Health Care

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Women's health issues
Why 1965 money standards are not enough
States or federal responsibility
Medicare reform: who, what, and how?
Women's rights and women's health
Patients' rights
Medical Research: At issue:

What's the Problem Now?

Before World War II, people paid for their own medical care if they could.

Women's health issues.

Because women are responsible for the health care of their families, and because there are health conditions that are solely related to women's bodies, the expansion of health care, the fairness of health insurance, and the guidelines set by government particularly affect women. At issue are:

Family planning services, including funding for education for teenagers about responsible decisions about sex.

International family planning services to help women avoid unwanted pregnancies.

Contraceptive coverage by insurance companies many of which already cover Viagra for men, but will not consider contraception for women as medicine. Female federal employees do have contraceptive coverage.

Government funding for medical research for women's health. Much research has been done on and for men, but studies now show that women have different rates of disease as well as different diseases. Separate funding for women's health is a serious concern.

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Medicare (for those over 65) and Medicaid (for the poor) were designed in 1965 before so many people became elderly and before many high tech methods for testing and treatment were invented and discovered. The taxes that support these programs are not enough to cover the costs of the doctors and hospitals (which are reimbursed by the federal government) and the costs of advanced medical education that is paid for by Medicare.

Many people spend themselves into bankruptcy deliberately in order to qualify for Medicaid and not be a burden to their children. Medicaid has been subject to fraud by both patients and doctors.

The uninsured

Even with the federal/state program for insuring children of the working poor (SCHIP), there are thousands of uninsured children -- 250,000 in Pennsylvania alone. With a renewed emphasis in both major parties for education of the poor, health care is now tied into a push by some to provide quality early childhood day care and health services as part of the total package.

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Maintaining the public's health is a state responsibility. Oversight of states through regulation, however is the province of the federal government through an agency of the Department of Health and Human Services called the Center for Medicare and Medicaid Services.

Republicans tend to want to leave health care to the states, citing the importance of flexibility. Democrats tend to want one federal guarantee to all, citing fairness. It should be noted that more of the state governments are Republican controlled while the Democrats had a critical margin in the federal Senate.

All must agree that by the year 2011, the baby boomer generation will begin to retire and add to the number to be served by Medicare. The debate over what we should and can do highlights the following:

Quality

The facts are that high quality health care requires high technology testing and procedures. Early diagnosis is the best way to prevent serious complications. Early diagnosis requires both testing and particularly talented doctors that can figure out how symptoms may connect and should be treated.

Since 1965, quality health care has been less and less focused on hospitalization and nursing homes and more and more attuned to research-based prescription medicines that keep people out of the hospital. Some basic research is done by the federal government through the National Institutes of Health, but a very high percentage of medicines are researched, tested, and marketed by private companies, many of them American.

When the debate focuses on quality, the issue is how to get prescription drug benefits to everyone. Should insurers be required to offer them? Should employers be required to provide them in their benefit package?

Cost

Many people cannot afford the most talented doctors and the technology necessary for diagnosis and treatment. Under Medicare, all individuals are entitled to the same services, no matter what income they have.

Should those people who can afford to pay for some of their health care do so, if they so choose, while some who cannot pay have their health care paid for from our tax dollars?

Should those with less means have fewer services available to them? Should there be a two- or three-tiered system with a means test?

When the debate focuses on cost, the issue of prescription drugs shifts to questions such as:

Should manufacturers be required to sell at lower prices or to everyone at the same price they offer to a large purchaser, such as the federal government?

Should doctors be required by law or by insurance companies to offer generic medicines rather than patented medicines for particular ailments?

Overall medical costs are going up. However, it is important to note the reasons why. More and more patients, doctors, and hospitals are resisting managed care (HMOs) which pay doctors in advance for each patient and, thereby reward giving less care. Patients want choice. Consolidation of hospitals also gives them more power in negotiating higher payments from HMOs and other insurers.

Understanding

Many people do not want to concentrate on their symptoms and do not pay attention to warnings about their health. Many do not know how to choose a doctor or evaluate their own treatment. Many do not know the names of the medicines they take or how they are supposed to work. Many do not follow directions of their doctors or the manufacturers of the medicines.

Should people who educate themselves about their health pay less than the ones who do not? If someone gets sick, should there be a determination that it is bad luck, bad genes, or bad behavior? How would payments be determined and by whom?

An allied issue is lawsuits against doctors and hospitals for poor outcomes of treatment. These malpractice suits differ from state to state, but they also drive up the cost of medical care. Some government officials wish to cap the payments a patient can receive from a judge or jury, no matter what the injury. Payments are awarded for loss of livelihood and for pain and suffering.

