to be hospitalized should be
encouraged to refuse because of the cost? Or go hospital shopping? Or
generate income for Medicare? No other advanced system considers co-pays as
a serious tool for cost containment or income, and most consider them
clinically perverse as well as unethical. Several have used them and then
dropped them because of their administrative costs, nuisance and perverse
effects on patients and staff. No evidence exists that co-pays lower the
rate of increasing costs – they just make the sick pay some of them.

The European overview addresses a number of other forms of cost sharing,
such as benefit limits, and in a recent Health Affairs article (Web
2002:W229), Lee and Tollen address both, but with a very different tone.
Lee and Tollen write about excluding drug benefits, or prevention services,
or high-cost cases with the same neutrality that they might write about how
employers could save on company cars by not having air conditioning or
remote access systems or anti-lock brakes. You can cover the prescription
drugs that board-certified physicians think sick patients need for their
illness or not. It’s treated as morally neutral as deciding whether you
want to pay for AC or remote access on a car or not.

The myth of co-pays as an effective tool is perpetuated by econometric
models like the Hay model used by Lee and Tollen, that builds in assumed
savings; so that it “proves” by definition that any co-pay policy saves
money. “Cost-sharing” is also a highly political and moral term, with its
share-the-burden connotation. Who can be against sharing, or choice or
empowerment? These American policy themes make in nearly impossible for
policy makers to be realistic about the bad choices, disempowerment and
impoverishment that many “cost-sharing” policies impose, such as limiting
coverage for needed services and imposing high co-pays. Have they read in
Tom Rice’s seminal book about the realities of consumer choice in health
economics?

Suppose we call co-pays, Making the Sick Pay? Then it is clearer what is
going on, that the policy goal is to provide disincentives to patients to
not follow what their doctor recommends. I.e. we spend great sums training
doctors well and acknowledge that they are masters of diagnosis and
treatment with licenses to do both, but then punish patients financially for
following doctor’s orders.

At the end of their article, Lee and Tollen mention that just as much can be
saved by having a group-model HMO in which health care teams can hold costs
down by providing evidence-based integrated care within a system that
minimizes duplications, waste and overhead; so there’s a third choice beside
not covering needed services or making the sick pay for being treated.

In the rest of the world, this third option stands for the main event.
Costs are contained effectively and over time through supply-side measures
and through organizing the delivery system well. You can’t do this without
some form of universal health care, however. Costs cannot be contained
without getting your arms around the whole system. Otherwise you get what
European experts observe has been happening in America for years, one
partial initiative after another that leads to providers shifting costs to
some other part of the system. Cost-sharing in patchwork system, together
with consumer “choice” and “empowerment” will lead to new cost shifting and
poorer care for those who need it most.

Donald W. Light, Ph.D., Professor of Comparative Health Care Systems, UMDNJ
and Fellow, Center for Bioethics at Penn

(Although this message is quite long, it is important. The Covering the Uninsured campaign is designed to end with comprehensive reform of our health care system. It has a real possibility of being successful. We should be aware of their agenda and be involved in the process. The future of our health care system may depend on it.)

CoveringTheUninsured.org A project of the Robert Wood Johnson Foundation http://coveringtheuninsured.org/

Covering the Uninsured is a campaign to “raise awareness of the challenges facing the 39 million Americans with no health insurance.” In addition to the Robert Wood Johnson Foundation, coalition members for the campaign include the U.S. Chamber of Commerce, AFL-CIO, The Business Roundtable, Service Employees International Union, American Medical Association, American Nurses Association, Health Insurance Association of America, Families USA, American Hospital Association, Federation of American Hospitals, Catholic Health Association of the United States, and AARP.

This is a very important campaign. It may set the stage for the future of health care in the United States. The initial phase of the campaign is to establish an awareness amongst the public that reform is absolutely essential. Theoretically, options for reform then will be presented and the nation will decide on the policies that we wish to follow. But, in fact, it may be that the agenda for reform is already established and this campaign is merely to gain acceptance of the policies that will best serve some of the special interests in the coalition.

Cover the Uninsured Week will be held beginning Monday, March 10, 2003. The goals will be to “raise public awareness of the problem… demonstrate broad support for action… generate significant media attention… encourage other national organizations to join… foster cooperation… and link multiple coverage initiatives with a single rallying point…” With diverse views on options for reform or “multiple coverage initiatives,” we should ask what “single rallying point” they have in mind.

Let’s look at the events of Covering the Uninsured Week. They will take place nationally and also with a focus on 25 cities.

Monday, March 10 – Town Hall Meetings Politicians of all levels will hold town hall meetings and media events and issue proclamations in a high profile effort to publicize the plight of the uninsured.

Tuesday, March 11 – On Campus Schools for health professionals and other colleges will hold academic events to raise awareness and to begin to look for solutions for the problems of the uninsured.

Wednesday, March 12 – Health Fairs Free health screenings will be provided with press conferences stressing that the uninsured should have access to health care everyday.

Thursday, March 13 – Business & Labor Day The full events of the day are presented below.

Friday thru Sunday March 14-16 – Interfaith Events The faith community will raise their voices in support of “health care as a fundamental human right,” and “in many media markets, weekend services will represent the conclusion of the weeklong activities, and a special effort will be made to reach religion page reporters as well as local religious papers and magazines.”

