This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
The group that got health care passed is packing up and going home
By Harold Pollack
The Washington Post, January 5, 2014Harold Pollack: [S]ingle-payer folks … might ask: “Wouldn’t we have a better system if we had a single payer? Why didn’t HCAN [Health Care for America Now] and its friends push for that?”
Richard Kirsch [chief executive of HCAN]: What’s the expression: “If wishes were horses, beggars would ride?”
Yes — if we could wave a magic wand and design a rational health-care system that would control costs while providing much better access, we wouldn’t design our current one. The ACA was the best that we could get through the American political system. The fact that we failed in every previous instance in the past 100 years reflects the reality that there hadn’t been a reform designed to deal with the realities of American politics….
http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/05/the-group-tha…
****
Implementing health reform: Four years later
By Timothy Jost
Health Affairs, January 2014How did things go so wrong [for the Affordable Care Act]? Why is there so much bad news?….
More devastating for the future of the ACA, however, were the 2010 midterm elections. Republicans picked up sixty-three seats in the House, swinging control of the chamber from the Democrats to the Republicans. Before the 2010 elections, Democrats controlled fifty-two state legislative houses and the Republicans thirty-three; after the elections, Republicans controlled fifty-three and the Democrats thirty-two. Before the 2010 election there were twenty-six Democratic and twenty-four Republican governors, and after there were twenty Democrat and twenty-nine Republican. Many saw the election as a referendum on the ACA.
By Kip Sullivan, J.D.
Was the Affordable Care Act politically feasible? Was it “the best” America could do in 2009 and 2010? Was single-payer legislation more or less feasible than the ACA? It is still too early to pronounce on the fate of the ACA, but it is not too early to discuss the political feasibility question. We have much to learn from looking back at the muffled debate about that issue among universal coverage advocates prior to the enactment of the ACA.
Since the modern American single-payer movement was formed in the late 1980s, many supporters of universal coverage have claimed that single-payer is not politically feasible. Those who made this argument (Bernstein and Marmor refer to them as “political yes buts” http://healthaffairs.org/blog/2008/08/28/medicare-for-all-why-we-should-…) never explained why multiple-payer “solutions” would be more feasible than single-payer. In the worldview of the “yes buts,” only single-payer proponents had to answer that question. If, on any given day, single-payer proponents could not point to 60 votes in the US senate or majority votes in the US House or in state legislative chambers, the conversation was over: Single-payer was not politically feasible and had to be taken off the table to make room for more “realistic” legislation.
This simple counting-noses definition of “political feasibility” avoided two issues that many observers inside and outside the single-payer movement consider paramount: Any legislation that proposes to achieve universal coverage, or even to cut the uninsured rate substantially, is not politically feasible, or at minimum is no more feasible than single-payer legislation, if
(1) it doesn’t simultaneously reduce health care spending or
(2) is so complex it cannot be implemented within a reasonable period of time.
This definition of feasibility asks not merely whether a given legislative body can be pushed into enacting a given bill. This definition asks as well, once the bill is enacted, is it politically sustainable? By this more realistic definition of political feasibility, a bill might have enough votes to pass a given legislative body, but if the bill can’t contain costs or can’t be implemented within a reasonable period of time, it shouldn’t be assumed to be politically sustainable and therefore should not be assumed to be more politically feasible than other approaches.
Sustainability depends ultimately on how the public perceives legislation after it is enacted. If the public punishes lawmakers who voted for the putative “universal coverage” legislation and rewards legislators who are hostile to government doing anything to help the uninsured and to lower health care costs, the legislation may die on the vine or be repealed.
One would think that this definition of political feasibility would have appealed naturally to the Democrats and their supporters who pushed the ACA because it asks them to take into account the impact of the ACA on voters’ perceptions of Democrats. In other words, it asks Democrats to consult their own self-interest in the course of picking a solution to a problem. It is a noble thing to suffer retribution at the polls for a bill that does good things for people when you know it’s going to work. But it is foolish to suffer retribution for a bill you suspect, or should suspect, will fail, or at minimum, will perform far below the expectations your rhetoric about the bill has created.
When in June 2009, congressional Democrats unveiled the health care “reform” bills that would become the ACA, I and many others were filled with apprehension. Our concern was not that some version of these bills might not pass. To the contrary, our concern was that it might pass (and thereby demonstrate it was “politically feasible” in the narrow sense of the phrase) but not be politically sustainable. In a June 2009 comment on this blog entitled, “Democrats’ hype about health care reform will hurt them,” I said:
“President Obama and Democratic congressional leaders are playing a dangerous game with health care reform. They are raising the public’s expectations sky high before figuring out how to meet those expectations. They are promising to give us the moon – significant cuts in health care costs and universal coverage or something close to it – but even at this late hour they have failed to publish anything resembling a detailed plan to do that. And the hints they have given us about the ‘reforms’ they are likely to endorse indicate they haven’t got a clue how to cut costs.”
http://pnhp.org/blog/2009/06/04/democrats%E2%80%99-hype-about-health-car….
I wanted a real debate about the political feasibility of the Democrats’ multiple-payer solution versus our single-payer proposal, and I thought the most effective way to make my argument was to appeal to Democrats’ self-interest, not just their altruism. Although I doubted the altruism of some members of Congress, I didn’t doubt the altruism of the vast majority of ACA supporters — I knew their desire to minimize the suffering inflicted on this country by our health care system was real. What I questioned was their understanding of how expensive and complex the ACA was going to be. If they didn’t understand that, how could they grasp what a political liability the ACA would be for Democrats? How could they intelligently evaluate the risk that future Congresses might not have enough Democrats in them to protect the ACA from underfunding or outright repeal?
But the debate about political feasibility that I and many others hoped for never came to pass. The single-payer and multiple-payer wings of the American universal coverage movement never discussed whether the ACA would be more feasible — that is, be more likely to pass AND be more sustainable — than a single-payer. We never debated whether the simplicity and efficiency of a single-payer made it more feasible, or at least no less feasible, than the costly and insanely complicated ACA. ACA proponents simply pronounced single-payer “off the table” on the ground that powerful opponents would have made a majority vote in Congress impossible. And that was that.
