THE NATIONAL HEALTH CARE CRISIS: AN ANALYSIS OF PROPOSED SOLUTIONS STEPHEN GORIN and CYNTHIA MONIZ The health care system in the United States faces a deepening crisis. Although the United States spends more on health care than any other industrialized nation, its citizens are less healthy and less satisfied with their health care than those in countries that spend less. This article provides an overview of the current crisis in the health care system, examines recent proposed solutions to reform the system, and analyzes these proposals in light of the values of professional social work.
Although the United States spends more on health care than any other industrialized nation, its citizens are less healthy and less satisfied with their health care than those in countries that spend far less. There are growing doubts about the ability of the current health care system to meet the needs of the population. The primary concerns are lack of access, the growing problem of long-term care, and the fundamental issues of cost and financing. As a solution to the health care crisis, social work has long advocated national health insurance. In 1935, the Committee on Economic Health Security, chaired by Frances Perkins, proposed the first government plan for national health insurance (see Trattner, 1989; Wenocur & Reisch, 1989). In the 1960's, prominent figures, such as Wilbur Cohen and Charles Schottland, played leading roles in Medicare's development. In 1979, the National Association of Social Workers (NASW) formally supported
national health insurance (NASW, 1991b), and the 1990 Delegate Assembly identified national health insurance as the association's chief policy priority (NASW, 1990a). REDUCED ACCESS TO HEALTH CARE
The passage of Medicare and Medicaid in 1965 was a major step forward in access to health care for elderly and poor people (Stan, 1986). Because most workers receive health insurance through their employers, it was assumed that the enactment of these two programs would ensure nearly universal access (Pepper, 1989). Today, however, between 31 million and 37 million individuals lack health insurance (Ginsburg & Prout, 1990). In addition, millions are underinsured. Underinsurance has been defined as discontinuous coverage, limitations in coverage that cause serious out-of-pocket costs, and no or inadequate catastrophic health insurance (Ginsburg
CCC Code: 0360-7283/92 $3.00 © 1992, National Association of Social Workers, Inc.
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
37
& Prout, 1990). Most estimates of the number of underinsured people are based on out-of-pocket and catastrophic costs. According to a 1984 study, in 1977 between 8 and 26 percent of the privately insured population under age 65 was underinsured (Ginsburg & Prout, 1990) . The U.S. Department of Health and Human Services estimated that 60 million individuals are insured but lack coverage for catastrophic care (Knox, 1989). The problem of access is exacerbated by the limits of government programs, particularly Medicare and Medicaid. For example, because of low reimbursemeni rates, many pediatricians refuse to participate in Medicaid, making it difficult for low-income children, who make up half of all Medicaid recipients, to obtain health care (American Academy of Pediatrics, 1989; Yudkowsky, Cartland, & Flint, 1990). Under Medicare, average out-of-pocket costs for those over age 65 are actually higher today than when Medicare began in 1965 (Sidel, 1991) . As a result of spiraling deductibles, copayments, and other out-of-pocket expenses, many senior citizens purchase Medigap insurance policies, many of which are overpriced, duplicate coverage, and do not cover services and costs that concern elderly people most, such as long-term care (Advocates for Senior Alert, 1990) . (This problem has been addressed by the Deficit Reduction Package of 1990, which sets standards for Medigap insurance [Leonard & Greenstein, 1990] .) Lack of Long Term Care Coverage -
The health care issue that has generated the most discussion and concern is long-term care, because private insurance policies and Medicare provide very little nursing home coverage (Families USA, 1990b; Kingson, Hirshom, & Cornman, 1986; Weiner, Hanley, Spence, & Murray, 1989). Although long-term care is usually identified as a problem faced by elderly people, in reality it affects "individuals of all age groups who have chronic, physical, developmental, or emotional impairments" (NASW, 1991a, p. 134; see also Senior Program of the California Rural Legal Assistance Foundation, 1989). Approximately 7 million elderly people and 4 million adults and 38
children with a chronic illness will at some point need long-term care (Long-Term Care Campaign, n.d.; Tarr-Whelan, 1990). Families have experienced enormous financial and emotional hardship.. Only 15 percent of home-based care is provided by nurses and other home care workers; most home care providers are wives and daughters. These family caregivers are often forced to reduce their work hours, take time off from work without pay, or even terminate their employment to care for their family members (Anastas, Gibeau, & Larson, 1990; Eckholm, 1990; Long-Term Care Campaign, n.d.). Increased Health Care Costs
Underlying the access and long-term care crises is the increasing cost of health care in the United States. Between 1960 and 1989, expenditures on national health increased from $27.1 billion to $604.1 billion; since 1980, national health spending has more than doubled (U.S. Department of Health and Human Services, 1990). There are numerous reasons for the high cost of health care in the United States, such as the aging of the population and government spending on Medicare and Medicaid. The most significant factor, however, is the high cost of health care. Between 1950 and 1988, health care costs have risen at a faster annual rate than the consumer price index, accelerating in the 1980s (Democratic Study Group, 1991). The primary cause of medical inflation in the United States is the lack of a single-payer system. First, the proliferation of private insurers (many of them controlled by physicians), with the acquiescence of government, has long enabled providers to charge whatever the market would bear. Second, the lack of a single-payer system precludes rational planning. Hospitals often engage in wasteful competition, leading to underuse and unnecessary duplication of equipment and trained personnel. Third, the lack of a single-payer system has also contributed to the high cost of administration; with more than 1,500 private insurers, approximately 22 percent of health care costs in the United States stem from overhead such as advertising,
HEALTH AND SOCIAL WORK / VOLUME 17, NUMBER 1 / FEBRUARY 1992
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
marketing, and billing (Ginsburg & Prout, 1990; Himmelstein & Woolhander, 1986; Illinois Public Action, 1990). PROPOSALS FOR HEALTH CARE REFORM
