As July starts to wind down and the August recess by Congress fast approaches, the debate over health care reform enters a late stage with increasingly bitter partisan differences over very divisive issues. Every day we hear about more Democrats siding with the Republicans, especially the Blue Dogs worrying about the high costs of plans on the table. Senate leaders are threatening that higher taxes and the public option will be deal-breakers. With President Obama pressing both parties for an early resolution of their differences, the hope for a bipartisan bill this year is rapidly fading. Each day brings new terms into the debate, ranging from triggers to exchanges and coops, without enough details or track record to gain our confidence that any real reform is on track.

As the debate gets more heated and polarized, confusion increases among the public. Not surprising, especially since that is the goal of stakeholder disinformation campaigns. Since the stakes are enormous — health care being 17 percent of our economy — market stakeholders are pulling out all the stops in their lobbying and advertising efforts to make sure that their markets aren’t bothered too much.

Individual mandates are part of the proposals being developed in both the House and Senate. Employer mandates can also be expected from the House and (except for small employers) from the Senate. The Senate’s Committee on Health, Education, Labor and Pensions (HELP) recently approved, by a party-line vote of 13-10, a proposal that would stop the ability of insurance companies from denying coverage based on pre-existing conditions and provide a public option for those unable to find an insurance plan. The House proposal calls for an individual and employer mandate, a public option, various attempts to offer guaranteed coverage and insurance market reforms, a government-run insurance exchange, graduated surtaxes on those making more than $350,000 a year, and government subsidies for those with incomes up to 400 percent of the federal poverty level ($88,000 for a family of four). Tax credit support is being considered by Senate committees for those with low to middle incomes.

The most intense disagreements are now whether (and how robust if included) a public option will be in “keeping the insurance industry honest”, changes in tax policies for employers and employees, the cost of a reform bill, and how and who will pay. After a charm offensive in recent months by the major corporate stakeholders — insurers, business, PhRMA, hospitals, and the AMA — which included voluntary pledges to save up to $1.5 trillion over ten years, most are now starting to backtrack on what were never solid or enforceable commitments. And now we are starting to see a circular firing squad forming up among the stakeholders intended to shift more risk to other stakeholders. For example, business organizations are describing the employer mandate in the more than 1,000 page House bill as a job-killer by requiring employers to pay a fee or penalty of 8 percent of wages and increasing the costs of hiring a new worker.

So doesn’t all that give us hope that health care reform is just around the corner? Unfortunately, no. All of these proposals are based on faulty assumptions:
• We are asked to assume that the private health insurance industry is worth preserving, that it offers increased choice, that its products offer better value, that it best fits our culture; all of these claims have been discredited by its track record, as documented by my recent book Do Not Resuscitate: How The Health Insurance Industry Is Dying, and How We Must Replace It.
• There is nothing in these various proposals that can rein in uncontrolled inflation of health care costs; they lack significant cost containment mechanisms; they relate only to federal spending on health care, not total health care spending or that which patients will pay; the costs of government subsidies are not clear, and the costs of expansion of Medicaid have not even been scored by the Congressional Budget Office (CBO).
• The non-partisan CBO today gives us the following sobering assessment of costs: “In the legislation that has been reported, we do not see the fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount and, on the contrary, the legislation significantly expands the federal responsibility for health care costs.”

So while we are getting assurances from the President and some legislators
that this year’s health care reform effort is on track, there is growing evidence that it will soon leave the track when and if an actual bill emerges from Congress.

You might think that the current legislative debate draws from health policy science. We do have such a science, with a substantial literature of what works and what doesn’t, but that knowledge is unfortunately not driving the debate. Instead, the debate goes forward based on unfounded ideology, corporate money and influence. Subsequent posts will examine some of the elements of the reform effort in more detail.

John Geyman, M.D. is the author of The Cancer Generation and Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It, 2008 by John Geyman. With permission of the publisher, Common Courage Press

Buy John Geyman’s Books at: http://www.commoncouragepress.com

Biotech firms lobby for say on healthcare

$66m effort to protect drug-patent exclusivity

By Lisa Wangsness
The Boston Globe
July 21, 2009

The 46 million Americans without health insurance are probably not spending much time thinking about how Congress should curb monopolies on expensive biotech drugs. But the issue, which offers a case study in the ways of Washington influence, is among dozens that have spurred a lobbying frenzy this summer as Congress debates a historic healthcare overhaul.

Pharmaceutical interests alone, including many from Massachusetts, spent more than $66 million on lobbying in just the first quarter of this year, up 25 percent from last year, according to the nonpartisan Center for Responsive Politics.

Biotech firms produce the most expensive drugs on the market, charging $10,000 to $100,000 a year for a single patient, and generics would seriously undercut those prices. In their quest to win a 12-year exclusivity period for their drugs, free from such competition, biotech companies have launched a massive education campaign about what they say are the sky-high research and development costs involved with bringing them to market.

To help carry the message, they are paying well-connected lobbying firms, sponsoring radio ads as well as academic studies, and contributing to the campaign coffers of influential lawmakers.

“You get one crack at it,” said Robert Coughlin, president of the Massachusetts Biotechnology Council, speaking of the task of drawing up a licensing system for “biogenerics.” “If it isn’t done right, it could literally put the biotech industry out of business.”

The quest for influence is not always obvious.

Howard Dean, the former Democratic Party chairman, wrote an opinion piece this month in The Hill, an influential Capitol Hill newspaper, arguing that fewer than 12 years of monopoly rights for biotech companies’ products “would prematurely rob innovators of their intellectual property and . . . destroy incentives to develop new cures.”

Within hours Joe Trippi, a Democratic consultant who ran Dean’s 2004 presidential race, hyped Dean’s opinion piece in a blog post that he sent to The Huffington Post, a widely read website. “He’s a doctor and lifelong advocate for health reform – he knows what he’s talking about,” Trippi wrote, urging readers to contact their lawmakers.

Dean failed to note in his editorial that he is an adviser to McKenna, Long & Aldridge, a global law firm that is advising the Biotechnology Industry Organization, the influential trade group. Nor did Trippi mention that his public relations firm handles social media projects in a partnership with the Boston public relations company Brodeur Partners, which also has BIO as a client.

Dean said his editorial was part of McKenna’s rapid-fire response to an unexpected, eleventh-hour Senate health committee proposal (which biotech firms ultimately fought off).

