Chicago Health Planning

a forgotten step toward socialized medicine in 1975

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These two articles were originally published in The Illinois Socialist in March, 1976, and May, 1976, respectively. The Illinois Socialist was the publication of the Chicago Democratic Socialist Organizing Committee, one of the predecessor organizations to Chicago Democratic Socialists of America.

 

Chicago Health Planning

by Bob Roman

The United States moved one step closer to socialized medicine early in 1975 when President Ford signed the Health Planning and Resources Development Act. This act establishes public planning institutions in the health care industry. Unlike earlier legislation, these new planning bodies have the teeth to enforce their decisions.

Illinois Health Systems Areas
HSA areas in Illinois 1975

The incisors of this act are the 200 local planning bodies known as Health Systems Agencies (HSA). The areas covered by each HSA were mapped out by the Governor of each state within certain demographic and administrative guidelines specified in the legislation. Illinois has eleven HSAs, including two that span state lines to encompass entire metropolitan areas.

HSAs, by law, have the power to: gather and analyze data; establish health system plans and annual implementation plans; provide technical or limited financial assistance to organizations seeking to implement the plans; coordinate activities with Professional Standards Review Organizations and other planning and regulatory bodies; review and approve or disapprove applications for Federal funds for health programs within the health systems area; annually recommend to the state projects for modernizing, constructing and converting health facilities in the area; as well as assisting the state in reviewing proposed capital expenditures and the need for new and existing health services in the area. Obviously this new planning institution will have a major say in the distribution of health care facilities.

An HSA can have one of three possible structures. It may be a public regional planning body. It may be a non-profit corporation. Or it may be a single unit of local government. Regardless of the structure chosen, between 50 and 60 percent of the HSA’s governing board must be consumer representatives. The remainder must be physicians and other health professionals, representatives of health care institutions (including HMOs), insurers, professional schools, and other allied professions.

Thus far the planning process may seem a little remote from the people, but a single paragraph in the law allows, but does not require, HSAs to establish Subarea Councils to advise them on community needs, planning, and the composition of the HSA governing board. These Subarea Councils are potentially a key arena for public participation in health planning.

The act also sets up new structures on a state level. The state is required to have a state planning agency which meets various Federal requirements. This agency more or less serves as the administrative arm of the State Health coordinating Council (SHCC). At least 60% of the SHCC membership is nominated by the HSAs in the state. Planning on the state level is seen mostly as the integration of each HSA’s annual health systems plans. The state planning agency and the SHCC do conduct reviews determining the need for new institutional health services, the need for existing institutional health services, and the need for all major capital expenditures by institutional health services. They are, however, expected to follow the HSAs’ health systems advice and plans in these reviews.

This is by no means a complete description of the new institutions set up by the act and the relations between them. But even from this limited description, it’s quickly apparent that the HSAs are potentially more powerful that the state government in the field of health planning.

The boundaries of the Health Systems area that includes Chicago includes only Chicago. (Do you wonder why?) There are two applications for the status of HSA in metropolitan Chicago. One is from the city itself. The other is a joint application from two groups active in health planning under previous Federal legislation, Comprehensive Health Planning Inc and the Chicago Community Health Planning Coalition (CHP-CCHPC).

Should the City of Chicago become an HSA, the HSA’s governing board would technically be the City Council. The responsibility for health planning, however, would fall on a commission appointed by Mayor Daley: the Commission for Health Planning and Resource Development.

The composition of the commission must follow the same legal requirements for consumer, professional and health care industry representation as other HSA governing bodies. But even within these legal requirements, the appointments to the Commission follow a pattern well established by other Chicago boards and planning commissions, even to the inclusion of the ever present William Lee, President of the CFL. Other interesting appointments include the fast-rising Alderman Bilandic, Alderman Wilson Frost, 1st Ward Committeewoman Lucia Gutierrez, Patrick A. Murphy, Grace Slattery, Alderman Bennet Stewart, and Robert Vanecko.

As might be expected, the City’s proposal is highly centralized. The only provision for public involvement in planning is a vague scheme for the establishment of an “Advisory Council Network” which will participate in “the decision making process through methods being developed by the Commission which may involve task forces, systematic plan hearings and ad hoc committees at such or/and suitable techniques.” The true nature of this “network” is illustrated by its inclusion under the program area “Community Education” in the City’s work program.