The United States remains one of the few industrialized countries in the world that have not established a national plan for universal health care. Although the American Medical Association (AMA) and conservative legislators have long opposed national health insurance (David, 1985; Moniz, 1990; Stan , 1982), the developing health care crisis has again placed it on the legislative agenda (Ginsburg & Prout, 1990; McManus, 1990; National Health Care Campaign, 1990a). Pressure and support for greater access to health care has come from diverse groups, including the medical and business communities, in recognition that something must be done. According to a 1990 survey, 60 percent of U.S. citizens believe that fundamental changes in the U.S. health care system are needed; 29 percent believe the system should be rebuilt completely (American Association of Retired Persons, 1989; Blandon & Donelan, 1990). In recent years, there have been myriad proposals to address the health care crisis. In the authors' view, these proposals for health insurance are most easily understood when grouped along two dimensions: public insurance versus private insurance and federal plans versus state plans. -
Play or Pay Model
Public insurance provides coverage with government funds raised through taxes. Private insurance relies on employers to provide health insurance to employees or contribute to a fund for this purpose (so-called "play or pay" schemes). To provide affordable health insurance to unemployed or uninsured, people, the fund is used to subsidize private insurance coverage. Either public or private insurance can be implemented at the federal or state level. The Pepper Commission's Plan. In March 1990, the U.S. Bipartisan Commission on Com-
prehensive Health Care (1990), known as the Pepper Commission, was appointed by Congress to recommend new health care legislation. To provide universal access, the commission recommended a play or pay scheme and the elimination of Medicaid. The commission also recommended a national program of nursing home and home care that would be available to severely disabled people regardless of income or age. Consumer Choice Plan for the 1990s. This plan is proposed by Dr. Alain Enthoven of Stanford University and Dr. Richard Kronick of the University of California at San Diego. Unlike the Pepper Commission's plan, this plan would preserve Medicare and Medicaid. It encourages the use of health maintenance organizations (HMOs) (Enthoven & Kronick, 1989). Health Access America. This plan is proposed by the AMA. The plan would expand Medicaid to provide benefits for all individuals living in poverty and would increase reimbursements to the level of Medicare reimbursement (National Health Care Campaign, 1990b). Universal Access Program. This plan is proposed by the National Leadership Commission on Health Care, a coalition of 38 corporations, unions, and foundations chaired by former presidents Nixon, Ford, and Carter. The plan would retain Medicare but, except for longterm care, would replace Medicaid with a state program for anyone not covered by employerprovided insurance or private insurance (Kern & Bresch, 1990). Reform Plan for Uninsured and Employer Coverage. Although not strictly a play or pay scheme, this plan, proposed by the Health Insurance Association of America, would provide a variety of tax and other incentives to encourage employers to offer low-cost insurance to employees. The plan would preserve Medicare and expand Medicaid eligibility (NASW, 1989). A few states have enacted and others have proposed employer-based plans (American Academy of Pediatrics, 1990; Illinois Public Action, 1990; NASW, Ohio Chapter, 1990; National Health Care Campaign, 1990c) . The most prominent of these is the Massachusetts Health Security Act of 1988, which was designed to ensure affordable coverage to the state's
THE NATIONAL HEALTH CARE CRISIS: AN ANALYSIS OF PROPOSED SOLUTIONS
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
39
500,000 uninsured citizens. By 1992, businesses with six or more employees will have to either provide health insurance or contribute to a state-run trust fund (Massachusetts Health Security Act, 1988).
ered services, such as cosmetic surgery. The new health care system would be financed by the federal government through a progressive income tax and an employer-paid payroll tax and supplemented by the states .(NASW, 1990b).
Single Payer Model
Similarities to the Canadian Health Care System
-
A number of plans rely on a single-payer approach, in which the government is the sole insurer. National Health Program for the United States. This plan is proposed by Physicians for a National Health Program, a national group of 2,500 physicians based in Cambridge, Massachusetts. A single public program would cover everyone; it would eliminate private insurance, Medicaid, and Medicare and would be administered on state and local levels (Himmelstein & Woolhander, 1989). Health Security Partnership. This plan is proposed by the Committee for National Health Insurance, Health Security Action Council (1989), which consists of representatives from organized labor, civil rights groups, academia, and health and welfare organizations. A federalstate plan would provide a basic federal benefit package that the states could supplement. Medicaid would be phased out; after five years, Medicare would also be phased out. U. S. Health, H.R. 2930. This plan is proposed by Representative Edward Roybal (D-Calif.). Representative Roybal's bill would expand Medicare into a universal single-payer system. Medicaid would be abolished (NASW, 1989). NASW National Health Care Board Proposal. NASW proposed its own national health care plan in spring 1990. NASW's plan replaces the current system with a National Health Board, a single-payer system offering full coverage, including long-term and mental health care for everyone living in the United States. The new system would be administered by the federal government; services would be delivered by the states in accordance with federal guidelines. Patients could choose from among any of the public and private providers participating in the program. The plan would eliminate private insurance, except for a few uncov40
Although the single-payer plans are largely based on the Canadian system, there are differences among them. The NASW and Physicians for a National Health Program plans, which are most similar to the Canadian system, would eliminate private insurance, Medicare, and Medicáid. The Physicians for a National Health Program plan would eliminate all cost sharing by consumers; NASW's plan would allow limited copayments for some outpatient services and cost sharing based on ability to pay for longterm care. Financing for both plans would come primarily from a progressive income tax. The Health Security Partnership and Representative Roybal's bill, on the other hand, would continue private insurance in a modified form. Representative Roybal's bill would expand Medicare, and the Health Security Partnership would eventually integrate Medicare into the program. Under the Health Security Partnership plan, there would be no cost sharing for those living below the poverty level, but deductibles would be established for others. The Roybal bill would maintain Medicare's current deductibles; eventually eliminate premiums for Part B (doctor's fees) of Medicare; and, except for those living below the poverty level, require coinsurance for long-term and skilled nursing home care. Financing for both plans would stem from a combination of taxes. A number of states are also considering singlepayer systems. Despite their underlying similarity, there are differences in these plans as well. For example, only Illinois and Washington would cover long-term care. Connecticut, Illinois, Indiana, and Missouri would not require cost sharing; Florida and Ohio would require small copayments for prescriptions and possibly for mental health services (National Health Care Campaign, 1990c).
