The accidental activists

Doctors in Massachusetts need to put health-care reform on the ballot before they can put it to the test

by Tinker Ready

It is Sunday morning, and Susan Bennett has put on her white lab coat and headed out the door. Instead of going to the hospital to check on her patients, however, the internal-medicine doctor walks to the corner of Harvard and Beacon Streets in Brookline, a clipboard in one hand and a pen in the other. Along with obstetrician Alice Rothchild, Bennett scopes out the citizens of Brookline as they pass by with their coffee and Sunday papers.

"May I approach you with a petition about health care?" Bennett asks, stepping into stride with a young woman in an anorak and running shoes. The woman wrinkles her nose, but she stops and listens to Bennett's spiel. Which goes something like this: We would like to put a question on the ballot that would set up a patients' bill of rights and expand coverage to the uninsured.

BENNETT AND Rothchild are working with other doctors, nurses, and medical students, under the auspices of a grassroots group called the Ad Hoc Committee To Defend Health Care, to get a question on next year's statewide election ballot that would ask voters whether Massachusetts should take another shot at health-care reform. This is not an American Medical Association production. They plan to push for change any way they can, even if it means taking it to the streets.

So brace yourself. The next signature your doctor asks for might not be needed for your medical records. The committee must collect 100,000 signatures by November 17 to get the question on the ballot. Most of these doctors have never walked a picket line or gone door-to-door in their lives. They're the people who draw your blood, deliver your babies, and write out your prescriptions. But over the past decade, their work lives have been turned upside down as employers have dumped traditional insurance plans in favor of less expensive health-maintenance organizations (HMOs).

HMOs specialize in cutting costs by limiting hospital stays and expensive treatments. Sometimes those limits are justified. But many doctors say they too often find themselves battling with HMO "reviewers" for permission to keep a patient in the hospital or to prescribe a certain drug. It was frustration with HMOs and insurance companies that led a group of Massachusetts doctors to form the Ad Hoc Committee To Defend Health Care in 1997. They issued a manifesto titled "For Our Patients, Not for Profits"; they held a "tea party," tossing HMO contracts into Boston Harbor. And they've enlisted Bernard Lown -- a Nobel Peace Prize winner for his role in International Physicians for the Prevention of Nuclear War -- as a spokesman. Noted economist John Kenneth Galbraith was one of the first to sign the current ballot petition.

But the question remains whether the public shares the doctors' angst enough to accept the changes needed to bring about meaningful health-care reform. In Massachusetts, about 10 percent of the population is uninsured, or about 600,000 people. The bottom line, however, is that most people are covered and worry that change would be for the worse, not the better. The state's last attempt at reform -- a 1988 plan to tax businesses to pay for expanded coverage -- was repealed before it became reality. Nationally, things have been quiet on the health-care-reform front since President Clinton proposed his unworkable plan in 1994. The insurance and pharmaceutical industries convinced the public that the health system wasn't in need of major repair, despite the fact that 45 million Americans and counting have no insurance. So when cost increases for coverage started to slow down, the momentum for change disappeared.

Still, it's hard these days to find someone who hasn't gotten into a tangle with one of the nation's increasingly stingy HMOs. In Massachusetts, insurers cut off drug coverage for seniors; the state had to step in and fill the gap to the tune of $42 million. Mount Auburn Cambridge Independent Practice Association, Inc. actually considered fining doctors for keeping patients in the hospital too long. And if such limits on coverage were responsible for the cost slowdown of the mid 1990s, they aren't working anymore. Both insurance premiums and the price of medical care are on the rise again.

As a result, change is in the air. Presidential candidate Bill Bradley has proposed a high-priced subsidy/tax-break plan to cover the uninsured, and now he and Vice President Al Gore are sparring over the issue. And Congress is poised to pass a bill that would give patients more leverage to challenge insurance-company coverage decisions. The Massachusetts petition would put a question on the ballot asking voters whether they want to establish a similar patients'-rights law and also set the state on a path toward "universal coverage" for all state residents. If it passes, a "health-care council" would devise a plan to set up such a program by the year 2000. The Boston Globe called the petition "as ambitious as it is vague," but that's intentional, say organizers. The fight over whether and how to provide coverage for everyone will come later. Organizers plan to argue for a Canadian-style system, where the government takes over insurance coverage and the doctors and hospitals remain private. But to begin the discussion, they first need to get the question on the ballot.

