We are proud of the NHS

By David Cameron
Conservatives
The Blue Blog
August 13, 2009

People still care about the issues they care about, and thanks to the internet they can voice their concerns whenever they want. Just look at all the support which the NHS (National Health Service) has received on Twitter over the last couple of days. It is a reminder – if one were needed – of how proud we in Britain are of the NHS.

Millions of people are grateful for the care they have received from the NHS – including my own family. One of the wonderful things about living in this country is that the moment you’re injured or fall ill – no matter who you are, where you are from, or how much money you’ve got – you know that the NHS will look after you.

That’s why we as a Party are so committed not just to the principles behind the NHS, but to doing all we can to improve the way it works in practice. So yes, we will spend more on the NHS, but we will also improve it so that it is more efficient and responsive to patients. People working on the frontline will actually be able get on with the job they signed up for, without getting tied up in a web of targets. And we will put more power in the hands of patients by giving them better information about the care they can expect to receive.

Underlying these reforms, and our whole approach to the NHS, will be one big ambition – that future generations will be even prouder of the NHS than we are today.

http://www.conservatives.com/News/Blogs/We_are_proud_of_the_NHS.aspx

The Right Honourable David Cameron MP is the leader of the Conservative Party in the United Kingdom. Many believe that he will replace Gordon Brown as Prime Minister.

For those of us in the United States who want to know more about the horrors of their government-run, socialist system of health care, Conservative David Cameron would be the first to expose how government ownership and management are a threat to the health of the people. But that is not his message.

As he says, “One of the wonderful things about living in this country is that the moment you’re injured or fall ill – no matter who you are, where you are from, or how much money you’ve got – you know that the NHS will look after you.” He has joined the people of his nation in supporting the NHS, in reaction to the outrageous distortions and lies being propagated in the United States.

Karen Ignagni, President and CEO of America’s Health Insurance Plans (AHIP) recently stated, “As the American people have learned the facts, support for a government-run plan has plummeted.”(AHIP release, Aug 4)

What facts? Lies about the United Kingdom’s NHS? Lies about Canada’s medicare? Or lies about the consequences of providing all of us the benefits of our Medicare program which is working so well for our senior citizens and individuals with long-term disabilities?

The British and Canadians have identified the lies and are waging a campaign to set the record straight. We need to greatly intensify our efforts to do the same here.

End-of-Life Care: Where Ethics Meet Economics

By Uwe Reinhardt
The New York Times
August 14, 2009

… the debate — really, shouting match — over health-care reform has focused on end-of-life care in recent weeks…

An earlier report in The Wall Street Journal had quoted physicians at Memorial Sloan-Kettering Canter Center in New York stating that “the standard treatment regimen for advanced colon cancer, which can include Erbitux [and Eloxatin and Avastin] in the mix, is close to $250,000 for 19-20 months of treatment. … And for that money, patients may get only a few months [of added life].”

And therein lies a dilemma increasingly faced by modern societies.

Readers are well advised to read Senator Isakson’s thoughtful comments on end-of-life planning, along with an equally thoughtful research brief “Advance Care Planning: Preferences for Care at the End of Life,” published in March 2003 by the Agency for Health Care Research and Quality.

The thrust of that research brief, as of the Senate bill and of Section 1233 of the House bill, was to enhance the probability that the end-of-life care actually received by a person should conform to his or her own preferences, rather than either the physician’s or the government’s preferences.

Health spending in the United States has doubled every 10 years during the past four decades. It may well do so again in the coming decade. As health spending grows year after year roughly twice as fast as the payroll that supports private health spending in this country, Americans sooner or later will have to confront the hard questions about access to expensive treatments, perhaps after a rational national conversation, if such can still be had in America.

Posted reader comment:

Ethics meets economics not only at the end of life, but throughout a lifetime of health care. Economics provides us with various alternatives on financing health care, and ethics provides us with the decency to do it the right way.

But the pervasive noise seems to be drowning reason out. For example, when a protester complained to Sen. Specter that he wasn’t listening to what they wanted, Sen. Specter asked him to tell him just that. The protester was flummoxed, and only after being prompted by several others in the audience, he said, “tort reform.”

It would be tragic if those crafting reform allow themselves to be influenced by those who understand neither the economics nor the ethics. Perhaps it would be even worse if they allow themselves to be influenced by the moneyed interests who understand very well the economics, but could care less about the ethics.

– Don McCanne, MD

http://economix.blogs.nytimes.com/2009/08/14/end-of-life-care-where-ethics-meet-economics/#more-26155

By Kip Sullivan, JD

When the Senate Health, Education, Labor and Pensions (HELP) Committee passed a bill on July 15 creating an anemic “public option” program, Health Care for America Now (HCAN) and other “public option” proponents were ecstatic. They welcomed the “public option” in the HELP committee bill, proclaiming it “strong” or “robust.”  But the actual provisions in the HELP Committee bill call for numerous “community health insurance options,” not the single “Medicare-like” plan promised by “public option” advocates. That means the individual “options” will probably be as small and weak as the co-ops now under discussion in the Senate Finance Committee. More importantly, these “community options” will almost certainly be run by insurance companies.

Finding the HELP Committee bill

To determine what the HELP Committee “public option” proposal is, one must first find a final version of the legislation that came out of the committee. Ordinarily, that is not a difficult process. But for some reason, the HELP Committee bill still has no bill number and, three weeks after it was voted out of the HELP committee, still is not available for the public to read. That might sound like a sloppy way to run a Senate committee, but I have confirmed with two sources that there is no final bill available.  An aide in the Washington office of Senator Al Franken (D-MN), with whom I spoke on August 7, referred me to the draft bill posted at the HELP Committee’s Website.  At this Website, the draft bill appears in two pieces, one labeled “the Affordable Health Choices Act” and the other labeled “the additional Chairman’s mark on coverage.”  It is in the “Chairman’s mark” segment of the bill, beginning at page 77, that we find “Section 3106: Community health insurance option.”

Summary of Section 3106 in semi-plain English

Section 3106 is difficult to read. It fails to offer clear definitions of critical terms, it uses different terms to describe the same thing, and it contains unnecessarily abstract language.  Because it is poorly written, it requires at least two readings to understand it.  I will tell you first what I derive from it in the plainest language possible, and then discuss some of its provisions so you can judge for yourself whether I got it right.

Section 3106 requires the Secretary of the Department of Health and Human Services (DHHS, the federal agency within which Medicare and Medicaid are housed) to create multiple health insurance companies that, together, will make “public” health insurance available for sale to the non-elderly in every state in the country.  The Secretary will not be using federal employees to make this happen.  The Secretary is required, rather, to contract with nonprofit insurance companies to create health insurance policies that will qualify as “community health insurance options.” (Some of the bill’s language seems to be confusing by design.  What meaning is conveyed by adding “community” and “options” to “health insurance”?)

The corporations that contract with the Secretary to create these “community” health insurance companies will be required to meet the same standards insurance companies currently must meet in order to serve as “Medicare Administrative Contractors” (MACs) to administer Medicare’s traditional program. These corporations must, in other words, be insurance companies.

To get some idea of which insurance companies meet current MAC standards, and are therefore the ones likely to get contracts with the Secretary under the HELP Committee bill, consider this list of the companies that now have MAC contracts with the Centers for Medicare and Medicaid Services (CMS, the agency that runs Medicare):

• Cahaba Government Benefit Administrators, a subsidiary of Blue Cross and Blue Shield of Alabama;
• First Coast Service Options, a subsidiary of Blue Cross and Blue Shield of Florida;
• Highmark Medical Services, a division of Highmark Blue Cross Blue Shield of Pennsylvania;
• National Government Services, a subsidiary of WellPoint, the nation’s largest health insurance company measured by enrollment (as opposed to revenues);
• National Heritage Insurance Corporation, which is a subsidiary of Electronic Data Systems (the firm Ross Perot founded) which is now a subsidiary of Hewlett Packard;
• Noridian Administrative Services;
• Palmetto GBA, a subsidiary of Blue Cross Blue Shield of South Carolina;
• Pinnacle Business Solutions, a subsidiary of Blue Cross Blue Shield of Arkansas;
• Trailblazer Health Enterprises, a subsidiary of Blue Cross Blue Shield of South Carolina;
• Wisconsin Physicians Services Health Insurance Corporation.