Days TBD – Arts & Culture “With the cooperation of arts communities, we will discuss the issue of the uninsured using art that people enjoy in their daily lives, including outdoor advertising, photographs, murals, television shows, newspaper cartoons, museum exhibits, etc.”

Before we look at the events planned for Thursday, Business & Labor Day, we should review the press conference at the start of this campaign in February. The day began with an editorial in The Washington Post, written jointly by Thomas Donahue, President and CEO of the U.S. Chamber of Commerce and John Sweeney, President of the AFL-CIO calling for making “the problem of the uninsured our nation’s top health priority and to help America solve it.”

Representatives of each of the coalition organizations spoke briefly, and most of them stated that reform must be limited to incremental measures.

Then Thomas Donahue said, “The other thing we should know is that there are a lot of private conversations going amongst the people here. I mean, we didn’t just show up here today to, you know, make a statement. We’ve been having a lot of conversation and I’m encouraged by it because it hasn’t got the vitriolic kind of who shot Jack, you know. It’s really-if this is the kind of problem-then how could we fix it and what ways might work.”

And he also said, “If we move vigorously towards a single payer system which, by the way, doesn’t work anywhere in the world, we’re gonna find a great migration away from the people that are providing the coverage, and we can’t afford that.”

With this narrower agenda in mind, let’s look at the activities planned for Thursday. Because of the subtleties, the entire concept page is reproduced here.

******************************* THURSDAY: COVER THE UNINSURED WEEK-BUSINESS & LABOR DAY

Concept These events will emphasize the interests of business and labor constituencies in expanding health coverage to the uninsured. They will highlight the joint interest of these constituencies in solving the problem, while allowing each to showcase their respective approaches. Since the rising cost of health care coverage is a growing concern of both business and labor groups, we will focus the event and messaging around health care coverage costs.

Day’s themes/messages · Employers and employees share concern about the uninsured and strengthening employer-based coverage. · Health insurance means economic security for working families, yet eight out of 10 uninsured Americans are in working families.

Potential activities · Business and labor groups cosponsor press conferences at the local level, or hold them separately · Nationally and locally, organizers place an op-ed co-authored by business and labor leaders · Pitch editorial boards about the event and the issue · Events staged to emphasize the special needs of small business owners, possibly in conjunction with corporate partners who cater to small business needs (e.g., Staples, Kinkos, Costco, Home Depot, beauty supply stores, etc.) · Round table discussion/forum with local business leaders, labor leaders, and uninsured workers, hosted by local media affiliates (e.g., NPR), to discuss the issue in-depth · Round table discussion/forum on national business channel such as CNBC or CNN-FN · Conduct and release findings of a national survey of business and labor that demonstrate their shared concern about the issue of the uninsured · Release a detailed research report outlining the costs of being uninsured to businesses and workers · Highlight compelling personal stories from the perspectives of business and labor about the uninsured

Potential participants · Local Chambers of Commerce · Local labor unions and members · Major employers in the region · Small businesses · Corporate sponsors · Uninsured people · Health Care Purchasing Alliances

Potential locations Hotel conference centers, union halls, Chamber of Commerce offices, schools, hospitals, etc. *******************************

Off hand, this looks very reasonable. Business and labor are both significantly impacted by the funding structure of our health care system, and they should have input to the reform process. But there are two striking features of Thursday’s agenda. One is the intense involvement and support heavily weighted to all sectors of the business community, with labor playing a supporting role, and with all other stakeholders excluded. This is particularly significant since intense media coverage is scheduled for that day.

The other subtle but crucial feature is the key phrase buried in the concept proposal, and that phrase is, “strengthening employer-based coverage.” It is most likely more than a coincidence that this is the policy supported by the U.S. Chamber of Commerce and the Health Insurance Association of America. In the absence of a universal health insurance program, most of the other organizations also believe, quite correctly, that we need to support employer funding of health care.

Of course, the single payer model would eliminate the employment link, but, as the initial press conference demonstrated, the single payer model has been excluded. By establishing firmly the principle that employer-based coverage must be strengthened, there will be no consideration of national health insurance, whether Medicare for All or a single payer program.

Also it is unfortunate that both the interfaith and arts communities are being enlisted to join in a massive effort to assist the uninsured without being informed that they are supporting the agenda of those that would benefit from an employer-based model.

Is there enough sound reason for all of us to support an employer-based model? What would that look like? Would it be play or pay? Would there be a mandate for employers to purchase plans or contribute to a fund?

Two measures might bring support to play or pay. One is that insurance benefit mandates could be eliminated, making the purchase of employer-based plans affordable. The plans could be stripped of benefits and/or shift a major portion of the costs to individuals, both of which are questionable policies because they erect financial barriers to care for those that have the greatest health care needs. This is hardly the purpose of health care coverage.

Another measure which could draw the support of business is to provide tax credits to make the purchase of plans more affordable for businesses. Much has been written about tax credits, whether for the employer or for the beneficiary, and there are very significant negative policy implications with various tax credit proposals. One of the most serious defects is that, to be effective, the credits must be very large, using public dollars to continue to feed the tremendous administrative waste characteristic of our fragmented system of health plans.

