Throughout the United States in the 1990's, the condition of the American health care system is consistently referred to as in "crisis." The components of that crisis are by now familiar: health care costs and health insurance premiums climb at a dizzying rate; employers, on whom the system has depended for decades, take desperate measures under intense pressure; the numbers of people uninsured or underinsured rise steadily; government at all levels appears unable to take even the smallest steps to interrupt the spiral. There is no good news to provide balance.

Meanwhile, what is the status of the Harvard health care system? Within our walls reside many of the world's foremost scholars in medicine, public health, business and finance, and public policy. Is the prescription for a sounder health care future being written here? What are the health care prospects for nearly 10,000 staff, many thousands of faculty and students, and thousands of their dependents who receive care under Harvard's auspices? Will the Harvard community's careful consideration and reform of its own health care situation provide leadership for our society's larger problems?

Certainly the health care situation is less desperate for members of the Harvard family than in the larger picture. Full, good quality coverage is available at relatively affordable premiums for nearly all students, faculty, staff and retirees, and their dependents. At the same time, our chances for averting a health care meltdown are no better on the Harvard campus than elsewhere in American society. For HUCTW's 3,600 members, health insurance is already expensive--the average support staff member's 15% share of premiums is costing her more than $600 this year, on an annual salary of $23,000. We can not afford several more years of uncontrolled inflation in premiums. Meanwhile, efforts at consistent, coherent application of our University's resources, involving our top administrators and renowned scholars in the solution of Harvard's health care problems, are utterly nonexistent. Harvard as a major employer and administrative organization is not only doing less than it could to secure its citizens' health care futures and set an example for resolving America's health care crisis. It is doing virtually nothing.

Cost Containment

Perhaps the central challenge in health care policy today is how to control costs and discourage inflation without negative impact on the quality or availability of health care. HUCTW leaders and Harvard administrators have spoken together since their earliest meetings about the urgent need for everyone within the Harvard community to participate in serious work on this issue. The first Agreement between HUCTW and Harvard, reached in 1989, called for intense joint work in a committee involving faculty, administrators and staff, on "issues such as managed care, quality of care, and cost containment measures." Within the past few years, many in our midst have spoken hopefully about the possibilities for forward-looking programs that would discourage redundant "double coverage," manage systems that allow unmonitored and sometimes duplicative referrals, and encourage providers to consider newer, less expensive treatments. The University is also fortunate enough to have an independent and largely self-contained Health Maintenance Organization (HMO) within its structure. The Harvard University Group Health Program (HUGHP) is managed, staffed, and utilized entirely by members of the Harvard community, provides excellent health care, and can be a workshop for innovation in programs aimed at affordability.

Despite all these hopeful conditions, the University has stumbled badly in addressing the challenge of finding ways to contain costs without taking health care opportunities away from people. There are no individual administrators or standing groups, either in the University or in any of the separate schools, that work on this issue consistently. Occasionally in the past three years, consultants have visited the campus, usually peddling unattractive plans which pretend to "quality-conscious" cost containment, while actually reducing benefits or limiting access. The University's participation in the Joint Health Care Advisory Committee, created in the HUCTW Agreement, has been reluctant and unproductive.

As a result of this inaction, everyone who depends on Harvard for health insurance is vulnerable. The history of the last ten years in American health care is filled with examples of large and small employers, unable or unwilling to find constructive ways to control costs, simply cutting benefits. It should not happen here.

HealthFlex Blue

The one development in Harvard health care in recent years which could have been described and experienced as a positive new program was not so received. A year has passed since the University removed Blue Cross/Blue Shield, a traditional indemnity or "freedom of choice" plan, from the faculty and staff health care menu and replaced it with HealthFlex Blue, a Blue Cross-affiliated "point-of-service" plan, and the change is still widely misunderstood. (A point-of-service plan is a hybrid between an indemnity plan and an HMO--see "Definitions" below.)

Harvard administrators had occasionally considered such a change in the past, but rejected the idea when consultants recommended introducing it with a higher deductible, and therefore a greater cost to patients, than the old Blue Cross plan. In the end, because HUCTW leaders have insisted on complete consultation about any large or small changes in health care offerings, we had a detailed understanding of the new plan and accepted it. As instituted, HealthFlex Blue charged an out-of-network deductible identical to the regular, annual deductible under the old Blue Cross/ Blue Shield. In other words, theoretically, no costs to patients were increased and better-managed care was made available to patients, at a lower premium. (See "managed care" in "Definitions" below.) In addition, the University is expected to save millions of dollars in its share of premiums under HealthFlex Blue, as compared with Blue Cross/Blue Shield.

Yet the change was met with great suspicion and anxiety, especially by faculty and professional staff. Communication about the switch was late and incomplete. Most members of the community had to interpret the change and make corresponding health insurance decisions without context or understanding of the challenges that led to it. Why did the introduction of the new program seem abrupt and unconvincing to so many on the Harvard campus? Primarily because the University did not reach a reasoned conclusion over time that a "point-of-service" plan was an appropriate idea here and ought to be pursued. Although such plans have been around for several years, Harvard administrators found themselves forced to react quickly to an attractive offer from the newly-formed HealthFlex Blue, and had to communicate the new option hastily. A careful, broadly-consultative decision about a point-of-service plan could have been reached. It was not, because no one in Harvard's administration was thinking about it.

Domestic Partners

More than three years ago, HUCTW raised the subject of a gap in Harvard's health care system: the failure to allow family coverage for "domestic partners," partners or relatives who are not spouses or legally-defined dependents, but participate in a long-term commitment to living together as a family.

After intensive negotiation on the subject in 1989, the Union and the University agreed to study that question in the Joint Health Care Advisory Committee, gathering information from other employers which have enacted such plans, considering legal and administrative implications, and estimating costs. That Joint Committee work has been completed, and detailed in a written report. The results are reassuring. A sizable and growing number of institutions, many of them similar in size and activity to Harvard, have introduced "domestic partners" family coverage, with consistently positive results. Previously uninsured members of the community obtain coverage, the degree of participation is relatively small and predictable, and costs are not significantly affected.

The Joint Committee is made up of several HUCTW designees, as well as top administrators from the Benefits Office, Financial Systems, the University Health Services, and a Medical School faculty member.