Most of the large health insurance companies, such as United HealthCare and Cigna, have also held similar contracts in the past.

Now that I’ve tried to explain Section 3106 in the Mother Tongue, it is time to immerse ourselves in the actual bill language. In the next section I review the language that indicates Section 3106 is proposing multiple “options,” not a single Medicare-like program. In the section after that I review the language that indicates the multiple “options” will be created by nonprofit insurance companies like Blue Cross Blue Shield.

Decoding Section 3106: Is it one “option” or multiple “options”?

Section 3106 proposes multiple “options,” not a single Medicare-like program, but this is not apparent at first. The first three sentences contradict each other.  The very first sentence says there will be multiple “options” serving “communities” (not the whole country):

“Nothing in this section shall be construed to require a health care provider to participate in a community health insurance option….”

The second sentence says the same thing about individual patients and repeats the phrase – “a community health insurance option.” These first two sentences indicate the HELP Committee is referring to an entity at the “community” level, not the national level, and the Committee anticipates there will be many of these entities, not just one of them.

But the third sentence confuses the reader by referring to the local entities as a single program:

“The Secretary [of the Department of Health and Human Services] shall establish a community health insurance option to offer … health care coverage… throughout the United States.”

But as we read on, we encounter provision after provision that indicates the HELP Committee definitely envisions a balkanized “option.” Some provisions reveal that intention by referring to “options” plural. Others reveal it by giving the states the authority to determine essential features of “options” sold within their boundaries, such as the required reserve levels and maximum benefits. A single national program can’t have 50 different reserve requirements and 50 different benefit levels.

Here are two examples of the use of “options” plural in Section 3106: (1) Under a section entitled “Applicable rules,” we learn a previously enacted law “shall apply to community health insurance options”; and (2) a section entitled “Ombudsman” begins, “In establishing community health insurance options, the Secretary shall….”

Here are two examples of provisions giving the states authority to define key features of “options”: (1) The only sentence in a section entitled “States may offer additional benefits” reads, “A state may require that a community health insurance option offered in such State offer benefits in addition to the essential health benefits required under [another subsection]”; and (2) under a section headed “Solvency,” we find, “A community health insurance option shall … be subject to the solvency standard of each State in which such community health insurance option is offered.”

A patchwork of 50 different reserve requirements and 50 different benefit levels seems a far cry from “public option” proponents’ vision of a single, Medicare-like plan covering the whole country.

Decoding continued: “Option” means Blue Cross Blue Shield

The second major cause of confusion in Section 3106 is its use of four terms, all of them vague, to describe the insurance companies that will sell the “options.” The bill uses these four terms interchangeably: “community health insurance option,” “qualified carrier,” “qualified entity,” and “contracting administrator.”

A brief example: In subsection 1 of a section entitled “Start-up Fund,” the bill establishes a “Health Benefit Plan Start-up Fund … to provide loans for the initial operations of a community health insurance option.” But subsection 2 says loan money from this fund is supposed to go to “carriers,” and subsection 3 says it shall go to “contracting administrators.” (“Carriers” is a term Medicare just phased out after four decades of use. The term referred to insurance companies which processed claims from doctors. Medicare now uses the term “Medicare administrative contractors.” The HELP Committee’s bill writers no doubt meant to refer to “contracting administrators,” not “carriers.” As I indicated above, “contracting administrators” will look almost exactly like the MACs that now serve Medicare.) Finally, subsection 5 says the loans must be repaid by “the community health insurance option” (not carriers or contracting administrators).

The only reasonable interpretation of this goulash is that insurance companies known as “contracting administrators” will be put in charge of creating health insurance companies all over the country that will contain “community health insurance” in their titles.

This interpretation is confirmed by subsequent provisions in Section 3106.  In a section entitled “Authority to contract,” the bill says the Secretary may “enter into a contract with a qualified entity” to perform the same duties MACs perform for Medicare, and once this contract has been signed the entity becomes “a contracting administrator.” (These contracts must last at least five years and may not last more than ten years.) In addition to meeting the MAC standards, contracting administrators have to be:

• non-profit;
• able “to offer a community health insurance option”;
• “eligible to offer health insurance” (I assume this strange phrasing means the insurance company is licensed in the state where it hopes to sell “options”);
• able to achieve “delivery of benefits”; and
• able to “promot[e] high quality clinical care.”

The requirement that the contracting insurers be able to “promote high quality clinical care” is a tip-off that the HELP Committee wants the insurance companies that will run the “community options” to use managed care cost-control tactics. A second tip-off is that Section 3106 does not guarantee patients the right to choose their own clinic and hospital.  Instead the bill only requires that a ”community” insurer will be one that “offers a wide choice of providers.”  In short, an entity that meets the MAC standards plus the additional criteria in Section 3106 amounts to your basic, non-profit managed care insurance company. The big ones these days include many Blue Cross Blue Shield companies and the nonprofit HMOs such as Kaiser Permanente, Group Heath of Puget Sound, and HealthPartners.

The only conceivable development that could keep existing non-profit insurance companies from winning the contracts to develop and run the “community options” would be the birth of dozens of non-profit companies with the expertise of insurance companies between the time Section 3106 becomes law and the time the law takes effect. In theory, that could happen. But it is extremely unlikely. It is unlikely because of the short time period between the date Section 3106 is enacted and the time it takes effect, and because of the difficulty of creating corporations with the expertise to create health insurance companies.

Section 3106 does contain language that should please HCAN and other “public option” advocates who were expecting the HELP Committee to endorse a Medicare-like “option.” In two places, Section 3106 says the Secretary “shall negotiate” provider rates. But without a guarantee that the “options” in each state will enroll tens or hundreds of thousands of people, and without a requirement that providers participate, this is a meaningless provision.

This leads me to my last observation about Section 3106.  How are contracting administrators supposed to create a customer base and a network of providers? Can they do it with whatever loans will be made available to them from the Start-up Fund? Section 3106 offers no answers to these questions.

Implications

If my interpretation of Section 3106 is correct – if the Senate HELP Committee’s “option” program is going to be balkanized and run by the nonprofit wing of the insurance industry – then reasonable people have to conclude that the deck is really stacked against the Committee’s “option” program. Even if Section 3106 authorized public employees, not Blue Cross Blue Shield employees, to create the dozens or hundreds of “community health insurance options” called for by Section 3106, the program would fail to pose any challenge to the insurance industry and might even die in the cradle. The health insurance industry has been very difficult to break into since at least the 1980s, and has become more so in the wake of the merger madness that swept through the industry in the early 1990s. But if public employees are not going to be directly responsible for creating the “community options” – if the nonprofit wing of the insurance industry is going to be doing that – then the entire “community option” project of the Senate HELP Committee amounts to a cruel joke on the public. Should the public trust corporations like Blue Cross and Kaiser Permanente to make a good faith effort to build competing insurance companies?

Section 3106 is a mess, but its meaning becomes clear after several readings. Section 3106 does not create the “Medicare-like” program promised by Jacob Hacker, HCAN, Howard Dean, and other “option” advocates. Instead it proposes a program that authorizes DHHS to create numerous health insurance companies tied to geographic areas, and to contract with members of the existing insurance industry to create and possibly run those companies.

Leaders of the “public option” movement have an obligation to advertise the HELP Committee bill truthfully. It is not accurate to say the HELP Committee bill creates a “robust” or “strong” public option. It is not even accurate to say the HELP Committee bill creates one “option.” The truth is the “option” is balkanized and very weak. In fact, HCAN, Andy Stern, Howard Dean and other “option” advocates who have praised the HELP Committee bill should do more than cease to praise it. They should tell Congress they oppose it.

Kip Sullivan is a member of the steering committee of the Minnesota Chapter of Physicians for a National Health Program.