Should a person who makes more money receive more from a settlement than someone with the same complaint who is paid less? How does one judge the amount of pain and suffering of another person?

Risk

Insurance companies do not want to accept high-risk people, such as the elderly or those with chronic conditions. To leave health care in the hands of insurers is to automatically exclude some people (and sooner or later -- all of us who get to be old). Insurance companies make decisions about which doctors, hospitals, medicines, and procedures are permitted the people on their lists, as a way to control costs.

If one assumes that costs must be controlled no matter how sick or injured someone becomes, there is no way to support health catastrophes that can happen to anyone.

If one assumes that insurance (private or public) that judges solely on the basis of risk is the only way to pay for medical care, then there is no way for the system to serve everyone, the sick and the well, the old and the young.

Policies and politics for solutions to healthcare

Every possible action has tradeoffs -- this is especially clear in health care. Within both national and state governments the ongoing debate about access to quality health care is framed by basic philosophy and, sometimes, religious belief.

The actual negotiations, however, move incrementally, bit by bit. Even those who prefer a national or universal health service (often called "single payer") on grounds of fairness, most often offer legislation and regulations bit by bit in an effort to extend health services to more Americans in a nation that has such serious philosophical and religious differences.

Quality, cost, or risk, especially for women

To judge each proposal, citizens, particularly women, need to note whether the guiding principle behind a political party, the President, a particular legislator, or a court decision is the principle of quality, cost, or risk. Then each proposal needs to be judged by how much progress toward better health is gained.

In our political system, for each proposal there are advocacy organizations and their lobbyists that promote their particular values to political parties and particular legislators, especially those up for reelection. For example:

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Who gets it? How do they get it? What will it cost? These are all points of contention between the political parties as they approach medical care in terms of bit-by-bit improvement, rather than a philosophy of overall entitlement to health. Both parties began the year 2001 with proposals that reflected their political base of strength, the states or the federal government.

Before the recession that began in the spring of 2001, there was a surplus in the federal and state treasuries from taxes targeted for Medicare, Medicaid, and Social Security. Both political parties and many academic and advocacy groups debated both how to plan for the future when so many will retire and how to pay for the new prescription medicines and new technology from the very productive pharmaceutical industry. This is even more of an issue now that we foresee an increasingly aging population.

Republicans, the states, private insurance

The Bush administration proposed $48 million to states over four years to give the poorest seniors prescription drugs, setting dollar amounts for income eligibility. Some Republicans proposed sweeping changes in Medicare along with Social Security, including age eligibility, increased co-payments, decreased entitlements, and a larger role for private insurance companies. Still to be explained is how the federal money would get to the states and how the insurance companies would be paid by the government to insure poor risks, that is the children of the poor, any of us with a chronic condition, and the elderly. All of us who live to get older get sicker as we age.

Democrats and prescription drugs within the current system

The Democrats wanted to provide prescription drugs through Medicare to all seniors who voluntarily sign up. Democrats proposed to cover the additional cost of a benefit for all in Medicare who wish it by allowing medicines to be imported and re-imported from foreign countries that charge less because they have national health services paid by taxes. The bill was passed and signed into law by President Clinton, but his Secretary of Health and Human Services refused to implement it on grounds that quality control would be at risk. The manufacturers of medicines oppose re-importing, as current pricing is determined within separate national markets.

Pricing and private enterprise

Pricing is a difficult issue. If the federal government through Medicare buys medicines for everyone over 65, there are sizeable effects on existing contracts. Pharmaceutical companies already sell to the federal government at reduced prices (for veterans, military, foreign aid) under a formula that requires a price for each separate medicine that is 24% less that the average commercial ceiling price. If Medicare were to buy very large amounts of medicine, the corporations might raise their commercial prices in order to factor higher prices into the 24% discount.

Recession, war, and healthcare

These issues were front and center before 2002. Now the country is in recession with many lost jobs and, therefore, lost tax revenue and with military and home defense costs added to government's agenda, the surpluses are gone at all levels of government, federal, state, and local.

The facts about health care have not changed and the differences of opinion based on differences in philosophy and priorities remain. In other countries health care is considered a citizen's entitlement, but there is not enough money in their treasuries from tax dollars to pay for high tech medicine and fast medical services. Therefore, many people who can afford it come to the United States for better treatment. On the other hand, there are Americans who go to Canada to buy their prescription medicines at lower prices that are restrained by the government.

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Reproductive choice and family planning are critical issues for women. There are activist organizations on all sides of this issue.

