This is the first of two parts on the crisis in health care. The second installment: Budget cuts are leaving a homeless, mentally ill population with few options.
Elvia is a mild-mannered, 38-year-old woman who worked in a bank in her native Mexico but now makes $480 a month taking coats and cleaning at a Latin nightclub in West Seattle. She pays $400 of that for a tiny room above the nightclub that she shares with her two young daughters, which leaves her the grand sum of $80 a month for any other expenses, including food, clothing, and health care.
Not surprisingly, she doesn't see the doctor often. Nor do her girls, ages 6 and 3. For her, the $10 co-pay required by her state-subsidized Basic Health Plan is a princely sum. Even the bus fare to South Park's Sea-Mar Community Health Center, the nearest place she could find that accepts Basic Health insurance, poses a significant dent in her monthly budget. She used to get free care through Medicaid at a clinic behind her home, until the state dropped coverage for illegal immigrants in October.
Elvia is one of the lucky ones. At least she's going to keep her health insurance. The state Legislature is now considering whether to kick some 60,000 childless adults off the Basic Health Plan almost half of the people it coversas proposed by Gov. Gary Locke in his attempt to shrink the state's gaping budget deficit or radically scale back the plan's coverage. The former would, for the first time in more than a decade, leave much of the working poor without a safety net other than relying on the charity of community clinics and hospitals. Even if these already crowded facilities will be able to absorb the influx, folks jettisoned from Basic Health will lack access to specialists and affordable medications.
And it's not only the poor who cannot afford our health care system. The signs of a crisis are everywhere: Doctors are refusing to see retirees who are insured by Medicare; the number of uninsured has risen (from 8 percent to 10 percent of the state's population over the last two years, and the number is poised to go higher if the governor's cuts go through); emergency rooms are overcrowded; doctors are leaving the state or retiring early because of inadequate payments from insurance companies and the government; health care inflation is alarmingly high; some prominent physicians' practices around the state recently closed because of financial trouble. The list goes on and on.
All of this is forcing health care back onto the political agenda, but it is being welcomed with about as much enthusiasm in legislative hallways as the plague. Politicians burned out on health care after the reform fiasco of the early '90s that occurred both federally and locally. It was a political failure, not a practical one; in this state, the then-Democratically controlled Legislature set a national first by adopting a plan for universal coverage, then dismantled the plan a scant 18 months later before it was even triedafter a Republican electoral sweep took Olympia. But that futile close to years of work, followed by the nasty battle between former Insurance Commissioner Deborah Senn and insurance companies over access to policies for individuals, has had a chilling effect.
"Even the advocates feel like they've been there and done that," says state Rep. Eileen Cody, the Seattle Democrat who chairs the House Health Care Committee. "There's a real sense of hopelessness." With Senn gone, the leadership on health care is subdued and the ideas for reform timid. Her successor, Mike Kreidler, has an interesting plan that just might catch on. But like everyone's these days, his ideas are a testament to how little is believed to be achievable.
THE POOR AND THE MIDDLE CLASS
Sea-Mar is the second biggest community health provider in the state, with nine clinics used heavily by Latinos. At its crowded South Park clinic, Dr. Drew Malloy, a wiry man with blond hair and a beard, bemoans the likely impact of proposed state cuts: "Basic Health has been a lifeline for people, especially for those with chronic conditions." Some patients have $200 or $400 monthly bills for drugs, such as those with diabetes, heart disease, or high blood pressure. "If they can't afford high-blood-pressure medication, they're going to end up having a stroke prematurely," Malloy says.
Then they'd probably end up in emergency rooms that wouldn't be reimbursed for their care, given another cut that Locke has proposed that would mean wiping out the "medically indigent" program by which the state covers some of the expenses for uninsured hospital patients.
