The healthcare system in the United States is ailing—suffering from rapidly rising healthcare premiums, a growing number of uninsured and an uneven quality of care. As the public has become more aware of these problems, there has been a renewed interest in healthcare reform. According to the latest Kaiser Family Foundation survey, healthcare is the number-one domestic issue independent voters want presidential candidates to address, trailing only the war in Iraq.

When former President Bill Clinton tried to overhaul the nation’s healthcare system in the early 1990s, there were 39 million uninsured Americans. Today, nearly 50 million people in the United States are uninsured, including 9 million children. Despite the rising number of uninsured, Congress has not enacted significant legislation to address healthcare coverage since 1996, when the State Children’s Health Insurance Program (SCHIP) was passed.

While there seems to be widespread agreement on the need for healthcare reform, the kind of reform needed remains in question. Many in healthcare say the best way to address the problem is to make access to healthcare coverage universal. The public appears to be willing to move to a more universal form of healthcare coverage as well: A January 2007 poll by “NBC News” and the Wall Street Journal found that most Americans are willing to pay more for their health coverage or in taxes to guarantee coverage for everyone.

Proposals to expand healthcare coverage are numerous and include a wide range of approaches. Some experts are calling for employer mandates, also known as “pay-or-play,” where employers have the option to either “pay” a fee to the state to provide insurance for their employees or “play” by providing the coverage themselves. Others support tax subsidies that allow individuals who don’t belong to any insurance pool to buy into an existing government program, such as the Federal Employee Health Benefits Program (FEHBP).

When asked by AFT Healthcare what should be done to control healthcare costs, an AFT Healthcare member from New Jersey said we should “expand Medicare to cover everyone, even if it means higher taxes. Many are paying out of pocket for coverage. Something needs to be done.”

A member from Vermont said, “It is time to separate healthcare coverage from employment—but the tax burden should be on employers as well as individual taxpayers.”

In the meantime, governors and state legislators are taking the lead in addressing the issue. More than a dozen states are considering a healthcare program to expand coverage to the uninsured, including California, Illinois, Maryland, New Mexico and Washington. In July, Massachusetts became the first state to require its residents to have health insurance.

Forgotten mission

The number-one reason the uninsured don’t have insurance is because it costs too much. Most Americans, 63 percent, still get their healthcare coverage through their jobs, but that number is decreasing every year as the cost of care grows. Today, most uninsured Americans are in the workforce but are not offered benefits through their jobs. Only 7 percent of Americans purchase health insurance on their own. Buying health insurance is much more expensive than getting it through an employer, because individuals must pay the full premium. In contrast, those with employer coverage pay an average of 16 percent of the premium for individual coverage, and 27 percent of the premium for family coverage. In 2006, the average premium was $4,200 for individual coverage and $11,400 for family coverage.

Purchasing health insurance is even harder for those with chronic health problems, since private insurers set unaffordably high premiums, based on the likelihood that the chronically ill will need significant health services—or they simply deny them coverage altogether.

Having health insurance usually means better health outcomes, because the insured are more likely to get proper care for preventive, chronic and acute care services. People who lack coverage often delay care or simply go without care. In fact, statistics show that the uninsured are almost twice as likely to delay getting the medical attention they need. 

Health professionals see the consequences, faced with patients who are much sicker than expected when admitted to the hospital, and who are discharged much sooner than they should be. In addition, the growing number of uninsured also contributes to overcrowded emergency rooms and uncompensated care. According to the Institute of Medicine, about 18,000 deaths among 25- to 64 year-olds in 2002 could have been prevented if those individuals had had insurance.

To understand what is causing costs to rise, AFT Healthcare asked members if they see waste and inefficiency in the healthcare system. 

According to a member from New Jersey, “Hospitals have forgotten their mission: to provide safe quality patient care, not to look good on the marketing pages. Why are so many hospitals wasting dollars employing greeters in tuxedos rather than providing the proper staffing? Providing appropriate staffing hospitals would save money. How? By reducing staff turnover, retaining highly qualified staff, increasing productivity, reducing hospital-acquired infections and reducing the length of stay, just to name a few. ”

“As long as we allow our healthcare system to be profit-driven, it is going to keep costing us more and more, and we’ll be able to afford less and less,” said an AFT Healthcare member from Guam.

Combating cost-shifting

As the cost of coverage grows, so do the challenges facing the union. Among those challenges are proposals to cut Medicaid funding and provider reimbursement in Medicare, as well as the trend away from employer-based insurance coverage in favor of “health savings accounts” and other tax incentives that shift more health insurance costs to workers. At the beginning of the year, President Bush offered a healthcare plan that would provide a new standard tax deduction for taxpayers who buy insurance. Bush’s proposal does not make a signifigant impact on the number of uninsured, has no cost containment mechanism and does not address ways to improve healthcare quality.  

“We worked hard to negotiate for [insurance] plans and we were successful because the people we were negotiating with and against had coverage—it wasn’t a foreign concept to them,” said AFT president Edward J. McElroy during the opening session of AFT Healthcare’s Professional Issues Conference (PIC) in Las Vegas in June.

There used to be an understanding between the union and the employers because everyone had healthcare coverage, president McElroy pointed out.

“For the last 10 years or so, just the opposite has been happening. In every difficult negotiation in this country, whether it’s the public sector or private sector, we’ve been holding on by our fingertips to keep what we’ve gained in terms of healthcare coverage and pension benefits. Why? Because many of the people who used to have these benefits don’t have them anymore,” said McElroy.

Instead of fighting to get the kind of healthcare coverage that many union members have negotiated, “People are saying, ‘I don’t have [coverage] so why should they?’ ” said McElroy. “You have to turn those arguments around. If no one else has healthcare and decent pensions, we’re not going to have them. We have to fight to expand the number of people who have the benefits we do.”

To counter employers’ efforts to shift healthcare costs to workers, the AFT has been focused on proactive bargaining and legislative strategies to protect workers’ and retirees’ access to quality healthcare. In addition, the AFT has established a healthcare task force to help prepare leaders at the local and state levels for the healthcare bargaining process. The national union has worked with leaders to help them evaluate their healthcare plans for quality, access and affordability, as well as to help them share best practices and innovative ideas concerning cost containment and collective bargaining. Another major goal of the national union has been to educate members about the interrelated problems of healthcare costs, quality and access.

Is ‘single-payer’ the answer?

In 2006, the AFT passed a resolution in support of a single-payer system. Single-payer national health insurance is a system in which a single public or quasi-public agency organizes healthcare financing, but delivery of care remains largely private.

The AFT resolution states that single-payer is the quickest and perhaps best way to achieve universal coverage and access to quality care at a reasonable cost. A single-payer system would prevent cost shifting and reduce administrative expenses.

The AFT also pledged its support for other proposals, such as employer mandates, extending eligibility of Medicare and Medicaid, and responsible statewide initiatives that would move toward achievement of its goals.

“We have to do everything in our power to get universal healthcare,” said Candice Owley, chair of the AFT Healthcare program and policy council and an AFT vice president. “Healthcare everywhere else in the world is a public service, not a commodity,” said Owley during her speech to union leaders and activists at PIC in June. “We, the labor movement, have to be the passion and the power that pushes this issue over the tipping point and I believe we can do it.”

Quentin Young, the head of Physicians for a National Health Program, a group of 14,000 doctors and other health professionals that favors a single-payer system, told the audience at PIC that healthcare reform must be a priority for labor.

“In every industrialized democratic country—in the history of health reform—labor was always there,” said Young. “I’m sorry to report that is not the case in the United States. We must join the rest of world with a system that is rational and works.”