AT THE BEGINNING of Deliverance, a big-city dweller and a backwoods mutant engage in "Dueling Banjos." By the end of the movie, the Atlanta businessman is dead and the hillbilly is about to be uprooted from his ancestral home, both victims of the other's culture.
Such may be the unfortunate result this year with Arizona's own version of dueling health care propositions. Prop 200, the Healthy Families Healthy Children initiative, and Prop 204, the Healthy Arizona 2 measure, seek to provide more medical care to Arizonans. They dip into the same pot of money to do so while using widely different approaches to service delivery.
In one page, Proposition 204 spells out how health care coverage is to be provided to approximately 130,000 uninsured poor people through extension of the existing state health program, AHCCCS. Currently, only those with very low incomes--less than $5,500 a year for a family of four, or one-third the federal poverty level--are eligible for AHCCCS. Proposition 204 would raise that limit to provide health coverage to everyone in the state making less than the poverty level.
This change is exactly what Arizona voters approved by a wide margin in 1996 when they adopted the Healthy Arizona initiative. Since that proposition was never funded by the state legislature, however, Prop 204 proposes to use tobacco settlement money, combined with federal funds, to pay for the increased coverage. The legal settlement money from tobacco companies is estimated to supply between $92 and $109 million a year for the next 25 years, for a total of approximately $3.2 billion.
Local physician Eve Shapiro chairs the Healthy Arizona 2 campaign. Asked what sick, poor people without health insurance do now for medical care, she explains, "They either go to emergency rooms for care, visit a doctor and don't pay, or usually they just forego care until their medical problem becomes very serious."
Shapiro points out that the lack of medical care for the nation's uninsured is one of the country's biggest problems and that the number of people without medical coverage pulls Arizona's ranking to the bottom. The best and most comprehensive solution to this problem, Shapiro says, is passage of Proposition 204.
Supporters of the measure also stress its other advantages. They say no new bureaucracy will have to be created to administer the program, since it simply increases the number of people covered by AHCCCS. They add that six existing health care projects, ranging from the WIC food program to a teen pregnancy prevention effort, will be funded for the next 10 years. Plus, backers of 204 insist, taxes won't have to be increased to pay to implement the proposition.
Despite those financial claims, backers of Proposition 200 call Healthy Arizona 2 "fiscally irresponsible" and charge that taxpayers will be stuck with an enormous bill if Prop 204 is approved. Their alternative proposal, they say, is the fiscally responsible method of providing better health care to Arizonans because it uses only the anticipated tobacco settlement funds, combined with existing cigarette tax money, to increase the level of medical care for the poor.
How Prop 200 does that is contained in a complex series of budgetary allocations spread over 11 pages of fine print that read like an accountant's fantasy. In general, the proposition would first fund the construction of a new $75 million state mental health facility and a $30 million state medical lab. Then, every year, for each of its estimated 200 million dollars:
· Approximately 75 cents would be allocated to a health care coverage account.
· Another 21 cents would go to a "Smart Beginnings Prevention" account aimed at family support services.
· An "Invest in Prevention" account would receive 3.5 cents.
· The last half cent would be divided between oversight and enforcement, and auditing the program's expenditures.
Under the language of the proposition, health care coverage is broken down into a series of sub-accounts to further divide the main pot of money. One-half would be spent for low-income children's health insurance. Other portions of this account would fund health care for some adults who can't afford it, pay for psychotropic medications, support community health centers, spend a little for programs directed at older Arizonans, and set aside $1 million for a health crisis fund.
Janice Palmer, communication director for the Healthy Children Healthy Families campaign, indicates that including construction of the two buildings in the proposition was a difficult choice. But, she says, there is a dire need for both buildings; the legislature should have funded them, but didn't.
Palmer also explains the proposition's rationale about limiting the number of low-income people provided with health care coverage to only children and their parents. "We looked at the intent of the tobacco settlement," she says, "and targeted children and health care by prioritizing so we can cover uninsured parents. Proposition 200 will only spend the tobacco tax money we have."
Backers of 204, however, point out that Prop 200 does not provide health care coverage to thousands of income-eligible "single adults, older adults whose children are grown or pre-Medicare retirees." Critics also charge that 200 re-allocates over $100 million in existing tobacco tax money to fund its long list of programs.
On the other hand, Palmer and others contend Proposition 204 contains a loophole that means it will require massive state subsidies to operate. They say tens of millions of dollars in additional state revenues will be needed each year, which will either require a tax hike or service reductions in other state programs. "If 204 passes," Palmer charges, "the taxpayers will be on the hook for much of the money."
204 supporters blast those claims as simply false. They counter with a financial analysis that shows that implementing the proposition will cost between $79 and $86 million a year, far less than is available from the tobacco settlement fund.
The financial outlook for funding 204 boils down to whether the federal government will provide a 2-for-1 match for the money Arizona spends on providing health care to low-income uninsured people. Those backing the proposition are confident the feds will pay and cite supporting information. Those opposing 204 believe the feds won't come through.
With tens of millions of dollars at stake, both sides have lined up as many supporters as possible. Backing Proposition 200 are a lot of hospitals, Tucson Mayor Bob Walkup and Casa de los Niños. Those favoring 204 include Congressman Ed Pastor, numerous health clinics and the Green Party of Arizona.
Because there is so much money riding on the outcome of the election, the campaign over health care has heated up. According to Cathy Nichols, outreach coordinator for the Proposition 204 effort, "The (Prop) 200 people made the choice to have a negative campaign against us. You have to follow the money on this." Nichols believes hospitals feel threatened because they might loose some of their federal funding for providing service to uninsured poor people if Proposition 204 is approved.
Just because the ballot contains two competing health care propositions that dip into the same source of money to implement their programs doesn't mean they both can't pass. If that happens, it comes down to which one gets more votes. Because it contains a "poison pill" clause regarding Prop 204, if 200 prevails, 204 is dead.
However, according to backers of 204, if their measure gets more votes and there is money available, some of the 200 programs could actually be implemented. Another oddity, says Cathy Nichols, is that because of the wording of Proposition 200, if it receives a majority of votes but less than 204, hospitals still stand to gain an extra $28 million in annual state funding.
So the stakes are high and there won't be a happy Hollywood ending for someone in this case of dueling health care propositions.