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Following the Flurry of Health Care Legislation, Where Next?:
An Update on Health Care in the U.S.
The Comstock Club of California
Sacramento, California
Wednesday, November 10, 1999
12:00 P.M.

Nancy W. Dickey, MD
Immediate-Past President
American Medical Association

Good afternoon. And thank you for that warm welcome. It's great to be back here again visiting with all of you. Because you are a premier forum for thoughts and ideas, I'm please to share a few thoughts and a couple of ideas.

Health care legislation reminds me of the highway system out here: Exit ramps diverting you from the real destination. If you miss a sign, you may have to go well out of your way to get back.

Now when I stood before this group a little more than a year ago, I described the flaws in America's system of health care, and I outlined some of the AMA's ideas for reforming that system. And in many ways, the AMA was ahead of the curve then on these issues - and I believe we still are.

But that doesn't mean the issues have gone away - far from it. And one of the issues may be: How - when - did health care become such a topic of regulation and legislation? Somehow, over a couple of decades, it has moved from our kitchen tables to one of the major issues at Congressional Hearing tables.

In the last year, we've seen a flurry of health care legislation from Washington - and we hope, in the end, it won't end up signifying nothing - so far, it's been mostly sound and fury. And fury may indeed be the operative word - at least when it comes to what the American people are feeling about the stake of our health care system right now. So today, I'd like to share with you some actions that are being taken to address the issues concerning health care. And let you know how you can add your voice to that of the AMA and other concerned organizations - to improve the health care picture for yourselves - and for all Americans.

Let me tell you a little about an article I read this weekend that sums it up pretty well. It appeared in the Washington Post -- but I'm sure it will be reprinted all over - and it's called "What Worries Americans." The results may surprise you. The article discusses a survey taken last month throughout the United States in which Americans all said that their greatest single concern - from a list of 51 possible worries - is that:

"Insurance companies are making decisions about medical care that doctors and patients should be making."

Imagine -- Two-thirds of the people responding to this survey chose that as their number one concern. Republicans, Democrats and Independents alike. More than education. More than taxes. More than any of the political hot buttons that are always pushed coming into an election year. In fact, three out of the top five concerns for all political groups were related to health care. Concerns about HMOs were at the top of each list of worries - but other health issues appeared as well -- public health issues like drugs, the threat of school violence and other concerns, like the elderly not getting medicines and the possibility of losing one's own medical benefits.

No, Americans aren't happy with the current health care marketplace - but they're petrified of being shut out of it. In fact, in another widely-reported, bipartisan survey taken this fall, pollsters found increasing support for using budget surpluses to help the uninsured. Some 44 million at last count. That concern is so great that these Americans say they'd be willing to pay higher taxes - of up to $50 per year -- to help those who lack health care insurance coverage. And a majority of people have said they'd be more likely to vote for a candidate who talks about having real concern - and real solution -- for the uninsured.

Recently, we've even been hearing Presidential candidates in the 2000 race raise the issue of health care reform. Not all of them - but at least a beginning. But you can be sure that all the candidates have read these polls - and they have to know that health care - and particularly the might of the HMOs and the plight of the uninsured - have returned to the top of the public agenda.

It's possible that at least some of those concerned Americans in the surveys were reacting to a recent, prominent news story - actually very good news -- and one that has made many a headline -- about the passage in the House of Representatives of the Norwood-Dingell Patients' Bill of Rights legislation. There was extensive coverage of that story - and the reason why it was considered so significant is because the AMA and other patient advocates had to beat back a very expensive and widespread insurance industry attack to do it.

We consider the passage of Norwood-Dingell to be one of the most significant legislative victories for patients in congressional history. It is legislation aimed at providing patients needed protections from managed care abuses. Providing for appeal when care is denied. Holding plans accountable when they make decisions that jeopardize your care. And even giving you access to emergency room services when you need them.

This bipartisan House bill - the Norwood-Dingell Patients' Rights Bill -- delivers the essential protections patients and voters are demanding. Doctors will be able to make medical decisions. Health plans will be held accountable for their actions. And patients can appeal if their care is delayed or denied. But make no mistake - the opposition is strong. The for-profit health plans out there don't want things to change. They want to pursue their profit margins without paying the piper.