“It was a huge scramble, all hands on deck,” Dean said.

The legions of lobbyists, strategists, and legal consultants involved include former senior aides to key lawmakers and executives. Top biotech companies are clients of Foley Hoag, a law firm with offices in Boston and Washington, which has deployed Nick Littlefield, former staff director and chief counsel for Senator Edward M. Kennedy’s health committee, and Paul Kim, the former deputy health counsel to the Kennedy’s committee.

Biotech won a major battle last week when Kennedy’s Senate health committee gave biotech firms the 12-year protections they wanted, plus six months for pediatric versions. The committee rejected a proposal by Senator Sherrod Brown, Democrat of Ohio, for a much shorter monopoly period. After the vote, generics companies said they wouldn’t even bother trying to make generic biologics because the 12-year protection would make the enterprise unprofitable.

“The pharmaceutical industry, especially the biotech industry has an awful lot of power in the halls of Congress,” Brown told reporters.

State leaders from around the country, including Governor Deval Patrick, wrote letters to their delegations supporting a biotech-friendly bill. CEOs have flown to Washington to drive their points home. The Globe reported earlier this year that Amgen donated $1 million to the Edward M. Kennedy Institute for the United States Senate at the University of Massachusetts Boston, a project being developed by people close to the senator but not Kennedy.

In the health committee vote last week, a number of other left-leaning Democratic senators sided with the industry, including Patty Murray of Washington, Barbara Mikulski of Maryland, Jack Reed and Sheldon Whitehouse of Rhode Island, and Kay Hagan of North Carolina. Kennedy supported the measure by proxy.

Hagan, a freshman senator whose state is home to a biotech sector, was assigned to the health committee this winter. Few were surprised when she cosponsored the industry-friendly amendment. But biotech firms were not taking chances: In the first half of this year, they poured $16,000 into her campaign account. Hagan believes the protections are necessary to support research for new drugs.

http://www.boston.com/news/health/articles/2009/07/21/biotech_firms_lobby_hard_for_say_on_healthcare/

July 14 qotd on the 12-year data exclusivity amendment:
http://www.pnhp.org/news/2009/july/senate_help_amendmen.php

The vote on the data exclusivity amendment was covered in a qotd last week, at the link above. More background information is provided by Lisa Wangsness in her Boston Globe article. Because of the implications for the reform process unfolding in Washington, we are taking a second look.

Having a twenty year patent on a biological that can command a one hundred thousand dollar price tag is not enough for the biotech firms. They also want a 12 year lead time before competitors can begin to use the data, produced in our academic medical centers, for developing new innovative drugs or even generic equivalents. This doesn’t change the 20 year patent exclusivity, but it requires future competitors to wait 12 years before beginning their research that would be based on the existing data.

That slows future innovation and research. It slows the introduction of generics that can result in competitive pricing. It decreases the chance of breakthroughs that could replace a one hundred thousand dollar biologic with a two hundred dollar product that might be more effective and less toxic.

Watching the prolonged committee deliberations on the 12 year data exclusivity amendment, it was obvious that the arguments presented by the senators in support of this amendment had been written by the biotech lobbyists. It was also obvious that only a few of the senators had rejected the lobbyists’ overtures.

The Boston Globe article demonstrates that this was not about policy, but about process. It shows how the most powerful lobbyists can cast their nets and pull in the best of them.

Howard Dean was a part of the “all hands on deck” scramble to support the data exclusivity amendment. It was simply a job that he was expected to do as part of the McKenna rapid-fire response team.

It was particularly painful to watch Senator Dodd, acting chairman of the Senate HELP Committee, cast an aye vote by proxy on behalf of Sen. Ted Kennedy, even though Sen. Dodd had already cast a no vote on his own behalf. It would be unfair to speculate what may have caused Sen. Kennedy to communicate his wishes on that vote, but it is likely that Amgen feels that they paid a million dollars for that vote, fair and square.

Does anyone else agree that we need a fully transparent re-start on reform?

July 17, 2009

The group here in DC (visiting PNHP members and interns) has done many visits to Congressional offices this week. Most have been with the health legislative aides (LA’s) who vary in their backgrounds and experience. A few are new and need basic information on single payer but most are quite knowledgeable of the issues. A few even have health profession backgrounds. We have generally had good interactions with the LAs, who have expressed a lot of appreciation for our visits. One does get the impression that the LAs have an important role with their bosses. It also seems that interest in single payer is increasing over the past few days.

Yesterday we met with LAs and two Representatives. One of the Representatives came out of a committee that is marking up the House bill agreed with us that the main objective in the long run is to make health care a right, and that we need single payer reform, but he saw no way to get further than the current proposal now. In the committee, the Republicans were using delaying tactics, taking 5 minutes each for each of the 50 plus amendments, and making absurd statements.

I have been impressed with the grassroots movement for single payer across the country. Our message has been that single payer reform is necessary because the for-profit insurance industry will always be able to game the system to their advantage. While the Congress is increasingly aware that grassroots support for single payer is massive and growing, a major problem continues to be the huge distribution of money from the industry to politicians and organizations that have subverted and compromised the present reform movement. While our movement lacks their deep pockets, we have the support of the public. So it was nice to end the week with a victory for single payer: Representative Kucinich’s amendment to allow states to adopt single payer programs passed the Education and Labor committee today. While we have a long way to go before we have a single payer health care system at the state or national level, this was a start.

- Submitted by George Pauk, MD

We just learned that the Illinois House of Representatives adopted a resolution on May 31st, 2009 urging Congress to pass The United States National Health Insurance Act (HR 676) which would provide universal comprehensive health care coverage to all residents of the United States. The resolution, sponsored by Rep. Mary Flowers, acknowledges that “Americans already pay more per capita than any other nation nation for health care, almost twice the amount of other industrialized nations” yet ranks 37th in health care system performance.

The resolution was passed as a direct result of a highly successful lobby day in Springfield in March, 2009 hosted by Physicians for a National Health Program and National Nurses Organizing Committee. Over 300 citizen activists attended including Claudia Lennhoff of Champaign County Health Care Consumers, Donna Smith of National Nurses Organizing Committee and many patients, doctors and other health professionals. Many gave testimony at the legislative hearing regarding HR 311, the Healthcare for All Illinois Act sponsored by Rep. Mary Flowers, which would guarantee single-payer health insurance for every resident of Illinois.

