(Video links below)

Last night as the House Energy and Commerce Committee completed its markup of HR 3200, the House health reform bill, Chairman Henry Waxman interrupted Representative Anthony Weiner of New York to say that House Speaker Nancy Pelosi had promised that single payer legislation, HR 676, The United States National Health Care Act would come before the entire House of Representatives. Chairman Waxman:

The Speaker has said that she will allow this to be brought up on the House floor, and debated, and voted on.

Representative Anthony Weiner (NY-9, Brooklyn/Queens) had placed an amendment before the Energy and Commerce Committee that would have replaced the text of HR 3200 with the text of HR 676, the United States National Health Care Act. He was joined by fellow Energy and Commerce committee members Peter Welch (VT, Vermont), Mike Doyle (PA-14, Pittsburgh), Tammy Baldwin, (WI-2, Madison), Jan Schakowsky (IL-9, Chicago), Bobby L. Rush (IL-1, Chicago), Eliot L. Engel (NY-17, Rockland/Westchester).

Chairman Waxman asked for the single payer amendment to be withdrawn from committee debate in exchange for a debate and vote on the House floor. Representative Weiner hailed this victory in a brief statement:

Single-payer is a better plan and now it is on center stage. Americans have a clear choice. Their Member of Congress will have a simpler, less expensive and smarter bill to choose. I am thrilled that the Speaker is giving us that choice.

On the Mouth of the Potomac blog, NY Daily News Washington Bureau journalist Michael McAuliff reported:

The Brooklyn-Queens Rep. looked a little surprised when Chairman Henry Waxman said Pelosi would allow that vote, and made Waxman repeat the deal to be sure it was clear and on the record. It’s an especially big deal for advocates of a single health care system — who see it as cheaper and simpler than the complicated measure being drawn up — because they have been complaining that they have not even been able to get an airing of their position.

And having the vote of the floor of the House will force members to declare a position, and bring much more attention to the idea.

Reporting for The Hill Mike Soraghan wrote:

Legislation creating a single-payer system would be expected to lose, but would allow liberal members to record their support for the proposal. It will also be a tough vote for some Democrats who will be wary of upsetting the liberal base.

Many liberal lawmakers feel that the controversial “public option” that would compete with private insurers is a compromise from single-payer.

Single payer advocates should not be surprised by this turn of events. Chairman Waxman himself was a co-sponsor of HR 676 in the 109th Congress. Speaker Pelosi has also supported single payer in the past. Only this spring, at an event sponsored by the Christian Science Monitor, the Speaker told the audience:

… over and over again, we hear single payer, single payer, single payer. Well, it’s not going to be a single payer. …

Just one day before the Energy and Commerce Committee meeting, on July 30th, over one thousand single payer supporters swarmed through the halls of Congress to celebrate Medicare’s 44th birthday. Congresspeople and staff told us over and over again that back home grassroots clamor for single payer continues to build. In other words, across the nation, representatives have had the same experiences as the Speaker of the House.

Anthony Weiner’s initiative has created a new opening for us to educate our colleagues, our patients, our elected representatives, indeed everyone, about the need for a single payer program of national health insurance. A strong single payer vote in the House will mark a turning point in history.

As we accumulate momentum, we find steady support and fresh creativity for our great cause. What a wonderful time to join Physicians for a National Health Program. We need your voice!

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Video links:

The full Weiner amendment discussion at the Energy and Commerce Committee can be viewed here. Look at the bottom on the screen. The session is 6 hours 5 minutes and 38 seconds long. The Weiner piece begins at 3 hours 15 minutes and 40 seconds and ends at 3:32:53.

Representative Weiner introduces the single payer amendment at the Energy and Commerce Committee.

Representative Tammy Baldwin (Madison, Wisconsin) speaks for single payer at Energy and Commerce Committee

Representative Eliot Engel (Westchester/Rockland, New York) speaks for single payer at Energy and Commerce Committee.

Chairman Waxman interrupts Representative Weiner to ask that the amendment be withdrawn because Speaker Pelosi has promised to allow single payer before the entire House of Representatives.

As the debate over health care reform becomes all-out warfare between parties and within the Democratic party, Congress will adjourn shortly for its August recess with many of the key questions unresolved.  However, the bill as shaped by two or three House committees (H. R. 3200, America’s Affordable Health Choices Act) gives a point of departure to consider the most that we might expect out of such a bill.