One reason socialists favor planning and control of investment is it allows other values than those of the market place to be considered. But in doing so, it shifts the balance of power in favor of those doing the planning. This is why we insist the planning process be democratic and open to public participation.

The Machine is well aware of this second factor. City, and therefore Machine control of the HSA will firmly cement the health care industry into the corporate structure that supports the Machine. The potential power that the HSA will wield will discourage any nonsupport or opposition, and what corporate institution will want to if the usual state of Chicago nonplanning rules the field.

The CHP-CCHPC application is a complete contrast to the City’s proposal. While the institutional form is a non-profit corporation, the commitment is to public participation in planning. Consequently, the Subarea Councils are given a prominent role.

Chicago is demographically divided up into six Subareas. There are three regional offices serving each two Subareas. The Subarea Councils are given a specific role to play, including the nomination of HSA board members, the review of health systems plans and the formulation of local plans.

The CHP-CCHP application is also more specific and more comprehensive in the range of planning proposed that the City’s. Among the areas to be considered are recreation, population, water supply, housing, sanitation services, and environmental pollution. The HSA will also publish an annual Health Status of Chicagoans report. Considering the scope of the planning, this report has potential for an advocacy role in related but not strictly health care fields.

The whole issue of who will be the HSA will be decided by the Secretary of HEW, David Mathews. In deciding, the Secretary must give major consideration to the opinions of the Governor. The Walker Administration’s response has been to approve neither of the applications and to propose that the decision be put off from April to July while the two parties work out a single compromise application.

The reasons for this move are left to your speculation. The result, however, is to pretty well insure the domination of the planning process by the health care industry and Daley’s political mafia.


Chicago Wins HSA Funds

by Bob Roman

The City of Chicago’s application for the status of Health systems Agency has been given conditional approval over the Chicago Community Health Planning Coalition – Comprehensive health Planning Coalition application. This gives the City, and consequently the Regular Democratic Organization, control over Federal health planning funds and a good deal of influence in the health care industry in Chicago.

The official rationalization is that while both applications were “approvable,” the city’s was clearly superior in fulfilling the requirements of the Federal regulations implementing the National Health Planning and Resource Development Act. The Walker Administration’s recommendation that the decision be postponed while the two applicants combine applications was dismissed as the obvious absurdity it was.

If a rationalization is to be any good, it must have some connection with reality. Filing an application for a Federal grant is a bit like answering a rather long and involved essay question with specific requirements for information. The lower levels of the Federal bureaucracy check (among other things) to see if the required information is present. The City of Chicago paid a top-notch consulting firm an arm and a leg to prepare the application, so it is hardly surprising that City application was “better”.

Even given this, it does not mean that the decision was not political. Regulations can be bent a good deal. They were bent a good deal when the HSA boundaries were drawn for Illinois. All it took was a little pressure from the Chicago Congressional delegation.

But the hot potato has not yet come to rest. There are at least two suits filed in Federal District Court concerning HSA boundaries, particularly concerning the rump status of suburban Cook County. And conservatives in the medical profession are mounting a campaign to abolish the whole HSA system. The issue promises to continue smoldering.


Post Script

Not too many people remember that the United States actually came fairly close to having a national health insurance system (aka Single-Payer) in the early 1970s. President Richard Nixon had even made a counter proposal of something closely resembling what we now know as “Obamacare”. The irony is monumental from a lefty perspective though I expect conservatives can find plenty of ways to rationalize it. It’s only human.

The lack of consensus on competing proposals, the Watergate scandal and all the usual nonsense meant the moment passed and was forgotten. Except that one aspect of a national health system, public planning, did make it through the U.S. House and Senate and was actually signed by President Ford. I think it’s worth remembering this brief experiment in social democracy.

So these two articles dealt with the competition for just what entity was going to be doing that planning in Chicago. If I were to advise my younger self, I’d suggest easing up on the cheap cynicism regarding the old Democratic Machine, not because it was wrong so much as because it confuses issues regarding making planning to some degree both democratic and transparent.

I don’t know how the national planning mechanism came to an end (Carter killed it, probably), but some of the entities set up by the State of Illinois for health care planning on the state level are still in business. Health Systems Agencies are history, as is the old Democratic Machine.

