Affordable, accessible quality care is a right for all 
Any serious proposal must focus on rising costs, which almost every worker with health insurance has experienced in recent years through rising premiums, deductibles, co-payments and prescription costs.

If you're looking to identify the top domestic issue on the minds of Americans right now, healthcare would be the obvious choice. And it's easy to see why—for everyone from low-paid workers who simply cannot afford health insurance to union members who enjoy some of the best coverage available but worry whether that will change.

For the second group and their union negotiators, healthcare coverage has become the most important nonsalary bargaining issue. In many union locals, battles over healthcare are more likely than salaries to cause difficult contract negotiations and discontent among members.

In the states, Medicaid and other healthcare-related programs are consuming such a large and growing portion of their budgets that less funding is available for other public services.

For those without coverage—47 million at last count, according to 2006 U.S. Census Bureau figures—routine doctor and dentist checkups are an unaffordable luxury. The alternative of last resort is often the emergency room when health problems become impossible to ignore. A serious illness can be devastating to a family, with fully half of all bankruptcies in the United States due at least in part to medical expenses.

For the overall U.S. economy, total spending on healthcare in 2005 reached $2 trillion. This works out to $6,700 per person, or 16 percent of the country's gross domestic product. If current trends continue, the number will reach $4 trillion within 10 years.

Despite that astounding figure—far and away the largest of any country in the world—universal coverage is merely a fantasy when we still have so many Americans without coverage, including nearly 9 million children.

AFT president Edward J. McElroy calls it "unconscionable" that so many citizens lack health insurance in a country as rich as ours.

Key elements of reform
It should come as no surprise that healthcare has emerged as one of the top issues in the 2008 election campaigns.

The AFT, working in partnership with the AFL-CIO, plans to make the issue a central element of union efforts to elect worker-friendly candidates at all levels. An AFT resolution passed at the union's 2006 national convention promises that "the willingness of political candidates to address the national healthcare crisis will be an important criterion for the AFT in making political endorsements."

Hillary Clinton, who has made healthcare reform a central issue in her campaign, received the AFT's endorsement for the Democratic presidential nomination at the union's October executive council meeting.

As Clinton told the council earlier this year: "Once and for all, we need to get quality, affordable healthcare coverage for every man, woman and child. We can look and see that we spend more money than anybody in the world by a huge amount. ...And yet, we're not getting our money's worth."

The AFL-CIO has not endorsed a specific plan, but it has put together what it considers the key elements of healthcare reform. An effective plan, it says:

• controls rising and irrational costs;
• provides comprehensive, high-quality healthcare to all;
• gives every family the opportunity and the responsibility for preventive care;
• preserves the right to choose and use your own doctor;
• asks our government to play a strong role to curb corporate greed and incompetence and ensure more fairness and efficiency;
• lowers employers' costs and, in return, asks them to pay their fair share; and
• builds on what's best about American healthcare while drawing from what works in other countries.

A couple of these elements are worth noting. First, the plan has to preserve your right to choose or continue to use your own doctor and plan. No reform proposal will earn labor support if it imposes a new level of uncertainty on people who are comfortable with their current healthcare arrangements.

Second, any serious proposal must focus on rising costs, which almost every worker with health insurance has experienced in recent years through rising premiums, deductibles, co-payments and prescription costs.

As part of "In America, No One Should Go without Healthcare," an AFL-CIO campaign to draw attention to this issue, the federation commissioned a poll that reinforces just how important healthcare is to union members. The poll found that 71 percent of union members believe it is "critical" for elected officials to address healthcare. (By comparison, the figure was 75 percent for Iraq, 67 percent for terrorism and 43 percent for economic conditions.)

A central challenge for policymakers is to move the country closer to universal healthcare coverage. "Accessible, affordable healthcare should no longer be considered a privilege for some; it should be a right for all," McElroy wrote in a recent column.

Universal healthcare would be welcomed by AFT members in Guam. "We have one unified insurance plan for all public employees, and it's a disaster," says Matt Rector, president of the Guam Federation of Teachers, which represents 12,000 local government employees and retirees. "All of them have a $1,500 deductible per person"—per family member. Adding to the deductible cost is the health plan's requirement that all non-emergency care has to take place in the Philippines—the price of airfare alone is $400 to $600, Rector says. "Healthcare is designed so people can't afford to use it. All the cost is transferred to the employees."

Unlike many AFT locals who have a seat at the table to negotiate health benefits, Guam's public employee bargaining law prohibits negotiations over healthcare. But Rector is confident that by organizing more of the island's public and private workers—his local now represents 25 percent of the Guam government workforce—and through political action, the union can bring about change.

States take the lead
Other than the debate in Washington, D.C., between President Bush and members of Congress from both parties over the State Children's Health Insurance Program (SCHIP), the action on healthcare reform increasingly is being advanced by the states.

As the SCHIP debate showed, even a relatively small federal program—one that shouldn't be very controversial because it expands coverage to some of the most vulnerable segments of society—can generate plenty of conflict.

Because most state reform plans focus on expanding coverage to more of the uninsured (through methods such as requiring employers to cover their workers or pay into a state fund for the uninsured), they haven't had much effect on AFT members, who for the most part already receive coverage through their employers.

