Accountable: Making America as Good as Its Promise by Tavis Smiley, Stephanie Robinson (With)

From Barnes & Noble

The third volume in Tavis Smiley's Covenant series exhibits the same thoughtful attributes that made the previous installments such valuable additions to dialogues about the black community. Accountable: Making America as Good as Its Promise aims at setting practical standards for political and social leaders to assure that agendas will not only be established but also remain on track. Like its predecessors, this book by the PBS and radio personality is a model of measured, pragmatic, instructive thought.

From the Publisher

Accountable provides real-life examples of how crucial issues -- including health care, education, the economy, unequal justice, and the environment -- manifest themselves in our communities. The book demonstrates the urgent need to hold politicians and ourselves responsible, because the stakes have never been higher. Accountable examines present-day conditions and the consequences for America. At its core, this book is a tool with which the community can evaluate the successes or failures of its political leaders and of itself. This insightful book acknowledges the mistakes of the past while offering hope and inspiration for a better future.

Publishers Weekly

Bestselling author and television host Smiley picks up where he left off in his previous book to offer a critical look at the problems facing America and to grade the government (and society at large) on its efforts to substantively confront them. Ever the consummate professional, Smiley delivers his message of hope and promise with a commanding tone that demands his audience's attention. His candid and polished reading gives his political messages an arresting personal touch. An Atria paperback. (Feb.)

Joseph L. Carlson - Library Journal

Radio/TV personality and No. 1 New York Times best-selling author Smiley (Covenant with Black America) takes aim at the Obama administration, demanding that promises made during the campaign be upheld, especially with regard to minorities. Smiley himself reads in a strong, often strident voice that deserves to be heard; it's doubtful that anyone else could adequately convey his mixture of outrage toward past treatments of minority Americans and his hope for the future now that a President is in power who finally understands that the government is accountable to all citizens. Public libraries will be doing their patrons a service by purchasing this title. [Audio clip available through audio.simonandschuster.com.—Ed.]—Joseph L. Carlson, Vandenberg Air Force Base Lib., CA

Product Details

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Table of Contents

Read an Excerpt

It was a cool Monday evening in late March 2006 in Los Angeles, months away from the sweltering summer when the infamous L.A. smog is at its worst. Traffic was moving swiftly along South San Pedro Street near East 5th Street in the downtown area known as "Skid Row."2 Known also as the Nickel because of its location along 5th Street, Skid Row is "home"to one of the largest populations of homeless people in the United States. Also known for its tough streets, the Nickel this evening seemed like just another day in the neighborhood, the county's 74,000 homeless seemingly unaware of the headlines of the day.

While they may have been unaffected by the flap over President Bush's wiretapping program or the third-year-almost-tothe-day commemoration of the war in Iraq, L.A.'s homeless were dealing with conflicts that hit closer to home.

One of them was Carol Ann Reyes, a transient Los Angeles resident who spent most of her time not on Skid Row but in a Gardena public park 16 miles south of the city, supporting herself by collecting recyclable bottles and cans. Three days earlier, an ambulance had transported Reyes westacross Rosecrans Avenue through Compton to Kaiser Permanente's Bellflower Medical Center for treatment of abdominal pains and injuries resulting from a recent fall. Sixty-three years old, homeless, suffering from dementia and other physical ailments, Reyes remained at the hospital until a decision was made that she had been there long enough.

Though she still had a fever, persistent cough, and perilously high blood pressure, Reyes was discharged by hospital officials without their prescribing medication for her high blood pressure or even taking time to locate the clothes she'd worn upon admission. They simply called a cab, placed her in it donning her hospital gown and slippers, and paid the driver to take her 16 miles north of the hospital to Skid Row, presumably because it is the location of many of the city's homeless shelters.

Hospital officials claim to have called Union Rescue Mission, a wellknown shelter on Skid Row, to let them know that Reyes was on her way. Video surveillance footage taken that evening contradicted the directions, showing the taxi driving along San Pedro, making an illegal Uturn, opening the door, and literally dumping her onto the Skid Row streets.

Reyes wandered about in the street and on the sidewalk, lost, without any money, identification, or medical information until a Union Rescue Mission worker noticed her and ushered her to safety and the warmth of a bed. Days later when the news of this story broke, a tearful hospital vice president of communications apologized to her and to the community, vowing that this would never happen again.

But will it? Carol Reyes was not only dumped onto the streets by that taxi; she was dumped by Kaiser Permanente, she was dumped by our failing health care system, and she was dumped by America. And in the year after Reyes' case made headlines, police were investigating 10 different hospitals for allegations of patient dumping on Skid Row, including a paralyzed man found crawling in the streets without a wheelchair and with a broken colostomy bag.

Reyes is just one example of millions of Americans, either uninsured or underinsured, who have been abandoned.

Who should be held accountable for this maltreatment? Who will be accountable the next time?

