The House Republican leadership’s bill is more radical than legislation being considered in the Senate. Besides pushing beneficiaries into private insurance plans to get prescription drug coverage, the House legislation would also force many into private plans for their doctor and hospital coverage. In contrast, the Senate legislation would partially privatize Medicare by making private insurance companies the exclusive vehicle for obtaining subsidized prescription drug coverage. The Senate legislation would do less to push beneficiaries to enroll in private plans to obtain the doctor and hospital coverage they already have through Medicare.

This report exposes the disappointing history of private insurance plans in Medicare. Given their history, the House bill is likely to mean only more disappointment for seniors and people with disabilities.

The Bush Administration, Congressional Republicans, and a number of Democrats are proposing to privatize the Medicare program. Twenty years of experience with Medicare Health Maintenance Organizations (HMOs) reveals that privatized Medicare has been a dismal failure. Especially in California, which has lived with privatized Medicare more than any other state, giving private insurance companies power over the health care of senior citizens:

.. Reduces choice;
.. Increases costs to patients and government; and
.. Puts insurance company business decisions above medical decisions between patient and physician.

A pdf copy of The Dismal Failure of Medicare Privatization is available online.

107TH CONGRESS
1ST SESSION H. R. 3080

To establish a United States Health Service to provide high quality comprehensive
health care for all Americans and to overcome the deficiencies
in the present system of health care delivery.

IN THE HOUSE OF REPRESENTATIVES OCTOBER 10, 2001
Ms. LEE introduced the following bill; which was referred to the Committee
on Energy and Commerce, and in addition to the Committees on Education
and the Workforce, and Ways and Means, for a period to be subsequently
determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
A BILL
To establish a United States Health Service to provide high
quality comprehensive health care for all Americans and
to overcome the deficiencies in the present system of
health care delivery.
1 Be it enacted by the Senate and House of Representa2
tives of the United States of America in Congress assembled,
3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
4 (a) SHORT TITLE.—This Act may be cited as the
5 ‘‘Josephine Butler United States Health Service Act’’.
6 (b) TABLE OF CONTENTS.—The table of contents of
7 this Act is as follows:
2
•HR 3080 IH
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Purposes.
Sec. 4. Definitions.
TITLE I—ESTABLISHMENT AND OPERATION OF THE UNITED
STATES HEALTH SERVICE
Sec. 101. Establishment of the Service.
Sec. 102. Appointment of the National Health Board.
Sec. 103. Powers and duties of the National Health Board.
Sec. 104. Representation in local and regional authorities.
Sec. 105. Public accountability and financial disclosure.
Sec. 106. Inspector General.
Sec. 107. Establishment of health care delivery regions.
TITLE II—DELIVERY OF HEALTH CARE AND SUPPLEMENTAL
SERVICES
Subtitle A—Patients’ Rights in Health Care Delivery
Sec. 201. Basic health rights.
Sec. 202. Right to paid leave to receive health care services.
Subtitle B—Eligibility for, Nature of, and Scope of Services Provided by the
Service
Sec. 211. Eligibility for services.
Sec. 212. Entitlement to services.
Sec. 213. Provision of health care and supplemental services.
Subtitle C—Health Care Facilities and Delivery of Health Care Services
Sec. 221. Establishment of health care facilities and distribution of delivery of
health care and other services.
Sec. 222. Operation and inspection of health care facilities.
Sec. 223. Provision of health services relating to reproduction and childbearing.
TITLE III—HEALTH LABOR FORCE
Subtitle A—Job Categories and Certification
Sec. 301. Effect of State law.
Sec. 302. Qualifications of health workers.
Sec. 303. Establishment of job categories and certification standards.
Subtitle B—Education of Health Workers
Sec. 311. Health team schools.
Sec. 312. Service requirement.
Sec. 313. Payment for certain educational loans.
Subtitle C—Employment and Labor-Management Relations Within the Service
Sec. 321. Employment, transfer, promotion, and receipt of fees.
Sec. 322. Applicability of laws relating to Federal employees.
Sec. 323. Applicability of Federal labor-management relations laws.
Sec. 324. Defense of certain malpractice and negligence suits.
3
•HR 3080 IH
TITLE IV—OTHER FUNCTIONS OF HEALTH BOARDS
Subtitle A—Advocacy, Grievance Procedures, and Trusteeships
Sec. 401. Advocacy and legal services program.
Sec. 402. Grievance procedures.
Subtitle B—Occupational Safety and Health Programs
Sec. 411. Functions of the National Health Board.
Sec. 412. Community occupational safety and health activities.
Sec. 413. Workplace health facilities.
Sec. 414. Employee rights relating to occupational safety and health.
Sec. 415. Definitions.
Subtitle C—Health and Health Care Delivery Research, Quality Assurance,
and Health Equity
Sec. 421. Principles and guidelines for research.
Sec. 422. Establishment of institutes.
Subtitle D—Health Planning, Distribution of Drugs and Other Medical
Supplies, and Miscellaneous Functions
Sec. 431. Health planning and budgeting.
Sec. 432. Distribution of drugs and other medical supplies.
Sec. 433. Miscellaneous functions of the National Health Board.
TITLE V—FINANCING OF THE SERVICE
Subtitle A—Health Service Taxes
Sec. 501. Individual and corporate income taxes.
Sec. 502. Other changes in the Internal Revenue Code of 1986.
Sec. 503. Existing employer-employee health benefit plans.
Sec. 504. Workers compensation programs.
Subtitle B—Health Service Trust Fund
Sec. 511. Establishment of health service trust fund.
Sec. 512. Transfer of funds to the health service trust fund.
Sec. 513. Administration of health service trust fund.
Subtitle C—Preparation of Plans and Budgets
Sec. 521. Determination of fund availability.
Sec. 522. Preparation of regional budgets.
Subtitle D—Allocation and Distribution of Funds
Sec. 531. National budget.
Sec. 532. Special operating expense fund.
Sec. 533. Distribution of funds.
Sec. 534. Annual statement, records, and audits.
Subtitle E—General Provisions
Sec. 541. Issuance of obligations.
Sec. 542. Definitions.
4
•HR 3080 IH
TITLE VI—MISCELLANEOUS PROVISIONS
Sec. 601. Effective date of health services.
Sec. 602. Repeal of provisions.
Sec. 603. Transition provisions.
Sec. 604. Amendment to Budget and Accounting Act.
Sec. 605. Separability.