Probably the greatest concern about employer-based coverage is that it leaves in place most of the flawed policies of our current system. Expanding coverage under our current system of funding care will cause a further increase in health care costs, perpetuating one of the primary problems in health care that we should be addressing. An employer-based program would require continuation of a safety net public program, such as Medicaid. The under-funding and lack of willing providers would continue to threaten access for those dependent on the public program. Employers would want to have access to other programs with serious policy deficits such as association health plans, consumer-driven products, especially MSA-type individually delegated accounts, and a greater market for “affordable” insurance products devoid of protection for the beneficiaries. And public “welfare” programs continue to experience revolving door enrollment, leaving many without coverage at any given time. In contrast, a program of social insurance, such as Medicare, has virtually 100%, permanent enrollment.

An employer-based system of coverage that came close to including all of the uninsured would increase health care costs and would increase inequities in our system, inequities in the way we fund health care and inequities in the access to health care. Insuring the Uninsured Week appears to be specifically designed to promote this approach. Other approaches would be granted a day of token discussion in academic environments. But Tuesday, the On Campus day, has activities limited to campuses with no significant media outreach. It is most likely understood by those supporting the employer-based model that academic centers are not very effective in converting sound ideas into public policy. The On Campus concepts that leak into the massive media events of Thursday can be dismissed readily with simple sound bites (“Americans don’t want socialized medicine”).

It is important that Americans understand that we can provide equitable access to comprehensive health care services for everyone, fund it equitably, and contain health care costs through a publicly administered program of universal health insurance. The Cover the Uninsured Week process will not deliver that message. In fact, it seems to be designed to suppress it.

What can we do?

Two major elements are supporting the Covering the Uninsured project. Some are very self-serving and would benefit greatly from the employer-based model to be advanced by this process, especially HIAA. Others are truly concerned about issues of health care justice and want to move us closer to a system that would approve access and coverage. After decades of thwarted efforts, these individuals and organizations believe that the process will require compromise. Although we agree that the political hurdles appear to be almost insurmountable, we also believe that we must take the strongest stand on behalf of health policies that will bring us the best system possible within the limits of our resources. These policies are achievable, though not without an enormous effort on our part.

Individuals that are active in the coalition organizations that do support health care justice and individuals that work closely with those organizations should immediately open new discussions of policy solutions for our health care system. Special attention must be given to the policy implications of the employer-based agenda for Cover the Uninsured Week. In my opinion, an investigation should be undertaken to determine why an apparent effort has been made to limit policy considerations to a narrow model that would be self-serving for some members of the coalition, but risks increasing costs and inequities for the rest of us. Those responsible should recommit to an open process or withdraw.

If the agenda proved to be inflexible, then some might consider discrediting the process and then initiate another campaign to widely publicize the benefits of an equitable and affordable system of funding health care. But discrediting the Covering the Uninsured process should be avoided since a negative approach would be detrimental to the entire health care reform movement. The Covering the Uninsured process does have the important potential for educating the public on the problem and, very importantly, on rational solutions, if the process is not commandeered by self-serving interests. It would be far, far better to work to assure that all reasonable policy options are publicized than to try to defeat yet one more effort at reform.

Our friends in the coalition really do care – as much as we do. We must make every effort to convince them to return to a consideration of fundamental issues of sound policy and to include those options in the media events for the Covering the Uninsured process.

We already have the resources for comprehensive care for everyone. Sound public policy could assure that our resources benefit us all, equitably and efficiently. Employer-based coverage would fall short of these goals. A publicly administered program of universal insurance would establish equity and efficiency while providing affordability. The public needs to understand that. Let’s all work together to be sure that they do.

Don McCanne

Please circulate this to people that do care and want to work together to support sound policies of health care justice.

=–==-=-=

Professor Donald W. Light on Covering the Uninsured:

Covering the Uninsured is not likely to have much success beyond another round of gap-filling efforts, unless it includes covering the under-insured and the thinning of coverage that is now the chief policy of employers, through higher cost-sharing and thinning of services covered. The Foundation leaders love CHIP. CHIP has been their great hope. If we want the nation to think beyond CHIP-like solutions, this campaign has to be broader and speak to the majority of employees and employers about how the employer-based system is falling apart and making businesses less competitive in global markets by burdening them with the costly side issue to their main products or services.

=-=-=-=-=-= Bob Griss, Director, Center on Disability and Health, on Covering the Uninsured:

If the underlying aim of the $10 million dollar Robert Wood Johnson Foundation funded “Strange Bed-fellows” campaign is to discredit universal health care approaches like single payer or Medicare-For-All by focusing only on incremental approaches, there are four strategies that advocates for universal health care should prepare for.

One is to demonstrate the limitations of the incremental approaches like the current structure of CHIP, tax credit approaches, Medical Savings Accounts, and Associated Health Plans that have distracted Congress every time the plight of the uninsured has been debated over the last several years.

A second strategy is to demonstrate the advantages of universal health care at the national or state levels to overcome the problems that incremental approaches create. This approach can benefit from highlighting the experiences in other countries with different forms of universal health care distinguishing between the structure of the program and the level of resources that are devoted to health care in their systems compared to the public and private dollars that are devoted to health care in the US.