Four years have now passed since the enactment of the ACA. The sky is clotted with chickens coming home to roost. Evidence that the ACA was never as sustainable as its proponents implied is all around us. This evidence includes evidence of the damage the ACA has inflicted on Democrats. Timothy Jost’s article in the January 2014 Health Affairs contains an excellent summary of the unhappy history of the ACA. One of the most important paragraphs in his paper is the one quoted above in which he notes the damage Democrats suffered during the 2010 elections and that many believe this damage was due in part to the enactment of the ACA in March of 2010. Jost also predicts more bad news for the ACA as a substantial portion of the people insured through exchanges discover their choice of provider has been restricted and their out-of-pocket payments are very high. We are going to see more heartwarming stories about sick people finally getting the medical care they deserve, thanks to the ACA, but it will not be enough to forestall more damage to Democrats (especially if Republicans manage to nominate candidates who can refrain from discussing “legitimate rape” and similar subjects).
None of us have a crystal ball. I don’t claim that if Democrats and groups supporting the ACA had used the opportunity presented to us in 2009-2010 to promote HR 676 instead of the ACA that HR 676 would have passed by March 2010 or even by now. I’m reasonably sure something good would have been enacted — for example, an expansion of traditional Medicare and Medicaid to more people (Bob Kuttner makes a similar argument here http://www.huffingtonpost.com/robert-kuttner/obamacare-republicans_b_429…).
I am, however, absolutely certain about one thing: The universal coverage movement in America would be in a much better position to bring the long fight for universal coverage to a successful conclusion than we are now. There are several reasons why I’m so sure about that.
First, whether we had won big or won some incremental improvements in 2010, the public would have been exposed to a debate about a real solution to the health care crisis as opposed to a debate about make-believe cost containment schemes such as exchanges, “accountable care organizations” and punishing hospitals for “excess” readmissions.
Second, the health insurance industry would be receiving less money from the taxpayer and would be, therefore, less powerful than they are now. The insurance industry has been driving away private-sector customers in droves over the last few decades. If public purchasers — state and federal governments — had long ago stopped throwing money at Aetna et al. with legislation like the ACA, schemes to overpay Medicare Advantage plans, and legislation privatizing state Medicaid programs, the industry would by now be a shadow of its former self and a much less potent opponent of universal coverage.
Third, the political environment for health care reform would be less toxic than it is today, not because conservatives wouldn’t be leveling the same extreme charges they level at all forms of health care reform no matter how innocuous, but because the public would be less vulnerable to extremism and ultimately less cynical about real reform.
ACA proponents may disagree with my assessment of where we might be today if they had joined ranks with the single-payer movement and had fought for HR 676. What they can’t deny is they refused to engage in a real debate about the political feasibility (narrowly defined) AND sustainability of the ACA versus single-payer. They might have learned something if they had.
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John T (Jack) Garland
February 1st, 2014 at 9:00 pm
Thank you, Kip Sullivan, for the thorough analysis of the shameful way that the advocates for SINGLE PAYER were denied the opportunity to make their case before the passage of ACA. Agree that we would now be in a better position — whether or not the better choice had been passed. We have a difficult task to educate the public officials, both about the merits of single payer AND the level of support that the public and physicians have already demonstrated (about 60%). Keep up the good work spreading the word.
BarbaraPower
February 2nd, 2014 at 12:22 pm
Interesting commentaries although I no longer read this as a 21st Century set of arguments. Our world in the US has radically, and perhaps irretrievably, changed since the year 2000. Concepts such as “political feasibility” are a disguise for copping-out, especially with respect to this topic.
Who still believes we even have a 2-party system in the US? References to democrat or republican players are quaint, but useless to those affected by the decisions made and inflicted on citizens. The terms which best describe our method of governing in the US are: oligarchy, plutocracy, or better yet, syndicate-based.
Who among the thoughtful (anywhere and of any age) couldn’t see how flawed the ACA was from the start. Or how corrupt it was in its design.
Who among the thoughtful couldn’t see from the start how [intentionally] impossible it would be to implement?
Who among the thoughtful couldn’t see from the start that it was just another transfer-of-wealth from those who have little to those who have much?
Re: HR 676 although a profoundly positive step forward is now out of date since our economy has endured a nose-dive with no real end in sight – especially on the jobs front. I mean, here, jobs in the real sense of solid and secure employment, at wages from which taxes can be paid SO THAT a Medicare for All system can be funded.
There really is a limit to how much the few truly employed citizens in the US can be taxed, when our tax system has overwhelmingly leaned toward NOT taxing the wealthy, ever. Or worse, delivering our tax dollars to subsidize the oligarchs.
So back to the beginning: if we are interested in actual transformation then perhaps it is time to acknowledge that the terms “Political Feasibility,” “Political Will,” and “Sustainability” are conversation STOPPERS and, as such, completely unproductive.
We’ve spent trillions on war and Political Feasibility was barely, if ever, obsessed over as much as it [always] is in the realm of health care, edu, equitable justice.
Time and again, including in the hugely valuable updates from Don McCanne, I hear a message which calls for large-scale active demonstrations by the populace. The tragedy here is that the populace by and large can barely keep their heads above water, never mind being able to afford the costs associated with being arrested for demonstrating.
I would be glad to demonstrate actively IF I could get a day or two off from working 2 jobs, and IF I had a lawyer, pre-paid, to help me with the inevitable arrest and court appearances. Also, I would probably lose my job. Is this what the populace should be ready to do ?
I urge readers of this blog to read Hedrick Smith’s current book and to listen to this interview with Lord Adair Turner on al jazeera UK
http://www.aljazeera.com/programmes/headtohead/2013/06/201361294652861958.html
To summarize, Adair states that because our economic (and political) systems could not deliver Jobs, the answer/solution we average citizens received was “let them eat debt.”
