Got insurance?

Rhode Island has the lowest percentage of uninsured residents in the nation, but it's a hollow victory when 70,000 people still lack access to health care

by Kathleen Hughes

Geri Butterfield

GERI BUTTERFIELD will remind you of your kindergarten teacher, or the neighbor who bakes banana bread for you out of the blue. She likes to work with babies and the elderly. If you were standing in a long line at the grocery store, she might start chatting with you and you wouldn't mind -- the time would go faster. A 61-year-old Warwick resident and former health-care worker, she is small, dark-haired, warm, and open. Her only son died of AIDS in 1999 at age 37, and her husband is a retired jewelry maker who uses Medicare. As for Geri, she has no health insurance whatsoever.

"I pay out of pocket for doctor's visits and eyeglasses," Butterfield says. For the prohibitively expensive Prozac and Accupril (blood pressure) prescriptions she needs, she relies on samples from her doctor. After leaving a job at a nursing home in 1992, Butterfield used 18 months of COBRA coverage and then bought her own policy. When rates topped $300 per month, with a $1500 deductible, she quit and for the last two years has carried no health insurance. "I pray a lot," Butterfield says. "If I have a catastrophic illness, we lose everything -- the house, everything."

In September, the US Census proclaimed that Rhode Island has the lowest rate of uninsured residents in the nation -- just under seven percent, or about 70,000 people. But although the state has won some kind of race, health-care coverage remains far from secure -- given episodes like the 1999 meltdown of Harvard Pilgrim -- and certainly not guaranteed for all. Many of those who lack health insurance are women like Butterfield -- too young for Medicare and, without any children under 19, too old for Medicaid. Many others are men in their 20s who choose extra income over health insurance. And none of these 70,000 people have coverage for a flu shot, stitches in a cut finger, or a cancer screening. The United States is the only Western industrialized nation where this is the case.

As a result, a 17-year-old boy with testicular cancer was basically abandoned, because he had no insurance, when he walked into the emergency room at Landmark Hospital in Woonsocket a few years ago, explains Maria Montanaro, CEO of Thundermist Health Center in Woonsocket. A Landmark urologist, who was legally bound to see the indigent patient only once, advised the boy and his mother to get insurance and come back. Thundermist officials tried to find a urologist to do the necessary surgery for free, yet failed. Finally, they sent the boy to the Rhode Island Hospital emergency room, where, at last, a urologist agreed to perform the surgery for free. Almost six weeks had elapsed, though, and the cancer had metastasized. With chemotherapy -- an expensive therapy that perhaps would have been unnecessary if the boy had been treated sooner -- he is now fine.

Although the Census found that 1.7 million more Americans were insured in 1999 than 1998, the number of uninsured has climbed to 43 million, up from 31 million since 1988. Last year's slight improvement, furthermore, was a result of more employers offering insurance in a strong economy, and things have since cooled considerably. In good times, even profitable corporate superhero Microsoft has been known to deny benefits to those "temp workers" with tenures of two years or longer. Now, citing the Washington, DC-based Economic and Social Policy Research Institute, the New York Times reports an anticipated increase of 10 percent to 30 percent in health insurance costs this year, which could increase the ranks of uninsured Americans beyond 50 million.

What hope is there for a remedy? Both Al Gore and George Bush promised Medicare reform and a prescription plan to help seniors; Ralph Nader proposed single-payer universal health-care. Although the former has slight promise for the uninsured, it's likely to happen, thanks in large measure to the lobbying power of senior citizens. Other incremental steps that would help the uninsured, such as tax credits and premium subsidies, are already occurring on a state-by-state level, but are subject to economic swings and political whims.

Single-payer universal health-care, in which the payment stream would be handled by a centralized public body, with patients still choosing their doctors from practices, clinics, and hospitals, makes sound economic and humanitarian sense to a lot of people besides Nader, including the New England Journal of Medicine, the American Medical Students Association, and Harvard Medical School's Dr. Steffie Woolhandler, who founded Physicians for a National Health Plan (PNHP).