Certain organizations monitor the debate and provide education, publicity, and support for reproductive choice as a medical entitlement. They lobby for legislation that specifically guarantees women the right to make their own medical choices. For example, the Pennsylvania Human Relations Commission considers health insurance plans that are offered to employees a form of compensation and are, therefore a "term, condition, or privilege of employment."

The federal Equal Employment Opportunity Commission ruled in December 2000 that a company that pays for other prescription drugs and employs 15 or more people must include prescription contraceptives.

President Bush eliminated contraceptive coverage for female federal employees from his budget proposal. In the House of Representatives the coverage was restored.

Organizations that believe that their religious beliefs should prevail in restricting reproductive choice also monitor and provide education, publicity, and support and lobby for legislation that prohibits what they consider an immoral choice. The Family Research Council, a group supporting the Bush position, believes that "fertility is not a disease and contraception is not a medical necessity."

The courts

Advocacy organizations continuously monitor court cases and potential appointments to courts that reflect these opposing points of view. There is constant monitoring of cases and candidates which challenge or support the case of Roe v Wade in which the Supreme Court in 1973 confirmed for women the right to reproductive choice, including abortion, as a right to privacy.

New technologies and continuing differences

State governments now support the use of the abortion pill RU 486 since its approval by the Food and Drug Administration and pay for it to poor women through Medicaid. In 26 states there are restrictions such as approval only in cases of rape, incest, and a threat to the life of the mother. NARAL Pro Choice conducts monitoring of patient education and government action in the individual states.

International implications of actions by our government on reproductive choice and family planning

In January of 2001, President Bush signed an executive order that prevented U.S. aid to any international group that used its own money to support abortion, including surgical procedures, counseling (known by opponents as the "gag rule"), or lobbying foreign governments.

In January of 2002, at question was U.S. aid for the United Nations Population Fund that provides maternal health, family planning, and HIV/AIDS prevention services to poor countries. The Republicans in Congress are split on this issue and the President has not yet agreed to the promised $34 million already approved by Congress.

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Debated is the right to appeal decisions about medical coverage and/or sue doctors, hospitals, insurance companies, or health maintenance organizations over denial of care or poor outcomes. Among the rights under discussion are emergency care, medical specialists, and an independent medical review of decisions on claims.

Debate continues on whether there should be:

Unrestricted appeals and right to sue.

Restricted right to sue either by a different review process or by dollar limits.

Right to sue in state courts where larger verdicts have occurred or federal courts.

Individual states have passed some legislation about patients' rights, either the right to appeal a decision or the right to sue. However, it is estimated that half the population of the U.S., including most employees of large corporations and many people who work for governments, are not permitted to sue by state laws.

Patients rights; government and employers

Where do leaders and organizations stand? When George W. Bush was Governor of Texas he refused to sign such a bill, but let it become law without his signature. Business groups worry that a lawsuit would include employers who purchased a health plan from the HMO or an insurance company. Others argue that employers need not worry as long as they do not make individual decisions about the health care of any single employee.

Will lawsuits drive up the cost of health insurance, and will employers drop health insurance as a result?

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Separate funding for research on women's health

The uninhibited right of medical research to use stem cells from undeveloped embryos for research in treatment of disease.

The limited right to use stem cells from umbilical cords only or cells already harvested in months previous to legislation or Presidential executive order.

Cloning of animals, and the cloning of embryos only for research.

Confidentiality

The right of patients to prevent employers and others from access to their health records, including information on genetic testing and preexisting conditions.

New ideas

Health Plans Pay Bonuses for Quality

Six California health insurers said on January 14, 2002 that they would change their standards for paying doctors. The current system gives a doctor a lump sum for every patient he or she signs up (pay per head or "capitation").

Under the new plan, doctors would be paid bonuses for meeting standards for quality care, including breast cancer screening, childhood immunizations, and chronic conditions such as coronary artery disease, diabetes, and asthma. Funds for these bonuses will come from higher premiums, expected to rise 10 to 15%.

Critics point out the possible tradeoffs of the money being taken out of other health care services and the difficulty of establishing patient satisfaction with their health service. Will patients have access to health specialists?

States negotiating lower prices for prescription drugs by combining purchases for Medicaid eligible low income individuals with purchasing for uninsured people, even if they are not Medicaid eligible. Such large purchases would require lower discounts from manufacturers. Maine Rx is the first such law. It is supported by several other states and opposed by the pharmaceutical industry on grounds that it changes the Medicaid law and wrongly interferes at the state level with interstate commerce. The Department of Health and Human Services had not expressed its view before the case went to the Supreme Court in January, 2003.

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