In the first three parts of this series Access Press has looked at the “Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance” that was published in the August 13, 2003 issue of the Journal of the American Medical Association. We summarized the overall proposal and a couple of different ideas for financing a system of National Health Insurance (NHI). In this final installment, we will consider some of the implications of the NHI plan – as proposed by the Physicians’ Group – specifically for people with disabilities (PWDs).
The problems with the current health care system in the United States affect everyone, but often present special challenges to PWDs. In a major survey of PWDs published this past December, the Kaiser Family Foundation found that “People with disabilities are at risk in the health-care system because of their wide-ranging health-care needs, their relatively heavy use of prescription drugs, health-care and support services, and typically low incomes.” The Kaiser study reported that, in 2003: 46 percent of PWDs went without some necessities (e. g. eye glasses, equipment) due to cost; 17 percent had a problem finding a doctor who accepts their insurance; 16 percent reported problems paying for home care services (for people whose sole coverage is Medicare, the number was 60%), and; 36% spent less on basic needs (e. g. food, heat) in order to pay for health care.
Here are some particular issues currently facing people with disabilities, and some thoughts on how the NHI plan might affect them:
Adverse selection is the tendency of people with poorer than average health expectations to sign up for insurance more than healthier people. As disability advocate Laura Remson Mitchell wrote in the Los Angeles Times, “The truth is that without a mechanism to cover everyone, many healthy individuals simply won’t be part of the insurance pool. That means people with health problems will make up an ever-larger percentage of the pool, thereby pushing up premiums. Unfortunately, as premiums continue to climb, price will drive more and more employers and low-risk individuals out of the market. This is the destructive cycle that will ruin any system that depends on purely voluntary, private decisions about health coverage.” Under the NHI system this would cease to be an issue, since everyone would be mandated to participate in the program, thus spreading risk as widely as possible.
Risk avoidance refers to the problem of insurance companies trying to insure only healthy people. This is the industry version of “adverse selection,” and in practice it means that applicants with disabilities and expensive chronic conditions are simply rejected for coverage. Advocate Chris Duff of AXIS Healthcare relates a conversation he had recently with “an unnamed HMO administrator,” on why HMOs don’t want to cover PWDs: “It’s a lose/lose for us. We don’t want to serve PWDs because, if we do it well, we’ll attract a lot of PWDs, our costs will go up, and we’ll lose money. If we do it poorly, we’ll get a bad reputation.” Under the NHI system this, too, would cease to be an issue, since everyone – disabled or not – would be guaranteed coverage.
Coverage tied to employment. With unemployment levels among PWDs remaining at very high levels (50 to 75 percent), the private-sector practice of tying health insurance to employment is a huge problem. While this has become less of an issue in Minnesota since the 1999 passage of the Medical Assistance for Employed Persons with Disabilities program, that program is limited and many states have no such program. Again, under the NHI system this would problem would be eliminated.
Cost of coverage. Given their lower average incomes, the issue of affordability of coverage looms even larger for PWDS than it does for the general population. While Medicaid serves many of those with the lowest incomes and some of those at the higher end of the income spectrum may be able to afford private insurance, many near-poor – those with incomes just above the poverty line – face the greatest challenges in terms of access to health-care services and high out-of-pocket costs. Roughly 5 percent of PWDS have no insurance at all. All of these issues of access would be addressed under the NHI plan, which would cover everyone and would be financed by a system of progressive taxation.
Drug coverage. As the recent discussion of expanding drug benefits under Medicare illustrated, affordability of prescription drugs is a huge problem. Under the NHI program all prescription drugs and medical supplies prescribed by a licensed practitioner would be paid for by the federal government, based on a national formulary, and made available to all with no out-of-pocket charges.
Non-disability-related health care. Many care providers focus so much on the disability-related health care needs of their patients that the more general needs are neglected. The Kaiser study pointed out that PWDs “are less likely than the general population to receive preventive services [e.g. mammograms, dental exams] and receive these services considerably less frequently than is generally recommended.” Under an NHI plan, where there would be no possibility of saving money by risk avoidance and cost-shifting, it would be clear that prevention and wellness is in the best interests of everyone. This would make it far more likely that PWDs would receive such care at the same rate as the general population.
Home services often not covered. Advocates stress that there is a big difference between health insurance and long-term care insurance. Many PWDs need little in the way of “health care’ of the type covered by health insurance. Instead, the greatest ongoing need may be for ongoing support for activities of daily living. The NHI program would cover people with disabilities of all ages for all necessary home and nursing home care, with local public agencies in each community determining eligibility and coordinating care. The Physicians’ Proposal states that “Since most elderly people and people with disabilities would prefer to remain in their homes, the program would encourage home- and community-based services.” Again, since the program is universal, the fiscal advantages of keeping people in their homes and in their communities would be a powerful incentive to follow through on this promise.
There are some risks for Minnesotans with disabilities in going to the NHI system.
State-to-state variation. Many people with disabilities rely on Medicaid to pay for needed health care and support with activities of daily living. Under the current system, coverage under Medicaid varies widely from state to state. Currently, the health care system and public programs serving PWDs are better in Minnesota than in many other states. This means that there is a risk of a reduction in benefits for Minnesotans under the NHI system, as there may be political pressure to level the “playing field” at a mid-point rather than at the higher Minnesota level.
Benefits design/definition of disability Chris Duff points out that “We need to have different programs for different needs, and there is a great risk of a universal system gravitating toward a one-size-fits-all approach, which would ill-serve PWDs… The danger is a tyranny of the [able-bodied] majority over the minority.”
In the end, advocates stress that, under any new universal system as well as under the current system, the most important thing is that PWDs have a seat at the table. The crucial decisions about design, implementation, program eligibility, benefit sets, and so forth – the decisions that determine the quantity and the quality of health care for most people with disabilities – will have to be made under any system. If and when our current dysfunctional health care system is replaced by a system of National Health Insurance, the degree to which the needs of people with disabilities are met will depend, as it does now, on the political clout of the disabled population.
The final word goes to Ida Hollander, Executive Director of Physicians for a National Health Program, sponsor of the Physicians’ Working Group for Single-Payer National Health Insurance. In an interview with Access Press, she said, “It’s important for PWDs to be very active in the [health care] reform movement… Groups that work with PWDs must participate in the movement, educating people about the needs of PWDs. That is just really important.”