Summary:

Panelists from Staten Island Community Groups and PNHP encountered angry jeers from “anti-government” mob in Staten Island Church Healthcare Forum Wed Aug. 12^th.  Differences between single payer and current house bill were felt to be irrelevant by the vocal audience members.

Details

This meeting was organized by Staten Island Family Health Care Coalition.  Katie Robbins (Healthcare Now) and I were asked to present the House Bill 3200 and our critique.  Katie missed our talk part due to a subway mishap but videotaped the event and will edit it.  Event organizers told us that OFA was invited but did not send anyone to the meeting.  There were police present as a menacing call was received by organizers prior to the event saying “there better not be any illegal immigrants there.”

I explained the basics of 3200 and where 3200 fits into the legislative process.  I said I was for single payer, Medicare 2.0 for all and that it is a terrible misconception that healthcare is a zero sum game whereby the some must sacrifice to cover the uninsured.   With “everybody in, nobody out” public insurance for all there would be plenty to go around and we could all do better by getting better value for our healthcare dollar with this fiscally conservative program.  Jeers and interruptions came from the audience.

Other panelists included the MC, an internist with the Richmond MSSNY (AMA affiliate), a representative from the Richmond Chamber of Commerce, who outlined her members concerns with high costs of compliance with 3200, a representative from an HHC “safety net” facility who told stories of how help was needed for many, a representative from Jewish Community Services who tries to connect people with insurance about current problems of loopholes in eligibility as well as eligibles who don’t know they can get Medicaid, the director of a SI FHQC who described hardships at his centers and expressed concern that primary care physician supply would be inadequate to meet needs if everyone were insured.   Many in the audience were impatient with all presentations, wanting to speak and clearly angry that Cong. Mc Mahon was not there.  This was expressed through heckling, groaning, eye-rolling and interruptions.

A representative from McMahon’s office was present and attempted to field questions from the jeering crowd about McMahon’s non-presence.  He committed to a future event with McMahon to explain the legislation as it evolves.

The MC then had audience members line up at a microphone to speak and tried to limit those who were yelling out.  The first audience member mocked the bodyweight of the woman who convened the conference.  This drew disapproval even from some among the “angry yeller” ranks, but also laughter.  Major themes expressed by the group in an apparently orchestrated fashion: need to minimize government and taxes, accusations that proposed health reform is, variously “Trojan horse” for single payer or “Soviet” “Socialized medicine”.  Someone yelled out from the sidelines questioning Obama’s citizenship.  Right after that, one man, one of few blacks in the audience got up and left.

Other recurrent themes were the need for personal responsibility to buy insurance (“they got ipods, they should buy health insurance”), that illegal immigrants and others who “contribute nothing” are getting free services at the expense of “hard working Americans”.  In response to a panelist’s story about a foot amputation in a diabetic who could not afford healthcare someone called out “Come on, she really couldn’t afford the $200 podiatry visit?”.  When one panelist told the story of an insured person who nearly lost her house to pay for chemo an audience member called out to say “My insurance covered my chemo”.

Along with demands that the government get out of healthcare was rage at proposed cuts to Medicare and purported ineligibility for Medicaid for homeowners (sometimes in the same sentence) while illegals get a “free ride”.   One of the panelists who worked getting people insurance had earlier said that the “homeowner exclusion” was a misconception.    One person demanded “an end to class warfare”.

Other ideas expressed: Tort reform will control costs, tax cuts would lead to more jobs and then everyone could afford “to take care of themselves without the government”.  I and others occasionally interjected to indicate points of fact on what was and was not in the bill (ie many of the suggested changes to public programs made by “the angry” are in the bill, the bill does not provide insurance to undocumented immigrants etc.).

We ended late when we had to leave the venue (a Moravian Church).  Someone from the audience came up to me afterwards and made a comment I think is correct.  He said noone cares what’s in the bill, it’s not really about the bill or healthcare but a bigger worldview.

In this worldview all of the panelists are part of an elite monolith who “don’t get it”.   Some or all of the “the angry” were from the Staten Island Tea Party Organization.  I’d estimate they made up half the crowd of about 150.  They were coordinated and had notes.   A rallying cry to throw representatives who vote for reform out of office and “keep listening to talk radio” led to fist pumping and cheers.

A soft spoken young man working with the forum organizers volunteered to give Katie and I a lift to the train.  In the car he said he was really for socialized medicine rather than single payer.

Press coverage in Staten Island Advance (no mention of single payer) http://www.silive.com/news/advance/index.ssf?/base/news/1250163911258370.xml&coll=1

Based on comments at a July 1^st Federalist Society debate on health reform

Single payer:  freedom, choice and quality

Healthcare is a human right.  It is fundamental and instrumental to life, liberty and the pursuit of happiness.

We are paying for a first rate system but getting a mediocre one, getting phenomenally low value on the dollar.  We spend twice as much as other developed nations but are not healthier as a result.  In many indices of major health outcomes we trail other developed nations.  We have scarcity in the midst of excess.  This is a scandal and a shame and we can do better.

I reject the notion that many propose, that healthcare is a zero-sum game in which universal access threatens quality.  Universal access combined with public accountability will enhance quality.  The whole system is stronger and better if we all go in together to one big risk pool.  By publically insuring everybody, we could, with the money we are spending now, provide what we need/when we need it healthcare for everyone.  This is single payer, Medicare 2.0.  It is public insurance with private delivery.

Single payer is controversial in some circles.  However, it’s beneficial effects regarding cost containment are generally conceded on all sides.  I will not dwell on these.  I will focus instead on how single payer can enhance freedom, choice, and quality in American medicine.

The “Other in our midst”

Before going on I want to first address a pernicious idea promoted by many who oppose health reform head on.  It is rarely spoken of directly.  There are many who would like you to believe that there is some “other” in our midst whose ills and lifestyles account for the poor health status and high costs of Americans.  These are, variously, overweight, substance abusing, drunken driving, gun-fighting, illegal immigrant, unwed mothers, smokers and others.

“Others” aren’t the cause of high costs

The idea that the bad aspects of our system are limited to various “others” is a folly, and a dangerous one.   The “expensive” people in healthcare are the sick and, alas, we will all be there someday, somehow.  The single biggest risk factor predicting high utilization of healthcare services is not obesity, smoking, drinking or other putatively “voluntary” lifestyle factors.  It is age.  The bulk of healthcare spending in any given year is on a very sick minority.  The majority has an interest in protecting this minority because, literally, we could join them anytime.

“Others” aren’t the cause of bad US healthcare outcomes.

There are more unwed mothers and many, many more smokers in Europe.  Conventional wisdom about alcohol use aside, there is no evidence that Europeans suffer fewer medical complications of alcohol overuse than we do.  They are also rapidly gaining on us in girth and also have large populations of documented and undocumented immigrants.

Quality and Quantity of US Care

As I have said we have scarcity in the midst of excess with healthcare distribution according to ability to pay/get reimbursed.  Up to a third of overall medical expenses are judged to be due to unnecessary interventions.  At the same a third of Americans say they are cutting back on medications and routine medical care due to cost.

Make no mistake, unnecessary procedures are not just expensive, they cause net harm including permanent injury and deaths.   High costs are not just lamentable for bean counters, they mean large numbers of Americans don’t seek timely care and don’t take meds.

High Tech Care, Research and Innovation

Our supposed reward for accepting the harsh reality of un- and under-insurance is high tech medicine and a system on the cutting edge of research and innovation.  This is a false choice.  Systems without for profit insurance are clearly able to support high quality and high tech medical care as well as cutting edge research.

There are more frequent hip replacements in Sweden and more bone marrow transplants in France and Italy.   Japan and several European countries have many more CT and MRI machines per capita than we do.

Biomedical researchers benchmark advances in knowledge by numbers of journal articles and how often other researchers cite those articles.  The US trails several European nations in this regard. Half the top ten pharmaceutical companies are European and pharmaceutical industry R&D per capita is greater in Sweden, Denmark and the UK than in the US.

We do a lot of clinical trials, but, frankly, these are rarely designed to answer questions clinicians want answered (like is this medicine any better than what we’ve got already) instead they are focused on marketing needs.

