The true colors of the partisan divide on health care

Background for today’s Quote of the Day: California has served as a unique laboratory for the application of health care policies in the reform movement. The process is handicapped by the fact that a two-thirds vote is required in both the Assembly and the Senate if a measure would result in a tax increase. Since the Republicans control over one-third of each chamber, and they vote as a block against any tax increase, reform measures have been limited to those that do not require significant additional state spending.

Although in this environment it would be almost impossible to enact a state-funded system of universal coverage, it is truly remarkable what the legislators have been able to accomplish with the support of dedicated advocates such as the leadership of California’s Health Access.

Today’s message discusses one small but important issue: the excessive fees charged uninsured patients who have no choice when they must access the health care system on an emergency basis. The debate over this legislation
is very instructive because it reveals the true colors of those on each side of the partisan divide.

I am especially indebted to Anthony Wright, Executive Director of Health Access, who granted me permission to distribute excerpts from his message for today.

Quote of the Day:

HEALTH ACCESS UPDATE
Tuesday, August 24, 2004

CA ASSEMBLY VOTES TO PROHIBIT HOSPITAL OVERCHARGING OF UNINSURED

On Monday, August 23rd, the California Assembly passed SB379 (Ortiz) to
prohibit hospitals from overcharging uninsured patients, and provide other consumer protections. Both SB379, and a similar bill, AB232 (Chan) are expected to be voted on in the Senate and, if successful, be sent to Governor Schwarzenegger’s desk by the end of the week. Both bills would provide first-in-the-nation consumer protections for self-pay hospital patients.

SPECIFIC PROTECTIONS FOR HOSPITAL PATIENTS: The bills that address aggressive hospital billing and collections, SB 379 and AB232, are similar. They address an issue raised by dozens of “uninsured and overcharged” patients that have been sent to collections, court, or bankruptcy for the simple act of seeking needed care. Both bills ensure that self-pay hospital patients:

Are informed of their consumer rights and financial options; Have at least 120 days before being sent to collections; If they are under 400% of the federal poverty level (under $60,000 for a family of three), don’t pay more than the Medicare, Medi-Cal or worker’s compensation rate for treatment.

A fact sheet on the bill is available at:
http://www.health-access.org/ab232_fact_sheet.htm

The text for AB232 (Chan) is at: http://www.leginfo.ca.gov/pub/bill/asm/ab_0201-0250/ab_232_bill_20040817_amended_sen.html

The text for SB379 (Ortiz) is at: http://www.leginfo.ca.gov/pub/bill/sen/sb_0351-0400/sb_379_bill_20040817_amended_asm.html

ASSEMBLY DEBATE: Assemblywoman Wilma Chan, the author of AB232 (sponsored by Health Access California), served as the floor manager on the debate on SB379, by Senator Deborah Ortiz. She started the discussion by talking about a specific patient who, when her health insurance ran out, was forced to pay four times the amount that her insurance had paid for a similar treatment. Chan made the point that hospital debt is a leading cause of personal bankruptcy.

REPUBLICAN OPPOSITION: Several Republicans rose to argue against the bill,including Assemblymen Tim Leslie, Tom Harman, Dennis Mountjoy, Ray Haynes, and at the end of the discussion, Tony Strickland.

Leslie questioned why “Democrats want to attack hospitals, and they are continuing to make hospital operations more difficult.”

Harman made several points in his objections. “Hospitals are businesses.They are run like any other business, whether it is a manufacturing business, a service business, a barber shop, a beauty salon.” He mistakenly stated that, “this bill simply says, well, you’ve got to provide free medical care to certain types of patients… that you can’t use wage garnishment or a collections agency…. Well, how else are they going to collect it if they don’t pay it?” He admitted that “we need to have a plan where everyone can get the necessary medical treatment that they need.

I support that in some fashion, I don’t know exactly what it would be.” Finally, he referenced the individual story that Chan cited in her opening: “I’m sorry, but maybe that person should have had better health coverage, maybe that person should have thought about this problem. That’s what we have bankruptcy court for…. Is it any different than a contract debt? How is it different from any other kind of debt? I submit to you that it is not.”

Mountjoy also misrepresented the bill, stating that it said that “if you are a hospital that is serving a patient, and if they are low-income, you gotta give it to them. Well, why don’t we do that for plumbers?… And the electrician, he ought to give you a break, too. Where in the Constitution does it say that we owe folks health care?… We don’t own them health care.” He continued, “why should we put the burden on a business like hospitals?… They are a business not unlike any other. They are there to make a profit, they have a board of directors that looks for that every month.”