HEALTH AND SOCIAL WORK/VOLUME 17, NUMBER 1 /FEBRUARY 1992
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
SOCIAL WORK VALUES AND HEALTH CARE REFORM
Which of these approaches is most consistent with the values of professional social work? The primary values of the profession are described by the Council on Social Work Education (1984) as follows: "Social workers hold that people should have equal access to resources, services, and opportunities for the accomplishment of life tasks, the alleviation of distress, and the realization of their aspirations and values in relation to themselves, the rights of others, the general welfare, and social justice" (p. 3). Building on these values, in 1979 the NASW Delegate Assembly identified the principles of a national health program (see Waxman, n.d.). The most fundamental of these principles are universal access, comprehensive benefits, financing based on progressive taxes, and publicly regulated cost containment. Universal access, regardless of race, ethnicity, age, Bender, sexual preference, income, religion, or geographic location, would entitle everyone to health care: "To ensure equality of opportunity for health care, all population groups should be served within the same national health program . . . there [should] be [no] separate categories, arrangements, or services that distinguish consumers" (NASW, 1991b, p. 142). Universal access would make health care a right, not a privilege. A national health care system should also offer comprehensive services. In addition to basic health care needs, the program should include preventive as well as long-term and mental health care: These "services should be provided in ways that recognize and enhance the integrity of each person in the context of family and community" (NASW, 1991b, p. 142). A national health care program should be financed primarily through progressive taxation. NASW's (1991c) Tax Reform Policy states that "The principle of ability to pay as measured by income and wealth is just. . . It [progressive taxation] can adjust inequalities of income and wealth" (p. 179). Finally, publicly regulated cost containment measures are essential to a national health care
system. Cost containment should eliminate duplication of unnecessary and expensive equipment and procedures; it should reduce current physicians' fees and hospital costs through prospective global budgeting, in which the government determines the resources available for the prospective year; and it should reduce the incidence of illness through an expansion of preventive medicine (NASW, 1991b). Representative federal and state proposals for public and private insurance plans are shown in Table 1. Of the federal proposals, the federalpublic approach, or national health insurance, is more consistent with the four social work principles discussed and the values of the profession than the federal-private approach. The major problem with the Pepper Commission's plan and the other federal-private plans is that they would preserve our multipayer system of financing and perpetuate the problem of unnecessary administrative and billing costs. A recent study found that commercial insurance companies are less efficient than government programs such as Medicare (Citizens Fund, 1990). Other studies have shown that curtailing the costs of insurance administration could save billions of dollars a year (Families USA, 1990a; Himmelstein & Woolhander, 1986). A recent cost analysis of the NASW proposal estimated an annual savings of $9.6 billion in administrative, billing, and similar costs (Center for Policy Studies, 1990). The state plans are limited in terms of universal access and cost containment. Only residents of the states that enact health insurance plans would have universal access to health care. The lack of a nationwide single-payer system would undermine cost containment. Even if all 50 states enacted state-public plans, this would still be less efficient than a national single-payer system. CONCLUSION
Despite the drawbacks of the state and employer-based approaches, any of the current health care proposals would improve the health care system. Social workers should support national health insurance as a reflection of their commitment to social workvalues, but theyshould
THE NATIONAL HEALTH CARE CRISIS: AN ANALYSIS OF PROPOSED SOLUTIONS
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
41
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
Yes Financed from employer and individual contributions; state funds; federal funds received for Medicare, Medicaid, Veterans Administration; state taxes on tobacco and alcohol. Partial Single-payer system but limited to state. Reduced administrative costs. Resource allocation through planning. Prospective global budgeting for hospitals and long-term care facilities. Fee-for-service payment, capitation, or salaried basis for practitioners based on rates set by Illinois Universal Health Care Plan.
Yes Lacks specifics. Proposed individual and employer contributions, federal revenues, and state funds equal to Medicaid expenditures. Partial Efforts limited by lack of national single-payer system. Lowers cost ofprivate insurance through cost-sharing and insurance reforms. Managed care.
Yes Financed by federal income tax and employer-paid payroll tax. Additional financing from states.
Yes Single-payer system. Reduced administrative costs. Resource allocation through planning. Prospective global budgeting for hospitals. Prospective global budgeting for other facilities. Fee-for-service paymentfor practitioners based on rates set by NHB.
Financing based on progressive taxes
Publicly regulated cost containment
Partial Efforts limited by lack ofa national or state single-payer system. Lowers cost of private insurance. Managed care.
Yes Financed through employer and individual contributions and state funds. Individual private insurance purchased on sliding fee scale.
No Basic.preventive.and diagnostic services, including physician and hospital care. Limited mental health services. No longterm care.
Partial Limited to state residents covered through employer-provided insurance. Play or pay rules. New public fund to offer affordable insurance to everyone else. Medicaid expansion.
Private-Massachusetts
NOTES: NASW = National Association of Social Workers; CHAMPUS = Civilian Health and Medical Program of the Uniformed Services.
Yes Basic, preventive, and diagnostic services, including physician and hospital care. Prescription drugs; vision, dental, and hearing services. Mental health and substance abuse services. Long-term care.
No -Basic, preventive, and diagnostic services, including physician and hospital care. Limited mental health care. Long-term care.
Yes Basic, preventive, and diagnostic services, including physician and hospital care. Prescription drugs; vision, dental, and hearing services. Mental health, substance abuse treatment and rehabilitation, and hospice care. Catastrophic and long-term care.
Partial Limited to state residents covered by a new Governing Board. Private insurance coverage phased out over three years (exceptforservices notcovered) .
Yes Employer-provided. Playor pay rules. Medicare remains. Medicaid replaced by a new public plan.
Comprehensive benefits
Public-State
Private-Pepper Commission
State
Yes All U.S. citizens covered by a new federal National Health Board (NHB). Medicare, Med-icaid, CHAMPUS, veterans health programs phased out.
Public-NASW
Federal
Universal access
Social Work Principles
Table l. Representative Federal and State Proposals
not view other approaches as detours from this goal. Employer-based and state programs can be used as stepping stones to a national system. Essential to any system of national health insurance are the principles of universal access, comprehensive benefits, financing based on progressive taxes, and publicly regulated cost containment. To the extent that state and employerbased approaches embody these principles, social workers can advocate the expansion and transformation of these approaches into a federalpublic system. About the Authors
Stephen Gorin, PhD, is Assistant Professor, University of New Hampshire, Durham, NH 03824-3596 and Lecturer, Plymouth State College, Plymouth, NH. Cynthia Moniz, PhD, is Assistant Professor, Plymouth State College, Plymouth, NH. The authors acknowledge the assistance of Madeleine Golde, NASW, and Sam Flint, American Academy of Pediatrics. References
Advocates for Senior Alert. (1990). The Medigap mess. Washington, DC: Author. American Academy of Pediatrics. (1989, February 8). Testimony, B. Harvey, Health & Environment Subcommittee, Energy & Commerce Committee, House, on infant mortality initiatives. Elk Grove
Village, IL: Author. American Academy of Pediatrics. (1990). State access initiatives. Child Health Financing, 7(2), 2-3. American Association of Retired Persons. (1989). Access to health care: An analysis of recent polling data. Washington, DC: Author.