About 30 people attended the Ad Hoc Committee To Defend Health Care's mid-September organizing meeting in Harvard Medical School's palatial Warren Albert Building. A veteran of five signature-collection campaigns, activist (and, come January, Cambridge city councilor) Jim Braude stood before them and wrote "57,000" on the blackboard. That's the number of validated signatures they need to get on the ballot. He then added 50 percent -- a 28,000-signature cushion to make up for double signers and other errors. He then rounded it up to 100,000 to cover a new rule that allows the election commission to reject messy petitions. "Anybody good in math?" he asked, and he divided 100,000 by 60 -- at the time, the number of days left before the petition was due. "If you can't get enough people to collect 1600 signatures a day, you don't deserve to get the question on the ballot," Braude said.

Doctors seem supportive of the petition and sign gladly, Rothchild says. She gets nothing but pats on the back when she asks for signatures at Beth Israel Hospital, where she admits patients. But the rank-and-file doctors seem to have left it to activists such as Rothchild and Bennett to do the actual footwork. Not that the two don't have anything else to do. Both have demanding jobs -- and children. When she collects signatures, Rothchild wears a button that reads, BE KIND. I HAVE A TEENAGER.

DAVID BLUMENTHAL has been watching the momentum for health-care reform go up and down for many years. At Harvard's Institute for Health Policy, where he serves as director, his office has a straight-on view of the Bunker Hill Monument. In 1775, a group of patriots fought hard there but lost the first battle of the Revolutionary War. Blumenthal says he feels the same thing will happen to anyone fighting for health-care reform these days. It's a point he made in an article published last June in the New England Journal of Medicine. "The political will required to enact universal health care coverage or to abandon the market model is unlikely to materialize for a decade or more, if then," he wrote. A lot of people took this to mean that Blumenthal is opposed to reform. He's not. He wishes the petitioners well. Blumenthal even thinks that the single-payer system is probably the only way to cover the uninsured. He just doesn't think we're ready for it.

"I don't think we're going to get universal access until we are willing to trust government enough to be responsible for a highly personal service that is available to the great majority of people," he says. "What that means is that you need a really genuine, deep, broadly felt crisis to precipitate really significant change." And the public doesn't seem to be feeling that yet. But many doctors are: for example, David Himmelstein, a Harvard Medical School doctor practicing at Cambridge Hospital who founded Physicians for a National Health Program 15 years ago. Himmelstein also co-authored a study published this past summer in the Journal of the American Medical Association. In it, he compared care offered by for-profit HMOs with care offered by not-for-profit HMOs. He found that, in the for-profit plans, children were 12 percent less likely to get immunizations. Women in the for-profit plans were eight percent less likely to receive mammograms and six percent less likely to get early prenatal care. The list goes on.

Himmelstein hasn't limited his activist efforts to publishing. He's hit the streets with Rothchild, Bennett, and hundreds of others. At a recent fundraising road race for breast cancer, the bearded doctor collected 300 signatures in two hours. "Not only does virtually everyone I ask sign it, the passion with which they sign it is quite striking," he says. He doesn't disagree with Blumenthal that the public may not be ready right now for sweeping health-care reform. But he believes people can be persuaded.

By late October, the group was still short 20,000 signatures, and Lown sent an
e-mailed plea for help to the committee's list serv. "We are now down to the wire," he wrote. "The next two weeks will determine whether our small Gideon's Army will succeed." Now, with less than a week left before the November 17 deadline, petition organizers say it's still too early to call.

Braude, meanwhile, acknowledges that many doctors, although supportive, are a bit uncomfortable with the petition process. So the committee has been relying on its core group of activists and medical students. "It's a pretty inspiring group, but the flip side is that they haven't done this before," Braude says. "This is not just some political issue they've decided to embrace. This is their lives."

Tinker Ready, a Cambridge-based health and science writer, can be reached at tinkerr@mediaone.net..