Haynes decried the “Orwellian state” he was in. “When you order somebody to give stuff away for free, or you order somebody to work for free, that is what is known in the parlance as slavery. We are basically ordering hospitals to be our slaves.”

Later, Strickland stated that “part of the reason why costs have gone up in the hospital is that the hospitals are providing a lot of charity care. The uninsured are not paying their hospital bills…. The hospitals are shutting down their emergency rooms because they are providing too much charity care.”

DEMOCRATIC REBUTTALS:. Democrats that rebutted these claims include Assemblymembers Lloyd Levine, Hannah-Beth Jackson, and Jackie Goldberg. Levine responded, “more and more people are going without health care in California. And frankly, I actually… resent the implication that they should have had thought of this sooner, and gee, they should have had health insurance. The cost of health insurance is continuing to skyrocket…, many families cannot afford health insurance, and to say ‘oh, it is their fault,’ really misses the point…. We need to pass this bill and do everything we can to make sure people have access to health care when they need it.”

Jackson brought the discussion back to the question that the bill addresses:
“Is it correct that many hospitals charge uninsured people higher rates than what they charge and are willing to receive from insurance companies and Medicare?” She continued: “This is a bill that tells hospitals that you can’t take advantage of poor people who don’t have insurance… Let’s be fair to the people that are least able to pay by not forcing them to pay more than you and I who have the benefit of having health insurance. It is a sad state of affairs when anybody takes a predatory practice to charge the least able to pay more money for any service because they can… The goal is to give everybody, whether they are rich or poor, a chance to have quality health care at a fair and reasonable price.”

Goldberg also clarified that the bill “asks that the hospitals require nothing more than the higher of Medi-Cal, Medicare, or worker’s comp.So it is not free. And why is this business different than any other business? Well, this business you can’t live without, in some cases.” She also cited statistics that showed that while the uninsured are a small percentage of the patients in many hospital chains, they account for a disproportionate share of the profits. “The only way that could be true is to be gouging those folks as compared to people who have insurance…”

Chan closed by rebutting the arguments: “This does not in any way call for free care. Back in the 80s, I believe, there were strict limits on what a hospital could charge. This does not even go that far… It just says,if you go to the hospital, there should be some ceiling on what you can be charged. Collection agencies can be called in, but this bill gives the person a chance.” She concluded: “We are not talking about something free here, we are talking about basic fairness.”

The bill passed with an unofficial vote of 41-31, along party lines.

Health Access California:

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Comment: Although there is certainly a partisan divide over concepts of the appropriate roles of government and the marketplace in addressing problematic social issues, in general many Americans believe market forces must be allowed the freedom to address these issues without significant government intervention. But most also believe that when the market is unable correct significant social injustices then the government should enter to provide policies that will satisfy our quest for simple fairness.

I find it difficult to believe that most politically conservative individuals personally identify with the comments made by the Republican legislators in this debate on price gouging of the insured for emergency care. I believe that if Republicans knew what their own elected legislators were doing they would replace them with conservatives who were, in fact, truly compassionate. They need to prove that Compassionate Conservatism is not the Big Lie.

Mike Luff on Canada’s vacillating solidarity

In the last Quote of the Day message, a Globe and Mail article on Canadian solidarity and the right to health care ended with: “When they came to take away the rights of the destitute, I was not destitute, so I did not speak out. Then they came to take the rights of the ill.”

My comment following the quote posed the question: “Whether in the United States or Canada, is it solidarity that is vacillating, or is it merely due to our all too feeble efforts to involve ourselves in the political process?”

Mike Luff, National Representative for Canada’s National Union of Public and General Employees (NUPGE) responds:

With respect to your question (above), I would submit the following response: it’s not an “either/or” issue. The problem is both diminishing solidarity and confidence in the political process. But I believe we can change this. By honestly answering two deceptively simple questions: If not us, who? If not now, when? Allow me to elaborate, please.

Conviction and courage are almost nonexistent in politics in Canada and the US. It’s so bad we even tell jokes about it. One I heard goes like this.

Question: Why is a politician like a banana?
Answer: Because he starts out green, turns yellow and then goes rotten. But it is no laughing matter. The problem is not that politicians don’t live up to our expectations – the problem is that they too often do live up to our expectations and behave like politicians. They too often show no conviction and courage. They too often play us for suckers. This is what we’ve come to expect from the “people’s representatives” in Ottawa and Washington. It’s very dangerous. Because it pushes most people to give up on politics. To throw our hands up and follow the famous bumper sticker advice: “Don’t vote. It only encourages ’em.” That’s the real danger. Because the more people give up on politics the closer we edge to giving up on democracy itself.

