Strong medicine for the healthcare access crisis?
By Ted Bobrow
When Governor Jim Doyle laid out his health care proposal during his State of the State address in January, he dramatically transformed the debate about health care in Wisconsin. He summed it up succinctly: “The simple truth is, the time has come for the wealthiest nation in the world to provide access to affordable, comprehensive health insurance for its citizens – and Wisconsin can lead the way.”
It’s an attractive scenario and perhaps very timely.
Health care in today’s United States is truly Dickensian: the best of worlds and the worst of worlds. For the very wealthy and for people with good health insurance, there is practically no limit to the quality of available care.
What a wonderful world we live in, eh? Well, some of us do. In reality, the U.S. is a nation of haves and have-nots, where 47 million people, including 9 million children, have no health insurance.
For many in this group, paying out-of-pocket for a routine mammogram or even going to an emergency room at the onset of chest pains is not an option.
And the problem is only likely to get worse. With the cost of health care and the insurance to pay for it escalating at twice the rate of inflation and the primary U.S. employment base shifting from large companies to small (less than 100 employees), fewer and fewer employers are able to offer decent health coverage.
Early innovations in our own state served as the model for the nation’s current system of unemployment insurance. The time may be right to turn Wisconsin’s progressive tradition towards the problem of the uninsured.
The Clinton plan: a costly lesson
While access to basic medical care would seem to be a need most appropriately addressed at the federal level, neither the President nor Congress have shown much interest in comprehensive health care reform since Bill and Hillary Clinton’s ill-fated attempt in the early 90s.
When President Clinton took office in 1993, he identified health care as the first big challenge of his presidency and he appointed his wife to head a task force to come up with a solution. First Lady Hillary Clinton, now a senator from New York and the frontrunner for the Democratic nomination for president in 2008, assembled a group of the nation’s leading thinkers on health care and got to work.
The Clinton task force eventually put forth a proposal that sank like a stone. There were many reasons for this failure, but the most instructive of all was that the Clintons did not build adequate support for the proposal among several key stakeholders including, incredibly, Congress and the American people.
The Clinton proposal was complicated, and it became an easy target for opponents, most notably health insurance companies and small businesses, who argued that it would take control away from families and put Washington in charge of picking doctors and managing care.
The insurance companies ran an effective ad campaign featuring a fictitious couple, the infamous “Harry and Louise,” who lamented the loss of control over their health care decisions.
President and Mrs. Clinton presented their proposal to members of Congress as a fait accompli, assuming that the Democratic leaders would salute smartly and do as they were told. It turned into a costly lesson of the ways of Washington for the Clintons.
But the problems have remained and intensified.
Taking it to the states
In recent years, much of the attention to health care reform has shifted to the states and the passage of legislation in Massachusetts last year may be a sign that the floodgates are about to open. So far, over 3,600 bills pertaining to healthcare have been introduced in state legislatures since the 2007 session began, with 19 governors addressing health care reform in their state of the state addresses, according to the National Conference of State Legislatures (NCSL).
The Massachusetts legislation, signed by then-Governor (and now presidential hopeful) Mitt Romney (a Republican), requires every resident of the state to have health coverage. While many praise steps like these as bold, others scoff that they amount to little more than a present to the insurance industry. It’s one thing to mandate coverage and another thing to address the issue of how to pay for it.
Here in Wisconsin, there have been three serious proposals for health care reform floating around the last few years.
• Sen. Mark Miller (D-Monona) and Rep. Charles Benedict (D-Beloit) back the Wisconsin Health Security Act, often referred to as the single-payer plan, which would require the state to provide health insurance to all of its citizens.
• The Wisconsin Health Care Partnership Plan, supported by the Wisconsin AFL-CIO, is supported by Sen. Russ Decker (D-Schofield) and Rep. Terry Musser (R-Black River Falls) builds on the model of worker compensation and guarantees all workers health insurance.
• A third plan, called the Wisconsin Health Plan, authored by David Reimer, who served as budget director for Gov. Doyle and Milwaukee Mayor John O. Norquist, was introduced during the last legislative session by Rep. Jon Richards (D-Milwaukee) and former Rep. Curt Gielow (R-Mequon). It would provide coverage for all state residents and provide incentives for controlling costs.
All three are ambitious and comprehensive, and all three were struggling for attention. Now, Governor Doyle has demonstrated the power of his office by ratcheting up the momentum for health care reform with his proposals.