The case of “proton pump inhibitors”

I want to discuss one particular type of drug because I think the case illustrates how profit incentives can distort quality and value in healthcare and why it’s so important to Big Pharma to negotiate with many different payers rather than a single powerful one.  Multiple payers keep Americans paying the highest drug prices in the world and make it profitable to recycle old inventions rather than come up with new ones.

Take, for example proton pump inhibitors (PPIs ).  This category of medication was discovered in the late 80s and was a significant advance.  It’s used for stomach problems. The bedrock science research used to discover the drug was supported by US taxpayers via the National Institute of Health.  Nexium, the purple pill you may have heard of or actually take, is manufactured by an Anglo Swedish company which is the market leader in the PPI field. It is used mostly to treat heartburn, re-christened by industry marketers more ominously as GERD or gastroesophageal reflux disease.

New developments in this area since the late 80s looks like this:  6 new branded PPIs in 15 different forms made by 5 different pharmaceutical companies only 2 of which are American.  There is no scientific basis for believing any of the new formulations are better than the original one.

The original idea and basic research was done by an Austrian born and Scottish educated American.  He was working for a Swedish company at the time and is now at the US Dept of Veteran’s Affairs.

The basis for the most recent new PPI patent, issued over 20 years after the innovative compound was discovered, was for compounding the drug with baking soda so it would be “immediate release”.   Ultimately $44M was spent on product research and $48M was spent on marketing including a full time sales force of 400.   This is poor health value for dollars spent.

The PPI market is now driven largely by inappropriate prescriptions which are now estimated to accounting for up to 70% of all usage.  The problem is bigger than the money wasted.  Stomach acid fights infection as well as causing stomach irritation.  Use of these drugs causes increased rates of pneumonia and has contributed to the emergence of a treatment resistant superbug known in shorthand as “c diff”.

Now I’d like to address choice.

We need to get real on choice.  If there’s a single payer, everyone takes it.   I looked up my choice with my current plan (Aetna FEHB) versus traditional non-privatized Medicare.  I looked up my choices in two places: Wilkes-Barre PA and zip 10025 on UWS Manhattan where I live and work.  In both places I had more choices of doctors in a range of specialties with Medicare.  Sometimes Medicare recipients had over four times as many doctors to choose from as I did.  No, I didn’t get “just the best”, most everyone on Aetna also took Medicare.

I also know about choice available with private versus public Medicare from the range of referral options I discovered I had for my patients at Bellevue.  Want cancer care at Sloan Kettering or deep brain stimulation neurosurgery for Parkinson’s at Columbia?  You better have “real” public Medicare, not one of the privatized “Advantage” plans, because they don’t take them.

Private insurance offers the false “choice” of picking which for-profit shareholder accountable entity will get to limit your choices.   Let me say it again. Private insurance means limited choices.   Single payer means you choose to see anyone you want.

Let’s talk Wait Times

When I was pregnant many years ago I had private insurance but had to pull strings to get an appointment with an OB/GYN anytime in the first trimester of my pregnancy.

Last week I called up my gynecologist’s office to check on appointment availability and found there is a two 2 month wait.

Wait times for various services are related to the profitability of delivering those services rather than to medical urgency.

These are the wait times I found for Columbia Presbyterian Eastside Practice on East 60th Street in Manhattan:

To see dermatologist to evaluate a “suspicious mole”: 3 months

To see a dermatologist for a cosmetic evaluation: 2 weeks

For medical evaluation for insomnia which may include a lucrative “sleep study”: 3 weeks.

To get a mammogram: 3 months

I could get my hip replaced electively in Toronto sooner than I can get a mammogram or see my GYN in Manhattan.  I know that because wait times and procedure availability for all sites is web published in Ontario to help patients choose where to go for care.  No equivalent information is available to me in NY.

Let me address the feared army of bureaucrats:

I have seen this army.  It is not coming, it has already arrived!  US physicians report MORE external reviews of their clinical decisions to control costs than doctors in other countries.  Here’s a recent example from my practice to show you why we feel that way:

This was at a model private rural care delivery system in Pennsylvania with sophisticated electronic health records.   I ordered an ultrasound of the carotid arteries in a patient who had just had a stroke.  This is deeply within standard non-controversial medical practice since carotid artery disease can cause strokes.  A screen popped up informing me that the patients insurance would not cover the test.  I don’t know how much the test costs, our medical culture involves ordering from a menu with no prices.  It seemed safe to assume it was at least several hundred dollars an amount my clinical judgment told me might be challenging for this particular person.

In the great tradition of modern medicine, using all the bureaucratic skills as I have learned in dealing with multiple payers and random requirements over many years, I jiggered his ICD-9 diagnosis codes until the procedure was flagged as approved.  This was a waste of my time.  My time, by the way, was paid for by the greater “system”.

That same week I was also called on to consult on a patient who found herself in the “donut hole” of the entirely private Medicare part D drug plan, unable to afford critical medicines for multiple sclerosis.  I confess, I had nothing to add.  She needed the drug, it’s massively expensive (>1K/mo), there is no cheap alternative, and she could not afford it.  Industry patient assistance programs had multiple barriers to access and, when Part D was initiated, categorically declined to assist most of these patients.  I suggested a social worker get involved although I knew a social worker had already been involved. End of depressing consult.  She was in the hospital for timely performed elective knee replacement, paid for by her insurance.

All of the drugs which can change the course of multiple scleroris are “biologics”.  There is no current pathway for these to become generic and deal making in the production of current democratic legislation includes protections to further protect these agents from generic competition.

I want to adress freedom.

Single Payer separates insurance from employment, thus liberating business from a major drag on international competitiveness.  Single payer also ends the “job lock” phenomenon where people stay in dead jobs because of insurance availability.  The end of job lock supports a flexible labor market and the healthy entrepreneurship, which is the backbone of American innovation.

Private Health Insurance: not enough security

There is no freedom without security.  Private insurance does not provide even the relatively healthy population they cover with health security.  Most US bankruptcy involves medical debt.  Medical bankruptcy is unknown in other developed nations.

This past june the LA Times reported that congressional investigators found that three private health insurers canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.

It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.

A Texas nurse said she lost her coverage, after she was diagnosed with aggressive breast cancer, for failing to disclose a visit to a dermatologist for acne.

The sister of an Illinois man who died of lymphoma said his policy was rescinded for the failure to report a possible aneurysm and gallstones that his physician noted in his chart but did not discuss with him.

One employee, for instance, received a perfect 5 for “exceptional performance” on an evaluation that noted the employee’s role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.

American Values

Now I do not always feel that Uncle Sam is my best friend.  Nonetheless, I do feel better about Uncle Sam than I do about these private insurance companies.  It’s not very complicated, the government is publically accountable, privately held companies are accountable to their shareholders.

Most Americans including most physicians support single payer health insurance.  Special interest health industry lobbies are spending $1.4M DAILY to help spread a message of fear about health reform and continue on with a “business as usual”.  But American values and American health are best supported by a single payer system.

I am not afraid of the postal system.   I am not afraid of the highways.  I am not afraid of Medicare and I am proud to serve in our Department of Veteran’s Affairs.  I have seen the rough edges and devastating human consequences of our failed system over and over again.  Government provision of health insurance is the best way to guarantee healthcare quality and assert individual freedom and choice in obtaining this basic human right.

Health care for all

By Helen Thomas
San Francisco Chronicle
Politics Blog
August 12, 2009

It’s all so sad. Well-organized conservatives have launched a full-scale attack on health care reform. And they appear to be winning — for now.

I covered the battle to create the Medicare system back in the 1960s. The cries of “socialized medicine” worked for years until President Johnson rammed Medicare through Congress in 1965.

What kind of a nation are we if we do not provide everyone with the excellent medical care that only some of us now receive?

I continue to think the so-called single-payer system is the only answer to the nation’s obligation to make sure that no one lacks health care. Yes, single payer means a government-run health insurance program for all — the prevailing system in Canada and in many nations in Europe.

President Obama is making a big mistake by ignoring the single-payer proposal.