But we do have the power to stop the drift to democratic despair. To do this we must come on strong. Remind people that to give up on politics is to give up on ourselves – and that we are not about to do that. We must rally regular, everyday people with the conviction they can hold out for themselves and we must give them the courage to use their ballots to finally do it. We must state and restate our conviction that it is regular, everyday folks who make history every day when we shut off the alarm clock, get the kids off to school and go into work. We must have the courage to say this is our world and we are not about to throw up our hands and lose it by default to the fools in Ottawa and Washington – elections will be won and lost until we get what we want.

The example of how we got Medicare in Canada in the first place should give us strength. The people that thought up and fought for Canada’s Medicare didn’t put their faith in politics or politicians. They put their faith in people, in each other. There were 105 people at the founding meeting of the movement to fight for Canada’s Medicare. There were 20 construction workers; 19 unemployed men and women; 15 farmers; 12 members of Parliament; six housewives; six teachers; six railway workers; six nurses; three journalists; two lawyers; two union leaders; two steam engineers; one miner; one professor; one hotel keeper; one retired minister; one merchant; and one motion picture operator. And not one stuffed shirt in the lot. They were all regular folks. They had nothing much going for them except their belief in themselves, their common desire to make the world into a better place and their faith in the power of ordinary people to do extraordinary things.

It is what made them strong then. It is what makes us strong now. It is what will keep us strong in the future.

It’s just a fact that civilization doesn’t happen because we leave it to other people. We have to stand up and fight for it – as if the cause depends on each one of us, because it really does! We must make it plain that we are going to hold out for what is right and just and ours. We must do this because we owe it to ourselves and to all the other women and men of good will who came before us and all those who will follow. We must be, as they were and will be, the change we wish to see in the world. Let us together openly declare that we are the ones who will lead by example, with conviction and courage, and we will do it now!

Mike Luff
National Representative
National Union of Public and General Employees (NUPGE)
NUPGE is Canada’s second largest union.)

Mike Luff on Canada’s vacillating solidarity

In the last Quote of the Day message, a Globe and Mail article on Canadian solidarity and the right to health care ended with: “When they came to take away the rights of the destitute, I was not destitute, so I did not speak out. Then they came to take the rights of the ill.”

My comment following the quote posed the question: “Whether in the United States or Canada, is it solidarity that is vacillating, or is it merely due to our all too feeble efforts to involve ourselves in the political process?”

Mike Luff, National Representative for Canada’s National Union of Public and General Employees (NUPGE) responds:

With respect to your question (above), I would submit the following response: it’s not an “either/or” issue. The problem is both diminishing solidarity and confidence in the political process. But I believe we can change this. By honestly answering two deceptively simple questions: If not us, who? If not now, when? Allow me to elaborate, please.

Conviction and courage are almost nonexistent in politics in Canada and the US. It’s so bad we even tell jokes about it. One I heard goes like this.

Question: Why is a politician like a banana?
Answer: Because he starts out green, turns yellow and then goes rotten. But it is no laughing matter. The problem is not that politicians don’t live up to our expectations – the problem is that they too often do live up to our expectations and behave like politicians. They too often show no conviction and courage. They too often play us for suckers. This is what we’ve come to expect from the “people’s representatives” in Ottawa and Washington. It’s very dangerous. Because it pushes most people to give up on politics. To throw our hands up and follow the famous bumper sticker advice: “Don’t vote. It only encourages ’em.” That’s the real danger. Because the more people give up on politics the closer we edge to giving up on democracy itself.

But we do have the power to stop the drift to democratic despair. To do this we must come on strong. Remind people that to give up on politics is to give up on ourselves – and that we are not about to do that. We must rally regular, everyday people with the conviction they can hold out for themselves and we must give them the courage to use their ballots to finally do it. We must state and restate our conviction that it is regular, everyday folks who make history every day when we shut off the alarm clock, get the kids off to school and go into work. We must have the courage to say this is our world and we are not about to throw up our hands and lose it by default to the fools in Ottawa and Washington – elections will be won and lost until we get what we want.

The example of how we got Medicare in Canada in the first place should give us strength. The people that thought up and fought for Canada’s Medicare didn’t put their faith in politics or politicians. They put their faith in people, in each other. There were 105 people at the founding meeting of the movement to fight for Canada’s Medicare. There were 20 construction workers; 19 unemployed men and women; 15 farmers; 12 members of Parliament; six housewives; six teachers; six railway workers; six nurses; three journalists; two lawyers; two union leaders; two steam engineers; one miner; one professor; one hotel keeper; one retired minister; one merchant; and one motion picture operator. And not one stuffed shirt in the lot. They were all regular folks. They had nothing much going for them except their belief in themselves, their common desire to make the world into a better place and their faith in the power of ordinary people to do extraordinary things.