The Covenant opens with a chapter, "Securing the Right to Health Care and Well-Being," positioning it as the first and most important covenant. And while the health care crisis in our nation disproportionately affects people of color, to be sure the crisis is an American one -- red, white, and blue -- pulling at the very fabric of our flag.

There is a proverb that says: "When you are not your natural self, you don't do anything well." This elder wit is trying to tell us that physical weakness prevents accomplishing anything and everything that otherwise might be done. Indeed, when a family member is sick, all other concerns -- education, employment, justice, democracy -- pale in comparison. Moreover, when a community is sick, that can threaten the economy, the stability, and, depending on the breadth of the problem, the very survival of a nation. And when a nation is sick, as we have seen with the devastating impact of HIV/AIDS in Africa, it can threaten an entire continent and ultimately humanity.

Few would argue the moral integrity of the aspirational concept of health care as a fundamental human right. It is arguably more important than other socalled fundamental rights -- the right to freedom of expression or religious belief. And the right to life, possibly the most important of our fundamental human rights, would certainly be rendered meaningless without a complementary right to health care.

But in America the notion of universal health care and the varied and complicated paths to its achievement have become some of the most vexing and problematic issues of our time. The health care crisis in this country was a pressing political issue throughout the 2008 presidential election. As we inaugurate the second president of the new millennium, it remains the most intractable domestic policy issue, a problem we have been trying to solve since 1914.

In his new book, Critical: What We Can Do about the Health-Care Crisis, former Senator Tom Daschle of South Dakota presents a well-researched, exhaustive inventory of America's history of seeking health care reform. The cacophony of today's health care debate does little to remind us that this discussion has been underway in America for 95 years. Daschle explains the early debates during the Progressive Era (1890s-1920s), when reformers sought free medical care and related benefits for workers. All such efforts failed, with opponents decrying national health insurance as socialized medicine. It was the first real national debate on the issue, setting the stage for interest groups -- both for and against -- to become firmly entrenched in their positions.

During the Great Depression, America had another opportunity to reform the health care system when an advisory committee recommended that President Franklin D. Roosevelt create a system of universal health care as part of his landmark Social Security Act. But Roosevelt decided not to push for a health insurance add-on to Social Security, worried that opposition from the American Medical Association would sink his entire legislative reform effort.

Roosevelt's decision set the stage for the evolution of both the dominance of employer-sponsored health care programs in the United States and the continuing difficulties faced by the millions who remained uninsured, unable to secure protection against the growing cost of illness. Our employment-based system of health care became institutionalized during the World War II era and in the decade following, as the federal government enacted laws that made such plans favorable for the purpose of taxes and labor relations. Today, employer-based health care remains the most prominent form of coverage. This coverage, however, is completely voluntary for employers to provide, and it has shrunk in recent years. In 2000, 65 percent of employees received employment-based coverage; a mere seven years later, just 59 percent were covered, resulting in more than 2 million more people without coverage.

Health care reform remained on the national agenda for most of our presidents in the post-WWII era and beyond -- Harry S. Truman, John F. Kennedy, Lyndon B. Johnson, and Richard M. Nixon. Under Johnson, the nation saw the passage of Medicare, "the largest expansion of health care coverage in American history." Medicare guaranteed medical coverage to the disabled and those over age 65, representing a positive first step towards health care reform. Despite this progress, millions of people under 65 remained uninsured, and subsequent attempts to deal with the crisis by Presidents Nixon and Carter, as well as Massachusetts Senator Edward M. Kennedy, failed.

In the 1980s, managed care began to emerge as a beacon of hope. President Nixon signed the HMO Act in 1973, designed to encourage the private sector to create group practices that would be well managed, costeffective for insurance companies, and more affordable for the insured. The initiative provided the opportunity for a Republican administration to propose an alternative approach that would take the steam out of Senator Kennedy's push for national health insurance. And with the cost of employer-based benefit plans exploding, the "HMO march" began to pick up speed in the 1980s and early '90s. By 1993, 51 percent of all workers received employer-sponsored health insurance provided by some form of managed care plan.

American workers were content by and large with the HMO model as employers began to rely more and more on the concept. Presidents Ronald Reagan and George H. W. Bush largely ignored the health care crisis during the 1980s.13 Even President Bill Clinton's failed universal health care plan, led by First Lady Hillary Rodham Clinton in 1993, was modeled after HMOs.

As time passed, managed care began to reveal that it might not be the panacea that America had been looking for after all. Some consumers grew frustrated with the way managed care providers impinged on traditional doctor-patient relationships, denied coverage of expensive illnesses such as AIDS and cancer, and refused to pay in some cases for emergency room care. Those fortunate enough to have coverage struggled through the bureaucracy of HMOs, making life-and-death decisions on the basis of cost and benefit. Beyond these frustrations, for individuals such as Carol Ann Reyes, even the broken managed care system was out of reach.

These socalled "management decisions" about a patient's health care have sometimes had grave and even deadly consequences, demonstrating the critical need for serious reform of the health care system for all Americans.

