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March 02, 2007

Health Care For All: A Possibility or a Pipe Dream?

There's a New York Times/CBS News poll out today that shows a majority of Americans think the federal government should guarantee health care for all. Most importantly, they're willing to incur a tax hike in order to meet that goal. And they think Democrats are more likely than Republicans to make that goal a reality.

Only 24 percent said they were satisfied with President Bush’s handling of the health insurance issue, despite his recent initiatives, and 62 percent said the Democrats were more likely to improve the health care system.

Americans showed a striking willingness in the poll to make tradeoffs to guarantee health insurance for all, including paying as much as $500 more in taxes a year and forgoing future tax cuts.

But the same divisions that doomed the last effort at creating universal health insurance, under the Clinton administration, are still apparent. Americans remain divided, largely along party lines, over whether the government should require everyone to participate in a national health care plan, and over whether the government would do a better job than the private insurance industry in providing coverage.

Though we are still stuck in the mud over whether a private or publicly funded system would be most effective, that gap is growing wider as well. Only 38 percent say the private insurers should hold the reins while 47 percent want a government-run approach. This really isn't a surprise. The recent election was about a major foreign policy issue -- the war in Iraq -- and a growing problem on the domestic front -- the lack of available and affordable health care. And Democrats won on both issues. There are now 47 million Americans who have no health insurance at all. That figure is an increase of 6.8 percent since year 2000.

Washington State has over 600,000 residents who live without proper health care, and that number is growing for adults as well as children. We have a good program for covering the uninsured, namely the Basic Health Plan, sponsored by former state senator (and current U.S. Congressman) Jim McDermott in 1987. The BHP covers over 100,000 low-income residents with basic health services. Those between 100-200% of the federal poverty level are subsidized, while those over 200% of the poverty level pay a reduced fee to be in the plan. It's a very effective program which has, unfortunately, suffered cuts when the state was in the red. Last year, thanks to our budget surplus, the BHP started adding enrollees again. As an example, it costs the state just under $48 million (in December 2005 dollars) to pay for 25,000 enrollments. That includes the benefit, communications and administrative costs. The plan's prescription drug purchasing is negotiated by a consortium of government and private entities. (Congressional Democrats wanted the federal government to have the power to negotiate prices for the new Medicare Prescription Drug Plan, but Bush and the Republicans said "no").

So, how do we reach the goal of universal health coverage? The insurance companies are not in business to lose money, but can they, realistically, be part of a universal system? Massachussetts passed legislation requiring everyone to buy insurance, and Schwarzenegger wants to do the same in California. Theoretically, it may be possible (and some will be subsidized) but it still leaves the insurance companies in a grand position. As the poll shows, Americans are beginning to feel more trusting of a socialized system.

The Washington State Legislature has put a whopping 166 health care related bills on the docket for the 2007-2008 biennium. Many of them are forward-looking, like HB1088, which improves delivery of children's mental health services. Some are long overdue, such as HB 1703, allowing DSHS to create a pilot program to locate domestic violence advocates and specialists in the offices of Children's and Family Services. One of the most comprehensive is HB 1569, "Reforming the Health Care System in Washington State". Since the pdf is 39 pages long I'll just point to a couple of sections: Sec. 402 requires that employers with more than five employees "adopt and maintain a cafeteria plan...that provides a premium only plan option so that employees can use salary deductions to pay health plan premiums." (Offering coverage is hard for some small business owners but, conveniently, HB 1638 provides tax incentives for employer-provided health care.) Sec. 404 requires that by year 2012 anyone 18 years or older "must obtain and maintain creditable coverage". So, is Washington State planning on going the way of Massachussetts and California in order to cover everyone?

Since there's a consensus that we want to see universal coverage, we need to start talking about what we are willing to give up to get there, because it isn't going to pay for itself. The NYT/CBS poll respondents said they'd pay up to $500 more a year and forgo future tax cuts to make the dream a reality.

What are you willing to give up so we can reach the goal?

Posted by shoephone on March 2, 2007 at 01:52 AM in National and International Politics, Policy, Washington Culture | Permalink


Seems to me there is no piecemeal solution to the healthcare access conundrum. Jettisoning for-profit insurance in favor of Medicare for all is the big solution, but of course, that is the very industry (along with big Pharma) which has spent many decades purchasing our legislators to keep their wealth transfer shell game chugging along. We need a revolution, not tinkering.

