Beyond
the Pataki-Rivera
“Health Care First” Package
By Robb Burlage
“Together,
Pataki and Rivera are essentially socializing medicine in New York…In New
York City more than half of all revenues at private hospitals come from
public dollars…[but] by the close of 1999, New York had more working people
without health insurance than any other state.”
-Steve
Malaga, Manhattan Institute, in the New York Post
Albany Triangulation as
Fiscal “Socialization”
The “Health
Care First” Reform Package proposed by Governor Pataki and passed by the
State Senate and Assembly — the “iron triangle” of New York State politics
— at 2 a.m. on the morning of January 17th, was put in place this year
even before the Governor’s Budget Message went to the legislative bodies.
1199/SEIU Health and Human Service Workers Union President Dennis Rivera,
together with the state’s largest lobby and campaign contributor, the mega-merged
hospital industry represented downstate by the Greater New York Hospital
Association (and its president Kenneth Raske) and upstate by the Health
Care Association of New York State, joined with the Republican Governor
to blitz the Republican Senate and Democratic Assembly leaderships.
The legislation
they pushed through provides Worker Recruitment and Retention funds for
hospital, nursing home and home care workers as the basis for raises and
training opportunities for mid-level and direct care employees. This
effectively ended the union’s contract dispute with the League of Voluntary
Hospitals, stalled since before 9/11. Especially in recognition of
the bargaining power of the liberal-labor-Black and Puerto Rican members
of Democratic Assembly, the legislation also streamlines enrollment and
recertification in Medicaid and Child Health Plus, expands Medicaid eligibility,
and increases reimbursement for community health centers.
(continued below box)
The
New John L?
In widespread local
and national media interpretations of the deal-making role of Dennis Rivera,
the leader of 1199/SEIU, has been compared to “old-fashioned labor leaders”,
including John L. Lewis, the famously fedora-wearing and industry-promoting
labor leader of more than half-century ago. Lewis was long-time leader
of the United Mine Workers in sometime collaboration with the Bituminous
Coal Operators of America. In promoting his industry, there was even
a Coal Marketing Division within his union. Perhaps Lewis’ greatest achievement
was the network of Appalachian hospitals and health centers emphasizing
occupational health and safety and funded by the industry through the UMWA
Health and Welfare Fund. Saul Alinsky and Tom Bethell have written
biographies which draw union organizing lessons from Appalachia’s “John
L”. Those who have known John L. and the current state health care
industry/union situation say that the hat doesn’t yet fit. John L.
is remembered not only for creatively fulfilling his responsibility of
protecting the union membership, retirees’, and families’ needs, but also
seeking to lead the industry with an ongoing, comprehensive social vision
and helping create and lead a new public/social service CIO unionism, a
form that is still needed today for all sectors, organized and still-being-organized.
(continued from above)
The fiscal-socialization
of health care in New York State has meant a biennial search by Albany’s
executive-legislative triangle for new revenue sources to subsidize the
unionized hospital industry. This year’s centerpiece is an estimated billion-dollar
payoff for legislative approval of the for-profit conversion of Empire
Blue Cross-Blue Shield. The proceeds from this conversion are allocated
in this package largely to the unionized health care workforce, including
a direct grant to the NYC Health and Hospitals Corporation. These
funds are on top of surcharges on hospitals and insurers for graduate medical
education and the “bad debt and charity pool” to cover services to the
uninsured. Added this year is a surcharge on long-term care and a
projection (based on what looks now like wishful thinking) of greater federal
Medicaid cost-sharing.
In recent
years, health care funding has increasingly relied on windfall, one-time-only
State revenue sources such as multi-billion Federal Tobacco Settlement
two years ago, and now expected proceeds from the Blue Cross conversion.
The capturing of these one-time funds for this purpose is controversial
with some consumer advocacy groups and, especially, Democratic legislative
leaders. There is severe criticism from consumer groups, and threats
of class action suits, challenging the capture of Blue Cross conversion
funds, rather than the planned non-profit foundation that would have been
set up to seek expanded insurance coverage and community health innovation
for low-income consumers and the uninsured. There is criticism, as
well, that most of the money will continue to support a wasteful and expensive
medical center system rather than move toward reforms that would expand
coverage while lowering cost.
