The nation's lawmakers last month explored incremental proposals to reduce the number of Americans who lack health insurance while leaving intact President Bush's request for $400 billion over 10 years for Medicare reform.
The House and Senate each passed versions of the 2004 budget resolution containing the Medicare provisions. Congress has until April 15 to reconcile them and send a joint budget to Bush. However, final Medicare spending likely will depend on the duration of the war and recovery in Iraq.
Congress and the White House also responded with a flurry of proposals (see box) to events organized last month by the Robert Wood Johnson Foundation, business, labor and other healthcare groups that make up the Covering the Uninsured coalition.
Some 41.2 million people were uninsured in 2001, including 8.5 million children, according to the most recent U.S. Census Bureau figures. But a report by Families USA and the Lewin Group puts the number at nearly 75 million people under age 65 who went without insurance sometime in 2001 and 2002.
Former Oregon Gov. John Kitzhaber, M.D., said the entire underpinning of the current system needs to be challenged, including consideration of means testing for seniors covered by Medicare and the development of a safety net for all citizens. The objective of the healthcare system should be health and not just access to care, Kitzhaber said at a March 16 meeting of healthcare journalists in San Francisco.
"We don't want to pit young vs. old, but we have to have the courage and honesty to view Medicare and Medicaid through the lens of the 21st century," Kitzhaber says. "What are we getting compared to what we're paying for?"
Kitzhaber did not seek re-election in 2002 and now meets with national stakeholder groups to help frame the healthcare debate for the 2004 presidential election.
"I don't think the medical profession can hide behind the notion of clinical autonomy anymore," he says. "They can't practice in splendid isolation thinking their choices don't impact other areas."
Bush advocates a multipronged approach to the uninsured that includes Medicaid reform, expansion of the role of community health centers and tax credits. He proposes spending $89 billion over 10 years on tax credits to help offset the costs of health insurance. The administration also touts its plan to treat more uninsured by adding or expanding 1,200 new community health center sites to care for 6 million more Americans.
About 40% of the 13 million patients treated at health centers have no insurance. Bush's budget for 2004 would increase funding for health centers by $122 million and bring total funding to a record $1.6 billion.
"Expanding the total number of centers is the right way to go," says Merle Cunningham, M.D., medical director of the Sunset Park Family Health Center Network in Brooklyn, N.Y.
Sunset is one of the largest community health centers in the nation, serving 90,000 patients with 600,000 visits annually.
Proposals for the uninsuredHR1181 Reps. Nancy Johnson (R-Conn.), Katy Grainger (R-Texas) and Albert Wynn (D-Md.) picked up Bush's charge and introduced tax credit legislation that would provide $1,000 to $3,000 to help people pay for health insurance.
S 588/HR 1205 Sen. Jay Rockefeller (D-W.Va.) and Rep. Pet Stark (D-Calif.) proposed a federally subsidized program modeled after Medicare to provide universal coverage for children.
S 654 Sens. Olympia Snowe (R-Maine) and Jeff Bingaman (D.N.M.) introduced a bill to improve the Medicare safety net by ensuring that health centers can participate in Medicare+Choice, receive free or donated services and supplies and expand preventive services under traditional Medicare. Reps. Jerry Weller (R-Ill.) and John Lewis (D-Ga.) introduced a companion bill in the House.
S 581 Sens. Orrin Hatch (R-Utah) and Ron Ryden (D-Ore.) proposed legislation to further study the insurance problem by allocating $3 million to create a Citizens' Healthcare Working Group.