A third approach is to dispel the myths about universal health care that have been promoted by special interests who benefit from market-driven health care. Among these myths are that quality would suffer, individual choice would be constrained, and costs would increase.

Fourthly, besides dispelling these fears, we need to identify policy changes that would become possible under universal health care such as being able to conduct quality assurance efficiently and effectively, and reward providers for functional outcomes rather than just for procedures delivered as a mechanism for cost containment.

The challenge is not to convince the public that the uninsured have a problem, but to demonstrate how with the resources currently provided, all people can be better off under universal health care. This message must be taken to Town Hall meetings, academic centers that train health professionals, community health fairs, union halls and corporate boardrooms, religious organizations, and the institutions which shape our mass culture. The goal of this effort should be to create a social movement for a right to health care in the US that works not just for special interests but for the whole society.

Bob Griss, Director Center on Disability and Health, Co-chair, Health Task Force of the Consortium for Citizens with Disabilities and Board Member, UHCAN

(Although this message is quite long, it is important. The Covering the Uninsured campaign is designed to end with comprehensive reform of our health care system. It has a real possibility of being successful. We should be aware of their agenda and be involved in the process. The future of our health care system may depend on it.)

CoveringTheUninsured.org A project of the Robert Wood Johnson Foundation http://coveringtheuninsured.org/

Covering the Uninsured is a campaign to “raise awareness of the challenges facing the 39 million Americans with no health insurance.” In addition to the Robert Wood Johnson Foundation, coalition members for the campaign include the U.S. Chamber of Commerce, AFL-CIO, The Business Roundtable, Service Employees International Union, American Medical Association, American Nurses Association, Health Insurance Association of America, Families USA, American Hospital Association, Federation of American Hospitals, Catholic Health Association of the United States, and AARP.

This is a very important campaign. It may set the stage for the future of health care in the United States. The initial phase of the campaign is to establish an awareness amongst the public that reform is absolutely essential. Theoretically, options for reform then will be presented and the nation will decide on the policies that we wish to follow. But, in fact, it may be that the agenda for reform is already established and this campaign is merely to gain acceptance of the policies that will best serve some of the special interests in the coalition.

Cover the Uninsured Week will be held beginning Monday, March 10, 2003. The goals will be to “raise public awareness of the problem… demonstrate broad support for action… generate significant media attention… encourage other national organizations to join… foster cooperation… and link multiple coverage initiatives with a single rallying point…” With diverse views on options for reform or “multiple coverage initiatives,” we should ask what “single rallying point” they have in mind.

Let’s look at the events of Covering the Uninsured Week. They will take place nationally and also with a focus on 25 cities.

Monday, March 10 – Town Hall Meetings Politicians of all levels will hold town hall meetings and media events and issue proclamations in a high profile effort to publicize the plight of the uninsured.

Tuesday, March 11 – On Campus Schools for health professionals and other colleges will hold academic events to raise awareness and to begin to look for solutions for the problems of the uninsured.

Wednesday, March 12 – Health Fairs Free health screenings will be provided with press conferences stressing that the uninsured should have access to health care everyday.

Thursday, March 13 – Business & Labor Day The full events of the day are presented below.

Friday thru Sunday March 14-16 – Interfaith Events The faith community will raise their voices in support of “health care as a fundamental human right,” and “in many media markets, weekend services will represent the conclusion of the weeklong activities, and a special effort will be made to reach religion page reporters as well as local religious papers and magazines.”

Days TBD – Arts & Culture “With the cooperation of arts communities, we will discuss the issue of the uninsured using art that people enjoy in their daily lives, including outdoor advertising, photographs, murals, television shows, newspaper cartoons, museum exhibits, etc.”

Before we look at the events planned for Thursday, Business & Labor Day, we should review the press conference at the start of this campaign in February. The day began with an editorial in The Washington Post, written jointly by Thomas Donahue, President and CEO of the U.S. Chamber of Commerce and John Sweeney, President of the AFL-CIO calling for making “the problem of the uninsured our nation’s top health priority and to help America solve it.”

Representatives of each of the coalition organizations spoke briefly, and most of them stated that reform must be limited to incremental measures.

Then Thomas Donahue said, “The other thing we should know is that there are a lot of private conversations going amongst the people here. I mean, we didn’t just show up here today to, you know, make a statement. We’ve been having a lot of conversation and I’m encouraged by it because it hasn’t got the vitriolic kind of who shot Jack, you know. It’s really-if this is the kind of problem-then how could we fix it and what ways might work.”

And he also said, “If we move vigorously towards a single payer system which, by the way, doesn’t work anywhere in the world, we’re gonna find a great migration away from the people that are providing the coverage, and we can’t afford that.”

With this narrower agenda in mind, let’s look at the activities planned for Thursday. Because of the subtleties, the entire concept page is reproduced here.

******************************* THURSDAY: COVER THE UNINSURED WEEK-BUSINESS & LABOR DAY

Concept These events will emphasize the interests of business and labor constituencies in expanding health coverage to the uninsured. They will highlight the joint interest of these constituencies in solving the problem, while allowing each to showcase their respective approaches. Since the rising cost of health care coverage is a growing concern of both business and labor groups, we will focus the event and messaging around health care coverage costs.

Day’s themes/messages · Employers and employees share concern about the uninsured and strengthening employer-based coverage. · Health insurance means economic security for working families, yet eight out of 10 uninsured Americans are in working families.

