PRESIDENT'S COLUMN HEALTH INSURANCE LEGISLATIVE UPDATE Alma R. George, MD President, National Medical Association Detroit, Michigan

INTRODUCTION It is a pleasure and an honor to address the members of the Congress of National Black Churches. I am not only pleased to have the opportunity to address you, but I am also proud of the recent coalition that has been formed between you and the National Medical Association (NMA). As president of the NMA, we look forward to working with you to strengthen this essential and monumental relationship. At this time, I would like to recognize the efforts of the NMXs immediate past president, Dr Charles Johnson as well as the Reverend Michael Lemmons in forming and forging this coalition. As president, I am here on behalf of an organization that represents over 16 000 physicians throughout the United States, the Virgin Islands, and Puerto Rico who are among the primary providers to the medically underserved and low-income minority populations. The majority of NMA members are African-American physicians; however, we welcome as active participants any health-care professional who is interested in promoting the science of medicine and better health care.

ACCESS I assumed the presidency of the NMA at a time when the health-care system in this country, specifically with respect to African Americans, could not be worse. Access, or should I say lack thereof, to adequate health care continues to be the primary problem facing the Dr George is Director, Primary Care Initiative, Surgical Services, St Joseph's Clinic, Samaritan Health Center, Detroit, Michigan. Presented at the Annual Consultation of Congress of National Black Churches, December 10, 1991, Detroit, Michigan. Requests for reprints should be addressed to Dr Alma R. George, National Medical Association, 1012 10th St, NW, Washington, DC 20001. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 1

African-American community today. According to the Bureau of Labor Statistics, one million Americans annually lose their health insurance. Estimates of the number of Americans who have no insurance range from 32 to 37 million. One third or more than 12 million of them are children, and 15 million are women of childbearing age. These 37 million Americans represent a segment of our population that has increased by 25% since 1980. An additional 26 million Americans have no insurance for substantial periods of time. There are also 60 million Americans who have inadequate insurance to fully accommodate their needs. Virtually all Americans are at risk; however, it is the low- and middle-income families who are subject to the greatest threat. The numbers of underinsured and uninsured are, unfortunately, expected to increase during these recessionary times of the 1 990s as employers struggle to curb skyrocketing medical costs by reducing staff and cutting benefits. Insurance in this country is primarily employerbased. Those without employment generally have no insurance and therefore do not have access to adequate health care. Because minorities in this country suffer higher rates of unemployment, we do not have proper access to adequate health care. However, even citizens with jobs are dissatisfied with the adequacy of health coverage provided by their employers. A study by the Service Employees International union entitled, "Labor and Management on a Collision Course Over Health Crisis" revealed that the number of striking employees involved in disputes where health benefits were a major issue quadrupled between 1986 and 1989. In 1985, the "Report of the Secretary's Task Force on Black and Minority Health" (better known as the Heckler Report) indicated that 60 000 excess deaths 17

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among African Americans and minorities could have been prevented if they had received health care that is received by most nonminorities (360 000 deaths from 1985 to 1991). In November 1990, the National Institutes of Health reported that the lifespan for African Americans had continued to decrease despite the lengthening lifespan for the majority of the population. Health care must become more accessible (in both cost and availability) to all citizens in this great nation. As a result of the factors that hinder access to adequate health care, African Americans suffer a greater proportion of illnesses and diseases. In 1962, the leading cause of death for all Americans was cardiovascular disease, which was responsible for 55% of all deaths. That percentage had decreased to 44% by 1989 for nonminorities. However, today, hypertension is the number one killer of African Americans. It afflicts 28% of African-American adults compared with 17% of white adults. Hypertension accounts for a higher incidence of strokes in African Americans. Studies show that African Americans are two to three times more likely to have a stroke than whites, and the stroke mortality rate is 66% higher than that for whites. These variations can be attributed to the lack of access that African Americans have to health care as compared to their white counterparts. I am pleased, however, to report to you that the NMA has testified before the House Appropriations Subcommittee and has closely worked with members of the US Congress on the Labor-Health and Human Services Appropriations Bill for the upcoming fiscal year. The legislation was signed by President Bush on November 26, 1991 and is recognized as Public Law 102-170. In this law, Congress specifically directs the National Institutes of Health to consult with the NMA in efforts to ensure fuller participation of African-American researchers, practitioners, and patients in every aspect of research, including clinical trials, because it is recognized that the impact of hypertension, heart disease, and strokes affect African Americans disproportionately.

