Why a Public Health Care Plan is Best for Women

September 22, 2009

Jan Erickson, Director of NOW Foundation Programs

UPDATE: The Senate Finance Committee this week will be considering amendments to the legislation offered by its chair, Sen. Max Baucus (D-Mont.), which we summarized in a recent action alert. Some 500 amendments have been filed, including at least eight that oppose women's access to abortion and related matters. Sen. Jay Rockefeller (D-W.Va.) will offer an amendment that would establish a public insurance program that appears to be a fairly robust plan, but would prohibit coverage for abortion services, except in cases of rape, incest and threat to the life of the woman. Other proposed amendments include restoration of abstinence education, no pre-emption of state laws regarding abortion, application of so-called conscience clauses in the provision of health care services and non-discrimination against health care providers that do not offer abortion services, among others.

NOW Backs A Single-Payer Plan

In 1993, the National Organization for Women adopted a resolution in support of a national single-payer health care plan because we believed that this was the most efficient and affordable way to provide health care coverage to everyone. We still believe that.

This would be a program where the federal government (as the single-payer) would pay the bills, and private doctors, clinics and hospitals would continue to provide the services. A single-payer approach -- similar to that in Canada -- would cut costs by 20 to 30 percent (maybe even more), and most of the 47 million persons without health insurance would be covered. Despite organizing activities of single-payer supporters all over the country and leadership from some members of the House, the single-payer plan never got a fair hearing during the health care reform debates in Congress. The media -- taking a cue from their corporate sponsors and conservative Washington insiders -- downplayed this important plan that would truly solve our nation's health care crisis.

Millions Spent to Defeat Reform -- With millions being spent by highly profitable private health insurance companies to lobby against any health care reform bill and conservative Republicans (plus a few Blue Dog Democrats) opposing even a public insurance plan, the chances of a national single-payer plan are less than zero at this time. That is the unfortunate political reality.

President Obama appears to have backed away from a previous commitment to a public insurance plan (which would be similar to a single-payer approach), though he much earlier said that a single-payer plan is the way to go. Right now, Democrats in Congress just want to get any reform bill passed -- no matter whether or not it will constrain costs or cover everyone. Democratic leaders do not want a repeat of the 1994 mid-term election when they lost control of the House to conservative Republicans as the Clinton health care reform plan went up in flames. The goal of the Republicans is to defeat reform efforts and to damage the Obama presidency, along with taking back control of Congress in the 2010 elections.

Majority Wants Public Plan -- Our fear is that Congress may drop efforts to incorporate a public option, even though a majority of voters want one. A new poll reported in the New England Journal of Medicine indicates that 63 percent of physicians support a public insurance plan (along with traditional private insurance), with another 10 percent supporting a public plan alone (no private insurance whatsoever).

According to another survey conducted by the conservative Economic Benefits Research Institute and supported by an array of investment, insurance and manufacturing companies, 83 percent of respondents support "creating a public health insurance plan that anyone can purchase." And it should be noted that in this same survey 75 percent of respondents supported expanding Medicare and Medicaid.

So why is Congress ignoring what is clearly a strong public desire? The simple answer is that millions of dollars flowing to members' re-election campaign funds and the frightening displays of hatred from right-wingers, with industry backing, have scared the leadership away from focusing on a robust public plan. This is a clear example of how weakened our democracy has become; our elected leaders are more responsive to wealthy corporate interests than to the public. It is especially tragic that this is happening at a time when we must bring health care costs under control as baby boomers age, plus we need to find resources to cover the 47 million uninsured, and as our economy becomes more uncompetitive globally.

Advantages of a Public Plan -- A not-for-profit public plan would be funded through payroll deductions -- like Social Security and Medicare -- and could be supplemented by funding from other revenue sources. Such a plan would allow everyone to keep their own doctor, assure that all medically-necessary services are provided, prohibit exclusions for pre-existing conditions and bypass the problem of insurance company approval for payment of services, among many other advantages. Advocates for a strong public insurance plan have said that such a plan would be voluntary, open to everyone, offer affordable care, and limit premium payments and out-of-pocket expenses. It would prohibit basing premium rates on age, gender or other factors. The chief benefit of a strong public plan would be that it should be large enough to negotiate for lower prices from health care providers and from drug manufacturers. Administrative costs for a strong public plan would be minimal -- as opposed to the 20 to 30 percent exacted by profit-driven private insurers.