To:     Vic Sidel

Frank Goldsmith

From:  Len Rodberg

Re: Proposed Modifications to Dellums Bill

I have reviewed the Dellums Bill, looking especially at those sections which our more recent experience suggests should be modified.  I don’t believe the core of the plan  — the provision of services in publicly-funded, prospectively-budgeted facilities by salaried personnel — should be changed.  However, there are a few things I would propose be changed, as follows:

1. We should strengthen the patient rights section in two specific ways: (i) by emphasizing that all users in a region should have equal access to all needed services, regardless of the location of their community, and (ii) that any limitations or delay in access to services should be based only on limits on available service personnel and physical facilities — that there shall be no financial barriers at the time of the provision of services, and that priorities in the use of services should be set by medical personnel using criteria of medical necessity.  (We can draw on language from the Kennedy/Wellstone et al proposals for some appropriate language, but we may want to go beyond them.)

2. We should move the ability to hire staff from the community level to the regional level.  This not only makes more sense, from the point of view of the staff, which would then have more mobility within the system, but it reflects what we have learned about the lack of experience, and the potential for corruption and nepotism, in community-level boards.  We should also emphasize the role of regional boards in assisting community boards in setting up and operating services.  And we should make clear that district health boards are responsible for specialized health services, whether in- or out-patient, so that medical specialists will generally be accountable to them for their services (Sec. 221(b)(2) does this in “such other health care facilities” language).

3. We should strengthen the informed consent provisions, especially in the patient rights and reproductive rights sections.  At present, these provide for access to services but do not seem to protect sufficiently from excessive or potentially dangerous treatment.

4. In explaining how cost savings will be achieved, we should emphasize, more than we did twenty years ago, the elimination of profits, now running as high as 30%.

5. We should introduce some more contemporary terms such as “case manager” (how about “care manager” instead?), “facilitator”, and “ombudsman”.

Do you agree with these suggestions?  Do you have other ideas for modifications we should make.  I will draft language that will implement these modifications and would welcome other suggestions you might have for improving the bill.

by Leonard S. Rodberg*

During the health reform debate of the 1970s, the Health Service Act — generally referred to as the Dellums Bill — was first introduced into the Congress. Every two years since then, as each new Congress has convened, this legislation has been reintroduced.  More recently, it has been introduced, as HR 3000, by Rep. Barbara Lee (D.,CA), Congressman Dellums’ successor. (Copies may be obtained by writing to Rep. Lees’ office.)

To help prepare for renewed activism around health care reform, I will review here the design of that legislation, describing its objectives and the basis of its design. This will provide one starting point for thinking about national health programs. The issues we were addressing in the mid-70s remain the most critical problems facing medical care today, and the design put forward then remains a valuable guide to a progressive approach to health policy.

REALISM OR UTOPIANISM?

The Dellums Bill was the first legislation ever introduced into the US Congress that would create a national health service. Those of us who participated in developing it were accused of being “utopian”. We were under no illusion that this draft legislation would quickly be enacted, or even that it would soon be widely debated in the media. Our objective was not, at that stage, to pass legislation, but to educate the public on the need for a new way of organizing and delivering health services in this country. Beyond this, though, there are a number of reasons why the charge of utopianism was wrong:

The Dellums Bill did not emerge out of the heads of a few people of off-beat political or ideological persuasion. It grew out of the experience of the civil rights movement and other movements of the 60s and early 70s and out of the experience of many health professionals, minority groups, women’s groups, and others in that same period.

The initial decision to develop such legislation was reached in 1972, when Congressman Dellums asked the Medical Committee on Human Rights to prepare a draft of the principles that should underlie a national health program. The Medical Committee, an organization of health workers performing support work with the civil rights movement, prepared a statement of principles which became the basis for the Health Service Act. As the legislation evolved, many other groups representing the elderly, minorities, women, social workers, labor unionists, public health professionals, health policy analysts, and others were involved in its preparation and gave it their support. The American Public Health Association, American Medical Student Association, the National Association of Social Workers, the Gray Panthers, the United Electrical Workers, and other organizations gave it their backing. The experiences of these groups, and their demands for improvements in health services, are reflected in many provisions of the Dellums Bill.

It is clear that the concepts which lie behind the Dellums Bill have a constituency. It is not a constituency that counted prominently in American politics, but it is substantial and it is broad. It is also clear, from national polling data, that it could have the support of a much wider part of the general population, if its content could be made known to them. When the general public is asked for its views on the future of the nation’s health system, a large percentage always indicate that they favor making the government responsible for the provision of health care.

What are the limitations of National Health Insurance?  It would not offer significant benefits to more than 15-20% of the population, that portion which now lacks insurance or is underinsured. While it is quite true that this part of the American population needs help, it is also true that they do not have health insurance because they do not have the political power. If they are not sufficiently well organized to obtain health insurance from their employers, are they likely to garner the support needed to achieve Congressional passage of National Health Insurance?  Our intention in designing the Dellums Bill was to develop a health plan that would benefit a majority of the population of the country, not just those who are presently uninsured or underinsured.