Read more about the lobby day at the Champaign County Health Care Consumers website

Read the full text of HR 233

Corporate America has highjacked the health care debate and threatens to make real health care reform impossible. Since corporate dollars trump individual votes, we have a corpocracy, not a democracy.

This is not a new story, but is still an under-recognized one. By a landmark ruling of the U. S. Supreme Court in 1886 (Santa Clara), corporations were granted rights as “persons”. Over the years since then, corporate values and goals have been codified into law, and courts have defended the rights of corporations to pursue their primary goal — making a profit for their shareholders.

The scope of corpocracy goes beyond what most of us realize. According to a 2007 report of the Institute for Policy Studies, 51 of the top 100 economic entities in the world are corporations. Wal-Mart and Exxon Mobil each have higher annual revenues than the gross domestic product of Poland or Saudi Arabia. The top 200 corporations account for about one-quarter of total economic activity in the entire world.

Most of these large corporations are multinational and largely immune from the laws of any one nation. They are free to set up partnerships of convenience across borders, seek out countries that best serve their interests, and often pay little or no taxes.

But there are serious downsides to all this corporate power. In a 2009 assessment of the long-term effects of conservative economic policy (International Journal of Health Services), Robert Chernomas and Ian Hudson at the University of Manitoba document the extent to which corporations have redistributed wealth and power away from most of the population to themselves, thereby contributing to increasing poverty, illness and economic instability. And of course, the war chests of the large corporations trump the democratic process along the way. FDR recognized this hazard in 1938 in these words: “The liberty of a democracy is not safe if the people tolerate the growth of private power to a point where it becomes stronger than their democratic State itself. That, in its essence is Fascism — ownership of government by individual, by a group, or any controlling private power.”

Corporate influence and control within the medical industrial complex is also much larger than it may appear. General Electric, for example, as one of the twelve largest corporations in the world, in addition to its interests in manufacturing of jet engines, locomotives and industrial turbines, is heavily involved in medical diagnostic equipment, information technology, and development of robotics. Moreover, as a media giant with broadcast and cable television operations such as NBC, its reach also extends into banking and financial services.

When it comes to trying to rein in the uncontrolled costs of health care, corporate interests naturally use their economic and political power to protect their markets. For them, our costs are their revenues, so their battle is to perpetuate the status quo and limit government intrusion. They do so by campaign contributions to both sides of the aisle in Congress, lobbying, and control of the media. Over the last 40 years, the lobbying industry has grown from a small group of lawyers and influence peddlers to a multi-billion dollar industry employing thousands of people, including almost 200 ex-senators and ex-House members who became lobbyists through the revolving door. The five largest private health insurers and their trade group (America’s Health Insurance Plans) spent more than $6 million on lobbying in the first quarter of 2009, while Pfizer, the world’s biggest drugmaker, spent more than $9 million during the last quarter of 2008 and the first three months of this year. And as expected, conflicts of interest abound in the political process. The Washington Post recently reported that up to 30 members of Congress who hold key committee memberships in Congress (in both parties) have major investments in health care companies totaling somewhere between $11 and $27 million. Conflicts of interest even extend into the White House, where the Director of Health Care Policy has served on the boards of several health care corporations.

Corporate control of the media largely shapes what the public learns about the issues, thereby distorting the democratic process. The U.S. media system is dominated by about 25 corporations, which range across TV networks, cable TV channels, radio stations, newspapers, book publishing, magazines, motion pictures and others. Seven are in the first tier, including Time Warner, Viacom, News Corporation, General Electric and Disney. A second tier includes about 20 corporations, including Gannett, Clear Channel and the New York Times. The reach of these giants stretches the imagination. Clear Channel, for example, is the largest radio chain in the country, owning 1,240 radio stations with only 200 employees. According to Ben Bagdikian, dean emeritus of the Graduate School of Journalism at the University of California at Berkeley, most of these stations are operated with the same pre-recorded material. The great majority of content disseminated by these media giants is slanted to the conservative side.

So business being business, why is this bad? Again, corporate media favor their own interests, and work against objective analysis of events and issues. As a result, an under-informed voting public is disadvantaged and marginalized in the political process.

What does the body politic want concerning health care reform? Everyone wants affordable access to health care with free choice of physician and hospital. A majority of the public has wanted national health insurance (NHI) for many years. Changes in the electorate will further increase the numbers of Americans wanting NHI. Baby Boomers, the first of whom reach 65 years of age next year, are being bombarded by the high costs of their health care as their savings have dried up, 401(k)s have evaporated, and their planned retirements delayed. And three of five of the Millennial Generation, now 80 to 95 million strong, support NHI. The public will be angry and bitter when they discover how far short of their needs any of the current “reforms” now on the table will fall.

So when, if ever, will the democratic process prevail over corpocracy? In his recent interview of Wendell Potter, past director of public relations for Cigna and now vocal critic of the private health insurance industry, Bill Moyers answers this question:
The game goes on and the insiders keep dealing themselves winning hands. Nothing will change – nothing – until the moneylenders are tossed out of the temple, the ATM’s are wrested from the marble walls, and we tear down the sign they’ve place on government – the one that reads, “For Sale.”
1083 words
_________________________________________________________________________________________
John Geyman, M.D. is the author of The Cancer Generation and Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It, 2008 by John Geyman. With permission of the publisher, Common Courage Press

Buy John Geyman’s Books at: http://www.commoncouragepress.com/index.cfm?action=book&bookid=376

by Kip Sullivan

The people who brought us the “public option” began their campaign promising one thing but now promote something entirely different. To make matters worse, they have not told the public they have backpedalled. The campaign for the “public option” resembles the classic bait-and-switch scam: tell your customers you’ve got one thing for sale when in fact you’re selling something very different.

When the “public option” campaign began, its leaders promoted a huge “Medicare-like” program that would enroll about 130 million people. Such a program would dwarf even Medicare, which, with its 45 million enrollees, is the nation’s largest health insurer, public or private. But today “public option” advocates sing the praises of tiny “public options” contained in congressional legislation sponsored by leading Democrats that bear no resemblance to the original model.