In 2003 before he became a U.S. senator from Illinois, Obama actually called himself a single-payer “proponent.” But now that he is president, Obama has buckled to Republicans and conservative Blue Dog Democrats in pursuit of consensus. My question is if Congress passes a watered-down version of health care that doesn’t truly cover everyone, is the result worth it?

President Obama should lay down markers for real health care reform — meaning we all kick in to a national program instead of fattening the pocketbooks of the insurance financiers.

Instead, the president has given up on Medicare for all, calling single payer “impractical.”

He still has time to do the right thing and nothing to lose.

For the full article:
http://www.sfgate.com/cgi-bin/blogs/nov05election/detail?blogid=14&entry_id=45426

Helen Thomas doesn’t ever give up, thank goodness. As she writes, President Obama “still has time to do the right thing.”

The Value of Provider Networks and the Role of Out-of-Network Provider Charges in Rising Health Care Costs

AHIP (America’s Health Insurance Plans)
August 2009

One tool that health insurance plans use to improve quality and make health care more affordable for consumers is the establishment of provider networks.

Some out-of-network providers are charging exorbitant prices — several hundred or even over a thousand percent of the Medicare reimbursement for the same service in the same area. Recent examples: $4,500 for an office visit when Medicare would have paid $134; $14,400 for removal of a gallbladder when Medicare would have paid $656; and $40,000 for a total hip replacement when Medicare would have paid $1,558.

Consumers who are charged exorbitant fees by out-of-network providers incur additional costs because the protection against balance billing generally does not extend to services provided out-of-network. This detracts from the ability of health plans to offer affordable access to out-of-network providers for those consumers who want the advantages of a network, but also maintain the option to go out-of-network if they choose.

Report:
http://www.ahipresearch.org/PDFs/ValueSurvey/AllStatesReport.pdf

And…

New Report Examines Out-of-Network Charges by Some Physicians

AHIP
August 12, 2009

While the issue of how much is appropriate for out-of-network physicians to charge has not been part of health reform discussion to date, this report demonstrates that it needs to be. No mechanism exists to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.

“As policymakers pursue health care reform, we encourage them to look at how much is being charged for services, particularly since higher charges don’t mean high quality of care,” said AHIP President and CEO Karen Ignagni. “With the nation facing the crushing burden of rising medical costs, all stakeholders should be focusing on constructive ways to bring costs under control.”

Press release:
http://www.ahip.org/content/pressrelease.aspx?docid=28028

As we look at comprehensive health care reform, we really have to ask ourselves just what is it that the private insurance plans are providing us in exchange for their exorbitantly high administrative costs and the costly administrative burden they place on the health care delivery system?

Risk pooling? Public systems pool risk much more effectively than private plans. In fact, the private insurance industry wastes resources in their efforts to avoid risk. They’re not selling us the equitable risk pooling function that we want, and yet they’re charging us more for their lousy services. We don’t need that.

Managed care? Patients and their health care professionals do not want intrusive administrative managers intervening in their care. The private insurers have received that message and have backed off on the more explicit prohibitions of care. What they have not backed off on is selling us ever more of their wasteful, expensive managed care administrative services that are no longer particularly effective in moderating health care costs increases. They are perpetuating their unwanted intrusions, and they are charging us more for that. We don’t need that either.

So what service are they providing us? They have instituted private sector price controls by establishing contracts with hospitals, laboratories, health care professionals and other sectors of the health care delivery system. Their report released this week confirms that this is an important function. Prices set by the health care industry are much higher than prices dictated by the health insurance industry. If you think health insurance premiums are high now, just think of what they would have been without the private sector price controls applied to the contracted networks of providers.

Of course, there are trade offs. It is very expensive to provide the administrative services of both the insurers and the providers that are necessary to establish and manage these contracts. More dollars are diverted from actual health care to pay for these administrative excesses. A more perverse trade off is that patients are denied their free choice of health care professionals, hospitals, and laboratories since they must choose from the limited in-network panels provided by the insurers. They are limiting our choices, and they are charging us more for these unwanted services. Who wants that?

There is one more trade off that has left a gigantic, gaping hole in the private insurance model of health care financing. There are many legitimate reasons why an individual may receive care from out-of-network providers. When the private insurers do not have contracts with these out-of-network physicians and hospitals, they have no ability to dictate private sector prices. If the private insurers pay the full out-of-network fees, in-network providers will cancel their contracts and then demand the same prices, thus driving up our insurance premiums. If the insurers do not pay these high out-of-network fees, the patient is stuck with them. This is one of the reasons that individuals with “good” insurance end up in bankruptcy due to medical debt.

The timing of this AHIP report is no accident. Congress and the administration have now agreed that individuals will be required to purchase private health plans, perhaps with the additional option of a private model plan that is public in name only. Since the insurers have agreed to provide coverage for everyone not covered by other public and private plans, and since they will continue to use contracted provider networks (PPO, POS, and HMO), they understand that a solution to the high prices of out-of-network providers will have to be provided.

What is their solution? Although it appears only between the lines, their proposal is really not that subtle. “Out-of-network providers are charging exorbitant prices.” AHIP places the entire blame on those who refuse to sign their contracts. “No mechanism exists to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.” AHIP obviously is calling for a mechanism to control the prices of providers with whom the insurers have no contract.

Lacking the ability to enforce private market contracts that were never agreed to, there is only one other entity that can provide a price-control mechanism. Jumping out from the space between the lines of their report, that entity is obviously the government – yes, the GOVERNMENT! AHIP is implicitly supporting government price controls for health care. But then that isn’t such a foreign concept for them. For decades, they’ve been using price controls through their own private bureaucracies.

So the only service they are providing is a profoundly expensive, administratively wasteful set of fragmented, restricted networks of providers that fall short of controlling prices throughout the system, and for that we have to give up our choice of health care professionals and facilities, not to mention giving up more of our money.

What if we got rid of the private insurers and had the government do it instead? Our experience with Medicare should give us an idea of how that might work. The administrative waste in the Medicare program is much less than that of the private plans. The additional administrative burden placed on the health care delivery system would be reduced dramatically since the providers would have to deal with only one payer and one set of rules. Not only would all risks be pooled together into a single pool, that pool would be funded much more equitably based on ability to pay. Since virtually all physicians and hospitals would participate in the program, patient choice would be almost unlimited, including the right to choose an integrated health system, if so desired.

Just like the private plans, Medicare has established prices for those contracting with the program. But what about those providers who do not have contracts? These are like the providers over whom the private insurers have no control. Well, Medicare is a government program. As such they dictate the prices, with slight adjustments, for non-contracted providers. The only way a physician can charge a Medicare patient the full list price is to refuse to bill Medicare for any patient at all for a minimum of two years, and to have this patient sign an agreement that he or she likewise will not try to collect from Medicare.

So we already have the heavy hand of government administering price controls. But isn’t that what AHIP is not so subtly advocating? GOVERNMENT PRICE CONTROLS for those providers who refuse to sign their private insurance contracts! If the government is going to control prices anyway, then why would we need or even want the private insurance contracts?

BusinessWeek’s statement this past week that the health insurers have already won should not be accepted as a given, but should be considered a challenge to us to demand, in loud and clear terms, the reform that we need. Let’s make it a very hot August for our representatives in Congress, but let’s make our message effective by being polite while we generate heat.

From: Douglas W. Elmendorf, Director

To: Honorable Nathan Deal, Ranking Member, Subcommittee on Health, Committee on Energy and Commerce, U.S. House of Representatives
Congressional Budget Office
Letter
August 7, 2009

This letter responds to the question you asked at a July 16, 2009, committee markup concerning the Congressional Budget Office’s (CBO’s) analysis of the budgetary effects of proposals to expand governmental support for preventive medical care and wellness services.

Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.

Researchers who have examined the effects of preventive care generally find that the added costs of widespread use of preventive services tend to exceed the savings from averted illness.

Wellness services include efforts to encourage healthy eating habits and exercise and to discourage bad habits such as smoking.

