Debra Hardy Havens, BS, RN, FNP Washington Representative for NAPNAP Capitol Associates, Inc. Washington, DC
of Health Care Reform
he Health Care Reform issue is one of the top domestic policy issues of the year and is expected to remain so for the next several years. Health care reform is a broad term encompassing the issues of expanded access to care for the uninsured and new constraints on the ever-rising cost of health care. However, there is no consensus on the exact problem or solutions. Health care reform means different things to different groups. To date numerous Commissions, federal, state, and local committees, task forces, think tanks, coalitions, businesses, and others have put much effort into studying the issue and in developing proposals for solutions. Nonetheless, a consensus on the issue has not been reached. n HISTORY-“WHAT
IS PAST IS PROLOGUE”
The issue of health care reform is not new. In fact, the last time that the United States seriously considered national health care dates back to the early 1970s when politicians, pundits, and academics alike believed a program of national health insurance was inevitable. During that time, lawmakers hoped to build on their mid 1960s successes in creating Medicare and Medicaid by putting together a national plan that would guarantee all Americans access to health care through insurance. President Richard Nixon was pressing his own plan, featuring mandatory employer-paid health insurance-the first formulation of “pay-or-play-for all full-time workers. His plan also included heavy reliance on prepaid health care through a relatively new phenomenon known as health maintenance organizations, or HMOs, the earliest form of “managed care.” On the Congressional front, both Senator Edward Kennedy (D-Mass.) and then House Ways and Means Committee Chairman Wilbur Mills (D-Ark.) were pushing for a broader program financed out of tax revenues in which the federal government would become the insurer for all citizens and the payer of all billsnational health insurance.
JOURNAL OF PEDIATRIC HEALTH CARE
However, the momentum for reform was lost because of the “all-or-nothing” approach led by Senator Kennedy, which was backed by organized labor, and the c‘take-whatever-we-can-get” approach by the Senate Finance Committee Chairman Russell Long (D-La.). In addition, other political events that caused the demise of two other key players of the time, President Nixon and the Watergate incident and Rep. Mills’ Tidal Basin affair, helped to delay any reforms. Similarly, today, Congress is being distracted from major policy issues by its own internal problems or “scandals” involving ethics and the internal operations of Congress such as its banking system and Post Office. In the mid 197Os, President Jimmy Carter sought to revive the reform issue but then clashed with Senator Kennedy who wanted to move faster. By the end of the decade, the issue of major reform lost all momentum. In the early 1980s President Ronald Reagan began a decade of cost containment and a period of sharp growth of the uninsured. When the 1980s began an estimated 27 million Americans were without health insurance, and by the beginning of the 1990s the estimates had risen to 37 million. Twenty years later, the issue of major health care reform, is “hot.” Numerous major proposals have been presented. They vary greatly. Generally, these ideas fall into three categories: national health insurance, “playor-pay,” or incremental reform. Interestingly, Senator Kennedy now proposes a “play-or-pay” approach, and Republicans generally are promoting an incremental reform approach with various liberal Democrats supporting national health insurance. Among these plans, proposals range from . incremental reform to comprehensive reform; . employment-based to publicly financed; . play-or-pay to single payer; . 100% tax financing to premium and tax financing; , incorporation of private insurers to eliminating private insurers;
. strict cost controls to flexible cost controls; . inclusion of long-term care to exclusion of longterm care; and . a federal plan to a state plan to a federal/state combined plan. Although these plans differ, nearly all of the proposals try to focus on the affordability of and access to health care services, with the quality of care a major concern. Within this general category is a myriad of many other issues. Examples include medical malpractice/liability reform, development of medical practice guidelines, capital and technology costs and controls, cost shifting, claims processing and overall administrative costs, statemandated benefits laws, self-insured plans versus stateregulated plans, identification and use of managed care, and emphasis on preventive and primary care versus acute care. Each of these brings a different perspective and affects the system. Health care reform is a complicated and complex issue. No easy answers exist, and a solution of “one size fits all” does not appear to be available. What does seem apparent is that each community and state presents unique problems with unique solutions. Whatever new major system is devised, it will need to be flexible to meet these individual and unique needs. n