And levels of debt (individual and sovereign) are a fact of life from every possible analysis. Debt works magnificently to keep citizens down, everywhere. And this bigger picture ties in to all discussions about equity — health care and otherwise.
Chris Lowe
February 2nd, 2014 at 8:00 pm
As an abstract intellectual matter I agree with Kip Sullivan that “political feasibility” should include “political sustainability.” Had that definition been used, the debates of 2009 might have been different. But that is the same kind of counterfactual history as saying that if the political debate had focused on what would work, single payer would never have been put “off the table.”
In reality, however, political feasibility was a narrow self-fulfilling claim put forward to evade talking about the substance of real reform. It was a claim only about what could be passed.
I question how useful it is for our movement to refight 2009. It is destructive to stew in our resentments at being marginalized. Schadenfreude, while having its pleasures, may keep us from thinking politically about people who favored the HCAN approach in 2009 who might now be brought into active work to build the single payer movement.
The key point is not that we were right in 2009 (or 1994, or 1990, or 1970, or 1962). The key point is that the private insurance based system *will continue to degenerate* not just for those in the Exchanges but for the employment-based sector. Indeed, the latter is more important.
Here in Oregon we are taking a grass-roots organizing approach to build a mass movement for single payer that will *change the political reality.* We are making it impossible for politicians to refuse to talk to us on the claim of political realism, by organizing a coalition that is building chapters in all 60 state legislative districts. No state legislator, wherever they fall on the political spectrum, will go without constituent pressure for single payer. We are forcing the debate onto the terrain of substance.
Our coalition includes state and local branches of many groups that were members of HCAN in 2009, and/or supported Oregon’s own incremental, Massachusetts model process that started about 2007. Many of those groups, including trade unions and community groups, are working even now to help people get expanded Medicaid or sign up our state exchange despite its complete technical failure. But in HCAO, they sign up for an explicitly single payer effort that cannot become an incrementalist vehicle. The more momentum we build, the more some activists in those organizations get engaged with us and bring their organizations into fuller support.
The point is to avoid forcing people to choose between organizing for the fullness of what we need, in time, and immediate needs of their constituents now. Rethinking 2009 for what *we* can learn to move forward is good. Rehashing our resentments against people who we thought and may still think should have known better is actually self-defeating. We need most of those people (a few opportunists excepted) in order to win.
Please note: I am not arguing for “compromise” on substance. Quite the opposite. I am arguing for bringing people who may now see that it didn’t work into our movement, by not attacking their motives then.
The Washington Post article to which Kip Silverman responds contains some other things we should think about. First, HCAN is dead. This leaves the field open for us in a different way. We should strategically examine its shards for opportunities. Both MoveOn.org and the AFL-CIO have endorsed single payer since 2010, though clearly there are still pro-“public option” forces in both. How does our movement build the pro-s.p. forces in those contexts and get more resources into our struggles?
Second, we should pay attention to pseudo-incremental proposals that are out there. The HCAN ex-director cites favorably the same proposal the well-meaning Alan Grayson has put forward, to expand Medicare on a buy-in basis. We should oppose this vigorously, as it expands the tendency in Medicare Advantage and Part D plans to commodify Medicare, reduce its social insurance aspects. If we expand Medicare gradually, it should be by expanding its tax base and egalitarian public social insurance features. Don’t Sell Medicare!
A related idea with similar problems was floated by Michael Moore the filmmaker at the beginning of the year. He wants, apparently, to push for “public options” in the state exchanges. That is a complete dead end, just adding another epicycle to our orrery, another ramp and bowling ball and bird cage to our Rube Goldberg machine.
Finally, we should make more of the fact that it is the public side of the ACA, the expansion of public social insurance under Medicaid, that is working best, except where politically obstructed by wreckers.
Above all, though, we must look forward more than back, and look to how to build a large, organized movement to which politicians must respond. Being right is not enough. We must be organized behind our good ideas.
DrSheriDWahlen
February 3rd, 2014 at 2:42 am
If you mean, “Were there people with gobs of money willing to give more of it to politicians/legislators in exchange for pushing the legislation through?” I guess the answer is: No. I continue to insist we got the health care system the health care insurance industry wanted, b/c they have the money and power, and we’re living under that other “Golden Rule.” The one that says those who have the gold rule. The two reasons politicians from either major party win their seats at the table are 1) They have the money and connections to people with money & 2) Both major parties have adopted the “business conservative ethic.” Neither major party really WANTS to support issues that benefit the “bottom” 99% or so of us who work hard for a living. The Republicans demonize us as “class warriors” or liberals or Nazis or evil socialists or call us moochers, but they sure aren’t supporting a living wage or universal education or universal health care so we don’t HAVE TO mooch. The Democrats just want us to vote for them b/c they’re “not Republicans” or b/c they’re not as crazy as the Far Right, but they’re quick to disown unions and people supporting fairer distribution of economic gains (earned from our increased labor/productivity, but not shared by us) as “socialists,” too. Well, so be it. If supporting sharing and cooperation and treating the people who actually DO the work in this country more fairly and making sure we don’t become economic pariahs when we become to old or sick or injured to continue to work hard makes me a socialist, I’m a socialist. If demanding better health care, food and education for children who have NO money/political power to fight for their own survival needs makes me socialist, I’m a socialist. If fighting against privatization (and the resulting plutocracy) of public goods and services makes me socialist, I’m a socialist. If we could only harness the voting power of all people who work(ed) for a living to front candidates for office who come from the same group WITHOUT having to pony up the same amount of money Dems & Reps do, we might have a fighting chance at providing health CARE–not insurance, but CARE for every last one of us. But, as long as we continue to equate income and human value and “goodness” and success, I’m afraid we ARE stuck with having the health care the insurance industry is willing to give us, at the price they set.
