Debate Over Ballot Question that would Provide Universal Access to Health Care Heats Up
On Tuesday, November 7, Massachusetts voters may decide to make sweeping changes to the way in which health care is delivered in the state. Or, they may leave the system entirely untouched. On the ballot is Question 5, a petition that would provide access to health care to all state residents by July 1, 2002. The question has triggered a tumultuous battle between supporters and opponents. At stake is the manner in which every Massachusetts citizen will receive and pay for medical care.
Opponents to Question 5 say the petition leaves too many questions unanswered,
will put HMOs out of business, and will drive up the costs of health insurance--leaving
even more people uninsured. Advocates refute the claims, saying the petition
reflects a moral imperative to deliver quality care based on patient needs,
not financial bottom lines. ATS has invited a representative of each side
to explain the opposing positions:
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PRO Jerry Avorn In 1997, members of the Ad Hoc Committee to Defend Health Care, of which Jerry Avorn is a member, wrote "For Our Patients, Not for Profits: A Call to Action" published in the December 3, 1997 issue of JAMA. The paper urged the health care industry to become more patient-centered and less profit-oriented. Three thousand other health care professionals signed the document. "Something needed to be done to change the dangerous path that we as a nation were on--to redirect the incentives of the health care system purposefully and importantly, instead of tinkering trivially with co-pays and deductibles," said Avorn. Avorn said that Question 5 will not end managed care but may change the system as we know it. A provision in the petition allows patients to go outside of their networks if they choose to pay a fee; the proposed law does not dissolve the networks, he said. "Managed care needs to be organized in a way that is more sensitive to patient needs and clinical realities," said Avorn. "Unfortunately, managed care has become more a management of finances than actual management of patient care." Avorn dismisses concerns that the petition will actually lead to more people being uninsured due to increased premiums because of the way in which the petition is set up. The proposed law both guarantees universal access and bars insurance companies from raising premiums higher than the national average. The money that would be needed to cover costs for the uninsured would come not from more expensive premiums, but instead from cutting bureaucratic overhead within the companies and curbing poorly executed financial ventures, said Avorn. He added that the fact that the state's HMOs and insurance companies have announced that they will contribute significantly to a $4 million advertising campaign to defeat Question 5 is an example of how substantial sums are wasted in the present system. If the petition is supported by a large majority of voters, Avorn feels that the legislature will feel compelled to enforce it, unlike in the past when health care measures have died slow deaths at the State House. He said that he and other advocates will remind legislators of their duties if they choose to ignore the law. Some critics of the petition have feared it would replace Chapter 141, the patient bill of rights that was enacted in Massachusetts in July. At the time of the bill's passage, many experts believed that Question 5 would go away as a result, and some early signers of Question 5 withdrew their support for the ballot initiative. But Avorn said that his group has spoken with lawyers about the fate of Chapter 141 if Question 5 passes. According to Avorn, the Supreme Judicial Court will address any points at which the two overlap or depart to "harmonize" the documents. Avorn would like voters to keep in mind that "every industrialized nation has figured out how to provide universal access to health care to its citizens except for the United States. It's not the poor who are at risk; they have Medicaid. It's the working folks who have to worry about economic downturns and loss of coverage, and the middle class who don't know whether they will be able to keep their doctors if their coverage changes. This country and this state are too rich to allow for that."
