New York Health Care - Policy Issues and Reviews

There are many markers, both historical and current, indicating the importance of a healthcare system to Americans. Various efforts to implement a universal healthcare system have been rejected. The alternative complex system has Americans spending $5,267 per capita on health insurance annually. This is almost two and a half times more than the world's median, $2,193. Although there are hundreds of billions more spent here per year on health insurance, we have little to show for it. American life expectancy is lower, we go to the doctors less, and we have fewer doctors than most other western countries. The United States leaves 45 million people without insurance while spending more than Countries with universal healthcare. (Gladwell, 2005). According to Dye (2005) most of the uninsured are working people who are not poor enough to qualify for government funded insurance (p.116).

New York is very familiar with the countries ineffective healthcare system. Reported in 2003 there were 3 million New Yorkers uninsured. That was 25% of the state's population without insurance. Approximately 1 million of the uninsured were eligible for one of the public health programs offered by the state. (Jones, 2003). According to a 2005 U.S. Census Bureau report, 13% of New Yorkers were uninsured. This is a small percentage compared to some states such as Texas which lead with 23.6%. However it is no small number when compared to Minnesota's 7.9%. Furthermore, of the 16,548 individuals covered 12,932 of them were covered by private insurances. 11,559 of that was employment based. Only 1,538 were direct purchase. 5,856 individuals make up the entirety of government covered individuals. While 2,474 were left uncovered. (U.S. Census Bureau, 2006).

Under current New York laws the state primarily regulates plans "sold to sole proprietors, individuals directly purchasing their own insurance, and small to mid-size businesses (Empire Center, 2006)." Larger companies are generally regulated by the federal Employee Retirement Income Security Act (ERISA). The 2006 Interactive New York Guide to HMO's offers information regarding New York's government healthcare options. They recognize Governor George E. Pataki for proposing and signing into law important legislation increasing availability for comprehensive health insurance coverage for "New York's uninsured workers and their families." It seems simple enough. Child Health Plus advertises that even if the family income is seemingly high, people should still apply as the children may still be eligible.

So why is it that not all New Yorkers are covered yet? What keeps the estimated 2,474 individuals from applying or qualifying? Jones (2003) seems to think that one of the barriers is the application and documentation process. He suggests that the application process become more streamline and that the recertification process be made easier. Another idea is that when these individuals are shifted into the HMO plans the process becomes too complicated. Additionally he feels that the population needs to understand the system and its resources better. This helps individuals utilize preventative services. In the long run Jones suggests that these efforts will save money now being paid to medical bills for the uninsured. (Jones, 2003).

Another factor influencing the efficiency of such services is funding. The Fiscal Policy Institute issued a Citizens Action Report in July, 2007 stating that Medicare advantage overpayments were jeopardizing New York's Child Health Plus Expansion. They report that a privatized Medicare plan "is costing taxpayers $709 million annually in corporate handouts (FPI, 2007)." This plan was enforced under the assumption that private insurers could provide equal services at a lower cost. The result was loss of some services and higher rates. This is an example of a policies adverse affects. Under new regulations any expansion on child health insurance will have to be paid for by increasing revenue or cutting spending for other programs. "One way to pay for insuring more children would be to eliminate windfall overpayments to insurance companies through the Medicare Advantage program (FPI, 2007)." The Citizen Action and FPI analysis have determined that it costs $1,113 more annually per New York enrollee in MA than it would cost to provide care for each of them in traditional Medicare. (FPI, 2007).

Federalism is challenged by programs. (Dye states that federalism divides "power between the nation and the states (p.13);" but various healthcare policies blur this distinction). Medicaid, for example, is a federal and state combined program. The federal government attaches requirements to the funding, but the States are left freedom on most utilization levels.

The level of care is often determined by the states distribution amounts. Lack of reimbursement requires doctors and hospitals to double book and render less costly services in order to compensate for typical wages. This leads to unequal healthcare and long waits with little attention. (p.114-115). This is reminiscent of Roth's (2002) elite theories that show policy benefiting the haves (privatized insurance companies) and "appeasing" the needs of the "have nots" (the uninsured). This theory would describe the have nots receiving benefits that further benefit the haves.

Medicare is federally funded, determined, and enforced. In New York (2005) there were 2,879,429 beneficiaries of Medicare. Program payments per beneficiary in 2002 were $7,180. Total Medicare Advantage enrollment (2007) was 649,400 in New York. 68% of which were enrolled in the HMO plan. 54% of contracts are with HMO's. (StateHealthFacts.org). HMO's pose challenges for its recipients as many are confused by referral and authorization processes. With the highest number of contracts being with HMO companies it appears that Roth's elitist theory can again be applied. The vulnerable population, (have-nots) are senior citizens that make up the bulk of all Medicare recipients.

Besides the Medicare Advantage consumers there are various other HMO's that serve a broader population. None the less they are equally uninformed. "Although medical care is ostensibly reckoned a market commodity, according to economic theory it must be a most curious commodity because consumer choice is not only irrational and uninformed, but often relinquished to physicians (Roth, 2002, p.109)." According to Roth people are uninformed about the insurance policies they purchase. This is decidedly so because healthcare is not primarily marketed toward the patients, rather the "private insurance corporations or the government, the real consumers (p.109-110)."