Theodore R. Marmor, PhD
February 3rd, 2014 at 12:00 pm
The plea for a serious discussion about political feasibility by Kip Sullivan takes us back to the really limited debate about that in 2009-10. The argument attributed to both Harold Pollack and Richard Kirsch is just circular rather than convincing. The ACA was the best that we could have in 2010. How do we know that? Because that is what was produced in 2010. No, the test is what else could have been proposed–or done–that was feasible politically and would have had a better trajectory than the ACA, a reform package designed to win Republican support that never emerged and consists of complex patches on the patchwork of American medical care as of 2010. Kip raises the right evaluative question, but the defensive circularity goes on and on. (by the way, the ‘yes but’ attributed to me may have confused description with my convictions).
I think a good case–not a perfect one–can be made that we would be better off now if Obama had decided the economic stimulus was the key to his first term and that expanding Medicare to those 55 and older was within either the feasible set or would have left Obama in a strong position to fight for that as Kennedy had pushed the original Medicare bill every year of his Presidency. The ACA is not universal health insurance in practice, whatever was said in theory. It is a source of devil-like complexity, one that does not have a straight-forward picture of how to expand financing coverage, let alone deal with the second-order effects that provide the Republicans the basis for criticism and lying about their own earlier inducements of private health insurance expansion.
Any evaluation of a political outcome must consider the counter-factual question of what else was doable then. One should not expect easy agreement of course, but ruling out the question by repeating what transpired is not defensible intellectually. And, worse, we are left with an administratively costly and complex arrangement in which it is hard to see what can be done to make it easy to work, let alone to understand.
We have more to learn from German modes of administration of multiple plans, but keep in mind that there the benefit package is for most purposes common, not differentiated. And there are overall constraints on the budget through limits on the contributions. We lack both. Don–it really should be possible to treat the feasibility question both historically and turn it to use for where we are now.
Theodore R. Marmor, PhD, Professor Emeritus of of Public Policy and Management and Professor Emeritus of Political Science, Yale University
Ellen R. Shaffer, PhD, MPH
February 3rd, 2014 at 12:00 pm
To the contrary, the single payer movement has failed to successfully educate the public about what is wrong with the health care system, and why we need a single authority with the power of the federal government to set prices if we are to escape the disastrous cycle of bad access to crummy health care that costs too much. It is not an easy set of concepts to convey compellingly to people who don’t work in the health care system, or are so ill that they are regular patients, still a small fraction of the US public. Nevertheless.
Having presented this argument consistently and assiduously for decades, including to explain legislation I have helped to write, and including in articles about the Affordable Care Act analyzing pro’s and con’s, I can report a 99% – 100% rate of failure showing up at any public gathering of single payer supporters and asking them to describe what the system would do and why they support it.
Did we not advance the idea and substance of Medicare for All? Did we not attempt to capture the essence of the price-fixing power of the public sector, while hedging our predictions for its success, in advocacy for the public option?
Insurance companies are bad. (We got that across.) Profit in medical care is dodgy at best. Physician reimbursement is too high and ineffectively distributed, but this can only be understood in the context of a political economy that is way out of whack re: income distribution and political engagement. It is well beyond wishful to contend in this day and age e.g. that a single payer system would magically reimburse health care professionals and institutions in a way that would incentivize quality, respect and engage patients, and control costs.
Single payer advocates did testify in Congress, and many including myself wrote, spoke and organized. We did not succeed. Our opponents were better financed and staffed, and history was not on our side. That the ACA passed at all was in fact a testament to some very nimble and extraordinary moves by Congressional leaders. It might have made a difference if we’d had better arguments; better strategies (like cross-issue alliances); better tactics; or lived somewhere else (with more dense population and less geographic spread, a culture and practice of social solidarity, a more vibrant intellectual community, different socioeconomic demographics). Maybe not. Attributing our failure entirely to the energy and/or bad faith of those who differed gives them entirely too much credit. And dooms us to continuing to fail.
Ellen R. Shaffer, PhD, MPH, Co-Director, Center for Policy Analysis, San Francisco
Kip Sullivan, JD
February 3rd, 2014 at 12:01 pm
I agree with each of Ted’s points: the feasibility question is an important one, Kirsch’s argument is circular, and Obama probably would have been better off concentrating first on jobs and putting off health care reform until later in his first term or until his second term.
I don’t understand much of what Ellen is saying, and disagree with those comments that I do understand.
Let me preface my reply to Ellen’s comment by noting that her political trajectory resembles Kirsch’s. Like Kirsch she was deeply involved in the campaign for single-payer in the early 1990s, then crossed over to the multiple-payer camp and became a severe critic of the single-payer movement while simultaneously claiming that she would support single-payer if only it were politically feasible. http://www.salon.com/2010/05/22/progressives_practical_healthcare_guide/ http://www.counterpunch.org/2010/06/29/scare-tactics-spin-and-health-care/
She opens her reply to me with the classic “yes but” double standard: A strict standard for single-payer advocates and a loose or nonexistent standard for multiple-payer advocates. She states that the single-payer movement has “failed to convince the public” that we need a single-payer. Note that she said nothing similar about what ACA proponents did or failed to do. Did HCAN and Max Baucus “convince the public” that we needed an individual mandate, accountable care organizations, and a one-trillion-dollar-per-decade bailout of the health insurance industry before shoving those provisions through Congress? Of course not. But, in the worldview of “yes buts,” that’s neither here nor there. Only single-payer advocates have to demonstrate 60 votes in the US Senate and majority support among the public before they’re allowed even to be at the table, much less write a bill and get hearings on it.
In fact, large majorities of the public have agreed with the single-payer movement since at least the 1980s http://www.pnhp.org/sites/default/files/docs/2011/Kip-Sullivan-Two-thirds-support-medicare-for-all.pdf.
Her second paragraph makes no sense. She seems to be saying single-payer advocates don’t know how to make the case for single-payer. If that’s a correct interpretation, I have no idea what she’s talking about.