Of course now, that House bill that we endorsed, and the Senate bill that we opposed are in conference committee. And with the Congress leaving for its winter recess today - and not coming back until January - we won't have a final bill until 2000 - if then. Because there are some political shenanigans involved in that conference committee - with most of the conferees appointed having opposed the bill and only one who actually voted for the Norwood-Dingell bill.

I promise you, though, that American physicians - led by the AMA -- will continue a vigilant fight on all fronts. Not just to make sure a strong bill emerges from conference - but to continue to support our patients against the special interest insurance lobby. A lobby that spent more than $100 million dollars in the past year to make sure that the strong, bipartisan Norwood-Dingell bill would not be passed. What were they so afraid of? In the final analysis, it all boils down to a single word. It all comes down to: accountability. In short, we want it. Insurance companies don't.

When they harm a patient, they want to walk away - and say sorry, what a shame - that's just too bad. But we think patients deserve more than that. For too long now, most insurance companies have been exempt from accountability. It's time to reach out to our senators and representatives, and make it clear - America's patients and physicians want this accountability. And, we want it now. We think that if a health plan does something to harm our patients - then they should have to make it right.

The insurance companies are so hell-bent on their bottom line - that they have already diverted more than $100 million from patient care to fund an irresponsible propaganda campaign to scare patients and intimidate Congress in their efforts to pass real patient protections.

Make no mistake, the threat of accountability is a very big stick. So big, in fact, that just this week, one major insurance company voluntarily issued a statement that it will stop putting bureaucrats ahead of doctors when it comes to the needs of patients. United Health Care says they're going to stop spending money on bureaucratic wrangling with physicians over medical decision-making. But one insurance company alone - big as it is -- doesn't answer the needs of the two-thirds of Americans who responded to that Washington Post survey last month. And that's why a Patients' Bill of Rights is needed.

Before House passage, the AMA did everything possible to generate a groundswell of grassroots support for Norwood-Dingell. We asked physicians all over the country to talk to their representatives. And they came through for us. Now, we need your help. As well as continued help from physicians. Because in this great country, it's the communication directly from you, the people, to them, the lawmakers, that is the fundamental mainspring of democracy.

You say: Why now? Because the next few weeks - through early 2000 - will be a negotiating time to pick what parts of the very good Norwood-Dingell Bill and what parts of the very limited Senate Bill actually get mashed together and sent to the President for his signature. Your Congressmen, your Senators need to know that you expect them to exert leverage on the small group of conference committee members.

But, when you're speaking to your representatives, don't forget another patient-physician issue that's been hot this Congressional session, in addition to the Patients' Bill of Rights - and that's the Campbell Bill. This is another piece of legislation whose progress Congress is postponing until after next January. The Campbell Bill would allow physicians to negotiate collectively with health plans regarding contract terms that affect patient care. In effect, this bill restores physicians' ability to advocate for quality care for our patients, and strengthens the physician-patient relationship. From a slow start, the bill now has broad bipartisan support from many parts of the country. And physicians' grassroots efforts are helping bring the issue to the forefront in Congress. In fact, largely due to an aggressive campaign by the AMA and our Federation partners, 173 legislators have joined on as co-sponsors of HR 1304.

So if you're part of that two-thirds majority of American citizens who are concerned about the state of health care in this country - and if you're here today, you probably are - please get in touch with your representatives in Congress about the Campbell bill as well.

You know, when I was in medical school, many years ago - I had no idea that the profession I had chosen would become - in my lifetime - so highly regulated and publicly legislated. And I would imagine that you had no inkling of that as patients. That Congress would have to legislate even good news decisions like the recent Pain Relief Promotion Act - which encourages doctors to treat pain adequately and effectively - but prohibits assisted suicide. Or last week's adjustment to the Balanced Budget Act - that finally has provided some more reasonable coverage for home health, hospice and nursing care. The payments under Medicare for all these services were slashed in 1997 - last week's adjustment will not make them whole, but should keep them from closing their doors.