Anastas, J. W., Gibeau, J. L., & Larson, P. J. (1990). Working families and eldercare: A national perspective in an aging America. Social Work, 35,405-411. Blandon, R., & Donelan, K. (1990). The public and the emerging debate over national health insurance. New EnglandJournal of Medicine, 323, 208-212. Center for Policy Studies. (1990). Cost analysis of the NASW national health care proposal. Columbia, MD: Author.
Citizens Fund. (1990). Premiums without benefits: Waste and inefficiency in the commercial insurance industry. Washington, DC: Author.
Committee for National Health Insurance, Health Security Action Council. (1989). The health security partnership: An equitable and universal national health plan. Washington, DC: Author. Council on Social Work Education. (1984). Handbook of accreditation standards and procedures (cur-
riculum policy statement). New York: Author. David, S. (1985). With dignity: The search for Medicare and Medicaid. Westport, CT: Greenwood Press. Democratic Study Group. (1991, May 24). DSG special report: Why conseroatives don't talk about America's health system. Washington, DC: Author.
Eckholm, E. (1990, March 27). Haunting issue for U.S.: Caring for the elderly ill. New York Times, pp. 1,18. Enthoven, A., & Kroniek, R. (1989). A consumerchoice health plan for the 1990's. New England Journal of Medicine, 320, 29-37,94-101. Families USA. (1990a). To the rescue: Toward solving America's health cost crisis. Washington, DC: Author. Families USA. (1990b). Families USA Foundation calls for a Federal Trade Commission investigation of insurance industry abuse of frail elderly nursing home insurance buyers: A preliminary investigation.
Washington, DC: Author. Ginsburg, J. A., & Prout, D. M. (1990). Access to health care. Annals of Internal Medicine, 112, 641-661. Himmelstein, D. U., & Woolhander, S. (1986). Cost without benefit: Administrative waste in U.S. health care. New England Journal of Medicine, 314, 441-445. Himmelstein, D. U., & Woolhander, S. (1989). A national health program for the U.S. New England Journal of Medicine, 320, 102-108. Illinois Public Action. (1990). Universal health care—We can't afford to go without it. Chicago: Author. Kern, R., & Bresch, J. E. (1990, January/February). Systematic health care reform: Is it time? Health Progress, pp. 32-44. Kingson, E., Hirshorn, B., & Cornman, J. (1986). Ties that bind—The interdependence of the generations. Washington, DC: Seven Locks.
THE NATIONAL HEALTH CARE CRISIS: AN ANALYSIS OF PROPOSED SOLUTIONS
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
43
Knox, R. (1989, April 17). Is a solution in sight for 1990? Boston Globe, pp. All, A14. Leonard, P., & Greenstein, R. (1990). One step forward: The deficit reduction package of 1990.
Washington, DC: Center on Budget and Policy Priorities. Long-Term Care Campaign. (n.d.). What is longterm care? Washington, DC: Author. Massachusetts Health Security Act of 1988, Department of Medical Security, Boston (1988). McManus, M. (1990). Corporations and unions join forces to support national health insurance. Child Health Financing Report, 4,4. Moniz, C. (1990). The NCSC: The rok of the elderly in the enactment of Medicare. Unpublished doctoral dissertation, Brandeis University, Waltham, MA. National Association of Social Workers. (1989). Comparison of six national health care proposals (Legislative Update). Silver Spring, MD:
Author. National Association of Social Workers. (1990a). Delegate assembly program priority goals 1991-1994.
Silver Spring, MD: Author. National Association of Social Workers. (1990b). National health care proposal (executive summary). Silver Spring, MD: Author. National Association of Social Workers. (1991a). Long-term care. In Social work speaks: NASW policy statements (pp. 134-136). Silver Spring, MD: Author. National Association of Social Workers. (1991b). National health. In Social work speaks: NASW policy statements (pp. 141-144). Silver Spring, MD: Author. National Association of Social Workers. (1991c). Tax reform. In Social work speaks: NASW policy statements (pp. 178-180). Silver Spring, MD: Author. National Association of Social Workers, Ohio Chapter. (1990). A position paper on universal health coverage in Ohio. Columbus: Author. National Health Care Campaign. (1990a). Big business grapples with the health crisis: Common sense vs. ideology. Health Care News. Washington, DC: Author. National Health Care Campaign. (1990b). AMAHealth access campaign (summary). Washington, DC: Author. 44
National Health Care Campaign. (1990c). State health care plans (summaries). Washington, DC: Author. Pepper, C. (1989). Long-term care insurance: The first step toward cornprehensive health insurance. Journal of Aging & Social Policy, 1, 9-15. Sidel, V. W. (1991). Health care for a nation in need. New York: Institute for Democratic Socialism. Senior Program of the California Rural Legal Assistance Foundation. (1989). Long-term careA Buide. Washington, DC: Long-Term Care Campaign. Starr, P. (1982). The social transformation of American medicine. New York: Basic Books. Starr, P. (1986). Health care for the poor: The past twenty years. In S. Danziger & D. Weinberg (Eds.), Fighting poverty: What works and what doesn't (pp. 106-132). Cambridge: Harvard University Press. Tarr-Whelan, K. (1990). Long-term care: A family struggle. Washington, DC: Long-Term Care Campaign. Trattner, I. (1989). From poor law to welfare state: A history of social welfare in America. New York: Free Press. U.S. Bipartisan Commission on Comprehensive Health Care. (1990). A call for action-Final report. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (1990, December 20). HHS News (press release). Washington, DC: Author. Waxman, H. (n.d.). Health Care for All resolution. Washington, DC: U.S. Government Printing Office. Weiner, J., Hanley, R., Spence, D., & Murray, S. (1989). We can run, but we can't hide: Toward reforming long-term care. Journal of Aging and Social Policy, 1, 87-102. Wenocur, S., & Reisch, M. (1989). From charity to enterprise: The development of American social welfare in a market economy. Urbana: University of
Illinois Press. Yudkowsky, B., Cartland, J., & Flint, S. (1990). Pediatrician participation in Medicaid: 19781989. Pediatrics, 85, 567-577. Accepted March 26, 1991
HEALTH AND SOCIAL WORK / VOLUME 17, NUMBER 1 / FEBRUARY 1992
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
Although the United States spends more on health care than any other industrialized nation, its citizens are less healthy and less satisfied with their health care than those in countries that spend far less. There are growing doubts about the ability of the current health care system to meet the needs of the population. The primary concerns are lack of access, the growing problem of long-term care, and the fundamental issues of cost and financing. As a solution to the health care crisis, social work has long advocated national health insurance. In 1935, the Committee on Economic Health Security, chaired by Frances Perkins, proposed the first government plan for national health insurance (see Trattner, 1989; Wenocur & Reisch, 1989). In the 1960's, prominent figures, such as Wilbur Cohen and Charles Schottland, played leading roles in Medicare's development. In 1979, the National Association of Social Workers (NASW) formally supported
national health insurance (NASW, 1991b), and the 1990 Delegate Assembly identified national health insurance as the association's chief policy priority (NASW, 1990a). REDUCED ACCESS TO HEALTH CARE
The passage of Medicare and Medicaid in 1965 was a major step forward in access to health care for elderly and poor people (Stan, 1986). Because most workers receive health insurance through their employers, it was assumed that the enactment of these two programs would ensure nearly universal access (Pepper, 1989). Today, however, between 31 million and 37 million individuals lack health insurance (Ginsburg & Prout, 1990). In addition, millions are underinsured. Underinsurance has been defined as discontinuous coverage, limitations in coverage that cause serious out-of-pocket costs, and no or inadequate catastrophic health insurance (Ginsburg
CCC Code: 0360-7283/92 $3.00 © 1992, National Association of Social Workers, Inc.
