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Health care reform: Where do we go from here?

From the June 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By William A. Reynolds, FACP

In last month's column, I reviewed the rise and fall of the Clinton administration's attempts at national health care reform. This month, I'll take a look at the problems that are exacerbating the need for reform and report on conversations I've had with legislators on health care reform viability in today's political climate.

The problem worsens

Since President Clinton's health care reform efforts failed, most of the nation's health care problems have only worsened. More than 42 million people in the United States lack health care insurance, and the link between poverty and inadequate health care is increasing. Just as importantly, however, the high rate of inflation in health care has led to dramatic changes in how health care is financed and how health care services are delivered.

While managed care health plans have helped slow the rate of inflation in health care, these cost savings have not been without major problems. Some managed care organizations have responded by denying care, particularly high-cost procedures, treatments and hospital stays. There are no uniform quality standards throughout the industry, and physicians are frequently subjected to onerous restrictions and demands on how they practice. As a result, there is a rising tide of concern by patients in managed care plans that is becoming the subject of legislative action at the state and federal levels. (For a good review of this subject, read "Health Against Wealth" by George Anders, a Wall Street Journal reporter.)

There has also been a major change in the political climate. A conservative Congress is addressing budget deficits and beginning to recognize that unless legislative changes are made, Medicare and Social Security will go bankrupt. The Republican-controlled Congress, along with President Clinton, agree that the deficit needs to be eliminated in the next few years and that growth in Medicare spending must be reduced. With little enthusiasm for new taxes and spending cuts, the prospect of significant federal health care reform in the next four years appears grim. (Peter Budetti has published an excellent review of this subject in the Jan. 15, 1997, issue of The Journal of the American Medical Association.)

What legislators say

To sharpen my own perspective on the prospects for health care reform—and to learn what goals and tactics the College should adopt for the near term—I interviewed a number of legislators. They include Sens. Max Baucus (D-Mont.) and Conrad Burns (R-Mont.) from my home state, as well as Sen. William Roth (R-Del.), chairman of the Senate Finance Committee, and Sen. Jay Rockefeller (D-W.Va.), also on the Senate Finance Committee. Both Sens. Baucus and Rockefeller also serve on the Health Care Subcommittee of the Finance Committee. I also spoke with Rep. Pat Williams (D-Mont.), my local Congressman who is retiring after serving in the House for 18 years and chairing a health care subcommittee, and his successor, Rick Hill, a Republican. Each interview was 30 to 60 minutes long, and all but one occurred in February 1997.

During the interviews, I focused on two questions. First, with the ultimate goal of universal health insurance coverage in mind, I asked what goals ACP can realistically expect to accomplish in the next four years. I also asked how the College, which is a 501(c)(3) nonprofit organization and can perform only a limited amount of lobbying, can most effectively influence Congress.

Only Sen. Rockefeller was optimistic that federal legislation to help cover the uninsured will be passed. All of the legislators I spoke with predicted decreases in Medicare spending and the growth of managed care Medicare health plans. In addition, quality standards for managed care Medicare patients like those proposed by ACP were favorably received by the legislators I spoke to, and some also suggested providing case management for Medicare patients with complex or chronic disease. The goal is to improve quality while reducing costs for patients with traditional Medicare insurance.

In February, Sen. Rockefeller thought that his plan with a Republican cosponsor to extend insurance coverage through Medicaid covering the 11 million uninsured children would be adopted. Sen. Rockefeller also felt that legislation that would subsidize coverage for workers moving to or from welfare, unemployment and employment would be politically viable.

During the first quarter of 1997, a host of bills to extend coverage of children were introduced in both houses of Congress. Leading the pack was the Hatch-Kennedy bill, which would cover an estimated 5 million children through a cigarette tax.

Separate proposals by President Clinton and a number of legislators have thickened the plot. On April 30, with little publicity, Sen. Rockefeller joined with Sens. Chafee (R-R.I.), Jeffords (R-Vt.), Breaux (D-La.) and 20 cosponsoring senators to introduce a bill that would potentially cover 5 million children through an extension of Medicaid. A majority of Senate Finance Committee members have already signed on. There is about $17 billion in the budget available for children's health insurance.

The Hatch-Kennedy bill was added as an amendment to the budget resolution and rejected by the Senate on May 21. Passage of a children's insurance package isn't universal coverage, but it would be one part of achieving that goal.

The College's role

It is interesting to note that the Republicans aren't opposed to efforts that encourage states to expand health care coverage on their own. That's why ACP should urge Congress to provide incentives to states to expand community-based rating and set up regulated insurance programs to provide a menu of insurance programs much like California and the Federal Employee Health Benefits Plan do.

Many states have already made significant progress in expanding insurance coverage; these states include Arizona, Hawaii, Minnesota, Oregon, Vermont and even Tennessee, with its flawed TennCare plan. Prospects for improving coverage of the uninsured may be better in state legislatures during the next four years than in Congress.

In next month's column, I'll talk about some of the ways College members can increase our influence on the legislative process.

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