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Health Reform Inches Ever Closer
Report on a convocation, entitled "Health Coverage 2000 - Meeting the Challenge of the Uninsured" in Washington D.C. on January14, 2000 at the National Press Club
by: Arthur L. Kovacs, Ph.D.
American Psychological Association Designated Representative

I want to share with as many colleagues who will read this some impressions I gained from attending an all-day event yesterday at the National Press Club. Some of you may have seen the convocation live on C-Span. It was titled "Health Coverage 2000 - Meeting the Challenge of the Uninsured."
The event was funded by a grant from the Robert Wood Johnson Foundation, and it was organized jointly by Families USA, probably one of the most active and effective advocacy organizations in Washington with its advocacy efforts focused on achieving affordable quality universal health coverage for all Americans, and as its organizing partner for the conference, the Health Insurance Association of America. What is noteworthy at the outset is that these two groups most typically are in intense adversarial confrontations with each other around a broad range of health care issues and dilemmas. That they could put aside their differences and begin to work cooperatively on what to do about the growing scandal of those without health coverage is itself a remarkable breakthrough. As the sponsors began their planning, they put out invitations to other groups concerned about health matters who might want to come forward with additional proposals for addressing the problem of the uninsured. In the end, the two initiating groups were joined by the American Hospital Association, the American Medical Association, the American Nurses Association, the Catholic Health Association of the United States, the Service Employees International Union (the union of health care workers), and the United States Chamber of Commerce - all of whom had recommendations to bring to the table.
The meeting was moderated by Susan Dentzer, the Health Unit Correspondent on Jim Lehrer's PBS News Hour. Later on, she invited Representative Dick Armey to comment on the Congressional perspective on the problem of the uninsured, and he was followed Governor Howard Dean of Vermont who described the role the states can and must play in seeking a solution. There was extensive press coverage, and the audience - myself included - had some, if limited opportunity to raise concerns or to make comments.
The day ended with a summary panel discussion on what common ground seemed to be emerging. For that discussion, Ms. Dentzer was joined by Sheila Burke, the Executive Dean of the John F. Kennedy School of Government and by Judy Feder, Dean of Policy Studies at Georgetown University. I was privileged to attend the convocation representing the membership of the American Psychological Association. Two members of the Practice Directorate's advocacy office were also in attendance for parts of the day, Marilyn Richmond in the morning and Peter Newbold in the afternoon.
The first reaction I want to share in this correspondence is a sense of sadness and regret about a structural matter. Last February, the APA Council passed a resolution making it a matter of high priority for our Association to be involved in health policy matters. Yet here we were at an extremely important convocation merely as bystanders and observers. Please note that the leadership of our profession keeps issuing a clarion call that it is time for psychology to be recognized not only as an important health care profession but as a PRIMARY care profession. So let me raise for all who read this my absolute conviction that if we indeed are committed to creating such a self-identity, we MUST begin to be heard as a significant voice about GENERAL matters of health care - and about the system within which it is financed and delivered. So far at least, our advocacy and public education efforts have not been enough in those directions. They have been mainly focused on protecting and advancing our traditional role as a "mental health" profession - supporting parity proposals and trying to mute the devastating effect managed care has had on mental health benefits and accessibility. But we have had next to nothing to say about matters of general health, its financing, and its delivery. The next time such a convocation occurs, it is imperative that the American Psychological Association be one of the presenters!!! I did the best I could to do something to contribute to the dialogue. There was a table containing lots of handouts available. I had brought 100 copies of "Toward the Raising of the Nation's Consciousness: the Psychosocial Components of Citizens' Health Status and of National Health Care Costs" authored by myself, Dorothy Cantor, Russ Newman, Gerald Koocher, Wayne Sotile, Harold Eist, and Golnar Simpson. It was a piece many of you have seen, one developed and forwarded in response to an invitation by the Bill Bradley campaign staff. While this document is clearly not an "official" policy of the American Psychological Association, it seemed helpful to have something thoughtful to put forth from our constituency even in such an informal manner. I am pleased to report that the handout was gobbled up quickly.
Now let me make some observations about the substance of the convocation. I had made a cynical prediction before entering the auditorium that we were going to watch a set of hand wringings about how terrible was the problem and then a set of proposals, each of which would recommend that the proper solution would be to gore someone else's ox. I was delighted that this did not turn out to be the case at all. By the end of the first few hours, it became my sense that there was enough commonality of purpose across disparate constituencies so that continuing dialogue could indeed produce a unified proposal for addressing the uninsured and underinsured in a way that almost all the stakeholders would endorse. Depending on the outcome of the nation's presidential and congressional elections, then, we might indeed be on the threshold of a major legislative initiative in the next year or two.
The morning began with a description of the problem. There are now 44 million legal residents of this nation without health insurance: a number that has been going up by a million a year for the past seven years of an unprecedented economic recovery! One of the problem is that the very recovery itself has been driven by a growing number of individual entrepreneurs working for themselves and by the start up of thousands of small companies employing few workers and not willing or able to provide health benefits. I was surprised to hear that 8 out of 10 persons without health insurance are employed!
The actuaries and the demographers do not have hopeful predictions for any better future. If the economy remains strong, by the year 2010, 52 million Americans will be uninsured; if there is a recession, 58 million!
All the presenters were in agreement that the nation has a wonderful present opportunity to do something about the problem because of our economic health and because of the promise of continuing surplus federal budgets. While some of the groups (see below) believed in the absolute necessity for a fundamental overhaul of the entire health care financing and delivery system, all were willing to join in embracing the need for an incremental step for the uninsured, one that needs to be implemented fairly quickly. All were prepared to build on the present complex and clumsy system to find ways to expand and refine existing features of that system in order to start driving the numbers of uninsured downward rather than upward. Depending on the particular suggestions made, the proposals put forth could send the aggregate down from 44 million to some much lower number - as little as seven million for the most ambitious set of recommendations.
Let us all remember that the nation now has grown six separate and distinct health care systems, each with its own funding mechanisms, eligibility requirements, benefits packages, and administrative practices. These are:

The military and Veterans Administration systems owned and operated by the federal government.