It is what made them strong then. It is what makes us strong now. It is what will keep us strong in the future.

It’s just a fact that civilization doesn’t happen because we leave it to other people. We have to stand up and fight for it – as if the cause depends on each one of us, because it really does! We must make it plain that we are going to hold out for what is right and just and ours. We must do this because we owe it to ourselves and to all the other women and men of good will who came before us and all those who will follow. We must be, as they were and will be, the change we wish to see in the world. Let us together openly declare that we are the ones who will lead by example, with conviction and courage, and we will do it now!

Mike Luff
National Representative
National Union of Public and General Employees (NUPGE)
NUPGE is Canada’s second largest union.)

Annals of Internal Medicine
August 17, 2004
Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study
By Eve A. Kerr, MD, MPH, et al

We believe that this is the first study to use equivalent instruments and methods to compare quality of diabetes care for patients treated in the VA system with quality for those in commercial managed care systems. We should note that the average results for diabetes quality among the commercial managed care plans participating in this study are at or near the top of diabetes performance when compared with national results for commercial plans participating in the National Committee for Quality Assurance accreditation process. Despite this relatively high level of performance in the commercial plans, we found that the processes of care and 2 intermediate outcomes for VA study participants were better than or as good as those for commercial managed care participants. In many cases, the observed differences in quality of care between VA and commercial managed care were large.

…as an integrated health care system, the VA system has implemented several simultaneous, national-level strategies, such as an integrated electronic medical record, unified nationwide guidelines, service integration, alignment of payment incentives, and effective performance monitoring. While almost all commercial managed care plans also had established diabetes quality improvement and monitoring systems, the Chronic Care Model suggests that changes in several domains of care and investment in quality by organizational leaders are necessary to move the quality needle effectively.

Our results suggest that a federally sponsored national health care organization can provide care that is equivalent to or better than that provided by high-performing commercial managed care plans.

http://www.annals.org/cgi/content/full/141/4/272

Comment: So much for “the government can’t do anything right.”

The Globe and Mail
August 20, 2004
Then they came for health care
By Rick Salutin

It has been a summer of dire warning about eroding health care, leading doomfully toward a health summit in September. This is not new. For a decade, virtually the entire political class and opinion elites have said our health care is not “sustainable,” as if it is a coastline faced by a weather system. The sole public voice (aside from the public) to reject this fatalism has been Roy Romanow. This week, he noted that tax cuts have cost $250-billion in revenue since 1996 while health costs have risen just $108-billion. In other words, the decline in health care is a result of free human choice.

The reason public opinion has resisted elite wisdom about our hopeless health care is not that people adore those “free” doctor visits, but that they have come to see it as a basic right. It may not have begun that way,but it soon took on that air. This sense of health care as a right makes it resistant to fiscal fear-mongering. What would you say if you were told we cannot afford free speech, or democracy, due to current economic conditions? Health care is different and similar. But rights can be lost, as well as gained. To shed light on how that happens, let me take another case: the right to be free of destitution, known disparagingly as welfare.(Welfare is not just about being poor but being destitute. Welfare incomes are often about 15 per cent of average income and miles below the poverty line.)

The sense of welfare as a human right emerged in the 1960s, like health care. It, too, occurred by stealth. Till then, welfare had been akin to charity, bestowed by their betters on the poor, who were seen as partially or wholly responsible for their plight. But during the Depression, the destitute started being seen as victims of market forces largely outside of their control. The token of this change was the 1966 Canada Assistance Plan (CAP), which offered federal funding for welfare as long as the provinces made it universally available, provided a decent living standard and removed distinctions between the worthy and unworthy poor. It was a kind of informal acceptance of the right not to be destitute.

The retraction of this right — one of the “givebacks” of the 1990s — was the work of then-finance minister Paul Martin. His 1995 budget abolished the CAP, replacing it with the Canada Health and Social Transfer, a pot of money the provinces were handed with far fewer conditions attached. Ontario and B.C. swiftly brought in the old divisions between the worthy and unworthy poor, plus programs such as workfare. The right of Canadians not to be destitute was effectively repealed. It’s striking that this did not extend to the health component of federal funding. There, standards stayed in place and the right to health care stood. The ill as a class were now treated as more fully human, as mirrored by their rights, than the poor — surely due to calculating the votes involved.

