Time for a second opinion:

...This administration denies that...

...As Senator Kennedy has demonstrated, few other issues stir their souls so completely...

...Those people who were medically poor had their premiums subsidized by the county...

...This could be achieved by screening the population as they enrolled, and then providing mandatory assignment to all participating plans...

...But some mechanism must be employed, or some plans will suffer from so-called "adverse selection," and will likely fold...

...It would provide coverage for a comprehensive set of benefits for a set period of time, and yet keep freedom of choice for recipients among the competing plans...

...Government, or an agent designated by the government, should certify plans both for assurance of quality as well as fiscal stability...

...Regulation could control costs...

...That argument ignores reality...

...Only the willfully ignorant still believe that the private, voluntary sector will rush in to fill the gap...

...Certainly, it is not the reimbursement system alone which is responsible for our high costs and inefficient systems...

...Should this change be employed on a widespread basis by the federal government, the most visible sign to the community would be the rapid formation of a variety of health plans representing organized health-care systems...

...Robert Dole to provide medical coverage to those recently unemployed...

...The reaction in Congress has been, to be kind, unenthusias-tic...

...When the payment is made by a third party, i.e., government or an insurance company, the problem is compounded...

...To date, the administration vows to veto proposals by Rep...

...Well-designed attempts by the Carter administration to do so by using selective price controls were defeated in the Congress through the fierce lobbying of the health-care industry...

...Thus, a shift from our current retrospective financing system to a prospective system would have a galvanizing effect on the marketplace, Moreover, the plans would have to compete on the basis of quality as well as efficiency...

...The poor are the sickest people in our community...

...Too many people aren't covered...

...It can also play a valuable role as a broker among the plans, particularly for public beneficiaries...

...Finally, the administration sent its ideas on health cost containment to Congress...

...Faced with staggering deficits, they have elected to make deep cuts of their own in programs for the needy, compounding the effect of the Reagan cuts...

...Naturally, planning was a political process and, just as naturally, the pros usually won...

...They are often the chronically ill, and the costs of their care is paid by a hidden tax, added to the hospital and physician bills of the private, paying patient...

...So what we must do is structure the market for the sake of equity as well as access...

...It will cost more money, but it is a requirement of a decent society...

...The miracle is that these efforts have succeeded as well as they have, given the fragile structure they operated within...

...Not surprisingly, many hospitals and other providers will welcome the change...

...Because health benefits are tax deductible, the tax expenditure or lost revenue to the Treasury from our employed population is actually larger than federal spending on health care for the poor...

...The reality mocks the president's assertion that no one is being hurt by his policies...

...Our population is aging...

...And providing health coverage to those unable to secure it through employment or welfare should be a first priority for all those who claim justice is the end of government...

...Scientific gains-have made treatment more expensive...

...Not only would Medicare recipients be freed of the need to purchase "Medigap" insurance or face high deductibles, but all consumers would benefit because the practice of "cost shifting" by health-care providers would be diminished...

...President Carter's temporizing on the issue cost him dearly among the faithful...

...The states offer no relief...

...Liberals should seek their support...

...They consist chiefly of raising the patient's deductible for Medicare, reducing the overall federal expenditure for Medicaid by cutting some eligibility and benefits, and limiting the amount of health benefits employees THOMAS higgins is director of the department of human services of Multnomah County in Oregon...

...In most communities, a coalition of health providers, better organized and more sophisticated than consumers, became the dominant force in planning decisions...

...The evaluation of the program indicated that it actually saved about twenty percent of the costs that could have been necessary had it operated according to a traditional fee-for-service system...

...And despite the fact that we are spending more as a society on health than any other country in the world, we clearly are not getting our money's worth...

...Collecting for those services from patients is onerous...

...Some would be hospital-based...

...Quite the contrary...

...With federal and state legislation, local health planning bodies worked toward a rational allocation of health-care resources...

...It is true that neither Medicaid nor Medicare typically pay 100 percent of customary fees under the present fee-for-service system...

...And, as we conquer infectious diseases, more of our people are subject to long-term, expensive illnesses...

...To that end, in the decades since the New Deal, they passed legislation that built thousands of hospitals and trained tens of thousands of doctors, nurses, and other practitioners and researchers...

...If the consumer decided to pick a plan which provided more services, e.g., chiropractic care, than called for in the basic package, the consumer would pay the difference between the voucher and the plan...

...Nevertheless, having chased that will-o-the-wisp for years, and now faced with a deepening crisis for millions of medically poor people, clearly these advocates of change must examine incremental reforms which hold promise of success...