The Medicare system for the over 65 age cohort and for the disabled paid for by the government but administered by a variety of fiscal intermediaries around the country.

The Medicaid system for the disadvantaged, paid for with a mix of federal and state monies and administered via a variety of different kinds of schemes.

The Child Health Insurance Plan (CHIP) created by the Congress last year to begin to cover children, particularly children in poor families, who do not otherwise possess health coverage. CHIP, too, is a federal-state partnership similar to Medicaid.

Private sector health insurance owned and operated by the member companies of the Health Insurance Association of America and purchased both by employers and by private individuals. These plans, of course, run the gamut from indemnity insurance through PPOs, IPAs, for-profit HMOs, and non-profit HMOs.

Emergency care for the noninsured, typically through emergency rooms in hospitals who by regulation are obligated to see even those who have no health coverage of any kind and therefore must secure enough funds through the other forms of reimbursement to absorb the costs of charity care.

I am a psychologist. I have some mild obsessive personality traits that leave me yearning for order and the beauty of simple, spare elegance. So I find what I have described above to be quite foolish, wasteful, and dissonant.

Be that as it may, let me describe the main features of the various proposals:

American Hospital Association - AHA supports incremental policy measures designed to expand health care coverage across three specific population groups making up the biggest mass of the uninsured: 1) children, 2) working families with up to 150% of the stipulated federal family level poverty index, and 3) the near elderly and early retirees. It proposes to do so by enhancing CHIP, covering pregnant women in Medicaid, extending coverage in all programs to legal immigrant children, adding single childless persons at or below 150% of poverty to Medicaid, and extending COBRA until middle aged persons become eligible for Medicare.

American Medical Association - Advocates using consumer choice and decision making as the driving force. It wants to shift the tax benefits of health insurance purchase from employers to workers. For workers who were not given enough to purchase plans by employers, a refundable tax credit would be issued by the government. AMA is also very supportive of enhancement of the CHIP program and wants Medicaid to be changed to a voucher system that would allow recipients to choose from an array of plans.

American Nurses Association - This was the only group that dared to advocate for a massive overhaul of the system. ANA proposed covering everyone under Medicare and merging parts A and B to save large administrative costs. They also had crafted a very thoughtful phase-in approach to prevent chaos in moving from one system to another.

Catholic Health Association - CHA also advocated an expansion of CHIP. In addition, it proposed giving premium subsidies to individuals whose annual incomes were below $35,000 and to families below $50,000. The Federal Employees Health Benefits Plan would be made available to anyone who was temporarily unable to get group insurance.

Families USA - The organization proposed three interventions that would "cure" at least 70% of the problem: Pegging Medicaid eligibility at 133% of the federal poverty level; providing state programs for adults who were not parents, one modeled on CHIP, that would help states give subsidies to all adults between 133 and 200% of the federal poverty level, and giving states matching funds to help subsidize COBRA for those who lose employment.

Health Insurance Industry of America - Well, it should come as no surprise to hear that the insurance industry wants to make more profits. Its proposals were mainly directed at how to help those without insurance secure dollars to buy insurance. Added to this is a call to give extra tax benefits to small employers to help them afford health insurance for their workers. It also wants to be free of the threats of regulation and of litigation which "drive up health care costs." It proposes to reach the first of these priorities through a system of federal vouchers for those in need and the second by changes in the tax code. In order to reach the third, it wants a repeal of mandates, curbs on litigation, and a reduction in "regulatory burdens." So what else is new?

Service Employees International Union - I found these proposals to be exciting and thoughtful. I wanted to cheer. SEIU calls its proposals "The American Health Security Plan." Under its provisions, families would be able to choose their own health plan, and at a minimum be guaranteed benefits equal to those available to member of Congress through the Federal Employee Health Benefit Plan. Everyone would have access to health care - including preventive, medical, mental health care and prescription drug coverage - and would be able to maintain coverage in the case of job change, a disabling illness, or other life changes that currently threat continuity of coverage.

United States Chamber of Commerce - There were no surprises here, either. The Chamber also wanted curbs on regulation and on litigation. In addition, they ran against the tide and suggested that an even greater use of ERISA protections be made, namely that small businesses could ban together in groups and that the group could then be treated as a single employer, engage in self-insurance, and be subject to ERISA protections on the conduct of the group's operations.

After listening all day, for me, the bottom line is this:

APA   must begin to create its own visions of what the nation's health care system should look like and how it should operate if it is serious about being a "health care profession."

APA      must find ways to get invited to the table when significant presentations and negotiations are being made. We must become participants and not observers.

We have a host of natural allies out there. The American Hospital Association, AMA, the ANA, Families USA, the Catholic Health Association, and the Service Employees International Union are all suggesting interventions I believe most members of APA would embrace with great enthusiasm.

In order to move forward with what I believe to be psychology's most noble agenda - and one of great benefit to the public - I have long ago put a new business item, now known as "30B" in the Council agenda. An article about that item and about my aspirations will appear in the February MONITOR. I urge everyone who reads this to rally around and join in the effort. It is long past time for APA   to rise to its mission and to become a clarion voice in this nation advocating sensible principles for achieving meaningful health care reform.