Lessons of Proposition 186

...As for overutilization, Canadian researchers say there has been little evidence of it since the single-payer regime was adopted in 1971...

...All residents would be issued a health security card that entitles them to comprehensive medical care from providers of their choice, whether physicians in private practice, health maintenance organizations (HMOs), clinics, or hospitals...

...The Rightward shift in Congress leaves virtually no hope of reviving the Clinton plan...

...And the single-payer bills introduced in the outgoing Congress by Representative Jim McDermott (D.-Wash...

...They chafe under micromanagement by faceless "utilization reviewers...

...A tobacco tax would raise a token 1 per cent of the total budget...

...excess is due largely to administrative overhead...

...INDEED, the lessons to be learned from California now appear to hold the key to meaningful health care reform, for in the immediate future this will have to come from the states...

...A tireless campaigner, he is continuing to press the issue locally and will assist those in the states of Washington, Colorado, Vermont, and Missouri who are poised to take it up...

...In any event, given California's higher projected rateof health care spending per capita (40 per cent above Canada's), its citizens had even less cause to worry about rationing than the Canadians did...

...Their experiences may eventually lead them to recognize that government intervention is needed-that, as Lingappa puts it, bureaucratic macromanagement is preferable to bureaucratic micromanagement...

...The California version was backed by the state branches of the League of Women Voters, the American College of Physicians and Surgeons, the National Association of Medical Students, and numerous trade unions, plus others...

...But measures of that sort will neither control escalating medical costs nor provide universal coverage...

...Some voters may have thought it a half-baked idea, served up in a referendum because it was too flawed to survive legislative scrutiny...

...And the system he would preside over was pictured as combining the efficiency of the Post Office with the compassion of the Internal Revenue Service...

...Their success in collecting over 1 million signatures to get the proposition on the ballot was a near-miracle, but they lacked the staff and money to cultivate this base of support...

...eyeglasses, hearing aids and other essential items would be fully covered, unless small copayments proved necessary to keep the system solvent...

...The proposed Health Commissioner was caricatured as a "czar'' who would have awesome power...

...The California plan avoided this problem by setting a ceiling on expenditures...

...So did the state's largest senior citizens' group, the California chapter of the American Association of Retired Persons...

...A study by KPMG Peat Marwick, an independent accounting firm, reckoned the average family's savings at $550 a year...

...Economic insecurities were also played upon to sow doubt...

...employers would remit between 4.4 and 8.9 per cent of payroll, in proportion to the size of their workforces...

...In California, this sentiment was deftly exploited...

...That cites as its source a 1991 survey by Statistics Canada, Health Status of Canadians-which, as it happens, contains no such finding...

...Perhaps an increasing number of physicians around the country will come to the same understanding that has led Dr...

...Proposition 186 was tagged "the government takeover of health care...

...Had the statisticians factored in reductions in auto and liability insurance, whose medical components would no longer be needed, their estimate would have been even higher...

...A little over $2 million was raised, much of it at house parties...

...Of those...

...They might have relieved fears of an inevitable deficit by confining initial coverage to vital services, with expansion to occur as funds allowed...

...Hospitals will continue to be absorbed by huge conglomerates and run by distant CEOs responsible only to shareholders...

...For 1996, these revenues would have amounted to $105 billion...

...Lingap-pa, who goes by his nickname, Vishu, holds an MD from Cornell and a PhD in cell biology from Rockefeller University...

...Actually, a bill similar to 186 had received a majority vote in the California Senate, though shy of the two thirds required for passage...

...Its approval would have established California as the first state in the union to adopt a Canadian-style health insurance system...

...Why, then, did Proposition 186 garner a meager 27 per cent of the vote...

...Along with several colleagues at UCSF, notably the health policy analysts Kevin Grumbach and Thomas Bodenheimer, he was a principal author of the "California Health Security Act" that made its way to a public referendum...

...In making decisions on propositions, people tend to take the "shortcut" of looking to see who has endorsed them...

...New capital projects of more than $500,000, for example, could not be undertaken without supervisory approval...

...Pharmaceutical firms will not be restrained from raising drug prices...

...SANFORD LAKOFF, a new contributor to the NL, is a professor of political science at the University of California, San Diego...

...The disapproving "Senior Coalition" depicted in the commercials is actually a Right-wing direct-mail outfit reportedly under investigation by the U. S. Postal Service...