You’re Either At the Table or On the Menu

Originally published in New Ground 123, March — April, 2009. In retrospect, too many of us in DSA spent time defending Obamacare, I think mainly because it had such a rogue’s gallery of enemies. In any case, I also regret my ambivalence in this article.

by Bob Roman

Having spent a week in the hospital recently, I followed the Obama Administration’s White House health care summit with some interest. That the principles Obama hopes Congress uses in drafting health care legislation emphasizes lowering the cost of health care over everything else (despite his remarks that bowed toward universality) was no surprise. Obama made it clear enough while campaigning for President that he had no interest in pushing for a universal publicly run health insurance plan (a.k.a. “single-payer”). What was a surprise was his Administration’s hostility toward advocates of such a plan. That they did not invite a single advocate for the “single-payer” option until pressured to do so is hardly likely to have been a mistake. It was instead a message.

The usual lefty narrative for why repeated attempts at a national health plan have failed is to blame the medical and insurance industries (or more generically the “capitalists”). We’re not wrong about that. But the fact is that our government is structured to discourage any legislation that is not supported by some degree of consensus among all the interested parties. The need for a super-majority in the Senate to end debate is simply the most obvious aspect. There is also the committee system within the House and the Senate, the need for the co-equal House and Senate to negotiate their differences, the possibility of a Presidential veto and the super-majorities needed to over-ride it, and ultimately review by the courts. At each step along the way, there are opportunities for a willful party to kill outright or fatally sabotage a proposal.

During the last significant attempt at systemic health care reform during the Clinton Administration, advocates of a “single-payer” approach to health care were every bit as enthusiastic in opposing Clinton’s proposal as the usual suspects from industry and finance were. With no consensus, none of the competing plans went anywhere. “But. . .,” Obama said, “this time will be different.”

So should advocates of “single-payer” get with the Obama program? Certainly Obama is correct in that the air of desperation that exudes from the less well off on this issue has not only grown but also spread to business and to health care providers. This gets politicians’ attention. The aggravated distress provides a perfect rationale for some past supporters of “single-payer” to accept whatever comes out of the process and proclaim victory.

But it also makes sense to continue demanding the whole loaf: in this session of Congress, HR 676 “Medicare for All” for example. But failing that, would we settle for legislation that allowed for and supported experiments in “single-payer” health care on a state level (HB 311, currently being considered by the Illinois General Assembly, for example)? Or would a reform that would gradually erode private insurance in favor of a public system suffice? At what point, if any, should advocacy for civilized social medicine become part of the veto process?

Cook County Saved?

the fiscal problems are nothing new

Originally published in New Ground 117, March — April, 2008.

by Bob Roman

Supporters of county health care services (and supporters of county government in general) had some reasons to celebrate on March first after the Cook County Board, very much at the last minute and by the skin of their teeth, passed a “balanced” budget that preserves County services, including health care. Better still, from the perspective of the Emergency Network to Save Cook County Health Services, was the passage of an ordinance that essentially puts the county’s Bureau of Health Services into receivership. The ordinance passed is largely the ordinance proposed by the Network except for one major pill embedded in the dog food. The original legislation proposed a board formed entirely independently of County government by representatives from a list of stakeholder organizations. As passed, representatives from a select list of “stakeholder” organizations will meet to nominate candidates for the independent board. From that list of 20 candidates, Todd Stroger (as County President) will select 9 board members. This board will be expected to reorganize the Bureau into a reasonably efficient organization, including setting up a billing system that will allow for greater reimbursement from Medicare and Medicaid. After three years, unless the County Board decides otherwise, management of the Bureau will return to the County Board.

The reform ordinance was a way of taking health services out of the stalemate between those wanted to raise taxes and were defensive regarding management and those who, out of opportunism or out of middle class outrage or out of a hidden libertarian agenda, felt no tax increase was necessary but a lot of “fat cutting” was.

The Emergency Network to Save Cook County Health Services was formed early last year with the blessings and support of AFSCME and SEIU when it became obvious that Cook County was headed for a fiscal crash landing with health services being one of the biggest casualties. Chicago DSA signed on in October. Based at Citizen Action/Illinois, it did a great deal of the coalition building necessary for this victory. Some of the members do not love some of the others though apparently they worked together well enough while facing the crisis. Afterwards, the self-congratulations often did not credit others in the effort.

A great deal of credit also belongs to Chicago Federation of Labor President Dennis Gannon. By some accounts, his shuttle diplomacy at the climax pretty much clinched the deal between County President Todd Stroger, liberal board member and swing vote Larry Suffredin, and some of the other stakeholders. The tax increases were no larger than immediately necessary and the health services reform ordinance was largely what the Network had proposed albeit possibly less “independent.”