PROPOSED REFORMS The problems of health-care costs and providing adequate access to all citizens is finally gaining attention. There are at least 13 bills currently pending in Congress that seek to overhaul the health-care system in this country. As you might expect, these bills differ tremendously in the means to bring about a new health-care system. At this time, I would like to briefly summarize some 18

of the legislation currently under consideration: * On June 5 of this year, democratic leaders in the US Senate introduced a bill that attempts to overhaul the health system in this country. Senate Bill 1227, introduced by Senators George Mitchell (D, Me), Edward Kennedy (D, Mass), Jay Rockefeller (D, WVa), and Donald Riegle (D, Mich), incorporates the recommendations of the Pepper Commission in that it would guarantee Americans access to health insurance through the "pay or play" system. The "pay or play" concept would require employers to provide insurance to their employees and their dependents, or pay a tax that would go into a fund. The fund would be used to cover those individuals who are not employed and to subsidize those with low incomes. * Representative Dan Rostenkowski (R, Ill), chairman of the House Ways and Means Committee, has introduced a bill that also incorporates the "pay or play" concept. However, Rostenkowski's bill would also authorize the secretary of Health and Human Services to implement mandatory fees nationwide for physicians, hospitals, and other health-care providers at the level necessary to keep national health expenditures from exceeding the national cap. * Representative Marty Russo (D, Ill) introduced HR 1300, which is essentially a copy of the Canadian health-care plan. This bill would require the federal government to pay for all health-care costs. It is predicted that the savings in administrative costs would be enough to cover all uninsured Americans. * Representative Pete Stark (D, Calif), has introduced HR 650, referred to as Mediplan. This bill would entitle all citizens to insurance for a core package of acute and preventive services. Mediplan would be financed primarily through employers and income taxes. * On the more creative side, Representative Don Pease (D, Ohio), introduced a bill that would be financed by nearly doubling the 200 per pack tax currently levied on cigarettes. The bill calls for the creation of regional insurance plans on a sliding fee scale for those without insurance. * On the Republican side, Senator Dave Durenberger (R, Minn), ranking republican on the Senate Finance Committee's Medicare Subcommittee, introduced Senate Bill 700 entitled the "American Health Security Act." This bill is directed at small businesses that have problems providing insurance to their employees. The bill would require insurance companies that sell policies to employers with less than 50 workers to comply with consumer protection requirements such as guarantees of renewal policies. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 1

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These bills offer dramatic changes in the structure of our current health-care system. Although it is estimated that it will take considerable time before any major reforms are implemented, the introduction of these proposals encourage debate and forces lawmakers to pay attention to the severity of the problem of health care in this country. In June of this year, the General Accounting Office (GAO) released a report entitled "Canadian Health Insurance: Lessons for the United States." This report was prepared at the request of Representative John Conyers, Jr (D, Mich), who is chairman of the House Government Operations Committee. As you probably know, Canada has a publicly funded health- care system whereby all citizens, regardless of their income, receive comprehensive care for all medically required services. The GAO Report revealed that if the US were to adopt a program similar to the one in Canada, the savings from reduced administrative waste would be sufficient to cover the 37 million Americans who currently lack health insurance. Moreover, these savings would eliminate other charges such as copayments and deductibles for everyone else. The publicity surrounding this report has prompted action from the administration. Last month, Secretary of Health and Human Services Dr Louis W. Sullivan met with health groups in an effort to develop a uniform nationwide health insurance billing system. According to Dr Sullivan, such a system could save more than $20 billion a year by cutting paperwork.

OUR AGENDA Although proposals have been offered by members of Congress, the administration, labor leaders, and interest groups, we must ensure that the needs of our community are met. As I mentioned earlier, we are in a

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"crisis" situation. We can no longer wait on the programs and policies of others to get us through. We have always looked to the black church for support and leadership. In fact, many, if not most, black ministers find themselves in dual roles as both spiritual and political leaders. Historically, the black church has been a foundation for the organization and advocacy of movements that have brought about significant political and moral changes. The civil rights movement was unquestionably the most significant revolution in this country during this century. There is no doubt that the strength and power of this movement was based in the black church. Our churches have consistently been there to feed the hungry and clothe the naked. We have also called on the church to take specific action to accomplish a goal, such as organizing voters to get a candidate in or out of office and to register us to vote. I submit to you that we are in a time of crisis when we need to once again call on the help of the black church. Racism is once again on the rise in this nation. There is an anti-affirmative action/anti-civil rights sentiment that is quite prevalent in today's society. We must organize and embellish the coalition of the NMA, the Congress of National Black Churches, and others. We need your numbers, your organization, and your strength to battle the health-care crisis that is affecting our community. There is no reason that our coalition cannot bring about a major change in this country. What good are civil rights if our family members are dying simply because they cannot receive adequate health care? I encourage you to work with the NMA in taking on this monumental task. It is not an easy one, but we have the strength, the knowledge, and the ability to succeed.

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Health insurance legislative update.

PRESIDENT'S COLUMN HEALTH INSURANCE LEGISLATIVE UPDATE Alma R. George, MD President, National Medical Association Detroit, Michigan INTRODUCTION It i...
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