WASHINGTON ? It was far from the usual exchange between a member of Congress and a constituent.
During a mega-sized conference call with more than 6,000 of his constituents last month, Fourth Congressional District Rep. Mike Ross had to assure one nervous woman, “I'll never vote for any bill to kill old people.”
Ross's constituent, like many other senior Americans, had been scared by reports that the main House bill for achieving universal health care coverage called for “death panels” or “death squads” that would guide the elderly toward filling out a living will and do-not-resuscitate orders before deciding if their lives justified the expenditure of more health care resources.
Although the bill calls for nothing of the sort ? it called only for Medicare to provide counseling to the elderly about “end of life” matters such as living wills ? the exchange highlighted how fear and suspicion have, for the second time in 20 years, stymied the debate over changing the nation's health care system and threaten to derail it.
Ross and other Democrats in the Arkansas delegation say they want health care reform as badly as President Obama, but when they came home this month for their August recess they found themselves caught in the crosshairs of a backlash. It was a backlash from constituents who voiced fears that the president and Democratic congressional leaders were pushing a health plan that would greatly expand the federal government's powers over some of their most personal matters. The uproar had been stirred by conservative interest groups, statements from some prominent Republicans and conservative talk radio.
Ross and six other Blue Dog Democrats kept the health bill blocked in the House Energy and Commerce Committee until the end of July, when Chairman Henry Waxman gave in to their demands.
“I'm the guy who put the brakes on this,” Ross has bragged to his constituents, while also telling them he would not vote for any bill that allows federal funding of abortions or provides health care to illegal aliens.
He also told a woman in McGehee, “The last thing I'm going to do is let the government get between you and your doctor.” An insurance company? That's apparently OK.
It is a situation laced with irony. For if health care reform ? especially making health insurance coverage more available to the working poor ? should be an easy sell to anybody, it ought to be to Arkansans. After all, Arkansas measures far worse than most states when it comes to availability of health insurance.
According to figures released in July by the staff of Energy and Commerce, Arkansas's Fourth Congressional District, which covers southern and parts of eastern Arkansas, would get the following benefits under the main House bill: 124,000 previously uninsured individuals would gain access to “high-quality, affordable” coverage; up to 12,500 small businesses would receive tax credits to help them provide coverage for workers; an estimated 1,500 families could escape bankruptcy each year; providers would get covered for $155 million of previously uncompensated care, and up to 6,700 seniors that fall in Medicare's “doughnut hole” for prescriptions would be covered.
The staff based its figures on information from Gallup health surveys, the Census Bureau, the Centers for Medicaid and Medicare Services and the House Committee on Ways and Means.
The first strike against Arkansas is that 40 percent of its 2.8 million population lives in the countryside. Rural areas traditionally get the short end of the stick when it comes to health care availability and reimbursement, various federal government and university studies have showed.
One of the most recent was published in July by the Edmund Muskie School of Public Service at the University of Southern Maine in conjunction with the federal Office of Rural Health Policy.
“More than 20 years of research has demonstrated that rural residents are at a greater risk of being uninsured compared to urban residents,” it said. It then went on to explain why: Rural Americans are often employed by businesses too small to afford coverage for their employees or they are self-employed in jobs such as farming, and can't get reasonable rates.
For those who do get some coverage from their employers, they are likely to be plans with higher cost-sharing requirements.
“As a combined result of these benefit limits and their generally lower incomes, rural residents are more likely to be underinsured (defined as having high out-of-pocket costs for health care compared to income). Individuals that are underinsured often experience the same financial barriers to getting needed health care as the uninsured,” the study said.
What region of the country you are in also makes a difference.
“It's definitely worse in the South,” Andrew Coburn, a USM professor who contributed to the study, said about the uninsured in a telephone interview. “It has to do with the economies of the rural South and the incomes of the rural South.”
Southern states also tend to make it harder for people to qualify for Medicaid, the federal-state health insurance program for the poor, he explained.
Thanks to the program Arkids First and similar expansions of Medicaid in other states, health coverage for children of rural residents has expanded over the last decade, the Maine study points out. In 1997, Congress approved Medicaid's State Children's Health Insurance Program.
Overall, however, people who can't afford insurance pay the ultimate price.
“If you look at the national data what you essentially find is that rural people have poorer health,” Coburn said.
