(Circulation. 2000;101:e9040.)
© 2000 American Heart Association, Inc.
Cardiovascular News |
Cardiovascular News
Health Care for All—In Maryland, At Least
Healthcare advocates in Maryland say that a statewide health plan to provide coverage to everyone—even the state’s 836 000 uninsured—is not only possible, but it will save money. They are pushing for a statewide debate that will result in a plan that meets the needs of Maryland specifically, said Glenn Schneider, spokesman for the Maryland Citizen’s Health Initiative. The statewide group is funded by the Abell Foundation, the Blaustein Foundation, the Casey Foundation, the Fund for Change, the Kreiger Fund, the Open Society Institute, the Straus Foundation, and the W.W. Kellogg Foundation. Its website is www.healthcareforall.com
"Our hope is, over the course of the next 2 or so years, to debate, discuss, and finally come up with a plan that is unique and works for Maryland so that we can cover everyone who needs health care," said Mr Schneider. More than 16% of Maryland citizens lack health care, and 100 000 of the uninsured are children. The premise of the group’s message is that "everyone in Maryland is entitled to have comprehensive health insurance, regardless of age, race, and economic status. If you live here in Maryland, you are entitled to health care."
The basic tenets of the plan are that everyone:
- Should have a choice of doctors
- Is entitled to a comprehensive set of benefits appropriate to his or her age and sex
- Has the right to have medical decisions left to the patient and provider without undue interference from an insurance administrator
- Is entitled to a comprehensive set of benefits appropriate to his or her age and sex
The debate must precede the plan, said Mr Schneider. Health advocates in Maryland have watched proposals for health plans come and go on the national scene and have been disappointed to see nothing come of such proposals. This group feels "that we can do it here in Maryland because we know that the people of Maryland support universal health care."
A poll by the organization found that 78% of the state’s population support the following statement: "if you are a resident of Maryland, you are entitled to comprehensive healthcare coverage." When the question was whether Maryland workers are entitled to a comprehensive set of health benefits, the number of people in favor jumped to 90%. "Now that is a public show of support," said Mr Schneider. In Maryland, 70% of those who are uninsured are people who work and their families.
A recent study the group commissioned from the Lewin Group indicated
that a single-payer model to cover everyone in Maryland, including the
uninsured, would actually reduce total health spending in Maryland by
$345.8 million. Most of the savings would come from the lower costs
of administering such a plan. Bulk purchasing of pharmaceuticals would
also lower costs in that area. A multipayer scenario would achieve
fewer administrative savings, but it would cost only $207 million more
in healthcare sending (an increase of 1.1% of current healthcare
spending).
The costs of such a plan would benefit families, according to the Lewin
Group. Under the single-payer plan, families with incomes 
$100 000
per year would pay more in taxes, but that increase would be offset by
the elimination of premium payments and reductions in out-of-pocket
spending for health care. Those with incomes of >$100 000 per year
might see a total increase in out-of-pocket costs.
However, a single-payer plan would be very inclusive, covering medically necessary in-patient hospital treatment, physician services (including those for preventive care), hospital outpatient services, prescription drugs, laboratory tests, and mental health services (including those for substance abuse and tobacco cessation). The program would also cover preventive dental care and vision examinations, but it would not cover orthodontia, private hospital rooms, or eyeglasses. Patients would be responsible for a $10 copayment for outpatient services or services in a doctor’s office.
"The only thing that would change in the healthcare system is who pays for the care," said Mr Schneider. Patients would be responsible because their copayment would go up if they elected to see a specialist without a referral from a primary care physician.
More than 600 organizations, including many in the healthcare field, have signed onto the coalition’s goal. "The fight for universal healthcare has been going on since the early 1900s," said Mr Schneider. "Toward the end of last year, all the advocates got together and decided to begin the debate. There hasn’t been any success in any other attempts to do this. We decided to start with the people. We will build grass roots support for the idea and come up with a plan together that we can take to the Legislature." Mr Schneider hopes that proposed legislation can be taken to Maryland’s legislative body in the year 2002.