...The county was their broker as they chose between competing plans...

...If the reforms suggested in financing health care are implemented, the costs will be relatively minor because overall utilization will decline, resulting in major savings...

...It might be well to " swap " this responsibility for ending general revenue sharing, but in any event this is properly a federal responsibility, and it would give the federal government increased flexibility to implement needed reforms...

...others would be physician associations or primary care networks, and still others would be organized by insurance companies or employer groups...

...For a while, liberals embraced planning...

...When things get bad enough," whatever that means, theoretically the public will demand and get sweeping reform...

...As a series of articles in The Oregonian documented last year, the tragic consequences are sickness and death that should have been avoided...

...The consumer would be advised every six months of the various plans being offered, and select one...

...so are our politics...

...Simply stated, most health care is delivered on a "cost-plus" basis...

...A general sense that the poor have suffered enough from cuts in Medicare and Medicaid, together with an almost solid phalanx of opposition from business, labor, and the health care industry to the tax proposal, makes the outlook for most of Mr...

...For eight years we operated just such a broker model in Multnomah County, Oregon...

...Competition, not regulation, was promised by the Reagan administration as an alternative means of reforming the system...

...Savings from a system which encourages, by its very nature, controls on utilization should make up the difference...

...REAGAN'S HEALTH POLICY Time for a second opinion THOMAS HIGGINS NOWHERE IN America is the Reagan administration's policy of indifference toward the health care needs of the poor more sadly evident than in the Northwest, where I direct a department of human services...

...There is much to praise in this approach...

...Just as there is no free lunch, so is there little "charity" care...

...Or, as we did in Multnomah County, such individuals could be referred to a publicly-operated plan, if one is available...

...It would be necessary, of course, for the voucher to be fixed at a high enough rate to encourage plans to compete for it...

...But it is not enough...

...It is a hollow bluff to assert that the system can be completely converted through direct political challenge...

...Amid a crippled economy, thousands of people who are indigent, but ineligible for welfare, receive little or no medical assistance...

...Liberals and the Democratic party should commit themselves to expanding the Medicaid program, reversing the policies of the Reagan administration...

...The government should also act to insure that no one health plan received a disproportionate number of chronically ill people from its programs...

...Instead of the present emphasis on the expensive treatment of acute illness, focus would be placed on prevention and early intervention...

...Some Medicare recipients would receive "catastrophic" coverage, and some would participate in a voluntary voucher program...

...Medicaid should serve not only those who are eligible for welfare (AFDC and SSI), but also those who are "medically needy," including the unemployed and the underemployed, in the same fashion that the food stamp program does...

...In most communities, Medicare and Medicaid combined account for about forty percent of the health dollars spent...

...But these measures also left the nation with a big and growing bill...

...Medicaid, like Medicare, should be wholly a federal responsibility , as a matter of simple equity...

...It is time to restore the health of our people to its rightful place on the nation's agenda.s rightful place on the nation's agenda...

...Under THE PROPOSAL I have outlined, which owes its inspiration to the pioneering ideas of Professor Alain Enthoven from Stanford University, the voucher would be issued to every eligible individual...

...For many liberals and Democrats, this political frustration only fueled the quest for a national health insurance program, complete with all the necessary regulation to contain costs and assure quality and accessibility of services...

...And this expansion should serve the medically needy in every state, as an entitlement, instead of only in some states as is the case now...

...America's health care industry is unique...

...The clients of this program, called Project Health, received unbiased counseling about the benefits and costs of the various plans...

...But, as has been pointed out, the fee-for-service system encourages excessive utilization...

...A much ballyhooed "voluntary effort" ensued, but once the heat was off it died quickly and with no lasting effect...

...and we are falling behind other industrial nations in comparative health...

...The plans would be required to provide a minimum but comprehensive set of benefits at a prepaid, fixed amount...

...The argument has been made that such incremental reforms remove the incentive for national health insurance...

...there is too much waste and duplication...

...I prefer that course, because the publicly-operated plan can also serve as a valuable means of continued competition...

...This is, if you will, the "soft path" to reforming health-care delivery, but I believe it is more practical than our previous methods...

...For them national health insurance has been the Holy Grail of domestic policy...

...Let me illustrate how it would work...

...can receive without paying taxes on them...

...Excess capacity in equipment and facilities is the major cause of inflation in health-care costs...

...It may be objected that states and localities cannot absorb their share of increased Medicaid expenditures...

...Henry A. Waxman and Sen...