Taxes were the big story for the mainstream media. This increase will make the sales tax in Chicago the highest in the nation. In addition to being regressive, it will likely discourage commerce compared to the suburbs. But this is only a small part of the story. The sales tax increase is estimated to be worth $400 million in additional revenue per year but only brings $74 million (the increase happens just in time for Christmas shopping) against the estimated $234 million deficit this year. The rest of this year’s deficit is being made up by the anticipated surplus next year. But according to the Center for Tax and Budget Accountability, Cook County’s revenue problems are primarily structural. The taxes the County has available to it will not cover the anticipated increases in expenses. If this year’s deficit was about $200 million, next year’s will likely be about $400 million. The problem is resolved for this year, and with management efficiencies maybe next year, but feces will be airborne again in 2010.

In this context, a possibly independent and professional board may be a risky victory. Stroger is certainly sensitive to the issues of services and good jobs in “The Community.” Cynics, with more than a little justification, will sneer “patronage” instead. Yet most patronage these days is not in the form of jobs but in the form of contracts. Politics is nowhere near as labor-intensive as it once was; money counts for more. If County finances become impossible, what better armor for a politician’s hind end than an independent board to make nasty decisions like privatization or massive cuts?

The other part of the tax story, though, is the money not being collected. Some of this is part of the current left critique: the ubiquitous Tax Increment Financing districts that skim increases in property tax revenue to opaque and unaccountable local projects. But with regard to property taxes, there is always a considerable pool of other money that is not being collected. Tax bills that are being appealed, bills that are being contested in court, bills that are being settled for change on the dollar, bills that won’t ever be paid. Likewise, the sales tax is also evaded. How many dollars are missing? It can amount to more money than you might expect, but that’s a subject for another story.

The Wounds That Never Heal

a review

Originally published in New Ground 113, July — August, 2007.

by Bob Roman

Flashback: Posttraumatic Stress Disorder, Suicide, and the Lessons of War by Penny Coleman. Boston: Beacon Press, 2006. 223 pages, $23.95.

Post Traumatic Stress Disorder (PTSD) has become recognized as an inevitable consequence of war, and this book is a wonderful discussion of PTSD, it’s history, and the efforts (or lack thereof) to treat it in just that context: war. My only problem with the book is that I agree far too much with the author. Why is this a problem? A great part of the book deals with the Vietnam War, a history that is very much in dispute and often written from a particular point of view. I would feel more comfortable, actually, with someone I had political disagreements with.

For example, Coleman discusses the Nixon Administration’s campaign to blame Vietnam veterans’ problems on abuse the veterans suffered from protesters and radicals. The iconic image, of course, is the spat-upon veteran. Coleman uses Jerry Lembcke’s work, The Spitting Image, to refute this; after extensive research, he was unable to find any evidence such a thing happened. But Lembcke’s research could be absolutely solid and still be wrong. Even if it never happened, why does it feel, to many, as though it did? Why would that be of any concern aside from politics? It turns out that one of several things that leaves combat veterans vulnerable to PTSD is a related violation of a sense of “what’s right.” This mostly applies to the soldier’s relations with the military (including peers), but it could apply to the soldier’s relation to society and country in general, especially given that soldiers were rotated out of Vietnam as individuals and not as units. For a good account of just how general a violation of “what’s right” could be during Vietnam, I’d recommend a slim book of poetry first published in 1976: The Long War Dead by Bryan Alec Floyd. As poetry, the quality is uneven but in affect each poem is etched with blood.

Aside from brief excursions into the Trojan and American Revolutionary wars, Penny Coleman begins her history with the American Civil War. The state of medicine in the States did not allow for any consistency in diagnosis, never mind treatment, but some military doctors made astute observations, even if military practice remained barbaric. For the U.S. military, at least, the big breakthrough was World War I. Apparently someone prior to our entry was paying attention to the European experience; the military devised a scheme to provide effective battlefield maintenance, essentially patching up soldiers well enough that they could be sent back to the front though their post-war fates are another matter. Coleman weaves together a number of interesting strands in her discussion of PTSD up to the Vietnam War: advances in psychology that provided insight into what was happening to these soldiers, lessons learned then discarded for bureaucratic convenience in time for the next war with a pretty consistent lack of interest in providing help to soldiers after their wars, and the epidemic of suicide that seems to plague combat veterans.