Of course, single-payer is abhorrent to health maintenance organizations and private insurers, because it could render them obsolete. Blue Cross Blue Shield, Tufts Healthcare, and Harvard Pilgrim each spent over $1 million to narrowly defeat a recent Massachusetts referendum on universal health-care; overall, the $5.5 million opposition campaign outspent their adversaries 50-to-one. In Rhode Island, Blue Cross has spent $1.8 million on a survey and its narrow, slippery summary, mailed to every household in the state in October, which alleges Rhode Islanders' opposition to national health-care.

As US Senator Jack Reed points out, neither state legislatures nor Congress are likely to embrace single-payer national health-care any time soon, given the historic lack of political will for it. Beyond this, a tax-cutting, "small government" Republican president, plus a closely divided House and Senate, and an economic slowdown, mean, as Reed notes, "There isn't an atmosphere for bold proposals."

And yet, what's so bold about guaranteeing health-care for every citizen, especially when the alternative is the perpetuation of severe vulnerability for 43 million Americans? We are, it seems, consigned to living with (or without) some of the best medical care in the world, and the most inefficient system for delivering it.

APART FROM STRANDING so many Americans without insurance, the current health-care system, directed by more 1500 managed care organizations and private insurers, is more expensive than it needs to be since it's riddled with administrative inefficiency. And whether or not a health insurance company is for-profit or not, the industry spends hundreds of millions on executive salaries (Ronald Battista, president of Blue Cross Blue Shield of Rhode Island, makes $397,000), public relations, lobbying, and campaigns. In 1998, the health-care and insurance industries spent $243 million in federal lobbying, and they dropped $66 million more on federal elections last year, according to the Center for Responsive Politics in Washington, DC. Blue Cross Blue Shield itself spent $9.2 million on lobbying in 1998, more than Boeing, General Motors, and AT&T. How far, one wonders, could this money go toward insuring 43 million Americans?

Efforts to diminish the ranks of the uninsured by creating new programs or extending old ones are being made on a "baby steps" basis in more than a dozen states. Such efforts are largely being left to the states because of the new federalism launched with welfare reform, in which states, rather than the federal government, are deemed caretakers of citizens' social welfare. Another factor contributing to Washington's reluctance to tackle health-care is the grand flop of Clinton's plan in 1994. As Joe Klein wrote in the New Yorker in October, the effort lacked sufficient political support within the Democratic Party even before the Republicans refused to pass any health-care reform that their opponents might get credit for. And the uninsured, unlike the health insurance industry, or even the elderly, have no money and little lobbying power in Washington, although low-cost, grassroots lobbying -- the sort the uninsured look to -- can make an impact on the state level.

The problem, however, is that it's inherently inefficient and costly for individual states to make piecemeal attempts at repairing the same problem. Like a leaky roof, patches and new drainage systems may work for a while (and we haven't even begun to address all the leaks), but eventually, you'll have to replace the whole thing. In his campaign platform, Nader argued, "Providing universal health-care can only be accomplished through a single-payer system. No country has ever achieved universal coverage with private health insurance."

Incidentally, managed care was supposed to be the miracle patch to rising health insurance costs in the '90s. The fact that managed care isn't particularly cheap, and came to be seen as a symbol of uncaring bureaucrats, has actually helped the single-payer cause, says activist Kate Coyne-McCoy, co-founder of Health Care Organizing Project, who made health-care a focus while unsuccessfully running for Congress last year.

Legislation to promote a single-payer system has been proposed in about a dozen states over the last two years. In Maryland, a study for the Healthcare For All coalition found that single-payer could save the state $346 million, while universal health-care without single-payer would cost the state an additional $207 million. California is completing a similar study. Another report, by the Congressional General Accounting Office, indicates that a single-payer system could realize $225 billion in federal savings in the first four years of implementation, simply through streamlining the administration of insurance bills. Patients could keep and choose their own doctors, as they do now. Doctors would not work for the government, nor would the government take over hospitals.