Her third paragraph suggests she’s lost touch with the single-payer movement. She asks, Didn’t we do a good job promoting the “public option”? Wrong question. The “public option” that Democrats supported in 2009 (as opposed to the original version of the “option” proposed by Jacob Hacker) was a sickly little thing that didn’t remotely resemble a single-payer. http://pnhp.org/blog/2009/07/20/bait-and-switch-how-the-%E2%80%9Cpublic-option%E2%80%9D-was-sold/ But Ellen called the “option” absolutely essential.
In her fourth paragraph in her reply to me she states rather clearly why she has lost interest in single-payer and has become a managed care advocate. She repeats the standard managed care canard about the fee-for-service payment method (it cannot “incentivize quality”) and then invents accusations I’ve never heard of (FFS causes doctors not to “respect and engage patients”). In the interest of brevity, let me just say these claims are nonsense.
Her last paragraph is hard to follow. She seems to say the single-payer movement had as much access to Congress, and to the back-room planning sessions, as, say, SEIU, AHIP, the drug industry, or the hospitals. I really can’t tell you what the rest of the paragraph says, other than it promotes the usual “yes but” thesis: Our opponents were just too powerful, what else could a good Democrat do but vote for an insurance industry bailout?
It would have been helpful if Ellen had addressed the main point of my comment: That discussing political feasibility would have been helpful prior to 2009. I hope her disdain for the subject is not typical of all ACA advocates.
Scott Tucker
February 3rd, 2014 at 12:03 pm
Health Care and “Political Feasibility”: a patient responds
Health care reform is contentious, and requires a good deal of historical knowledge. Moderating debates so that enlightenment prevails over static is justified, but the history of health care movements includes the efforts of patients to find a public voice and be heard.
If PNHP truly wants to create a movement for equality in health care, then the debate should also be opened to health care activists who are not health care professionals. For this reason, the gatekeepers who posted this message might reconsider allowing more health care activists beyond the gate:
“PNHP welcomes comments on its blog by its physicians and medical student members, and other health professionals active in the movement for single payer national health insurance. Comments by other readers are welcomed but may not be posted.”
Kip Sullivan is correct in arguing that “political feasibility” is itself a circular argument if we simply accept the ACA as an act of God, rather than as the outcome of a flawed political process. Though Sullivan does not make clear (to me, anyway) what he would propose as a countervailing political movement, or a practical point of leverage to move the “immovable” object of our present corporate political system.
Barbara Power comes much closer to speaking my own mind by asking:
“Who still believes we even have a 2-party system in the US? References to democrat or republican players are quaint, but useless to those affected by the decisions made and inflicted on citizens. The terms which best describe our method of governing in the US are: oligarchy, plutocracy, or better yet, syndicate-based.”
The ACA proponents were not simply pragmatists, which is their own view of themselves. They were also partisan apparatchiks who put their party above honest debate and the best practical solution.
Most of them are ready to walk away from the ACA to some other partisan gig, saying, “Our job here is done.” If they are within White House circles, of course they have to defend the ACA. That goes with their jobs.
Kip Sullivan wrote his article in good faith, but the damage is done. And the people who need their noses pressed to his text will not pay attention. Sullivan is arguing that the public understanding of health care reform would be much more advanced now if only more people had fought for what we really needed, and not just for what was deemed “politically feasible.”
He’s right, but he will also be trapped in the congressional circles of hell unless he (and we) find a way to put the worst career politicians out of business. The worst cases are emphatically bipartisan, so any political diagnosis that simply tilts against Republicans will also tilt at windmills. Democrats in Congress were also very effective in shutting down any open debate about a single payer system, and finally excluded even discussion about the much weaker “public option.”
One big factor missing during the health care debate and “reform” was a healthy labor movement. That made a huge difference in gaining national health care in Canada, but unions were deliberately and systematically downsized in this country. In consequence, this country lacks a principled electoral party of basic social democracy. That is no accident. That is the strategic consequence of a bipartisan consensus against social democracy.
The Clintonian wing of the Democratic Party, still quite strong, deliberately reduced “liberalism” to a nineteenth century doctrine of the “free market.” Thus Hillary Clinton dismissed David Himmelstein’s arguments for single payer many years ago with her flippant comment, “David, tell me something interesting.”
My view is that the republic is endangered, and I am a fairly square creature of the Enlightenment and of the radical republican tradition. A class conscious approach to basic social democracy (in education, housing, health care, transportation, energy, foreign policy) is part of the unfinished business of the Enlightenment.
Now and then I meet outright anarchists, mostly youngsters, who regard Washington, DC as a remote marble mausoleum. If I told them their vote counts there, they would laugh in my face. And in fact I do not believe that argument myself. It belongs in a Civics 101 class, among the other hermetically sealed illusions.
So I am 58 years old, living with HIV (diagnosed in 1986), a veteran of ACT UP, and can only advise the young that basic democracy may require a second American Revolution. Peaceful, if possible.
Though I wish the good doctors of PNHP well, you will never break out of your professional isolation without making practical common cause with a wide spectrum of other health care activists who are not health professionals. Including veterans of the movements for women’s health care and veterans of the AIDS activist movement. That is one path of solidarity to pursue, while also avoiding the path of congressional “feasibility.”
Create the citizen movement for health care, and the career politicians will follow. But they will not lead. There are just too many corporate lawyers and millionaires in Congress to expect any kind of social democratic leadership from the class and the interests they represent.
My husband and I met Dr. Don McCanne at an early meeting of the Santa Monica chapter of PNHP, and my interview with McCanne (in the form of a conversation, since we are both health care advocates) was published at Truthdig.com . McCanne is providing one bridge of communication between health care professionals and other health care advocates, so I am glad to promote his wonderful daily columns known as Quote of the Day. This is where I encountered Sullivan’s column, and that’s what brought me to knock at the door here at the PNHP site.
My husband and I only went to two of the PNHP meetings, since it became clear that much of the funds, time and energy would be spent lobbying politicians in Sacramento. Well, each state of this disunited union is a special case, and in California there are indeed career Democrats who introduce decent health reform bills. Each PNHP chapter is free to pursue a chosen course.
