The Washington Square Health Foundation, Inc. grants funds in order to promote and maintain access to adequate healthcare for all people in the Chicagoland area regardless of race, sex, creed or financial need. The Foundation meets this goal through its grants for medical and nursing education, medical research and direct healthcare services.

As a guide to other foundations and other service providers and as a part of the Board’s stewardship of charitable funds, the Washington Square Health Foundation, Inc. has developed a grant evaluation system to ensure that the objectives of various projects are carried out in the manner prescribed by the approved grant.

The Foundation wishes to impress on the philanthropic community that the careful evaluation of the outcomes of grant projects is as important as the appropriate selection of grant recipients.

Mrs. Ruth M. Rothstein, Chief of Cook County Bureau of Health Services, presents the key note address to the Washington Square Health Foundation Board of Directors and their guests, Executives from over 25 not-for-profit health care organizations at the 2003 Annual Grant Information Exchange Dinner.

She currently serves or has served on numerous boards, commissions and committees, including the American Hospital Assoc., IL Health & Hospitals Assoc., Nat’l Assoc. of Public Hospitals, IL Health Care Cost Containment Council, the University of Chicago Health Policy Research Council, Finch University of Health Sciences/The Chicago Medical School, Inst. for Diversity in Health Management, the Jewish Women’s Foundation of Metropolitan Chicago, and as VP of the Jewish Federation Board of Directors.

President Angelo P. Creticos MD presents a check to Mrs. Ruth M. Rothstein, Chief of Cook County Bureau of Health Services for a grant made to the County Care Foundation, for the Cook County Bureau of Health Services.

Among the many recognitions that she has received for her contributions to the field of health care and her community are the Chicago Civic Federation’s Lyman Gage Award for Individual Civic Achievement, the American Hospital Assoc. Russe Award, the Chicago Minority Business Development Council’s Impact Award, the Chicago Institute of Medicine’s Russe Citation for Compassion in Medicine, and Rush University’s highest honor, the Trustee Medal. She holds an Honorary Doctorate of Laws degree from Kenyon College, and an Honorary Doctor of Humane Letters from Rush University.

I believe Mrs. Rothstein's presentation is an excellent review of the historical roots of today's health care crisis, as well as an insightful analysis of the pertinent issues.

Reflections on the Chicagoland Health Care System
Guest Speaker Ruth M Rothstein, Chief, Cook County Bureau of Health Services
Washington Square Health Foundation Grant Information Exchange Dinner
December 11, 2003

Good evening, thank you for inviting me to talk with you tonight. I was given ten to twelve minutes to reflect on the past, present and future of health care. That’s a tall order but I will be able to do it because I have a single overriding theme that is very much on my mind these days. It is always on my mind. It is about justice in health care. It is a national concern; it is a Chicago issue.

WHERE I AM COMING FROM
You know from the introduction that I am responsible for managing medical services for all the underserved, uninsured poor, mostly minority populations in Cook County. The Cook County Bureau of Health Services is the third largest health system in the United States. I am able to bring you a view from the battlefield. This is where we fight to provide quality care to those who cannot afford to pay.

Let me take a moment to tell you more of my personal history so you’ll understand why I believe in what I do. My point of view is that of a woman who has seen her share of inequities: gender inequities, religious discrimination and color barriers. I have been active in the Labor movement since I was a teenager. Very early in my life, I observed people taking action to overcome wrongs. I learned the techniques for promoting social justice, how to advocate for the less fortunate.

I became an activist. When I look at my career, I am most proud of how I have brought health care closer to the people, especially those most at-risk: the working poor, the homeless, children and families on welfare, teenage mothers, victims of HIV/AIDS and senior citizens living alone.

The Jewish values instilled in me during my youth combined with practical lessons learned in the Labor movement shaped my life. We measure our success in life in terms of our impact on others, particularly on people in very difficult circumstances. When I entered the health care field, my values led inevitably to a belief in universal health coverage.
I would like to say that the health care system is better now than it was when I began my work in the 1960’s. The truth is that much is better, but a great deal is not. If we had a dollar for every time a speaker got up to say the health care system is broken, we would be rich. It is broken. Here we are in the 21st Century and after the Medicare Overhaul Bill was signed on Monday, it is not fixed. In fact, it might get even more confusing.

HISTORICAL CONTEXT
From the Greeks up to World War I, the task of medicine was to struggle against lethal diseases, to ensure live births and to manage pain. It accomplished these objectives with meager success. Physicians and hospitals did what they could. They gave charity care to those who couldn’t afford to pay and sometimes turned the poor away. Regardless of whether people sat on clinic benches or in private doctor’s offices, the care they got was not very different from the palliative care of today.