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
37
& Prout, 1990). Most estimates of the number of underinsured people are based on out-of-pocket and catastrophic costs. According to a 1984 study, in 1977 between 8 and 26 percent of the privately insured population under age 65 was underinsured (Ginsburg & Prout, 1990) . The U.S. Department of Health and Human Services estimated that 60 million individuals are insured but lack coverage for catastrophic care (Knox, 1989). The problem of access is exacerbated by the limits of government programs, particularly Medicare and Medicaid. For example, because of low reimbursemeni rates, many pediatricians refuse to participate in Medicaid, making it difficult for low-income children, who make up half of all Medicaid recipients, to obtain health care (American Academy of Pediatrics, 1989; Yudkowsky, Cartland, & Flint, 1990). Under Medicare, average out-of-pocket costs for those over age 65 are actually higher today than when Medicare began in 1965 (Sidel, 1991) . As a result of spiraling deductibles, copayments, and other out-of-pocket expenses, many senior citizens purchase Medigap insurance policies, many of which are overpriced, duplicate coverage, and do not cover services and costs that concern elderly people most, such as long-term care (Advocates for Senior Alert, 1990) . (This problem has been addressed by the Deficit Reduction Package of 1990, which sets standards for Medigap insurance [Leonard & Greenstein, 1990] .) Lack of Long Term Care Coverage -
The health care issue that has generated the most discussion and concern is long-term care, because private insurance policies and Medicare provide very little nursing home coverage (Families USA, 1990b; Kingson, Hirshom, & Cornman, 1986; Weiner, Hanley, Spence, & Murray, 1989). Although long-term care is usually identified as a problem faced by elderly people, in reality it affects "individuals of all age groups who have chronic, physical, developmental, or emotional impairments" (NASW, 1991a, p. 134; see also Senior Program of the California Rural Legal Assistance Foundation, 1989). Approximately 7 million elderly people and 4 million adults and 38
children with a chronic illness will at some point need long-term care (Long-Term Care Campaign, n.d.; Tarr-Whelan, 1990). Families have experienced enormous financial and emotional hardship.. Only 15 percent of home-based care is provided by nurses and other home care workers; most home care providers are wives and daughters. These family caregivers are often forced to reduce their work hours, take time off from work without pay, or even terminate their employment to care for their family members (Anastas, Gibeau, & Larson, 1990; Eckholm, 1990; Long-Term Care Campaign, n.d.). Increased Health Care Costs
Underlying the access and long-term care crises is the increasing cost of health care in the United States. Between 1960 and 1989, expenditures on national health increased from $27.1 billion to $604.1 billion; since 1980, national health spending has more than doubled (U.S. Department of Health and Human Services, 1990). There are numerous reasons for the high cost of health care in the United States, such as the aging of the population and government spending on Medicare and Medicaid. The most significant factor, however, is the high cost of health care. Between 1950 and 1988, health care costs have risen at a faster annual rate than the consumer price index, accelerating in the 1980s (Democratic Study Group, 1991). The primary cause of medical inflation in the United States is the lack of a single-payer system. First, the proliferation of private insurers (many of them controlled by physicians), with the acquiescence of government, has long enabled providers to charge whatever the market would bear. Second, the lack of a single-payer system precludes rational planning. Hospitals often engage in wasteful competition, leading to underuse and unnecessary duplication of equipment and trained personnel. Third, the lack of a single-payer system has also contributed to the high cost of administration; with more than 1,500 private insurers, approximately 22 percent of health care costs in the United States stem from overhead such as advertising,
HEALTH AND SOCIAL WORK / VOLUME 17, NUMBER 1 / FEBRUARY 1992
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
marketing, and billing (Ginsburg & Prout, 1990; Himmelstein & Woolhander, 1986; Illinois Public Action, 1990). PROPOSALS FOR HEALTH CARE REFORM
The United States remains one of the few industrialized countries in the world that have not established a national plan for universal health care. Although the American Medical Association (AMA) and conservative legislators have long opposed national health insurance (David, 1985; Moniz, 1990; Stan , 1982), the developing health care crisis has again placed it on the legislative agenda (Ginsburg & Prout, 1990; McManus, 1990; National Health Care Campaign, 1990a). Pressure and support for greater access to health care has come from diverse groups, including the medical and business communities, in recognition that something must be done. According to a 1990 survey, 60 percent of U.S. citizens believe that fundamental changes in the U.S. health care system are needed; 29 percent believe the system should be rebuilt completely (American Association of Retired Persons, 1989; Blandon & Donelan, 1990). In recent years, there have been myriad proposals to address the health care crisis. In the authors' view, these proposals for health insurance are most easily understood when grouped along two dimensions: public insurance versus private insurance and federal plans versus state plans. -
Play or Pay Model
Public insurance provides coverage with government funds raised through taxes. Private insurance relies on employers to provide health insurance to employees or contribute to a fund for this purpose (so-called "play or pay" schemes). To provide affordable health insurance to unemployed or uninsured, people, the fund is used to subsidize private insurance coverage. Either public or private insurance can be implemented at the federal or state level. The Pepper Commission's Plan. In March 1990, the U.S. Bipartisan Commission on Com-