How we, the people, decide to spend our time and resources in public life is finally both a matter of conscience and a strategic political choice. For myself, my real vote must be cast against the whole corporate system, including both of the big capitalist parties.
The brutal experience of the AIDS epidemic taught many patients that we had to take our fight to the streets, the courts, and yes indeed, the hospitals. In the early days, we often educated doctors in the Standard of Care. Some doctors became allies, but some doctors lent their professional credentials to their bigotry. We will never forget the deeply entrenched medical resistance from many doctors who had never encountered patients advocating for our own lives and health before.
The health care system in this country is a class divided system. The political movement necessary to win health care for all must therefore be a highly class conscious movement, rooted in the daily experience of people well beyond the strictly professional circles of doctors. Politics is not a science in the strictly empirical sense of a laboratory experiment, but we can still take an empirical view of what does and does not work in social movements for basic public goods such as health care. The two party system does not work for our public good. That is an objective political problem that the good doctors of PNHP will recognize sooner or later. Better sooner.
Solidarity,
Scott Tucker
Ellen R. Shaffer, PhD, MPH
February 3rd, 2014 at 12:09 pm
As an example of a statement made too briefly, I have always asserted that reimbursement mechanisms of any sort (FFS, capitation and/or salary) are not inherently a magic bullet to produce the care outcomes or delivery system we want and need. A raft of delivery system reforms (that would work much better in a single payer system, no question about it, for a slew of reasons) and other changes are necessary; some are happening. There are single payer systems where this isn’t being managed as well as possible; single payer systems may be necessary, they are not sufficient. Again understandably, it took awhile for the single payer movement to dive into these issues, and we’re the stronger for it; the delay took a toll. (What this has to do with “feasibility” is a longer discussion.)
Secondly, just for the record, and despite a mistaken impression that I have become a managed care apparatchik, I invite Kip and others to catch up with my article on this subject:
Am J Public Health. 2013 Jun;103(6):969-72. doi: 10.2105/AJPH.2012.301180. Epub 2013 Feb 14.
Shaffer ER The affordable care act: the value of systemic disruption.
Abstract: It is important to recognize the political and policy accomplishments of the Patient Protection and Affordable Care Act (ACA), anticipate its limitations, and use the levers it provides strategically to address the problems it does not resolve. Passage of the ACA broke the political logjam that long stymied national progress toward equitable, quality, universal, affordable health care. It extends coverage for the uninsured who are disproportionately low income and people of color, curbs health insurance abuses, and initiates improvements in the quality of care. However, challenges to affordability and cost control persist. Public health advocates should mobilize for coverage for abortion care and for immigrants, encourage public-sector involvement in negotiating health care prices, and counter disinformation by opponents on the right.
PMID: 23409911 [PubMed – indexed for MEDLINE]
You might also refer to my work taking on the tobacco industry (www.cpath.org) and the anti-abortion movement (www.oursilverribbon.org), as well as occasionally musing about the health care system. I don’t think that this means you have to agree with me. and I’m not averse to spirited disagreement, but I have to believe that all of our purposes are better served discussing what I actually think, if that interests you, rather than misattributing motives and perspectives that are not mine. I think this set of arguments will not likely be successfully hashed out via Don’s blog. Kip. I appreciate your energy, and will go back and read your stuff more carefully. If you ever want to engage in an actual discussion let me know.
Best, Ellen Shaffer
Jeoffry Gordon
February 3rd, 2014 at 12:12 pm
In response to QOTD debate about what was possible in 2008-9, in addition to remembering the huge war chest and number of lobbyists involved by the major industries and professions controlling 20% of the economy consider this report in the Guardian where Glen Greenwald (of all people) clearly lays out how the legislation was an inside job by the insurance industry orchestrated by one person. In my mind all the legislative hearings, conferences and angry Tea Party demos etc were a sly tactic funded by industry titans to keep the public’s eye off the real action.
Jeoffry Gordon
Jeoffry Gordon
February 3rd, 2014 at 12:13 pm
I am still the type of a political scientist who believes in sub rosa personal connections and links rather than formal policy pronouncements and stand by my impression of the crucial and important role of Liz Fowler for the insurance industry in creating ACA as it was passed.
In addition, although few of us and even fewer in the media discuss it, Obama may have made a conscious important trade off for the good of the country. He got “imperfect” health reform, BUT
1. He built in subsidized universal national health insurance for all legal residents of the USA who were earning less than 138% of poverty level (only to be frustrated by the Supreme Court.)
and 2. He marginally redressed income inequality by building in a 0.9% additional Medicare payroll tax for individuals earning over $200,000 and couples earning over $250,000 and he added a new 3.8% tax on unearned income to help pay for ACA. Thus he brought taxes on the top 1% back to the marginal levels as they existed when Ronald Reagan was President.
Frank Goldsmith, DrPH
February 3rd, 2014 at 12:14 pm
Thank you gain,Ted, for trying to make sense out of the last period of time. Your social insurance book, I think, will be our first step bact to universal health care and not promoting profit making as a method to get to universal health care [ACA]. Ezra Kleins idea of for profit making insurance carriers fighting for the business; when any one knows that these carriers are a cartel of companies working togther to share the profits of healthcare.
Kim’s attempt to make sense of Ellen’s comments is admirable, but her attempt wasn’t successful due to the contorted narrative of Ellen.
When you, in this case Ellen, devoted your life to a universal health system; and fully understand how that is to be done; but then drop those principles in favor of supporting what is feasible….all rationality is lost. This is especially true when that policy is mired in the very opposite of what you’ve always believed. George Carlin knew how to describe this, but I can’t find the words.
By putting health care on the same buying level as purchase an automobile or other consumer goods; or choosing health insurance as if you were making an airline reservation …. that is akin to Nancy Reagon’s “Just say No” campaign.
