A memorable moment in the 1997 movie “As Good As It Gets” comes when the protagonist played by Helen Hunt, a hard-working waitress and mother of an asthmatic little boy, loses it when she learns that her health insurer will not pay for a doctor-advised diagnostic test. She explodes: “Those f—king HMO bastard pieces of s—t.” The doctor says, “I think that is their technical name.” The theater audience howls, familiar with HMOs’ finely honed buck-passing skills.
Those skills are more than just an irritation; they define health care in the United States. According to economist Paul Krugman, HMOs employ 2 to 3 million people whose job it is not to render health care but to try to get someone else to pay the bill — the inevitable result of our multi-payer system.
Is help on the way? If the Bush administration had its way, even the status quo would be scaled back in favor of a “no payer” system in which health care is paid for out of one’s own pocket, the government’s policies having “encouraged” us to set up private accounts for this purpose.
Exactly how such “encouragement” would allow the waitress played by Helen Hunt to set up a “private account” as an alternative to her HMO is a mystery. In fact, we should wonder how this waitress came to have health insurance at all. In real life, she would likely be a representative of the “Wal-Mart effect”: one of the 20 million working adults who have no health insurance at all.
The status quo is intolerable; proposed “solutions” are disheartening. Last week there came reports that a distinguished group of labor, industry and health care policy figures — which has been meeting secretly for months and is expected to present its proposals to Washington — was considering options which, for workers, consists of little more than tax credits and payroll check-offs. The group apparently is not considering one slightly more radical approach that takes a page from the book of HMOs: Pass the health care buck to employers.
In various versions of what is called “pay or play,” pending in a dozen or more states and cities, employers would be required to provide coverage or pay into a fund that, directly or indirectly, helps insure their workers. In some of the plans, only the largest employers would be covered. It was just such a proposal, covering employers of 10,000 or more workers — read Wal-Mart — that was defeated by the voters in California last year following a fierce and well-financed campaign by its opponents.
Similar measures now on the drawing boards in Connecticut, Oregon and Maryland have already died in Washington State. In New Jersey’s effort, only state contractors would be affected. In Massachusetts and a few other states, part of the arsenal is “naming and shaming” — publishing the names of the employers of workers on public assistance — in the hope that those employers will take steps to restore their good name. A bill pending in the New York City Council covers uniquely local employers, such as hotels and building services, who cannot easily escape to Westchester or New Jersey.
There is surprising support for these efforts in the business community. In New York City, many employers who now provide health care to their employees — usually pursuant to a collective bargaining agreement — support “pay or play” because it would erase the competitive advantage now enjoyed by their stingy competitors.
Liberal and progressive faith-based organizations have also played a key role in many of these state and local efforts, organizing their communities and thus elevating the issue to one of voter concern rather than merely a battle of lobbyists. These notably include the Greater Boston Interfaith Organization, which includes 65 congregations, two of them synagogues.
In New York City, Congregation B’nai Jeshurun — also one of two synagogues among scores of faith-based organizations supporting the New York Health Care Security Act — sponsored a packed-house “accountability forum” in April attended by more than 700 congregants, community activists, union members and others. Few will forget the sight of scores of burly members of Laborers Local 1500 and United Food and Commercial Workers standing in the balcony of the sanctuary swaying to the strains of Shehecheyanu.
There are, of course, flaws in “pay or play.” For one, it is subject to complex legal challenges, which means that even the versions that become law will not become realities for some time. More important, it is only a partial fix — a solution that is not the answer to the larger problem.
If every pending “pay or play” effort were to pass and take effect, still millions of people, workers and others would remain unprotected. So, is the effort worth fighting for?
Yes, because — as has happened often in our history when states are the laboratories for reform — a multiplicity of local schemes might lead to a call by big business for a uniform national solution. And yes again, because it cannot be bad to give dignity and security to tens of thousands of workers and their families so long as we keep our eyes on the prize: a single payer system that covers us all.
Kathleen Peratis, a partner in the New York law firm Outten & Golden, is a trustee of Human Rights Watch.