NHeLP Comments on the Citizen Health Care Working Group Proposed Recommendation

Citizens? Health Care Working Group
7201 Wisconsin Avenue, Room 575
Bethesda, Maryland 20814
Re: Comments on Interim Recommendations 
To the Citizens? Health Care Working Group:
The National Health Law Program (NHeLP) submits these comments in response to the Interim Recommendations that the Citizens? Health Care Working Group (WG) issued on June 1, 2006 and updated on July 18, 2006. NHeLP is a national public interest law firm that seeks to improve health care for America’s working and unemployed poor, minorities, the elderly, and people with disabilities. NHeLP serves legal services programs, community-based organizations, the private bar, providers, and individuals who work to preserve a health care safety net for the millions of uninsured or underinsured low-income people. Established over 35 years ago, NHeLP?s areas of expertise include Medicaid and the State Children?s Health Insurance Program (SCHIP); civil rights; linguistic access and cultural competency of health care; reproductive health access; and racial and ethnic health disparities. We have reviewed the Interim Recommendations in light of our expertise to assess how they would impact low-income individuals in the above-mentioned areas.
We appreciate the opportunity to comment on the Interim Recommendations and hope the Working Group will seriously consider our suggestions. Our comments are divided into three parts. Part I sets forth general comments on the recommendations. Part II details our comments on the WG?s statement of values and principles. Part III includes our comments on each of the six recommendations.
A. Provide Further Clarity, Detail, and Consistency to the Values and Principles and to the Recommendations. 
1. Clarify the Values and Principles to create a stronger framework for the recommendations. 
We agree with many of the values that the WG has identified. Indeed, as the Preamble recognizes, Congress designed the WG, in part, to identify the ?overarching values and aspirations? that constitute the heart of the health care system. Because the recommendations build on the Values and Principles, it is vital that the WG clarify them to create a more coherent foundation for the
2. Further detail the execution of the recommendations. 
The WG should also provide more details on its plans to execute the recommendations. Generally, the recommendations lack a clear explanation of the financing and implementation mechanisms. We have highlighted the various areas in which the WG should further articulate its vision, which is necessary to understand the recommendations? impact on all Americans ? particularly low-income individuals.
3. Resolve the potential inconsistencies between the ?medically effective? and ?evidencebased? terminologies. 
?Throughout the Values and Principles and the recommendations on benefits, quality and efficiency, and end-of-life care, the WG uses various forms of the terms ?medically effective? and ?evidence-based.? For instance, the WG seems to use the phrases ?effectiveness of treatments? and ?medically effective? interchangeably. Similarly, the WG refers to ?evidence-based science,? ?evidence-based medicine,? ?evidence-based best practices,? and ?medical evidence? without defining these terms. If the terms effectiveness of treatments? and ?medically effective? are the same, then the WG should select one and define it. Similarly, if the various forms of the ?evidence-based? terms are the same, then the WG should choose one of the terms to use consistently and define it. If the terms do have different meanings, the WG should define each term and explain how it differs from the others. As we explain in Part III.B.3 regarding coverage of benefits, we suggest the WG broadly define the standards based on these terms.
B. Replace All References to ?Citizens? With ?Americans? to Reflect That the Recommendations Address Health Care for Immigrants. 
The WG should consistently refer to ?Americans? instead of ?citizens? to reflect that the recommendations address all Americans, which the WG should define to include immigrants. Currently, the Working Group seems to use the terms ?citizens? and Americans? interchangeably, but the latter term is more consistent with the WG?s mission. Indeed, Congress called ?for a nationwide public debate?to provide every American with?quality, affordable health care coverage,?1 which strongly suggests the inclusion of immigrants in both the process and the result.
1. Immigrants financially contribute to society and are not a fiscal burden. 
Non-citizen immigrants, like citizens, pay taxes to federal, state, and local governments. These include income taxes, sales and property taxes, and the full range of license and user fees.2 An immigrant and his or her future descendants contribute, on average, $80,000 more in taxes than they will receive in public benefits.3 Nor do immigrants disproportionately use high cost health care such as emergency departments. A recent study found that the ?communities with the highest levels of [emergency department] use did not necessarily have the highest numbers of uninsured, low-income, racial/ethnic minority, or immigrant residents.? Indeed, immigrants ?had much lower [emergency room] use than citizens.?4 Because immigrants are contributing taxpayers, the recommendations must treat them as stakeholders in the health care system. Thus, we urge the Working Group to clarify that its recommendations apply to all Americans, not just citizens.
2. Including immigrants is necessary to achieve health care for all. 
Any system for providing quality, affordable health care for all Americans cannot ignore immigrants ? a sizeable segment of the American population. For instance, the WG designed its recommendations on affordability and benefits to reduce the number of, and fiscal burden on, the uninsured. Indeed, the uninsured pass on their cost of care to two main groups: (1) to consumers who absorb those costs by paying higher premiums for private insurance and (2) to taxpayers who pay the costs of the uninsured?s care through the funding of government programs.5 Because immigrants, relative to other sub-populations, are ?more likely to be uninsured over an entire year,?6 solutions that do not insure immigrants probably would diminish any progress toward reducing the negative fiscal impact of the uninsured.
Furthermore, from a public health perspective, ensuring that immigrants have access to preventive and emergency care is imperative. For instance, restricting immigrant children?s access to immunizations could make those children more susceptible to disease, thus jeopardizing the health of other people who are not immunized. Similarly, restricting immigrants? access to treatment during an emergency epidemic, such as the bird flu, would stymie efforts to curtail transmittal of the disease. Therefore, the WG should clarify that its recommendations apply to immigrants because addressing immigrants? health care needs is essential to achieving the larger goal of health care for all.

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