Potential activities · Business and labor groups cosponsor press conferences at the local level, or hold them separately · Nationally and locally, organizers place an op-ed co-authored by business and labor leaders · Pitch editorial boards about the event and the issue · Events staged to emphasize the special needs of small business owners, possibly in conjunction with corporate partners who cater to small business needs (e.g., Staples, Kinkos, Costco, Home Depot, beauty supply stores, etc.) · Round table discussion/forum with local business leaders, labor leaders, and uninsured workers, hosted by local media affiliates (e.g., NPR), to discuss the issue in-depth · Round table discussion/forum on national business channel such as CNBC or CNN-FN · Conduct and release findings of a national survey of business and labor that demonstrate their shared concern about the issue of the uninsured · Release a detailed research report outlining the costs of being uninsured to businesses and workers · Highlight compelling personal stories from the perspectives of business and labor about the uninsured

Potential participants · Local Chambers of Commerce · Local labor unions and members · Major employers in the region · Small businesses · Corporate sponsors · Uninsured people · Health Care Purchasing Alliances

Potential locations Hotel conference centers, union halls, Chamber of Commerce offices, schools, hospitals, etc. *******************************

Off hand, this looks very reasonable. Business and labor are both significantly impacted by the funding structure of our health care system, and they should have input to the reform process. But there are two striking features of Thursday’s agenda. One is the intense involvement and support heavily weighted to all sectors of the business community, with labor playing a supporting role, and with all other stakeholders excluded. This is particularly significant since intense media coverage is scheduled for that day.

The other subtle but crucial feature is the key phrase buried in the concept proposal, and that phrase is, “strengthening employer-based coverage.” It is most likely more than a coincidence that this is the policy supported by the U.S. Chamber of Commerce and the Health Insurance Association of America. In the absence of a universal health insurance program, most of the other organizations also believe, quite correctly, that we need to support employer funding of health care.

Of course, the single payer model would eliminate the employment link, but, as the initial press conference demonstrated, the single payer model has been excluded. By establishing firmly the principle that employer-based coverage must be strengthened, there will be no consideration of national health insurance, whether Medicare for All or a single payer program.

Also it is unfortunate that both the interfaith and arts communities are being enlisted to join in a massive effort to assist the uninsured without being informed that they are supporting the agenda of those that would benefit from an employer-based model.

Is there enough sound reason for all of us to support an employer-based model? What would that look like? Would it be play or pay? Would there be a mandate for employers to purchase plans or contribute to a fund?

Two measures might bring support to play or pay. One is that insurance benefit mandates could be eliminated, making the purchase of employer-based plans affordable. The plans could be stripped of benefits and/or shift a major portion of the costs to individuals, both of which are questionable policies because they erect financial barriers to care for those that have the greatest health care needs. This is hardly the purpose of health care coverage.

Another measure which could draw the support of business is to provide tax credits to make the purchase of plans more affordable for businesses. Much has been written about tax credits, whether for the employer or for the beneficiary, and there are very significant negative policy implications with various tax credit proposals. One of the most serious defects is that, to be effective, the credits must be very large, using public dollars to continue to feed the tremendous administrative waste characteristic of our fragmented system of health plans.

Probably the greatest concern about employer-based coverage is that it leaves in place most of the flawed policies of our current system. Expanding coverage under our current system of funding care will cause a further increase in health care costs, perpetuating one of the primary problems in health care that we should be addressing. An employer-based program would require continuation of a safety net public program, such as Medicaid. The under-funding and lack of willing providers would continue to threaten access for those dependent on the public program. Employers would want to have access to other programs with serious policy deficits such as association health plans, consumer-driven products, especially MSA-type individually delegated accounts, and a greater market for “affordable” insurance products devoid of protection for the beneficiaries. And public “welfare” programs continue to experience revolving door enrollment, leaving many without coverage at any given time. In contrast, a program of social insurance, such as Medicare, has virtually 100%, permanent enrollment.

An employer-based system of coverage that came close to including all of the uninsured would increase health care costs and would increase inequities in our system, inequities in the way we fund health care and inequities in the access to health care. Insuring the Uninsured Week appears to be specifically designed to promote this approach. Other approaches would be granted a day of token discussion in academic environments. But Tuesday, the On Campus day, has activities limited to campuses with no significant media outreach. It is most likely understood by those supporting the employer-based model that academic centers are not very effective in converting sound ideas into public policy. The On Campus concepts that leak into the massive media events of Thursday can be dismissed readily with simple sound bites (“Americans don’t want socialized medicine”).

It is important that Americans understand that we can provide equitable access to comprehensive health care services for everyone, fund it equitably, and contain health care costs through a publicly administered program of universal health insurance. The Cover the Uninsured Week process will not deliver that message. In fact, it seems to be designed to suppress it.

What can we do?

Two major elements are supporting the Covering the Uninsured project. Some are very self-serving and would benefit greatly from the employer-based model to be advanced by this process, especially HIAA. Others are truly concerned about issues of health care justice and want to move us closer to a system that would approve access and coverage. After decades of thwarted efforts, these individuals and organizations believe that the process will require compromise. Although we agree that the political hurdles appear to be almost insurmountable, we also believe that we must take the strongest stand on behalf of health policies that will bring us the best system possible within the limits of our resources. These policies are achievable, though not without an enormous effort on our part.