Maine, Massachusetts and Vermont are among the states where healthcare reform legislation has been enacted in the past couple of years. Many more state legislatures are debating statewide healthcare proposals, with California being the most prominent.
One big sticking point for unions in California, including the AFT's state federation, has been Gov. Arnold Schwarzenegger's proposal to require individuals to buy health insurance as a way to cover more citizens.

"We're opposed to that unless people can afford it," says California Federation of Teachers (CFT) president Marty Hittelman. The various competing reform plans in California wouldn't affect many of his members, Hittelman says, although any requirement that part-time employees be covered would be helpful to some adjunct faculty members in the state—people like AFT member Neal Kelsey.

Kelsey, a part-time religious studies instructor at Victor Valley College, calls himself "underinsured." He and his wife pay $850 per month for a catastrophic policy with a $5,000 deductible that doesn't cover prescriptions, office visits, dental or vision care. "I fear that if we actually had to use the insurance," he says, "we would be stuck with huge out-of-pocket expenses that would seriously challenge our financial situation."

Hittelman says it is likely that a ballot initiative—possibly more than one—will end up on the state ballot in 2008. Ultimately, what the California federation has endorsed is a so-called single-payer plan for the state.

A single-payer plan is one in which healthcare is financed through one source, usually the government at some level (state or federal), rather than insurance companies. It's a concept—similar to national plans in Canada and much of Western Europe—that goes beyond what most policymakers in Washington, D.C., and the states are proposing today, but it has attracted growing support.

The 2006 AFT convention resolution says that a single-payer system could "prevent cost shifting and reduce administrative expenses."

The state of Oregon illustrates a more narrowly focused legislative approach to controlling healthcare costs. This year, AFT Oregon persuaded the Legislature to let every school district join a statewide insurance program. The new law will be especially helpful to part-time school employees who often spend a huge chunk of their salary just to cover health insurance costs. With a larger pool of employees, costs should go down for all workers.

A challenge for locals
The push for healthcare reform, whether single-payer or something more incremental, is driven in large part by steadily rising costs. The most recent Kaiser Family Foundation annual survey showed that healthcare costs rose at the smallest level since 1999, but the 6.1 percent increase was still well above the rate of inflation and wage increases.

Since 2001, healthcare costs have soared 78 percent, compared with 17 percent for inflation and 19 percent for wage growth. The bottom line in 2007: The average annual premium for family coverage was $12,106, which is almost exactly what a full-time minimum wage worker earned in 2007.

For local affiliates, these cost trends have led to growing pressure from management to raise employee contributions or to cut benefits.

The Professional Staff Association at Rhode Island College is a fairly typical example, where local president Rob Bower says, "Members are not happy, but they know increased healthcare costs are a reality." Under the local's last contract settlement (2004-07), members began paying a share of the healthcare premium for the first time in the history of the union. "We are in negotiations now and there is pressure to increase the premium share," says Bower, a member of the AFT Public Employees program and policy council, noting that there's also pressure to raise co-pays and increase fees for things like emergency room visits. "If a package can be negotiated that will give a net increase to keep up with the cost of living, they can live with a greater share of the healthcare premium costs."

The problem, however, is that salary increases often don't cover members' new out-of-pocket healthcare costs. The increase in premium share in 2005 from 15 percent to 20 percent for Baltimore city employees, combined with the institution of co-pays for doctor visits and increase in prescription drug co-pays has created a crisis situation, says City Union of Baltimore president Brenda Clayburn, noting that many of her members make $30,000 or less annually.

Clamor over the changes resulted in a citywide labor-management task force on healthcare. But Clayburn says the recommendations reported out of that task force—including one that would increase retired city workers' premium share to as much as 80 percent—weren't labor's.

Dissatisfied with the direction the task force took—Clayburn says management representatives "talked about the price tag" rather than engaged in thoughtful dialogue over cost-containment options—CUB has taken the issue to the mayor.

Even when a local union reaches what it considers to be a good settlement that holds the line on healthcare costs, challenges remain. "Our members are irate that certain healthcare providers are pulling out of United Health Care, the plan negotiated by the state and in place until 2010," says Rhode Island's Bower. "This is causing the unions around the state to work more closely together in bringing pressure on the governor and the Legislature to improve the situation."

Now is the time
One concern that union members express, when conversations about healthcare reform move beyond general issues to more specific proposals, is that they might lose out as the focus turns toward achieving universal coverage. But that doesn't have to be the case, explains AFT research and information services department staffer and healthcare expert John Abraham. In addition to being the right thing to do, covering the uninsured can benefit those who already have insurance. When the uninsured get expensive urgent and emergency care, he explains, those costs are shifted to people with good coverage.

"The best thing to do is to get more people covered in the healthcare system so their routine and preventive medical needs are met," he says. This will bring costs down overall and reduce pressure on those with good insurance plans.

With that goal in mind, it's more important than ever to elect the right people to office in 2008—people with the political will to deal with it.

How does your health insurance premium rate:

Health insurance premiums for state and local government employees
rose 6.6 percent, compared to a 6.1 percent average increase
for employer-provided health insurance nationwide.