No Public Plan in Senate Finance Committee Bill -- The Senate Health, Education, Labor and Pensions (HELP) Committee bill makes provision for a public insurance plan, though no details have been provided; while the newly-released Senate Finance Committee Chairman's Mark legislation does not offer a public plan, it instead offers a network of health co-operatives. These co-ops would do little to bring down the costs of health care, as has been demonstrated in several locales -- notably in the 70-year-old co-op in Seattle, Wash. The House reform bill, H.R. 3200, as produced by three separate committees, contains a public option, but with certain limitations that might make it less effective in controlling health care costs. The House bill has not yet gone to a floor vote.

Only Way to Control Costs -- Why do we care about whether there is a public health insurance plan? A public plan covering many millions of people would have the power to negotiate the cost of medical services. The ability to negotiate the prices of prescription drugs and other medical supplies is extremely important. Unless the U.S. can get a handle on providers' fees and prescription drug prices as more baby boomers age, the cost of health care will continue to spiral upward.

Protection of the private for-profit insurance industry, as the Senate Finance Committee bill provides (and the other major bills do), will continue to keep our economy less competitive globally, make it difficult for small business owners (a significant proportion of which are women) to offer insurance and less able to address the core factors leading to rising health care costs. Predictably, there will be increasing burdens on individuals and families to pay for expensive insurance premiums, deductibles and co-pays.

In the meantime, it is important to underscore how much more effectively a comprehensive, robust, affordable and guaranteed public health insurance plan would be to meet women's health care needs -- as these are distinct from those of men.

Women Have Different Life Situations -- Because of the way in which society has placed care giving predominantly on the shoulders of women and continues to penalize with sex-based wage discrimination, women are forced to make a series of choices that men do not. As a result, women have a complicated life story: as young women beginning their working careers (often at relatively low wages and almost always with sex-based wage discrimination), changing jobs, starting a family, working part-time and then at various points working full-time, possibly divorcing and seeing their income decline, caring for an elderly or sick family member, having a major disease (often with no one to care for them) or a chronic condition and then retirement (frequently with no pension income, modest savings and Social Security).

No Gender Rating Allowed -- A strong public health insurance plan open to all with no restrictions that is always there is the best solution. It is critically important that we have a public plan that does not penalize women for seeking essential preventive and routine care and for being the sex that reproduces. It is women's necessarily higher utilization that is blamed for gender rating. The fact that women have babies and more often utilize the health care system has been targeted by insurers who charge women more and, in the individual insurance market, often do not cover maternity services. A public plan is needed where contraceptives and all other reproductive health care services are provided -- with no limitations and no hassles.

Millions of Women Uninsured -- Over 17 million women in the U.S. have no health insurance. Many tens of millions more have been without health insurance at some point over a prior two year period. For those lucky enough to have insurance, many are under-insured and/or have costly deductibles and co-payments. Whether reform of private insurance -- especially the individual market -- will significantly help the currently uninsured is an important question. Huge subsidies will be necessary for low- and even moderate-income earners, should their only recourse be private insurance.

Uncompensated Caregiving Affects Health Coverage -- Because women are the caregivers who do the lioness's share of caring for children or ill relatives they are often forced to work part-time or temporarily. Therefore employer-dependent insurance is not the answer. If there were a national program to assure dependable child care and more affordable long-term care, it might be a different story for the millions of women who can only work on a part-time basis. Many more women than men are likely to be part-time workers and contingency workers and, as consequence, do not have employer-related health insurance coverage. Again, these sex-specific work patterns are related to the lack of family-friendly work policies and support programs in the U.S.

With reduced income, even modest co-payments and deductibles are a barrier to care. Many of these women may have earnings somewhat higher than the income requirements so they may not qualify for subsidies and will still have difficulty paying for insurance coverage on their own. If there is no robust public plan adopted, then a very generous expansion of Medicaid may be the solution. Certainly, a close scrutiny of the insurance subsidy proposals should be made in light of the realities of these women's lives.

Disability Coverage Problematic -- Women who become disabled and who apply for coverage under SSI government assistance or under private disability insurance often have to wait a lengthy period before they qualify and begin to receive benefits -- sometimes as long as three or more years. Because they are often too disabled to work, they must use savings or rely on friends and relatives for help with living costs, medical services and prescription drugs. Their health condition frequently declines under those circumstances. Would any of the proposed reforms address their needs? A public plan, on the other hand, would always be there for them.