But opponents of single-payer have their own figures and rhetoric, and, invariably, a lot more money to get their message out. The "No on 5" campaign that defeated the Massachusetts referendum for universal health-care, cited two studies, one by the Massachusetts Taxpayers Association, which contributed $7000 to the campaign, and another by Brandeis University. Both studies pegged a nearly 40 percent premium increase to the cost of introducing universal health-care, with the first year costing $1.5 billion more than the current system.

However, the taxpayer association's study was a survey of HMO executives, and the Brandeis study, Woolhandler says, simply looked at how much it would cost to insure every American, without considering the efficiencies created by a single-payer plan. There are more numbers, particularly lost savings drawn from the abolition of networked providers, but most of this hinges on the assumption that private industry -- with competition -- can do things more cheaply than the government.

And yet Medicare, which was bandied about for nearly 50 years, and championed by three presidents before Lyndon B. Johnson finally, barely, won its passage, is a very efficient and popular system of quality care, with administrative costs of only two percent, compared with the nine percent to 30 percent consumed by our private insurance system, according to Physicians for a National Health Plan. Does the eventual passage of Medicare (followed by Medicaid) hold promise for universal healthcare? Perhaps. Yet Medicare and Medicaid can be seen as gradual steps, meant to address specific groups, not a total overhaul of the system. Medicare was also passed as a logical extension of Social Security, and Medicaid is largely administered by each state, with some federal money. So both programs, in some sense, are more closely linked to the gradual, state-based reform of health-care than sweeping federal changes on the order of enacting single-payer. Finally, "new federalism," as well as Reagan's successful promulgation of the notion that government is never the solution to social ills, has worked against a national health-care plan, regardless of the numbers.

And then there's Canada. Held up for a time as a great example of an efficient national health plan with free choice of doctors and services, it has experienced great turmoil recently, driven primarily, Macleans magazine online says, by gross under-funding, hospital downsizing, and poor rehabilitation and transition care. As a result, patients have stayed for days in an ER hallway for lack of beds "upstairs," a man died after being turned away from a choked ER, and people are referred to the US for more expeditious cancer treatments. The US, however, would not face the same problems, asserts Physicians for a National Health Plan, because our health-care system doesn't face the same kind of under-funding.

As for local opposition, the recent statewide consumer survey, Project Blueprint, done by Blue Cross Blue Shield of Rhode Island, was something of a campaign against single-payer universal health-care, even though no such plan is being considered in Rhode Island. Of course, BCBS has an interest in the findings, not least because, as president Ronald Battista writes, "The results of this research will form the foundation for the future direction of Blue Cross and Blue Shield of Rhode Island." If BCBS emphasized the decidedly lukewarm feelings that people have for private health insurers, the desire for fundamental change, and concerns about the uninsured, it would be promoting its own obsolescence.

If it is the states that will reform health-care in the next few years, and not the federal government, they will generally do it by extending Medicaid, the federally funded health insurance program for the poor, and Medicare, through a combination of state funds and federal CHIP (Children's Health Insurance Plan) funds, subsidies, and tax credits. Indeed, RItecare, Rhode Island's extended Medicaid program, is partly responsible for the relatively low percentage of uninsured Rhode Islanders.

As for the possibility of states passing single-payer plans for universal health-care, Coyne-McCoy, Woolhandler, and others, are optimistic. "It's going to be more feasible to [achieve it] on a state level," Coyne-McCoy says. "Influencing state legislatures, one state at a time, may be as much as citizens can hope for." But fellow activist Marti Rosenberg, director of Ocean State Action and the Health Care Organizing Project, says 50 different plans would be a mess. Ideally, she says, a few states would pass plans that worked, and a national plan would follow.

Christy Ferguson, director of the Rhode Island Department of Human Services, state Senator Elizabeth Roberts (D-Cranston), and state Representative Betsy Denigan (D-East Providence), are less than optimistic about single-payer's chances in Rhode Island. "The insurers are too strong," Denigan says. "We don't see that [single-payer] universal health-care can be passed." Notes Roberts, "I think incremental change [within the existing system] is what everybody deals with better." Ferguson says extending coverage to the 70,000 uninsured state residents, by expanding Ritecare, is a matter of finding enough money and political will. Such cash, however, could be hard to find during an economic downturn.