Individuals that are active in the coalition organizations that do support health care justice and individuals that work closely with those organizations should immediately open new discussions of policy solutions for our health care system. Special attention must be given to the policy implications of the employer-based agenda for Cover the Uninsured Week. In my opinion, an investigation should be undertaken to determine why an apparent effort has been made to limit policy considerations to a narrow model that would be self-serving for some members of the coalition, but risks increasing costs and inequities for the rest of us. Those responsible should recommit to an open process or withdraw.

If the agenda proved to be inflexible, then some might consider discrediting the process and then initiate another campaign to widely publicize the benefits of an equitable and affordable system of funding health care. But discrediting the Covering the Uninsured process should be avoided since a negative approach would be detrimental to the entire health care reform movement. The Covering the Uninsured process does have the important potential for educating the public on the problem and, very importantly, on rational solutions, if the process is not commandeered by self-serving interests. It would be far, far better to work to assure that all reasonable policy options are publicized than to try to defeat yet one more effort at reform.

Our friends in the coalition really do care – as much as we do. We must make every effort to convince them to return to a consideration of fundamental issues of sound policy and to include those options in the media events for the Covering the Uninsured process.

We already have the resources for comprehensive care for everyone. Sound public policy could assure that our resources benefit us all, equitably and efficiently. Employer-based coverage would fall short of these goals. A publicly administered program of universal insurance would establish equity and efficiency while providing affordability. The public needs to understand that. Let’s all work together to be sure that they do.

Don McCanne

Please circulate this to people that do care and want to work together to support sound policies of health care justice.

=–==-=-=

Professor Donald W. Light on Covering the Uninsured:

Covering the Uninsured is not likely to have much success beyond another round of gap-filling efforts, unless it includes covering the under-insured and the thinning of coverage that is now the chief policy of employers, through higher cost-sharing and thinning of services covered. The Foundation leaders love CHIP. CHIP has been their great hope. If we want the nation to think beyond CHIP-like solutions, this campaign has to be broader and speak to the majority of employees and employers about how the employer-based system is falling apart and making businesses less competitive in global markets by burdening them with the costly side issue to their main products or services.

=-=-=-=-=-= Bob Griss, Director, Center on Disability and Health, on Covering the Uninsured:

If the underlying aim of the $10 million dollar Robert Wood Johnson Foundation funded “Strange Bed-fellows” campaign is to discredit universal health care approaches like single payer or Medicare-For-All by focusing only on incremental approaches, there are four strategies that advocates for universal health care should prepare for.

One is to demonstrate the limitations of the incremental approaches like the current structure of CHIP, tax credit approaches, Medical Savings Accounts, and Associated Health Plans that have distracted Congress every time the plight of the uninsured has been debated over the last several years.

A second strategy is to demonstrate the advantages of universal health care at the national or state levels to overcome the problems that incremental approaches create. This approach can benefit from highlighting the experiences in other countries with different forms of universal health care distinguishing between the structure of the program and the level of resources that are devoted to health care in their systems compared to the public and private dollars that are devoted to health care in the US.

A third approach is to dispel the myths about universal health care that have been promoted by special interests who benefit from market-driven health care. Among these myths are that quality would suffer, individual choice would be constrained, and costs would increase.

Fourthly, besides dispelling these fears, we need to identify policy changes that would become possible under universal health care such as being able to conduct quality assurance efficiently and effectively, and reward providers for functional outcomes rather than just for procedures delivered as a mechanism for cost containment.

The challenge is not to convince the public that the uninsured have a problem, but to demonstrate how with the resources currently provided, all people can be better off under universal health care. This message must be taken to Town Hall meetings, academic centers that train health professionals, community health fairs, union halls and corporate boardrooms, religious organizations, and the institutions which shape our mass culture. The goal of this effort should be to create a social movement for a right to health care in the US that works not just for special interests but for the whole society.

Bob Griss, Director Center on Disability and Health, Co-chair, Health Task Force of the Consortium for Citizens with Disabilities and Board Member, UHCAN

Families USA Special Report September 2002

Children Losing Health Coverage

The State Children’s Health Insurance Program (SCHIP), now five years old, has made rapid progress in reducing the number of children without health coverage. By December 2001, there were approximately 3.5 million low-income children enrolled in SCHIP. Despite this record of success, and despite the large numbers of children still in need of health insurance coverage, SCHIP’s progress may now be reversed. A combination of factors – pending reductions in federal SCHIP funding, the expected reversion of previously allocated federal SCHIP funds back to the U.S. Treasury, and growing state budget crises – is likely to reduce program enrollment and increase the number of uninsured children. The Bush Administration has estimated that SCHIP enrollment will drop by 900,000 between fiscal years 2003 and 2006; the worsening fiscal outlook in the states suggests that this projection may underestimate those losses. This anticipated decline in SCHIP coverage would take place at a particularly inauspicious time, as health care costs and unemployment are rising.