The Dellums Bill proposes a system which would actually work. That is, unlike many health reform plans that would not actually achieve their stated objectives, this plan, if it were put into effect, would actually solve the problems it is addressing. These problems are, in my view, the most serious issues facing the medical care system, and National Health Insurance, were it to be implemented, would not necessarily solve any of them.

GOALS OF THE DELLUMS BILL

What were our criteria in designing the Health Service Act? First was the issue of cost, not because it was central in our own thinking, but because it was the primary issue in the 70s, and it continues to be fundamental. The mainstream view was, and remains, that one of the principal problem with health care in America is that it costs too much. The health care problem is often defined as a cost problem. The Carter Administration, having coming into office in 1976 committed to developing a national health plan, set up a forty-member task force; one was a physician, thirty-nine were economists. To participate in the public debate, one has to recognize this and, at a minimum, propose a plan that would not fuel the cost inflation that is of great concern in the media and among policymakers.

The liberal solution was to impose some sort of regulatory cost control that would constrain further cost increases without tampering with the organization of health care. The cost problem is, in fact, very deeply structural. The US health care system has a financial structure designed based on fee-for- service, with payment based on the type and quantity of service delivered, but in a context in which there is third-party insurance coverage, rather than consumer payment, for many services. One cannot have this mix of an entrepreneurial market structure (on the part of both physicians and hospitals) and third-party reimbursement without expecting a continuing spiral of costs.

The right-wing solution is to make the “consumer” (as the patient receiving the service has come to be called) responsible for holding down costs. Whether by sharing the cost through higher deductibles and co-payments, being taxed on health-related fringe benefits, induced to choose providers on the basis of cost, or being forced to leave high-cost inpatient services prematurely, patients are being forced to shoulder the burden of containing costs.

Our alternative is to reject the inherently inflationary fee-for-service system, a structure that is obsolete, both economically and technologically.  In an era of capital-intensive medicine, in which assurance of payment is essential for the provision of service, the fee-for-service model makes no sense. No one designing a health system today, with the massive, heavily-capitalized institutions that make up the health care industry, would opt for a fee-for-service model of payment, if other options were available. The growth of managed care prepaid health plans or HMOs attests to the recognition of this on the part of consumers as well as the health care industry itself.

In addition, the fee-for-service system is inherently oriented toward an acute care, curative approach to medicine. This may have been appropriate a century ago, or even fifty years ago, when infectious and viral diseases were the principal threats to health. However, the illness structure we face today, in what has been called the Second Epidemiologic Revolution, is very different.  Unlike infectious diseases, the principal diseases we face today — cancer, heart disease, stroke — are not amenable to short-term acute treatment. They require long-term preventive action involving both individual and social measures. This suggests that we needed to organize the health care system so that it will emphasize prevention along with cure, while providing the stability that our massive health care institutions require.

Central as well to the thinking behind the Dellums Bill is the serious maldistribution of health care resources in the US. Large numbers of people in this country do not have access to health care facilities. The Federal Government finds that 50 million people — nearly a quarter of our population — live in officially-designated underserved areas. This is a major problem for the constituencies that would be most responsive to the Dellums Bill concept.

The medical care system, too, needs a dose of democratic involvement, to assure that the system takes into account the interests of the people who use or work in that system. Hospital boards are unrepresentative of the people that use the hospitals, and fee-for-service physicians act as private entrepreneurs. We need processes that will create democratic control of the health system, making it more responsive and accountable to the needs of people it serves.

SYSTEM DESIGN

The Health Service Act would create a community-based national health service. While this sounds like a contradiction, it is simply the application to the health system of the American idea of federalism, that different levels of political organization should be involved, each to perform their appropriate function.

To be explicit, the Act would create a nationally-funded network of regionally-planned, community-based prepaid health plans. The system would be nationally-funded, so that inequalities among communities would not prevent the equitable provision of health services.  Residents in every community in the land would have access to the system.  They could go to the service providers nearest to them, or to any others within the national system. The system would be regionally-planned, so that services would be available to each community with every region on a rational and equitable basis. The system would be community-based to provide the core of democratic control I believe to be essential. And these would be prepaid health facilities, replacing the obsolete and inflationary fee-for-service system with a prospectively-budgeted, prevention-oriented system of health care.

The intention is to design a national system that avoids the creation of a giant bureaucracy. No one wants a large, unaccountable bureaucracy running our medical care system. What we want is equity, national access, and greater justice in the health care system. Health care would be a right of every resident. This country, which led the world in establishing the idea that education should be a basic human right; would now catch up with the rest of the industrialized world in giving everyone access to health care as a matter of right.

If the central problem of an inflationary health care system is the fee-for-service system of providing and financing care, the answer is a nationally funded, prospectively-budgeted health plan. The system would be funded through national taxation, with these funds disbursed to each community on the basis of their population, so that low- and middle-income communities would have the same access to quality medical services as would higher-income communities. The funds would be made available through a system of annual budgets for capital and operating expenses, so that the provision of medical services would not be dependent on the receipt of individual fees for services offered. Services would be provided by salaried health workers.  Today, more than 95% of those who work in the health care system are salaried; under the Dellums Bill, all providers of services would be hired by the local boards that oversee the system.

Geographically, the system would be organized on the rational basis advocated by every health planner. Primary care services would be offered through community-based facilities, accessible in the localities where people live and work. General inpatient services would be provided on a somewhat broader level, and specialized services on a still-broader level, with overall planning and basic research finally conducted at the national level.