A majority of the book deals with Vietnam. This is not simply because of Coleman’s interests; the Vietnam war was different. Coleman uses the history recounted earlier in the book to compare and contrast with military practice during the Vietnam war. One of the more presently relevant observations concerns the implementation operant conditioning in military training after World War II. A study found that during that war, 75 to 80 percent of soldiers were not firing their weapons, even when their lives were immediately threatened. By the time of Vietnam, the firing rate had gone from 25 percent to 95 percent.

Intertwined with each chapter are personal testimonies by families of Vietnam veterans, accounts that give immediacy to the issues Coleman is discussing. All of the testimonies involve suicide. Coleman is making a point here, one that needs to be made. And it can be quite affecting, including one widow who exclaims, “This isn’t over, this isn’t over. It’s 1999, and my husband just died from the Vietnam War.”

After reading the book twice, I’m still not certain what all the political implications are. But an important one is the degree to which the Vietnam war was ended not by protest and politics here in the States but by the disintegration of the combat forces in Vietnam. This has become a fashionable observation in the anti-war movement today, recalling especially those soldiers who were active in organized resistance. This is perhaps a bit of wishful thinking on the part of wannabe revolutionaries; Coleman’s book documents that while there was considerable organized resistance, a better part it was very individual and sometimes violent (e.g., “fragging”). But this does suggest that anti-war organizing within the military and among veterans is not to be neglected.

Perhaps Coleman’s conclusion is correct:

“Those injuries to mind, and the deaths they so often provoke, do not deserve to be erased. They deserve to be included in an honest and honorable reckoning of war’s cost. They deserve to have a public as well as a private meaning. Perhaps the naked magnitude of the cost will convince us that finding peaceful solutions to our problems, though a tall order, offers a compelling, motivating ideal…”

Perhaps. Though Nelson Algren’s short story, “pero venceremos” comes to mind. The protagonist, a veteran of the Spanish Civil War, spends much of his time in a bar where he reiterates, endlessly, a particularly gruesome encounter in battle to the complete and uncomprehending distraction of his friends and acquaintances. Finally one of his friends tells him to forget it; the battle was a hundred years ago. No, he says, it’s just like yesterday. But after a long pause, he asks, “Did I say yesterday? It wasn’t even yesterday, the way it feels.”

“How does it feel, Denny?”

“It feels more — like tomorrow.”

The Empire Strikes Back!

pay or die…

Originally published in New Ground 110, January — February, 2007. The degree to which these recommendations (essentially a preview of Obamacare) provoked opposition from the wealthy should have been a clue as to the reaction to Obamacare. Obamacare’s coverage of lower-income persons was partially subsidized by taxes on the very well off, clearly adding fuel to the fire.

by Bob Roman

As this issue of New Ground goes to the printer, the final meeting of the Adequate Health Care Task Force will be happening. As reported in New Ground 109, the Task Force will be recommending to the Illinois legislature a health insurance scheme that resembles the plan recently passed in Massachusetts. A minority report advocating a “single-payer” (that is to say state run) insurance plan will also be submitted. In New Ground 109, I speculated that the insurance industry would present its own minority report. And indeed, 5 members (all appointed by Republicans) of the Task Force are submitting such a dissent.

This dissent is the opening shot in a campaign to prevent the legislature from doing much of anything on the issue of health care. Some of this involves whining about process: about how the Task Force went about its work, about how the interpretation of facts and assumptions made by the Task Force’s consultant (Navigant) didn’t fit with the libertarian dogma of the dissidents. You’ll be hearing more of this, as “unfair” is such an easy charge to toss at your opponents, especially if it’s a half-truth.

But the essence of the dissidents’ complaint is: “the plan advanced by the Adequate Health Care Task Force will, if implemented, increase health care costs, reduce consumer choice of health care coverage, have a negative effect on the quality of health care provided to the citizens of Illinois and restrain job growth.” Some of this, particularly “consumer choice” and “job growth”, are symptoms of libertarian dogma.

If this minority is ideological and self-serving, don’t assume they are also, therefore, stupid. In fact, some of the criticisms they make of the majority report are dead on, and others are plausible enough to scare skittish legislators. Among the latter, one example is the charge that the system proposed by the majority report would violate the federal Employee Retirement Income Securities Act (ERISA) that regulates employee benefit plans. In order to achieve uniformity across the states, ERISA preempts state laws. Maryland’s recent health care law aimed more or less at Wal-Mart was struck down by the courts using ERISA. Even if it does not apply in this case, proponents of the majority report had best get Attorney General Madigan on board as reassurance, at least.