About half of Arkansas families have incomes of less than $36,000 and 14.8 percent are on food stamps, just a step below Mississippi's 15.8 percent.
The Kaiser Family Foundation offers specifics on Arkansas, including:
• Only 46.6 percent of Arkansans get health insurance through their employers compared with a nationwide average of 53.4 percent.
• The number of uninsured Arkansans is 485,849, or 17.5 percent of the population, compared to 15.3 percent nationwide.
• Of Arkansas's uninsured, the vast majority, 420,810, are between 19 and 64.
• Only 45.2 percent of private businesses in Arkansas offer their employees health insurance, compared with 55.8 percent nationwide.
Other Kaiser statistics add to the depressing picture. Health spending in Arkansas is $13.35 billion a year ? or 15.4 percent of gross state product ? and going up at a rate of 6.7 percent, compared to 6.5 percent nationwide. Health spending per capita is $4,863 compared to $5,283 nationwide. The annual increase per capita is 5.7 percent, compared to 5.5 percent nationally.
Families USA, a health care advocacy and research group, says health care premiums have gone up 5.8 times faster than wages for Arkansans during this decade.
And according to the New America Foundation, family health insurance premiums are expected to increase 83 percent by 2016, which will cost the typical Arkansas family $21,715, or 48.4 percent of household income.
In 2007 and 2008, some 836,000 Arkansans, or 34 percent of all people under 65, were without health insurance at one time.
The connection between lack of health insurance and mortality, according to a 2005 New Yorkermagazine article that Arkansas legislative aides quoted in an interim report to the Public Health, Welfare and Labor Committee, is:
“The death rate in any given year for someone without health insurance is 25 percent higher than for someone with medical insurance. Because the uninsured are sicker, they can't get better jobs, and because they can't get better jobs they can't afford health insurance and because they can't afford health insurance, they get even sicker.”
The vicious cycle continues in another way as well. The hundreds of thousands of uninsured in the state add to the “uncompensated care” problems for doctors, nurses and hospitals. For Arkansas hospitals alone, the cost for uncompensated care in 2007 was $950 million, according to the Arkansas Hospital Association.
Health care advocacy groups contend that uncompensated care forces providers to charge more to patients who can pay, which ultimately results in higher insurance costs for everyone. They call it the “hidden tax.”
Summed up researcher Coburn: “It's not acceptable morally. It really undermines our insurance system.”
Darlene Byrd, an advanced practice nurse from Cabot, said she knows the uncompensated care problem all too well. Byrd serves on the federal government's National Advisory Committee on Rural Health and Human Services.
She practices at clinics across the state. She said she's seen a steady up-tick in patients who walk in without any coverage because they have been recently laid off from work.
One was a truck driver who had an abscess on his neck, she said. “He didn't have money to pay for his diabetic medications. He was at risk for more complications from his diabetes,” Byrd added.
She's seen other varieties of insurance difficulties as well, including a pregnant teacher who misunderstood her policy and “got stuck with a $4,000 delivery charge. Plus, the baby is not covered with insurance because it is too late to put him on her insurance.”
Complicating the picture, Byrd said, is a shortage of health care providers in rural areas.
“Making sure everyone has coverage doesn't make sure everyone has access,” she said. “We don't have enough providers in Arkansas right now to take care of all the children who are eligible for Medicaid benefits.”
She warned, “If you pass sweeping health care reform and [do] not address those issues, I don't know if we are going to be better off.”
As a provider, Byrd said she is undecided about a so-called “public option” to cover those who can't find insurance elsewhere. “If you have a public option, are you going to make sure the private sector can compete?” she asked. She does believe insurance companies should have to cover pre-existing conditions.
She also has seen first-hand how difficult it can be to sell health care reform politically.
“There is a lot of misinformation that is raising a lot of fear in people,” she said. Often, she said, those fears are based on things “taken totally out of context.”
Ross and fellow Democratic Rep. Vic Snyder found themselves in a raucous town hall meeting with constituents as soon as they came back from Washington.
Meanwhile, calls went out for Sen. Blanche Lincoln and fellow Democratic Sen. Mark Pryor to make themselves available for town hall meetings. Lincoln finally scheduled some. Pryor has held several mass telephone call “town halls.” And a group of First Congressional District citizens organized a “Boot Berry” rally Aug. 22 in Cabot to chastise Rep. Marion Berry, also a Democrat, for not doing more to separate himself from Obama and House Speaker Nancy Pelosi on various issues, including health care. About 100 people turned out.
