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There is not much that unites commercial fishermen. Or, so it seems. A slight change in words, and our industry sounds like the old Kingston Trio song, the Merry Minuet -- trollers hate trawlers, trawlers dislike longliners who hate trappers, and no one seems to like anyone very much. But over the course of the past few years it seems there has been one thing fishermen, large boat and small boat -- from whatever gear type -- throughout the nation could agree on, and that is the need for health care for the fleet.
This is certainly what the Commercial Fishermen of America's Board quickly found when it began putting together its list of priorities to work for on behalf of the nation's fishermen. Since 1981, commercial fishermen were left at the mercy of private insurers to get medical coverage, after access to the U.S. Public Health Hospitals -- the old "marine" hospitals -- and their contract physicians in ports around the nation was cut-off to commercial mariners, including fishermen.
To refresh everyone's memory and a lot of folks in the current Congress, Congress passed and President John Adams, in 1799, signed into law legislation to provide for "maintenance and cure" for those working aboard U.S. registered, or "documented," vessels, including fishing boats, through a system of marine hospitals. This was later expanded to include a network of contracts with private physicians to provide care in smaller ports where no marine hospital existed. The system grew into what became known as the U.S. Public Health Service and coverage was expanded to include certain other populations, including native Americans.
No one labeled this as "socialist" -- the term did not even exist then. Nor did they call it "Prussian," the term used by health care opponents in the early part of the last century when President Theodore Roosevelt first proposed a comprehensive public health care system for the nation.
The act of Congress and its signing by the first President Adams was simply a pragmatic step by a young nation to build a strong merchant and fishing fleet -- helping entice young men (mostly) to work in jobs aboard vessels that were hard, dangerous and often low-paying. There were other reasons, too. Mariners visiting foreign ports could contract highly communicable diseases and these hospitals provided the first line of defense against foreign-borne epidemics from spreading across the country.
The system was not perfect. The quality of care often varied between hospitals, much as veterans have experienced between different VA hospitals, which are also government run. This, however, is not much different than variations in the quality of care between not-for-profit, for-profit and community institutions that exist today.
Between Congressional oversight and hospital advisory boards made up of constituents, most of the hospitals were responsive to patient needs. The contract physicians were often those recommended by fishermen to the USPHS, which often meant the best doctors in a community were selected. No one complained of "government getting between the doctor and the patient."
Let's also be clear on the limitations in the old system. It only covered the individual working on board the vessel. It did not cover his/her family. This was often a reason fishermen, particularly on some of the smaller fishing vessels, such as trollers, would bring their families on board during the season. Otherwise, they may have relied on a spouse's other job to cover family members.
For a period between the 1930's and the 1960's there was also affordable health insurance through non-profits such as the "Blues" -- Blue Cross and Blue Shield -- before they began having to compete with for-profits that were then "cherry-picking" their customers by insuring only the young and healthy, leaving the Blues with everyone else. Since that time the Blues became for-profits as well, and have engaged in the same sort of selective coverage for most of the past two decades.
For a period, then, there was private health care available for a fishermen's family. But even before the Blues or without them, the marine hospitals did provide the critical health care for the bread-winners of then mostly one-income households. Thus a fisherman's serious injury or illness could be treated without it drawing on the last financial resources of the individual or family, threatening the loss of their vessel or home.
Moreover, marine hospital coverage was restricted to those aboard documented vessels. Fishermen working on smaller, non-documented vessels were not eligible for coverage through the marine hospital system. That meant those owning state-registered boats were not included.
In November 1980, one of the U.S. Pubic Health Service's -- and fishermen's -- greatest champions in the Congress, Senator Warren Magnuson, was defeated. In 1981, with no champion for the system, with Congress in a cost-cutting mode and with a new federal Reagan Administration in place that had campaigned against "big government," nearly two centuries of public health care for the nation's merchant and fishing fleet was ended. The political defense of the system was weak. Ship owners sought to cut the nominal amount they contributed to the system, and some unions and other associations saw the prospect of offering up group health insurance as a benefit to their members and thereby bolstering their numbers, so both groups were loathe to defend the marine hospital system.