In 1991, Elizabeth and Steven Hilsabeck were on the verge of achieving the American dream of homeownership in a small town near Austin, Texas. Though the Hilsabecks each earned a good salary, virtually every home in Lakeway, Texas, exceeded their price range until they came across a 2,400-square-foot home priced far below market value. Undaunted by the extreme makeover that their new home would need, the Hilsabecks quickly secured the property and began creating their dream home bit by bit, doing most of the work themselves.

Their dream continued to come true when they learned the following spring that Elizabeth was pregnant, expecting twins. The Hilsabecks flourished as they planned their nursery and finished renovating their home. About six months into her pregnancy, Elizabeth began to have contractions. Staving off the babies for three days, her small-framed body could hold out no longer. She went into labor and gave birth to twins after only 25 weeks of gestation.

The Hilsabecks knew that the prognosis for their new daughter Sarah and son Parker was grim. Each baby weighed only one pound, 13 ounces. But they were grateful for their excellent medical care and Steven's insurance coverage, especially since Elizabeth would have to quit her job to care for her premature twins.

The Hilsabecks were initially satisfied with Prudential's PruCare coverage, which paid hundreds of thousands of dollars worth of their medical costs, leaving them with only a $50 copayment. Their worries also eased as their daughter Sarah steadily improved. But their son Parker showed no such promise. When the twins were seven months old, the Hilsabecks learned that Parker had cerebral palsy. Without an extensive physical therapy regimen, their doctors advised that Parker might be confined to a wheelchair for life. To make matters worse, only a few days into Parker's treatment, PruCare stopped paying for his care. First, the company said that it would cover only 60 days of therapy over Parker's lifetime, although the actual limit was 60 days per year. The company also made processing mistakes, resulting in erroneous denials. Further tensions mounted when PruCare deemed that Parker's therapy was not covered, claiming it was "habilitative" rather than "rehabilitative" because Parker -- who had learned to crawl and was building muscle strength -- had never walked before. Finally, the company argued that Parker's medical treatments were not "medically necessary" because there was no guarantee that a child in his condition would ever walk.

Steven tried to find a new job paying more money, but the insurance company for his prospective employer would not cover Parker; Steven was thereby forced to remain in his lower-paying job. The Hilsabecks eventually lost their dream house -- and their marriage. But Elizabeth became a crusader for health care reform, and Parker finally learned to walk. Still, this success came at a very high price.

Ironically, during the time that the Hilsabecks' story was unfolding, Bill and Hillary Clinton were working on a national level to solve America's health care crisis.18 For all the bickering that occurred in Washington during the Clinton health care debate, would "Hillarycare" have helped the Hilsabecks? The family had the type of insurance that was being proposed for millions. Perhaps it would have allowed Steven to accept that new job offer without the threat of leaving Parker completely uncovered because of his preexisting condition, but would the new managed care company have made its "management" decisions differently about Parker's care? Would the 1,342-page Health Security Act have redressed Parker's situation at all?

Who is accountable to the Hilsabecks?

Steve and Leslie Shaeffer know something about a managed care company's interpretation of preexisting conditions. More than a decade after the Hilsabecks' ordeal began and Hillary Clinton's H.R. 3600 initiative had ended, the Shaeffers were living the American dream in Murrieta, California -- a bedroom community outside of San Diego. Steve was a self-employed tile installer and Leslie was a stay-at-home mom, caring for their four-yearold daughter, Selah. A successful entrepreneur, Steve acquired health care coverage with Blue Cross Blue Shield for his family in 2004, regarding his $498 monthly premium as "the price of peace of mind." Yet when Selah was diagnosed with aggressive fibromatosis -- a rare and fast-growing tumor -- only a few months later, his peace of mind would be tested.

Blue Cross initially covered Selah's care, including the pre-authorization of much of her treatment. Once her bills exceeded $20,000, however, the company canceled Selah's managed-care coverage, accusing her parents of having left out key background health information when filling out their insurance application. Leslie received a letter from Blue Cross alleging that she and Steve failed to disclose a bump on Selah's chin that would have resulted in a denial of coverage. Leslie countered, saying she took Selah to the doctor after filling out the application, and the doctor told her that the bump on Selah's chin wasn't serious. A few weeks later, doctors discovered the extent of Selah's illness. The four-year-old had surgery for nearly seven hours to remove the tumor, which had spread to her mouth and jaw. Portions of Selah's mouth, jaw, and throat wall were also removed as a precaution.

Blue Cross refused to pay for the operation and threatened to make the Shaeffers repay the $20,000 it had already paid for treatment. Two years later, when the Los Angeles Times reported their story, Leslie described her family as being "in big trouble" as the couple faced "more than $60,000 in medical bills and feared the loss of their dream home." They were still struggling to stave off creditors as they tried to figure out how Selah could keep seeing the physician they credit with saving her life.

They thought they had insurance. Who is accountable to the Shaeffers?

