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Local concerns emerge as Clinton's health reform package starts unfolding.

While the nation's mayors and municipal elected officials generally applaud the Clinton Administration's far-reaching health care reform proposal, concerns still exist regarding major gaps in the proposal that could have a profound effect on the future of public health care delivery.

Many of those concerns, as well as news about local innovations in health care delivery,, were presented throughout a series of four workshop sessions in the "Health Care" track at the National League of Cities' 70th Annual Congress of Cities and

Exposition in Orlando, Florida.

Moderated by Wayne Creelman, M.D., psychiatrist-inchief, medical director, and senior vice president of patient care services of BryLin Hospitals in Buffalo, New York, the health care mini-series focused on a wide range of issues in public health care' delivery, insurance, and risk management. While serving as councilmember of Cape Elizabeth, Maine, Creelman charred NLC's Human Development Steering Committee.

These workshops focused on reform of the nation's massive health care system and especially President Clinton's health care proposal which has been met with a multiplicity of alternative plans.

What follows are key remarks and highlights raised in each of the workshops in this vital series on health care reform.

"Health Care Reform and Our Cities and Towns: Will Our Pocketbooks, Policies, and Priorities Ever Be the Same?" This session devoted much attention to the single-payer element of the Clinton plan, a method of reimbursement that has been followed in the Canadian health care system and in other countries.

The single-payer element, all speakers agreed, would produce a striking change in the business of health care and how the nation's citizens secure medical treatment.

Mary Ann Mahaffey, city council president in Detroit, Michigan, and a member of NLC's Human Development Steering Committee, said the Clinton plan addresses in constructive and unprecedented ways the enhancement of America's health care but needs improvement in several areas.

Among them: beefing up substance abuse, mental health, and long-term care programs; providing equal treatment for public and private employers, especially with regard to premium caps; improving accessibility to health care in areas with great distance between population centers in states with low population density; facilitating greater interstate coordination to ensure availability of health care, specifically in areas where health care often is obtained by traveling along state lines; promoting wellness programs as a preventive-medicine tool; assuring commitment to eliminate discrimination against persons with "pre-existing conditions" during the transition to and within the fully implemented plan.

Regardless of which plan or alternative is implemented, "federal and local leaders must work toward improvement and innovation, use taxpayer dollars more wisely and properly, and do whatever is possible to decrease the monstrous bureaucracy in the existing health care system," Mahaffey cautioned.

Recognizing that the U.S. spends much more on health care than any other industrialized nation, Richard Kronick, Ph.D.--a representative of the U.S. Department of Health and Human Services and one of the architects. of the Clinton plan--said the primary feature of the Clinton proposal is health care security, meaning that Americans who lose jobs will not have to fear the resulting loss of health care benefits.

Employers, while required to pay 80 percent of employee health care benefits, do have the option of paying health care benefits in excess of the 80 percent threshold.

Kronick said the six cornerstones of the Clinton plan--security, responsibility, savings, quality, choice, and simplicity--make it a plan whose time is coming.

"Quality has taken a back seat in the considerations of discussions on health care," agreed William Straub, M.D., a radiologist and principal in the Jackson Hole Group in Wyoming, a policy think-tank which developed the managed-care concept. Municipal officials need to look at the Clinton proposal in terms of costs, access, and quality, Straub said, praising the Clinton Administration for placing health care on America's priority action list.

Will the health care plan cause local tax increases? Mahaffey sad the plan not only will not require local funding, but it also should reduce local health care expenditures. It also will promote preventive care as a means of easing the greatest plight of public health care--the overloading of public hospitals as a result of emergency admissions of uninsured and underinsured patients. The plan also promises to beef up inadequate health care facilities.

To prepare for the most unpreeedented change in health care, elected local officials should hold public hearings and conduct public awareness activities to alert their employees and citizens about the Clinton proposal. Local officials, said Mahaffey, also should work with local providers and health care coalitions as part of this process.

Andrews suggested that municipalities seek information from their state municipal leagues about the impact of the proposal on their employee benefit plans so they will be ready to consider the most cost-effective and affordable options available. Finger, acknowledging that "we practice medicine in the U.S. as if we were in the Dark Ages," said our nation rations health care on the basis of people's ability to pay. Health care reform will occur and is a foregone conclusion, Vinger said. Canada, where Vinger has received his medical training and practiced medicine, has one-tenth the population of the U.S. and has for years utilized a cost-effective health care system, one that the nation should strive for.