As medicine advanced, more was asked of doctors and hospitals but more care could not be delivered without incurring greater costs. Today, large pharmaceutical companies spend an average of 1.7 billion dollars to develop a new product, gain FDA approval and market the product. Doing more costs more; some people were cut out of the picture. Today, they are the uninsured. In the 1930’s, people began to acknowledge that something needed to be done. In the 1960’s, something was done—Medicare and Medicaid were enacted—for the poor and the elderly.

Through the end of the 19th century in America, most care for the sick took place in the home. There wasn’t much that could be done for the gravely ill. Only those who were too poor to pay a doctor to make a house call used hospitals. A hint at the evolution of health care took place early in the republic. In 1793, the first local health department was formed in Baltimore, Maryland. In 1789, congress established the Marine Hospital Service to provide temporary relief for ill seamen. It was the first prepaid medical care program in the U.S. and was the beginning of government-mandated health care in this country.

While Germany enacted its family social programs under Bismarck in the 1880’s, the idea of health care coverage for Americans took hold very tenuously. In 1912, when he ran for president, Theodore Roosevelt’s Progressive Party platform included the words, “the protection of home life against the hazards of sickness through the adoption of a system of social insurance.” In 1915 (and during the following few years), the American Medical Association itself called for compulsory health insurance modeled after German law. Later, in 1920, the AMA did an about face.

Proposals reappeared from time to time over the years. While countries such as Chile and Japan adopted national compulsory laws in the 1920’s, the concept of universal insurance in the U.S. only took root a decade later, at the time that our social security system was established.

I’d like to take a moment to pay special tribute to Dr. Wilbur Cohen. Although his name no longer is familiar to us, we owe him a great deal. He played a defining role in the passage of Social Security. Time and again, he persuaded legislators on both sides of the aisle to introduce and support the Social Security Act. After it was signed by FDR in 1935, he worked tirelessly to pave the way for Medicare.

History shows the slow progress towards acceptance of the concept of health care coverage, not for all, but for select populations. We were living with the legacy of fear of the Soviets, of Socialism, of living in a ‘welfare state’.

Hospital payment plans like Blue Cross and commercial insurance against the cost of hospitalization had been developing during the 1930’s. The AMA took a position against compulsory health insurance but supported tax-supported medicine for the poor and voluntary insurance for those who were not indigent.

In 1939, Senator Robert Wagner introduced a bill to create national compulsory health insurance for all employees. The AMA opposed it. The bill died. In 1943, the Wagner-Murray-Dingell Bill was introduced and then reintroduced in 1947. It called for the creation of a compulsory national health insurance program for all people. Congress took no action. President Truman repeatedly called for a compulsory national health program, even the Social Security Administration itself recommended a program for health insurance for beneficiaries but congress took no action. The programs were killed. Bills languished in committee.

Many viewed the enactment of Medicare and Medicaid in 1965 as the first step on the journey to national health insurance. Even Presidents Nixon and Carter advanced proposals to extend health care coverage to the non-aged. Except for new methods of hospital reimbursement under Medicare, little has changed.

Almost 40 years have elapsed since the passage of Medicare and except for the increasing dominance of managed care; there has been no fundamental change in the way America’s health care is delivered. The new prescription drug program is the largest expansion of Medicare since its creation but it still leaves basic problems unresolved (more on this later).

There was a flurry of excitement during the early years of the Clinton Administration. A 500-person task force produced a 1,300-page proposal for universal coverage. Powerful groups with a stake in maintaining the status quo militated against it. For many years, organizations like the AMA lobbied strenuously against universal care. They feared the loss of control under ‘socialized medicine’. Hadn’t they already lost control through managed care contracts? Insurance companies lobbied against it. Those who stood to gain were politically weak. The AARP did not support it. Some complained the plan was too complex. Yes, the plan was intricate but we were living with a labyrinth of reimbursement and administrative procedures.

NEEDED: A SECOND OPINION
The new prescription drug law is even more complicated than the Clinton plan. The New York Times headline says it in a nutshell, “Medicare Law’s Costs and Benefits are Elusive.” I think we need a second opinion.

The exact parameters of eligibility, coverage and cost are complicated and will differ based on beneficiaries’ incomes and region of the country. Drug coverage will not be available until 2006 but beginning in April of 2004, Medicare beneficiaries could buy drug discount cards. They will provide discounts of 10-25% on at least 200 of the most commonly prescribed prescription drugs at a cost of as much as $30 per year for beneficiaries. That seems simple but in 2006, the picture becomes more complex. Tuesday’s New York Times had to create a graph to demonstrate how seniors might make decisions about their participation. Medicare beneficiaries may have to hire statisticians to help them make a decision.

In a CNN/USA Today/Gallup poll, 75% of 1,075 adults in their telephone survey said the benefit is too complicated for beneficiaries to understand, 84% of the respondents ages 65 and older expressed that concern.