Both the Hilsabecks and the Shaeffers had every reason to believe that their managed care insurance providers were looking for any excuse to dodge their children's bills, dumping them much in the same way that Carol Ann Reyes was dumped in the Nickel by the hospital that no longer wanted to help her. Millions of Americans have their own health care horror stories, dealing with the frustrations of managed care, the high cost of private insurance, and the cost-cutting policies of profit-driven hospitals. Their stories, along with those of the Hilsabecks, Shaeffers, and Carol Ann Reyes, have fueled a renewed call for health care reform in the United States.

We often speak of the health care crisis in America, but in many ways it is inaccurate to call it a "health care" crisis. After all, this country has the preeminent health care system in the world with its first-rate pharmaceuticals, cutting-edge medical technologies, and unparalleled investment in the health sciences. More precisely, the crisis in America that these stories exemplify is better described as the lack of access to the excellent health care that our country undoubtedly provides.

And the crisis is different for different segments of our population. The crisis of Carol Ann Reyes as a poor and uninsured American excluded from the Medicaid system is different in many ways from that of the millions of working-class families who are too well off financially to qualify for state aid but cannot afford to purchase health insurance on their own. Still different are the problems of elderly Americans caught up in an inadequate yet bloated Medicare system.

Then there is the cross-cutting and seemingly insurmountable problem of health disparities in our nation that seems to persist and proliferate no matter how much the overall health of the nation improves. Importantly, though The Covenant defined the first covenant broadly as "Securing the Right to Health care and Well-Being," the lens through which this covenant is described was that of health disparities and the impact on the African American community. Indeed, The State of Black America 2008, the National Urban League's annual report on the well-being of Black America, devoted a special section in that year's edition to black women's health, opening with a chapter examining the impact of health disparities among African American women.

Health disparities occur when differences "exist in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States." With respect to every major disease or public health issue -- heart disease, stroke, cancer, diabetes, HIV/AIDS, infant mortality, and addiction -- African Americans are among the hardest-hit populations. Disparities also exist in connection with the lack of access to health care. African Americans, as well as other minorities and persons with disabilities, tend to face barriers to receiving health services at disproportionate rates. For example, when The Covenant was published in 2006, an estimated 1.8 million African American children had no health insurance, representing 13 percent of black children. More shocking is a statistic for Mexican Americans, revealing that as many as 39 percent of this group in 2006 had no health insurance. And according to The State of Black America 2008, 18 percent of all women in the United States have no health insurance, with 2 million of these women (16 percent) being African American.

One of those uninsured African American women is Alyce Driver. When her story was told in February 2007, she was a hard-working mom who had held various jobs -- in a bakery, as a home-health aide, and as a construction worker -- but none of them offered health insurance. She previously had Medicaid coverage for her sons DaShawn and Deamonte, but the family had recently lost its coverage.

Though all states have opted to provide dental benefits to children covered under the State Children's Health Insurance Program (SCHIP), finding a dentist willing to accept these benefits can be a major challenge. Patients have been known to travel up to three hours and to wait many months in search of services. And specialty services, such as surgery as opposed to routine cleanings, are even more difficult to find. In Maryland, where Driver lived, this coverage was offered to her children as an expansion of their Medicaid benefits, but fewer than one in three children in the program received dental care in 2005 because of substantial barriers.

By the fall of 2006, Driver was seeking dental care for both of her sons. Twelve-year-old Deamonte had a toothache. But she was more focused on frantically trying to find a dental surgeon willing to help DaShawn, who needed six teeth extracted. She waited from October 5 to January 16 for a dentist willing to take Medicaid for "emergency" care. However, by the time Deamonte's aching tooth got any attention, Driver learned that the toothache had been caused by an abscess, the bacteria from which had spread to his brain. A few weeks later, he died.

Because Deamonte could not get an $80 extraction, he ended up with a brain infection, a six-week stint in Children's Hospital, two surgeries resulting in $250,000 worth of unpaid medical bills for taxpayers to bear, and -- most regrettably -- a death certificate.

News of the twelve-year-old boy's death shocked many people, including Robyn Fleming, a former staff member of Goodwill of Greater Washington. She described on the Women's Foundation blog that Driver had been in a vocational program that Fleming had taught, and that she "strived for more for herself and her family.... Alyce, along with many other women, came to this program as a last hope. Hope that they will learn something new, hope that they will find support and assistance when they couldn't get it anywhere else, hope for another chance at life!"

But a twelve-year-old is dead because no one could figure out how to fund an $80 visit to a dentist. Fleming wrote, "I feel as if I failed Ms. Driver. But in reality we all failed Ms. Driver."

Who is accountable to Deamonte?

The Covenant set forth "Securing the Right to Healthcare and Well-Being" as its first and arguably most important covenant. The end of that chapter lays out what individuals, government, and community leaders can do to impact this issue. THE COVENANT In Action next provided a toolkit to equip citizens with the instruments to effect change on this and all The Covenant issues. ACCOUNTABLE now helps any citizen assess whether America has lived up to the aspirations enshrined in The Covenant and set forth a measuring tool for future evaluation.