According to the Congressional Budget Office, the “public options” described in the Democrats’ legislation might enroll 10 million people and will have virtually no effect on health care costs, which means the “public options” cannot, by themselves, have any effect on the number of uninsured. But the leaders of the “public option” movement haven’t told the public they have abandoned their original vision. It’s high time they did.

The bait

“Public option” refers to a proposal, as Timothy Noah put it, “dreamed up” by Jacob Hacker when Hacker was still a graduate student working on a degree in political science. In two papers, one published in 2001 and the second in 2007, Hacker, now a professor of political science at Berkeley, proposed that Congress create an enormous “Medicare-like” program that would sell health insurance to the non-elderly in competition with the 1,000 to 1,500 health insurance companies that sell insurance today.

Hacker claimed the program, which he called “Medicare Plus” in 2001 and “Health Care for America Plan” in 2007, would enjoy the advantages that make Medicare so efficient – large size, low provider payment rates and low overhead. (Medicare is the nation’s largest health insurance program, public or private. It pays doctors and hospitals about 20 percent less than the insurance industry does, and its administrative costs account for only 2 percent of its expenditures compared with 20 percent for the insurance industry.)

Hacker predicted that his proposed public program would so closely resemble Medicare that it would be able to set its premiums far below those of other insurance companies and enroll at least half the non-elderly population. These predictions were confirmed by the Lewin Group, a very mainstream consulting firm. In its report on Hacker’s 2001 paper, Lewin concluded Hacker’s “Medicare Plus” program would enroll 113 million people (46 percent of the non-elderly) and cut the number of uninsured to 5 million. In its report on Hacker’s 2007 paper, Lewin concluded Hacker’s “Health Care for America Plan” would enroll 129 million people (50 percent of the nonelderly population) and cut the uninsured to 2 million.

Until last year, Hacker and his allies were not the least bit shy about highlighting the enormous size of Hacker’s proposed public program. For example, in his 2001 paper Hacker stated:

[A]pproximately 50 to 70 percent of the non-elderly population would be enrolled in Medicare Plus…. Put more simply, the plan would be very large…. [C]ritics will resurface whatever the size of the public plan. But this is an area where an intuitive and widely held notion – that displacement of employment-based coverage should be avoided at all costs – is fundamentally at odds with good public policy. A large public plan should be embraced, not avoided. It is, in fact, key to fulfilling the goals of this proposal. (page 17)

In his 2007 paper, Hacker stated:

For millions of Americans who are now uninsured or lack … affordable work place coverage, the Health Care for America Plan would be an extremely attractive option. Through it, roughly half of non-elderly Americans would have access to a good public insurance plan…. A single national insurance pool covering nearly half the population would create huge administrative efficiencies. (page 5)

Hacker’s papers and the Lewin Group’s analyses of them have been cited by numerous “public option” advocates. For example, when Hacker released his 2007 paper, Campaign for America’s Future (CAF) published a press release praising it and drawing attention to the large size of Hacker’s proposed public program. The release, entitled “Activists and experts hail Health Care for America plan,” stated:

Detailed micro-simulation estimates suggest that roughly half of non-elderly Americans would remain in workplace health insurance, with the other half enrolled in Health Care for America…. A single national insurance pool covering nearly half the population would create huge administrative efficiencies…. Because Medicare and Health Care for America would bargain jointly for lower prices …, they would have enormous combined leverage to hold down costs.

When the Lewin Group released its 2008 analysis of Hacker’s 2007 paper, CAF’s Roger Hickey wrote in the Huffington Post, “efficiencies achievable … through Hacker’s public health insurance program” would save so much money that the US could “cover everyone” for no more than we spend now.

The switch

Now let’s compare the “single national health insurance pool covering nearly half the population” that Hacker and other “public option” advocates enthusiastically championed with the “public option” proposed by Democrats in Congress, and then let’s inquire what Hacker and company said about it.

As readers of this blog no doubt know, the Senate Health, Education, Labor, and Pensions (HELP) Committee, and three House committee chairman working jointly, published draft health care “reform” bills in June. (The third committee with bill-writing authority, the Senate Finance Committee, has yet to produce a bill.) According to the Congressional Budget Office, the “public option” proposed in the House “tri-committee” bill might insure 10 million people and would leave 16 to 17 million people uninsured. The “public option” proposed by the Senate HELP committee, again according to the Congressional Budget Office, is unlikely to insure anyone and would hence leave 33 to 34 million uninsured. The CBO said its estimate of 10 million for the House bill was highly uncertain, which is not surprising given how vaguely the House legislation describes the “public option.”

Here is what the CBO had to say about the HELP committee bill:

The new draft also includes provisions regarding a “public plan,” but those provisions did not have a substantial effect on the cost or enrollment projections, largely because the public plan would pay providers of health care at rates comparable to privately negotiated rates – and thus was not projected to have premiums lower than those charged by private insurance plans. (page 3)

Obviously the “public option” in the Senate bill (zero enrollees, 34 million people left uninsured) and the “public option” in the House bill (10 million enrollees (maybe!); 17 million people left uninsured) are a far cry from the “public option” originally proposed by Professor Hacker (129 million enrollees; 2 million people left uninsured). Have we heard the Democrats in Congress who drafted these provisions utter a word about how different their “public options” are from the large Medicare-like program that Hacker proposed and his allies publicized? What have Professor Hacker and his allies had to say?

In public comments about the Democrats’ “public option” provisions, the leading lights of the “public option” movement imply that Hacker’s model is what Congress is debating. Sometimes they come right out and praise the Democrats’ version as “robust” and “strong.” But I cannot find a single example of a a statement by a “public option” advocate warning the public of the vast difference between Hacker’s original elephantine, “Medicare-like” program and the Democrats’ mouse version.

For example, on June 23, Hacker testified before the House Education and Labor Committee that “the draft legislation prepared by [the] special tri-committee promises enormous progress.” He went on to enumerate all the benefits of a “public option.” Yet the House tri-committee proposal bore no resemblance to the public plan he described in his papers and that the Lewin Group analyzed. Later, when Kaiser Health News asked Hacker in a July 6 interview why “your signature idea – a public plan – has become central to the health care reform debate,” Hacker again praised his “public plan” proposal and offered no hint that the “public option” so “central to the debate” was very different from the one he originally proposed.

