PRESIDENT'S COLUMN HEALTH-CARE REFORM: NMA'S VISION Richard 0. Butcher, MD President, National Medical Association El Cajon, California
Greetings, ladies and gentlemen. I am a family physician who has been in private practice in San Diego for the past 25 years. I have watched health care change in this country from the perspective of one whose practice represents the primary access point for most Americans. As a practicing physician and a small employer, I have come to understand the fundamental flaws in American health policy. As you know, this country operates under basic policies that define those goods and services that are provided by the public for everyone's benefit versus those goods and services where you must pay for those that you use. On the left side of the ledger, you find such items as highway construction, road maintenance, police and fire protection, and public education. These are paid for with federal and state funds, which originate from the American people through taxes. On the right side of the ledger, you find automobiles, homes, clothing, and vacation trips. These items are purchased in the open market, by individuals who have sold their time and effort in exchange for money. On the left side, taxes pay-on the right side, you pay. It's very simple, correct? Well, I wish it was that simple. When we add health care into the equation, we immediately encounter the great paradox in the public health policy. Health care sits on both the left and the right sides. On the left side, we pay because every hospital in America must provide emergency care to any person who appears in the emergency room, regardless of his or her ability to pay and regardless of Presented at the Fifth National Conference on Health Care for the Poor and Underserved, Meharry Medical College, October 5, 1992, Nashville, Tennessee. Requests for reprints should be addressed to Dr Richard 0. Butcher, National Medical Association, 1012 10th St, NW, Washington, DC 20001. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
how high the bill. This is not optional. It is a federal requirement. In addition, for those who meet certain eligibility requirements for Medicare or Medicaid, federal and state governments provide funding for needed health services. The revenue to finance these governmental expenses comes from taxes. On the right side of the ledger, however, are those who have health insurance. Most people in America obtain their health insurance through employment. They call it a "fringe benefit." It is an additional benefit, rather than more money. Some companies have begun paying their workers the money that would have been used to buy health insurance, causing the employee to shop around for health insurance. This is considered health-care management by choice and chance. These are employers who want to avoid the 15% and 20% increases in the cost of health-care insurance by shifting the responsibility to the employee and shafting him or her for the increased cost. This is why I contend we have entered an era of health-care policy by "shift and shaft." Here the employees don't really feel the financial weight of their job-provided access to health care. The health insurance card comes with the employee ID. Recently, employees are being given options. They are free to choose the low-option plan with no out-ofpocket costs where they must use those hospitals and physicians they are told to use, or they can choose the high-option plan, where they have freedom of choice (like the good old days), but they must contribute to their health insurance premiums with payments from their biweekly check and again every time they use services. Soon we will take away all responsibility for health care, and it will be left up to the traditionally uninformed individual and the government to decide the outcome, thereby making an already competitive industry even more confusing. 1009
You must recognize that health care is very expensive. Many American companies report that health insurance premiums are the fastest growing cost of any expense they encounter. Some companies have gone so far as to relocate to avoid such expenses. Those of you who watched a recent "60 Minutes" segment know just how far these companies are prepared to go to keep making profits and avoiding fringe benefits such as health-care premiums. Even the federal government is paying businesses to relocate to Central and South America to circumvent minimum wage laws and rising health insurance costs. This head-in-the-sand approach must end; as the old saying goes, "You can run, but you cannot hide." All Americans are going to have to come to grips with the fact that the American people expect adequate health care access as a right-a right they think they are already paying for and quite frankly, they may be. In 1991, the American people (through business, federal and state budgets, and out of pocket) paid the bill for their health care-$817 billion. There are a quarter of a billion Americans (253 million according to the 1990 Census, to be exact). That translates to about $3300 per person. Many people feel that this is enough to provide health care for everyone. Nevertheless, there are 37 million Americans (almost 15% of the population) who have to beg, borrow, or steal their access to health care. I, as president of the National Medical Association (NMA), contend that this is a disgrace. It is a disgrace for the society with the highest standard of living in the world-we throw away more in a year than many people in the world will have that year-and yet we cannot guarantee adequate health care for our people. It is only the United States and South Africa, among all Western nations, that don't provide basic health care. And the basic problem is that all of the major providers have placed their own corporate interests and their own success ahead of the needs of the American people. We could have national health care overnight if we had a legislature that was willing and able to provide the leadership necessary to close this gap. Fortunately, the American people have a history of rising up and forcing its leadership to do the right thing. The people of Pennsylvania have shown the way. Senator Wofford wasn't expected to win the Pennsylvania US senatorial election. Wofford made a simple commitment to his residents, "I will fight for a national health policy for all Americans." A simple statement. Minnesota has adopted a far-reaching mandatory health program, with broad community support. The key to these and other successes is that the patients must 1010
