The United States has a growing health crisis. Almost 30 million people have no health insurance and another 86 million adults are underinsured – meaning they have inadequate health insurance or can’t afford the co-pays and deductibles required before their insurance coverage kicks in.

Although the United States spends over twice as much on healthcare per person each year as the average wealthy nation, the status of our health is poor and our lives are getting shorter. Over 500,000 families go bankrupt each year because of medical illness, almost two-thirds of all personal bankruptcies, something that doesn’t happen in other wealthy countries. And, people are dying at higher rates in the United States than in other wealthy nations because they can’t afford necessary medications such as insulin for diabetes. Life expectancy in the United States is falling.

The fundamental problem with the healthcare system in the United States is that it is designed to create profits for a few rather than guarantee healthcare to everyone. Corporations are taking over all aspects of the system giving them a tremendous amount of control over prices and what health care people can or cannot have. Major health insurance companies currently receive most of their revenues from the government by providing “public insurance” such as Medicaid managed care organizations and Medicare Advantage plans. The government has become a cash cow for the health insurers, a guaranteed payor that will line their executives’ and investors’ pockets.

The first and most basic step that needs to be taken in order to create a functioning healthcare system that is universal, improves health, and controls costs is to decommodify health care. Health care does not belong in the marketplace.

The Hawkins Healthcare Plan outlined below treats health care as a human right and a public good. It starts by immediately implementing National Health Insurance, what is commonly called today a single-payer, improved Medicare for All. In the second phase, it builds out a National Health Service where health care facilities are publicly owned, health care workers are salaried, and the system is governed by community boards elected by the public (two-thirds of the seats) and health care workers (one-third of the seats). The second phase conducts a national assessment of unmet healthcare needs, develops a plan to meet those needs, implements the plan, and converts the system to a fully public and democratically-run healthcare service.

The Hawkins Healthcare Plan, culminating in a community-based National Health Service, has its roots in the Josephine Butler United States Health Care Service Act, which was introduced into every Congress for over 20 years, from 1977 to 1998 by Rep. Ron Dellums. It was developed by medical and consumer advocates, and particularly by Civil Rights Movement veterans in the Medical Committee for Human Rights. It is time to again expand the health care reform agenda from socialized insurance for privatized care to a fully socialized and democratic system – publicly funded, publicly administered, and publicly delivered.

Phase 1: Universal, comprehensive coverage and conversion to non-profit

In phase one, all people will be covered with comprehensive benefits and profits will be removed from the system.

On January 1 of the year after the bill is signed, all people residing in the United States or its territories will be automatically registered in a National Improved Medicare public health insurance program, which will replace all other public and private health insurances. Residency will not require citizenship. The Veterans Administration and the Indian Health Service will continue, but with full funding instead of the current underfunding.

Every person will receive a Medicare card that enables them to seek care at any health facility in the United States and its territories. If a person seeks care, they are presumed to be covered and will receive treatment whether they have a card or not. This card will grant coverage for the duration of each person’s life. Discrimination based on age, ability, gender or gender identification, sexual orientation, race, religion, national origin, ethnicity, political or other opinion, social origin, property, birth, or other status will be prohibited and a process for registering, investigating, and resolving complaints of discrimination will be established.

All medically necessary care will be covered including hospitalization, surgery, emergency services, transportation, outpatient care, checkups, preventive care services, diagnostic and treatment services, rehabilitation, physical and occupational therapy, substance abuse services, mental health care, vision, hearing, dental care, reproductive services, pharmaceuticals, medical devices, home and community-based habilitative care, as well as home-based and institutional long-term care and support services. In-home and community-based treatment will be prioritized. Complementary services provided by licensed individuals, such as chiropractic care and acupuncture, will also be covered. Authorization for services outside the standard of care will be made in consultation with health professionals with relevant expertise. The system will respect patients’ individual autonomy, allow medical choice and protect informed consent. An appeals process for patients who are denied care will be established.

Family members who provide short, medium, or long term care in the home will be compensated for providing that care in an extension of the Family Medical Leave Act. Parents will be provided with extended leave for the first year of each child’s life, encouraging both parents to take time off to provide care, with compensation and their job guaranteed when they return.

There will be no out-of-pocket costs for care such as copays or deductibles, and no supplemental health insurance will be needed because the National Improved Medicare for All will provide all medically necessary services.

The system will be funded up front by allocating current public healthcare dollars (about 70% of current spending) to the system and filling the gap using progressive taxes on individuals/families, both earned and unearned income, who earn more than 150% of the adjusted* Federal Poverty Level and on large corporations.

All licensed health professionals will be included in the healthcare system. Patients can choose their health professional and stay with that person or change caregivers if they so desire. If a patient requires specialized care, they can seek care at any facility in the United States or its territories.

All health facilities will be required to be either public or non-profit institutions or independent not-for-profit practitioner offices. Investor-owned facilities and not-for-profits that operate like investor-owned facilities will not be included in the system. Facilities, excluding independent practitioners, will receive a global budget to cover operating costs and a separate budget for capital improvements. Health professionals working in these facilities will be salaried. Independent practitioners may continue to bill the system as fee-for-service under a new payment system that compensates for time spent caring for a patient, including care coordination.

Negotiation for reimbursement for services will occur between the Department of Health and Human Services and health professional organizations. Incentives will be provided for those who practice in underserved areas or in types of medical practice that are lacking such as primary care. Payment arrangements that shift risk or reward to health professionals such as value-based or performance-based methods or managed care or accountable care organizations will be prohibited. Provision of services for cash or that is outside the system in any way will be banned.