The biggest illusion is calling it a ‘prescription drug law’ while it contains a slew of changes having more to do with changing Medicare than prescription drugs. It has a grab bag of provisions that are unrelated to prescription drugs. It is replete with little-known, restrictive provisions and may contain a great many surprises in the implementation.

Let’s look at costs, estimated at $400 billion over ten years. Congressional Budget Office Director Douglas Holtz-Eakin released analysis showing that the Medicare Legislation could cost as much as $2 trillion in the 10 years following that first decade. These are national issues but they will assuredly become Illinois and Chicago issues as well. Inasmuch as the devil is in the details, let’s look at some of the details in this new law. Let’s see who are the winners and losers; you keep score.

Here’s a scorecard, courtesy of the New York Times:

One group of winners is low-income elderly who are not on Medicaid. They will receive an annual subsidy of $600 credited to their drug discount cards. Beginning in 2006, the premium and deductible will be waived for people with incomes up to $12,123 per year. This will be phased out at a $13,500 income level.

Losers will be dual eligibility couples—persons eligible for coverage under both Medicare and Medicaid. They lose the nearly 100% coverage they get under Medicaid. They will be covered under the Medicare drug benefit and will have to pay out-of-pocket costs.

Another group of winners is middle class Medicare beneficiaries. They can participate in tax sheltered H.S.A.’s. On the other hand, Medicare beneficiaries will not be permitted to buy insurance to cover part of their share of prescription drugs. They won’t be allowed to purchase what is called ‘Medigap Insurance’. This is said to ensure that beneficiaries remain sensitive to costs.

Furthermore, means testing will begin. Beneficiaries with annual incomes above $80,000 will have to pay higher premiums for drug coverage and outpatient care. There is another feature that makes judging winners and losers difficult: Medicare eligible persons can drop conventional Medicare and join private managed care plans subsidized by the government. After having been dropped by HMO’s in the past, will seniors choose to enroll this time in private plans? Will the current 12% of Medicare beneficiaries who are in private plans rise to the predicted 35% by 2007?

The biggest questions surround the role of private insurers in administering the new benefit, the New York Times reports. About 12% of beneficiaries are now enrolled in private plans—a figure that the Bush administration expects to increase to 35% by 2007—but it is not clear if competition between traditional Medicare and private plans will lower costs. According to the Times, private-sector insurance companies have a “mixed record of controlling costs.”

What about the uninsured? Yes, some low-income seniors will benefit but once again, the uninsured do not. Medicaid payments to hospitals will increase and may benefit the uninsured—but only indirectly. Who pays for the uninsured to get medical care outside of a hospital? Who pays for uninsured or underinsured people who cannot afford prescription drugs? Who pays for their diabetic test strips, insulin or hemoglobin A1C testing? There is no answer in this law to the plight of the forgotten.

Details about the law are still fuzzy, and none of it kicks in until 2006. Will there be time to fine tune it and get it right between now and 2006? At that time, will all Americans gain the right to healthcare coverage? Does congress have time to revisit the law, reach compromises and fix measures piece by piece? I hope so.

MILLIONS LEFT WITHOUT INSURANCE
We still have no rational health care system. To our enduring shame, more than 41 million Americans lack health insurance. We have excluded these people from their right to health care. It is not an issue of poverty. Last year, more than 25 million adults who worked full time or part time were without health coverage. More than 1.8 million in our own state under the age of 65 are uninsured. That means that in Chicago, one in six people walking the streets has no health insurance.

The gross domestic product increased 8.2 % in the third quarter of this year. During that same period, there was a loss of 146,000 jobs. Many of those 146,000 and their families lost their health care coverage despite the substantial upturn in our economy.

The 1990’s were among the economically strongest times in our country’s history. We had an unprecedented nine uninterrupted years of growth and, until very recently, we lived through a prolonged period of peace. They were the best of times and yet, they have been the worst of times for health care. We prospered, but we didn’t make any gains in caring for our uninsured population. Their numbers actually grew during that period. For the wealthiest country in the world, this is indefensible.

BUSINESS HAS BORNE THE BRUNT
For the most part, the burden of health care has been borne by the employed and by their employers. Even those who are working may not be covered. Many employers do not offer health benefits. One headline screams, “Small Businesses are terrorized by Healthcare Costs.” The article cited an astronomical 18.83% spike in premiums for one group of downstate small businesses—the national average is about 15%.

Businesses small and large are asking workers to take on more of the cost of insurance. Companies are raising the amount employees contribute to health care premiums or contracting with plans that increase co-pays or deductibles. The result is that employees have been paying a greater share for their care while they watch their coverage shrink.