Bill after bill -- that is why it is imperative to be in touch with legislators concerning these health care issues. There are many more patients in the United States than there are insurance companies - but the insurance companies' voices are the ones that are being heard. And if we want to get the message across - we all have to join in and let those people who are making the laws know just what we're worried about. Because, I tell you, some days it sure seems as if like those politicians in Washington - just don't have a clue.

The intensity of public concerns about health care seem strange when you think that most people agree that our country has the best medical care in the world. Of course, not every American gets to experience the benefits of that care. As I mentioned a moment ago - 44 million Americans - 16 percent of our population -- do not have health insurance coverage at all. Even though as a nation, we spend $1.1 trillion dollars in health care each year. That's $3,700 dollars for each and every person living in our nation. Even though, last year, the organizations that employ Americans spent more than $310 billion dollars on health benefits. And even though, in absolute numbers, we spend two to three times what every other country in the world spends on health care.

So, while a majority of Americans do have health insurance coverage, a significant minority does not. And the situation here in California, just as in my home state of Texas, is a lot worse than it is in other parts of the country. The number of uninsured in our states is a lot bigger than the national average: 24.5 percent of the population in Texas; 22.1 percent here in California. And California's number of uninsured is rising by almost 50,000 per month - almost all of whom are employed.

No wonder so many Americans in those polls are afraid of losing their health insurance - it's happening all around them. In fact, according to the California Medical Association, employer-financed health insurance coverage has dropped from 75 percent of employees covered fifteen years ago - to only 58 percent workforce coverage today. And just half of the children of those who are employed are covered by health insurance. And California is not alone. The employer-funded insurance coverage that Americans have relied upon for the past fifty or so years is a system that is fast unraveling.

Now before I go more deeply into the actions being taking to solve this problem of universal coverage, let me define some terms. First of all, access. I don't want you to confuse this question of insurance coverage with access to health care. Because, in fact, every American has access to health care. Anyone can come into our emergency rooms. We'll take care of their problems. The medical and health communities work hard to make sure that patients can receive care - particularly critical care - when they need it. For instance, the Shriners Hospital here in Sacramento -- and Shriners Hospitals across the country -- open their doors not only to the insured, but to the uninsured. And in teaching hospitals, 30 percent of all admissions are medically indigent patients.

The physicians out there in the community are doing their part as well. They offer a wide variety of free and sliding-scale programs. Actually, about 75 percent of all physicians treat some of their patients for free. And in communities across the country, hundreds of them, free or low-priced, sliding-scale clinics have been set up.

During my last three years of travel for the AMA, I've made it a point when I've been in a community to try to visit free clinics. In fact, I had an opportunity to visit Sacramento's own Spirit Clinic. You meet a phenomenal quality of people there. Lots and lots of doctors who are working there because they have a mission to treat people who wouldn't otherwise be treated. These doctors and the nurses and other practitioners who work with them are on a caliber with those who work for the international group that just won the Nobel Peace Prize - Doctors Without Borders. Except they work within the borders of our nation, one of the wealthiest on earth.

But it is access late in the disease, often at the most expensive time and site. We too often refuse to provide the patient a Pap smear. But we do assure treatment of her cervical cancer. We won't provide regular monitoring of the asthmatic. But we will pay for the ICU when a crisis occurs. And this occurs at a cost - cost in missed education, as youngsters miss school due to preventable illnesses. Cost to employers as workers' absenteeism rises due to chronic illness or early death of a trained employee. And cost to everyone who pays part of the cost shift, passing on the cost of caring for the uninsured.

So when I speak of universal coverage, I'm not really speaking about access, although it is more an issue than we like to admit. But you've got to be careful when you talk about universal coverage, because everybody assumes you're talking about a government system. You see, there are lots of ways to provide the solution to the uninsured and one of them happens to be a government-driven health care system, like the ones in Canada, or Sweden, or Britain. The government-driven system ought to be on the table to be talked about, not because I embrace it - I don't - but because it's such an obvious possible solution. That kind of system might be working for them - but few believe that it is the appropriate solution here in our large, diverse and market-driven nation.