Health facilities that choose not to convert to the above will be acquired by the system for the market value of the facility. Financing the buy-out would require approximately one percent of total health spending using a Treasury Bill at a rate of three percent interest over 15 years. These facilities will become publicly-owned and will be turned over to the local government and communities for oversight.

A democratic structure for community and worker control and accountability will be established at the community, district, regional, and national levels. At the local community level, health boards will be elected, two-thirds by the general public and one-third by the health care providers in the community. These boards will appoint members of the district boards, which in turn will appoint the regional boards, which will appoint the national board.

Health system analysts and planners have found that a rationally organized health system should have these four levels to optimize the provision of inpatient care in clinics, outpatient care in general hospitals, specialized care in regional medical centers, and overall budgeting and planning.

• The community health board will serve a contiguous geographic area having a population of between 25 and 50 thousand people and provide comprehensive outpatients services through a community health center or centers.
• The district health board will serve a population of between 100 to 500 thousand people and provide inpatient services through a general hospital.
• The regional health board will serve a population of between half a million and 3 million people and provide a specialized medical services, health worker eduction, and regional planning through a regional medical center.
• The national health board will administer the general operating funds, retaining a portion for national planning and research with the balance allocated to each region on a per capita basis alongside supplementary grants directly to communities and districts with particular needs.

Every community health facility will be evaluated annually by the community health board. That review will inform improvements to the facilities. These reports will be collected by the district health board and used in an annual review of health needs in the district. The district reports will be integrated into the regional health boards evaluation of health outcomes and health needs. These regional reports will be submitted to the national health board annually for health planning. Capital improvements must be applied for and approved at the community, district, regional, and national levels. The yearly review will identify areas of potential fraud and abuse for investigation.

Workers who are displaced from employment as a direct result of the new system will be prioritized for hire into the new system. Those who are not hired in the new system will be eligible for up to five year’s support with their current income and benefits and retraining for a new job.

Prices for pharmaceuticals and services provided by the system will be negotiated on a yearly basis. Pharmaceutical and medical device corporations that fail to satisfactorily negotiate with the system may lose their license to produce their drug or device and the healthcare system will assume production. A national formulary will be established that provides evidence-based information about licensed pharmaceuticals and medical devices to health professionals and the public. Pharmaceutical and medical device representatives who directly market their products to health professionals and direct-to-consumer advertising will be banned.

Phase 2: Improvement of health outcomes and transition to public healthcare service

Within two years after the initiation of the new system, a national system of medical records will be established and provided to all health professionals. The new system will be constructed to support high quality care and reduce administrative burden on health professionals. Information from the new system will be used to develop an anonymous national database of health service utilization and health outcomes. A national public health commission will be established to use the database to determine where there are unmet health needs and health disparities, to identify areas needing intervention, and to locate outliers in the system that may need attention.

Within four years after the initiation of the new system, a comprehensive plan of action will be developed by the public health commission to identify priority areas for urgent intervention such as construction of health facilities, recruitment of health professionals, and training of health practitioners in areas where there are deficiencies to improve health outcomes. Implementation of the plan will begin within six months after completion. All new facilities will be publicly-owned.

Within five years after the initiation of the new system, a review of health education will be conducted and teaching institutions will be converted to a public system that may be expanded to meet needs as determined in the comprehensive plan of action. All students (including physicians, dentists, nurses, nurse practitioners, physician assistants, pharmacists, social workers, therapists, and caregivers) will be provided with education at no cost up front with the expectation they will serve in the system for a minimum of fifteen years. Residency programs will be restructured to accommodate the need for increases in certain areas such as primary care. Sufficient numbers of health professionals will be trained to meet needs for lower caseloads across the spectrum from social workers to therapists, caregivers, nurses, physician assistants, and doctors.

Within five years after initiation of the new system, the Veterans Administration will be incorporated into the national system. Specialty centers for veterans will continue to exist, but from day one, veterans can choose where to seek care. Indian Health Service facilities will also be incorporated into the national system. Indian Health Centers and Hospitals will continue to exist, but from day one, all tribal members can choose where to seek care. Indian Health Facilities will have oversight by local commissions composed of tribal members and will receive additional resources to establish culturally-appropriate systems and practices.

Within six years of the new system, the public health commission will establish yearly public health priorities and plans to address them will be implemented. This may include public education projects, changes to infrastructure, and policy changes to impact the social determinants of health.

Within eight years after initiation of the new system, all pharmaceutical and medical device manufacturing and distribution will become publicly owned and medical research will be fully funded through public institutions. National priorities for research and development will be established by the Department of Health and Human Services based on input from the public health commission and the annual health system reviews.

Within ten years after the initiation of the new system, all health facilities will be acquired and operated by the national health system and a network of care facilities will be established. All residents of the United States and its territories will have access to community-based primary care. Primary care facilities will refer to local specialty care facilities and tertiary care facilities. All health professionals will be salaried employees with compensation based on cost of living, seniority in the system, workload, and incentives for working in underserved areas.

*The current Federal Poverty Level is grossly inadequate. It has not been updated in any meaningful way to estimate the actual costs of living. A better estimate is provided by the Economic Policy Institute. The current Federal Policy Level needs to be doubled or tripled to reflect real costs of meeting basic necessities.

This plan was developed in conjunction with Dr. Margaret Flowers, the campaign’s principal healthcare adviser.  Dr. Flowers directs and is an adviser to the Physicians for a National Health Program’s board of directors.

Howie Hawkins 2020

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