An estimated 18,000 people in the United States die unnecessarily each year because they have no health insurance, according to the nonprofit Institute of Medicine of the National Academies.
Robin Salerno is trying her best to not become one of them. But Salerno has adrenal cancer, no insurance and few options.
A resident of Wolcott, Wayne County, she works six days a week at a local diner, earning about $17,000 a year. That’s too much to qualify for Medicaid or Family Health Plus.
Salerno might qualify for Healthy NY, an insurance program for small businesses and workers whose jobs don’t offer insurance, but services for her cancer might not be covered for a year.
"If I wait a year, I might not be around," said Salerno, 50.
The cheapest private-market plan in Wayne County would cost her $767 a month — half of her monthly income.
Instead, she has been paying out-of-pocket for medications, doctor’s visits and such tests as MRIs and CT scans. Portions of her tests have been paid by the U.S. Department of Health and Human Services’ Hill Burton funds program for free or low-cost care — and by financial help from her mother.
Salerno is not alone in her struggle with the U.S. health-care system. Grassroots groups across the state and nation have been working to reform the health-care system, which some say is becoming increasingly unaffordable due to rising health costs.
This year’s presidential campaign also has fueled the debate, with both presumptive presidential nominees drafting health-care reform plans, details of which are available on their respective Web sites.
Presumptive Republican nominee John McCain’s plan would allow consumers to direct how their health-care dollars would be used, create a guaranteed coverage plan for the uninsured and sick, create a tax credit to offset the cost of insurance, and expand the benefits of health-savings accounts.
Presumptive Democratic nominee Barack Obama’s plan would create a national health plan available to all and funded in part by employers who do not offer health insurance. He would also implement a health-insurance exchange that would help individuals to buy private insurance plans.
New York state also took up the issue in July 2007 when its departments of health and insurance formed the Partnership for Coverage panel to study obstacles to health coverage. According to its Web site at www.partnership4coverage.ny.gov, the panel’s ultimate goal is to develop, evaluate and recommend proposals for achieving universal coverage by building on existing programs.
The panel led hearings across the state during the fall of 2007.
"While many promoted expansion of public programs, others cautioned about the cost of such expansions, the impact on the state budget and the public tax burden and concern about replacing private dollars with public dollars," stated the panel’s May 28 report to Gov. David Paterson, summarizing the findings of its hearings.
The report notes that the Washington, D.C.-based Urban Institute was hired in December as a consultant to develop and study several models of proposals for universal coverage. As part of their work with the Partnership for Coverage, the state departments of health and insurance also are considering ways to contain health-care costs.
The state Catholic conference has also recommended this approach.
"Attempts to address the issue of the uninsured cannot succeed unless and until we examine the causes for the high costs of health services," said Ron Guglielmo, director for health care for the New York State Catholic Conference, during testimony to the state panel.
According to the Kaiser Family Foundation, U.S. health-care spending grew 6.7 percent in 2006 to about $7,026 per resident, accounting for 16 percent of the nation’s gross domestic product. Per-capita health-care spending has more than doubled since 1990. And, according to the Centers for Medicare and Medicaid Services, health-care spending is projected to rise to more than $12,750 per person by 2016.
Longer life spans, more intensive treatment of chronic illness, increasingly expensive prescription drugs and technology, an aging population and higher administrative costs are driving these cost increases, the foundation said.
Fidelis Care, the New York state Catholic bishops’ health-insurance plan, has provided thousands of New Yorkers with health coverage through Child Health Plus, Family Health Plus and Medicaid programs. Yet millions of state residents aren’t eligible for these programs and still cannot afford private insurance, acknowledged Mark Lane, Fidelis Care president and CEO.
"There are 3 million people in New York state who can’t afford (insurance) or who have decided not to have it," Lane said. "For the vast majority, affordability is an issue."
No easy answers
Lane said there are several ways to make health insurance more affordable, but that each poses its own combination of benefits and drawbacks. Among the possible trade-offs inherent in the various plans are reducing benefits to cover more people; capping medical costs and freezing providers’ reimbursement rates; mandating that everyone obtain insurance; and rationing care to limit high-cost or high-risk procedures.
"There are no easy solutions," he said.
The high administrative cost of health insurance is the target of several reform proposals. Dr. Leon N. Zoghlin of Hilton, a retired family-practice physician who volunteers at the St. Joseph’s Neighborhood Center on South Avenue in Rochester, contends that insurance-company bureaucracy and profit margins have led to higher costs for medical care.
