When American Hospital Association trustees voted in January 1996 to revive the issue of increasing healthcare coverage, they knew they were fighting an uphill battle.
After all, it was less than a year and a half since the death of the Clinton administration's universal coverage health plan. Budget issues were dominating Congress. The number of uninsured Americans had passed the 40 million mark without so much as a blip on the radar screens of lawmakers or health or consumer groups.
But now, more than a year later, James Bentley, the AHA's executive vice president for policy, says it has been even more difficult than the board imagined.
"It's been disappointing and frustrating," Bentley says. "People are convinced there is nothing you can do. It's everybody's problem, but it's nobody's problem. Nobody is taking it on as their own problem. The worst conclusion is that people say there is nothing we can do and forget about it."
Actually, "forget about it" is exactly what many of the groups that once supported universal coverage have done.
"There is no doubt that there are a bunch of organizations that have some battle fatigue," says Ron Pollack, executive director of Families USA, a Washington-based healthcare consumer group that was one of the most enthusiastic supporters of the Clinton health reform bill. "But I think they will soon get a second wind. The interest in expanding healthcare (insurance coverage) hasn't gone away."
The problem certainly isn't going away. When the Clinton administration released its health insurance reform plan in 1994, which would have increased health coverage by requiring employers to cover their workers, there were 39 million uninsured Americans. Some estimates now show about 41 million are without coverage.
Not surprisingly, employer-sponsored health insurance coverage for full-time workers continues to decline. According to the Employee Benefit Research Institute, nearly 73% of full-time workers had coverage in 1992, when President Clinton took office. That number is projected to drop below 70% within two years.
Hospitals' uncompensated-care costs have remained steady over the past decade, accounting for about 6% of total costs annually (March 24, p. 18). According to AHA figures, that amounted to $17.5 billion in 1995, the latest year for which such statistics are available.
One group that supported the Clinton reform plan and its goal of universal coverage but has since turned its focus elsewhere is the Catholic Health Association.
William Cox, executive vice president of the CHA, says the lack of activity by provider and consumer groups on universal coverage "doesn't mean they don't want to do something, but right now it doesn't pass the laugh test on Capitol Hill."
Families USA, the CHA and a number of other groups are focusing on increasing the number of children covered by health insurance. Since Clinton announced at the Democratic National Convention last summer in Chicago that expanding health coverage for children would be one of his priorities, it has become the only healthcare reform game in Washington.
Republicans, taking a strategy out of the Clinton playbook, quickly answered with their own plan to increase children's coverage. Several proposals are now in circulation, many of which focus on getting into the Medicaid program the estimated 3 million children who are eligible for benefits but aren't enrolled. Other plans would expand Medicaid coverage or give the working poor tax breaks to help pay for private insurance.
Children, the groups argue, are a politically "safe" group, meaning one that is difficult for politicians to oppose. However, Pollack says he still believes the chances of enacting a plan are "probably less than 50-50" because there seems to be little consensus on a plan.
One group that still clings to the hope of universal health insurance coverage is the dwindling cadre of single-payer system advocates. On March 20, Rep. Jim McDermott (D-Wash.) reintroduced his single-payer plan in Congress with slightly more than 20 co-sponsors. At the height of the healthcare reform debate in 1994, McDermott's bill had nearly 100 co-sponsors.
McDermott says the problem of the uninsured will not "go away simply because Congress no longer talks about (it)."
The reintroduction of the single-payer bill is primarily a symbolic gesture because it has almost no chance of enactment this year.
And that is one of the chief obstacles facing those still working to increase health insurance coverage.
The AHA board's decision to readdress the issue of the uninsured was based on "a feeling that we were uncomfortable that it is becoming publicly acceptable that some large number of people will not have (health insurance) coverage. It's something that is acceptable in polite company," Bentley says.
This past January, the AHA board said it would work to reduce the number of uninsured by 4 million over the next two years. The goal is a somewhat nebulous one that would be achieved through community projects, outreach programs to other groups and private companies, and just about any other project or program that could lead to an increase in the number of insured Americans. However, it remains one of the very few steps being taken by any health or consumer group to address the problem of the uninsured.
According to Bentley, the AHA board hopes to select three or four national initiatives in which to become more involved when it meets in April.
"The board had a sense by the end of last year that it was possible to get the coverage issue back on people's minds," Bentley says.
AHA leaders are convinced the issue of universal coverage must be taken to heart by the middle class before it will again get national attention.
"We need to dispel the myth that you don't have to worry about this because you will always have the emergency room to fall back on," Bentley says. "Even some (AHA) members think that."