Last March, Marion Constantinides bruised her upper arm after slipping on a sheet of ice. Another fall two weeks later further aggravated the injury, tearing a muscle in her arm and sending her to a primary care center in Squirrel Hill for an evaluation.
Unfortunately, the visit proved pointless. Although her doctor said the injury required minor surgery, Constantinides left the clinic deciding to simply let her arm heal itself.
"That's what happens when you're uninsured," says the 57-year-old Greenfield resident, who resorted to physical therapy, which she had to perform herself, to help heal the tear. "If I'm ever in a bad accident, I hope it's a big one, and I hope it's the last, because I can't afford treatment."
But that might soon change for Constantinides and nearly 800,000 other uninsured Pennsylvanians if Governor Ed Rendell's health insurance policy, "Cover All Pennsylvanians" (CAP) is adopted by the state legislature this month. As part of "Prescription for Pennsylvania," Rendell's comprehensive health plan unveiled last January, CAP is expected to offer more coverage at a cheaper price than the state's current adultBasic plan.
AdultBasic provides insurance for adults who meet certain income requirements. Administered by the Pennsylvania Insurance Department, adultBasic offers basic benefits, including preventive care, physician services and in-patient hospitalization.
But some health care advocates say it doesn't offer enough.
"Right now, a lot of the uninsured fall through the cracks," says Jessica Seabury, executive director of the Consumer Health Coalition, a nonprofit organization that works to improve access to health care. "CAP would expand quality and affordable coverage to uninsured Pennsylvanians. It's a huge step in the right direction."
But not everyone agrees, especially many Republican legislators who say Rendell's remedy would raise taxes and use a portion of the surplus in doctors' medical malpractice funds. Legislators from both parties have introduced more than a dozen bills concerning health-care reform; some of the more liberal bills propose single-payer plans, while the more conservative plans recommend tax credits.
But as legislators debate the bills as this issue goes to press, one thing is obvious: It's unlikely that Rendell's plan will pass unscathed.
That has Seabury and other CAP supporters concerned.
"How strong a [program] is this going to be?" Seabury says. "Is this just going to be another Band-Aid?"
As it stands now, Seabury says, CAP is much more than just a bandage -- it's a plan that would provide the uninsured with "peace of mind."
"It will enable me to get care," says Constantinides, who is one of more than 100,000 uninsured adults in Allegheny County, according to 2004 statistics from the Pennsylvania Insurance Department.
According to Amy Kelchner, communications director for the Governor's Office of Healthcare Reform, CAP would offer everything in the state's current adultBasic plan, plus prescription drug and mental health and substance-abuse coverage. It also would not allow insurance companies to deny coverage due to pre-existing conditions.
Kelchner says Rendell's public/private plan would be offered by Blue Cross/Blue Shield, including local insurance provider Highmark, as well as any other insurance company that would like to take part.
Under CAP, the cost for employers will be about $130 per employee; currently, the average cost of health insurance in the private market is about $295 per employee.
For individuals, the average cost of health insurance through Blue Cross/Blue Shield providers is about $500 per month. With CAP, that cost will range from $10 to $280, depending on family income.
The monthly premium rate for the adultBasic program is $33.50.
Kelchner says the plan would cover about 500,000 of the nearly 800,000 uninsured Pennsylvanians. Among those who would be ineligible are undocumented immigrants, people eligible for Medicaid and people who have not lacked health insurance for at least six months.
Although Rendell sees the merits in a single-payer insurance model, Kelchner says it's possible to insure all Pennsylvanians without destroying the private market. Since 92 percent of the state's population already has health insurance, CAP, she says, adds to the model that is currently in place.
Funding for CAP will be provided through a combination of federal dollars, employer and private premium payments and state funds.
State funding, which is the most controversial, would come from a 10 cent increase in the cigarette tax, and a new tax on smokeless tobacco and cigars. Also, CAP would use about half of the surplus from the MCARE Abatement Fund, which Rendell started in 2002, with a 25 cent tax per pack of cigarettes, to help physicians pay for their medical malpractice fees and reverse a trend of doctors leaving the state because of outrageous liability charges.