Before lawmakers and health policy makers attempt any major health care reforms, they will seek the public’s views and opinions on the issues. Realizing this, many efforts have and will continue to be made to measure the public’s opinion on the nation’s health care system and the wide variety of suggestions for its improvement. Some of the data revealed thus far have provided insight into the public’s understanding and views on the issue. More importantly, these views present opportunities for advocates of reform to educate the public and present their own opinions. As an example, recent data compiled by polls and focus groups by the Health Insurance Association of America (February 1992) gave the following public opinion: n “Nationally, over one-third of all Americans (35%) rate ‘reducing the cost of health care’ as one of the top two problems they want their Congressman to work on, second only to ‘improving the economy’ (37%).” n
“A large majority of the Americans (75%) with health insurance coverage are satisfied with the quality of health care they personally receive. Twothirds of those who have insurance report being satisfied with its overall cost to them personally.” “Only one-in-five voters are satisfied with the nation’s health insurance system and only one-in-ten
are satisfied with national health care costs. Even though many Americans who currently have health care coverage are satisfied with it, they recognize that others have been pushed out of the system. They are extremely concerned this could happen to them.” n “One fourth of the citizens think the system ‘is beyond repair and needs to be rebuilt from scratch’ and another four-in-ten think it ‘could work, but significant changes are needed.’ An overwhelming percentage think the system should be reformed (45%) or radically changed (45%), while less than one-in-ten think it should be kept the same.” . “Cost containment and economic concerns are clearly the driving forces behind the current health care debate. At the same time, the public definitely wants universal health care coverage, as 56% say ‘making sure all Americans have access to health care’ is one of their two most important considerations when contemplating reform. To a large degree, these considerations are counterbalanced by the desire of many people to maintain the quality and choice they now enjoy.” . “About 49% of the Americans do not believe that a government-oriented plan will adequately address the problem.” The bottom-line issue for Americans, the Congress, and the Administration appears to be who is going to pay for any major health care reforms. Essentially Americans want increased access and reduced costs while retaining choice and quality-more for less. To date, no one has been able to come forth with such a proposal. The biggest obstacle of the day to enacting major health care reform is finding the funding for these major programs in the face of the huge federal deficit. This presents policy makers with the age-old dilemma of providing a new benefit that the country wants but being burdened with the public’s unwillingness to pay for it. Therefore it appears that if anything is going to get done on health care reform, it would have to be something at the margins that is low cost and on which a consensus has been reached. n
The good news is that health care is at the forefront of the political debate. Numerous hearings, briefings, and debates have occurred and will continue to occur through this session of Congress and the Presidential debates. Moreover, children and children’s health issues have received much attention over the last several years. Events that have helped to draw attention to children are the National Commission on Children; the Administration’s Advisory Council on Social Security that highlighted efforts on prevention, prenatal care, and
bmlal of Pediatrr
alternative health care delivery systems for children; the Pepper Commission; the work of the Infant Mortality Commission; and others. This is a golden opportunity to learn about health care policy and formulate your own ideas and opinions. The National Association of Pediatric Nurse Associates and Practitioners (NAPNAP) has appointed a Task Force that has studied the issue and will be forwarding recommendations on principles and elements that should be incorporated into any plan-be it incremental, pay-or-play, or national health insurance. Your
ideas and view points on the health issue would welcome. H
REFERENCES Health Insurance Association of America. (1992, February). “Anyone listening to voters”, “Public opinion on health care reform: recent Jindings.” Omaha, Nebraska. National Health Policy Forum. (1992, February 19). “Systems reform then and now: the search for consensus, a test of political will.” Issue brief no. 588. George Washington University, Washington, DC. Briefing session.
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