prehensive Health Care (1990), known as the Pepper Commission, was appointed by Congress to recommend new health care legislation. To provide universal access, the commission recommended a play or pay scheme and the elimination of Medicaid. The commission also recommended a national program of nursing home and home care that would be available to severely disabled people regardless of income or age. Consumer Choice Plan for the 1990s. This plan is proposed by Dr. Alain Enthoven of Stanford University and Dr. Richard Kronick of the University of California at San Diego. Unlike the Pepper Commission's plan, this plan would preserve Medicare and Medicaid. It encourages the use of health maintenance organizations (HMOs) (Enthoven & Kronick, 1989). Health Access America. This plan is proposed by the AMA. The plan would expand Medicaid to provide benefits for all individuals living in poverty and would increase reimbursements to the level of Medicare reimbursement (National Health Care Campaign, 1990b). Universal Access Program. This plan is proposed by the National Leadership Commission on Health Care, a coalition of 38 corporations, unions, and foundations chaired by former presidents Nixon, Ford, and Carter. The plan would retain Medicare but, except for longterm care, would replace Medicaid with a state program for anyone not covered by employerprovided insurance or private insurance (Kern & Bresch, 1990). Reform Plan for Uninsured and Employer Coverage. Although not strictly a play or pay scheme, this plan, proposed by the Health Insurance Association of America, would provide a variety of tax and other incentives to encourage employers to offer low-cost insurance to employees. The plan would preserve Medicare and expand Medicaid eligibility (NASW, 1989). A few states have enacted and others have proposed employer-based plans (American Academy of Pediatrics, 1990; Illinois Public Action, 1990; NASW, Ohio Chapter, 1990; National Health Care Campaign, 1990c) . The most prominent of these is the Massachusetts Health Security Act of 1988, which was designed to ensure affordable coverage to the state's
THE NATIONAL HEALTH CARE CRISIS: AN ANALYSIS OF PROPOSED SOLUTIONS
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
39
500,000 uninsured citizens. By 1992, businesses with six or more employees will have to either provide health insurance or contribute to a state-run trust fund (Massachusetts Health Security Act, 1988).
ered services, such as cosmetic surgery. The new health care system would be financed by the federal government through a progressive income tax and an employer-paid payroll tax and supplemented by the states .(NASW, 1990b).
Single Payer Model
Similarities to the Canadian Health Care System
-
A number of plans rely on a single-payer approach, in which the government is the sole insurer. National Health Program for the United States. This plan is proposed by Physicians for a National Health Program, a national group of 2,500 physicians based in Cambridge, Massachusetts. A single public program would cover everyone; it would eliminate private insurance, Medicaid, and Medicare and would be administered on state and local levels (Himmelstein & Woolhander, 1989). Health Security Partnership. This plan is proposed by the Committee for National Health Insurance, Health Security Action Council (1989), which consists of representatives from organized labor, civil rights groups, academia, and health and welfare organizations. A federalstate plan would provide a basic federal benefit package that the states could supplement. Medicaid would be phased out; after five years, Medicare would also be phased out. U. S. Health, H.R. 2930. This plan is proposed by Representative Edward Roybal (D-Calif.). Representative Roybal's bill would expand Medicare into a universal single-payer system. Medicaid would be abolished (NASW, 1989). NASW National Health Care Board Proposal. NASW proposed its own national health care plan in spring 1990. NASW's plan replaces the current system with a National Health Board, a single-payer system offering full coverage, including long-term and mental health care for everyone living in the United States. The new system would be administered by the federal government; services would be delivered by the states in accordance with federal guidelines. Patients could choose from among any of the public and private providers participating in the program. The plan would eliminate private insurance, except for a few uncov40
Although the single-payer plans are largely based on the Canadian system, there are differences among them. The NASW and Physicians for a National Health Program plans, which are most similar to the Canadian system, would eliminate private insurance, Medicare, and Medicáid. The Physicians for a National Health Program plan would eliminate all cost sharing by consumers; NASW's plan would allow limited copayments for some outpatient services and cost sharing based on ability to pay for longterm care. Financing for both plans would come primarily from a progressive income tax. The Health Security Partnership and Representative Roybal's bill, on the other hand, would continue private insurance in a modified form. Representative Roybal's bill would expand Medicare, and the Health Security Partnership would eventually integrate Medicare into the program. Under the Health Security Partnership plan, there would be no cost sharing for those living below the poverty level, but deductibles would be established for others. The Roybal bill would maintain Medicare's current deductibles; eventually eliminate premiums for Part B (doctor's fees) of Medicare; and, except for those living below the poverty level, require coinsurance for long-term and skilled nursing home care. Financing for both plans would stem from a combination of taxes. A number of states are also considering singlepayer systems. Despite their underlying similarity, there are differences in these plans as well. For example, only Illinois and Washington would cover long-term care. Connecticut, Illinois, Indiana, and Missouri would not require cost sharing; Florida and Ohio would require small copayments for prescriptions and possibly for mental health services (National Health Care Campaign, 1990c).