The plan envisions, then, a four-tiered structure beginning with what we called the “community”, an area of between 25 and 50 thousand people where primary care services would be provided. Our model is the community health center, of which there are now hundreds throughout the country. The plan does not require, though, that each community build a physical structure or “community health center”. Instead, the community health system would be a coordinated network of primary care providers, integrated with each other so users of the system could easily find their way through it without the kind of confusion that users today, particularly the elderly, experience in trying to get medical care.

An elected Community Health Board would administer the local health institutions and the health advocate for the community. The overall system rests on the belief that the health problems facing us are best dealt with on a preventive basis, not through attempted after-the-fact cures. The Community Health Board could provide — or demand from the local government — actions that would prevent illness and enhance the health of its constituents.

The next level above the Community is the District, serving approximately 250,000 people with general inpatient hospital services. Above that is the Region, serving a metropolitan-sized area with specialized inpatient services (e.g., trauma services, organ transplants). The Region is also the level where health worker education would be carried out.

Medical schools, nursing schools, etc., would be incorporated into this system, so that health worker education and training would be oriented toward the kind of medical care and preventive services offered within the system. The community-based, prevention-oriented approach would be integral to the training of newly-graduating health workers. Much of this would take place in community-level primary care settings, rather than in the typical specialty-oriented hospital base that is common today. Education would be free, but students would be obligated, as in the National Health Service Corps, to serve in this system for a specified period when they graduate.

In an attempt to deal with excessive physician dominance within the health system, the plan includes provision for health worker teams that would supervise patient care and for educational ladders, through which health workers could expand their skills and move into areas of broader medical responsibility.

The National level of the system would focus on the planning of financing arrangements, establishment of standards for the provision of care, and setting research goals and priorities.

To achieve equitable access to health services, funds would be allocated to Regions, Districts, and Communities on a per capita population basis. Funds would not be distributed, as they are in an insurance system, through the institutions that provide services, wherever they happen to be but, rather, on the basis of the people using the services, to the Communities, Districts, and Regions where people live. Funds would then be allocated by the health boards at each level to the institutions within their responsibility.

A supplemental fund is provided for groups such as the elderly and the poor known to have more expensive health care needs and requiring more funds than the average.

The system does not attempt to forbid or do away with private practice. It simply says that this U.S. Health Service would be free to users, and no one who works for it can provide private care “on the side”, nor use its facilities for private patients. So it takes a hard line on dual loyalties, but does not attempt — as does no country in the world — to eliminate private practice.

SUMMARY AND CONCLUSION

The Health Service Act was devised using concepts developed in the civil rights and other movements of the 60s and early 70s. It shows a progressive vision of how medical care could be organized. The model remains relevant in spite of the changes that have occurred in health care since it was first prepared. The problems it addresses — escalating cost, maldistribution of resources, lack of preventive emphasis, lack of democratic accountability — are still with us, exacerbated by the growth of the for-profit managed care industry. It still describes the kind of health care system we should want. If it is what we want, we should organize for it, and get it.

* Leonard Rodberg teaches urban studies at Queens College/CUNY. In the mid-70s, while at the Institute for Policy Studies in Washington, DC, he coordinated the drafting of the Dellums Health Service Act and was a founder of the Coalition for a National Health Service.  He is a member of the Board of Directors of PNHP-NY.

Health Program

The American Public Health Association,

Recognizing that equal opportunity to attain and maintain good

health should be the central goal guiding the financing and provision

of health care; and

Having developed comprehensive criteria for a national health

care program that would remove financial, organizational, and social

impediments to achieving this goal;¹ and

Having, pursuant to those criteria, consistently supported a national

tax-based single-payer plan,² because of its simplicity, its

capacity to contain national health care expenditures without jeopardizing

the nation’s health,^3,4 and its facilitation of public accountability;

and

Recognizing that the need for such a program becomes more

urgent as insurance coverage declines and health care becomes increasingly

unaffordable for many U.S. residents;^5-8 and

Realizing that, unless aggregate national expenditures for health

care are contained, payer-driven efforts to limit costs are likely to result

in cost shifting and would possibly worsen patient outcomes; and

Recognizing the nation’s seriously deteriorating public health

infrastructure;^9-10 and

Considering that, to assure the availability and accessibility of

prevention programs and essential community providers, a major

emphasis on community-based public health programs is needed; and

Concerned that the past year has witnessed wholesale for profit

corporatization of U.S. health care, with a pronounced trend toward

profit maximization and oligopoly;^11-15 and

Believing that a privately capitalized, profit-maximizing health

care industry is unlikely to be the route to cost-effectiveness and

universal access, and, that unless effective regulation of that industry

can be instituted, adoption of single-payer is unlikely to yield the

savings usually associated with single-payer unless the entrepreneurial

model on which health care is currently being reorganized is abandoned;

and

Reaffirming its support for legislation to achieve universal,

comprehensive health care, legislation that reflects the Association’s

14 principles for a national health care program and that covers all

residents of the United States, Puerto Rico, the Northern Marianas, and

U.S. territories, regardless of legal resident or immigration status; and,

to this end;

Reaffirming its support for a single-payer approach to health care

financing, with provision for (a) fair payment to providers, via mechanisms

that will minimize incentives either to overserve or to underserve,

and (b) planning and evaluation with participation by both consumers

and providers; therefore

1.  Urges strengthening of public health programs, with a major

emphasis on essential public health services and community-based

programs as essential parts of a national health program, with funding

at a level of at least 3 percent of all health expenditures;

2.  Urges the President and Congress to take all necessary steps

to propose and enact legislation to achieve these ends;

3.  Urges Congress, in the interim, to facilitate state initiatives

and ERISA (Employee Retirement Income Security Act) waivers to

extend and expand coverage, including state-level single-payer initiatives;

4.  Urges Congress and U.S. healthcare researchers to institute

studies of the impact of corporatization in the healthcare system upon

cost-effectiveness and accessibility of health care, so that Congress can

respond with legislation to protect the public; and

5.  Supports proposals that would extend and/or expand coverage

incrementally, so long as (a) they are consistent with APHA’s

established criteria, (b) their adoption can be considered a step toward

universal coverage and unlikely to impede enactment of a single-payer

system, and (c) they would not reduce the levels of existing services

and protections before replacements of at least equivalent scope and

quality become available.