Zoghlin is a member of Physicians for a National Health Program, which advocates a single-payer system in which the government or a single nonprofit entity would pay private doctors and hospitals to deliver health care.
Critics of single-payer systems charge that such a system would usher in socialized medicine, but Zoghlin notes that single-payer health proposals do not call for the government to own all the resources and means for production and distribution, as it does with respect to the U.S. Veteran’s Administration.
"We would funnel all our funds through the government, but care would be delivered by private sources or community not-for-profit sources, like hospitals," Zoghlin said.
Zoghlin points to the single-payer insurance systems of many other developed countries and the lower administrative costs of Medicare, which is a single-payer system for the elderly and disabled, as compared to the costs of private insurance. He said he believes businesses are warming to a single-payer system because of spiraling health-insurance costs, and that doctors increasingly support the idea due to frustration with insurance-company denials and low reimbursements.
Yet some worry that proposals calling for increased government control over health care would lead to a loss of quality, a rationing of care, longer wait times or other negative consequences.
"I’m fearful that if the government takes over the health industry, then that would be the end of it," said Dick Hastings of Perinton, who attended a May 8 talk in Rochester on health-care reform.
For its part, the Partnership for Coverage panel said advocates of a single-payer system need to provide more specifics on how such a model would operate in New York state.
Insurers told the panel that the state’s restrictive regulations on health-maintenance organizations and other mandates have made coverage plans for small businesses and individuals unaffordable. Empire and Excellus Blue Cross Blue Shield, for example, presented proposals to change state regulations to allow HMOs to merge the markets for individuals and small businesses, potentially decreasing the cost of such plans, and to add lower-priced consumer-directed plans.
Rather than endorsing specific plans for reform, such organizations as the Catholic Health Association and the American Cancer Society are advocating standards for reform. Not surprisingly, the Catholic Health Association frames the debate in moral terms.
"This debate really speaks to our values and national priorities," said Jeff Tieman, CHA’s senior director of health-reform initiatives, during a May 8 talk as part of the Downtown Community Forum at St. Mary Parish in Rochester.
Tieman delivered similar talks to the board and management of St. Joseph’s Hospital in Elmira May 8 and to the Catholic Media Convention in Toronto, Canada, May 29.
Tieman noted that the consequences of allowing large numbers of people to remain uninsured or underinsured include delayed treatment; expensive and inappropriate treatment in emergency rooms; and emotional and economic tolls on families. About half of bankruptcies are due to medical debt, he said, and 80 percent of the uninsured are members of working families.
CHA asserts that health care should be available and accessible to all; oriented toward health and prevention; sufficiently and fairly financed; transparent and driven by consensus; patient centered; and safe, effective and designed to deliver quality.
"This is a matter of community health and well-being," Tieman said May 29. "We don’t want to be surrounded by sick people. We want to be surrounded by people who are healthy."
Hillary Clarke, regional advocacy director and federal-issues manager for the Eastern Division of the American Cancer Society, said her agency’s standards for evaluating health-care proposals are: adequacy of coverage, availability based on medical history and inclusive eligibility standards, affordability for those with limited means and administrative simplicity. The society was one of many organizations that presented its agenda for health-care reform to the Partnership for Coverage panel.
In the case of cancer and other debilitating diseases, Clarke noted that even those who have insurance may struggle to afford coverage or lose their coverage if they are unable to work due to treatments.
"Any of us is one bad diagnosis away from a bad financial disaster," Clarke said.
Some clergy and health representatives from the Greater Rochester Community of Churches began developing their own standards for health-care reform during a June 10 breakfast at Colgate Rochester Crozier Divinity School. The breakfast was sponsored by the Healthcare Education Project, which is a collaboration of Greater New York Hospital Association and the 1199 SEIU Healthcare Workers East, a union of health-care workers.
One advocate suggested the group work together on systemic change.
"I believe we make no headway in improving health care by blaming or accusing anybody or any health-care institution," observed Sister of St. Joseph Christine Wagner, director of St. Joseph’s Neighborhood Center on South Avenue in Rochester.
Sister Wagner told of a physician from the Democratic Republic of Congo who toured the center. He had been tasked with rebuilding his country’s health-care system after it was destroyed by civil war.
His perspective helped her reconsider her ministry, she said.
"We are blessed with the resources we have," she said. "All we need to do is put these resources together."