Posted by: op99 | Mar 2, 2007 5:49:21 AM

This is the issue that has continued to stump some of the brightest minds and the most innovative thinkers, and the obstacle - which has only gotten bigger, not smaller - is a combination of the private insurance industry and Big Pharma. And, if we're being honest, it's also people who want excellent health care, but don't want to pay a lot for it - either out-of-pocket or via insurance premiums.

I've often wondered if the government could start incrementally lowering the age at which one becomes eleigible for Medicare, as a way of transitioning over to a more all-encompassing single-payer system, but since the low reimbursement rates to providers are causing more and more of those providers to opt-out of the system, that has to be addressed - even if the age-eligibility remains the same.

And dare I say it? There has to be some way to teach people that the government is not required to pay when people want what they can't afford and don't have to have. My state is looking to quadruple the income-eligibility level of the CHIP program, so that more children can have health converage, but the unintended consequence of that is people who see the availability of that safety net as permission to have more children they couldn't afford in the first place.

What am I willing to give up? I wouldn't mind contributing as taxes the same amount I pay in premiums (right now, that's about $5,200 a year), as long as I get the same access to care, and I don't get caught in an unmanageable bureaucracy.

Posted by: Anne | Mar 2, 2007 6:20:43 AM

It's a fascinating and critical issue. It's essentially how to we transition over to a more European way of thinking of government after decades of fiercely clutching our market-oriented approach?

Clearly, as you say, the people are ahead of the politicians on this one as well. But I can't imagine what it will take to pry the long, greedy arms of the Pharma and insurance industries from our purses.

Posted by: Lynn | Mar 2, 2007 10:49:40 AM

Oops. Just deleted my own comment.

I think this issue presents the perfect case study for state legislatures leading the way towards increasing their own risk pools, and increasing coverage, using existing models (yes, like Medicare and the BHP!) to get there. Many states are already moving in that direction, because as you say Lynn, the politicians are in the clutches of Big Pharma and the insurers, and state and local budgets (and providers) are stressed to their limits. States come up with solutions because they have to, and, unlike the federal government, they have to balance their budgets.

The federal govt. is simply not going to take this on without support from state legislatures proving it can be done. "Grassroots" may not be exactly the right word for what I'm thinking, but in the meantime: isn't it possible that state legislatures being able to provide wider access -- and rein in costs -- can make good use of federal grants, without us having to upend the entire system and make the Fed the number one provider? This approach doesn't leave pharma and the insurers out of the process. Instead, it makes room for them to be part of the solution.

Since I'm not a health care expert I can't claim any expertise, but state run systems (including the nice benefits our govt. employees enjoy) prove that the initiatve already exists for providing better than average care. But I'm convinced we need a new revenue stream to make it happen. So, we probably can't get there from here without a state income tax.

(preparing self for incoming hurled tomatoes...)

Posted by: shoephone | Mar 2, 2007 11:36:54 AM

There is no free lunch, so I think taxes are inevitable. If they are fair and not disproportionately borne by the wage-earners, or take the form of increased user fees for things like car registrations and licenses, and everyone can potentially participate in the plan, it might not be so terrible.

At some point, the savings that derives from people being healthier has to begin to offset the cost. Of course, then we may have a serious population problem...

Posted by: Anne | Mar 2, 2007 1:01:36 PM

If you look at the total cost of all health care in the US, it will include huge premiums being paid for profits of insurance carriers and drug companies. A substantial portion of the population has substandard access to healthcare, and the cost is born disproportionately by the middle class.

Contrary to Republican propaganda, Medicare and Social Security are huge government bureaucracies that are quite lean, and run very efficiently. So if you extract the "profit premium" from the total amount of the nation's current health delivery tab, health care could be provided to all for the same or lower total cost as is being paid now, but under a totally different distribution paradigm. (Who gets care - everyone - and who pays for it - a progressive taxation scheme.)

This is a ridiculously simplistic description, but if you don't have a major paradigm shift to single payer and universal coverage, it's just going to be the old rearrangement of deck chairs on the Titanic.

Posted by: op99 | Mar 2, 2007 9:23:11 PM

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