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Health Care: What Cure?

Philosophical Differences Make Debate Tougher

April 15, 2007
By MARK PAZNIOKAS, Courant Staff Writer

Senate Bill 1 began life in January as a simple, one-sentence statement of purpose: "To ensure that all Connecticut residents have access to affordable, quality health care."

Three months later, universal health care remains a widely shared goal, but legislative ambitions are now tempered by competing philosophies, budget realities and the complexities of American health care.

"It takes a lot of time," said Senate President Pro Tem Donald E. Williams Jr., D-Brooklyn, a co-sponsor of S.B. 1 with every Democrat in the Senate. "It's heavy, heavy lifting."

With the insurance industry on the sidelines - lawmakers have not summoned insurers for negotiations - legislators have been working in small groups on competing plans to control costs and expand access.

But a consensus has yet to emerge on a basic philosophical question: Is the system irreparably broken, or does it simply need improvements to ensure that everyone has health coverage?

"When we finish with the philosophical, we will get to the practical conversation," said Keith Stover, a lobbyist representing the Connecticut Association of Health Plans.

A half-dozen plans have been floated, starting with Gov. M. Jodi Rell's limited proposal to mandate coverage for newborns and improve access to the state's current Medicaid system at a modest cost of $18.9 million next year and $36 million in 2009.

Other plans would cost at least $100 million, more than Rell seems willing to spend, given her commitment to boosting state aid for education. Most would attempt to expand health care access by raising Medicaid reimbursement rates to hospitals, doctors and other health providers who say they cannot afford to treat many Medicaid patients.

On Thursday, Democrats endorsed a budget built around health care reform, an issue they say is more pressing than education aid. Their plan would increase health care spending by $303.5 million next year and $350 million in 2009. Half would go to raise Medicaid and other reimbursement rates.

The state now provides coverage for 205,000 children and 89,000 parents through HUSKY A, which is part of Medicaid, and another 17,000 children through HUSKY B, a program for uninsured children whose family incomes are higher. The federal government reimburses half the costs of HUSKY A and 65 percent of HUSKY B.

Still to be determined: Beyond higher reimbursement rates, how will access to care be expanded? And how will the state control costs?

Aetna, the Hartford-based health insurer, broke with other insurers earlier this year and called for mandatory coverage for all residents. Mandatory coverage is necessary to end the march of the uninsured to emergency rooms for expensive care that is leaving hospitals financially stressed, said Mark Bertolini, an executive vice president at Aetna.

California Gov. Arnold Schwarzenegger has proposed requiring all residents to have insurance coverage, which could cost the state $12 billion in premiums. He also would mandate that 85 percent of insurance premiums go to health care.

Leaders of the Democratic majority in Connecticut have differing priorities and ambitions, though they insist that a consensus plan will emerge.

House Speaker James A. Amann, D-Milford, who is narrowly focused on a plan to guarantee health coverage for every child, wonders if the state can afford a broader effort.

"Whatever we do has to be sustainable," he said.

His Senate counterpart, Williams, is dedicated to universal coverage, even if it takes a series of interim steps over several years.

Williams said those interim steps could include creating large purchasing pools and expanding community and school-based clinics, as well as raising Medicaid reimbursement rates.

House Minority Leader Lawrence Cafero Jr., R-Norwalk, said radical change is unnecessary. Even with as many as 400,000 residents uninsured, Connecticut still does better at providing coverage than most states, he said.

"Isn't it worth looking at what we have and trying to make it work better?" Cafero asked.

Single-Payer

Meanwhile, organized labor and a range of advocacy groups are demanding a single-payer system that could diminish or eliminate the role of the health insurance industry, which employs about 22,000 people in Connecticut.

Under a single-payer system, participants would contribute to a single health care fund that would pay doctors and other health providers. Williams prefers a single-payer system, but he sees a continuing role for insurance companies.

Others do not.

Rep. John C. Geragosian, D-New Britain, said a single-payer system without insurance companies would remove the cost of insurance-industry profit from the system, a necessary step toward lower costs.

"Insurance companies add relatively little," Geragosian said. "Why should I believe that the people who perpetuate this system would be part of the solution?"

Industry representatives say they cannot understand a wish by any legislator to dismantle one of the state's sources of good-paying jobs.

"Think about a single-payer system in the insurance capital of the United States," Bertolini said.

A universal single-payer system is not an immediate option, leaders said.

The non-partisan Office of Fiscal Analysis recently estimated the cost of single-payer policies for every Connecticut resident under age 65, when they are eligible for Medicare, at between $11.8 billion and $17.7 billion.

Williams said such a system could save billions, since total health spending in Connecticut is $22 billion.

But Williams said no one is seriously suggesting that Connecticut launch a single-payer system that would attempt to enroll nearly 3 million people immediately.

"We're not going to hold hands and all jump off the cliff," he said.

Williams is among the legislators interested in Comptroller Nancy Wyman's proposal to use the combined buying power of state and municipal employees to purchase health coverage.

"That would be single-payer," Williams said. "You prove that it works. It's a scientific approach to single-payer."

Wyman estimates that the pool's purchasing power and administrative efficiencies would allow small towns to save as much as 15 percent, while larger cities would see lower amounts.

Kevin P. Lembo, who represents consumers in the state Office of the Healthcare Advocate, said purchasing pools can leverage prices, but he is positioning his office as the voice of caution on broader health reform.

"It is easy to do it fast and get it wrong," Lembo said of health reform. "And the downside is very far down."

Lembo said he is encouraged by the legislative focus on health care, but he is concerned about competing groups and the apparent absence of the industry and academics from the discussion.

Rep. Brian J. O'Connor, D-Clinton, co-chairman of the insurance and real estate committee, is leading one centrist group studying how to improve the current system. Advocates and liberal lawmakers still are pressing for a move to a single-payer system.

O'Connor did not attempt to block a single-payer bill in his committee, even though he is concerned that the quality of care could suffer under such a system.

"We voted that out to continue the discussion," he said.

Juan A. Figueroa, president of the Universal Health Care Foundation of Connecticut, said he expects a consensus around reform to emerge in coming weeks.

"As the debate gets sharpened at the Capitol, I think you will see these groups coming together," Figueroa said. But he added, "You do need more leadership coming from the inside."