What surprises me, I guess, is Ellen’s condemning attitude toward the single payer movement. She knows how wrong she is. the campaign, via PNHP and others, for single payer was the most comprehensive, thorough campaign which used every possible democratic method to get its point across, could not have been better.
But, the Democratic Party said no. That meant President Obama said no. And, that meant that any non-profit seeking support from the Dem Party, and all that means, had better get in line if it wanted to survive.
But, there is no sense in engaging in personal attacks; using words said in one period of time as proof of some other statement said later. There is no end to that.
Pollock, Krisch, Schaeffer, Klein and others should do the berst they can to make the ACA as less destructive as possible. I really hope they achieve at least some of their goals.
But, the larger battle for social insurance that will give us true universal health care as defined by those who wrote the book, must go on.
Frank Goldsmith, DrPH
Marc Sapir
February 3rd, 2014 at 12:15 pm
I was disturbed by the gaudy ignorance of Ellen Shaffer’s response to Kip Sullivan that Don McCanne posted and thought to tackle her mistatements and non-sequiturs point by point myself. Then I saw that Kip has done a handy job based on the facts and history. Nevertheless an adjunctive broad point or two: the idea that politics, policies and laws in these United States–the decisions of its Congress and Executive branch–presently derive from the public’s will is contradicted by literally thousands of events in the recent past alone–including that the public would be quite happy to have Medicare for All. It is the Media and the political class who have precluded the honest and open debate that would force the issue. To blame anyone else is like blaming the public for the fact that Congress has managed to undermine the right to abortion, despite the public’s supportive views of women’s rights.
The reasons why single payer was “not politically feasible” within the time of the health care reform debate were two–one proximate and one fundamental, but neither having anything to do with what the citizenry wants or needs, feasibility or the problems of the single payer movement. The proximate reason was that the Obama Administration (not the Republicans) blackmailed, intimidated and nearly terrorized anyone in Congress who might have had the temerity to even try and discuss or debate Single Payer on the floor of Congress. We all know well enough that John Conyers and Anthony Wiener had their committee chairmanships and standings in the Democratic Party threatened. We all know that Drs. Flowers and Paris were arrested by Senator Baucus and so forth. The Media more or less censored for the White House. Obama might have gotten at least the Medicare at age 55 had he not undermined that debate. He made his deal with the devil and instead he is undermining Medicare by failing to carry out his promise to end Medicare Advantage over-costs if not the entire scheme.
The more fundamental reason has to do with the moment of history we are in. The country has gone fascist in the Musolini sense that Wall Street power, (eg. Goldman-Sacks et al), which always had an outsized dominance in politics before, now is actually running politics from the inside, not just via lobbyists. And health care is one of only 3 economic sectors in the Market (along with defense and electronics) with consistently huge profit margins from within the US economy. In fact, I think the reason why the Tea Party and the entire Right, rather than the Occupy Movement (including Single Payer), are squatting on our political playing field presently is to provide a Wall Street and Democrat Party threat to us all: if you don’t let Wall Street continue to run our country, well look over here at these Koch and Fox-addicted folks ready to really worsen the cultural crisis. And if Ellen Shaffer wants to blame public opinion for what this government does, let her also think about blaming us all for the US role in promoting wars and occupations, militarism, murderous dictatorships, torture, political assassinations and even many terrorist groups we have set up and funded the world over. The argument about “not politically feasible” reminds me of some liberal Zionists who repeat over and over the mantra that a single democratic State in Israel-Palestine is not politically feasible. For 67 years their ruse, a two state solution, has never been “politically feasible” for Israel, yet they lecture to us about what an impractical idea simple democracy is.
Joe Sparks
February 3rd, 2014 at 12:17 pm
The trouble with political feasibility, is many things are considered politically unfeasible until they happen. For example, if somebody would have told at the beginning of 2007, that an African-American man would be elected president in 2008, i would have said they were crazy. I would have said the same thing in January 2008.
We need to be willing to make our case and make it powerfully. Unfortunately, I think the messaging of single-payer has been flawed and a strategy is lacking to keep the idea current in the minds of Americans. Both need improvement. (As an aside, I am a communications specialist who could help with both.)
Joe Sparks
ershaffer
February 3rd, 2014 at 8:15 pm
What an utter crock. Please note that the article Kip refers to in order to document my defection from the single payer campaign is dated May, 2010, months after the ACA was enacted. While I disagree that that my article represents any such thing, Kip’s charge is blatantly and intentionally dishonest. As Frank Goldsmith and others should know, because I did it and he did not, I was a leading and vocal proponent not only of single payer the slogan but single payer concepts and principles within APHA during the actual debate over the ACA. I devoted 3 years to analyzing the bill and pushing for the most progressive provisions possible, including initiating a national discussion list. When I mobilized to push for the bill’s final passage in Feb/ 2010 I assure you I did so at the explicit request of single payer sponsors in Congress who were panicked that the bill would collapse. Every one of them voted for the ACA, for which they were roundly excoriated. Kip would not dare rewrite history and claim that they were traitors to the cause all along. He knows that is an abject lie, and so should you all. That many of you find his logic compelling and mine now incomprehensible may be evidence of differences among us, though I am not sure it has to do with policy. Shame on you, Kip. Next time I see you coming my knives will be sharper.
oxfeld
February 4th, 2014 at 12:18 am
Although the ultimate goal is a national health plan, new social policies are sometimes implemented first at the state level. Then, when there is a concrete illustration of why and how they work, they look more “feasible,” and it is easier to build momentum in advocating for their adoptation at the national level.
One case in point is social security, which was first implemented at the state level in New York when Franklin Roosevelt was governor.
While numerous studies show that single payer is both efficient and just, it will still look much more “feasible” to those who remain unconvinced after a few states have implemented a publicly funded health care system for all their residents.
I realize that a state based “single payer” model cannot be a pure “single payer” because there will always be out of state patients, who still have private insurance, and Medicare recipients will not lose their Medicare — so the state will become a secondary payer for some.