More to the point are the dissidents’ complaints regarding the lack of cost containment measures and complaints (and questions) about just who is going to pay for this system. Employers will be expected to pay about $1.5 billion. Since this is money not necessarily going to the insurance industry, to any good libertarian it’s obviously a burden and a waste. But there are also some 3 to 3.5 billion dollars in expenses (and more as those numbers do not include start up expenses) that are not funded by the majority report. Unfunded mandates have become common in the past quarter century and typical under the Blagojevich Administration, but they should make you very afraid.

These dissidents can’t simply say “no”, not in the face of so much heart-breaking testimony collected by the Task Force. But they are mostly content with restating elements of the insurance industry’s proposal to the Task Force. To be fair, this was not the worst proposal to the Task Force. It might cover up to 28% of the presently uninsured (some of the other proposals covered fewer), and if you have sufficient income so that you could save or invest, you might do well enough provided you’re not especially sick. It represents an attempt to address the anguish of those denied access to health care (or bankrupted by it) while preserving the primacy of the financial industry. (Insurers are not in business to cover your butt against misadventure. They are in business to make money by investing your premium payments.)

That the other Republican appointees to the Task Force did not join this dissent suggests these dissidents just don’t get it. Health care is not just another commodity; it is a basic human right, not a reward for being the biggest rat in the race.

 

Universal Health Care How!

Obamacare, anyone?

Originally published in New Ground 109, November — December, 2006.

by Bob Roman

In New Ground 103, “Everybody In! Nobody Out!”, I predicted the obvious: that as the Adequate Health Care Task Force (mandated by the Health Care Justice Act of 2004, see New Ground 99, “The Health Care Justice Act Unfurls”) finished its work on recommending legislation to reform health care in Illinois, the Campaign for Better Health Care (CBHC) decisions on what to support would leave it “in trouble with some part of its constituency”. The moment is nigh. If not too many people are seriously pissed off at CBHC (I hope), the coalition it cobbled together for the Health Care Justice Act is fracturing nonetheless.

The Task Force had hoped to finish its work prior to the November election; however, its approach to the task, trying for a consensus among the stakeholders, has delayed its report until the start of the next General Assembly session in January. The recommendation (not surprisingly, see New Ground 103.2) is likely to resemble the plan passed early this year and presently being implemented by Massachusetts. While the CBHC’s 2005 meeting was studiously uncommitted, by May of this year CBHC had submitted a report to the Task Force that essentially asked the Task Force to examine various features of the Massachusetts approach. On the other hand, at the 2006 CBHC meeting this past October, Jim Duffett, CBHC’s Executive Director, made it clear that the CBHC would not automatically support whatever the Task Force produced.

The Massachusetts approach is a good example of the current fad in legislation: public policy as an item to be marketed. In this case, the “hook” is individual responsibility combined with community responsibility to facilitate the fulfillment of that responsibility for those who are poor. This is a powerful argument when expressed properly.

For health care policy, this means that individuals would be “mandated” to obtain health insurance, something like the way drivers are required to have automobile insurance. Typically this would be done as it is today: through employment. Employers would be “mandated” to provide insurance or, if they do not, to pay the State additional taxes. Individual policies would be subsidized for lower income levels, and Medicaid would be available for the truly less well off. The State would also set standards for insurance policies. Unlike automobile insurance, failure to buy health insurance would not be a criminal matter. In Massachusetts there are tax consequences. It’s pretty obvious that in such an approach the details are vitally important.

Those with some familiarity with health care policy will note that in preserving private insurance, the Massachusetts approach preserves the administrative overhead (and profits) that consumes an unfortunate portion of each of today’s health care dollar. Depending upon how the employer “mandate” is implemented, there will be an incentive for employers to dump employees into individual policies and for low-wage employers, Medicaid. Unless you assume that “demand for health care at zero price may be close to infinite” (There are economists that delusional. The quote is from “Implementing Mandates” by C. Eugene Steuerle of the Urban Institute, 1994.), a “single payer” approach is guaranteed to be far less expensive.