“It's very unpleasant for them, I'm sure,” Art English, political scientist at the University of Arkansas at Little Rock, said of the Democrats in the Arkansas delegation.
Many political analysts see the furor over health care reform fueled ? at least in part ? by the continued refusal of many white “red state” voters, especially in the South, to accept Obama, the nation's first black president. The opposition, they say, has a racist tinge.
Ernie Oakleaf, head of Opinion Research Associates, a Little Rock polling firm, agrees.
Watching news reports on some of the congressional town hall meetings, in Arkansas and elsewhere, he said, reminded him of the racial unrest during the era of former Gov. Orval Faubus.
David Wasserman, analyst for the Cook Political Report in Washington, D.C., said, “The debate is coming down to perceptions about Obama.” In Arkansas and other parts of the South, he added, “last year's election speaks for itself.” Obama lost to Republican John McCain by 20 percentage points in Arkansas.
English, the UALR professor, and Calvin Jillson, political analyst at Southern Methodist University in Dallas, said they feared race was playing a role as well.
Despite their need for more health coverage, Southern whites continue to cling to notions of “states' rights, deregulation and individual responsibility,” Jillson said.
But Harvey Edwards, 52, one of those behind the “Boot Berry” rally, denied that racism was a factor in disliking the Democrats' health insurance proposals.
“I don't care what color anybody is. We are opposed to socialism,” he said. “The race issue is a smokescreen.”
Why aren't Arkansans more concerned about the shortage of health coverage in the state?
“As Bill Clinton once said, ‘Change is hard,' ” said University of Virginia political analyst Larry Sabato. “Even some of the people who would be better off are concerned that the devil they know is better than the one they don't know.”
Ross, who heads the Blue Dog ' health care task force, has been a frequent guest of Sunday morning news programs and other network coverage. His rise to a near-household name over the past month has been “a matter of being at the right place at the right time,” said congressional expert Norm Ornstein of the American Enterprise Institute, a conservative Washington think tank.
The Center for Public Integrity, which does investigative journalism, notes that the Blue Dog PAC has done far better than most in gathering contributions this year. The PAC then turns around and distributes them to various caucus members, including Ross.
The health care and climate change debates have also turned Ross and the Blue Dogs into fund-raising machines. Their PAC has been particularly successful in raising funds this year, and in addition to PAC contributions to Ross, the congressman received $86,000 from health-related sources during the first half of the year, according to the Center for Responsive Politics, a nonpartisan research organization on campaign funding. (He's raised close to $1 million from the health industry during his career.) The total includes contributions to his official campaign committee and his personal political action committee.
But the figure doesn't include money coming from health care lobbyists. The names of several are sprinkled throughout his Federal Election Commission filings.
Political observers say the higher his profile is, the more the money pours in. “For Ross it's Christmas in August,” SMU's Jillson said.
As of June 30, Ross had $950,194 in cash on hand for his 2010 race.
Lincoln, a long-time member of the Senate Finance Committee, which is expected to finalize its work on the health bill when Congress convenes shortly after Labor Day, has come under fire from the right and the left.
Left-leaning bloggers and groups have wanted Lincoln to become more aggressive on behalf of Obama's goals. Her tendency to vacillate on her support for a public option has garnered their wrath.
Conservative bloggers in Arkansas want her to do more to separate herself from the party's central figures in Washington. Lincoln's office denies their allegations that she was scared off from holding town halls. Aides said she planned to honor during the August break the many other meeting and speaking requests she receives. Her aides also note that in anticipation of summer action on health care, she held public meetings on the subject this spring and during the July 4th congressional break.
Like Ross, Lincoln has received hefty campaign contributions from health-related sources, the Center on Responsive Politics reports. At $957,000, they are by far her largest source of industry contributions so far for her 2010 race. As with Ross, the total includes contributions to her official campaign committee and her personal political action committee. During her career, she has received $2 million from the health industry.
Intermittent polls show some potential weakness in her 2010 re-election effort. Lincoln is a two-term incumbent.
“I've noticed that Blanche Lincoln has been keeping her head low,” said Jillson, the SMU political scientist.