Doyle has called for the expansion of the state’s current programs serving low-income children and their parents, BadgerCare and BadgerCare Plus, to cover more people. He addresses two of the obstacles facing many uninsured.
The first is the cap on income. Currently, many families make too much to qualify for assistance but too little to afford private coverage. Doyle pledged to make BadgerCare Plus available to all children in Wisconsin, regardless of income. The cost would begin at about $10 a month.
The other obstacle is that these programs are only available to people with children. Milwaukee County’s General Assistance Medical Program (GAMP) offers emergency medical care to low-income adults without children, but adults are only eligible for state subsidized assistance if they have dependent children. Doyle’s proposal, considered radical by some, would extend coverage to low-income adults without children, benefiting up to 71,000 adults in Wisconsin.
While the three earlier proposals were languishing, the governor has forced the legislature to consider his package because he included it in his budget. As proposed, Doyle’s plan appears straightforward. Expand existing programs so they cover more of the uninsured. Streamline programs and make them easier to understand and more accessible. But when it comes to health care, nothing is ever simple.
Less than meets the eye?
On the surface, the governor has already answered the most difficult question in his budget: how is Wisconsin going to pay for this?
According to Jason Helgerson, policy director at Wisconsin’s Department of Health and Family Services, an increase in the cigarette tax would cover much of the cost of this expanded coverage and the federal government would pay for much of the rest.
Doyle has affirmed the latter. “Because of the way we are structuring the program,” he said in his recent state of the state speech, “the federal government will pay most of the cost – bringing us an additional $60 million from Washington.”
Doyle is also proposing a new hospital tax that would impose a 1 percent tax on revenues at Wisconsin’s 130 hospitals. That could bring in nearly $1 billion in direct revenue and matching funds from the federal government over the next two years.
The governor proposes returning $700 million of that to hospitals to reimburse them for the care they provide to poor people, boosting the state’s reimbursement rate under Medicaid from 63 percent to 83 percent.
So Doyle has structured this to appeal to health care providers and consumers. Paul Nannis, vice president of government and community affairs for Aurora Health Care and former health commissioner for the city of Milwaukee, is supportive of the Doyle plan.
“This would be a major step forward in providing health coverage to people in Wisconsin who are currently without insurance,” Nannis said. “It’s huge.”
“AARP wants a plan that best serves the needs of consumers,” Gail Sumi, assistant state director of AARP’s Wisconsin office, said. “People need quality health care they can afford that also provides access to preventative services. States can’t wait for Congress.”
Sitting in a coffee shop on the day after Gov. Doyle presented his budget, David Riemer is reserved in his praise.
Riemer, former budget director for Milwaukee Mayor John O. Norquist and Gov. Doyle, is the author of the state’s BadgerCare program. He gives Gov. Doyle credit for moving the debate forward but wishes he went farther.
“Everything he’s proposed is great,” Riemer said. “But there’s a big difference between expanding access and making sure everyone is covered.”
To a certain extent, Riemer says, most everyone already has access. Many people eligible for BadgerCare are simply not enrolled in the program and others who can afford private insurance just aren’t paying for it.
There needs to be a major outreach effort targeting these people, he says, and no health care reform package is complete without cost containment measures.
Another potential Achilles heel in the governor’s proposal is its reliance on federal dollars. President Bush’s proposed budget is already seeking to squeeze dollars out of the Medicaid program and Doyle’s proposals would require waivers that may not be forthcoming.
Helgerson is optimistic, however, since Congress also weighs in on the budget.
“We hope the federal government will not walk away from the nation’s low income families,” he said.
Let the debate begin
So the stage is set for a serious debate on health care in Wisconsin as both houses of the state legislature struggle to approve a new budget.
And that’s the way our system of government always works, for better or worse. As David Riemer said, “when it comes to improving access, you won’t get there without bipartisan compromise.” Medicare and Medicaid were created in the 1960s, “because LBJ knew how to cut a deal. Today, that is the challenge nationally and in the states.”
And perhaps it isn’t too foolhardy to imagine comprehensive health care reform on the federal level with a Democratic-controlled Congress and the prospect of a Democrat in the White House in 2009. Is it possible that the lady who chaired the ill-fated Task Force on Health Care Reform in 1993-4 had the opportunity to redeem herself leading a second Clinton administration?
It could be an interesting few years. VS
Ted Bobrow is a writer and communications consultant who lives in Milwaukee. He has worked for AARP in Washington, DC, Gov. Doyle in Madison, the Alzheimer’s Association in Chicago and Froedtert Hospital in Milwaukee.