Many Massachusetts health care activists were not at all happy with being saddled with a health care plan that is kinder to insurance companies than it is to the health care recipient. In Illinois, an “Illinois Single Payer Health Care Coalition” is being formed to promote what will be a minority report from the Task Force for a “single payer” solution. There is also no guarantee that the insurance industry will be happy with what the Task Force comes up with, even though the Massachusetts plan was largely developed by Blue Cross Blue Shield.

Because enacting legislation on both the state and federal levels in the United States requires some degree of consensus, this split in the coalition probably does not improve prospects for health care reform in Illinois. But Massachusetts is going into its plan with a very large pot of money to cover the initial costs while Illinois has persistently failed to deal responsibly with its finances, including consistently failing to fulfill its constitutionally mandated responsibilities to fund education. Add to that a smaller Democratic majority in the General Assembly and plurality in the electorate as compared to Massachusetts and it becomes unclear that anything the Task Force might propose has much of a chance. It may be that this whole effort will become, at best, another exercise in public education.

There is such an unmet need for health care in Illinois that this ongoing disaster will be used to browbeat dissidents to the Task Force consensus proposal. How could they endanger passage of a reform that would make such a difference in the lives of so many? “Impractical” and “utopian” will be among the epithets deployed.

But an inadequate plan is not necessarily any different than no plan; Massachusetts is an example of this, too. This is not that state’s first experience with a universal health care plan. In 1988, Michael Dukakis got the state legislature to pass a public / private universal plan. Because of a failure of financing and political leadership, it was never implemented and was mostly repealed in 1996. Yet another failure of liberalism, in concept and politics. De ja vu all over again?

Everybody In! Nobody Out!

This was originally published in New Ground 103, November — December, 2005.

by Bob Roman

In contrast to some previous years, the Campaign for Better Health Care’s (CBHC) annual meeting was a robust affair. Held at the Holiday Inn Mart Plaza in Chicago this past November 10, it brought together nearly 400 participants from around the state. While there was some mainstream press coverage, it was mostly in the context of the keynote speaker, Governor Rod Blagojevich, and his “Kids Care” program and his administration’s suspect hiring and contracting practices.

The reason for the increased interest by health care activists and the reason for journalistic neglect is fairly similar: the Health Care Justice Act. To recap, the Health Care Justice Act sets up the “Adequate Health Care Task Force” that will draft legislation dealing with the health care crisis for the state legislature to consider next year, the goal being to have the legislation in effect by 2007. Depending upon what the task force recommends, this may (or may not) be a major, radical change in health care in Illinois.

So why is Kids Care a story and Health Care Justice not? Part of it is that anything talked up by a bunch of politicians is considered news. Then too, Kids Care comes in the context of conflict: a looming election contest, threatening criminal prosecutions. But while the implications of the Health Care Justice Act could be radical, no one really knows at this point. It’s all just possibilities; it’s all just complicated ambiguities. Nobody knows who the winners and losers will be. Thus there is no overt conflict thus no drama thus no story.

“Everybody In! Nobody Out!” the crowd at the meeting enthusiastically chanted in a ritual not unlike singing “Solidarity Forever” at union events. But if the actual implications of the Health Care Justice Act are presently ambiguous, this year’s CBHC annual meeting was also a study in ambiguity. The meeting was a careful balancing act between maintaining interest and enthusiasm for the process of the Health Care Justice Act and a studied openness as to the specifics of the Task Force’s product. After all, if no one knows who the winners and losers will be, it’s hard to organize opposition to the process.

For example, one of the major presentations at the meeting was by Larry Boress of the Midwest Business Group on Health. It was a Power Point slide show entitled “Affordable, Accessible Health Care: A Smart Business Decision”. Much of this dealt with educating “consumers” about health issues and providing what might be called “transparency” regarding the quality and price of the services available. Some of this would be of interest in any health care system. But the thrust of this presentation was to explore ways of making health care an interchangeable commodity, a necessity if “consumer based” (which is to say “free market”) approaches to health care have any chance at universal application.

Boress’ presentation was politely received.

The CBHC also included, in the meeting packet, an answer to Boress’ presentation in the form of a reprint of a New Yorker article from August 29, 2005. “The Moral-Hazard Myth: The Bad Idea Behind Our Failed Health-Care System” by Malcolm Galdwell examines the assumptions made by ideologues obsessed with supply and demand curves and the gruesome consequences in real life.

