Star Tribune from Minneapolis, Minnesota • Page 12

12A SundayOctober 61991 Star Tribune ATI Roadblocks to reform it Healthcare Continued from page 1A ccro rcfcrm cpllcno State's U.S. senators both want reform, but differ oh details Description Legislation introduced by Democratic leadership in Congress requires employers to insure workers or pay tax into public plan to cover the uninsured. Pro Covers all individuals. Could be easily implemented using existing insurance structure. Con Doesn't restrain cost.

No financing mechanism established. Outlook The bill has support from some labor and business groups, but passage isn't likely any time soon. President Bush said he would veto any measure that adds burdens to business. Description Legislation introduced by Sen. Dave Durenberger, and others proposes new rules that would make modest or low-cost insurance available to the self-employed and those working for small businesses.

Other legislation proposes to expand Medicaid to cover more of those who are uninsured and limits malpractice liability claims. Pro Easy to set up, could foster competition. Con Requires well-educated consumers, doesn't guarantee universal coverage and requires public spending to cover those not covered under other plans. May not control costs. Outlook Maybe the easiest legislation to pass because it is least disruptive of the current system.

the efficiencies or the prices we need. The prescription is to fix the market not throw it out We need to do that by. Fixing the private insurance market especially for small business pie and the self-employed. Reshaping the economic incentives in the tax code, which currently provide a $100 billion subsidy for inefficient and overpriced care. Spending the money it will take to finance care for the near poor, especially mothers and children.

Fixing our product and professional liability laws and controlling the medical technology arms race, so we can get quality improvement at a price we can afford. Doing nationally what the Mayo Clinic has done better than anyone on the planet: reinvent medical practice. Invention is the genius of the American system and why Minnesota is a health care leader. A single-payer system would destroy the kind of creative problem-solving we need. Anywhere you look in public programs, public housing, public works or even public education, diversity and innovation stops and quality of service suffers.

We could end up with a national health system with the efficiency of the Post Office, the purchasing skill of the Pentagon and the compassion of the IRS. Just ask anyone who has to deal with Medicare how they like a single-payer system. And besides, the reality is that our "single payer," the national government is broke and goes a billion dollars deeper into debt every single day as it is. Description Legislation backed by Sens. Robert Kerrey, Paul Wellstone, and others would scrap or reduce private health insurance and replace it with a single, government payer that would provide insurance for all.

Modeled after the Canadian system, this state-controlled insurance would be financed through payroll, income and other taxes; the government would set annual budge ts and medical fees. Pro Would reduce expense of insurance, doctor and hospital bureaucracy. Would provide universal access. Con Could stifle innovation and research; could create delays for high-tech procedures. Outlook Growing in popularity nationally, but strenuously opposed by insurance and pharmaceutical interests and those who fear the budget impact of a new program.

Tnri rTh si twpi i 1 Minnesota's senators have committed themselves to health care reform. But they attack the problems of cost and access from different perspectives. Below, Democrat Sen. Paul Wellstone tells why he supports the Cana-: dian-style single-payer approach to reform and why he thinks Republican Sen. Dave Durenberger's incremental approach to repairing the current system won't work.

After Wellstone's remarks, Durenberger explains his point of view and tells whats wrong with the single-payer option. Wellstone: The national health insurance program is the most efficient and most equitable path to health care reform. All Americans would be guaranteed access to health care. Everyone would be covered under the same system, instead of the confusing and inefficient patchwork we have today. The federal and state governments would finance the system.

But services would be delivered through the same sources as today. In other words, consumers would have the same choices if not more as they have today in the selection of their health care providers. The key to a single-payer system is that by streamlining die financing and administration of health care we can save billions of dollars each year. In fact, a recent report by the General Accounting Office concluded that the administrative savings alone of a single-payer system would be far more than enough to pay for insuring all of the uninsured and offer the potential for more substantial cost savings in the future. Incremental reform will not solve our problems in large part because it does not allow us to control the growth in health care costs.