Whatever
the short-run, union-industry creativity of this new revenue generation
— and regardless of its ability to get the projected match from Washington
— there is a general debt and fiscal crisis that continues to confront
the City and State. This affects all of labor, not just health workers,
along with many communities, and most sectors of the State’s economy. Within
the health care sector itself, there are deepening cuts in mental health
and public health funding, even as there is much talk, but little money,
for bioterrorism-related public health preparedness and “Homeland Security”.
And the absence of health insurance – over three million people statewide,
more than a million, including 1 in 4 adults, in New York City without
coverage – continues to be an affront to our sense of health care justice.
Recent efforts by the Governor and the State Legislature have helped hardly
at all: a recent report from Citizen Action found the new Family Health
Plus program, for low-income families, and Healthy NY, for small businesses,
have together enrolled a total of 15,000 people in a year, compared with
the million New Yorkers who were promised insurance under these plans.
(continued below box)
From 1968:
The Continuing Struggle for Health Care
The Patchwork financing
system for health services in America is the most costly, discriminatory,
and irrational in the world. The proliferation of costly private insurance
systems with overlapping and maldistribution of enrollments, narrow, rigid,
fee-based services coverage, and the absence of effective quality review
and services-coordination mechanisms has created a growing system-crisis,
reflected in rapidly escalating costs without noticeably improved distribution
or quality of services. This irrational and discriminatory pattern, even
with the uneven reforms of Medicare and Medicaid, can only be compared
to the financial and administrative mess in England through World War II
which made National Health Service necessary on efficiency grounds, even
more than equity...The commitment to a new wave of community-controlled
comprehensive health services will require a generation of effort, as will
the professional and political structure for a rational pattern of financing
and for a totally publicly accountable system of services. The challenge
to the private medical governments is to become truly public service-oriented.
--From a paper prepared
for the National Conference of Student Health Organizations, 1968
(continued from above)
A “Perfect Storm”:
Putting Health Care Back on the Agenda
The rarely-convergent
“perfect storm” image was used last year by the National Coalition on Health
Care, as it launched a national media blitz to focus attention on the lack
of health insurance among millions of Americans. An unprecedentedly
diverse grouping – unlikely to hold its unity very long if the specifics
of policy move to the legislative negotiating table — including the American
Medical Association, AFL-CIO, American Nursing Association, AARP, Health
Insurance Association of America, American Hospital Association, Catholic
Health Association — even the investor-owned Federation of American
Hospitals — criticized deteriorating insurance coverage, rising health
care costs, and called for a larger federal role. Every established
health care-interested group but the global pharmaceutical industry was
there. (And can they be far behind, promoting some kind of universal
subsidy of their own — except that the expanded federal role might lead
to government regulation, purchasing, and pricing, all anathema to them?)
(continued below box)
The Role
Labor Could Play
The costs
of our nation’s failure to ensure good and affordable care for everyone
are formidable. Our healthcare system provides cutting-edge care
for some and costly neglect for others, in particular, those at the margin
of the economy and the labor force for whom health care means a visit to
the nearest emergency room when illness is too painful to endure. But even
those who have long been able to see good doctors, benefit from state-of-the-art
technology, and find relief in modern pharmaceuticals are confronting pressures
to absorb greater financial burdens, accept higher co-pays and deductibles,
pay higher out-of-pocket costs, and face limits on the number of physician
visits.
There
is little evidence that labor’s strength is engaged in resisting these
measures. In health care as in other areas of our social and economic life,
the long-cherished promise and hope for a labor movement that can elevate
the values of solidarity and justice to places of honor and power in American
life, humanize the workplace, curb corporate abuse of power, and empower
the federal government as a central instrument to ensure that decency,
security and opportunity are honored and realized in our national politics
remains unfulfilled.
— Sumner M. Rosen, from
a review of Marie Gottschalk, The Shadow Welfare State, in New Labor Forum,
Issue 10, Spring 2002.
(continued from above)
The coalition
for insurance expansion points to the “perfect storm” convergence of:
1 - The
recession: “Since most non-elderly Americans get their insurance through
their jobs, anything that increases joblessness inevitably reduces the
ranks of the insured… a trend that would undermine the nation’s employer-based
health care system”. An estimated 2 million workers lost their health
insurance in the last year — either they lost their jobs, or they and their
employers could not afford the rising cost of insurance. The Coalition
is projecting 45 million uninsured by the end of this year.