… obesity is the end result of several interacting factors that are not all intrinsically unhealthy. One of those factors is obviously diet, which can be hard to regulate because many foods are safe to eat in moderation. Another key factor is lack of exercise, a bad habit that — like a poor diet — can be difficult for individuals to change and is particularly difficult for policymakers to influence. Approaches for losing weight reflect those difficulties: A variety of interventions appear to succeed in the short run, but relatively few participants are able to maintain their weight loss for a long period of time.

http://www.cbo.gov/ftpdocs/104xx/doc10492/08-07-Prevention.pdf

And…

The Impact of Prevention on Reducing the Burden of Cardiovascular Disease

By Richard Kahn, PhD; Rose Marie Robertson, MD, FAHA; Robert Smith, PhD; David Eddy, MD, PhD
Circulation
2008;118:576-585

Aggressive application of nationally recommended prevention activities could prevent a high proportion of the (coronary artery disease) events and strokes that are otherwise expected to occur in adults in the United States today. However, as they are currently delivered, most of the prevention activities will substantially increase costs.

http://circ.ahajournals.org/cgi/reprint/118/5/576

And…

Does Preventive Care Save Money?

By Joshua T. Cohen, Ph.D., Peter J. Neumann, Sc.D., and Milton C. Weinstein, Ph.D.
The New England Journal of Medicine
February 14, 2008

Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not.

http://content.nejm.org/cgi/reprint/358/7/661.pdf

Prevention and wellness programs frequently can be very beneficial for our physical health and our sense of well being, and when they are, they may well be worth the investment of our time and money.

What is troublesome is that Congress and the administration have chosen the most expensive model of health care reform, and they are pretending that the savings from prevention and wellness will be a major source of financing that reform. They contend that much of the benefit allegedly would be beyond the ten years budgeted, because it would take that long to realize the savings. But almost all studies indicate that the hoped for savings will never materialize. We’ll be spending more instead.

Yes, improved prevention and wellness programs should be a goal of our health care reform efforts, but the two most urgent goals are to include everyone and to make health care affordable.

Including everyone is easy. Simply make enrollment automatic for everyone.

Affordability is much more difficult, but you do not begin by choosing the most expensive model of reform, then adding programs that cost yet more money, and then pretending that they will magically reduce costs well off into the future when there is no evidence to support that wish-it-were-true policy.

The first and most important step toward attaining affordability would be to reject the most expensive model of financing health care, and instead enact the least expensive model which also happens to be the most effective: a single payer, Medicare-for-all national health program. The task of improving prevention and wellness programs would be much simpler and less expensive under such a model.

Dear PNHP colleagues and friends,

We at Physicians for a National Health Program are terribly saddened to report the sudden and unexpected loss of one of our staff members, Nicholas Skala, who died over the weekend in his Chicago home at the age of 27 of unknown causes.

Nick was one of our nation’s most gifted and dedicated advocates for single-payer national health insurance — for truly universal, comprehensive and quality care for all. His incisive mind, wide-ranging knowledge and formidable skills of argument were devoted entirely to bringing about a better world for everyone.

To his friends and co-workers, he was an extremely witty and compassionate human being, and a great source of inspiration and encouragement.

Nick had only recently returned to Chicago from two months in Washington, D.C., where he contributed significantly to the cause of single-payer health reform in multiple ways. He was committed to working for PNHP in our Chicago office during the next six weeks prior to his return to his classes at Northwestern University Law School.

His death is a heavy blow to our organization and to the entire single-payer movement.

We at PNHP extend our deepest and most sincere condolences to Nick’s family and friends.

We vow to redouble our efforts to bring about Nick Skala’s vision.

Sincerely,

Ida Hellander, M.D.
Executive Director

by Kip Sullivan, JD

Conservatives never base their opposition to single-payer on the ground that it is “politically infeasible.” They oppose single-payer on policy grounds and they say so. The “political feasibility” argument is used exclusively by proponents of universal health insurance who profess to admire single-payer systems but who refuse to support single-payer legislation in any meaningful way (and often support legislation that impedes single-payer’s progress) on the ground that single-payer cannot be enacted, soon or at all. Merton Bernstein and Ted Marmor refer to these people as “political yes buts.”

“Political yes buts” have been lecturing single-payer advocates since the modern American single-payer movement began in the late 1980s. Several “yes buts” took issue with a comment I posted on July 20 on this blog entitled “Bait and switch: How the ‘public option’ was sold.” In that comment, I compared the original version of the “public option” promoted by Jacob Hacker, the intellectual godfather of the idea, and Health Care for America Now (HCAN) with the version incorporated in two bills introduced by congressional Democrats in July.

I reported that Hacker’s original proposal called for a public health insurance program that would enroll 130 million people whereas the “public option” contained in the Democrats’ House bill would enroll 10 million at most and the “public option” in the Democrats’ Senate HELP Committee bill would enroll approximately no one. (Now that Democrats in the House have compromised away to the Blue Dogs a requirement that the “public option” use Medicare’s rates plus 5 percent, I assume the Congressional Budget Office will attribute roughly zero enrollment to the House version too.)

I stated that a “public option” with zero to 10 million enrollees might not survive and, if it did, it would have little effect on health care costs and the number of uninsured and underinsured. I criticized the leaders of the “public option” movement for failing to notify the public that the mousey “options” in the Democrats’ bills bear no resemblance to the huge “public option” originally proposed by Hacker and celebrated by HCAN.

My July 20 comment moved rapidly over the Internet, starting with a few blogs maintained by some long-time single-payer advocates (including Black Agenda Report and Corrente), and triggered much discussion. From what I could see, most of it was appreciative. However, there was some criticism. The critics didn’t challenge my facts, nor my conclusion that the “public option” had undergone great shrinkage, nor that its advocates had failed to apprise the public of that fact.

The criticism fell into two categories. The first category boiled down to the argument single-payer advocates have heard for two decades: Single-payer legislation is not feasible, or is less feasible than some version of the “public option.” The second type of criticism amounted to: It doesn’t matter that the “public option” has been degraded to a tiny ghost of its former self because it will inevitably be strengthened after it becomes law.

Here is an example of the “political feasibility” argument:

Simple fact: Single-payer is not within the realm of possibility this term.

Here is an example of the argument that it’s ok to support the mouse version of the Democrats’ “public option” because fundamental reform is usually achieved by building on small incremental reforms:

The author doesn’t even seem to understand how legislation is made….The fact is, it will be a lot more politically difficult for members of Congress to vote against those future incremental improvements than to vote against the entire plan now. Once it’s in place, and constituents start calling their elected officials with complaints, they’re going to have to fix those problems – or at the very least, not get in the way of the solution….We won’t get there overnight, but this bill will at least be a decent start.

Here is an example by a critic who makes both arguments:

As Teddy Kennedy says, the most important thing is to get a public plan by hook or crook and then expand it. But I would love to know why this fellow and others like him believe that, all things being equal (the same presidential campaign, the same economic conditions) single payer could have been sold more effectively than a public plan.

I address both types of criticism in this paper.

The feasibility argument is old, and it’s backwards

I first heard the “political feasibility” argument from members of a Minnesota health care reform commission in the spring and summer of 1990 when the coalition for which I was working, the Health Care Campaign of Minnesota, started visiting commission members to drum up support for single-payer legislation. I remember very clearly hearing the political feasibility argument on a hot summer day in 1990 in the office of Senator Linda Berglin, a commission member who also chaired the Senate health committee. Berglin, who was and still is from the safest Democratic-Farmer-Labor district in Minnesota, said she wouldn’t support single-payer because “we can’t beat the insurance industry” (or words almost exactly like those). A year later she was claiming that legislation that relied on HMOs to contain cost would have a much greater chance of passing in Minnesota and that’s what she was going to focus on.

Over the years 1992 through 1994, Minnesota’s legislature did in fact pass a series of bills (collectively referred to as “MinnesotaCare”) that were supposed to achieve substantial cost containment by encouraging faster enrollment in HMOs, and thus establish universal health insurance by July 1, 1997. Of course, it all fell apart, beginning in 1995. Minnesota is no closer to universal health insurance today than it was in 1990 when I was first advised by my betters about how politically infeasible single-payer is and how politically feasible the HMO approach would be.