At first there were a number of private insurers clamoring for this new business from the fishing fleet, offering up group health insurance programs for fishermen and their families at extremely attractive rates. But many of these programs turned out to be "too good to be true" and these companies began to fail, or failed to honor their coverage, or cancelled as quickly as possible.
It became fairly obvious why the fishing fleet had needed its "public option" over all those years. Most of the fleet was not covered by state worker's compensation programs (there had never been a need before with the marine hospital system) and thus injuries or illness related to work were not covered. The fleet was also aging, and many younger fishermen chose to go without coverage, meaning the groups turned out to be mostly those older fishermen the insurers had sought to avoid.
By 1995, most group programs offered for fishermen's associations were gone and fishermen and their families were left to seek out individual coverage -- if it was even available, much less affordable. Group plans were a way to protect those with pre-existing medical conditions, but now that was all gone. Health care for fishermen for a least the past 15 years has mostly consisted of being covered under a spouse's package, paying dearly if one could find an insurer or HMO -- or just going without like some 35 million other Americans.
We have no illusions that the new health care program passed by Congress and signed by President Obama a few months ago is going to be perfect, or that there will not be start-up problems. Among other things, it does not get at the cost-containment issue. And keep in mind that many of the bill's provisions do not begin immediately.
But what it means is that every commercial fisherman in the nation and his or her family should now be able to get health care coverage, which is so critical when losing a fishing vessel or one's home can be only an illness away.
Here's what J.J. Bartlett, with the Massachusetts Fishing Partnership Health Plan, which has been providing care to Massachusetts fishermen since 1997, had to say about the new federal health care legislation:
"It took more than a year for the U.S. Congress to enact a bill reforming the nation's health care system. And what an excruciating process it turned out to be! Be that as it may, the new law represents a giant leap forward for fishing families everywhere in the U.S.
"On several occasions over the past year, Fishing Partnership Health Plan (FPHP) administrators and board members briefed White House and Congressional staffers on the plan's success in bringing high-quality, affordable health coverage to Massachusetts fishermen. Those discussions often centered on how the plan worked with fishing industry outreach workers living in the state's fishing ports to seek out uncovered fishermen and help them obtain health care coverage. Without that kind of outreach, the FPHP would not have been able to successfully reduce the number of uninsured Massachusetts fishing families.
"Fishermen have always faced unusual obstacles when trying to obtain quality health coverage. Health insurance in this country is designed to work through employers. The larger the employer group, the better. As we know, fishermen do not work in big offices with human resource departments. Even if they did, who would want to offer coverage to the most dangerous industry in America? As it turns out, few companies do. Fishing families are 3 to 4 times more likely to be uninsured.
"Sadly, people without health care coverage are sicker and die younger than people who have insurance. A Harvard study published in the American Journal of Public Health found that 45,000 people die each year because they do not have health care coverage. Furthermore, hundreds of billions of dollars are lost because uninsured, sick workers are less productive or out of work.
"The health reform law will change this by ensuring that fishing families will have access to health care coverage by 2014. The law calls for the formation of insurance pools that group together individuals and small businesses. This will provide fishermen with the opportunity to purchase private insurance at a market competitive rate. The monthly insurance bill will be further reduced for those who cannot afford the full rate. This is what we set up for fishermen in Massachusetts in 1997 and it is the model Massachusetts established for all residents in 2006. Now, 97% of the people in Massachusetts have health care coverage.
"2014 is a long way away, but there is a lot of work to be done between now and then. Billions of dollars will be spent to train doctors who will work in rural areas, and to build community health centers in places that do not currently have access to health care. This will be very important to fishing communities in places like Alaska. The law changes insurance rules so that insurance companies will no longer be able to deny people coverage because they have a preexisting condition, or kick people off their plan when they get sick. There will be minimum standards so that insurance companies will not be able to take your money and offer you a "junk" policy in return. Moreover, there will be no lifetime limits on the amount of health care you can receive.