For the full report: http://www.familiesusa.org/SCHIPreport.pdf

Comment: It is very unfortunate that the one significant success in expanding coverage, SCHIP, is now threatened with reversals. Our piecemeal policies to expand coverage have been ineffective. A decade of prosperity has only resulted in an expansion of the numbers of uninsured. And now we are faced with an explosion in the numbers of under-insured as policies are adopted to shift risk to those with coverage.

There is some hope of ameliorating this one blip in SCHIP. Quoting further from the Families USA report:

“Several senators, including Senators Jay Rockefeller and Lincoln Chafee, as well as the original sponsors of SCHIP (Senators Orrin Hatch and Edward Kennedy), have recognized this problem and are working to fix it. Legislation on this matter is likely to be considered before Congress adjourns this fall.”

So we may be able to apply one more patch to our sieve of health care coverage. But our current policies can result only in greater increases in financial barriers to care. Let’s throw out the patch kit and adopt policies that would assure that our abundant health care resources are accessible and affordable for everyone. An equitably funded, publicly administered, universal health insurance program is precisely what we now need.

The Business Journal September 6, 2002 Universally controversial By Shelley Herochik

Supporters call it Measure 23, the Oregon Comprehensive Health Care Finance Act of 2002. It’s also known as the single-payer health plan.

The measure, which proposes a ground-breaking funding mechanism to support comprehensive coverage for all Oregon residents, is the only universal health care initiative on a state ballot this November.

Insurance companies such as Regence (Blue Cross/Blue Shield) say that more than money-indeed their very existence-is at stake. Under Measure 23, the need for third-party insurers would be eliminated, since the pool, and not the insurer, pays practitioners’ bills.

“That’s irresponsible public policy for Oregon,” said Leonard Hagen, manager of legislative affairs for Regence.

One member of the progressive community, the Oregon AFL-CIO, has chosen not to endorse the measure.

“Although the federation supports a universal health care program,” said research and education director Lynn-Marie Crider, “a financing mechanism that puts more of the responsibility on employers would be more appropriate.”

But the American Federation of Teachers, a member of the AFL-CIO, has taken a different position.

“The cost to our members under the proposed structure may be less than the total package in their collective bargaining agreements,” said Richard Schwarz, AFT’s executive director. “We believe it is a solution.”

http://portland.bizjournals.com/portland/stories/2002/09/09/focus1.html

Comment: The opposition of the insurance industry to a single payer health plan is understandable since their very existence is at stake. But why should labor be opposed?

Health benefits have been a very important negotiating tool for labor’s leadership. It is in the interests of union leaders to continue to be able to negotiate with employers the entire employee benefit package. Losing the right to negotiate health benefits risks weakening the role of unions. On the other hand, if a single payer system were adopted and equitably funded, the health care costs of union members would actually diminish. So, actually, it is in the interests of union members to end the employment-linkage of health care coverage and adopt a single payer system.

Apparently, in Oregon, the parent AFL-CIO organization is more interested in meeting the needs of its leadership, whereas the subsidiary, the American Federation of Teachers, is more interested in meeting the needs of its members.

The Business Journal September 6, 2002 Universally controversial By Shelley Herochik

Supporters call it Measure 23, the Oregon Comprehensive Health Care Finance Act of 2002. It’s also known as the single-payer health plan.

The measure, which proposes a ground-breaking funding mechanism to support comprehensive coverage for all Oregon residents, is the only universal health care initiative on a state ballot this November.

Insurance companies such as Regence (Blue Cross/Blue Shield) say that more than money-indeed their very existence-is at stake. Under Measure 23, the need for third-party insurers would be eliminated, since the pool, and not the insurer, pays practitioners’ bills.

“That’s irresponsible public policy for Oregon,” said Leonard Hagen, manager of legislative affairs for Regence.

One member of the progressive community, the Oregon AFL-CIO, has chosen not to endorse the measure.

“Although the federation supports a universal health care program,” said research and education director Lynn-Marie Crider, “a financing mechanism that puts more of the responsibility on employers would be more appropriate.”

But the American Federation of Teachers, a member of the AFL-CIO, has taken a different position.

“The cost to our members under the proposed structure may be less than the total package in their collective bargaining agreements,” said Richard Schwarz, AFT’s executive director. “We believe it is a solution.”

http://portland.bizjournals.com/portland/stories/2002/09/09/focus1.html

Comment: The opposition of the insurance industry to a single payer health plan is understandable since their very existence is at stake. But why should labor be opposed?

Health benefits have been a very important negotiating tool for labor’s leadership. It is in the interests of union leaders to continue to be able to negotiate with employers the entire employee benefit package. Losing the right to negotiate health benefits risks weakening the role of unions. On the other hand, if a single payer system were adopted and equitably funded, the health care costs of union members would actually diminish. So, actually, it is in the interests of union members to end the employment-linkage of health care coverage and adopt a single payer system.

Apparently, in Oregon, the parent AFL-CIO organization is more interested in meeting the needs of its leadership, whereas the subsidiary, the American Federation of Teachers, is more interested in meeting the needs of its members.

September 11, 2002

We mourn the senseless and tragic loss of nearly 3000 young adult lives on
September 11, 2001.

We mourn the senseless and tragic loss of over six times as many young adult
lives since September 11, 2001, lives lost merely because these individuals
lacked health insurance.

We mourn for the potential consequences of an arrogance of national leaders
who would rationalize the preemptive destruction of lives, as if that were a
good and noble effort.

