Health Care

By Dennis Hayashi

We Need Quality and Affordable Health Care!

That movement for health reform is every bit as relevant today as it was a decade ago. The Institute of Medicine in Washington, D.C. just issued a report revealing the extent to which Americans are uninsured when it comes to health care. More than 43 million Americans are presently uninsured--and 80 percent of them are from working families. The institute called for universal medical coverage by the end of the decade.

The fact is millions of Californians who work hard for a living don't have coverage. According to the California Health Care Foundation, more than 640,000 of the state's uninsured have annual incomes of $70,000 or more and about 1.6 million have incomes of more than $50,000 a year. Some 1.3 million children in California--one out of seven--are uninsured. Equally troubling is that many working people will lose their insurance when they retire. "The growth in health care costs and insurance premiums is outstripping general inflation and family and business incomes," according to Dr. Robert Ross, president of the California Endowment. This growth rate of 59 percent in our state is below the national average, he notes. Many businesses face double-digit annual hikes in premiums. Employment-based health coverage is shrinking in California. There is no excuse for a state as economically productive as ours being unable to provide all of its residents with health care. There are legitimate differences of opinion about how to do it. But we must begin with the premise that health care is fundamental regardless of income or station in life.

We Need More Access to Coverage

Last year saw enactment of Senate Bill 2, the landmark law by state Senate leader John Burton (D-San Francisco) requiring all but small employers to either provide employee health insurance or contribute into a state fund that provides it. Rather than repeal SB 2, as some in the business community advocate, we should improve upon the delivery of coverage as the law is implemented, including subsidies for small business owners.

Large corporations, including low-wage employers such as McDonald's and Wal-Mart, are sponsoring an initiative to repeal SB 2. It appears headed for the Nov. 2 general election ballot. I oppose it. We need more access to health coverage, not less.

Similarly, a number of proposals from Governor Schwarzenegger would make access to health care even less available for the Californians who need it the most. He wants to shut out as many as 300,000 children who currently qualify for the Healthy Families program that provides health insurance to kids from needy families. He also wants to freeze enrollment in California Children's Services that offers care to some of the most needy youngsters suffering from chronic health problems or disabilities such as cancer, congenital heart disease, hemophilia, HIV/AIDS, diabetes and cerebral palsy.

Although the governor says everyone should sacrifice to solve the budget crunch, his cuts disproportionately impact low-income women. More than 2 million elderly women would be hit by Governor Schwarzenegger's plan to cut MediCal provider payment rates by 10 percent. Elimination of the In-Home Supportive Services program could push more than 175,000 blind, elderly and disabled women out of their own homes and into more expensive nursing facilities.

I think we need to pursue other answers. We can seek federal matching funds for groups such as pregnant women whose care is already covered by state dollars. Making permanent even a 1 percent increase in the share of MediCal insurance paid for by the federal government would yield about $325 million for the state. A recent federal economic stimulus package provided a temporary hike in the federal share of the states' Medicaid (our MediCal) spending. It amounted to a boost of roughly 3 percentage points in the federal match for MediCal, producing approximately $1 billion in savings for California. But that boost in the federal match will go away next July. Working with other states, California should find ways to continue the increase in the federal share of the state's medical costs for the needy.

I support full funding of Healthy Families coverage for children. Denying access to needed care even for short periods can seriously undermine kids' health. I also think we should continue the state's pioneering "express" enrollment of children into health coverage when they sign up for school lunch and Food Stamp programs.

The governor also wants to cap enrollment in the state's AIDS Drug Assistance Program. This proposal would put low-income people with inadequate or no health insurance on waiting lists. They would only receive life saving drugs when a current enrollee dies or otherwise drops out of the program. Such heartlessness cannot be tolerated in a compassionate society.

Just as important as health care access is the quality of health care. The state Department of Managed Health Care now provides a place where the public can turn when people are denied adequate treatment. I intend to review the nature of complaints filed thus far and address any major inadequacies in the delivery of care.

When deciding which candidate has the background and commitment to work for improved health care access and affordability for all Californians, please consider my record.

Fundamentally Changing the Health Care System

The fast-rising costs of providing health care was a big worry expressed during the 1992 presidential election. It was becoming less and less affordable even then. What's more, the health provider industry was swiftly moving towards what was called managed health care. More and more, health coverage was being taken over by health maintenance organizations, or HMOs. The oldest and one of the largest and most respected is Kaiser Permanente, established by pioneering industrialist Henry J. Kaiser to provide health care to workers building ships in his yards during World War II.