During the 2008 presidential election, the major candidates agreed that the U.S. health care system was in dire need of a makeover. This fact, along with the health care horror stories presented, would lead most people to conclude that we have yet to reach our full potential when it comes to health care. The key questions are what are the potential solutions to this dilemma? Who should take part in crafting them? We must ensure that the entities that are part of the solution -- the government, private employers, insurance providers, doctors, hospitals, and citizens themselves -- are not unduly burdened by the remedy. Finally, how will the American citizenry know that these solutions are working?

With 47 million Americans without health insurance (9 million of whom are children), any governmental solution must be sweeping and comprehensive. The solution must immediately be tailored to assist poor and working-class Americans who do not qualify for Medicaid, are too young to benefit from Medicare, and are either unemployed, entrepreneurs, or employed by businesses that do not offer health coverage. Although most Americans seem to seek a nationwide solution to this crisis, much can be learned from the experiences of state governments that have tackled the issue.

The Commonwealth of Massachusetts attempted such a solution in April 2006 when it adopted the most comprehensive attempt to date by a state to provide near-universal health care coverage. The key components of the Massachusetts plan were to expand eligibility for Medicaid and its State Children's Health Insurance Program (SCHIP). Lawmakers created two new avenues to access the expanded coverage: (1) through Commonwealth Care, a publicly subsidized coverage for adults ages 19 and older with incomes below 300 percent of the federal poverty level; and (2) through Commonwealth Choice: Private, unsubsidized coverage available to any resident who is not offered coverage through his or her employer. Another key element of the plan was it mandated all citizens to carry coverage whether they wanted to or not. Two years after its implementation, the plan is now a victim of its own success: enrollments outpace expectations and state budget officials are struggling with how to pay for the overage.

One of the biggest challenges is the punitive and mandatory provision of the law, requiring Massachusetts citizens to prove on their income tax returns that they carry health insurance or face a penalty for failing to do so. Critics argue that the commonwealth's approach does not guarantee affordability, does nothing to control costs, and thereby excludes broad classes of people, in effect abandoning universal health care. Many who are deemed able to afford the coverage end up spending well over the allegedly capped level of 10 percent of their monthly income on health care.

Massachusetts' challenge with its health care mandate may explain why Barack Obama's plan to move America to "universal" health care did not include such a mandate, opting instead to focus more intensely on cost containment. Upon announcing his plan in May 2007, Obama focused on affordability as its centerpiece, with a specific promise to reduce health care costs for each American family by $2,500. Other key provisions are guaranteed eligibility, notwithstanding preexisting conditions; comprehensive benefits similar to the Federal Employees Health Benefits Program that members of Congress enjoy; subsidies; simplified paperwork; the ability to take your coverage with you to a new job; and a system that would be monitored to ensure high quality and efficiency. Though there is no health care mandate for adults, the plan mandates that children be covered.

The other major Democratic presidential hopeful, Sen. Hillary Rodham Clinton of New York, unveiled her health care plan about the same time. Like the Obama plan, Clinton's "American Health Choices Plan" also recognized affordability and cost-containment as a key strategy in achieving the goal of universal health coverage, but her primary emphasis was "to be the president who accomplishes [the goal of providing quality affordable health care for every American]." For all of the debate during the campaign between Clinton and Obama about health care, the substance of their proposals was strikingly similar. Clinton packaged her plan neatly around three key points: Affordability -- America will give tax credits to working families to help them cover their costs; Availability -- no discrimination or disqualification for preexisting conditions; and Reliability -- if you lose or change jobs, you keep your health care insurance coverage.

The GOP presidential nominee, Sen. John McCain of Arizona, proposed similar health care reform. His plan started with a "Call to Action," envisioning that "we can and must provide access to health care for every American." It focused largely on tax policy, incentives to insurance providers, and tort reform. McCain promised to reform the tax code to give every family a $5,000 tax credit to offset the cost of insurance; to make insurance more portable, following Americans from job to job; and to expand Health Savings Accounts for families. He promised a laundry list of activities, including working with states to develop best practices to facilitate access to health care and lowering health care costs through a variety of mechanisms.

Private organizations and commentators have also offered big ideas about government solutions to the health care crisis in America. In 2008, Project HOPE: The People-to-People Health Foundation published an article, "Building Blocks For Reform: Achieving Universal Coverage With Private And Public Group Health Insurance." "Building Blocks" offered what it called a "pragmatic approach" to universal health care, arguing for a mix of public and private solutions -- mandatory employer contributions, an extension of the Medicare system, tax credits, and an expansion of the SCHIP and Medicaid programs.

Overall, the 2008 presidential campaign demonstrated that Americans may finally be ready to resolve the health care crisis in this country. It was a top domestic issue, second only to the related issue of the economy. The major presidential candidates recognized that the federal government needs, at a minimum, a comprehensive plan to address the massive gaps in America's health care system: varied and specific strategies designed to eliminate health disparities and to support poor Americans, working- and middle-class Americans, and the elderly. Now that Barack Obama is president, it remains to be seen whether he can garner the political support to answer this clear call to action by the electorate and whether the electorate will hold him accountable for doing so.