Another major part of the program was a reprise of last year’s panel discussion about the Health Care Justice Act. This year the panelists included Mark Blum (Executive Director, America’s Agenda), Kao-Ping Chua (Jack Rutledge Fellow, American Medical Students Association), Rachel Rosen DeGolia (Operations & Organizing Director, UHCAN), and Steve Scheer (Principal, Health Management Associates). The panel’s topic was to be rather broader, but moderator Elizabeth Brackett (The News Hour with Jim Lehrer) found the process and the prospects of the Health Care Justice Act to be more interesting. While Mark Blum had a great deal to contribute, Steve Scheer was perhaps more interesting. Evidently a long-time campaigner for universal health care, he has reached the point where he has become a somewhat dogmatic advocate of incremental reforms. In light of the long and disappointing history of efforts toward universal health care in this country, Scheer’s attitude is understandable. But such a promiscuous love of tinkering is unwarranted. There are worthy incremental reforms that make significant improvements to the lives of a large constituency, such as Medicare and (to a lesser extent) Medicaid. Then there are reforms that are… incremental?

The keynote address by Governor Rod Blagojevich largely concerned his new Kids Care program. Quite possibly this program qualifies as a worthy incremental reform; it covers a significant constituency for whom it will make a real difference. On the other hand, it is to be paid for, in part, by placing Medicaid recipients into “managed care” programs. In the context of private, for-profit insurance, “managed care” becomes shorthand for rationed care with an additional cut removed for profits. Does this “incremental reform” amount to spreading thin services even thinner? One has to sympathize with Republican whining about vagueness.

Blagojevich, or his speechwriters, have apparently been reading Jim Wallis and listening (though not too closely) to George Lakoff. The Governor spent much of his speech proclaiming his budget as a “moral document”, a testament to family values, etc. All of which might sound convincing if Blagojevich had taken any risks in the budget’s composition.

The lack of overt, active opposition to the Health Care Justice Act process does not preclude the possibility of sabotage. Or is it incompetence? The past President of the United Food and Commercial Workers Union, Doug Dority, spoke to the meeting, briefly, in his capacity as the President of America’s Agenda. He condemned the performance of the Illinois Department of Public Health in arranging the hearings mandated under the Health Care Justice Act. The first hearing at Trinity UCC Church in Chicago was well attended. (The UofC Young Democratic Socialists worked with other campus groups to bring students to the hearing. Over 500 people attended.) But the venues for subsequent hearings were finalized at the last minute, often with no more than a week’s advance notice. Chicago DSA has been sending postcards advertising the hearings and the opportunity to testify to our database in the zip code(s) surrounding the hearing sites, but it’s not clear how useful this is if recipients only get three or four days notice.

It is possible to submit comments (that is, to testify) by mail and email. You can mail your written testimony (typed, double-spaced, 8.5″ x 11″ paper) to Tracy Morgan, Illinois Department of Public Health, Division of Health Policy, 525 W. Jefferson St., Springfield, IL 62761. Or you can email your comments to hcja@idph.state.il.us. For more information, go to http://www.idph.state.il.us/hcja/

CBHC is also working on getting legislators in the Illinois House and Senate to endorse health care reform. Among other things, the pledge insists “that efforts cannot stop with covering all children in Illinois ­ we must cover all Illinoisans!” and commits the individual to attending a public hearing of the Adequate Health Care Task Force. For more information, call the CBHC at 312.913.9559 or go to http://www.cbhconline.org/HCJC/index.htm.

These are interesting times for health care politics in Illinois. The coming year will be when we decide if it is a time of meaningful change or meaningless hot air. CBHC has drafted a set of criteria by which to judge whatever the Adequate Health Care Task Force produces. Viewed through ideological eyes, it’s easy to imagine that only a universal (“single payer”) solution would adequately address the criteria. But in fact, they are mostly vague enough to encompass any number of approaches. And the criteria are broad enough that any given solution to health care in Illinois is likely to shortchange some aspect of them. The criteria are not useless as a tool for judgement, but the range of possible solutions makes it likely CBHC will be in trouble with some part of its constituency when it has to decide.

Post Script: My table at this event was in an obscure corner of the hall, a sort of alcove actually. Blagojevich’s speech was at the end of the event. When he concluded, he was surrounded by well-wishers and lobbyists demanding his attention. Nobody at my table joined the scrum. We stood there in deep conversation when suddenly an outstretched hand appeared before me. It was the Governor, on his way out of the hall, demanding a handshake. I obliged. He was so needy.