A half-dozen other states have suffered the same lesson. Legislative leaders, egged on by left-of-center groups that didn’t know much about health policy but which maintain close relations with Democrats, thought they could achieve universal coverage by funneling more tax dollars through “managed care” insurance companies. This occurred recently in the state of Massachusetts where “Romney-care,” a program that requires Massachusetts residents to buy health insurance from that state’s bloated insurance industry, was enacted in 2006. The program is having a very hard time staying afloat. All these multiple-payer state initiatives foundered because they did not contain cost.

It is now the summer of 2009. You can imagine my reaction to people who claim single-payer isn’t politically feasible but that other proposals that leave the insurance industry at the top of the health care food chain are. I want to get out my guitar and sing in a sad, tremulous voice, “Where have all the flowers gone …. When will they ever learn?”

How many times must universal coverage advocates rush onto the battle field to promote a multiple-payer solution and get slaughtered before they realize they can’t get to universal coverage that way? How many defeats will it take till they know that universal coverage without cost containment is not politically feasible? How many times can they be fooled into thinking that there are ways to cut costs other single-payer?

There are several reasons why the lessons of previous defeats don’t sink in with many universal coverage advocates. I’ll discuss two here: (1) insufficient knowledge of how social change happens; and (2) insufficient knowledge about the role that promoters of market-based solutions to the health care crisis played in marginalizing single-payer legislation in Congress.

Naivete about social change

As the remarks by critics of “Bait and switch” quoted above suggest, some “political yes buts” have a superficial understanding of how social change happens. They think it happens quickly or not at all, and they think it begins and ends in Congress.

This view of social change is often expressed in the mantra quoted above, “Single payer is not within the realm of possibility this term.” The implication is that if single-payer advocates cannot demonstrate that they have at least 51 percent of the votes lined up, they should retreat to the sidelines and watch the “political yes buts” do their thing. It implies that social change must occur within a single session of Congress rather than over the course of many sessions. It implies that movements for social change should, in the event that they do not have a majority vote locked up at the beginning of any given session of Congress, put their campaign in moth balls and forgo the opportunity to educate the public and build their movement through lobbying, testimony, rallies and all the other tools associated with campaigns to move bills in Congress.

In short, it implies an absurd Catch-22. To get the “political yes buts” to join them, single-payer advocates must show proof of having a majority of Congress on their side; but to get a majority of Congress on their side, the single-payer movement must build and wage a campaign relentlessly over many years in the face of active discouragement from the “yes buts” – and without pestering Congress with ideas unfairly characterized as utopian.

These demands, when they are spelled out, are obviously irrational. Universal coverage under a single-payer system is going to be difficult to achieve. The difficulty may be on the order of the difficulty of ensuring voting rights for women and civil rights for black people, to name just two examples of movements that took decades to accomplish their goals. If the leaders and supporters of these movements had accepted the Alice-in-Wonderland rules recommended by the “yes buts,” the women’s suffrage and civil rights movements would never have happened.

Naivete about the role of promoters of market-based alternatives to single-payer

The second reason some progressives don’t draw the right lessons from the failure of previous attempts to achieve universal coverage is that they fail to understand the role that advocates of bad policy have played in splitting the universal coverage movement and weakening support for single-payer within Congress. This is particularly true of the failure of Bill Clinton’s Health Security Act in 1994. The conventional wisdom within the “yes but” wing of the universal coverage movement is that Clinton’s bill died because advocates of universal coverage did not rally around his bill quickly enough in the face of “Harry and Louise” ads, and because Clinton didn’t engage in skillful “messaging.” The fact that the Health Security Act was a horrendous bill is not part of the “yes buts’” folklore.

There have been three cycles of health care reform in the last half century – 1970-73, 1992-1994, and 2007 to date. At the dawn of each cycle, single-payer legislation had already been introduced. But early in the cycle, single-payer legislation was “taken off the table” (to quote a statement Sen. Max Baucus now wishes he had never made). Each time the Democratic leadership chose instead market-based proposals that had no track record and no evidence to support them. Each time they favored reform deemed more “politically feasible” than single-payer because it left the insurance industry in place. In all three cycles, the alternative, market-based proposal was promoted by one or two policy entrepreneurs (that is to say, it wasn’t an idea that bubbled up from the grassroots).

Single-payer legislation was the first out of the chute during the 1970-1973 cycle. In January 1970, Sen. Ted Kennedy introduced what we would today call a single-payer bill. But Kennedy and other leading Democrats quickly abandoned single-payer in favor of a theory about cost containment called the “health maintenance strategy.” This strategy revolved around a new-fangled type of insurance company proposed by a Minnesota physician named Paul Ellwood that Ellwood called the “health maintenance organization.”

Ellwood would become rich and famous selling his HMO idea. He single-handedly convinced President Richard Nixon to endorse legislation to subsidize the formation of HMOs all over the country. While Ellwood worked the Republicans, the AFL-CIO worked the Democrats. Within a year, Kennedy and many other Democrats had been persuaded to abandon the single-payer approach in favor of legislation that would subsidize HMOs. The 1970-1973 cycle ended with the enactment of the HMO Act of 1973. Thus was the world’s first HMO industry born. As we all know now, the HMO experiment failed.

Two decades later, when the 1992-1994 cycle opened, single-payer legislation was not only in place in Congress it had also been introduced in many states (the first state single-payer bill to be introduced was introduced in Ohio’s legislature in 1990). The first modern-day single-payer bill was introduced in the US House by Rep. Marty Russo (D-IL) in 1991 and in the Senate by Senator Paul Wellstone in 1992. But as was the case during the previous cycle, the Democratic leadership was seduced by an alternative to single-payer. Once again, Paul Ellwood played an important role in luring Democrats away from single-payer.

Late in 1992, candidate Bill Clinton was persuaded by representatives of a group Ellwood helped form, the Jackson Hole Group, to support something called “managed competition.” The Jackson Hole Group was a coalition of insurance company executives and conservatives who met regularly at Ellwood’s mansion in Jackson Hole, WY. The theory of “managed competition” held that if the insurance “market” were tweaked (with report cards on insurance companies, for example), competition between insurers would intensify, Ellwood’s beloved HMOs would gradually seize more market share, and this would drive industry-wide premiums down. Clinton’s endorsement of “managed competition within a budget” catapulted what might have remained an obscure idea into the political lime light. When Clinton was elected, single-payer legislation once again languished while the Clintons, with help from groups like Families USA, AFSCME, and Citizen Action (now called USAction), flogged their managed competition bill. The 1994 cycle ended with the death of Clinton’s bill in September 1994, and the unraveling of similar managed competition legislation enacted in Minnesota and Washington.

Déjà vu

The cycle we’re in now bears many similarities with the last two cycles. When this cycle began (2007 is as good a year to pick as the first year of this cycle, although that is somewhat arbitrary), single-payer legislation was better positioned than ever before to be taken seriously by Democrats. Single-payer bills had been introduced in several states as well as the US House (Sen. Bernie Sanders would introduce a single-payer bill in the Senate in 2008). Polls were showing that two-thirds of Americans and 60 percent of doctors support single-payer (or “Medicare for all”) legislation.

But once again an articulate policy entrepreneur appeared on the scene to sell a market-based alternative to single-payer that would leave the insurance industry at the top of the health care food chain, and once again the Democratic leadership fell for it. This time the entrepreneur was not Paul Ellwood. This time the policy entrepreneur was Jacob Hacker, a professor of political science at Berkeley. Just as Ellwood and the Jackson Hole Group had before him, Hacker said enhanced “competition” among insurance companies was the solution to the health care crisis. (The name of Hacker’s latest paper is “Healthy competition.”) This time enhanced competition would not come from “managing” competition, but from the creation of a “public option.” This time the coalition that promoted the alternative to single-payer was not the Jackson Hole Group, but HCAN, assisted by a sister coalition called the Herndon Alliance.

The Herndon Alliance was founded in 2005 by many of the same groups that would create HCAN in 2008. The Herndon Alliance paved the way for HCAN’s promotion of the “public option” with some laughable “research” claiming to find that Americans want a “public-private-plan choice” approach and don’t want a single-payer system. I have written elsewhere about the bogus “research” conducted by the Herndon Alliance. Suffice it to say here the Herndon Alliance cooked up a new and more insidious version of the “political feasibility” argument.