But really the issue we're talking about here in the United States is everybody being covered by health care insurance. Everyone having access to care and a way to pay for that care. Now the AMA has had policy backing the issue of universal coverage for more than a decade. We believe that the health of the American people is a national asset - that the success of our nation depends upon that asset. And that one of the most important investments we can make for our future lies in ensuring that all Americans are included in our health care system. And in recognizing that if we do not address the issue, there is measurable cost to the country in not ensuring all Americans are included in our health system.

But obviously, an important part of forging the solution to this problem of lack of coverage is how to pay for it. It's clear that the solution to universal coverage - just as I explained it here last year -- should be based on individual contributions as well as employer contributions, and that the tax system should be reformed, with refundable tax credits for whoever pays the premium.

Structuring tax credits would give relief to those who need to buy insurance, level the playing field for the self-employed, and motivate many people who up until this point have said, "Why spend the money on insurance when I hardly have enough for the necessities?"

We also strongly believe that the solution should consider building on existing and already funded programs for low-income families such as Medicaid/CHIP programs at the state level. Here in California, CHIP - the federally mandated Children's Health Insurance Program - is known as Healthy Families, and Medicaid is, of course, MediCal. Some work is sorely needed on MediCal, of course, where $1 billion dollars is spent per year just enrolling people. And where, I'm told, government workers are celebrating that they've simplified the onerous 25-page enrollment application to a mere 22 pages. But if we cannot or will not achieve universal coverage a time when our economy is as strong as it has been in this decade, then we certainly will not be inspired to do it when we get into a time that dollars are short and there is no surplus to fund our decisions.

By now, you may be wondering why I'm telling all of you about these solutions - and the problems that are behind them. And it's because I believe there is something you can do about them. Because the Comstock Club is one of America's key forums for opinion leaders. And that means, no doubt that you're going to be hearing from plenty of the candidates for the 2000 election. So when they come here to talk to you - I want you to do something, as patients and members of the American public - I want you to hold their feet to the fire. Demand the same kind of accountability from them that the Patients' Bill of Rights is demanding from the insurance companies. Demand to know where they stand on the critical health care issues today. Issues like universal coverage. Medical decision-making. And other key issues like Medicare reform and prescription coverage for Medicare patients. And tell them your vote depends upon their answers.

Surely in a country as rich and prosperous as ours, a country that has made such huge progress in curing cancer, learning how to do transplants, a country that has moved HIV from a death sentence to almost a chronic illness for most people - surely this country can and must do better in terms of making sure that our health care system works for everyone - that everyone has access to care and a way to pay for that care.

With your support we can, indeed, find solutions that we can live with as taxpayers, as employers and employees, and as Americans. We can expand coverage, and I think we will also find ways to bring down costs or at least level out the costs. And we can remove medical decision-making from the hands of the insurance companies - and put it back where it truly belongs - in the hands of the patients and physicians of America.

You know, we can talk until we're blue in the face about different approaches, different efforts, political and social issues involved. But the bottom line is this: when a loved one is sick - the world begins at the sickbed. Because at a time like that, nothing else matters, not politics, not insurance plans. All that matters is that our loved one gets the care he or she needs. Making our health care system work for all us is ultimately possible if we work together. This is something we can do. Something we must do; something we will do. Not just for ourselves and our families, our employers and our employees, our friends and our communities, but so we can all live together in a society where every one of us - each and every American - will have the benefits of the finest health care in the world.

Well, that flurry of legislation: Patients' Bill of Rights, Balanced Budget Act, Campbell Bill, Insurance for everyone. Following the flurry - Where are we? We hold in our hands many promises - like a bill through one House of Congress, but no delivery on the promises yet. We see emerging preeminence of the issue - but few commitments to solutions. And we come back to the possibility of you setting the agenda.

Regulation and legislation are likely to continue in health care, but like a California freeway interchange, they could peel off in any direction. Then you the voters, the thought leaders, can pick up the map and be the navigators. The future of our health system is largely in your hands.

Thank you - and welcome aboard.


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