HEALTH CARE/Joan Retsinas

Health Policy: Springtime Optimism

Spring is too lovely a time for despair. When the sunshine is luring crocuses to life, even Cassandra would take a break from doom-saying. And because this year's vernal equinox coincides with a soaring Dow, I, like Pangloss, see the world -- even health care policy -- through the lenses of optimism.

True, the census of uninsured Americans mounts; and our two presidential contenders have not made grandiose promises -- which suggests that as president neither would propose grandiose solutions. True, health plans' finances remain shaky; and hospitals' finances, shakier. Yet some glimmers bode well for patients. Here are a few.

Transplant donations have risen. We still have waiting lists -- but the number of kidney and liver donors doubled, from 1,918 donors in 1988 to 4,273 in 1998. The reason probably lies in heightened public awareness, spurred by a fiercely-contested federal regulation to eliminate the regional bias in waiting lists -- a regulation that took effect in March. (The old system made your residence a key factor in your chances of getting a donated organ). Perhaps the brouhaha surrounding the legislation propelled more would-be donors to sign the requisite forms.

Congress resolved the Catch-22 of disabled beneficiaries. Of the 9 million Medicare/Medicaid beneficiaries classified as "disabled," many would like to work. Indeed, the Americans with Disabilities Act is supposed to help people with disabilities work. Medicare's $700/month earnings threshold, though, bars most beneficiaries from working: if they earned more than $700/month, they would lose their government coverage. A computer programmer who earned $20 an hour could work no more than 35 hours a month without losing health insurance.

The prospects for a part-time employee to get other insurance are dim: Few part-time workers qualify for an employer's health care insurance. As for individual policies, they are exorbitantly expensive; and individual policies for a person with a disability even more so. At last, Congress has dropped the $700 threshold. Medicare will continue to cover those workers, and Congress will give states grants to enable low-income disabled workers either to buy into Medicaid, or buy into their employer's insurance.

Even though Congress has relegated "the uninsured" to the back of its legislative burner, state legislatures haven't. With varying levels of enthusiasm, states are embracing and extending their Children's Health Insurance Programs, covering families above Medicaid poverty-levels. Today, CHIP covers 2 million children. Admittedly, CHIP is not a panacea: 11 million children remain uncovered. The rise in CHIP coverage is balanced by declines in Medicaid coverage, as clients leave the welfare rolls, and by declines in private-sector coverage, as some small employers drop insurance. But for states the program marks a step forward as an insurer. Workers who can't afford the premiums for their company's plan can join their state's plan. As more people come under the umbrella of their state's subsidized insurance, more taxpayers may recognize health insurance, like education, as a legitimate state expense. While states are not the optimum vehicle for universal insurance, they are feasible ones.

States may also be starting to protect the physicians and hospitals that are battlefield casualties in the insurance wars. Today six national for-profit insurers have survived from a bigger corps of ten years ago. When a health care insurer closes, it can leave physicians and hospitals with unpaid bills. In 1998 two New Jersey health plans failed -- owing providers $150 million. New Jersey's Assembly recently passed a law that would divide up the losses: one-third to be borne by the remaining health plans, one-third by the taxpayers, one-third by the providers. Again, not a panacea, but a plausible approach.

The most optimistic analyst would concede that these are mini triumphs at best, yet in the best of all worlds, these mini triumphs will be harbingers of more substantial legislative actions. That, after all, is the promise of spring.

Joan Retsinas is a sociologist who writes about health care in Providence, Rhode Island.

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