We now spend more than 25 percent of our health care dollars on administration and bureaucracy. Many proposals for incremental reform would only make our health care system more confusing and' therefore more costly to administer. In addition, most incremental proposals do not include a structure for allowing us to contain other aspects of health care costs. Durenberger: At a time when the world is looking to us for our markets and our inven-r tive ways of getting things done, we should look to those same strengths to solve our health care crisis. Health care in America is in trouble because the market system is not producing Description Legislation backed by Sen.

William Cohen, R-Maine, and Mitch McConnell, would provide tax credits for people to buy their own insurance. Pro Easily established, could foster competition among insurers. Con Requires well-educated consumers. May not solve problem of rising costs or the uninsured. Outlook Legislation originally proposed by the conservative Heritage Foundation is beginning to draw wider interest.

year giant with many fat appendages, Blue Cross of Minnesota spokesman Earl Johnston describes U.S. health care as "complex and labor-intensive," but "this pluralism provides a broader array of technologies and services and more room for flexibility and innovation." Indeed, for those who are well-insured, U.S. care is the most technologically advanced in the world. And the insurance system, until now, has paid the bills for most people. But discontent is rising.

The country has awakened with alarm to the realization that costs are out of control. In a New York TimesCBS poll last month, 79 percent of those surveyed said the U.S. system is seriously sick. A Wall Street Journal poll found 69 percent of those surveyed (including 62 percent of conservatives) favored providing health care to everyone along the lines of the Canadian system even if it requires a tax increase. But significant change isn't coming soon.

Not according to such health policy leaders as Sen. Dave Duren-berger, and Senate Majority Leader George Mitchell, D-Maine. They say it could be a decade before we see comprehensive reform. But if everyone from left-leaning Democrat Sen. Paul Wellstone of Minnesota to conservative Republican Rep.

Newt Gingrich of Georgia is demanding change, why is there legislative gridlock? Robert Crittenden, a health adviser to the National Governors' Association, told a policy journal recently that "when tackling vested interests, even having 90 percent of the public wanting change is not enough." Consider what reform advocates faced in the Minnesota Legislature last year. "There were more than 70 full-time lobbyists out at the Capitol," said Rep. Paul Ogren, DFL-Aitkin. He said the industry succeeded in watering down universal health care legislation approved by the Legislature last year and it pressed successfully for the governor's veto. (The governor's office said the veto was decided independent of any lobbying).

"They have clout because of their campaign contributions and because they represent many thousands of independent insurance agents in every district," Ogren said. Power politics In Washington, advocates of a Canadian-style system also confront the health lobby's power. "We're talking about industries with trillions of assets and they would clearly suffer under a Canadian-style program," said Dr. David Himmel- stein, a Harvard public health professor and a leading advocate of the Canadian system. "They have enormous clout that goes deeply into the society." Even moderate proposals for change face the gantlet of industry groups.

Sen. Edward Kennedy, can tell you about it. He joined Majority Leader Mitchell this year in introducing a modest overhaul of the system that would help the uninsured by requiring most companies to offer health benefits or pay into a public insurance pool. The bill would provide universal coverage but it is so lacking in structural reform that Kennedy rejected it 20 years ago when a similar version was proposed by President Richard Nixon. But even that mild consensus proposal, which has been endorsed by some labor and business groups, faces significant political opposition.

After two years of stroking labor, the insurance and health care industries, Mitchell said that passing the bill could still take as long as it took to pass acid rain legislation nine years of debate and cajoling. As in the acid rain debate, the conflicts are strong. For example, small-business people oppose requirements that they purchase insurance. Conservatives fear higher taxes. Labor contends that too large a portion of insurance costs may be shifted to workers.