"None of this will be easy -- nothing in health care, or fishing, ever is. The system may remain complicated, but soon grant funding will be available for fishing organizations to educate their members on the health care options that are available to them, and to assist their members in signing up for the appropriate programs. I am proud that the Fishing Partnership Health Plan was able to work with organizations like the Commercial Fishermen of America and the National Family Farm Coalition, to make sure that this outreach funding will be available to fishing, farming, and ranching organizations.
"Massachusetts' Senators John Kerry and the late Edward Kennedy, as well as Congressman Barney Frank deserve credit and thanks. When Senator Kennedy was Chairman of the Health, Education, Labor & Pension Committee, he guaranteed that this key outreach language was in the original bill. Senator Kerry was responsible for amending the final reform bill to include this legislation, and Congressman Frank used every minute of the time allotted for him to speak on the House floor to promote health outreach funding for fishing, farming and ranching organizations. Thanks to their efforts, fishermen and fishermen's wives will be trained to provide health care outreach to fishing families.
"I work closely with fishing families, but I am not a fisherman. So, I will end with the words of a fisherman's wife, who wrote to me about what it meant for her to get health care coverage for the first time:
"As a fisherman?s wife, I worry. I worry about my husband's safety. I worry about the weather and the catch. I worry about the boat and the gear. I worry about the many unforeseen expenses that come with this life. I worry about the price of the catch. I worry about rivalry at sea. I worry about the kids, the car, the bills and the cat. But one thing we never have to worry about is health coverage and access to high-quality health care. We know that, if we ever need immediate medical attention, we can get it, no questions asked. That's a wonderful feeling."
"All fishing families and all Americans deserve this security. And now, it's the law of the land."
In a March 28th New York Times article, health columnist Tara Parker-Pope wrote that the new bill "will require most Americans to obtain health insurance. It will also offer federal subsidies to lower premiums and significantly expand eligibility for Medicaid.
"The changes will mean that 94 percent of legal residents not covered by Medicare will have health insurance, up from 83 percent now, according to the Congressional Budget Office.
"While the biggest changes will not take effect until 2014, some important provisions will begin as early as June, while others will kick in by the end of the year. These include significant new restrictions on the insurance industry and new protections for consumers who already have health insurance. There are also perks for Medicare recipients and help for young adults. And in just 90 days there will be new coverage for people who have lost health insurance and can't qualify for an individual policy."
"The basic thrust of this law is that all of these nooks and crannies, all these gaps where private insurance has left you without any option, those are going to be taken away," said DeAnn Friedholm, the Campaign Director of health reform for Consumers Union, the nonprofit publisher of Consumer Reports. "It's complicated, but it does establish a very key, important policy that you're going to have options, regardless of your health situation or your employment situation."
Parker-Pope, in her column, also answered a number of questions that people have been asking; this, after all, was a 2000-page plus bill. Many of the new rules are expected to be released by the Department of Health & Human Services at the end of this month.
Presently Uninsured. "If you haven't had insurance for six months, and you can't afford or don't qualify for insurance because of a pre-existing medical problem, you may be eligible for a new federal 'high risk' pool to be offered by the end of June," wrote Parker-Pope. "The cost of the monthly premiums hasn't been announced, but the rates are to be based on a 'standard population,' suggesting they will be based on a healthier group than typically used to calculate premiums for high-risk plans. On average, an enrollee won't pay more than 35 percent of covered benefits, and annual out-of-pocket costs won't be more than $5,950 for individuals and $11,900 for families. In addition, there are no lifetime limits -- meaning the policy won't be canceled if someone requires expensive medical treatment."
Difference between the new federal pool state high-risk pools or Medicaid. "The federal plan is expected to offer more-affordable coverage than the existing state plans and will not impose the same income restrictions as Medicaid. State plans also typically impose high deductibles and premiums (some charge as much as $1,200 a month), and up to 12-month waiting periods before covering pre-existing health problems," explained Parker-Pope.
Immee benefits for Medicare recipients. "This year Medicare recipients with high drug costs will get a rebate of up to $250. And in 2011, the plan will pick up a larger share of brand-name drug costs. In addition, Medicare recipients won't be charged co-pays or deductibles for preventive care like immunizations and cholesterol screening," Parker-Pope explained. "The drug rebate is the first step in a 10-year plan to close the 'doughnut hole,' the gap that occurs because Medicare Part D stops reimbursing for prescriptions after the first $2,830 in costs a year. The retiree must then pay all drug costs until they reach $6,440, at which point Part D pays again."
