The Five Borough Report
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. 
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   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.

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    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.
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 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

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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?)
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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.

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    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.
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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.

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   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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