HEALTH AND SOCIAL WORK/VOLUME 17, NUMBER 1 /FEBRUARY 1992
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
SOCIAL WORK VALUES AND HEALTH CARE REFORM
Which of these approaches is most consistent with the values of professional social work? The primary values of the profession are described by the Council on Social Work Education (1984) as follows: "Social workers hold that people should have equal access to resources, services, and opportunities for the accomplishment of life tasks, the alleviation of distress, and the realization of their aspirations and values in relation to themselves, the rights of others, the general welfare, and social justice" (p. 3). Building on these values, in 1979 the NASW Delegate Assembly identified the principles of a national health program (see Waxman, n.d.). The most fundamental of these principles are universal access, comprehensive benefits, financing based on progressive taxes, and publicly regulated cost containment. Universal access, regardless of race, ethnicity, age, Bender, sexual preference, income, religion, or geographic location, would entitle everyone to health care: "To ensure equality of opportunity for health care, all population groups should be served within the same national health program . . . there [should] be [no] separate categories, arrangements, or services that distinguish consumers" (NASW, 1991b, p. 142). Universal access would make health care a right, not a privilege. A national health care system should also offer comprehensive services. In addition to basic health care needs, the program should include preventive as well as long-term and mental health care: These "services should be provided in ways that recognize and enhance the integrity of each person in the context of family and community" (NASW, 1991b, p. 142). A national health care program should be financed primarily through progressive taxation. NASW's (1991c) Tax Reform Policy states that "The principle of ability to pay as measured by income and wealth is just. . . It [progressive taxation] can adjust inequalities of income and wealth" (p. 179). Finally, publicly regulated cost containment measures are essential to a national health care
system. Cost containment should eliminate duplication of unnecessary and expensive equipment and procedures; it should reduce current physicians' fees and hospital costs through prospective global budgeting, in which the government determines the resources available for the prospective year; and it should reduce the incidence of illness through an expansion of preventive medicine (NASW, 1991b). Representative federal and state proposals for public and private insurance plans are shown in Table 1. Of the federal proposals, the federalpublic approach, or national health insurance, is more consistent with the four social work principles discussed and the values of the profession than the federal-private approach. The major problem with the Pepper Commission's plan and the other federal-private plans is that they would preserve our multipayer system of financing and perpetuate the problem of unnecessary administrative and billing costs. A recent study found that commercial insurance companies are less efficient than government programs such as Medicare (Citizens Fund, 1990). Other studies have shown that curtailing the costs of insurance administration could save billions of dollars a year (Families USA, 1990a; Himmelstein & Woolhander, 1986). A recent cost analysis of the NASW proposal estimated an annual savings of $9.6 billion in administrative, billing, and similar costs (Center for Policy Studies, 1990). The state plans are limited in terms of universal access and cost containment. Only residents of the states that enact health insurance plans would have universal access to health care. The lack of a nationwide single-payer system would undermine cost containment. Even if all 50 states enacted state-public plans, this would still be less efficient than a national single-payer system. CONCLUSION
Despite the drawbacks of the state and employer-based approaches, any of the current health care proposals would improve the health care system. Social workers should support national health insurance as a reflection of their commitment to social workvalues, but theyshould
THE NATIONAL HEALTH CARE CRISIS: AN ANALYSIS OF PROPOSED SOLUTIONS
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
41
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
Yes Financed from employer and individual contributions; state funds; federal funds received for Medicare, Medicaid, Veterans Administration; state taxes on tobacco and alcohol. Partial Single-payer system but limited to state. Reduced administrative costs. Resource allocation through planning. Prospective global budgeting for hospitals and long-term care facilities. Fee-for-service payment, capitation, or salaried basis for practitioners based on rates set by Illinois Universal Health Care Plan.
Yes Lacks specifics. Proposed individual and employer contributions, federal revenues, and state funds equal to Medicaid expenditures. Partial Efforts limited by lack of national single-payer system. Lowers cost ofprivate insurance through cost-sharing and insurance reforms. Managed care.
Yes Financed by federal income tax and employer-paid payroll tax. Additional financing from states.
Yes Single-payer system. Reduced administrative costs. Resource allocation through planning. Prospective global budgeting for hospitals. Prospective global budgeting for other facilities. Fee-for-service paymentfor practitioners based on rates set by NHB.
Financing based on progressive taxes
Publicly regulated cost containment
Partial Efforts limited by lack ofa national or state single-payer system. Lowers cost of private insurance. Managed care.
Yes Financed through employer and individual contributions and state funds. Individual private insurance purchased on sliding fee scale.
No Basic.preventive.and diagnostic services, including physician and hospital care. Limited mental health services. No longterm care.
Partial Limited to state residents covered through employer-provided insurance. Play or pay rules. New public fund to offer affordable insurance to everyone else. Medicaid expansion.
Private-Massachusetts
NOTES: NASW = National Association of Social Workers; CHAMPUS = Civilian Health and Medical Program of the Uniformed Services.
Yes Basic, preventive, and diagnostic services, including physician and hospital care. Prescription drugs; vision, dental, and hearing services. Mental health and substance abuse services. Long-term care.
No -Basic, preventive, and diagnostic services, including physician and hospital care. Limited mental health care. Long-term care.
Yes Basic, preventive, and diagnostic services, including physician and hospital care. Prescription drugs; vision, dental, and hearing services. Mental health, substance abuse treatment and rehabilitation, and hospice care. Catastrophic and long-term care.
Partial Limited to state residents covered by a new Governing Board. Private insurance coverage phased out over three years (exceptforservices notcovered) .
Yes Employer-provided. Playor pay rules. Medicare remains. Medicaid replaced by a new public plan.
Comprehensive benefits
Public-State
Private-Pepper Commission
State
Yes All U.S. citizens covered by a new federal National Health Board (NHB). Medicare, Med-icaid, CHAMPUS, veterans health programs phased out.
Public-NASW
Federal
Universal access
Social Work Principles
Table l. Representative Federal and State Proposals
not view other approaches as detours from this goal. Employer-based and state programs can be used as stepping stones to a national system. Essential to any system of national health insurance are the principles of universal access, comprehensive benefits, financing based on progressive taxes, and publicly regulated cost containment. To the extent that state and employerbased approaches embody these principles, social workers can advocate the expansion and transformation of these approaches into a federalpublic system. About the Authors
Stephen Gorin, PhD, is Assistant Professor, University of New Hampshire, Durham, NH 03824-3596 and Lecturer, Plymouth State College, Plymouth, NH. Cynthia Moniz, PhD, is Assistant Professor, Plymouth State College, Plymouth, NH. The authors acknowledge the assistance of Madeleine Golde, NASW, and Sam Flint, American Academy of Pediatrics. References
Advocates for Senior Alert. (1990). The Medigap mess. Washington, DC: Author. American Academy of Pediatrics. (1989, February 8). Testimony, B. Harvey, Health & Environment Subcommittee, Energy & Commerce Committee, House, on infant mortality initiatives. Elk Grove
Village, IL: Author. American Academy of Pediatrics. (1990). State access initiatives. Child Health Financing, 7(2), 2-3. American Association of Retired Persons. (1989). Access to health care: An analysis of recent polling data. Washington, DC: Author.