Originally, MCARE abatement funds were not part of the funding package, though; the program's funds replaced the "Fair Share Assessment," which would have charged employers who do not offer health insurance to their employees. Kelchner says employers were harshly opposed to the proposal, and Rendell eventually decided to replace it with MCARE funding.
Kelchner says the MCARE program, as a result of the cigarette tax and a dramatic drop in malpractice claims over the past few years, has created about a $500 million surplus. Rendell now wants to use part of that surplus to help fund CAP. He's so adamant about it, in fact, that he's vowed to withhold all MCARE's malpractice dollars from physicians until lawmakers agree to fund CAP.
"It doesn't make sense to give doctors so much more in [malpractice] abatement when there are so many people out there who don't have insurance," says Kelchner, who projects that the surplus will provide both doctors with their abatement needs and the uninsured with coverage for at least 10 years. "There is money to do both."
Money aside, argues Rep. Douglas Reichley, R-Berks, "[Rendell's] program doesn't cover all Pennsylvanians. He's putting all of his effort behind the concept of accessibility," and downplaying the potential for people to be put on a waiting list.
Initially, Kelchner says, "there should not be a waiting list for CAP" like there is with adultBasic, where the Pennsylvania Insurance Department estimates there are more than 75,000 people currently waiting to receive coverage. "But we can't say whether that will stay the case."
Rather than accessibility, Reichley says Republicans are stressing affordability. Reichley's bill, part of a Republican healthcare package aptly called the "Real Prescription for Pennsylvania," seeks to give employers tax credits for obtaining healthcare policies with disease-management protocols, which he says would minimize the effects of diseases or chronic conditions through integrative care.
"It's a wellness initiative on steroids," he says. "It will cut down on costs of long-term care and hospitalization," which in turn will lower insurance premiums.
When asked if that plan would take a long time to prove effective, Reichley said neither Republicans' nor Democrats' plans are "overnight solutions." But, he says, "Our policy is less expensive to taxpayers."
State Rep. Michael Sturla (D-Lancaster) who sponsors a CAP bill, realizes the partisan nature of the governor's plan, and he's upset with Republicans' general distaste for CAP.
"[Republicans] are not interested in helping people get health insurance," he says. "They would rather give tax credits. Tax credits do nothing. They don't do anything to increase the number of people who have insurance."
Somewhere between the political infighting, however, lie the state's medical professionals and insurers. Although the Pennsylvania Medical Society, composed of about 20,000 physicians and medical students, supports efforts to insure all Pennsylvanians, Chief Executive Officer Roger Mecum says "We haven't come out endorsing [CAP], per se.
"[Rendell's] goal is laudable," he adds. "But there are a lot of questions about whether [his administration's] estimates are right."
Mecum says he is concerned that Rendell's cost estimates are too conservative, and that funding might eventually run out. More importantly, he says, his organization has serious issues with the proposal to shift half of the medical malpractice funds toward CAP.
"[Medical malpractice] has improved a little, but not enough to take the pressure off," he says. "Medical liability costs are still unacceptable."
In February, PMS released a six-point statement on the MCARE situation, one of which specifically notes their opposition to "proposals that would tie approval of MCARE abatement extension to plans for funding the CAP program."
Highmark spokesperson Michael Weinstein says Highmark supports a lot of CAP's basic principles, like reducing costs and expanding access to healthcare. Still, he says, "The issue remains how this program is going to be paid for in a way that is sustainable over the long term."
But while debates in Harrisburg drag on, Constantinides is left "try[ing] not to think about" being uninsured. Right now, that's particularly difficult since she's due for a new glasses prescription.
"What do I do?" she says. "I have no way to cover it other than to save whatever little money I have."
- Heather Mull
- Jessica Seabury of the Consumer Health Coalition, says a proposed state insurance program is a way to provide health insurance to all Pennsylvanians.