The state's assault on health care for the poor goes deeper yet: The governor wants to drop optional hearing, dental, and vision care from Medicaid coverage, while at the same time, his administration has been seeking a federal waiver that would allow fewer people to be covered by Medicaid. (Currently, the Medicaid program is for poor children and their parents, provided they're not illegal immigrants, as well as disabled or pregnant adults earning below the poverty level. The state and federal governments split the costs of Medicaid. The state-funded Basic Health Plan picks up the slack for illegal immigrants and targets the working poor who earn slightly more than those qualifying for Medicaid.)
And yet, while Malloy is worried about his poor patients, he's struck by a phenomenon he considers even more striking. "You know what I think the really scary thing isthe way Medicare is being shunned by private physicians in this state," he says.
Medicare is a huge program of federally funded health insurance for most retired Americans 65 and older.
Malloy has received a pile of letters from doctors' groups in the last few months that begin "we regret to inform you" and end with how they're no longer accepting Medicare patients. In fact, a recent survey by the state medical association found that 57 percent of responding doctors were either limiting Medicare patients or dropping them altogether from their practice.
Malloy understands the reason: In March, the feds will implement a 4.4 percent cut in reimbursements to doctors for care of Medicare patients, a cut that comes on top of a 5 percent cut last year. To make matters worse, due to complicated bureaucratic reasons, the Medicare program was already paying doctors in this state much less than elsewhere; only eight states have lower payments.
Still, Malloy says, the decision to drop Medicare patients will have profound implications. "That means your parents and my parentsmiddle-class peopleare not going to be able to see physicians in the very near future. That's going to be a revolutionary change." In a way, it gives him hope: If the middle class is affected, if constituents of the powerful American Association of Retired Persons are up in arms, maybe reform really will come about.
Similarly, Dr. Hugh Clark is hoping that disgruntled seniors locked out of medical care will start creating a ruckus about Medicare payments with the same kind of fervor that has brought drug coverage for seniors to the political forefront. (Medicare doesn't provide coverage for prescription drugs.)
Clark is an internist specializing in geriatrics who belongs to the Minor and James Medical clinic. As it happens, the day before we talked in mid-January, Clark's group of internists unanimously voted to stop taking new Medicare patients.
"Enough is enough," is how Clark sums up the prevailing sentiment. While Medicare payments are going down, he says, expenses are going up. Most significantly, he notes that the cost of malpractice insurance is shooting through the roof his is going up 30 percent this year to the annual sum of $9,800a phenomenon that has spurred a lobbying campaign for legislative tort reform.
Doctors like Clark say they are fed up, not only with malpractice insurance costs and the low rate of Medicare reimbursement, but with similarly low fees paid by Medicaid (which physicians long ago began to abandon) and increasingly stingy private-insurance plans.
According to the state medical association, an increasing number of doctors are consequently moving out of state or retiring early. Clark himself is on the verge of retiring a couple of years earlier than he had planned. Ironically, that will put him on Medicare, too. How does he intend to find a doctor? "Beg," he quips without missing a beat. "I've been around a long time. I suspect doctors will not turn me down."
BIG PROBLEMS, TIMID LEADERSHIP
The problem seems to grow in inverse proportion to the leadership that stands ready to take it on. Up until a few years ago, we had fire-breathing Senn as insurance commissioner, who stepped down from office after her failed run against Maria Cantwell for the Democratic nomination for the U.S. Senate race. Contentious as she was, Senn was the only one willing to wrestle with insurance companies and keep the plight of consumers in everybody's face.
Senn's absence was especially noticeable when the governor announced his proposed cuts in December. One suspects Senn would have promptly held a press conference on the Capitol steps to dramatize the import and launch some feisty, if politically unpopular, initiative. In contrast, the reaction from her successor, Kreidler, was silence.
As if to underscore the diminished visibility of the Office of the Insurance Commissioner, it has been moved from the marbled grandeur of the Insurance Building on the main Capitol Campus in Olympia to a new nondescript insurance building in the strip-mall hinterland of Tumwater. (The governor displaced the insurance commissioner after earthquake damage to the Capitol.)