...In the case of California, the figure for hospitals is 20 per cent, and for HMOs anywhere from a high of 33 per cent registered by the profit-making Well Point to a low of 8-10 per cent reported by the nonprofit Kaiser Permanente...

...For patients, the system would not only be simple but as painless to the pocket-book as medical care can get: One would pay only for optional procedures, like face-lifts...

...So Proposition 186 may prove to be merely a battle that was lost, not a war...

...Independent studies indicate that the Canadian system is not only cost-effective but good at delivering care...

...Hospitals would be spared the exhaustive itemization of everything used for each patient, down to aspirin tablets and gauze pads, to fulfill insurance company demands...

...The U.S...

...Doctors, too, would not have to contend with as many as 1,500 different reimbursement standards and forms...

...During subsequentyears, Californians would have reaped additional savings from tight cost controls...

...ITS MANY ADVANTAGES have gained the single-payer approach impressive support from nonpartisan analysts, including such Federal entities as the General Accounting Office (GAO) and the Congressional Budget Office...

...The initiative suffered additionally from not having any prominent political godparents...

...This averages 26 per cent for national insurance companies...

...Since there was never an opportunity to debate this claim on television, the majority of voters were probably unaware that two thirds of California's employers already contribute to health coverage, that Hawaii has not lost jobs by imposing employer mandates, and thatmostuncoveredjobs,being in the service sector, cannot easily move out of state...

...For instance, nurses and senior citizens' groups were broadly portrayed as opposing the initiative...

...A national citizens' organization, Single-Payer Across the Nation (SPAN), has been formed to promote it...

...An elected Health Commissioner would have negotiated fees with representatives chosen by physician subgroups and set capitation budgets for HMOs as well as capital and operation budgets for hospitals...

...Financing would have come through taxation and the reappropriation of existing state and Federal resources from Medicare, Medicaid and Worker's Compensation...

...An editorial in the conservative San Diego Union-Tribune noted ominously, "More than 183,000 Canadians were on waiting lists for surgical procedures in 1993...

...In trying to respond to all the disinformation, participants in the grass-roots campaign for 186, run by a volunteer organization called Neighbor to Neighbor, were handicapped from the start by inadequate resources...

...Faced with serious cost constraints, third-party payers, such as employers, private insurance companies and state governments, are choosing to limit insurance benefits in arbitrary and inequitable ways, often without obligation to ensure that everyone receives adequate care...

...Local TV outlets, filled with the insurance coalition's spots, somehow did not find time to delve into health care amid their daily news diet of mayhem, weather and sports...

...In a recent report, the Council on Ethical and Judicial Affairs of the American Medical Association delivered a stark diagnosis: "Government-funded programs and private insurance companies both have had to limit or eliminate services...

...In many regions, it has already accumulated enough local monopoly power to set prices at will...

...No matter...

...Lingappa and his colleagues in California-as well as their counterparts at Harvard, Drs...

...Under the California plan, prescription drugs would require a copayment of five dollars...

...Nor could Proposition 186 attract a compensatory measure of publicity...

...Still, the proposition probably would have fared better had the drafters anticipated the more understandable criticisms...

...The essence of the advertising strategy was planting misleading impressions...

...Physicians know first-hand the disservices of private insurance...

...Under Medicare and Medicaid, cost reduction is possible only through arbitrary cutbacks in coverage and payments, causing providers to turn away some patients or shift their unreimbursed expenses to others...

...McDonald's is not going to relocate across the Arizona and Nevada borders and expect Californians to drive out whenever they get a Big Mac attack...

...It never received serious treatment on television- a significant factor in a state where, as the old saw has it, all you need for a rally is two people in front of the tube...

...Business groups and their consultants were shown grimly forecasting the loss of "hundreds of thousands" of jobs if 186 passed...

...Employers similarly stood to benefit in the form of lower Worker's Compensation rates...

...CALIFORNIA'S HEALTH BATTLE Lessons of Proposition 186 by SANFORD LAKOFF VISHWANATH LINGAPPA'S name may not be a household word outside his own family circle, but if the single-payer health care plan on the ballot in California as Proposition 186 had passed last November 8-instead of being trounced almost three-to-one-he would have deserved much of the credit...

...If the irrational hostility to a government role in medicine is overcome, and if the single-payer plan is adopted in even one state, Vishu Lingappa may yet become a household word- and a byword for genuine health care reform...

...The executive editor of the New England Journal of Medicine, Dr...

...As the spiral moves upward, all except the super-rich will be deprived of the freedom to use fee-for-service physicians...