Benefits for those with insurance. "Beginning in September, insurance companies will no longer be able to rescind a policy once someone gets sick, nor can they impose lifetime limits on coverage.... Today, honest mistakes on a lengthy insurance application -- like forgetting to disclose a parent's high blood pressure -- could be grounds for losing your insurance.... Under the new rules, companies generally can't rescind a policy for a minor application error," said Parker-Pope.
Phil Galewitz of Kaiser Health News explained some of the other provisions in a March 29 Los Angeles Times article, including the anticipated affect of the new plan on young adults (for the few young fishermen in the fleet), employers and premium costs.
Young Adults. "If you're an unmarried adult younger than 26, you can stay on your parents' insurance coverage as long as you are not offered health coverage at work. This benefit will begin later this year but will require regulations clearly spelling out eligibility criteria," said Galewitz. "In addition, people in their 20s will be given the option of buying a 'catastrophic' plan that will have lower premiums. The coverage will largely kick in only after the individual has $6,000 in out-of-pocket expenses."
Small Businesses. "Companies with fewer than 50 workers won't face any penalties if they don't offer insurance.... Companies can get tax credits to help buy insurance if they have 25 or fewer employees and a workforce with an average wage of up to $50,000. Tax credits of up to 35% of the cost of premiums will be available this year and will reach 50% in 2014. The full credits are for the smallest firms with low-wage workers; the subsidies shrink as companies' workforces and average wages rise," explained Galewitz. "Firms with more than 50 employees that do not offer coverage will have to pay a fee of up to $2,000 per full-time employee if any of their workers get government-subsidized insurance coverage in the exchanges. The first 30 workers will be excluded from the assessment."
Premiums. "People who are sick might face lower premiums than otherwise because insurers won't be permitted to charge sick people more; healthier people might pay more. Older people could still be charged more than younger people, but the gap couldn't be as large.... The bigger question is what happens to rising medical costs, which drive up premiums. Even proponents acknowledge that efforts in the legislation to control health costs, such as a new board to oversee Medicare spending, won't have much of an effect for several years." said Galewitz. "In November, [2009] a Congressional Budget Office (CBO) report on how the legislation -- which at that point had a tougher tax on so-called Cadillac insurance plans -- would affect premiums said that big employers would see premiums stay flat or drop 3% compared with today's rates. It also noted that employees with small-group coverage might see their premiums stay the same. And Americans who received subsidies would see their premiums decline by up to 11%, according to the CBO."
A part of the bill that didn't get much coverage in the debate is its emphasis on preventative care. So while it did not tackle some of the big problems of containing health care costs, it could help to reduce them over the long term with its emphasis on healthier diets and lifestyles. This is certainly good news for U.S. fishermen producing some of the healthiest foods in the world -- from wild salmon to sardines and anchovy, to low-mercury West Coast troll-caught albacore.
In a April 6th Greenwire article, Jason Plautz, wrote, "[a] large but relatively noncontroversial part of the law expands prevention and public health, an effort to keep people healthy before they needed treatment. As part of this effort, the government will set up a National Prevention, Health Promotion & Public Health Council, offer better insurance coverage for preventative screenings, encourage workplaces to offer incentives for employees that lose weight or stay healthy and require restaurants and vending machines to post nutritional information. One measure could even mean more money for parks and public lands.... Section 4201 allows the Secretary of the Health & Human Services Department to assign community transformation grants to towns or communities to make wholesale changes to make the population healthier. Communities applying would have to propose changes across a variety of areas, improving nutrition and physical activity in schools, offering better food choices, establishing exercise programs and making infrastructure changes to the town to encourage more activity."
Robert Pear in an April 4th New York Times article discussing the preventative provisions in the bill said, "[under] the law, chain restaurants will have to provide nutrition information on their menus.