Anastas, J. W., Gibeau, J. L., & Larson, P. J. (1990). Working families and eldercare: A national perspective in an aging America. Social Work, 35,405-411. Blandon, R., & Donelan, K. (1990). The public and the emerging debate over national health insurance. New EnglandJournal of Medicine, 323, 208-212. Center for Policy Studies. (1990). Cost analysis of the NASW national health care proposal. Columbia, MD: Author.
Citizens Fund. (1990). Premiums without benefits: Waste and inefficiency in the commercial insurance industry. Washington, DC: Author.
Committee for National Health Insurance, Health Security Action Council. (1989). The health security partnership: An equitable and universal national health plan. Washington, DC: Author. Council on Social Work Education. (1984). Handbook of accreditation standards and procedures (cur-
riculum policy statement). New York: Author. David, S. (1985). With dignity: The search for Medicare and Medicaid. Westport, CT: Greenwood Press. Democratic Study Group. (1991, May 24). DSG special report: Why conseroatives don't talk about America's health system. Washington, DC: Author.
Eckholm, E. (1990, March 27). Haunting issue for U.S.: Caring for the elderly ill. New York Times, pp. 1,18. Enthoven, A., & Kroniek, R. (1989). A consumerchoice health plan for the 1990's. New England Journal of Medicine, 320, 29-37,94-101. Families USA. (1990a). To the rescue: Toward solving America's health cost crisis. Washington, DC: Author. Families USA. (1990b). Families USA Foundation calls for a Federal Trade Commission investigation of insurance industry abuse of frail elderly nursing home insurance buyers: A preliminary investigation.
Washington, DC: Author. Ginsburg, J. A., & Prout, D. M. (1990). Access to health care. Annals of Internal Medicine, 112, 641-661. Himmelstein, D. U., & Woolhander, S. (1986). Cost without benefit: Administrative waste in U.S. health care. New England Journal of Medicine, 314, 441-445. Himmelstein, D. U., & Woolhander, S. (1989). A national health program for the U.S. New England Journal of Medicine, 320, 102-108. Illinois Public Action. (1990). Universal health care—We can't afford to go without it. Chicago: Author. Kern, R., & Bresch, J. E. (1990, January/February). Systematic health care reform: Is it time? Health Progress, pp. 32-44. Kingson, E., Hirshorn, B., & Cornman, J. (1986). Ties that bind—The interdependence of the generations. Washington, DC: Seven Locks.
THE NATIONAL HEALTH CARE CRISIS: AN ANALYSIS OF PROPOSED SOLUTIONS
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
43
Knox, R. (1989, April 17). Is a solution in sight for 1990? Boston Globe, pp. All, A14. Leonard, P., & Greenstein, R. (1990). One step forward: The deficit reduction package of 1990.
Washington, DC: Center on Budget and Policy Priorities. Long-Term Care Campaign. (n.d.). What is longterm care? Washington, DC: Author. Massachusetts Health Security Act of 1988, Department of Medical Security, Boston (1988). McManus, M. (1990). Corporations and unions join forces to support national health insurance. Child Health Financing Report, 4,4. Moniz, C. (1990). The NCSC: The rok of the elderly in the enactment of Medicare. Unpublished doctoral dissertation, Brandeis University, Waltham, MA. National Association of Social Workers. (1989). Comparison of six national health care proposals (Legislative Update). Silver Spring, MD:
Author. National Association of Social Workers. (1990a). Delegate assembly program priority goals 1991-1994.
Silver Spring, MD: Author. National Association of Social Workers. (1990b). National health care proposal (executive summary). Silver Spring, MD: Author. National Association of Social Workers. (1991a). Long-term care. In Social work speaks: NASW policy statements (pp. 134-136). Silver Spring, MD: Author. National Association of Social Workers. (1991b). National health. In Social work speaks: NASW policy statements (pp. 141-144). Silver Spring, MD: Author. National Association of Social Workers. (1991c). Tax reform. In Social work speaks: NASW policy statements (pp. 178-180). Silver Spring, MD: Author. National Association of Social Workers, Ohio Chapter. (1990). A position paper on universal health coverage in Ohio. Columbus: Author. National Health Care Campaign. (1990a). Big business grapples with the health crisis: Common sense vs. ideology. Health Care News. Washington, DC: Author. National Health Care Campaign. (1990b). AMAHealth access campaign (summary). Washington, DC: Author. 44
National Health Care Campaign. (1990c). State health care plans (summaries). Washington, DC: Author. Pepper, C. (1989). Long-term care insurance: The first step toward cornprehensive health insurance. Journal of Aging & Social Policy, 1, 9-15. Sidel, V. W. (1991). Health care for a nation in need. New York: Institute for Democratic Socialism. Senior Program of the California Rural Legal Assistance Foundation. (1989). Long-term careA Buide. Washington, DC: Long-Term Care Campaign. Starr, P. (1982). The social transformation of American medicine. New York: Basic Books. Starr, P. (1986). Health care for the poor: The past twenty years. In S. Danziger & D. Weinberg (Eds.), Fighting poverty: What works and what doesn't (pp. 106-132). Cambridge: Harvard University Press. Tarr-Whelan, K. (1990). Long-term care: A family struggle. Washington, DC: Long-Term Care Campaign. Trattner, I. (1989). From poor law to welfare state: A history of social welfare in America. New York: Free Press. U.S. Bipartisan Commission on Comprehensive Health Care. (1990). A call for action-Final report. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (1990, December 20). HHS News (press release). Washington, DC: Author. Waxman, H. (n.d.). Health Care for All resolution. Washington, DC: U.S. Government Printing Office. Weiner, J., Hanley, R., Spence, D., & Murray, S. (1989). We can run, but we can't hide: Toward reforming long-term care. Journal of Aging and Social Policy, 1, 87-102. Wenocur, S., & Reisch, M. (1989). From charity to enterprise: The development of American social welfare in a market economy. Urbana: University of
Illinois Press. Yudkowsky, B., Cartland, J., & Flint, S. (1990). Pediatrician participation in Medicaid: 19781989. Pediatrics, 85, 567-577. Accepted March 26, 1991
HEALTH AND SOCIAL WORK / VOLUME 17, NUMBER 1 / FEBRUARY 1992
Downloaded from https://academic.oup.com/hsw/article-abstract/17/1/37/588586 by Rutgers University Libraries/Technical Services user on 12 January 2018