The government must play a vital role in enforcing any state or federal plan to reform the health care system. Whether the plan relies on private or public entities, or more likely a combination of both, federal and state governments must ensure that fairness imbues the system through oversight and enforcement. By any reasonable measure, Parker Hilsabeck should have been well cared for under his family's policy. But where was the government oversight when Prudential offered his mother ridiculous and often incorrect interpretations of complicated legalistic policy language in an obvious attempt to avoid coverage? And what was the cost to the family of Elizabeth's incessant complaints that were expensive, time consuming, and required an ability to navigate complex systems?

The primary solutions for health care reform will be fashioned most likely by the federal government, even though private employers have played a historical, albeit voluntary, role in providing health care to most Americans. As health care costs have skyrocketed, some employers have challenged that role, offering less coverage to fewer employees, resulting in a skyrocketing number of uninsured and underinsured Americans. Consider the story of Gary Rotzler.

Gary Rotzler of Gilbertsville, NY, was one such American caught up in the erosion of employer-based health care. A hardworking, collegeeducated engineer from working-class roots, he married his high school sweetheart, Betsy, in 1978 and shortly thereafter took a well-paying job with one of Central New York's major manufacturers, from which he thought he'd retire. But in the era of mergers and acquisitions that defined the 1980s, Rotzler's employer was left in the hands of another company that paid a multimillion-dollar departure fee to the former CEO and downsized the company, just like most other manufacturers in that state. Rotzler was fortunate enough to escape the fate that snuffed the dreams of many of his coworkers by landing a new job, where he remained safe for a few more years. But in 1993, his new employer let him go in an era when engineering jobs were nearly impossible to find. He ultimately returned to his original employer, but this time reclassified -- as a temporary employee, who did not qualify for health insurance. Rotzler repeatedly requested to be reclassified as permanent so that he could obtain health insurance for his family. His requests fell on deaf ears.

Compounding his situation, his long hours and his quest to work overtime to provide for his wife and now three children distracted him from noticing that Betsy was getting sick. For her part, Betsy delayed seeing a doctor, instead trying a series of home remedies because of their health insurance situation. The family's worst fears were confirmed when Betsy finally confided in Gary, who took her to a local Planned Parenthood clinic, where she learned that she likely had breast cancer. By the time their family was able to arrange treatment at Memorial Sloan-Kettering Cancer Center in New York City, Gary had signed a consent form for treatment, a promise to pay for it, and a few days later, a death certificate. He was forced to declare bankruptcy; his hopes for the American dream and of providing a bright future for his wife and children became a distant ghost of his past.

Rotzler's story illustrates that as insurance becomes more expensive for employers to provide, more employers, even employers of large firms, may stop providing health care. Workers are left with the "choice" of forgoing health insurance at great risk to their families and their overall health care, as in the Rotzlers' situation, or self-insuring, which could expose them to the situation faced by the Shaeffers. But what are employers to do when globalization makes international competition nearly impossible if they must carry the high costs of insuring U.S. workers?

More than six out of 10 employees (63 percent) at most major corporations have employer-sponsored health coverage. But it comes at great cost to corporations that are generally unable to bargain with insurance companies as to cost-containment in an industry that is ancillary at best to the corporations' industry. Meanwhile, the insurance industry has no real incentive to cut its price point for customers who include not only these major corporations, but also the government, smaller corporations, and everyday consumers.

One proposed solution is to look strategically at a major corporation known for cost-containment: Wal-Mart -- "a company that understands how low prices can build market share and thus increase profits. Furthermore, it's a company with a culture of cutting costs that has shown no compunction in pushing suppliers to the wall over price. The Wal-Mart motto ought to be, 'Make it cheaper, or we'll find someone who can.'"

Wal-Mart has already applied its "always low prices" strategy to prescription drugs. In 2006, the corporate giant rolled out a program to sell a list of about 300 prescription drugs for only $4. It expanded the program a year later to include additional prescriptions as well as an option for consumers to purchase a 90-day supply of those drugs for only $10. More than 1,000 over-the-counter generic drugs are sold through this program, and higher priced specialty drugs for ailments such as osteoporosis, breast cancer, hormone deficiency, and other women's health problems are sold for only $9. The price point of these prescriptions is no accident. Wal-Mart has apparently studied the weak points of the prescription drug industry, uncovering the point where its customers were being squeezed by their insurance companies with high copays and coverage exclusions. It began offering a lower-priced alternative conveniently located in Wal-Mart stores.

The company is starting a similar program to provide medical services, in part through opening walk-in health facilities in its stores in Atlanta, Dallas, and Little Rock. It plans to open 400 clinics by 2010 that will be cobranded with local hospitals. Wal-Mart's competitors include not only Walgreens, CVS, Rite Aid, Costco, and Target, but also insurance companies that are likely already feeling the pressure to reduce copays resulting from Wal-Mart's action.