...Finally, many hospitals and physicians are profoundly disturbed about the human consequences of this administration's cuts in Medicaid and Medicare, and are ready to support change...

...To put the matter in clear perspective, it is important to take into account the gains for society from a healthier, more productive population...

...But altering payment systems is government's greatest opportunity for reform...

...I quite agree...

...They are still unremittingly hostile to national health insurance, but it is clear now that the only other alternative to prospective reimbursement is a cap on expenditures...

...More of the poor and elderly receive needed health care now than was the case before their enactment...

...Billing the government for them under the guise of allowable expenses has become a way of life for an army of creative hospital accountants, and it is still not enough...

...They believe with a majority of Americans that the poor should not have to depend on charity for the protection of their health...

...Actually, the number of health providers is at a historic high, but fewer than ever are willing to accept the poor as patients...

...What is most important, however, is that at a time when seventeen million people have lost their medical coverage because of the current recession, no support from this administration can be found for extending protection to those unable to provide for themselves...

...Already, some enterprising consultants are holding seminars for hospitals to explain methods for evading the new law...

...Conversely, if the consumer picked a plan which offered the basic benefits, but at less cost than the amount of the voucher, the consumer could keep the difference in cash or use it for additional services...

...And the perverse economic incentive in a fee-for-service payment mechanism leads to that excess capacity...

...Many who have been divided over questions of means, share these goals...

...Real competition might constrain costs, but without some regulation it is likely to curtail benefits, chiefly to those who need them most...

...In order to get that business, health providers in those areas would have to participate in at least one of several competing plans...

...And the American Medical Association, which vigorously contested the passage of Medicare and Medicaid, now opposes a reduction in their benefits...

...That legislation will encourage health-care providers to claim diagnoses that assure a higher payment, which could result in excessive utilization of services...

...For good or ill, their tradition has been to improve access to health care by increasing its availability...

...These new plans would join existing ones, including health maintenance organizations, but would not always resemble them...

...Such has been the experience of many well-managed plans, such as the Kaiser system, which demonstrate significantly lower rates of utilization without sacrifice in quality of care...

...They defer health care at a preventive stage, and so frequently receive it in the most costly setting, an emergency room...

...Cost is the greatest barrier to care...

...The assurance of equal access to health care is a sine qua non of social justice...

...Indeed, they are willing to support the expansion of efficient programs to provide for those in need...

...That does not mean, however, a precipitate rise in costs...

...The government should begin with a program of prospective payment based on vouchers for its Medicare and Medicaid beneficiaries in every market capable of sustaining organized health care systems...

...WHAT is possible is for the government to use its resources as leverage to make significant change in financing the delivery of health care...

...Inevitably, such caps are enforced by denying payment for some benefits that hospitals feel they must provide when ordered by a physician...

...Government's role in financing health care involves more than Medicare and Medicaid...

...THE most important thing government can do, of course, is provide basic health protection to those who are too impoverished to obtain it for themselves...

...Unless prompt action is taken, the Medicare Trust Fund, which provides hospital and physician coverage for elderly people, will be broke by 1985...

...Even as health costs escalate, skyrocketing past other goods and services, several hospitals serving the poor here are on the edge of bankruptcy from delivering unfunded care...

...I do not wish to imply that government has no constructive role to play in regulating this marketplace...

...The point is that most health-care providers would have powerful incentives to be associated with at least one of these competing plans, and government's purchase of care would be the catalyst...

...This form of prepayment is also significantly different from recently enacted legislation which tied reimbursement for Medicare to fixed payments based upon diagnosis...

...but during the first two years of the president's term, no such legislation was submitted...

...As a national community, social justice must be an essential element in our shared vision...

...They created the Veterans Administration health system, Medicare and Medicaid, and a variety of public and preventive health programs...

...But as we have painfully learned, regulation alone is both politically untenable and easy for providers to avoid...

...Health-care competition was better as campaign politics than public policy, for clearly real competition means losers as well as winners among groups that have been Reagan allies...

...The earliest rhetoric from the Reagan administration contained at least some interesting notions on controlling health costs...

...Reagan's policies grim...

...So WHAT about those not in the Reagan camp - the Democrats and the liberals generally...

...By most standards, these measures have been remarkably successful...

...Congress has approved a proposal by the Department of Health and Human Services to switch Medicare reimbursement for hospitals to fixed payments based upon diagnosis although, as I will discuss later, this proposal is flawed and invites evasion...

...Thus there would be an economic incentive to purchase care prudently...

...Yes, liberals and Democrats should continue to champion legislation for national health insurance...

...A lot of money is at stake...