Depending Upon Spouse's Coverage -- Divorced women who depended upon spouses for insurance coverage often find themselves without coverage -- at least for a period of time. Because women's income takes a dramatic dive following divorce, as numerous studies have indicated, their ability to obtain insurance in the individual private market is limited. Until their divorce becomes final, with property division and child support obligations decided, their ability to afford health insurance is constrained. Further, battered women who have to rely on their partner's insurance may find themselves needing to remain in an abusive situation.

Uninsured Women Face Serious Health Risks -- That uninsured women suffer is indisputable. The American College of Obstetricians and Gynecologists notes that uninsured women are three times less likely to have had a Pap test in the last three years, with a 60 percent greater risk of late stage cervical cancer. Breast cancer is 30 percent to 50 percent more fatal to uninsured women. Pregnancy-related maternal deaths are three to four times higher among women who receive no prenatal care. Going without prenatal care increases infant death rates by six times.

Reproductive Health Care Services Essential -- Restricting coverage of reproductive health care services hurts all women, and it especially hurts low-income women. All major health care reform bills would prohibit the use of public funds to pay for abortion services. For those insurance plans that are offered in the proposed health insurance exchanges, they would have to provide documentation that no public funds have been used for abortion services. The Hyde Amendment -- that horrendous provision in law that prohibits the use of federal funds to pay for abortion -- is cited as the reason for the continued prohibition. Right-wing opponents of abortion rights, reportedly, are still attempting to get a provision in health care legislation that would prohibit private insurance plans from covering abortion services, as many currently do. If they win, it will be a disaster for millions of women.

Not Covering Immigrants is Bad Policy -- The three major health care reform bills do not provide health insurance coverage for undocumented immigrants. This is plain bad public health policy. Under proposed legislation, "legal" immigrants would have to wait for a period of time and produce evidence that they are in the U.S. legally before getting coverage. Failing to provide coverage for immigrants is a tragic neglect and presents serious health risks and costs to society. It is also a violation of fundamental human rights. If access to health care is a human right, as many supporters of reform are claiming, it should apply to everyone, not just U.S. citizens.

There are multiple problems confronted by poor and modest-income rural women wholive where health care facilities are distant or limited, but the underlying problem of affordability for those groups would be best addressed in a public plan. A large, robust not-for-profit public plan would produce significant savings to improve our delivery system infrastructure in underserved areas.

Middle-Aged Women Have Special Challenges -- Women between age 45 and 65 -- particularly those who are single -- have special problems due to job loss because of personal health problems, having to care for relatives, an economic recession or other reasons. Because of their age, they also have difficulty finding employment. This is the time before they qualify for Medicare and have limited income and health insurance options, when they need a public plan.

A public health insurance plan should be open to anyone regardless of their current insurance coverage, their employment status and certainly without regard to pre-existing conditions and without higher costs because of women's more extensive use of the system. In the quest to establish a "level playing field" our fear is that any public plan that makes it into a final bill will be so constrained as to not be a truly affordable, accessible plan that will be available to all who need it.

Gender Rating a Special Problem -- Some 5.7 million women have to rely on the individual insurance market because they do not have access to an employer-based group plan or are self-employed or for other reasons. A public plan would avoid many of the problems found in the individual private insurance market: charging women considerably higher rates than men (insurers say this is necessary because women utilize health care services more often than men); denying or limiting coverage based on a current or past pregnancy or method of delivery (Cesarean section); failing to provide comprehensive maternity coverage; -- not to mention denial because of pre-existing conditions.

All the major reform bills would prohibit exclusions for pre-existing conditions, denials of payment for certain medical services and gender-rating in insurance plans. Whether insurers will continue to provide affordable coverage with such prohibitions in place remains to be seen. Our guess is that final legislation regulating the private market will be filled with numerous loopholes that will allow companies to carry on with their denials and increasing premium amounts.

NOW Will Continue to Push for Public Plan -- So while it looks like the prospects for a national single-payer plan (or a "Medicare for all" approach) are nil, hope does lie in the possibility for individual states to establish their own single-payer plans. The House Energy and Commerce Committee adopted a provision offered by Rep. Dennis Kucinich (D-Ohio) to allow states to do just that. As floor vote on this provision is expected, whether it remains in the final House-Senate version is a question. NOW will continue to pressure members of Congress for a robust public health plan as the only way to cover everyone and do so affordably. But, we will also continue to support a single-payer plan with the grassroots -- and supportive state legislators -- in states like California, Pennsylvania, Illinois and wherever else there is support for this most effective and affordable system of health care coverage.