Improving Access to Health Care
When the Executive Board met in 1987 at the beginning of the Annual Meeting, the stock market crash occurred. I remember thinking, “The net worth of APHA is going to go down. How are we ever going to manage?” Well, we managed, and now we are going to have a building of our own and no more worries of that kind. So this marks a very happy anniversary in that sense for me.
In 1987, when I had the most rewarding experience of my life serving as president of APHA, there were 37 million totally uninsured in the United States and many more with inadequate coverage. In the decade since then, the number of people who are totally unprotected against the cost of illness has risen to 41 million – not counting those with inadequate coverage. In my meetings with state affiliates around the country, it was very exciting to meet public health workers on the front lines and I talked at that time about what was one of the best kept secrets, the Canadian health insurance system with its one-tiered system of care covering the total population – despite my obvious bias. My mentor (and husband), Dr. Milton Roemer, urged that the United States replicate the Canadian strategy: The provinces of Saskatchewan first passed hospital insurance and then medical care insurance. Other provinces followed suit. And, finally, a national system covering the total population of Canada was established. All this is much more widely known today than it was then.
A similar state-by-state approach in the United States, however, has not been possible because of the barrier of ERISA, the Employment Retirement Income Security Act of 1974, which preempts state action related to employee benefits provided by self-insured plans. Today the growth of managed care has opened a window of opportunity to amend ERISA. Because ERISA has been interpreted as blocking state regulation of self-insured plans and even lawsuits against the plans for malpractice, federal and state legislative proposals to hold managed-care organizations accountable for the quality of care that they provide include some bills that propose amending ERISA to take account of the changing system of financing and organizing health care through managed-care organizations.
In the current climate of shifting responsibility for health and welfare to the states, a new day is dawning as the federal and state governments are expanding health insurance coverage for children who are poor. This is the most significant advance since the enactment of Medicaid. This success compels one to urge that in the next decade we should emulate Canada’s strategy by moving towards universal coverage through action on a state-by-state basis. Since South Africa is currently in the process of enacting a national health insurance system, we could thus overcome our lone shame of being the only industrialized country without a universal financing mechanism for health care. I hope that APHA will be able to take the lead in this strategy in the coming years.