Description Managed care by employers and insurers would more closely scrutinize doctor and hospital treatments. Several companies are moving toward use of written medical treatment guidelines as a way to economize and identify unnecessary treatments. Pro Could help control inflation resulting from overuse of medical facilities and equipment. Con Opponents say the extra scrutiny wouldn't work and would add another layer of expensive bureaucracy to an already over- loaded system. Outlook Fast becoming the option of choice for the private sector that can no longer wait for government action.

pllfld Situation While senior members of Congress shy from national insurance legislation, younger members are gravitating toward it "The situation is very said one congressional staffer. "Members are slack-jawed at the strong messages they are getting from constituents about health care." Rep. Martin Russo, has picked up 37 cosponsors for his Canadian-style bill. One Democratic presidential candidate, Sen. Robert Kerrey, has introduced legislation that would lead to a Canadian-style system.

Others, including Iowa Sen. Tom Harkin and Arkansas Gov. Bill Clinton, are studying it On the Hill, several legislators, including Sens. Thomas Daschle, and James Jeffords, are considering legislation that draws on the Canadian experience. Cast off fear of offending entrenched interests, exhorts Yale professor Theodore Marmor, who visits Washington frequently to discuss the economics of health care.

"Why is it so difficult for us to admit we can learn from other countries?" He contends that health costs can be reduced only through a system that concentrates political and financial authority to set budgets for hospitals and doctor's fees. "We need a change in the rules of the game," Marmor told Congress. "Not just tinkering, but far-reaching change." Incremental steps Tinkering, however, is closer to what Texas Democrat Lloyd Bentsen, chairman of the Senate Finance Committee, and Durenberger have, in mind. Bentsen said that what's really needed is "to take the system apart and put it back together again." But Bentsen said that can't be done without presidential leadership. Political caution, however, has kept President Bush from saying what his plan would be even though he made a campaign promise in 1988 to "provide access to health care for all Americans." In the meantime, Bentsen, like Durenberger, urges incremental reform.

Both senators, key participants in Finance Committee health deliberations, received more of their political action committee contributions in their last campaigns from insurance and health care interests than any other industrial sectors. This year, Durenberger plans to sponsor legislation to subsidize insurance for small businesses and to change the rules for insuring small groups of employees. Durenberger also advocates malpractice insurance reform and tighter regulation of health insurance sales. The industry's Washington representatives have already agreed in principle but not in detail to these steps. Like the insurance and health industries, Durenberger encourages looking to places such as Minnesota where "managed care" plans have reduced costs.

Under such programs, insurers and private companies hire experts who supervise and often second-guess medical decisions. Health maintenance organizations use managed care techniques, and their average rates are running about $800 a year less than conventional coverage. Critics argue that competing insurers won't be able to control costs effec-. tively over the long haul. They say that managed care just adds another layer of administrators to an already bureaucratized business without dealing effectively with the core reasons for runaway health costs.

Unique history Managed care is just the latest wrinkle in America's unique health insurance system. Our method of getting health coverage through work developed accidentally during World War II. As the country was girding for combat the War Labor Board placed a ceiling on wages. Unions then asked for "hidden raises" in the form of company-sponsored health plans. For decades, the system worked well.

Under the Oregon law, coverage would be denied for services deemed less important by an 11-member commission of consumers and health professionals. Hawaii is attracting attention because it has an efficiently run universal health plan. Hawaii requires all businesses to offer insurance to workers and provides state-financed basic health insurance for all those not covered through work. Private-sector advances in Minnesota are attracting international attention. Two Canadian provinces have contracted with Health Risk Management a Minneapolis managed care firm that specializes in developing physician guidelines for treatment of specific ailments.

The company estimates that it can save 10 percent of a company's health costs by using the guidelines and cost-management techniques. Description In the absence of action on the federal level, states could be given more flexibility in using Medicare and Medicaid funds to experiment with health insurance proposals. Legislation encouraging or requiring states to develop health care programs has been introduced by Wellstone and Reps. Martin Sabo, Ed Mar- key, and Bernie Sanders, a Socialist from Vermont. Pro States may be better suited to develop health care programs tailored to regional economic, political and care needs.

