What Else Can We Try?

June 06, 1994|By NEAL R. PEIRCE

If the docs can't solve the health-care crisis, how about a larger role for the nurses?

Or -- why not move even faster to those ''managed care'' systems that deliver health care with an emphasis on preventive and primary health care? With pre-negotiated fees for patients' total care, the incentives suddenly turn against costly high-tech medical procedures.

Another new strategy: If we're finding it morally wrong to deny health coverage to millions of Americans, especially the working poor, how about using states' buying power to offer the doctors and hospitals a deal they can't refuse? The message: ''Accept the working poor as patients, Medicaid recipients included. If you won't, you can't collect fees from serving a market you do want -- state and local government workers.''

Another strategy to get a breakthrough: If the doctors or insurers are blocking a state health-reform plan, just wait until there's a huge state budget deficit, and the only obvious way out is a tax hike. Then let the governor seize the moment of crisis and order health reform by executive order. (Gov. Ned McWherter in Tennessee did just that.)

Then there is Oregon's question: If the top priority is decent medical coverage for all citizens, the working poor included, why not cover thousands more and pay some of the added costs with state funds saved by denying coverage for keeping brain-dead patients hooked to machines or for treating minor, non-threatening ailments such as canker sores or diaper rash better treated at home.

The good news is that all these efforts are being tried in one or more states.

Nurse practitioners are demanding and getting from legislatures the right to provide more primary care, open their own clinics, dispense prescriptions and work with looser physician supervision.

Since January 1993, at least 15 states have expanded prescribing privileges for non-physicians. Legislators are accepting the idea that nurses are more inclined than physicians to preventive approaches and less inclined to high-tech medicine. What people often need more than complex medical attention is help in coping with their lives -- a role in which nurses often star.

State medical societies are bitterly opposed to broadened rights for nurse practitioners. Some (get this!) are even accusing nurses of getting too political.

''Managed-care'' systems are getting a solid test run in states ranging from Florida to Minnesota, Tennessee to Washington. In most cases, those systems are putting a damper on health-cost inflation. And they're changing health care. Vanderbilt Medical Center, a major teaching hospital, is downsizing its high-tech hospital services and opening clinics -- one in a public housing project staffed by nurse practitioners. A Vanderbilt official told Governing magazine: ''Instead of 'hospital,' we're now thinking 'health care system.' You won't recognize us 10 years from now.''

On the politics of health reform, Tennessee is the newest star performer. Medicaid's portion of Tennessee's budget ballooned from 13.4 percent in 1987 to 26.5 percent in 1993. The program was draining money from education and other critical services and poised for another budget-breaking rise.

So Governor McWherter used his executive-order power to institute TennCare -- a managed-care system embracing both Medicaid and working poor citizens. The legislature was glad to step out of the way and let the governor take the heat -- and heat there was. A firestorm of protest broke loose when physicians learned that unless they signed up to care for TennCare's less-than-affluent patients, they'd be barred from lucrative business under the Blue Cross/Blue Shield insurance plan for state and local workers.

But Tennessee's fiscal condition remains so grim that Governor McWherter is holding firm and legislators are backing him up.

Common sense and perseverance can pay off. Oregon incurred the wrath of Washington bureaucrats and special-interest medical lobbies when it first proposed to give health coverage to all poor people but exclude some services to make the system affordable. ''Rationing,'' cried some critics, as if thousands of Oregonians weren't already being deprived of health security.

But Oregon persevered. The Bush administration denied it the federal Medicaid waiver it needed, but the Clinton administration agreed. Now tens of thousands of the uninsured working poor are rushing to enroll in the Oregon plan, at almost twice the projected rate.

The newly insured tell poignant tales of care denied, of deep fear for their health and personal solvency. For Oregon to turn back, and un-insure them, would be unthinkable.

Virtually all state reformers believe strong federal legislation is needed to assure universal health care in America. In the meantime, through imagination and courage, they are blazing the way to what could be vastly more equitable and effective health care for Americans.

Neal R. Peirce writes a column on state and urban affairs.

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