One bill in the works, House 8360, known as the "RItecare stabilization bill," will help small businesses and the working poor with health-care. The bill responds, in part, to recent instances of insurance companies pricing small groups, such as the Rhode Island Medical Society, and the Rhode Island Health Center Association (RIHCA), out of their plans because of costly participants. In 1998, says Maria Montanaro, CEO of Thundermist Health Center in Woonsocket, her own breast cancer treatments caused United Healthcare to announce a 40 percent increase in premiums for Thundermist employees. Although United reduced that figure to 30 percent when Montanaro protested, Thundermist switched plans. One part of H-8360 prohibits insurance companies from factoring illnesses, such as Montanaro's, into premiums.

In RIteshare, a new RItecare program targeted at the working poor, the state will contribute to premiums for members of the low-income working poor who earn between 150 and 185 percent of federal poverty level. The participants will include some people currently on the completely cost-free RItecare who have employer-based insurance available to them. Although the program is initially aimed at reducing some of the high costs of RItecare, RIteshare, as a marriage of public and private resources, "could form the base for getting at all the remaining . . . uninsured," Ferguson says.

Other possible reforms include tax credits to ease the cost of premiums, and city or state agencies pooling the self-employed, professional organizations, and small businesses to collectively purchase insurance and thereby bid down rates. The latter could easily be a part of RIteshare.

These incremental reforms are evidence of a real desire to decrease the ranks of the uninsured in Rhode Island. And yet, despite the promise of these efforts, it's hard not to recall the studies which emphasize how expensive universal healthcare is without single-payer. Furthermore, when Ferguson points out that the six-point-nine percentage of uninsured residents means that the state, by standards of "full employment," has "full insurance," one recognizes an implication, perhaps unintentional, that six-point-nine percent is, statistically, as good as it gets.

THIS MEANS THAT what the uninsured continue to most critically need is a safety net. Enter community health centers, which offer primary care and an entrance point to a range of social services, on a sliding scale. Thundermist, in Woonsocket, is one of 23 such clinics in Rhode Island. It's about one-quarter federally funded, one-fifth state-funded, and one third fee-for-service based. Seventy thousand patients turn up at these centers each year, 26 percent of them completely uninsured, and 47 percent who are on RItecare.

On a gray Wednesday afternoon, Thundermist's three waiting rooms -- adult care, pediatrics, and obstetrics/gynecology -- each have two or three people waiting. Thundermist, the literal translation of "Woonsocket," was founded in 1969 and sees a quarter of all Woonsocket children, a fifth of its adults, and three-quarters of all AIDS/HIV-positive residents. Besides the health center itself, Thundermist runs three school-based clinics, two homeless shelters, and a soup kitchen. There's also a dental clinic and food pantry. Not every health center, however, is as successful or efficient. "We squeeze every penny out of our dimes," Montanaro says. In Warwick, the health center went bankrupt and closed a few years ago, and the South County health center was pulled from the brink of bankruptcy after recently partnering with Thundermist.

The problem in health-care isn't just health insurance, Montanaro notes, but access in general, which is adversely affected by poverty. Senator Roberts agrees: "We need to be sure we don't confuse universal insurance with universal care." Health centers, as anti-poverty programs firmly rooted in their communities, with local consumer advisory boards, have a permanent role in health-care, but expanding their operations could never solve everything. "We are not the solution [to the whole problem]," Montanaro says. "We need universal health-care."

IF COMMUNITY HEALTH centers such as Thundermist are a safety net for the uninsured, they're also a safety net for politicians -- who can point to clinics as a haven for the uninsured and proof that a health-care overhaul isn't really necessary. Apart from breaking through the propaganda to accurately convey the facts of single-payer, perhaps the greatest challenge in advancing this plan is relating the plight of those who need it the most -- those who will never be much helped by incremental reform or community health centers. They are the middle-aged working poor, not poor or young enough for Medicaid, not old enough for Medicare, and not rich enough to afford their own comprehensive policies, or health without them. Many of Rhode Island's 70,000 uninsured residents fit this bill.