This was bad news for the poor. But I’d say it was also bad news for the rest of us. The loss of the right not to be destitute makes the poor less fully human. The non-poor, meanwhile, become more fully human, and they get to show it by lording it over the poor, deciding their fate by giving or withholding welfare. This kind of social breakup is the essence of charity,which was defined in 1825, for instance, as something that exists “to signify the promoting of the happiness of our inferiors.” Welcome to the 19th century. Less human solidarity, more division and strife.

The accumulation of human rights is a social, historical process. It isn’t handed down once and for all. It can move ahead and fall back. If you can find a reason to deny the rights of the destitute, you can do the same for those of the ill. Why not give health care only to those who deserve it, who exercise, don’t smoke etc. It is not inherently illogical. The same for free speech. You can find reasons to withdraw it: terror, moral decay . . . The right to vote? At one time, it went only to those with property or other virtues.

When they came to take away the rights of the destitute, I was not destitute, so I did not speak out. Then they came to take the rights of the ill.

http://www.theglobeandmail.com/servlet/ArticleNews/TPStory/LAC/20040820/COSALU20/TPHealth/

Comment: Whether in the United States or Canada, is it solidarity that is vacillating? Or is it merely due to our all too feeble efforts to involve ourselves in the political process?

The Globe and Mail
August 20, 2004
Then they came for health care
By Rick Salutin

It has been a summer of dire warning about eroding health care, leading doomfully toward a health summit in September. This is not new. For a decade, virtually the entire political class and opinion elites have said our health care is not “sustainable,” as if it is a coastline faced by a weather system. The sole public voice (aside from the public) to reject this fatalism has been Roy Romanow. This week, he noted that tax cuts have cost $250-billion in revenue since 1996 while health costs have risen just $108-billion. In other words, the decline in health care is a result of free human choice.

The reason public opinion has resisted elite wisdom about our hopeless health care is not that people adore those “free” doctor visits, but that they have come to see it as a basic right. It may not have begun that way,but it soon took on that air. This sense of health care as a right makes it resistant to fiscal fear-mongering. What would you say if you were told we cannot afford free speech, or democracy, due to current economic conditions? Health care is different and similar. But rights can be lost, as well as gained. To shed light on how that happens, let me take another case: the right to be free of destitution, known disparagingly as welfare.(Welfare is not just about being poor but being destitute. Welfare incomes are often about 15 per cent of average income and miles below the poverty line.)

The sense of welfare as a human right emerged in the 1960s, like health care. It, too, occurred by stealth. Till then, welfare had been akin to charity, bestowed by their betters on the poor, who were seen as partially or wholly responsible for their plight. But during the Depression, the destitute started being seen as victims of market forces largely outside of their control. The token of this change was the 1966 Canada Assistance Plan (CAP), which offered federal funding for welfare as long as the provinces made it universally available, provided a decent living standard and removed distinctions between the worthy and unworthy poor. It was a kind of informal acceptance of the right not to be destitute.

The retraction of this right — one of the “givebacks” of the 1990s — was the work of then-finance minister Paul Martin. His 1995 budget abolished the CAP, replacing it with the Canada Health and Social Transfer, a pot of money the provinces were handed with far fewer conditions attached. Ontario and B.C. swiftly brought in the old divisions between the worthy and unworthy poor, plus programs such as workfare. The right of Canadians not to be destitute was effectively repealed. It’s striking that this did not extend to the health component of federal funding. There, standards stayed in place and the right to health care stood. The ill as a class were now treated as more fully human, as mirrored by their rights, than the poor — surely due to calculating the votes involved.

This was bad news for the poor. But I’d say it was also bad news for the rest of us. The loss of the right not to be destitute makes the poor less fully human. The non-poor, meanwhile, become more fully human, and they get to show it by lording it over the poor, deciding their fate by giving or withholding welfare. This kind of social breakup is the essence of charity,which was defined in 1825, for instance, as something that exists “to signify the promoting of the happiness of our inferiors.” Welcome to the 19th century. Less human solidarity, more division and strife.

The accumulation of human rights is a social, historical process. It isn’t handed down once and for all. It can move ahead and fall back. If you can find a reason to deny the rights of the destitute, you can do the same for those of the ill. Why not give health care only to those who deserve it, who exercise, don’t smoke etc. It is not inherently illogical. The same for free speech. You can find reasons to withdraw it: terror, moral decay . . . The right to vote? At one time, it went only to those with property or other virtues.

When they came to take away the rights of the destitute, I was not destitute, so I did not speak out. Then they came to take the rights of the ill.

http://www.theglobeandmail.com/servlet/ArticleNews/TPStory/LAC/20040820/COSALU20/TPHealth/

Comment: Whether in the United States or Canada, is it solidarity that is vacillating? Or is it merely due to our all too feeble efforts to involve ourselves in the political process?