Ditto for Hacker’s allies. Representatives of Health Care for America Now (HCAN), the organization most responsible for popularizing the “public option,” repeatedly describe the House and Senate HELP committee bills as “strong” or “robust,” always without any justification for this claim, and have repeatedly failed to warn the public that the “public options” they promote today are mere shadows of the “public options” they endorsed in the past. On July 15, the day the HELP committee passed its bill, Jason Rosenbaum blogged for HCAN:

The Senate HELP Committee has just referred a bill to the floor of the Senate with a strong public option.

Searching the websites of the organizations that serve on HCAN’s steering committee – AFSCME, Democracy for America, Moveon.org and SEIU, for example – one will find not a shred of information that would help the reader comprehend how small and ineffective the “public options” proposed in the Democrats’ bills are, nor how different these are from the one Hacker originally proposed. Yet these groups continue to urge their members and the public to “tell Congress to support a public option.”

Hacker’s original model compared with the Democrats’ mouse model

It has become fashionable among advocates of a “public option” to trash the expertise and the motives of the Congressional Budget Office. But the CBO’s characterization of the “public option” proposed in the Democrats’ legislation is entirely reasonable. This becomes apparent the moment we compare Hacker’s blueprint for his original “Medicare Plus” and “Health Care for America” programs with the “blueprints” (if tabula rasas can be called “blueprints”) contained in the Senate HELP Committee and House bills.

Hacker’s papers laid out these five criteria that he and the Lewin Group said were critical to the success of the “public option”:

• The PO had to be pre-populated with tens of millions of people, that is, it had to begin like Medicare did representing a large pool of people the day it commenced operations (Hacker proposed shifting all or most uninsured people as well as Medicaid and SCHIP enrollees into his public program);
• Subsidies to individuals to buy insurance would be substantial, and only PO enrollees could get subsidies (people who chose to buy insurance from insurance companies could not get subsidies);
• The PO and its subsidies had to be available to all nonelderly Americans (not just the uninsured and employees of small employers);
• The PO had to be given authority to use Medicare’s provider reimbursement rates; and
• The insurance industry had to be required to offer the same minimum level of benefits the PO had to offer.

Hacker predicted, and both of the Lewin Group reports concluded, that if these specifications were met Hacker’s plan would enjoy all three of Medicare’s advantages – it would be huge, it would have low overhead costs, and it would pay providers less than the insurance industry did. As a result, the “public option” would be able to set its premiums below those of the insurance industry and seize nearly half the non-elderly market from the insurance industry. According to the Lewin Group’s 2008 report, Hacker’s version of the “public option” would, as of 2007:

• Enroll 129 million enrollees (or 50 percent of the non-elderly);
• Have overhead costs equal to 3 percent of expenditures;
• Pay hospitals 26 percent less and doctors 17 percent less than the insurance industry (but these discounts would be offset to some degree by increases in payments to providers treating former Medicaid enrollees); and,
• Set its premiums 23 below those of the average insurance company.

I question some of Hacker’s and the Lewin Group’s assumptions, including their assumption that any public program that has to sell health insurance in competition with insurance companies could keep its overhead costs anywhere near those of Medicare (Medicare is a single-payer program that has no competition), especially during the early years when the public program will be scrambling to sign up enrollees. A public program will have to hire a sales force and advertise. It will have to open offices. It will have to negotiate rates, and perhaps contracts, with thousands of hospitals and hundreds of thousands of clinics, chemical treatment facilities, rehab units, home health agencies, etc. Or it will have to contract with someone to do all that. But I have little doubt that if a public program were to open with a large enough customer base, and it had the advantage of a law requiring that only its customers receive substantial subsidies, it could do what the Lewin Group said it could do.

Now let us compare Hacker’s original model with the mousey “public options” proposed by the Senate HELP Committee and the House. Of Hacker’s five criteria, only one is met by these bills! Both proposals require the insurance industry to cover the same benefits the “public option” must cover. None of the other four criteria are met. The “public option” is not pre-populated, the subsidies to employers and to individuals go to the “public option” and the insurance industry, employees of large employers cannot buy insurance from the “public option” in the first few years after the plan opens for business and maybe never (that decision will be made by whoever is President around 2015), and the “public option” is not authorized to use Medicare’s provider payment rates. (The House bill comes the closest to authorizing use of Medicare’s rates; it authorizes Medicare’s rates plus 5 percent).

Is it any wonder the CBO concluded the Democrats’ “public option” will be a tiny little creature incapable of doing much of anything? More curious is that CBO gave the House “public option” any credit at all (you will recall CBO said it would enroll maybe 10 million people). The CBO should have asked, Can the “public option” – as presented in either bill – survive?

Put yourself in the “public option” director’s shoes

To see why the “public option” proposed by congressional Democrats remains at great risk of stillbirth, let’s engage in a frustrating thought experiment. Let’s imagine Congress has enacted the House version (it is not quite as weak as the HELP Committee model and thus gives us the greatest opportunity in our thought experiment to imagine a scenario in which the “public option” actually survives its start-up phase). Let us imagine furthermore that you have been foolish enough to apply for the job of executive director of the new “public option,” and the Secretary of the Department of Health and Human Services (the federal agency within which the program will be housed) decided to hire you. It’s your first day on the job.

You know the House bill did not create a ready-made pool of enrollees for you to work with the way the 1965 Medicare law created a ready-made pool of seniors prior to the day Medicare commenced operations. You realize, in other words, that you represent not a single soul, much less tens of millions of enrollees. You will have to build a pool of enrollees from scratch. You also know the House bill authorized some start-up money for you, so you’ll be able to hire some staff, including sales people if you choose. You can also open offices around the country, and advertise if you think it necessary. But you know you can’t pay out too much money getting the “public option” started because the House bill requires that you pay back whatever start-up costs you incur within ten years. In other words, you may hire enough people and open enough offices and buy enough advertising to create a critical mass of enrollees nationwide, but you must do it quickly so that your start-up costs don’t sink the “public option” during its first decade.

The only other feature in the House bill that appears to give you any advantage over the insurance industry is the provision requiring you to use Medicare’s rates plus 5 percent, which essentially means you are authorized to pay providers 15 percent less than the insurance industry pays on average. But the House bill also says providers are free to refuse to participate in the plan you run.

