National Health Insurance (NHI)
Recently, there has been renewed interest in national health insurance as a solution to our health care crisis. President Carter and the strongly Democratic 95th Congress have pledged that passage of NHI legislation will be a top priority for this administration.
The American College of Nurse-Midwives has not yet formulated a position on this important question. We have only said that nurse-mid-wives should be included in any national health insurance bill.
The many different national health insurance proposals represent widely divergent approaches to health care delivery. The concepts and priorities underlying any ultimate legislation will profoundly affect the health and well-being of our entire nation.
As an important group of health care providers, with voice and influence well in excess of our numbers, nurse-midwives must study, discuss, and understand the complex issues involved in the NHI proposals. Only then can we unite on an informed basis, and support a position which will bring about the most progressive changes in our country's health care.
The History of NHI
The USA is the only industrialized country without a general program of government health insurance or a government-administered health service. But the idea of NHI has been around since at least 1912, when an NHI plank was part of Teddy Roosevelt's presidential campaign. The concept has been repeatedly raised, and always defeated by powerful forces on the health and political scenes: notably by organized medicine, organized hospitals, and the insurance industry.
At least 10 NHI proposals reached Congress between 1939–1950. In response, the American Medical Association began a $5,000,000 advertising campaign to defeat NHI in 1949. By equating NHI with communism and building on the McCarthy hysteria of the period, they kept NHI a dead issue through the 1950's.
The 1950's also saw the growth of a giant, private US health insurance industry. These companies would usually not insure the indigent or the aged. Thus, in 1960, a new NHI drive began, concentrating on the poor and the elderly. This culminated in the passage of Medicare and Medicaid in 1965.
The 1970's have seen at least 20 NHI bills submitted to Congress, representing every major interest group in the health field. The possibility of passagege of NHI legislation has waxed and waned with the political and economic climate.
Prospects for the Present
Now, President Carter and Congress say they are committed to quick passage of NHI legislation. It's safe to assume that not one of the many bills under consideration could be passed in its entirety; rather, bits and pieces from many will probably be combined into a final compromise - different from any of the original bills.
Rather than discussing the pros and cons of specific bills, it will be more useful to address two more general objectives: first, to formulate criteria by which to judge any NHI bill; and secondly, to expose the underlying network of power relationships and vested interests that invisibly determine the structure of the debate.
What to Look for In a NHI Proposal
- 1)Who is covered?— Is coverage restricted to certain groups of people, or is everyone included? Is coverage voluntary or mandatory?
- 2)What are the benefits?— Are all medical expenses paid for or only certain kinds? Do large out-of-pocket expenses remain, in the form of co-insurance, deductibiss, and limitations on coverage? Co-insurance means the patient pays a specified percentage of the hospital bill (usually around 25%), while the insurance pays the rest. A deductible means the patient pays a specified amount on medical care before the insurance takes over (typically, $150 per person or $400 for a family of four). A limitation means that the insurance pays for only a specified number of days in the hospital or medical visits per year. Most NHI proposals rely heavily on co-insurance, deductibles, and limitations as a way of keeping costs down. However, these mechanisms mean that people must pay up to thousands of dollars in medical bills before their insurance takes effect. They all discourage people (especially poorer people) from seeking health care - especially preventive care.
- 3)How is it finanaced?— NHI could be financed by regressive or progressive ways of collecting money. Regressive payment means that poorer people pay a greater portion of their income than richer people do. Social security payments, payroll taxes, and insurance premiums are all examples of regressive financing. If NHI is voluntary and financed by regressive payments, many poorer people will not be able to afford coverage. Progressive payment means that richer people pay a higher percentage of their income than poorer people do, as with a graduated income tax without loopholes.— Does the program use public funds to subsidize private insurance companies (e.g. Blue Cross, Blue Shield)?— Does the program allow public funds to be used for profit-making by health corporations like hospitals, drug companies, and medical supply houses?— Is reimbursement to hospitals and health care providers made in a way that will cause more accountability for public funds?— Is the plan adequately financed to provide quality health care?