One of the concerns at the time was that decisions about whether people would receive medical treatment and what kind of care it would be increasingly appeared to be made on the basis of cost rather than need.

The great majority of Americans get health coverage through group insurance plans supplied by their employers. That left out in the cold millions of working people, many of them low-wage employees, who didn't have benefits. A result of cyclical recessions--such as existed in the early 1990s and today--was that many better-paid workers were also forfeiting their health coverage.

Back in 1993, tens of millions of Americans had no recourse when it came to health care. The great majority of them were employed full-time. They worried constantly about illnesses or injuries that could render them and their families destitute. The Clintons were responding to these people and others concerned about having a more equitable health system.

I witnessed the whole process evolving from inside the Clinton administration. It began with the President and First Lady's longstanding interest in health care and delivery going back to their years in Arkansas, when he was governor. The primary policy responsibility for health issues rested within my Department of Health and Human Services.

The campaign started by drawing together as many different experts as possible reflecting a broad spectrum of philosophies and viewpoints. They included top executives from the big HMOs, representatives of small community health clinics, actuaries and other financial specialists from the health industry, experts from think tanks and universities, groups advocating for improved patient care and coverage of children, seniors, union leaders, big and small business organizations and representatives from the full range of health care professionals. Vigorous voices of liberal, moderate and conservative persuasions were all heard and considered.

Administration officials devoted a couple of years to long and detailed research and analysis with involvement by all the affected interests. I attended a number of these sessions, albeit my focus was on ensuring any proposal included protections against discrimination and that no particular group fell through the cracks or was excluded from coverage. One of the things the Office for Civil Rights inserted into the proposal being considered was a guarantee no American would be denied health care because of income.

These discussions and deliberations occurred at the staff level in a multitude of agencies and departments. Senior White House staff coordinated them. At many points, the President and First Lady both spent hours and days piecing together legislation to submit to Congress. This process stands in sharp contrast to reports about how the Bush White House and administration functions, most recently a book drawn heavily from former U.S. Treasury Secretary Paul O'Neil. He paints the picture of a distracted President Bush who rarely engages in substantial exchanges with cabinet members or staff where the pros and cons of different points of view are presented and freely evaluated. O'Neil said some meetings amounted to "a blind man in a room full of deaf people." The President has also recently boasted that he doesn't follow press coverage from major news outlets, preferring to find out what is going on in the nation and world through accounts filtered by aides who presumably tell him what he wants to hear.

One of the things I admired about President Kennedy was how he went out of his way to solicit the opinions of people who didn't necessarily agree with him. My experience within the Clinton administration was that President Clinton welcomed aides and cabinet members who would challenge him intellectually and offer contrasting arguments on important public policy matters. An effective leader, especially the Leader of the Free World, needs to participate in a free exchange of ideas.

Offering Health Care Choices

The ultimate concept from the Clinton administration was to give Americans choices in how they received coverage and who their health care provider would be.

Giving people choices involved asking and answering a number of key questions. Did people want treatment from a managed care provider like an HMO that could produce less expensive coverage? Did they wish to go to a particular physician with whom they had a relationship? Did they want the ability to follow that doctor if he or she moved from one network to another? How could patients be guaranteed they would get the best quality medical care available to address their particular needs? Should a single-payer network be created--such as they have in Canada--where the government takes over delivery of health care through a national operation, basically eliminating the private HMOs and insurance companies? (This last concept was not included in the Clinton proposal.)

There were many approaches to how health care would be financed. One proposal was to continue the present set up of having employers provide coverage to their employees, paid for either entirely by employers or through premiums shared by workers and employers. There were discussions about federal grants for the states to run their own systems, geared to the needs of their residents. There was talk about a "pay or play" system where employers could supply health insurance or contribute to some form of fund that would provide it to their workers. (This is similar to SB 2, the new California law.)

Before a proposal could be sent to Congress, the insurance industry paid for a series of television ads around the country. These were the "Harry and Louise" commercials depicting "average" middle-class Americans who attacked the Clintons and drew on scare tactics such as false suggestions Americans would have to give up their longtime family physicians. The special interests lined up early on to kill any attempt at meaningful reform.