2 - The
price of health care: Insurance premiums rose 11 percent between Spring
2000 and Spring 2001, the largest increase since the 1980’s. Premiums are
projected to go up even faster this year.
3 - Medicaid
deficits: Going into this fiscal year, twenty states were already expecting
Medicaid deficits, and that was before September 11 and everyone realized
that the ‘slowdown’ was really a recession.
Toward Universal Healthcare
with Public Planning
In these
strained circumstances, there has to be a fully-funded medical and public
health system able to take care of all patients. This will require an infusion
of federal dollars to expand the programs that now cover community health
centers, veterans hospitals and other facilities and that will direct new
funds into state, regional and localities’ departments of health and public
hospitals to make sure they are viable. But existing State and private
funds can be used much more efficiently. One way would be through
a Universal New York Health Care (UNY*Care) Plan (see box) which would
expand insurance coverage to all New Yorkers while reducing the cost of
administering the reimbursement process. It could provide universality
— the full involvement of everyone — along with a fully inclusive benefit
and contribution mechanism and transitional maintenance of organized labor’s
negotiated insurance plans.
Not-for-profit hospitals must be supported, but administrative costs such
as executive salaries, advertising, medical supply purchases, and other
spending that is not patient health care-related must be more stringently
controlled. Labor leadership, and not just the health care unions,
must, in coalition with consumer and public health-interested professional
groups and public policy advocates, seek to expand patient care capacity,
particularly in our communities, along with preventive and primary care,
mental health, chronic care, rehabilitation, and social care in a renewal
of health systems planning directed by the public sector. This could
be done through a publicly-directed health planning system like the Health
Systems Agencies that provided guidance on health system expansion until
Pataki de-funded them.
(continued below box)
UNY*Care: Universal
Healthcare for New Yorkers
The current
patchwork of private and public insurance programs, even with further subsidies
and expansions, cannot provide health care for everyone. Gaps in
coverage, avoidance of the truly sick by insurers, and chronic diseases
like AIDS are challenges that a private employment-based system cannot
overcome. As Dan Beauchamp, health policy planner for former-governor
Mario Cuomo, wrote a number of years ago, the current system leaves “no
one with responsibility for the needs of the state considered as a whole,
as one community.”
In 1988
Beauchamp and others developed a plan under which employers, insurance
companies, and the State and Federal Government would deposit their health
insurance money into a new health insurance superfund which would handle
reimbursement to doctors and hospitals. Everyone, no matter where they
got their insurance, would use a single insurance card, and there would
be a single set of benefits as well. An electronic network would
link the insurance companies, physicians, hospitals, and State agencies.
Insurance
would be community rated; “medical underwriting” (charging higher premiums
to those more likely to need medical care) and limits on pre-existing conditions
would be eliminated. All businesses could, at their option, join a public
insurance program, paying on the basis of a payroll tax, or they could
purchase a uniform private insurance package. Health insurance would
become a standard product; insurance companies would compete on the basis
of service and price (and, perhaps, for extra coverage). The State would
set overall negotiated expenditure targets for doctors, hospitals, and
other providers and would reform billing and payment systems to make these
targets effective. A Statewide electronic claims system would be
instituted. Claims would be filed to the new fund by physicians and hospitals,
not by patients, who would be relieved of this costly and confusing chore.
There would be one set of benefits, one way of paying, one bill, one point
of responsibility. UNY*Care — it’s worth trying.
(continued from above)
We should unite,
then, under the banner of “Universal Health Care Publicly Planned
for All New Yorkers”. This could be the beginning, in New York
State, of the democratization and social transformation of the health care
system and budget, as part of a national movement toward health care for
all. New York labor union, community organization, and public policy
leadership would have a unique financial basis to campaign for a visionary,
New New Deal program that would include:
— Universal,
accountable, affordable, insurance coverage
— Focused
investment on public health preparedness and comprehensive community environmental-occupational
health infrastructure
— Retraining
of health workers for comprehensive prevention and primary care, mental
and holistic health, chronic illness and social care, public health preparedness
and occupational-environmental protection and services
Robb Burlage founded
the Health/PAC Bulletin in the 1960s and is a lecturer and health advocacy
organization consultant with the Community Health Care Association of New
YorkState and the National and NYC Council of Churches. He notes
that his analytical opinions are his and not necessarily representative
of the organizations with which he works.
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