WHAT IT IS DOING TO OUR PEOPLE
I see the lack of universal coverage not only devastating to individuals, but also corroding health delivery. More hospital emergency rooms are clogged with patients using the ER as the last resort when they can no longer delay going to the doctor. The Stroger Hospital ER is experiencing record volumes.

Hospitals end up with debt from providing more charity care. That extra burden is putting a number of hospitals at risk of closing their doors. Many hospitals are walking a fine line.
When they have nowhere else to turn, the uninsured fall back on the public health system. We safety net providers—like the Parkland in Dallas and Grady Hospital in Atlanta—also are feeling the affects of the health insurance meltdown. Our Cook County Ambulatory System is shouldering the burden of almost one million visits per year.

A RIGHT NOT A PRIVILEGE
The basic problem as I see it is that America still has not embraced the principle that health care is not a privilege. Most people now agree that health insurance should be available to all but they are not willing to see it mandated. They are caught up in some old cliché about socialized medicine and big government. They fear rationing or increased taxes.

HOPE FOR CHANGE
You have followed the tortuous trail of the enactment of Medicare legislation. It took persistence, public acceptance and reworking. Medicare was not perfect when it was first enacted. It was refined and improved over time. It was tweaked and reshaped. There is hope for the development of universal coverage.

In this country, we spend about twice as much on health care as the average of other developed nations. As I said earlier, we still have more than 43 million uninsured. Since we spend liberally, the cost of caring for the uninsured should not be an impediment. The price tag for uncompensated care provided to the uninsured through public and private healthcare institutions is currently about $35 billion a year. The cost of insuring those who are currently uninsured would increase total health care expenditures a maximum of 70 billion dollars. That is less than the amount appropriated for the efforts in Iraq. As President Clinton noted, “We can’t be strong abroad if we’re not strong at home.”

Elliott Fisher, Professor of Medicine at Dartmouth, maintains that we will find that we have sufficient current capacity to cover the uninsured without increasing spending. He says that this would happen if we learn how to pay for better care, not just more care.

He could well be right but unless we take a fresh look at the system (not just the pieces of it), we are like the blind men; each touched a different part of the elephant and thought it was an entirely different animal.

TAKE ACTION
What I look for is fundamental, not piecemeal change. As you well know, I am an advocate of health coverage for all. In the past, when I spoke out in favor of universal coverage, I would say, “I know you don’t agree with me…” Now, more people agree, but we have to press for political will and public consensus. After they see the consequences of the current “Prescription Drug” legislation, more people may be open to making fundamental, not piecemeal changes. I am more convinced than ever that with something as fundamental as health and the health of our nation, we need a humane option today.

I suppose people would not be looking for solutions if the private market could have solved the problem. It has not. It can’t even fix the problems of those who have insurance. Political discourse and people like us should educate the public about the issue. Remember that USA Today poll in which 75% of adults in the phone survey said the benefit is too complicated for beneficiaries to understand? We must not let the health care debate disappear from the radar screen or the TV screen or the headlines. We need more explanations, more discussions and not just sound bites. When people are better informed, they will be less daunted by the idea of universal coverage.

INSUFFICIENT ACTION
Today we are faced with the health issues of obesity, diabetes and HIV/AIDS. More than half of Americans are either overweight or obese. The world is experiencing a diabetes epidemic primarily because people don’t exercise and do not eat properly. We are driving up health care costs in part because of our own behavior! We must warn people that they are personally contributing to our nation’s health care mounting costs.

The task is to both encourage people to adopt healthier lifestyles and adopt a system that will promote health care justice. We must clearly take responsibility for ourselves and for improving the system. We must adopt a system that assures healthcare justice for all. It must reflect the belief that “No man is an island, entire of itself; every man is a piece of the continent, a part of the main. Any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.”

I CHALLENGE YOU
I challenge you to judge the impact of our health care system by its effect on the most vulnerable—the uninsured—today’s forgotten. I challenge you to use all your power to help the public come to grips with the unspoken or unresolved issues. We must help the public understand the difficult trade-offs at stake. We must help answer questions such as:

• Can quality care be delivered at moderate cost?
• Will there be rationing of services? Will there be long waiting periods to receive procedures considered elective?
• How comprehensive should benefits be? Should all end-stage procedures be covered?
• Should undocumented residents be covered?
• Should those who still smoke be given lung transplants?
• What system can be paid for without rationing care?

Does the public believe that universal care means a free ride? The taxpayer will pay the $400 billion price of the prescription drug bill that was just made law. How should financing of future health programs be structured? Through insurance companies? From employers and employees? If so, where would funds for the uninsured come from?

It is also up to those of us who are dedicated to improving health to help the public grapple with the issues. They are very difficult. The public needs help. We, here in this room, must help the nation resolve this problem.