be placed first. Their needs must be at the core of any national health-care policy. As soon as you say that, you immediately recognize that patients have not been active participants in the health-care system. Prevention programs don't work, in part because the patients are not active partners in the prevention initiative. If the health-care system is going to save money when a family understands how to maintain its own good health, then that family should share in those savings. We will never have enough money to treat all of the health-care desires unless prevention becomes an issue of primary importance. I have practiced medicine for a quarter of a century. If I know anything, it is that people are less healthy now than they have ever been. Cardiac problems, hypertension, diabetes, obesity, alcoholism, substance abuse, and excess violence are problems that have their origin in the behaviors of our patients. Falls and auto accidents do not constitute our greatest problems. Motivating the American people to become active partners in health-care reform is where I am coming from-and fortunately I am not alone. Last August, I was inaugurated as the 91st President of the NMA, which is a nationwide organization of 16 000 black physicians. Thus, I have been elected to share our dreams and aspirations, hopes, and concerns regarding the critical issues of today. Health-care reform, obviously, is a major concern to us. You see, most of the current proposals would never have seen the light of day had they simply followed one basic principle-patients first. Two weeks ago, the NMA invited the leaders of seven major African-American health and social service organizations to a "health workshop" meeting in Washington, DC. We began to craft the guiding values and principles for health-care reform from an AfricanAmerican perspective. Seated at the table were organizations representing African-American physicians, dentists, nurses, and public health professionals, as well as the National Association for the Advancement of Colored People (NAACP), the National Urban League, and the Joint Center for Political Studies. The most fundamental realization that we feel happened that day was the recognition that there is enough money in the current health-care system-$817 billion is enough to provide health care for 253 million people. That is $3300 per person. However, there will never be enough money if patients don't become active participants in the health-care delivery system, particularly regarding prevention. It is essential that the system reimburse providers for preventive care as if such care is important. In addition, JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
both providers and indigent patients must have another door for access to health care than through the welfare building. Welfare stigmatizes everybody. The patients don't want to present it as a payment mechanism for health care, and the physicians don't want to receive it for payment because welfare pays very little and only after a fight. Imagine Medi-Cal in California paying a physician less than $12 for an office visit. Something is wrong with this picture. This year, the NMA is actively encouraging patients to register and vote by having registration forms in physicians' offices across the country. Our patients must come first. Whenever we can, we will inform them about health care reform and the issues that will affect them. The NMA will present the results of the health workshop to the electoral candidates and the legislature with the goal of advising those business professionals who are making policy decisions about the true needs of the people. Thank you for letting me share my views today. On behalf of the NMA, I encourage all of you to add health care to your list of requirements for all elected officials. We recognize that politics goes to two poles-money and people. While we are here at the Fifth Annual Conference for the Poor and the Underserved, we must recognize that one of the reasons they are underserved is that we refuse to vote our numbers. We are underserved because the government has figured out how to trickle down to those who don't vote. The communities that vote demand their fair share of public resources-and take some of the indigent's portion as well. You think not? Well, what did you think a poverty program was? You don't see any impact from the war on poverty except that it was lost. It was guaranteed employment for college graduates who didn't know what to do with the rest of their lives. We needed economic development and got handouts. People who vote then realize that they must influence their choices. Fragmentation has always been a strategy to keep poor people poor and the uninformed more uninformed. Thank you for letting me share my views and the activities of the NMA with you. It will take constant and consistent dialogue, commitment, and hard work to ensure that the underserved are served. Today, when facets of the middle-class society quickly approach
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underserved status, the call is an urgent one and a necessary one. In closing I would like to share with you the inspirational words that were written by my son Richard on his application to medical school. Who am I? What do I want? The direction that one should take in life is as ambiguous as the quest for the holy grail. I truly believe that the vision and the knowledge people seek in both cases resides within themselves. Confirmation of my ideas has come through work, experience, human interaction, observation, and other intangibles.
Watching my father through the years, his activity has ranged from home deliveries, to private practice, to training room work at San Diego State University. Work in my father's office has given me an insight into the doctor-patient relationship. On the political side, my father is involved with the Golden State Medical Association, past president of the San Diego County Medical Society, and the current president of the National Medical Association. He recently met with Senator Kennedy, Senator Rockefeller, and the Black Caucus. I have a close proximity to the cutting edge of medical policy in the United States. Knowledge in this area enhances personal awareness of my medical objectives. Coaching and teaching has given me a close look at human interaction. The title of this section is correct in describing the feeling that positive interaction creates: the look in an individual's eyes after learning information or a skill that could not be learned before, the stoic rapture in the face of a competing athlete, the unquestioned respect no one else will know, between teacher-student and coach-athlete. This is a part of me I hope to transfer to the health profession. It has been 4 years since I have been a full time student. I am ready to devote myself to the successful completion and practical use of medical school. The time off has allowed me to work constructively and search my inner self. I do not claim to have all the answers, but I know the direction to take. I am also positive that the path is truly my own. I am Richard 0. Butcher, ready to embark on the challenging road to a medical career. Upon acceptance into medical school, the benefits will be mutual.
Here lies the future of medicine. The ones who will be implementing the national health policy of tomorrow are studying medicine today.