Finally, the Clinton administration submitted a proposal that was so comprehensive it resembled a phone book. It essentially ensured coverage for almost everyone and preserved patients' choice of physicians. By 1994, what former House Speaker Newt Gingrich called the Republican revolution had taken place and his party controlled the lower house of Congress. The President's health plan was never seriously considered.

After that and through the remainder of President Clinton's two terms in office, bills were introduced in an effort to make incremental changes in health care coverage. The most notable example was the Children's Health Insurance Program (CHIPs) that provides federal funding to states for health insurance benefiting the children of low-income families. Here the program is called Healthy Families, and it has gone a long way in bridging the gap of health care for needy youngsters. Federal funding for this effort was administered through the Department of Health and Human Services, where I worked.

I also played a role in preparation of regulations to implement the Health Insurance Portability and Accountability Act of 1996 (HIPAA). My office and department also had primary responsibility for this area within the Clinton administration. HIPAA included important new protections for millions of working Americans and their families who have preexisting health conditions or could suffer discrimination in coverage because of a factor relating to their health. The regulations we drafted--they formally took affect last year--place requirements on employer-sponsored group health care plans, insurance companies and health maintenance organizations. Among their provisions are limiting the exclusion of persons because of preexisting medical conditions; banning discrimination against workers and their dependents based on their health status; and guaranteeing that health coverage will be renewed and available to certain employees and individuals.

Working with the Surgeon General

During my last year in the Clinton administration I served as counselor to the deputy secretary of the Department of Health and Human Services. My job was coordinating the department's participation in some key initiatives for the administration.

One was working closely with Dr. David Satcher, then surgeon general of the United States. The surgeon general is the nation's chief physician and head of the United States Health Corps. Structured as a military organization, it oversees public health policy for the country.

Since the 1960s, U.S. surgeon generals have been in the forefront of defending the public health of Americans, from initiating the nationwide campaign against tobacco use to educating people about sexually transmitted diseases such as HIV-AIDS.

My assignment was to work with Surgeon General Satcher by focusing attention on disparities in who receives critical life-saving medical procedures and treatments such as heart by-pass surgery and angioplasty. Several scholarly studies indicated substantial differences in the frequency by which men and women, African Americans, Latinos and whites benefited from procedures that could make the difference between life and death. The surveys were conducted by public agencies, including the National Institutes of Health, and respected private medical schools.

We wanted to encourage hospitals to review their records and determine whether or not there were major differences in how care is provided to patients from different ethnic and racial groups, and differences in the treatment afforded men and women.

This effort led to a series of public educational events highlighting the problem in different parts of the U.S. Doctors, hospital administrators, medical educators and patient advocates got together to raise awareness and promote more equitable care and access to care. It also eventually led to a partnership between the surgeon general and the American Public Health Association to reduce disparities.

Protecting the Disabled

In 1990, U.S. Senator Edward M. Kennedy (D-Massachusetts) and other lawmakers introduced an important civil rights bill boosting protections for people subject to discrimination because of their physical disabilities. Part of Senator Kennedy's proposal was properly defining disability to cover those who had previously been excluded from legal safeguards.

Before 1990, the law covered only persons with obvious disabilities such as blindness or injuries and illnesses relegating people to wheelchairs. But as society advanced, other less obvious afflictions were recognized as life changing. Changes in the law were needed in order for it to keep pace.

For example, it was recognized supermarket cashiers, computer operators and assembly line employees were suffering repetitive motion injuries causing severe pain and disability. These injuries could be conclusively diagnosed and treated so, together with some modifications in the job, workers could still be productive employees. But there were no protections against discrimination for such people under federal law.

As a public-interest attorney with a non-profit law firm, I was one of many advocates who weighed in to support the legislation. We helped get people to write letters to their elected representatives, traveled to Washington, D.C. to express support for the bill and organized meetings in the Bay Area to rally interest and backing for the Kennedy measure.

It faced major opposition from business groups, including the U.S. Chamber of Commerce, and conservative lawmakers from both parties. It was not an easy sell in Congress. However, the bill passed and landed on the desk of a Republican president, George H.W. Bush. He signed it into law in 1990.

Providing quality health care for all Californians must remain the highest priority for state government. It is a complex and difficult challenge. However, in the end isn't it in all of our interests to ensure we get the best care and coverage possible? I intend to keep working to realize that goal.