If the measure does not pass in 2002, "we will make it the number one issue in the state and elect a Legislature and governor who are supportive of our plan–whatever it is. Then we will work to get it enacted in 2003."
According to the Census, there are 836 000 people uninsured in Maryland and an equal number of underinsured, said Mr Schneider. "That’s outrageous." Many of those supporting the measure are those who provide health care, including groups of cardiologists, emergency physicians, pediatricians, and family doctors.
Other states with organized universal health initiatives are Massachusetts, Minnesota, Michigan, California, Washington, and Oregon.
Maine Seeks to Reduce Drug Prices
The state of Maine became the first in the nation to set a deadline for the nation’s pharmaceutical firms to reduce the prices of drugs to consumers. On May 11, 2000, the state’s legislature voted to institute price controls on drugs by the year 2003 and immediately began negotiating for lower drugs costs on behalf of half of the state’s residents.
Maine’s governor Angus King signed the bill within hours of its passage. He said, "If the industry can consolidate and increase its market power, so can we. We’re going to bargain on behalf of 50% of our citizens, and we think that they deserve the same consideration as other groups that get discounts based on their volume." King noted that the solution should really come from the federal government but that, in the meantime, "we got some people up here who need help." The bill would allow the state to negotiate on behalf of its 325 000 uninsured or underinsured residents as well as the 200 000 people in the state who are on Medicaid or are covered by prescription drug programs for senior citizens.
The law would also impose "profiteering" penalties of as much as $100 000 per action on drug manufacturers or distributors who charge excessive prices for drugs or restrict supplies to the state. A 12-member commission will review drug prices in the state. The commission will also pay an extra $3 fee to pharmacies for every prescription filled under the program.
Maine’s legislative leaders anticipate that the pharmaceutical industry will challenge the law in court. A similar bill is in negotiation in the Vermont legislature. Other states have also passed or are considering laws that would make pharmaceuticals more available—at least to specific classes of patients.
For example, 13 states have either passed laws or have bills pending that would make people on Medicare eligible for discounts given the states’ Medicaid programs for drugs. Four states will make Medicare patients eligible for discounts based on a federal plan. State bulk purchasing plans have been approved or have been proposed in 7 states. Maximum prices for states or price control legislation has been considered in 8 states.
The Maine measure has prompted opposition from the pharmaceutical industry. Alan F. Holmer, president of Pharmaceutical Research and Manufacturers of America, a trade association, told the New York Times that the law "gives a ‘go-away’ signal to innovators, including Maine’s promising biotechnology industry, and will depress the climate for investment in the state." He noted that Maine has become the most anti-business state in the United States.
Racial Variation in Coronary Revascularization Procedures
Veterans Administration researchers found that whites were significantly more likely to receive a revascularization procedure (either percutaneous transluminal coronary angioplasty or coronary bypass) than blacks, even when statisticians controlled for other factors (Arch Intern Med. 2000;160:1329–1335).
Researchers studied the records of 666 veterans, 326 of whom were black. Selection strategy ensured that the age, admitting diagnosis, fiscal year of admission, and admitting hospital were all similar for black and white veterans in the study. Researchers found that black patients had less severe coronary artery stenoses than white patients with similar diagnoses. They also found that black patients were more likely to have hypertension, diabetes mellitus, and current or past alcohol abuse. Otherwise, they found no differences in the factors that would affect a decision about revascularization; these factors include mean age, left ventricular ejection fraction, operative risk score, comorbidity score, prior acute myocardial infarction, chronic obstructive pulmonary disease, peripheral vascular disease, and cigarette use.
Black patients were less likely than whites to undergo a revascularization procedure (28% versus 47%). The racial difference was greatest when clinical circumstances or indications for percutaneous transluminal coronary angiography were equivocal. Also, when the indication for coronary artery bypass grafting was clearly appropriate and necessary, black patients did not undergo the procedure at the same rate as white patients. Researchers found that whites were more likely to accept physician recommendations to undergo either procedure, but racial differences did not fully explain the differences in the numbers of patients undergoing procedures.
"We believe that future studies in this area should directly address the physician-patient interactions that lead to a physician’s decision to offer revascularization and the patient’s decision to accept it," the authors wrote.
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