References

1.   A National Health Program for All of Us. Washington, DC: American Public Health Association; 1993.

2.   Toward a Comprehensive, Universal National Health Program. “Late-breaking’’ resolution adopted by APHA Governing Council, October 27,1993, San Francisco, CA. APHA.

3.   Canadian Health Insurance: Lessons for the United States. Washington, DC: General Accounting Office; 1991. GAO/HRD-91-90

4.   Congressional Budget Office analysis as reported by D. Priest, The Washington Post, December 17, 1993.

5.   Current Population Surveys. Health Insurance Coverage. Annual updates, 1988-1993. Washington, DC: Bureau of the Census.

6.   Blendon RJ, Donelan K, Hill CA, et al. Paying medical bills in the United States: Why health insurance isn’t enough. JAMA. 1994;271:949.

7.   Blendon RJ, Scheck AC, Donelan K, et al. How White and African Americans view their health and social problems. JAMA. 1995;273:341.

8.   EBRI Databook on Employee Benefits, 1995.

9.   Smith DR. Porches, politics and public health. Am J Public Health. 1994; 84:(5) 725-726.

10.  Projections of National Health Expenditures. Washington, DC: Congressional Budget Office, 1993.

11.  Tomsho R. Giant hospital chain uses rough tactics to push fast growth. Wall Street Journal. July 12, 1994.

12.  Anders G, Stout H. With Congress stalled healthcare is shaped by the private sector. Wall Street Journal. August 26, 1994.

13.  Hofmeister S. A $3.3 billion hospital deal is proposed. New York Times. October 12, 1994.

14.  Peterson I. Health care and hospital chains. New York Times. November 15,1994.

15.  Major healthcare deals of 1994. Jenks Healthcare Business Rept. 1995;6(8):3.
]]> http://nhsusa.wordpress.com/2009/10/03/9502-toward-a-comprehensive-universal-national-health-program/feed/ 0 ldw http://nhsusa.wordpress.com/2009/10/03/7018-a-national-program-for-personal-health-services/ http://nhsusa.wordpress.com/2009/10/03/7018-a-national-program-for-personal-health-services/#comments Sat, 03 Oct 2009 18:38:17 +0000 ldw http://nhsusa.wordpress.com/?p=34 ]]> 7018:  A National Program for Personal Health Services

To resolve the widely recognized crisis in our country’s health

care, the American Public Health Association recommends a national health care program to include democratically constituted consumer-majority policy-making bodies at every level of administration and with:

1.  Universal coverage

• for all civilian residents of the United States

2.  Comprehensive benefits

• including preventive, diagnostic, therapeutic, health maintenance and rehabilitative services for all illness categories and health conditions
• provided through primary care teams of physicians, dentists, nurses, and allied health workers that are linked with specialty consultative personnel, hospital, nursing-home, home-care, and all other necessary services to meet patients’ total health needs
• and meeting federal quality standards

3.  Financing by a combination of federal social insurance and general tax revenues

• to insure health care as a social right
• to achieve reasonable equity in paying for it

4.  Reform of the health care delivery system

• to assure equal access to good health care for all
• to achieve efficiency and effectiveness in the delivery of health care

• to facilitate interaction between private sector delivery functions and governmental financing functions

5.  Organization and administration involving federal, stale.

and local governments with the assistance of regional organizations for planning and evaluation

• with health-oriented direction at all levels

6.  Public accountability

• that assures maximum responsiveness of the health system to public needs
• with adequate data systems for monitoring performance and comparative evaluation

7.  Economic leverage of governmental financing on the delivery system including

• payment to providers of care for professional and institutional services to defined population groups on a per capita basis
• annually negotiated rates for institutional providers and choice of prepayment or fee-for-service payment for professional providers
• incentives for providers to adopt patterns of organization and payment aimed at achieving more effective and efficient services, particularly those embracing prevention of illness, accessibility, and continuity of care

8.  Revamped state programs for licensure of health facilities

and health personnel to insure that they

• meet a federal minimum standard
• encourage the elevation of standards to the highest possible level
• provide for consumer participation in policy-making bodies
• provide for reciprocity of professional licensure of health workers moving from one state to another
• promote facility development and franchising in proper relation to social needs
• include periodic inspection of facilities and examination of personnel
• provide prompt disciplinary action against those failing to comply with standards or other requirements

9. Adequate manpower, service, and facility resources with

• massive federal support for reorientation and expansion of basic and continuing education programs in the field of health; recruitment and support of students from segments of the population heretofore largely excluded from the health professions by economic, race. and sex discrimination; fostering the education of more professional health personnel who are interested in providing primary, personal, family health care; retraining present health workers and developing new types of health workers on a career ladder who can assume many of the tasks now performed by present types of health workers
• redirection and enlargement of federal support of organized health services and facilities with emphasis on support or regionalized health services; development of organized health care delivery systems with emphasis on primary care teams and internal linkages among various providers of services
• expanding research in health services to discover new and better ways of providing quality care most economically.