Con State-level programs will be unable to reduce costs effectively. More centralized control over budget and policy is necessary. Outlook State legislators across the country are picking up the issue, insurance, medical and pharmaceutical Industries continue to oppose comprehensive legislation that would limit their interests. A Way For Working Adults To Achieve A Degree of Large companies insured workers as a matter of course. Although some smaller ones never did, today more than ISO million Americans are covered through work-related plans.

For years, companies saw health insurance as an invisible cost. But during the 1980s the costs became more and more visible. A recent survey of health insurance at large and medium-sized firms showed that costs to these companies rose 46 percent from 1988 to 1990. And the rates are still climbing. Now, those companies have joined the chorus for reform.

Other countries evolved far differently. Where the United States has 1,200 competing insurers, other developed nations have standard universal coverage with centralized mechanisms to control costs. So there are choices. Adopt a Canadian-style system and the United States might check its double-digit annual health cost increase while providing access to the uninsured. But this could mean more waiting for certain procedures and new technologies.

Health Secretary Louis Sullivan and others say we should preserve our competitive system and move to gradual reform using managed care techniques. There is, at least near-unanimous sentiment that something must be done. Health care costs are rising more than 10 percent a year, twice the rate of economic growth. Without change, the number of people without insurance probably will double in five years, to 75 million. U.S.

products most likely will become less competitive and more workers will be pushed toward poverty by the burden of health costs. Which route to reform? It's a choice the country will soon have to make. (Research assistance for this series was provided by the staff of the Star Tribune library and news assistant Dorothy Meyer.) Success Find your next job in the easier-to-use classifieds. StarTribune College Paul Minnesota 55112 800-255-8706 States are leading way to innovative health care Finishing college through Bethel's Program in Adult College Education (PACE) will open the door to new career opportunities and give you the satisfaction of obtaining your bachelor's degree. PACE is specifically designed for adus.

Classes meet just one night a week and PACE takes months less than traditional college programs. PACE also maintains Bethel's tradition of academic excellence in a dynamic Christian environment and encourages you to apply learning to your professional interests. PACE offers majors in Organizational Studies, Business Management and Nursing. By Tom Hamburger Washington Bureau Correspondent Washington, D.C. With Washington moving gingerly toward health care reform, activists have been looking to the states, where some of most dramatic and controversial experiments have started.

In Oregon, an emotional debate has begun over a "rationing" law passed this year that could deny payment under Medicaid for procedures that are not deemed "cost-effective." By being more discriminating, the state plans to provide basic health care for all Oregonians with incomes below the federal poverty level, an additional 120,000 people. Previously, Oregon, like most other states, had provided coverage for only a portion of those in poverty. Last month, a group of Minnesota's largest health maintenance organizations proposed a wide-ranging insurance plan that guarantees coverage for all workers and provides care for Minnesota's 370,000 uninsured and underinsured citizens. The proposal calls for a 6 percent surcharge on inpatient hospital services. The proposal is gaining attention around the country not only because it is far-reaching but because it is a sign that care providers are willing to move aggressively to attack the access problem, even without the support of hospital or doctor groups.

The proposal is sure to get attention in the 1992 legislative session. This year, the Legislature adopted a health insurance program that would eventually cover all uninsured and under-insured residents. But Gov. Arne Carlson vetoed the measure because it had no specific source of funding. Proponents vow to override the veto next session.

The Hennepin County Medical Center proposes its own cure to the nation's access and cost problems. The public hospital found ways to save money and cover the uninsured by opening its own HMO, Metropolitan Health Plan, that provides services to a wide range of patients and competes successfully with private HMOs. Hennepin developed inpa-tient-care guidelines that have reduced costs up to 30 percent for some procedures. Rep. Martin Sabo, argues that health care programs can be administered well at the state level For the past several years, he has proposed a state-federal plan to provide health insurance for all Americans by requiring states to set up insurance pools for uninsured individuals and businesses.

The program would be funded by a 1.4S percent tax on unearned income. Bethel 3900 Bethel Drive, St 612-638-6423.