One common question is why is America so obsessed with the healthcare system yet living unhealthy lives? This question leads to debates over rights and privileges. Dye (2005) makes a distinction between "good health" and "good medical care". He explains that any decrease in infant and adult death rates is a result of an increase in public health and sanitation. Additionally many of the leading causes of death today are more a reflection of personal habits and lifestyles (p.114). On his list, however, is suicide which can often be attached to poor mental health and not lifestyle. Dye agrees that it is a unanimous concept that medical care is a right of all Americans. The challenge is determining rational strategies for implementation.

Dye states that a required Medicare deductible discourages "unnecessary hospital or physician care (p.115)." Gladwell adds that this concept also encourages recipients to take better care. Gladwell suggests that the patient responsibility in payment may encourage that individual to choose healthier lifestyles. "It is an attempt to make your use of the health-care system more efficient. Making you responsible for a share of the costs, the argument runs, will reduce moral hazard: you'll no longer grab one of those free Pepsis when you aren't really thirsty (Gladwell, 2005)."

Roth also makes implications that Americans care more for healthcare than they do for good health. However, is insinuated that this is the result of market manipulation. "We use too many drugs too often, including sugar, nicotine, alcohol. Our diets have too much fat (the use of fats in fast foods fattens not only us, but the profits of corporations) (p.108)." He concludes that most "want health" but do not necessarily "behave in ways that foster health." "This, of course, is a contradictory paradox in the lifestyle we lead, which increases the profits of powerful corporations (p108)." Roth believes that there is a divergence between medical progress and social change. If social change tilts toward the haves than that divergence will not benefit the have nots (p.107).

There are set backs in implemented policies however. For example, Medicare does not cover dental expenses (Dye, 2005, p.117). Gladwell explores the connection behind poor dental hygiene, poor health, and the "have-nots". He posits that dental work, considered, a luxury is more than that. Tooth decay can lead also to poor health, the inability to chew good foods, and employment discrimination which tentatively leads to continued deterioration of health. His description of how this ultimately leads a population of people who look significantly different from the rest further distinguishes the haves and have nots. (Gladwell, 2005).

While Dye (2005) explores the application of rationalism to healthcare policy, Roth (2002) uses a more elitist approach. Roth scrutinizes the relationship between market and policy. He depicts a society made up of the haves and the have nots. The haves are essentially big money making companies and have the greater influence over policy development. He explains that the market is ran by the "haves" not the "have nots" and that seldom are policies made representing the "have nots" unless the "haves" stand to profit from it. Roths view specific to health care is that it is that it is "not only a business, but is a big corporate business with important profits (p.112)." He declares that current attacks only use the rising cost of Medicare as an excuse for adopting private alternatives. These alternatives benefit the healthy and the haves (p.114).

Though Roth seemingly takes an extremist view his attempt to provide certain reform is commendable. He focuses briefly on the power of preventive measures. Many diseases could be prevented in a cost effective attempt to provide vaccines, adequate plumbing, healthy food supplies, and promoting exercise. "A rationing system like ours, which allocates too little for prevention in favor of cure, is perverse (p.119)." He challenges that one must look beyond "self" and see the world beyond them. This is difficult "as is recognizing the need for freedom, equality, and democracy (p.122)."

Many would not disagree with Roth's concept of rationing either. The first requirement of equitable rationing is to provide healthcare for the uncovered millions of Americans. He further posits that equality in coverage would result in an inequality of monetary distributions. He determines that the amount of money to be allocated must come from a democratic consensus and is a political decision. Currently he considers all determinations as being made "corpocratically". (Roth, 2002, pp.122-123).

Another valid argument, of Roths is that corporate domination is corrupting health care. He believes that the system should be democratic. He contrasts means in which physicians were granted authority in the past to the way in which they should be now. Under no means, though, does Roth agree that patients or physicians should relinquish power to "HMOs, managed care insurance corporations, or any other bureaucratic, capitalistic organizations whose exercise of authority is not legitimate but rather in nondemocratic domination (p.124)." His suggestion for rendering such issues is to unionize physicians.

Dye offers various model alternatives that can be used to explore the current condition of health care policy. The process model can be used as an effective tool to explore possible changes to the current policy. The "policy process" is a result of political scientists grouping "various activities according to their relationship with public policy (p.14)." The general outline includes problem identification, agenda setting, policy formulation, policy legitimation, policy implementation, and policy evaluation.

Problems with our current health care policy vary in interpretation but are already being identified. Systems such as Mathematica Policy Research, Inc. offer "timely and reliable information on the effectiveness of the health care investments and an accurate analysis of what needs remain unmet" to the policy makers (Mathematica Policy Research, Inc., 2007). They provide cost analysis for healthcare programs (Medicaid, Medicare, SCHIP) as well as the coverage for uninsured families. They also monitor the quality of care and service deliver, act to ensure public health, use innovative methods and technology, and examines the influence of public policy on the lives of the disabled and chronically ill. Current healthcare issues are uncovered individuals, cost, and lack of preventive funding.