They're people like Isabel Barten of Providence's Elmwood section, a single, self-employed gardener in her 50s, who spent three years with no insurance before making enough to afford her current $240-a-month plan, complete with $1500 deductible. "The idea that other people, my family, would have to pay my bills if I had an accident -- I didn't want that," Barten explains. Many people ask her why she doesn't get a "real job" with health insurance, as she had for 12 years as a certified nursing assistant. "This is my real job," Barten says. "I'm the happiest at anything in my whole life. I'm not making a lot of money, but I love it."

The fight for universal health-care, finally, is about freedom, not constraint, and so, it's ironically "American." It's about Barten's freedom to choose her work without being consumed by different insurance plans, changing premiums, covered services and deductibles. And yet, it's also about the freedom we continue to give the private insurance industry -- the freedom to dictate costs to us. As BCBS spokesman Brian Jordan says when questioned about the extremely low, capped enrollment of RItecare participants in a Blue Cross plan, "The bottom line for us is the bottom line." So long as the health-care system in the United States is administered by the private insurers and managed care, the bottom line will continue to be not health, but money. n

Kathleen Hughes can be reached at khughes[a]phx.com.

Project Blueprint's faulty architecture

Rather than highlighting public priorities, Blue Cross Blue Shield manufactured consent

PROJECT BLUEPRINT, a study conducted last year for Blue Cross Blue Shield of Rhode Island, contains a clear and unqualified finding on the "role of government": "The public wants drug companies to be more closely regulated. But the public does not want government to provide care, offer insurance, or control their health plan or benefits." But, at best, this statement is based on a very small number of vague questions. And at worst, the finding ignores more complicated findings, such as the parity between Rhode Islanders' desire for greater regulation of health insurers and drug companies. Or the fact that 73 percent of 1004 respondents said fundamental change, if not total reconstruction, is needed in the health-care system.

The BCBS summary further neglects to mention that, by a margin of 35 percent to 13 percent, the first priority among respondents for improving health-care was extending insurance to the uninsured, and that 43 percent of 300 employer respondents preferred "a national health-care plan [covering] every person" as the way to achieve this.

Careful omissions aren't the only builder's square used in BCBS' case against the "the role of government" in health-care. Few and ambiguous questions also help the cause. Consider the sole question on the government topic in the written survey, which involved 57,000 participants:

Is there another healthcare insurer you would prefer to have other than your present one?"

__ Yes __ No If Yes, Which One?

__ RI Blue Cross Blue Shield product

__ United Healthcare product

__ Harvard/Pilgrim

__ Government

__ Other

Given the specificity of the other options, the generic "government" makes me think of Medicare or Medicaid, seen by some to be stigmatized programs for the poor and elderly, rather than a new universal health-care system. A research professional at Brown University, who asked to not be identified, agrees that this question is unclear.

Blue Cross officials deny that their intention was to skew the results. Instead, they say, the survey sought an honest assessment of how Rhode Islanders feel about health-care. "Even if we said we wanted A, B, and C proven," BCBS spokesman Scott Fraser says, Alpha Research, Milliman and Robertson, and Harris Interactive -- the independent consultants who conducted the survey, "would have walked away."

But in the 1000-participant telephone survey, three of seven "policy priority" questions -- the three most direct questions in any of the Blue Cross surveys about the role of government in providing health-care -- were cut before it was conducted. Says Kinga Zapert of Harris Interactive, "We were over the limit in terms of length and needed to cut something . . . And we were obviously trying to retain what seemed like the main priority of the client."

As a result, "the role of government" -- which wasn't Blue Cross's main priority in the survey -- is the theme on which the insurer concludes its story. And the two consultants didn't write the project summary that was delivered to every household in Rhode Island this past fall (via the Providence Journal or the mail). The summary, as a whole, omits unfavorable findings.

Certainly, Project Blueprint gathered some relevant information that will be useful to Blue Cross. But the study works very hard to ensure that health-care reform and government regulation won't impinge on private health insurance companies. Considering this, it's hard not to see Project Blueprint as a savvy, subtle $1.8 million public relations campaign.