One recent morning in his neat-as-a-pin office, the 59-year-old Kreidler made a case for his low-key approach, evident in his quiet, conservative manner as well as in the substance of his ideas. "The system is really very much deteriorating right now, no question about it," says the former Democratic congressman, who is also an optometrist and a lieutenant colonel in the Army's Retired Reserves. "It is not sustainable. Nobody is saying it is. You need a comprehensive solution. You can't just go in and make piecemeal changes.
"At the same time," he argues, "you need a strategy that appeals to the broad middle," politically. Kreidler had a front-seat view of the backlash that ensued when the Democrats pushed for health care reform at the state and federal levels. After serving on a congressional committee involved in Hillary Clinton's reform effort, he lost his congressional seat after just one term to religious conservative Randy Tate in 1994. A little later, he watched the state dismantle reforms he had helped to come up with when he served on a task force appointed by former Gov. Booth Gardner.
The strategy he now champions aims for universal coverage but of a dramatically scaled-back sort. The coverage would be for "major medical" or "catastrophic" expenses, the kind of plan that has a $5,000 or $10,000 deductible.
The onus would be on individuals to buy their own insurance as a legal requirement, along the lines of auto insurance. In a blatant attempt to appeal to the right, Kreidler puts this in terms of "personal responsibility." But such plans would be relatively cheap, both because of their limited coverage and because, according to Kreidler's notion, the state would direct insurance companies to "pool" their clients when setting rates, rather than offering vastly different rates for the healthy and sick, young and old.
Although some have questioned whether mandatory health insurance could be enforced, Kreidler believes "you could get pretty close to 100 percent" compliance by tying it to things like employment, school enrollment, and obtaining a driver's license.
The notion has some momentum behind it. In Congress, Sen. John Breaux, an influential centrist Democrat from Louisiana, is pushing it. Locally, a Renton primary care doctor named Vern Cherewatenko has been proselytizing the major medical insurance model while spearheading a national movement among physicians to go to a cash-only system. (Most patients would be paying cash if their insurance only kicked in after $10,000.)
Kreidler says he's on the verge of creating a task force to flesh out the idea, with the aim of putting together legislation for the 2004 session. As yet, though, the opinion makers to whom Kreidler has been preaching haven't exactly gone wild with enthusiasm, and you can see why. A major medical insurance plan isn't going to do much for the person who can't afford bus fare to see the doctor, never mind up to $5,000 or $10,000 worth of annual expenses. And though Kreidler says that most employers would continue to offer full insurance, you have to wonder whether the burden wouldn't completely shift to the individual.
Kreidler admits that his plan is limited, which he accepts with a kind of defeatism. "I'm not wedded to this being the only plan," he says, animated now. "It's just the only one out there. The thing I don't want to do is to try to solve this problem and wind up failing again."
He speaks for a lot of people. There are, actually, a few other ideas out there, but they are all like ghosts, lacking the vigor of prior reform efforts. Gubernatorial hopeful Phil Talmadge, the former Democratic state legislator who championed the now-repealed state reform act of 1993, wants to leverage the state's buying power by appointing a single purchaser of its various insurance plans. He also looks to Oregon's example with Medicaidthe state broadened coverage but limited what it would pay for.
Onetime hell-raiser Senn, now a private practice attorney specializing in health care cases, has given up talking about universal coverage and rate regulation and is onto the notion of "wellness" care as a cost-saving health care fix. She talks up "health coaches" that some businesses have hired to help employees with problems like smoking and obesity.
From universal coverage to health coacheswhat a difference in the political climate. And even the most limited reforms are a hard sell at the moment. While the governor's proposed cuts call new attention to the health care crisis, they also put off any big-picture solutions; all legislators can think about is how to come up with a little more health care money, a few more Basic Health slots. As Randy Revel, vice president of the Washington State Hospital Association, puts it: "When you're up to your backside in alligators, it's hard to remember that your main job is to drain the swamp."