The American Public Health Association,

Noting that it has for the past 30 years, endorsed removal of

economic and organizational barriers to health care for the

American people; and

Noting that it has, for many years, supported a universal system

of financing health care for the entire population and major changes

in the organization and delivery of health services; and

Noting that the resolution adopted at the 104th Annual

Meeting in 1976 in favor of a national health service is an

Association statement of the appropriate health goal for the nation;

and

Recognizing the criteria for assessing legislative proposals for

national health service and national health insurance programs,

adopted at the 105th Annual Meeting in 1977;and

Noting the powerful forces opposing even moderate health

insurance proposals; and

Recognizing that the Medicare and Medicaid programs provide

social financing of some health care for particular segments of the

population and therefore represent programs from which we need to

learn lessons;

1.  Urges that, in order to remove inequities in access to health

services for the total population, it contribute to the enactment of a

sound national health insurance program by supporting legislative

action that would improve the nation’s system for financing of

health care; and would be consistent with further development

toward a national health service;

2. And therefore urges that such legislation should strongly

influence patterns of delivering care by promoting health centers,

health maintenance organizations, and regional organization of

hospitals, to assure comprehensive and integrated preventive,

therapeutic, and rehabilitative services and a major shift away from

fee-for-service payment of practitioners to more cost-effective

methods such as salary, capitation, and fee-for-time;

3.  Reaffirms support of those national health insurance

proposals that come closest to implementing the policy statement

on criteria for assessing national health service or national health

insurance programs adopted at the 105th Annual Meeting in 1977;

and

4.  Recommends specifically that any national health insurance

legislation enacted contain the following elements: 1) universal

coverage; 2) comprehensive service, including preventive services; 3) no co-payments or deductibles; 4) effective measures to remedy

deficiencies in rural and other underserved areas; 5) strong

safeguards of patient’s rights; 6) administration by governmental

health agencies; 7) national standards and other measures for quality

control of services; provisions for cost containment through

discouragement of fee-for-service payments and support of a system

of budget review and rate setting; 9) strong encouragement of health

centers, health maintenance organizations, and regional organization

of hospitals to improve the health care delivery system.

To:  Rep. Barbara Lee

Staff of Rep. Barbara Lee

APHA Medical Care Section Council

From: Len Rodberg and Ellen Shaffer

Re: Proposed Revisions in the United States Health Service Act

The original Dellums Bill, in the form of HR 1374 from the 105th Congress, has been reviewed by an informal working group communicating largely via e-mail. The group came up with a number of small-scale changes in language as well as a number of large- scale concerns about the overall structure of the bill, and of the health system which it would create. We believe the language changes can be made immediately, but the larger questions require much more detailed examination and review of alternatives before they can be implemented.

This memo presents these two categories of suggestions:

A. IMMEDIATE LANGUAGE CHANGES

1. Access to health care should not depend upon employment status, as it does in the present system.

In Sec. 2(3) and Sec. 3(1), insert “employment status” before “or previous health status.”

2. Recognize the growing number of uninsured persons.

Add the following to Sec. 2:

(4) The present health care system has failed to provide financial coverage for health care services for more than forty million Americans, and the number lacking such coverage grows each year.

Renumber the existing Sec. 2(4)-2(8) to 2(5)-2(9).

3. Recognize the importance of prevention and its absence in the present system.

Reword the new Sec. 2(5) as follows:

(4) The present health care system has failed to provide for sufficient effective preventive measures that would address the deterioration in occupational, environmental, and social conditions affecting the health of the people of this Nation.

3. Recognize the deleterious impact which for-profit medicine is having on the provision of health care.

Add the following to Sec. 2:

(7) The growth of for-profit medical care and for-profit managed care is making it difficult for medical personnel to provide, and patients to receive, the full range of health services they believe to be necessary and desirable.

Renumber Sec. 2(7)-2(9) to 2(8)-2(10).

4. Though the principle of salaried health workers is correct, using the term “salary” may create unnecessary problems in public presentations on the bill.

In Sec. 3(1), replace “salaried health workers” with “health workers employed by the United States Health Service”.

5. Users should be able to receive service at any facility within the Health Service.

In Sec. 201(1), change “receive high quality health care and supplemental services” to “receive high quality health care and supplemental services from any facility within the U.S. Health Service capable of providing such services”.

6. Care should be denied or postponed only for medical reasons.

Add to Sec. 201(3):

Any decision to deny or postpone care shall be made only on the basis of the user’s health care needs and the availability of service personnel and physical facilities. Users shall have the opportunity for timely appeal of any decision to deny or postpone care.

7. Patients should be informed of all possible treatments that are medically appropriate, regardless of their cost.

In Sec. 201(7)(A), change “alternatives to such service” to “all medically appropriate alternatives to such service”.

8. Patients should have access to persons who can help them receive the services they need.

In Sec. 201(10), add:

This shall include access to user advocates who shall–

(A) assist users in choosing the most appropriate sites from which to receive health services and the most appropriate health workers from whom to receive such services,

(B) provide counseling and assistance to users in filing complaints, and

(C) investigate instances of poor quality services or improper treatment of users and bring such instances to the attention of the applicable authority.

9. The regional boards should be responsible for ensuring that all users within their region have access to needed services, regardless of where they live or work within the region, and for ensuring that priorities in the use of services should be set on medical grounds alone. They should also be responsible for all hiring of Health Service staff for their region. (They are already responsible, under the Bill, for their education and training.)

Add the following to Sec. 221:

(e)(5) Each regional board shall assist the community and district health boards in its region in establishing and operating services. This shall include providing for the education of health workers, as provided by Sec. 311, hiring all health workers for the region, and purchasing or leasing of such premises as it deems necessary and suitable, in consultation with the appropriate community and district health boards in its region.