Still, the creation of a health care system for all of a state’s residents that is publicly financed will be an important first step in demonstrating that single payer not only works, but is politically feasible.
That is why we are working so hard in Vermont to make sure that the finanicng package for Green Mountain Care (publicly funded health care for all Vermonters) passes in 2015 when it comes before the legislature.
The Polemicist
February 7th, 2014 at 11:01 am
Kip Sullivan is right on the mark in criticizing both the circularity and the short-sightedness of the “feasibility” argument. As he points out, we saw in the 2010 elections, and are seeing again now, how wonderfully “politically feasible” the ACA is.
Fact is, the ACA was not pushed because it was more “feasible,” but because it was the best way the administration could come up with to save and subsidize the private health insurance industry that wrote it. Here’s an excerpt from my long post dealing with this, at Who’s the Boss? The Obamacare Deception
(http://www.thepolemicist.net/2014/01/whos-boss-obamacare-deception.html):
In 2009, in the midst of a severe crisis of capitalist legitimacy, it was not politically impossible to make the case for Medicare-for-all. When Newsweek runs a cover saying “We’re All Socialists Now,” it means that radical ideological and political possibilities had opened as a result of the near-collapse of the American capitalist economy. These were the possibilities that candidate Obama so craftily surfed on to his election in 2008, and that gave Democrats control of both houses of Congress. In that context, there was absolutely no reason to presume that it would be politically more difficult to make the case for an expanded version of the enormously popular Medicare program than for some complicated scheme to force people to buy private health insurance.
Obama did not refuse to make that case because he could not, but because he would not. He did not want to, because — despite the other impressions he loves to give gullible progressives – he is a free-market neo-liberal by conviction, and favors the private healthcare system. He wanted the deal that would save and strengthen private insurance companies, not the public social fund. When he said otherwise, he was lyi…, er, triangulating. Not telling the truth.
The details of how Obama locked himself up with insurance, hospital, and pharmaceutical lobbyists to write the ACA, and ordered Democratic legislators to drop any “public option” are well known, and were well known at the time – although they were at the time, and still are, ignored by delusional Democratic constituents who want to believe that their party leaders only produce such monstrous policies because they’re hogtied by Republicans.
Back in 2010, Glenn Greenwald pointed out that: “[T]here was already ample evidence that the White House had, in fact, secretly negotiated away the public option early on in the process, including confirmation from a New York Times reporter of the existence of such a deal, as well the fact that Russ Feingold said as clearly as he could that the reason there was no public option in the final bill was because the White House never pushed for it, because the final bill — without the public option — was the “legislation that the president wanted in the first place.” The White house “secretly bargained away the public option with corporate interests early in the negotiation process,” and then “spent months after that assuring their supporters that they were doing everything they could do have a public option in the bill.” In another piece, Greenwald wrote that the Democratic Party leadership: “pretended in public to ‘demand’ that the public option be included via reconciliation with a letter that many of them signed (and thus placate their base: see, we really are for it!), while conspiring in private with the White House (which expressed ‘sharp resistance’ to the public option) to make sure it wouldn’t really happen.” (See also Miles Mogulescu at Huffington Post, and David Dayen at Firedoglake, and a David D. Kirkpatrick in the NYT.)
Hogtied? Hogwash. The Republicans did not stop the Democrats from doing anything. The Democratic politicians did exactly what they wanted (and what their constituents did not want). The ACA passed with no Republican votes. Didn’t need ‘em. Another world of healthcare was possible. People were clamoring for it. America had voted for, and expected it. It was Democratic Party health industry stooges, with Max Baucus and Barack Obama in the lead, who stood in the way, insisting that nothing else was possible. The progressive constituency, and the people of America, were betrayed by Obama and conservative Democratic legislators, who never wanted any public plan, and by compliant progressive Democratic legislators who reneged on their sworn and signed promise not to vote for exactly the kind of capitulation to the insurance companies the ACA is. Prominent liberal groups and personalities – MoveOn, the unions, and the Michael Moores – collaborated in this betrayal en masse.
It was the progressive constituency, not the Republicans, that was being fought and played by the Obama and the Democratic Party, and it was Obama and the Democratic Party who should have been the targets of progressives’ relentless pressure for a single-payer system.
Consider even what might have been a “compromise” proposal: Would it have been “impossible” to get an extension of Medicare to cover everyone older than 54 and younger than 25, with others having the possibility of buying into Medicare? That would have been a real step in the right direction, because it would have preserved, strengthened, and extended the public social fund that serves the common good. It would also have grabbed all the boomers, all the students, and every parent, and brought a lot of new money into Medicare. Can anybody seriously think this would have been a harder sell, than the incomprehensible hodgepodge of the ACA?
(A well-connected Democratic source swore to me that the Democratic congressional leadership, working with Howard Dean, was ready to introduce some kind of Medicare expansion like that, but was ordered by the White House to drop it, which they dutifully did.)
Not only was it politically possible to make the case for single-payer Medicare-for-all, it would have been more politically/electorally advantageous to do so. If they had made the case forcefully for such a clear and simple solution, Obama and the supposedly progressive Democrats would have put the Republicans in the rhetorical position of arguing against Medicare. Even if, because of resistance by reactionary Democrats, they had failed to pass the legislation at first try, they would have laid the ideological and political groundwork for continuing the debate, and strengthening their electoral position. That is serious politics.
Instead, unable to generate any logic or passion for a complicated program involving forced purchases, new taxes, and hidden confusions – which, to this day, no one understands – Obama and the Democrats gave the Republicans a chance to pose as defenders of free choice and Medicare, and to re-constitute a newly aggressive, revanchist, laissez-faire ideology. In the context, it was an enormous defeat, with horrible long-, or at least mid-term consequences for the Democrats electorally, and for the country ideologically.
How’s that political “pragmatism” working out for the Democrats now? (“With [2014] elections looming, Obamacare rattling Democratic nerves.” http://www.cnn.com/2013/11/08/politics/obamacare-nervous-democrats/ )