So what do you do? Let’s say you open offices in dozens or hundreds of cities, you hire a sales force to fan out across the country to sign up customers, you advertise on radio and TV to get potential customers (employers and individuals) to call your new sales force to inquire about the new “public option” insurance policy. What happens when potential customers ask your salespeople two obvious questions: what will the premium be and which doctors they can see? What do your employees say? They can’t say anything. They haven’t talked to any clinics or hospitals about participating at the 15-percent-below-industry-average payment rate, so they have no idea which providers if any will agree to participate. They also have no idea what the “public option” premium will be because they don’t know whether providers will accept the low rates the plan is authorized to pay. And they have no idea about several other factors that will affect the premiums, including how much overhead the “public option” will rack up before it reaches a state of viability, or who the “public option” will be insuring – healthy people, sick people, or people of average health status.

So, let’s say you redeploy your sales force. Now instead of talking to potential customers, you direct them to focus on providers first. But when your salespeople call on doctors and hospital administrators and ask them if they’ll agree to take enrollees at below-average payment rates, providers ask how many people the “public option” will enroll in their area. Providers explain to your salespeople that they are already giving huge discounts, some as high as 30 to 40 percent off their customary charge, to the largest insurers in their area and they are not eager to do that for the “public option” unless the plan will have such a large share of the market in their area that it will deliver many patients to them. If the “public option” cannot do that, providers tell your salespeople, they will not agree to accept below-average payment rates.

In other words, you find that the “public option” is at the mercy of the private insurance market, not the other way around.

This thought experiment illustrates for you the mind-numbing chicken-and-egg problem created by any “public option” project that does not meet Hacker’s criteria, most notably, the criterion requiring pre-population of the “public option.” If the pre-population criterion isn’t met, the poor chump who has to create the “public option” is essentially being asked to solve a problem that is as difficult as describing the sound of one hand clapping. You need both hands to clap.

How did the mouse replace the elephant?

How did the “Medicare Plus” proposal of 2001 (when Hacker first proposed it) get transformed into the tiny “public options” contained in the Democrats’ 2009 legislation? The answer is that somewhere along the line it became obvious that the Hacker model was too difficult to enact and had to be stripped down to something more mouse-like in order to pass. Did the leading “public option” advocates realize this early in the campaign? Or midway through the campaign when the insurance industry began to attack the “public option”? Or late in the campaign when they found it difficult to persuade members of Congress to support Hacker’s original model? Whatever the answer, will they find it in their hearts to tell their followers their original strategy was wrong?

I suspect the answer is different for different actors within the “public option” movement. Hacker surely knew what was in his original proposal and surely knows now that the Democrats’ bills don’t reflect his original proposal. Hacker and others familiar with his original proposal were probably betrayed by the process. As the “public option” concept became famous and edged its way toward the centers of power, they couldn’t find the courage to resist the transformation of the original proposal into the mouse model.

For other actors within the “public option” movement, ignorance of Hacker’s original proposal and of health policy in general may have led them to rely on more knowledgeable leaders in the movement. Their error, in other words, was to trust the wrong people and, as the “public option” came under attack, to cave in to group think. This error was facilitated by the “public option” movement’s decision to avoid mentioning any details of the “public option” whenever possible.

What next?

Those of us in the American single-payer movement must continue to educate Congress and the public on the need for a single-payer system. We must also convince advocates of the “public option” that they have made two serious mistakes and, if they learn quickly from these mistakes, that real reform is still possible.

The first mistake was to think that a “public option” that merely took over a large chunk of the non-elderly market (as opposed to one that took over the entire market) could substantially reduce health care costs and thereby make universal coverage politically feasible. Any proposal that leaves in place a multiple-payer system — even a multiple-payer system with a large government-run program in the middle of it — is going to save very little money. Even if Hacker’s original Health Care for America Plan had taken over half the non-elderly market and then reached homeostasis (something Hacker swore up and down it would do), the savings would have been relatively small. The reason for that is twofold. First, any insurance program, public or private, that has to compete with other insurers is going to have overhead costs substantially higher than Medicare’s. (It is precisely because Medicare is a single-payer program that its overhead costs are low.) Second, the multiple-payer system Hacker would leave in place would continue to impose unnecessarily large overhead costs on providers.

The second mistake the “public option” movement made was to think the insurance industry and the right wing would treat a “public option” more gently than a single-payer. Conservatives have a long history of treating small incremental proposals such as “comparative effectiveness research” as the equivalent of “a government takeover of the health care system.” It should have been no surprise to anyone that conservatives would shriek “socialism!” at the sight of the “public option,” even the mouse model proposed by the Democrats.

The bait-and-switch strategy adopted by the “public option” movement has put the Democrats in a terrible quandary. Seduced by the false advertising about the potency of the “public option” to lower costs, Democrats have raised public expectations for reform to unprecedented levels. Failing to meet those expectations during the 2009 session of Congress, which is inevitable if the Democrats continue to promote legislation like the bills released in June, is going to have unpleasant consequences. Is there no way out of this quandary?

Conventional wisdom holds that if the Democrats don’t pass a health care reform bill by December, they will have to wait till 2013 to try again. But if the “public option” movement were to join forces with the single-payer movement, the two movements could prove the conventional wisdom wrong. This won’t happen, obviously, if the “public option” movement fails to perceive the reasons it failed.

It is conceivable the “public option” movement could decide the bait-and-switch strategy was wrong and that their only error was not to stick with Hacker’s original model. It should be obvious now that that would also be a tactical blunder. We have plenty of evidence now that conservatives will react to the mousey version of the “public option” as if it were “a stalking horse for single-payer.” We can predict with complete certainty they will treat Hacker’s original version as something even closer to single-payer. If a proposal is going to be abused as if it were single-payer, why not actually propose a single-payer? At least then, when a particular session of Congress comes and goes and we haven’t enacted a single-payer system, we will have educated the public about the benefits of a single-payer and have further strengthened the single-payer movement.

To sum up, “public option” advocates must choose between continuing to promote the “public option” and seeing their hopes for cost containment and universal coverage go up in smoke for another four years, and throwing their considerable influence behind single-payer legislation. At this late date in the 2009 session, it is unlikely that a single-payer bill could be passed even if unity within the universal coverage movement could be achieved. But if the “public option” wing and the single-payer wing join together to demand that Congress enact a single-payer system, December 2009 need not constitute a deadline.