(e)(6) Each regional board shall, in addition, and taking into account guidelines established by the National Health Board, take whatever steps are necessary to ensure that all of the above-listed health services are available and accessible in a timely manner to adults, infants, children, and individuals with disabilities in its region. Toward that end, it shall:

(A) ensure that users within its region have access to a sufficient number of each category of health worker including primary care providers, specialists, and other health care professionals. Such providers shall, to the maximum extent possible, be geographically accessible to all residences and work places within the region and shall be culturally and linguistically appropriate;

(B) ensure that services are available in a manner which ensures continuity of care, availability within reasonable hours of operation, and include emergency and urgent care services which shall be accessible at all times within the service area. Any process established to coordinate care shall ensure ongoing direct access to relevant specialists and shall not impose an undue burden on users with chronic health conditions;

(C) ensure that appropriate steps are taken to eliminate any transportation or other barriers to the timely receipt of services;

(D) ensure that a user who has a severe, complex, or chronic condition shall have access to the most appropriate health care coordinator; and,

(E) ensure that priorities in the use of services and facilities shall be set by the appropriate health care professionals using criteria of medical necessity. Any limitations or delay in access to services shall be based only on limits of available service personnel and physical facilities.

As used in this section, the term “health care coordinator” means a health worker who performs case management functions in consultation with the health care team, the patient, family, and community. The term “case management” means a coordinated set of activities conducted for the management of an individual user’s serious, complicated, protracted or chronic health conditions in order to ensure cost-effective and benefit-maximizing treatment.

Only regional health boards would be able to hire health care workers or purchase or lease facilities.

In Sec. 221(e)(1), change “hire health workers” to “utilize health workers”. In Sec. 321(e), change “hire” to “utilize”.

In Sec. 221(e)(2), change “purchase or lease such premises” to “utilize such premises”.

10. All decisions to provide or not to provide service should be based on clear criteria and should include provisions for appeal by the patient.

Add to Sec. 221(f):

The National Health Board shall also establish clinical decision criteria that shall apply throughout the Nation. The term “clinical decision criteria” means the recorded (written or otherwise) screening procedures, decision abstracts, clinical protocols, and practice guidelines used to determine the necessity and appropriateness of health care services. Such criteria shall be clearly documented and available to all health workers and shall include a mechanism for periodically updating such criteria. Each health board shall provide users with timely notice of any determination under these criteria to provide, deny, or delay provision of a service. Such notification shall include information concerning the appropriate procedure to appeal such decision.

11. No health worker should benefit financially from the provision or denial of services to individual patients.

Add Sec. 321(f):

No health board may establish financial arrangements with any of its employees which would provide direct or indirect payments as an inducement to provide, limit or reduce necessary services furnished to a user.

Renumber existing Sec. 321(f) to 321(g).

12. District health boards should review periodically whether hospital facilities are needed.

In Sec. 221(b), insert before “establish and maintain” the following: “periodically determine the necessity to establish and maintain in its district inpatient and other specialized health care facilities. Where found appropriate, it shall”.

13. Homemaking and home health services should be provided to any bedfast or severely handicapped individual.

In Sec. 213(b)(3)(B), eliminate “provision of such services eliminates the need for the individual to receive inpatient services”.

14. Allow for an expanded definition of preventive services. (More explicit language might be added after further study.)

In Sec. 221(a)(2)(B), at after “including” the following “, but not limited to,”.

15. Require consent before medical procedures can be performed for demonstration purposes.

In Sec. 311(b)(5), add at the end “or without their explicit consent”.

16. The proposed National Institute of Evaluative Clinical Research should gather evidence on clinical effectiveness and on the most effective practices.

In Sec. 422(2), add at the end of (A): “including identifying underservice, overservice, and inappropriate care and their consequences”. In (D), replace “new” with “most effective”. Add “(E) provide consumer education on clinical effectiveness guidelines and the most effective preventive, diagnostic, and treatment practices.”

17. Recognize the need for studying the health consequences of economic factors and of inequality by the proposed National Institute of Sociology of Health and Health Care.

In Sec. 422(5)(D), add “economic” after “social”; add “distributional” after “occupational”.

18. Require that health information be culturally appropriate.

In Sec. 433(b), before “and shall include”, add “including culturally appropriate descriptions for the Nation’s principal cultural and ethnic groupings,”.

B. POTENTIAL LONG TERM, MORE FUNDAMENTAL MODIFICATIONS

1. Streamlining. A number of people found the administrative and board structures in the Bill to be too cumbersome. The principal reason for this was the four-level structure of geography and administration designed by the drafters to ensure a democratic, bottom-up control structure for input and accountability within an organizational structure for a health system involving primary, secondary, and tertiary care. This involved, for instance, creating entirely new service delivery areas. One suggestion was that some existing areas (e.g. health service areas, health professional shortage areas, HHS and OSHA regions, or existing political divisions) might be used instead, although none may be appropriate for this purpose.

There was also a suggestion that the interim board structure be eliminated. This was introduced by the drafters as a way of establishing the new local service areas and the locally- controlled board organization. Some people felt it was too cumbersome, but no alternative has yet been developed.

2. Recent advances. The Bill could more directly reflect current developments where there have been advances in the last 20 years such as in information systems, clinical guidelines, and organizational standards for high quality care. For instance, Recent thinking on the assessment and improvement of the quality of health care might be incorporated into the Bill. This might include assigning explicit responsibility to some agency within the system for monitoring and improving health care outcomes on a population and individual basis and recommending steps to improve the quality and organization of health services. This would require some serious “task force” work and lengthy discussion, so that it would be carefully integrated into the unique health service framework set up by the Bill.