"Health insurance companies will soon have to cover all recommended screenings, preventive care and vaccines, without charging co-payments or deductibles.
"Medicare beneficiaries will get free annual physicals. Medicaid will cover drugs and counseling to help pregnant women stop smoking. And a new federal trust fund will pay for more bicycle paths, playgrounds, sidewalks and hiking trails.
"Those are some of the provisions Congress tucked into the legislation in an effort to reduce the huge toll of preventable diseases -- regardless of whether the initiatives also save money for the government, as some lawmakers expect.
"John R. Seffrin, Chief Executive of the American Cancer Society, said the new law would unquestionably save lives by increasing the number of people screened for colon cancer and breast cancer."
A few days later, in an April 9th New York Times article, Lesley Alderman reported, "[a]lthough one potential improvement in preventive medicine coverage will not take effect until 2014, it could be worth a few thousand dollars to you and your family when it happens. Beginning that year, the new law will let employers offer wellness incentives to their workers of up to 30 percent (raised from 20 percent currently) of a plan's total premium -- both the employer's and worker's portions. That would be up from the current limit of 20 percent of the total premium."
As we mentioned the bill is not perfect. In the effort to get it through the Congress, proponents had to deal with a well-funded lobbying effort from private health insurers and the pharmaceutical industry, never mind solid Republican opposition that appeared centered more on the 2010 elections than any specific provisions in the bill.
Journalist Bill Moyers in a March 28th article called the bill "a far cry from reformation. You can't blame President Obama for celebrating what he did get -- he and the Democrats needed some political points on the scoreboard. And imagine the mood in the White House if the vote had gone the other way; they would have been cutting wrists instead of cake.
"Give the victors their due: the bill Obama signed expands coverage to many more people, stops some very ugly and immoral practices by the health insurance industry that should have been stopped long ago, and offers a framework for more change down the road, if there's any heart or will left to fight for it.
"But reformation? Hardly. For all their screaming and gnashing of teeth, the insurance companies still make out like bandits. Millions of new customers, under penalty of law, will be required to buy the companies' policies, feeding the insatiable greed of their CEOs and filling the campaign coffers of the politicians they wine and dine. Profits are secure; they don't have to worry about competition from a public alternative to their cartel, and they can continue to scam us without fear of antitrust action.
"The big drug companies bought their protection before the fight even began, when the White House agreed that if they supported Obama's brand of health care reform -- not reformation -- they could hold onto their monopoly. No imports of cheaper drugs from abroad, no prescriptions filled at a lower price by our friendly Canadian neighbors to the north."
It is said that the enemy of the good is the perfect. For the fishing fleet anyway the new health care bill is major forward progress. It will make health care available to many in the fleet who could not get it before and it may make it more affordable for others.
The new health insurance exchanges provided for in the legislation are intriguing and may open new possibilities for fishermen to band together in health care groups best suited for their needs. How well all of this works will depend, too, on the health insurance companies and the pharmaceutical industry. If they continue some of their health care practices of the past, it will only be a matter of time before the legislation is revisited with calls for a "public option" or a "single payer" system. If the companies put a halt to the millions of dollar bonuses paid their top executives and curb their administrative overhead, this largely private system can work. If they don't, the only option will be going to a totally public system.
Likewise, for the pharmaceutical industry -- if they continue to gouge on the cost of drugs, look for a public clamor that Congress and the Administration will not be able to refuse, to open the borders to low-cost pharmaceuticals from Canada and elsewhere.
For the commercial fishing fleet, one hurdle has now been cleared and it's now up to us to make this program work for fishing men and women and their families. This was a much needed victory and now it's on to implementation and finding common ground on the other issues before us.
Sara Randall is the Program Administrator for the Institute for Fisheries Resources and serves as Interim Staff for the Commercial Fishermen of America. She can be reached at srandall@ifrfish.org or (415) 561-3474. Zeke Grader is Executive Director for the Pacific Coast Federation of Fishermen's Associations (PCFFA) and an attorney. He served on the Advisory Committee for the San Francisco U.S. Public Health Service hospital before 1981. He can be reached at zgrader@ifrfish.org or (415) 561-5080, ext. 224.