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Building a Progressive Majority in the States:
Health Care for All

Solving the health care crisis -- rising costs for everyone and lack of access for tens of millions of America -- should be a top priority for progressive leaders. Rightwing politicians, supported by pharmaceutical and other self-interested corporate lobbies have blocked many reasonable reforms in the past, but state leaders are beginning to enact innovative proposals that are models for reforming the system. There are clear options to help extend quality, affordable health care to all our states' residents.

The crisis in the health care system is clear. 45 million Americans have no health care insurance and for those that do have insurance, the costs of co-pays and other out-of-pocket expenses increase by the year, making health care costs the cause of nearly half of all personal bankruptcies. And while two-thirds of working families still get their health insurance through their employer, those responsible employers providing health care find it hard to compete in the marketplace with firms that don't. As irresponsible employers dump health care costs onto individuals and state Medicaid programs, the strain threatens to swamp employer, family and social services budgets across the country.

One key step to health care reform is reasserting the shared responsibility of employers to pay their fair share of health care costs. Under no scenario can individual, family or state budgets replace the current multi-billion dollar employer contribution to health care costs, so states should make it a priority to stabilize that employer contribution to employee health insurance. While comprehensive reform is needed to replace the current fragmented health care structure, states like Maryland, Vermont, Massachusetts and major counties in New York in the last year have enacted laws that require employers, especially larger ones able to afford it, to pay their fair share of health care costs. The details may differ but the core principle is to create a level playing field where responsible employers are not forced to drop health care coverage because they face unfair competition from unscrupulous competitors.

Progressives are taking important steps to extend affordable coverage to all our states' residents. Many states are moving aggressively to extend affordable health care to the uninsured population. This has come from a combination of subsidized coverage to more children of working families, better options for the unemployed, and offering subsidized lower-cost insurance options for individuals, families and small businesses, even as states are discussing more comprehensive reforms. One thing progressives should resist, however, are movements by the rightwing to use the rhetoric of "reform" to undercut quality care for those currently receiving Medicaid or other subsidized health options in their states.

Promoting aggressive cost savings from those profiteering from the health care system is one key way to help finance expanded coverage. States are beginning to use their regulatory and bargaining power as large consumers of health care to drive down excessive costs by pharmaceutical firms, insurance companies and health care providers. As lower health care costs in Canada and Europe demonstrate, a system with more universal coverage creates opportunities to drive down costs as special interest groups lose the ability to hide profiteering under the cover of hidden cost-shifting in a patchwork system.

As the health care crisis expands, voter support for dramatic action on health care reform only grows. To highlight the degree of support, a 2003 ABC/Washington Post poll found that even when given a choice between "providing health care coverage for all Americans, even if it means raising taxes, OR, holding down taxes, even if it means some Americans do not have health care coverage," 79% of adults preferred raising taxes to provide health care for all. And among Hispanics, a key emerging swing vote, a June 2005 Democracy Corps poll found that 87% of those voters were more likely to support a candidate promising that "all Americans have access to health care." While challenging in the details, health care reform is one of the most popular political issues for which progressive leaders can fight.

Key Health Care for All Policies:

Maintaining and Extending the Employer "Fair Share" Responsibility for Health Care Costs: To preserve employer contributions to the health care system, different states have begun holding irresponsible employers responsible for health care costs in a number of ways, including:

• Robust Requirements for Large Employers: To create a model that could later be expanded to more employers, Maryland, New York City and Suffolk County (NY) have each enacted laws that require certain large employers to provide a significant health care commitment to their employees.
• Smaller Broad-Based Fee: As an alternative approach, Vermont and Massachusetts enacted small health care fees on employers refusing to provide health care for their employees, but applied this assessment to nearly all employers in those states.
• Disclosure Laws: A limited but important step are state laws that collect and disclose the names of employers whose workers are forced to use publicly funded health care programs like Medicaid, SCHIP and uncompensated care funds in hospitals. Such laws not only shame irresponsible employers but give the public better information in designing new health care reforms.

Extending Health Care to the Uninsured: With the goal of extending affordable, quality health care to all state residents, states are taking a number of steps in that direction:

• Covering Kids: Building on the federal SCHIP program, states have been expanding health coverage to larger portions of the population, the most ambitious being Illinois' AllKids program to offer either free or heavily subsidized options for all children in the state.
• Covering Working Poor and Unemployed: A number of states have extended Medicaid to a larger percentage of the population, thereby expanding coverage and assuring workers that taking a job does not mean losing health coverage for them or their family. Other states like Vermont, Maine and (more tentatively) Massachusetts have enacted legislation to create a subsidized health care option available to a broader range of individuals and small businesses.
• Comprehensive Solutions: A few states such as Wisconsin are debating comprehensive approaches that would combine employer contributions, state resources, and individual co-payments into an integrated system to guarantee coverage for almost all state residents.

Health Care Cost Savings: Since the US spends roughly fifty percent more of its GDP on health care than comparable countries in Europe for generally worse health care results, it is not surprising that states have identified a range of reforms to cut costs by increasing efficiency and eliminating special interest profiteering by health-related companies, including:

• Prescription Drug Cost Controls: States can lower costs through tough bargaining with drug companies for bulk purchases, form purchasing pools with other states, and require "step therapy" regimes to only prescribe more expensive medications after less expensive drugs have been tried.
• Reviewing and Auditing Claims: State Medicaid programs should audit claims and eliminate providers who burden the system with excessive charges or unnecessary care. "Pay for performance" standards should be implemented to improve performance, eliminate wasteful procedures, promote less stressful conditions for caregivers to prevent medical mistakes, and eliminate racial and ethnic disparities in care.
• Health Information Technology: If states encourage hospitals and doctors' offices to implement health information technology to better track patients and avoid medical errors, estimates are that states could collectively save $77 billion a year on efficiency savings alone.
• Eliminating Conflicts of Interest: To prevent self-dealing and conflicts of interest, doctors should be prohibited from referring patients to care facilities, prescribing drugs or otherwise making medical decisions where they have a financial interest in the medical referral.