- 4)How is it administered?— Is administration under public control, or is it controlled by profit-making health care corporations?— What is the role of health providers and consumers?— How centralized/decentralized is the administration?— What are the provisions for cost and quality control?
- 5)Is access to service guaranteed?— Does the program attempt tc reorganize health care delivery to be more rational and responsive to human needs?— Does it include provisions that try to improve the overall supply, geographic distribution, and organization of health services?
The First Experiments with NHI: Medicare and Medicaid
Medicare and Medicaid are limited forerunners of national health insurance. The great problems of these programs have caused many people to look skeptically at NHI, fearing that the same mistakes would only be repeated on a grander scale.
Three effects of Medicare and Medicaid stand out most prominently:
- 1)The programs have caused medical costs to skyrocket — not only for program beneficiaries, but for the entire population.
- 2)Huge profits have accrued to doctors, hospitals, medical businesses, and insurance companies.
- 3)The people the programs were designed for have not been well served. As payments to providers have risen, program benefits have been steadily cut, and beneficiaries have had to pay increased costs. Thus, the elderly today pay more out-of-pocket medical expenses per year than they did before Medicare began. More than 20 million of the poorest people in this country are not even covered by Medicaid; and those who are covered f[Text missing in PDF] more and more cutbacks in services and limitations on eligibilit.
Many of the dismal effects of Medicare and Medicaid can be traced to the assumptions that structured the programs from their beginnings. The programs were created with the intent of preserving the status quo: building on existing, problem-ridden government benefit programs (social security and welfare), and enhancing the power and profits of the private health industry. Hospitals, doctors, and nursing homes were allowed to decide what to charge, and were paid through private insurance companies, usually Blue Cross and Blue Shield, who made little or no attempt to control costs. Under this arrangement, profits to providers rather than decent health care for beneficiaries became the guiding priority.
Is National Health Insurance The Answer?
It is often assumed that some form of national health insurance is the only possible solution to our health care crisis. The NHI proposals before Congress differ on who pays for and provides the insurance, and what services are covered. But can insurance solve our health care problems?
All the NHI proposals are basically government guarantees of payment to providers of health services (doctors and hospitals). With few exceptions, the NHI proposals would use profit-making insurance agencies to dispense public funds to profit-making health care providers. Under such an arrangement, the spiraling costs and inadequate services found with Medicare and Medicaid could become even worse.
National health insurance cannot fundamentally restructure our health care delivery system. It cannot guarantee access to health services, or redistribute medical workers and supplies according to need around the country. It cannot force health workers and hospitals to give high-quality, humane health care it is very doubtful that it can control inflationary costs and profiteering.
In short, it seems quite unrealistic to hope to change the nature of health care by having the same vested interests manipulating greater sums of money towards the profit-making ends they have been pursuing all along.
Progressive-minded people have pointed a way out of this dilemma by proposing not national health insurance, but a national health system for our country. The basis of this idea, which is being carried out in different ways by many nations, is that it is a necessary function of a national government to provide health care for all of its people. Under a national health system, the government would finance and deliver health care. It would set up health facilities, train medical workers, and establish priorities to meet the health needs of the entire country. Such a system would be governed not by the goals of private interests, but by democratic public authority. Profit-making would be prohibited on all levels, and the system would be financed by a progressive tax structure, in which large corporations and the rich would pay most. Our present two-class health system would be replaced by a one-class, public system, run by, for, and accountable to the people of the nation.
An effective national health service, or even a relatively comprehensive national health insurance program, seem very distant. Changing our health system into one that really meets human needs is a long, difficult process. The first step is understanding why things are the way they are: who is shaping and benefitting from health care as it is now? What would a truly people-oriented health system look like? Our ideas will be a basis for organizing for change, and our organizing will further develop our ideas in the context of concrete struggles.
Grateful acknowledgement is extended to the Health Policy Advisory Council for providing information pertinent to this editorial.