Wal-Mart exemplifies how corporations must work creatively to offer real solutions for consumers. Its "always low prices" as applied to health care are giving citizens more access to health care that they can afford.

The insurance lobby -- which has positioned itself as one of the most powerful groups of lobbyists in Washington, DC -- should strive to be part of the solution, rather than part of the problem. In the case of the recent Medicare prescription drug legislation, these lobbyists even influenced the law that prevented the federal government from negotiating with drug companies on cost.

In an era where the people are desperately seeking change on issues including health care and the economy, insurance companies must see the writing on the wall. Citizens will no longer support conditions that have health care costs on track to approach 25 percent of the gross domestic product in less than 20 years. Large corporations in a global economy cannot sustain the former situation, and this new era will certainly bring forth Wal-Mart-style competition with insurance companies that will ultimately impact their bottom line.

In June 2008, America's Health Insurance Plans (AHIP) Center for Policy and Research released a technical memo detailing AHIP's proposals to improve the affordability of health care. (AHIP is the national association representing nearly 1,300 member companies providing health insurance coverage to more than 200 million Americans.) This positive step indicates that insurance lobbyists understand the times and that they will clearly benefit from being included in the national conversation on solutions. In fact, the substance of their affordability proposals contains ideas such as health information technology reform that parallel those set forth in President Obama's proposal. What is needed, however, is trust building and a fully integrated conversation among consumer advocates, AHIP, and governmental actors.

Community leaders and health professionals will be crucial to making health care reform real and creating immediate change. They have access to the communities at need and know firsthand which problems are most pressing. They can fashion solutions that address real problems practically and effectively.

For example, a group of African American cardiologists realized in the 1970s that while heart diseases affected the black community disproportionately to the rest of the nation, there was little awareness of this higher risk, let alone ways to prevent their onset. Black communities were not receiving the attention or energies of the American Heart Association and other health organizations. These 17 doctors held themselves accountable as a community and created the Association of Black Cardiologists to raise awareness about heart disease and stroke in the black community. Not only did they provide health education for citizens, they also realized that forming the next generation of leaders was crucial to continuing their mission. Equally precarious: that there were too few African Americans in the medical profession, and specifically in cardiology.

The group did not wait for extensive support and funding. Instead, it launched initiatives for community education, beginning by using churches as centers for blood pressure screening. These community programs were soon supplemented by a fellowship program designed to motivate and prepare new African American cardiologists. Today, the group hosts symposiums, runs continuing education programs for physicians, and remains committed to its mission to educate the African American community about the dangers of heart disease.

Another effective yet simple solution: In response to rising prescription drug costs facing senior citizens, the Cristo Rey Community Center in East Lansing, MI, created a Prescription Assistance Program to help seniors navigate the programs available to receive prescription drug assistance. Many prescription drug companies have programs providing free or reduced-cost medication to those with demonstrated financial need. These programs, however, present a maze of paperwork as an obstacle to receiving assistance. Cristo Rey works as an advocate to help its clients receive the assistance to which they are entitled. The program has helped people like Anthony and Joan, a couple in their late 60s. They could not afford their monthly medications, which cost more than three thousand dollars; much of this huge expense is not covered by Medicaid. The couple's only source of income is Social Security benefits, which total little more than $1,000 per month -- barely enough to cover maintenance and living expenses. The Prescription Assistance Program provides Anthony and Joan with an advocate to help them fill out their application to the pharmaceutical companies, to provide the required documentation, and to follow up every three months so that they don't run out of medicine.

Achieving health care goals should not begin with arguments about Medicaid extensions and universal insurance coverage. Each and every one of us must be held accountable for our own health and well-being. We must understand that eating healthy and exercising is more than a cliché of the latest health care marketing campaign. Taking action to be responsible for the nutrients and toxins that we introduce to our bodies and deciding to stay physically active are actually expressions of civic participation and engagement. Similarly, partnering with our doctors for prevention is a much more active and democratic strategy than hiring a doctor after the fact to correct health problems that could have been prevented.

Roosevelt Johnson is a well-respected psychologist in Silver Spring, MD. In March 2008, Dr. Johnson was healthy, happily married, the father of three successful adult children, and a deacon at his church in Washington, DC. He led a healthful and fulfilling life. For years Johnson maintained a partnership with his personal physician. As an African American male over age 50 and with two older brothers who had survived prostate cancer, Johnson knew that he could not "sit in the back seat" where his health was concerned; nor did he want the "passenger's seat." When he reached his late forties, he educated himself extensively about prostate cancer and decided to "drive his own car." He learned of the dangers of prostate cancer and the latest developments in testing and prevention. He took that information to his doctor, who told him additional PSA testing was unnecessary. Johnson didn't let this stop him; he decided that with his risk factors, he would reject the standard medical advice to just complete an annual PSA screening. He opted instead to be screened quarterly, knowing this might require him to pay for the tests out of his own pocket. He reasoned that if he had cancerous cells too early to detect from a PSA screening, waiting another 365 days for his next one could have deadly results. Johnson even convinced his doctors that his tests should be covered by insurance because of his high risk factors.