Agenda setting requires the attention of mass media and public officials to problem areas. Currently politicians on the campaign trail are vigorously offering their cure for the current health care crisis. Hillary Clinton thinks that it is time for universal health care (hillaryclinton.com, n.d.). Clinton will attempt to tackle the many uninsured. Barak Obama wants to "create a health care system that works." He focuses on prevention and affordability that should save. (Barackobama.com, 2008). John Edwards promotes universal health care through shared responsibility, which includes holding business and employers accountable, affordable insurance options, and creating purchasing pools (johnedwards.com, 2007). Mitt Romney argues that affordable health care should come through market reform rather than government programs (mittromney.com, 2007). Tom Vilsack is promoting affordable and accessible universal health care as well (tomvilsack.com, 2007). It becomes abundantly clear that these issues have been brought to the attention of public officials and media.

The proposals of the presidential candidates are a result of policy proposals that have already been formulated. Currently in the headlines regarding health care are legislative decisions affecting the means in which healthcare will be perceived and attended to. Companies, Unions lobby in support of universal healthcare (February 07, 2007). President Bush addresses the governors and pushes his agenda for a new budget for a reform to healthcare but fails to address the governors issues regarding children health coverage (February 26, 2007). (Public Agenda).

Policy legitimation and implementation is also occurring currently in regards to health care. Recent headlines depict this as well. The senate passed a bill to increase funding for the State Children's Health Insurance Program (SCHIP).President Bush threatened to veto the bill but bipartisan votes of 68 to 31 are enough to override his threats (August 03, 2007). (Public Agenda).

Policy evaluation is happening and should continue to happen. "The Program Assessment Rating Tool (PART) was developed to assess the effectiveness of federal programs and help inform management actions, budget requests, and legislative proposals directed at achieving results (whitehouse.com, n.d.)." Continued evaluation of policies will help direct any need for rendering. Consideration for effectiveness, efficiency, and financial loss and gain should be used to measure success.

Current health care systems are at the least controversial with some believing that health care is a right and others a privilege. Some believing the responsibility lays in the hands of government and others the market or businesses. Proposals reflect personal opinions on each of these aspects. Various models are used to examine the current state of health care policies; however, the process model can be used as a tool for examining means for change.

References

BarackObama.com (2007). Quality Affordable Health Care for All by the End of Barack Obama's First Term in Office. Retrieved on August 7, 2007 from http://www.barackobama.com/issues/healthcare/

Dye, Thomas R. (2005). Understanding Public Policy eleventh edition. New Jersey 07458

Empire Center (2006). Treating the Symptom Instead of the Disease: The Weak Case for Re-Capping Health Insurance Rates. Retrieved on August 7, 2007 from http://www.empirecenter.org/Policy-Briefings/2006/03/treating_the_sy.cfm

FPI (2007). Retrieved on August 7, 2007 from http://www.fiscalpolicy.org/pressreleases2007/CANY_FPI_MedicareAdvantageRelease.pdf

Gladwell, Malcolm (2005). The Moral Hazard Myth. Retrieved on August 7, 2007 from The New Yorker at http://www.newyorker.com/archive/2005/08/29/050829fa_fact?currentPage=2

HillaryClinton.com (2007). Providing Affordable and Accessible Health Care. Retrieved on August 7, 2007 from http://www.hillaryclinton.com/issues/healthcare/

Interactive New York Guide to HMO's retrieved on August 7, 2007 from http://www.nyshmoguide.org/SpecialHealthPrograms.asp

Johnedwards.com (2007). Universal Health Care Through Shared Responsibility. Retrieved on August 7, 2007 from http://johnedwards.com/issues/health-care/health-care-fact-sheet/

Jones, David R.(2003). Still Millions Uninsured in New York. Retrieved on August 7, 2007 from Community Service Society at http://www.cssny.org/pubs/urbanagenda/2003_12_18.html

Mathematica Policy Research, Inc. (2007). Health Policy Research. Retrieved on August 7, 2007 from http://www.mathematica-mpr.com/health/

MittRomney.com (2007). Retrieved on August 7, 2007 from http://www.mittromney.com/Issue-Watch/Health_Care

Public Agenda (February 07, 2007, February 26, 2007, August 03, 2007). Retrieved on August 7,2007 from http://www.publicagenda.org/

Roth, William (2002).The Assault on Social Policy. Columbia University Press

State Health.Org (n.d.) retrieved on August 7, 2007 from http://www.statehealthfacts.kff.org/index.jsp

tomvilsack.com (2007). Affordable, Universal Health Care. Retrieved on August 7, 2007 from http://www.tomvilsack08.com/pages/affordable_universal_health_care

U.S. Census Bureau (2006). Retrieved on August 7, 2007 from http://www.census.gov/

The White House (2007). President Bush Discusses Immigration Reform. Retrieved on August, 7, 2007 from http://www.whitehouse.gov/news/releases/2007/06/20070626.html