A Silent Killer: The Health Care Crisis in Small Town America

The health care crisis in small-town America is leaving residents without even the routine care people in large metropolitan areas often take for granted. More and more rural hospitals are shutting their doors and rural practitioners are leaving small towns in search of more lucrative practices in more urban areas.

Steven Perkins, a former municipal administrator and now council member from Red Wing, Minnesota, who previously had responsibility for a 38-bed community hospital, sees the rebuilding of the rural healthcare infrastructure as a human-development and economic- development opportunity.

"These are desperate times that require innovative creativity," said John Seth, a family nurse practitioner from Goldthwaite, Tex., a small farming and ranching community that has seen the closure of its only community hospital "The remoteness of care is a crucial concern, as the nearest full-service facility is 80 miles away."

Feltman said various options used included the funding of a professional recruiter position by a city sales tax and a finder's fee awarded for providing a name of a physician looking to relocate to Grafton.

Deanna James, M.D., a clinical services director based at the Palm Beach County Public Health Unit in West Palm Beach, has used the National Health Services Corps to recruit physicians and physician assistants to staff two rural hospitals which serve 10,000 migrant and seasonal farm workers each year. However, recruitment of subspecialty physicians remains a problem, and patients must travel more than 50 miles to receive sub-specialty care.

The main obstacles facing small-town and rural hospitals are lack of high-tech diagnostic and clinical equipment, poor emergency response systems, and very few primary care physicians, said Creelman. "It's as if rural hospitals were regarded as an afterthought in federal policy considerations concerning health care reform."

Perkins said small communities can form coalitions designed to recruit and retain physicians and practitioners. Public funds and grants can help subsidize such efforts.

Communities also need more health care dollars to provide educational and preventive services, James said, noting the higher incidence of AIDS, tuberculosis, and teen pregnancy in her region.

Speakers agreed with NLC delegates who noted that the closure of small-town community hospitals affect jobs, the quality and accessibility of care, and local economies. Yet, health care cannot be examined or provided in a vacuum, James noted, and public forums can help leaders determine the type of self-help programs that constituents want for their communities. Group collaboration has been useful, Seth noted, telling attendees about a successful group purchasing venture by rural municipalities and providers for pharmaceutical products.

Creelman said statistics show that more elderly Medicare patients are hospitalized for substance abuse and alcoholism than for heart attacks. But the health care plan envisioned by the Clinton Administration overlooks funding for psychiatric and mental health services. Creelman warned that increased federal funding should be allocated to care for a rapidly growing elderly population.

"An ounce of prevention is worth a pound of cure" is a familiar adage which Creelman says actuarial experts should follow in the process of deciding funding levels for various aspects of the Clinton health care reform proposal, especially with regard to services rendered in rural and underserved areas.

Public Health and Hospitals: An Endangered Species Worth Saving

Some 800 public hospitals since 1980 have been forced out of existence by skyrocketing health-related costs. The outlook is even more dreary as public health facilities face a complex web of unfunded federal mandates and the high costs of providing care to the uninsured, illegal aliens, the homeless, and victims of domestic or gang-related violence. in addition, many public hospitals lack adequate equipment, facilities, and funding.

For many public clinics and hospitals, these problems have best been solved through innovation, equipment sharing, and collaboration.

Michael Spivey, an attorney who deals with health law and regulatory policy, said public hospitals have been and will continue to be more endangered as long as they render care to patients with no or very little insurance coverage. "Cost shifting of uncompensated care is not possible," he noted.

Under President Clinton's health security proposal, these patients will have a choice and opt for care in private facilities and the public hospitals will have to compete for these patients. But such hospitals will not be able to do so without the type of facilities and state-ofthe-art equipment found in larger medical institutions.

Melinda Rider, a community health advocate with the Institute of Action for Community Health at the Indiana University School of Nursing, said public hospitals must be a vital part of the community's health care system.

Becky Cherney, a consultant for the Florida Agency for Health Care Administration, said a major problem is cost inefficiency due to overdoing diagnostic procedures.

Rider advised community leaders to discuss the proposal as a starting point to determine a strategy to ensure continuation of public health services.

Collaboration, says Cherney, promotes good care, controls costs, and creates savings. improving procedures necessitate finding ways to control costs and yet maintain optimum quality.
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Title Annotation:Cities in Action: Working Together; Track Workshops Fostered Sharing, Shaped New Idea, Broadened Outlook on Our Cities' Future
Author:Darensbourg, Tommy
Publication:Nation's Cities Weekly
Date:Dec 13, 1993
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