Johnson's resolve paid off in 2007. His March screening revealed a slight elevation in his PSA blood level, as compared with his previous results. Though the elevation appeared trivial and remained within the acceptable medical range, true to form, Johnson insisted that his doctor probe further to uncover the source of the slight elevation. Days later, after a biopsy that he had insisted be performed, he and his wife sat before that same doctor, who delivered the results: early-stage prostate adenocarcinoma -- a highly aggressive form of cancer. The good news: the probability that it would be neutralized and contained. Because he educated himself on his risk factors and demanded early testing, Johnson discovered the cancer at an early stage, worked with his doctor to address his surgical options, and was able to avoid chemotherapy and radiation.

Johnson used his illness as a way to continue his lifelong vocation -- teaching and ministering to his community. He took his son with him to his procedures and doctor's appointments, so that his son would realize the risk his family history would eventually pose to him. Johnson later testified in church about his experience; the response was immediate. He recalled, "men started coming out of the woodwork," discussing the shame they felt at their diagnosis, the fear that kept them from getting screened. His decision to educate and hold himself accountable has had a ripple effect -- "breaking the silence" about prostate cancer in his community and leading others to do the same.

The most powerful tool we have as citizens to effect change is our vote. We should not allow our elected officials to make promises in their campaigns without fulfilling their obligations once in office. Use this list to hold our new president accountable on health care.

Barack Obama as Promised...

- Will make a new national health care plan available to all Americans with guaranteed eligibility; comprehensive benefits; affordable premiums, copays, and deductibles; simplified paperwork; easy enrollment; increased portability; and choice.

- Will provide tax relief for small business.

- Will create a Small Business Health Tax Credit to assist small businesses in providing employee health care.

- Will mandate health coverage for children.

- Will help patients by improving disease management programs and increasing transparency in health costs.

- Will lower costs by increasing competition in the insurance and drug markets.

Use this checklist to evaluate whether the entities that can make a differenceare doing all that they can to help America realize the goal of the firstCovenant: "Securing the Right to Health care and Well-Being." Reexaminethis checklist every six months to assess progress.

Our President

- Have you made implementation of a health care plan a priority within the first 100 days of your administration?

- Have you exercised good judgment, reached out to a broad number of constituencies who will be affected by health care reform, and engaged in transparent dealings that will strengthen the chances that implementation of reform will succeed?

- Have you retained the ability to oversee the new reforms, ensuring that neither private nor public entities behave unfairly or unethically?

- Have you provided for unbiased entities to evaluate the success of the new reforms at regular intervals to determine if benchmarks have been met?

Our U.S. Congressmen and Congresswomen

- Have you made health care reform a priority issue?

- Are you using monitoring and enforcement mechanisms to ensure that insurance companies, doctors, hospitals, pharmaceutical companies, and all entities in the health care system act in good faith and do not violate federal or ethical standards?

- Have you voted to expand health care coverage for children?

- Are you working to make health insurance more affordable for all Americans?

Our Governor and State Legislators

- Have you shown leadership on health care reform even where the federal government may be lacking?

- Do you have a plan to fill in gaps in health care coverage created by a federal plan?

- Can you implement that plan if necessary?

- Do you have an enforcement mechanism to ensure that insurance companies, doctors, hospitals, pharmaceutical companies, and all entities in the health care system always act in good faith and do not violate state, federal, or ethical standards?

Our Community Leaders and Faith-Based Organizations

- Do you have a plan or an initiative to monitor the political progress ofhealth care reform promises made by our governmental leaders and toadvocate when necessary?

- Do you have a plan or an initiative to educate your members about the progress of health care reform and about the availability of health care options in our community?

- Have you educated your members about health, nutrition, screenings, and risk factors for degenerative diseases such as diabetes, cancer, hypertension, and heart disease?

- Do you implement programs to improve the health of your community members, such as disease screenings, blood pressure checks, or fitness initiatives?

You and I

- Do I eat a healthy diet?

- Do I exercise regularly?

-Do I know where the health facilities in my community are and what services they offer?

- Do I have a primary physician whom I see at least once a year?

- Do I see myself as the best advocate for my own health?

- Do I understand the importance of cancer, HIV/AIDS, and other health screenings, and undergo the appropriate tests at the recommended intervals as determined with my doctor?

- Do I talk to my family, neighbors, children, friends, and community members about important health issues -- insurance coverage, access to services, and making health care affordable for all Americans?

- Do I talk to my family, neighbors, children, friends, and community members about maintaining a healthy lifestyle, such as the value of eating a healthy diet, exercising regularly, and seeing a physician at least once a year?

Copyright © 2009 by The Smiley Group, Inc.