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

Hearing: The Long Term Budget Outlook

Senate Budget Committee
July 16, 2009

Sen. Kent Conrad: Dr. Elmendorf, I’m going to really put you on the spot because we’re in the middle of this health care debate, but it’s critically important that we get this right. Everyone has said, virtually everyone, that bending the cost curve over time is critically important and one of the key goals of this entire effort. From what you have seen from the products of the committees that have reported, do you see a successful effort being mounted to bend the long term cost curve?

CBO Director Douglas Elmendorf: No, Mr. Chairman. In the legislation that has been reported we do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount, and on the contrary, the legislation significantly expands the federal responsibility for health care costs.

****

Sen. Judd Gregg: Well, Mr. Director, your testimony has been sobering today… The present plans as they’ve been produced have no significant cost spending events in them relative to reimbursement and relative to the way that they structure health care, that most American’s premiums aren’t going to go down and they will continue to go up, and that the debt of this country is unsustainable on our present course, and there isn’t a whole lot in this health care debate to date relative to the bills that have been produced that is going to do anything but continue to aggravate that and actually expand that problem. That’s my summary of what you’ve said. Is that a reasonable summary?

Douglas Elmendorf: … on the summary of the sobering perspective, yes, I agree with that, Senator. I’m sobered by having to give it.

http://budget.senate.gov/democratic/hearingstate.html

Is the health care cost debate limited to concerns about federal spending on health care, or is it about total health care spending? The distinction is very important because, if policies are limited to slowing the increase in the rate of federal health spending, many of those policies simply transfer costs from the government to individuals and businesses. It will give us little consolation to see the health care component of the federal budget in balance if individuals and businesses can’t afford health care.

It is informative to note that Chairman Conrad asked about products of the committees that would bend the long term cost curve, presumably the curve of the growth in our national health expenditures, and CBO Director Elmendorf’s response was limited to the trajectory of federal health spending.

Deficit hawk Gregg has continued to pound on the projected unsustainable growth in Medicare and Medicaid spending, and he is right that we should be concerned. But again, instead of policies that would merely shift costs out of the federal budget and on to individuals and businesses, we need policies that would reduce total health care cost increases to sustainable levels for everyone. This is what is interesting about Sen. Gregg’s question and Dr. Elmendorf’s response. They have concluded that the current legislative proposals are not going to have a significant impact on the upward trajectory of total health care costs.

It is unfortunate that the one measure that both indicated would be a very important policy to adopt would be to end the deductibility of employer-sponsored health plans. That helps with the federal budget, but it further increases health care costs for businesses and their employees.

For those who are very concerned about future federal deficits, there is a solution. Simply remove health care costs from the federal budget. Projections of future budget spending have been shown to be fully sustainable if health care costs are left out. Then set up a separate budget for health care financed through an equitably-funded universal risk pool.

President Obama has stated repeatedly that we must control health care costs as the first priority, and then we can cover everyone. The current proposals do neither. But with a single risk pool, and with the monopsony power of our own public administration we would be able to ensure health care value for absolutely everyone.

For Many Workers, Insurance Choices May be Limited

By Mary Agnes Carey and Julie Appleby
Kaiser Health News
July 15, 2009

President Obama and leading Democrats have stressed that people who like their employer-sponsored insurance would be able to keep it, under a health care overhaul. But they haven’t emphasized the flip side: That people who don’t like their coverage might have to keep it.

Under the main health bills being debated in Congress, many people with job-based insurance could find it difficult to impossible to switch to health plans on a new insurance exchange, even if the plans there were cheaper or offered better coverage. The restrictions extend to any government-run plan, which would be offered on the exchange.

The provisions could change, and there are a few exceptions: Workers would be allowed to buy insurance through the exchange if their job-based coverage gobbled up too much of their incomes or was too skimpy. Also, under the House proposal, people could get insurance through the exchange if they paid their entire premiums — a cost that would be prohibitive for many workers.

Democratic lawmakers and administration officials say the restrictions are critical to maintaining a strong employer-based insurance system, which covers 158 million Americans.

But critics argue that the rules run counter to suggestions from health care reform advocates that an overhaul could provide people with a broader choice of insurance options. The rules, they say, could be especially unfair to some lower-income workers who are enrolled in costly job-based insurance. Also, they argue, the restrictions would hurt the proposed public plan by limiting enrollment.

Jonathan Oberlander, associate professor at the University of North Carolina at Chapel Hill, said the restrictions create a “big gap between the rhetoric and the reality” of health reform.

“The rhetoric is that Americans will gain new alternatives,” he said. “But the reality is that they are putting up firewalls that are going to restrict the access of people with employer-sponsored insurance to the exchange.”

One result, he said, is that any public plan would be substantially smaller than what many backers are envisioning. That would reduce the public plan’s power to compete with private insurers and hold down costs, he said. The Congressional Budget Office estimates that nine million to 10 million people would enroll in the public plan by 2019.

http://www.kaiserhealthnews.org/Stories/2009/July/15/Firewall.aspx

Imagine presidential candidate Barack Obama telling his audiences during the campaign, “We promise you choice. For most of you already receiving your health insurance through your place on employment, we will provide you with the choice of keeping that insurance plan or paying heavy financial penalties for dropping off the plan, no matter how unhappy you are with it. For a select few of you, we will offer the choice of private plans within an insurance exchange, even if you can’t afford them, and maybe even throw in a public plan that a couple of you may be able to purchase, if you meet our rigid enrollment criteria.”

Choice? Over a year ago in a Quote of the Day I discussed the decision to market health reform as a matter of choice – of keeping the plan you have if that’s your choice. The title of that qotd was “Message trumps policy?”

This isn’t an “I told you so.” Er… uh… I guess it is.

If reform is to be effective, it must be based on sound policy science. Instead, it is being based on political messaging. It may sound good, but nothing fits together. What a disaster.

History tells us that societal blind spots are common throughout the centuries from one society, culture or continent to another. An example in the late 1700s involves the first cancer hospital in the world. It was established in Reims, France, but was forced to leave the city in 1779 because of the public’s fear of contagion — most people then believed that cancer was spread by parasites.

Fast forward to the current debate in the United States over how to reform our increasingly unaffordable and dysfunctional health care system. Do we have any blind spots as this debate boils over such fundamental issues as the roles of the free market vs. that of government, and whether health care is just another commodity to be bought and sold on the open market?