Let’s pledge to do all we can as a nation to prevent any further senseless
premature loss of lives, here or anywhere, regardless of the cause.

New York Times

September 3, 2002
Make It Illegal to Be Uninsured

To the Editor:

“Next Big Health Debate: How to Help Uninsured” (Business Day, Aug. 27)
summarizes the growing financial burden that the uninsured impose on those
who are insured.

Before our society ever succeeds in solving this problem, we must face three
imperatives. First, we must impose an individual health insurance mandate,
thereby making it actually illegal to be uninsured, as the purchase of
health insurance must not be a voluntary decision.

Second, for the 15 percent of the population who would be affected by this
mandate (and for only this segment), we must allow the insurers to offer
stripped-down policies with modest benefits and low costs.

Third, we must subsidize the fulfillment of this mandate through tax
deductions and tax credits, depending on the income level of the person or
family involved.

Kenneth S. Abramowitz
New York
The writer is a health care analyst.
http://www.nytimes.com/2002/09/03/opinion/L03HEAL.html

And a response:

September 10, 2002
Punishing the Poor

To the Editor:

A Sept. 3 letter writer proposes that it be illegal to be uninsured, and
urges that stripped-down policies be imposed on the poor, financed by tax
credits and tax deductions.

This would impose a severe financial burden on the poor. Moreover, tax
credits or deductions would be of minimal help to poor people, who pay
little or nothing in taxes. The letter writer’s proposal would make people
subject to sanctions (jail?) for the state of being poor and sick.

A better solution is to finance basic health care for all, no questions
asked, the way most civilized countries do.

Judith A. Fischman
New Smyrna Beach, Fla.
http://www.nytimes.com/2002/09/10/opinion/L10HEAL.html

Comment:  Henry Simmons, president of the National Coalition on Health Care,
has said that there are three basic models for health care reform: employer
“play or pay,” a single payer system, or individual mandates (Kondracke,
Roll Call, April 22, 2002). Other approaches would fail to assure universal
coverage, would fail to assure that health care would remain affordable, and
would fail to correct the major inequities in our system.

Mr. Abromowitz, who has previously expressed the “blame the patient for cost
increases” viewpoint, proposes the cruel solution of stripping away all but
the most basic of benefits for the “15%” of low income individuals. He fails
to acknowledge that his approach also applies to the majority since current
trends are to strip away benefits by making them unaffordable. Average
income individuals with significant acute or chronic disorders will be
unable to afford the care they need. And then he wants to make it “illegal”
to fail to participate in this highly deficient program.

Ms. Fischman’s comments demonstrate the absurdity of this approach of
charging the victim with a criminal act. It is possible that a refundable
tax credit could be generous enough to purchase an adequate insurance plan,
but then the combined private and public spending would be much more than
the single payer option, because of perpetuation of tremendous
administrative inefficiencies. And costs would remain difficult to contain.

The employer mandate, “pay or play,” would require subsidies for those
employers unable to afford to purchase plans for their employees or to pay
the tax that would be assessed in lieu of insurance. Also, programs would be
required for the unemployed and others that might be left out of an employer
mandate. In addition, the flawed policies inherent in a market of multiple
health plans would continue to perpetuate inequities and fail to adequately
control costs.

The simplicity of the design of a single payer system would assure
comprehensive benefits for everyone. Costs could be contained by
establishing a global budget. At our current level of health care spending,
$1.5 trillion, more than one-seventh of our gross domestic product, we
already have more than enough funds to pay for comprehensive care for
everyone.

Dr. Simmons’ words of wisdom on comprehensive reform are well worth
reviewing again:
https://pnhp.org/Press/2002/Quote_of_the_day/7.13.02.htm

The Sacramento Bee
September 8, 2002
Low profile for health care in campaign
By Aurelio Rojas

As Gov. Gray Davis and businessman Bill Simon move into the fall stretch in
their race for governor, rising health care costs have joined education as
the most important issues on voters’ minds, according to Field Poll Director
Mark DiCamillo.

Experts have warned for years the system is headed for collapse without
wholesale changes. But neither the Democratic incumbent nor his Republican
challenger is offering a cure.

The issue is complex — involving employers, state and federal agencies,
insurers, health maintenance organizations, hospitals, physicians and other
competing interests.

But pundits say the political calculus is simple. Middle- and upper-income
workers and the elderly make up the lion’s share of the electorate. And
those groups have access to health care, either through their employers or
the government after they retire.

Polls show voters are sympathetic to the plight of the uninsured, most of
whom work. But woe to the politician who proposes raising taxes to expand
coverage.

http://www.sacbee.com/content/politics/story/4320898p-5340111c.html

Comment:  Both houses of the California State Legislature are controlled by
progressives, Gov. Davis is a Democrat, and California’s health care
situation is deteriorating. Never was the moment for reform more opportune.
Yet, instead of comprehensive reform, Gov. Davis just blue penciled the
incremental step of expanding the Children’s Health Insurance Program to
include parents of covered children, even though two-thirds of the cost of
the expansion would have been paid by the federal government.

It seems that there is little hope for comprehensive reform until the
majority, who are relatively healthy and complacent with their current
coverage, decide that it is time. Will that ever happen?