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CON Nancy Kane Nancy Kane said she did not have an opinion on Question 5 until she read a copy of it last March. "I said 'Whoa, this has problems'," remembered Kane. "The petition sounds like motherhood and apple pie and underneath it's taking a sledgehammer to an imperfect system--but the shards of that system won't be perfect, either." Kane said she is supportive of the initiative's goal of universal access to health care but is concerned about the means by which its supporters hope to achieve it. She said that she and the rest of the authors of the Massachusetts Health Policy Forum report support the idea of coverage for everyone but don't agree that Question 5 is the best way to do it. Kane's biggest concern is the fate of the managed care system, which she thinks Question 5 will deeply undermine. Managed care has made health insurance more affordable and therefore within the reach of more people, said Kane. Question 5 would make it difficult for managed care providers to continue offering insurance at less expensive rates because the petition places unreasonable restrictions on the companies' ability to control costs, she said. If Question 5 passes into law, Kane said, it will raise costs for managed care plans (her fears were supported by a recently released study by the Massachusetts Taxpayers Foundations that says passage of Question 5 could cost as much as $5.6 billion a year; that figure is controversial.) The added costs will either be passed onto consumers or employers, who may choose to drop insurance plans and thus add to the uninsured pool, said Kane. "To cover everybody in the state would cost a couple of billion dollars per year," said Kane. "According to Question 5, insurers would be limited in passing on premium increases, and they can't control costs. Does that make sense? And when nonprofit managed care plans go bankrupt, they would be prohibited from being acquired by for-profit companies with deeper pockets." Kane said she would like to see universal health care coverage that results from a tax-based system in which everybody pays into a pool based on a payroll tax. She feels that Chapter 141, the Massachusetts patient bill of rights, already covers many of the managed care abuses that Question 5 addresses. "There have definitely been things that managed care companies have done that they shouldn't have, but the patient bill of rights is here to address that," said Kane. "Let's not blow up the managed care companies now." She doubts that the universal coverage part of Question 5 will be implemented even if it passes into law because the state of Massachusetts has a track record of failing to implement universal coverage mandates. She cited a 1988 law that called for universal coverage and then went a step further to mandate employers to provide it. The bill was repealed when small employers threatened to leave the state or claimed that implementing the measure would make them go bankrupt. Her advice to voters is to learn as much as they can about the initiative. Said Kane, "They don't have to read our analysis or listen to the proponents. They can read the initiative and draw their own conclusions." |
Avorn
was a founding member of the Ad Hoc Committee to Defend Health Care
and an architect of Question 5. A graduate of HMS, he has been a
practicing physician in the Longwood community since 1974. He is
currently the chief of the Division of Pharmacoepidemiology and
Pharmacoeconomics at Brigham and Women's Hospital and associate
professor of medicine at HMS. Go to 
Kane
co-authored a critique of Question 5 for the Massachusetts Health
Policy Forum in "An Analysis of Initiative Petition 99-4 'An Act
to Protect the Rights of Patients and to Promote Access to Quality
Health Care for All Residents of the Commonwealth'." For a
copy of the report, go to |
A Brief History and Explanation of Question 5 Question 5 originated in 1997 in the work of the Ad Hoc Committee to Defend Health Care, a group of doctors, nurses, and mental health practitioners in Massachusetts. Later, the related committee called Vote for Health--Yes on 5 based in Quincy, MA took up the cause. The committee collected more than 110,000 signatures to place the petition on the ballot. Question 5 proposes the formation of a Health Care Council that would make recommendations on how to provide universal health care to Massachusetts residents and conduct public hearings on the process. The council would include representatives of the Ad Hoc Committee to Defend Health Care, American Association of Retired Persons (AARP), American Federation of Labor--Congress of Industrial Organizations (A.F.L.-C.I.O.), Blue Cross and Blue Shield of Massachusetts, Health Care for All, Massachusetts Association of Health Maintenance Organizations, Massachusetts Business Roundtable, MassCARE, Massachusetts Hospital Association, Massachusetts League of Community Health Centers, Massachusetts Medical Society, Massachusetts Nurses Association, Massachusetts Public Interest Research Group, Massachusetts Senior Action Council, and others. The Health Care Council would work with a special legislative committee. The legislative committee would make recommendations by September 30, 2001 on how to enact laws to create the universal health care system by July 1, 2002. If passed, Question 5 would require that universal access be established before or on that date. The petition also guarantees that patients would have the right to choose their own doctors, regardless of network or hospital affiliation; patients would pay a fee if they choose to go outside of their insurance networks. The petition requires that at least 90 cents of every health insurance dollar goes towards health care and not administrative costs. And the proposed law would place a moratorium on the conversion of Massachusetts hospitals and health plans to for-profit status. |
