We are still on the topic of health care, more accurately health INSURANCE, even more accurately health care ACCESS reform. The GOP is still harping on this and doing their best to sabotage the very program modeled on that which their previous nominee for the office of president, Meandering Mitt bragged about until he stood a chance of nomination, at which time he dropped the subject like a hot rock and reissued his book with any references to Romneycare MAGICALLY revised and edited. More on this later. Junius Fils The American People 23 August, 2011 Ladies and Gentlemen: Given his small government ideology, Ronald Reagan could not have been expected to do much in the way of health care reform and he didnt. His basic tactic was to cut anything and everything concerning any government activity except defense. His administration folded 22 separate health programs into four block grants for the states (maternal and child health, mental health, primary care, and preventative health). Reagan also proposed capping the growth of the federal share of Medicaid funds at 5 percent, but this was blocked by Congress. In 1982 Congress enacted the Tax Equity and Fiscal Responsibility Act (TEFRA), which contained several measures to control Medicare costs. Included were strict limits on Medicare reimbursement to hospitals , and new incentives to encourage HMOs to enroll Medicare beneficiaries. {Both quotes from Quadagno, Jill. One Nation, Uninsured, Why The U.S. Has No National Health Insurance. New York: Oxford University Press, 2005. (P), Page 133} As part of amendments to the Social Security Act, in 1983, a cost control measure was enacted which, instead of reimbursing hospitals after the fact, hospitals would receive a predetermined amount based on what treatment was provided. (Quadagno, Page 135) Hospitals responded by shifting any costs not covered to other insurers, causing the other insurers to go up in flames, even though the predetermined amounts were later increased. Any attempt to establish reimbursement caps was, as usual, violently opposed by the medical industry. The industry, however, was no longer monolithic and those insurers (and their customers) who had their costs increased were no longer a guaranteed ally when it came to opposition to any government involvement in the process. Corporations, to save money, began downsizing the insurance programs formerly provided to their employees, a process which hurt the employee and his or her family, especially those employees with chronic or severe conditions or preexisting conditions. One response by the Reagan administration was the Medicare Catastrophic Coverage Act of 1988, an act which covered just what its name implies and which did not address the problem of long term care. Opposition, as usual, centered on the supposed creation of some sort of government monopoly and unfair competition with private providers. The bill, which was to be financed entirely by the elderly, capped the amount beneficiaries would have to pay for hospital and physician care at $2,146 per year and cover many other costs currently paid by individually purchased Medigap policies or by employees, including prescription drugs, mammography screening, hospice care, and even caregiver support for the frail elderly. (Quadagnoa, Page 153) The pharmaceutical industry opposed the drug coverage provisions, the Chamber of Commerce yelled SOCIALISM, and a rather sleazy organization called the National Committee to Preserve Social Security and Medicare screamed about tax increases. Due to a well-orchestrated campaign of misinformation, Congress repealed the act one year after they had passed it. This repeal hurt the business community because it prevented any mitigation in the health care costs they currently carried. For that reason, many businesses turned to the concept of managed care or HMOs. The idea of managed care is, in itself, not a bad one. Companies with programs providing health insurance to their employees sought out insurance companies which promised to provide coverage at lower costs. Insurance companies instituted groups of participating physicians and medical facilities to provide that service. Regardless of the specifics, the central tenet of managed care was that doctors and hospitals should no longer be able to choose whatever treatment they preferred. Under managed care they were no longer solely in charge of medical decisions and no longer in control of the allocation of health care resources The objective of managed care firms was to wrest control of services from physicians and hospitals and push providers to make cost-effective choices [Quadagno, Pages 160-161] Now, to me, this seems like the very rationing which was so loudly screamed as the unavoidable and evil result of any government program. Phrased differently, decisions were taken out to the realm of the medical PROFESSION and put in the hands of the medical INDUSTRY. The PROFESSION objected, properly, I think, that the patient took a distant second place to the bottom line. The emphasis was on denial of any services which could be denied and, when services were provided, they were provided at the convenience of the HMO. Doctors and medical facilities were rewarded for keeping financial costs down and punished for allowing expensive procedures. Doctors, medical facilities, and patients fought back in the courts. To jump ahead in chronology a bit, under George W. Bush, his administration attempted to cap rewards resulting from any lawsuits against HMOs, an attempt which failed in Congress. None of the backlash against HMOs prevented them from continuing the policy of attempting to limit or deny care to chronically and/or severely ill patients. While corporations were primarily concerned with containing costs, insurers had a vested interest in preventing the federal government from creating competing products and in structuring any new programs in ways that would preserve the private market. [Quadagno, Page 165]. That last sentence is poorly written. I believe it can mean two, not mutually exclusive, things the medical INDUSTRY had an interest in both creating THEIR OWN programs so as to avoid federal intervention and, also, avoiding the creation of competing FEDERAL programs. Yet, during the 1990s, the insurance industry emerged as the unchallenged master of the health care financing system, trumping physicians and hospitals and turning back challenges that might undermine their access to core markets. Industry leaders mobilized forces to fend off federal regulation, crush proposal for government-backed long-term care insurance, and national health insurance, and spur the development of new private company products. At the centurys end, the private insurance industry had vanquished any public sector alternative. [Quadagno, Page 170] The behavior of the health care INDUSTRY in victory was and has remained not something to brag about at the gates of heaven lest they be detained for further (one hopes enhanced) questioning. The overall issue and history of health care reform is of such complexity that I think it is time (for all of us) to read the phrase To be continued. I am, Ladies and Gentlemen, your most humble and obedient & etc Junius, fils