...To heighten their anxieties, opponents told scare stories about the supposed shortcomings of Canadian health care...

...That every major newspaper in the state, even the somewhat liberal Los Angeles Times, ended up urging the Health Security Act's defeat was yet another blow...

...Partial dental coverage, and long-term care at home and in institutional settings, would be phased in...

...In the first year of a single-payer regime, California wouldhave saved at least $ 10 billion on overhead alone...

...The sum was hardly enough to mount a statewide counteroffensive against a well-financed adversary...

...Consumers Union has found it the surest way to achieve affordable universal coverage...

...By contrast, administration was limited to 4 per cent of the budget for the state agency Proposition 186 would have established...

...A coalition of insurers and for-profit providers launched a $ 10 million offensive against the Health Security Act, saturating the airwaves from Labor Day onward with cunning negative ads by the very advertising agency responsible for the "Harry and Louise" campaign that proved so damaging to the Clinton plan...

...In fact, although a small association of executive nurses came out against 186, organizations representing the state's 160,000 care-giving nurses endorsed it...

...In 1992 Consumer Reports found that while Canadian providers were short of some of the latest technologies, they performed general surgeries, diagnostic tests and hundreds of other procedures without delay...

...At most the Republican leadership may do some minor tinkering with the existing system, like eliminating insurance discrimination based on pre-existing conditions...

...attracted nearly 100 Capitol Hill legislators...

...Eliminating paperwork and profiteering would flush much of the waste out of medicine...

...Perhaps most important, though, employees who changed jobs or suddenly found themselves unemployed would not have lost their coverage...

...Most families and businesses would have paid less in additional taxes than they currently shell out for insurance premiums and out-of-pocket expenses...

...Many felt the initiative seemed to promise too much too soon, and for "nothing," not even a copayment...

...45 per cent described themselves as 'in pain.'" The editorial writer apparently picked up the 45 per cent from a briefing paper prepared by a Right-wing California think tank...

...It is not uncommon for landmark social advances to be rejected before they are fully appreciated and accepted-witness the extension of suffrage...

...The source of the statement offers a ray of hope...

...In the scheme of 186, individuals were to be assessed 2.5 per cent of taxable income, with a surcharge of 2.5 per cent on income over $250,000 ($500,000 for joint filers...

...To be included, pharmaceutical firms would have had to lower their prices, as they already do for large buyers...

...The concept of the single-payer approach is simplicity itself, especially compared with the Byzantine architecture of the Clinton plan...

...They might have overcome objections to an all-powerful Health Commissioner by providing for an appointed bipartisan administrative oversight body-a la the University of California's Board of Regents-that would select a professional manager...

...The occasional stories in print were generally fair, but overwhelmed by the attention devoted to Proposition 187, aimed at cutting off benefits to illegal immigrants...

...Ancillary measures would have contained outlays in other ways...

...The main reason was its falling victim to the popular hostility toward government that marked the midterm elections...

...The Columbia/HCA Healthcare Corporation today owns 311 hospitals in 37 states and expects to grow fourfold, until it controls 20 per cent of the hospitals in every state...

...Some have been forced to abandon private practice altogether and join HMOs, or to work for hospitals where the bottom line overrides the lines on the medical chart...

...He practices at San Francisco General Hospital and teaches at its affiliated University of California medical school...

...The modest but ebullient Dr...

...Other fears were likewise reinforced...

...by comparison, the 23 other industrialized countries tracked by the Organization for Economic Cooperation and Development spent an average of 8.1 per cent...

...According to a nationwide CBS News-New York Times survey taken shortly before November 8, a scant 30 per cent of the respondents thought government effective in addressing social needs, while 60 per cent preferred the efforts of the private sector...

...Marcia Angell, gave it a ringing acclamation in her editorial column...

...The providers would bill a "single payer," a specially created government agency...

...Anyone requiring emergency care," the magazine said, "gets it immediately.'' A recent inquiry by the GAO concluded that autologous bone marrow transplantation to treat breast cancer, only recently regarded as experimental, is performed at the same rate in Canada as in the United States, with even better outcomes...

...Steffi Woolhandler and David Himmelstein-to champion the single-payer approach...

...They envisioned over-utilization and rationing and interminable queues...

...Another provision of the initiative called for an official prescription drug formulary...

...In 1992, the United States spent 13.6 per cent of Gross Domestic Product on health care...

...and Senator Paul D. Wellstone (D.-Minn...

...Not until 10 days before the election was a feeble advertising response launched...