Based on the content of the debate swirling around these questions and how the mainstream media are covering the story, we have two major blind spots in American culture today concerning health care — continuing denial that markets fail the public interest in health care, and that market failure leads to serious adverse economic, social and moral consequences. These two blind spots are interrelated and mutually reinforcing.

This recent statement by Rep. Paul Ryan (R-WI) illustrates the extent of our ideological blind spots about our market-based system. Commenting on a report by government analysts that health care spending will grow by about seven percent a year to a total of $4.3 trillion in 2017, he has this to say: “These are not signs that the health care market has failed.  In fact — and it is crucial to understand this — they are the predictable results of vast distortions imposed on the market over decades.  The government is the single greatest contributor to this problem.”

But markets in health care do not work the way they may in other sectors of the economy.  Here there is much less competition than market advocates proclaim, extensive consolidation within health care industries, wide latitude to set prices at what the traffic will bear, and pervasive conflicts of interest throughout the system encouraging over-utilization of wasteful, unnecessary and even harmful care.

The wreckage of markets in health care is all around us. Private insurers pursue their profits by many strategies to exclude or limit coverage of the sick. Their goal is to keep their medical loss ratios (the industry’s term for payments for medical care) below 80 percent, whereby they can retain at least 20 percent of premium revenue for overhead, profits and returns to shareholders. Whether hospitals, HMOs, nursing homes or mental health centers, investor-owned care has been documented by many studies to be more expensive and of poorer quality than not-for-profit care. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 has proven itself to be a bonanza for the drug and insurance industries. The government was prohibited from negotiating the prices of drugs as the Veterans Administration does so effectively, and the costs of drugs (the problem the bill was supposed to address) continue to surge upwards. Meanwhile the unregulated marketplace allows widespread profiteering through overuse in such areas as imaging centers, many of which are owned by the very physicians ordering the tests.

All this is predictable and of no surprise.  Joseph Stiglitz, Ph.D., Nobel Laureate in Economics and former chief economist at the World Bank, has this to say about markets: “Markets do not lead to efficient outcomes, let alone outcomes that comport with social justice.  As a result, there is often good reason for government intervention to improve the efficiency of the market.  Just as the Great Depression should have made it evident that the market does not work as well as its advocates claim, our recent Roaring Nineties should have made it self-evident that the pursuit of self-interest does not necessarily lead to overall economic efficiency.”

Our market-based system breeds costs, not restraint.  Despite the claims of their advocates, all of the various multi-payer proposals being considered in Congress, intended as they are to preserve a dying private insurance industry, have no effective methods to contain health care costs. With by far the most expensive system in the world, we ration care based on ability to pay. Despite the money we throw at health care, the quality and outcomes of our care compares poorly with many industrialized countries around the world that spend far less than we do.

And our societal blind spot extends as well to the social and moral consequences of our pro-market policies. As the income gap widens between the rich and poor and as the middle class falls into increasingly difficult straits in affording health care, our sense of social solidarity continues to erode.  Medical costs are now responsible for 62 percent of personal bankruptcies, most of whom were insured at the onset of their illness or accident.  All this while our supposed safety net, already frayed, further deteriorates in the face of increasing federal and state deficits.

So it is now time to take off our blinders and recognize these problems for what they are.  The government needs to play a greater role in health care, starting with a public system of financing that incorporates and builds on the strengths of our private delivery system.  Single-payer financing along the lines of the Conyers bill (H.R. 676) is an essential first step in the reform of U. S. health care for all Americans.

Whether we yet realize it or not, future generations will look back and wonder how we don’t see past our blind spots, in the same way as we find it hard to imagine the blind spot about cancer in France more than two centuries ago.

Adapted from The Cancer Generation: Baby Boomers Facing a Perfect Storm, 2009, with permission from the publisher Common Courage Press.  Order link

John Geyman, M.D. is the author of The Cancer Generation and Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It, 2009 by John Geyman. With permission of the publisher, Common Courage Press

Buy John Geyman’s Books at: http://www.commoncouragepress.com/

House of Representatives
July 14, 2009
H.R.____

To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.

SHORT TITLE.–This Act may be cited as the “America’s Affordable Health Choices Act of 2009″.

TITLE IV–AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle D–Other Revenue Provisions

PART 1–GENERAL PROVISIONS

SEC. 441. SURCHARGE ON HIGH INCOME INDIVIDUALS.

(a) IN GENERAL.–Part VIII of subchapter A of chapter 1 of the Internal Revenue Code of 1986, as added by this title, is amended by adding at the end the following new subpart:

“Subpart B–Surcharge on High Income Individuals

“SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.

“(a) GENERAL RULE.–In the case of a taxpayer other than a corporation, there is hereby imposed (in addition to any other tax imposed by this subtitle) a tax equal to–

“(1) 1 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $350,000 but does not exceed $500,000,

“(2) 1.5 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $500,000 but does not exceed $1,000,000, and

“(3) 5.4 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $1,000,000.

http://energycommerce.house.gov/Press_111/20090714/aahca.pdf

Health insurance and health care are no longer affordable for average-income individuals. Any reform proposal that would make health care affordable for everyone must include a transfer from the wealthy to average- and low-income individuals.

The authors of the House tri-committee reform bill explicitly acknowledge this fundamental principle by including a policy for a surtax on high income individuals to help finance the subsidies that will be required to assist individuals of more modest incomes with the mandated purchase of health plans. Has this taken care of the affordability issue?

Let’s go through the numbers again. Average health care costs for a family of four with an employer-sponsored PPO are now $16,771. That is the average cost for a relatively healthy sector of society. Many with greater needs pay more than that. That is the average health care spending under the best of conditions in our current multi-payer system, and it doesn’t even include insurer administrative costs.

Under this legislation, no subsidies are provided for individuals or families over 400 percent of the federal poverty level. For a family of four, that threshold is an income of $88,200. Thus average costs would be 19 percent of family income, and more for those with greater needs. By no stretch could that be considered affordable.

It’s great that the concept of income transfer has been accepted by the policymakers in Congress, but they need to go back to the drawing board to craft a plan that would actually work. (Hint: Provide all necessary services for everyone, and pay for those services through a single universal risk pool that is funded equitably using progressive tax policies.)