3. Salaried health workers. Since the proposal to put all health workers on salary is one of the most controversial elements of the Bill, it may be desirable to review this issue. Last time around (the late 70s) this was used as a basis for arguing the value of pre-paid vs. fee-for-service practice. This may still be an important argument, since much of what passes for “managed care” today still pays for services on a fee-for-service basis, i.e., hospitals and MDs are still largely paid on that basis.

4. A role for the states. One continuing argument has been around the fact that there is no role in the Bill for the states. Can one be found? The drafters could not find one that would maintain the national standards and accountability and the bottom-up accountability structure. The analogy, in short was more to the national postal service than to the local health department.

5. Population guidelines for geographic areas. The Bill sets rough population guidelines in defining health care delivery areas. Should it continue to do so, or is this too detailed? If they are kept, does it still have the right numbers? Are they appropriate for rural areas?

6. OSHA and EPA. The USHS takes over both the preventive/screening roles of OSHA and EPA and their enforcement roles. Since EPA’s responsibilities are so broad, this might at some point be re-examined, with only a portion of its environmental responsibilities subsumed under the USHS.

7. Sterilization waiting period. A 30-day waiting period is prescribed for any treatment that would affect reproductive capacity. This grew initially out of discussions with sterilization-abuse advocacy groups. It might be discussed with such groups again to see if a better formulation can be developed.

8. Generic drugs. Sec. 432(b)(3) provides that all drugs will be purchased by components of the USHS under a competitive bidding process, but they will be distributed under their generic names. This was intended to attack profiteering by the pharmaceutical industry. Should the requirement that only generic drugs would be used be reconsidered?

9. Access to medical records. At present, the Bill allows medical records to be withheld from patients in some circumstances. This was recommended by persons working in mental health, but it might be reviewed.

10. Local accountability. The Bill contains an extensive system of accountability for local boards such that they can, for instance, be put into “trusteeship” if they fail in various ways. This might be reviewed to see if it is either excessive or insufficient.

11. Malpractice. The Bill has the Federal Government providing malpractice protection for all employees of the USHS. This should be reviewed to ensure that plaintiffs have full rights to legal redress in the event of malpractice.

12. Union recognition. The Bill brings the USHS within the National Labor Relations Act but does not go beyond it. Language might be incorporated that would require the USHS to maintain neutrality in any union organizing drives and certification, and provide for recognition of the union based on card checks, without requiring an election.

13. Long term care. The Bill includes provision for long term care but does not spell out under what conditions it should be provided. This might be expanded using current thinking on ADLs.

14. Rural health. The Bill may need improvements to accommodate the special health care needs of rural areas.

15. Health workers. There may be need for some special provisions regarding the relation of the work that health workers do to the training they receive. The Bill is concerned with expanding the roles that health workers can play, to the maximum of their abilities. Today there may be the opposite concern, that workers are being required to perform work beyond their training or capabilities. The Bill also requires that all health workers get experience in both primary and secondary care; some exceptions may be needed for researchers and other specialized employees of the Health Service. Finally, the Bill does not provide for the setting standards for staffing levels. Some reworking of Sec. 303 and related sections may be in order.

16. Health planning. There may be some suggested revisions taking account of newer thinking on health planning._

—

HON. RONALD V. DELLUMS

in the House of Representatives

THURSDAY, APRIL 17, 1997

* Mr. DELLUMS. Mr. Speaker: I rise to honor the memory of Josephine Butler by introducing the Josephine Butler United States Health Act. This legislation is named after a heroic African-American fighter who lived in this Nation’s Capital. The Josephine Butler United States Health Service Act seeks a comprehensive, universal national health care system based on health care for people, not profits; on community control of health care, not corporate control; commits to the proposition that a health care system in the richest Nation in the world should be available to everyone living in this Nation, and that such a health care system must be dedicated to the whole person, their family, and their community.

* Josephine Butler was a holistic activist, whose passion and tireless energy encompassed not only health care but statehood for the District of Columbia, the environment, the trade union movement, women’s rights, the welfare of children, the arts, peace and justice for all nations, and neighborhood parks. Josephine Butler, called by some the Harriet Tubman of the District of Columbia, a founder and former chairperson of the D.C. Statehood Party, was guided by a fierce commitment to the right of self-determination for all peoples. Ms. Butler brought the D.C. statehood movement to people across the United States and to the United Nations.

* Josephine Butler was an international and a courageous peace activist. She was founder of the D.C. chapter of the Paul Robeson Society, and a founder of the World Congress of Peace. Her concern for peace was worldwide–from the former Soviet Union, to the island of Grenada, the Middle East, South Africa, and back to the District of Columbia. In 1994 Ms. Butler received the National Partnership Leadership Award from President Clinton for the work she had done in transforming the once crime-ridden Meridian Hill/Malcolm X Park into a place of beauty. Her work as cochair of the Friend of Meridian Hill led the President to cite the group as a `shining example for the nation’ of what community activism can accomplish.

* Josephine Butler, born January 24, 1920, moved to Washington, DC, seeking medical treatment for typhoid fever as a young girl from the Brandywine area of Prince George’s County where her father had been a sharecropper. She began working in a laundry and took the lead in organizing laundry workers in the D.C. area into a union. She remained involved in union activities, committed to the rights of workers for the rest of her life.

* In the late 1950′s and early 1960′s, Jo Butler was incapacitated with tuberculosis. Upon recovery, she became a volunteer for the D.C. Lung Association, and then the association’s community health educator, where she worked from 1969 to 1980. Her deep commitment to adequate health care for all led her to serve as a founding board member of the Committee for a National Health Service formed in the 1970′s. She died on March 29, 1997, but remains alive in our hearts, supporting our efforts to achieve universal health care for this great Nation.

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