Until about 2007, when the Herndon Alliance first began publishing its “research,” there was only one variant of the “political feasibility” argument, the one that said the insurance industry is too powerful to beat. The Herndon Alliance variant claimed single-payer is not feasible because Americans don’t want it. According to this variant, American “values,” not the insurance industry, are actually the greatest impediment to single-payer. According to the Herndon Alliance, Americans “value choice of insurance company” and “they like the insurance they have and want to keep it.” HCAN and Hacker picked up these refrains and promoted them vigorously to the public and to members of Congress. This inexcusable attack on single-payer no doubt helped key committee chairs in Congress (Kennedy, Baucus, Waxman, Rangel and Miller) feel more comfortable taking single-payer off the table and concentrating on the “public option.”

By early 2009, it was clear the Hacker-HCAN-Herndon Alliance propaganda for the “public option” and against single-payer had worked with the Democratic leadership, and that the Democratic leadership would fall once again for a market-based alternative and remove single-payer from the table. The removal of single-payer legislation took place without the firing of a single shot in public by the insurance industry and the right wing. It took place at the request of the “yes but” wing.

In the House, single-payer legislation, HR 676, has been rammed back onto the table, thanks to hell-raising by the single-payer movement, including the arrests of some brave doctors and nurses who disrupted hearings in the Senate Finance Committee last May. Last Friday night, Speaker Nancy Pelosi agreed to allow a floor vote on whether to substitute HR 676 for HR 3200, the Democratic leadership’s “public option” bill. This is a significant victory for the single-payer movement, but it should not have come so late in the 2009 session. If Pelosi and the three committee chairmen who wrote HR 3200 had permitted HR 676 to go through the normal committee hearing process, single-payer advocates would have had more time to educate Congress and the public about why a single-payer system is superior to all other alternatives.

It appears almost certain that the reform cycle we’re in now will end the way the last two did – with the Democrats’ competition-based alternative to single-payer going down in flames. It is extremely important that progressives, especially progressives in the “yes but” camp, understand why this happened. Yes, the ultimate villain in these dramas was the insurance industry and their conservative allies. But universal coverage advocates must understand the role of the “yes buts,” and the policy entrepreneurs they listened to, in splitting the universal coverage movement and in seducing Democrats to support legislation that was no more likely to pass than single-payer legislation and wouldn’t have cut costs if it had passed. If they don’t see this – if they persist in believing the insurance industry is the only force single-payer advocates have to contend with – they will, wittingly or unwittingly, help perpetuate the pattern we have seen in the last three reform cycles. They will, in short, perpetuate the insanity of doing the same thing over and over, seeing it fail, and not learning from failure.

It is not inevitable that a scrawny “public option” will be strengthened

The argument that any “public option” is better than none has rarely been articulated, but I suspect we will hear it more often as the reality sinks in that the “public option” in the Democrats’ bill is a joke. “Public option” advocates who learn for the first time that the “option” in the Democrats’ bill will insure few or zero people have only two choices: to abandon the “public option” movement, which is no doubt emotionally difficult to do for those who have invested heavily in the movement, or to continue to work for the Democrats’ version of the “public option” and rationalize that choice with the argument that a tiny “public option” can always be improved once it is established.

The problem with this argument is that the “public option” is not your typical government program. The “public option” is not like the space program or the various college loan programs, to take a few examples, all of which can be expanded or contracted as the years go by without seriously threatening the very existence of the program. The “public option” will be a business. And this particular government-run business may never get very big; it may not even survive. If it doesn’t get big, or doesn’t survive, it won’t develop the huge public fan base that protects popular programs like Social Security and Medicare. In fact, the reverse could happen. A miserable early performance may cause Americans to turn against the idea of a Medicare-like program for the non-elderly. Unlike public programs, businesses don’t have an indefinite time period to develop a supportive public. Businesses don’t automatically take root and go on living forever. The “public option” must prove its ability to survive and undersell the insurance industry quickly. Moreover, the “public option” will be attempting to break into a business that has been consolidating over the last few years. The insurance industry is extraordinarily difficult to crack.

“Public option” proponents who urge us to support even a token “public option” must remember how much is at stake here. At stake is not only the willingness of the public to believe that government health insurance programs can outperform the insurance industry. At stake as well is whether Congress will give the insurance industry a trillion dollars per decade of taxpayer money.

The Democrats’ legislation calls for subsidies to people under a certain income level (probably 300 or 400 percent of the poverty level) so all Americans can afford to obey the proposed law requiring them to buy insurance from either the insurance industry or the “public option.” These subsidies will probably amount to a trillion dollars per decade. If the “public option” doesn’t survive, or survives but never insures more than a tiny percent of the population, that will mean that all or nearly all of that trillion dollars will go to the insurance industry.

It is not written in stone that creation of the “public option” must go hand in hand with a huge bailout for the insurance industry. After all, one could imagine a scenario in which enrollees in the “public option” are the only ones who get subsidies. That was Hacker’s original plan. But Democrats decided early in their bill-writing process that subsidies had to go to both the “public option” and the insurance industry, and Hacker and company did not complain. That decision, plus the Democrats’ desire to achieve near-universal coverage, plus the Democrats’ decision to create only a tiny “public option,” means that if a “public option” is enacted it will be enacted only in conjunction with an enormous insurance industry bailout.

A well-fed insurance industry is bad news for both single-payer and “public option” advocates. An insurance industry strengthened by a trillion dollars per decade of new tax dollars will not only be in a better position to oppose single-payer legislation, it will also be in a stronger position to lobby Congress and the regulators to ensure the “public option” remains stunted.

“Public option” advocates should start talking about the “public option” as if it were inextricably tied to an insurance industry bailout. They should write the phrase “public-option-insurance-industry-bailout” on a Post-it note and paste it to their bathroom mirror to remind them to be honest with themselves and the public about this fact.

To sum up: “Public option” proponents who claim that any “public option” is better than no “public option” because even a skinny little program can be beefed up later are sadly mistaken. A weak “public option” may not survive to be beefed up later, and whether it survives or not, it will serve as fig leaf that will let Congress justify an insurance industry bailout. A strengthened insurance industry is the last thing either the “public option” or the single-payer wing of the universal coverage movement needs. Please say after me: A weak public option is far worse than none at all.

Single-payer will still require a political struggle

As I said in “Bait and switch,” I have no illusions about how difficult a single-payer bill will be to enact. I am under no illusion that a single-payer bill would have passed Congress in 2009 given the world as it was in December 2008. I do believe, though, that if the “yes but” wing of the universal coverage movement had thrown their considerable weight behind single-payer prior to 2009, say, in 1992 when the last reform cycle began, we would either have a Medicare-for-all style system by now, or we’d be on the verge of enacting one now.

Will HCAN and Hacker put out a call to their followers to do all they can to win the floor vote on HR 676 this fall? Or will they give lip service to HR 676 and sit on their hands? When the 2009 session of Congress ends, will HCAN et al. offer their usual misinterpretations of why reform failed?

How quickly America enacts a single-payer system will depend in part on whether progressives learn the real lessons of the failure of the “public option” movement in 2009. If the “yes but” wing draws the same lessons it drew from the failure of the Clinton bill – that the “base” was not well enough organized, or that the Clintons didn’t “sell” their plan skillfully – unity within the universal coverage movement seems unlikely, and the day we get to a single-payer system will be postponed.

I believe the “yes buts” must confront some inconvenient truths immediately. The “political feasibility” rationale for doing nothing to assist the single-payer movement was never a good one or, at minimum, after two decades of constant use, has become an embarrassment and must be discarded. It is foolish to argue that even the tiniest “public option” will constitute a victory that can be built on later. If the “yes buts” see these truths, then unity within the universal coverage movement should be possible. And if unity comes to the universal coverage movement for the first time in 40 years, single-payer can’t be far behind.

Kip Sullivan belongs to the steering committee of the Minnesota chapter of Physicians for a National Health Program.