As described in our last three posts, this bill calls for both an individual and employer mandate as well as a small public option to be available to the uninsured and employees of small employers through a national insurance exchange.  Individuals would be subsidized by the government to offset their premium and out-of-pocket costs.  People with household incomes up to 400 percent of the federal poverty level (FPL) would be eligible for subsidies.  Tax credits would also be provided to small employers with fewer than 25 full-time workers, covering up to 50 percent of their premium costs.  These new subsidies, of course, are in addition to the many subsidies the government already provides to individuals and employers through long-standing tax-exemptions of  insurance costs.  H.R. 3200 also calls for expansion of Medicaid for all individuals with incomes up to 133 percent of the FPL (about $14,000 for an individual and $88,200 for a family of four).

The CBO projects the cost of H. R. 3200 to be about $1 trillion over 10 years, not including the increased costs of Medicaid, for which it lacks jurisdiction to score.  “Conservative” projections estimate that the bill will increase the U. S. budget deficit by $239 billion in 2019.  Governors have already weighed in against the increased costs of Medicaid expansion, pleading for an increased federal role in paying for it, and political opposition to the bill’s inflationary trends seems certain to spread beyond the Republicans and Blue Dog Democrats to others.  As the debate intensifies, we can expect that eligibility for subsidies will be tightened up.

Returning to the affordability of health insurance, the supposed reason for reform legislation, there is an obvious disconnect from the impacts of a deepening recession.  Much of the population, including the broad middle class, are in increasingly dire straits in their ability to pay for necessary health care.  Average annual health care costs for a family of four are now $16,771, including insurance premiums, deductibles and other out-of-pocket costs.  For a family of four with an income of $88,200 (four times the FPL and much more than the median U. S. median income), these average costs exceed 19 percent of family income, well above the 10 percent considered by the Commonwealth Fund as a hardship level.

We have to remember that the costs of health insurance often have little to do with the total costs of health care for individuals and families.  For those with significant health problems, their costs will be much higher.  And although the current proposals in Congress call for annual limits on out-of-pocket spending ($5,000 for individuals and $10,000 for families), insurance premiums and out-of-network charges are not counted against these limits.

This bad situation is getting worse. The unemployment rate is poised to soon rise above 10 percent, and the broader unemployment rate is already more than 20 percent in a number of states.  Tax revenues have fallen precipitously in many states, and 16 states are now paying for unemployment insurance in borrowed funds.  Draconian cuts are being made in safety net programs all across the country.

So it seems certain that federal payments for subsidies will far exceed any projections that are now being discussed. There are at least 100 million Americans less than 65 years of age with incomes below 400 percent of FPL.  If eligibility for federal subsidies is set at that level, the CBO projects that their cost will be about $773 billion between 2013 and 2019. Concerning Medicaid expansion, the CBO has also estimated that extending Medicaid to an additional group of Americans with incomes for a family of four up to $33,000 a year would cost about $500 billion over 10 years.

We can be sure that the Senate will restrict subsidies below these levels and that any final health care reform bill, if ever enacted, will further exacerbate the problems Americans face in paying for health care.  And to boot, federal law would mandate them to purchase health insurance, under penalty of fine, and an underinsurance product at that.  A working draft of the “actuarial value” of insurance coverage in the Senate Finance Committee last month stated that a policy of “bronze” or “silver” value would cover 65 and 73 percent of total health care costs, respectively — undercoverage by any standard.  A family of four with an income at 300 percent of FPL would pay 15 percent of their income on health care. So we would end up with a mandate for inadequate coverage which much of the population, as well as taxpayers, cannot afford.

The strong conservative challenge that is building against H. R. 3200 is largely due to its deficit-busting certainty as well as its increase in entitlement to health care without credible cost containment requirements.  As a progressive advocate of real health care reform, I can only agree with these concerns.  What is likely to emerge from Congress on health care reform this year, if anything, will not be real reform and will only add to our problems.

Although still very much under-recognized and fought against by the medical industrial complex and complicit corporate media, there is only one solution to cost containment of our runaway market-based health care system.   H. R. 676, coupled with a private delivery system, is a paygo alternative that assures universal coverage of necessary health care for all Americans.  It would save up to $400 billion a year and provide a structure within which to put in place other cost-saving efficiencies.

The private health insurance industry is an impediment to reform, not part of the solution.  It has survived to this time only through generous subsidies from the government, whether in the employer-based or individual markets or privatized Medicare and Medicaid programs.  Until we recognize this, all of our incremental approaches to build on our multi-payer system will be of no avail.

Adapted from Do Not Resuscitate: Why The Health Insurance Industry Is Dying, and How We Must Replace It, and The Cancer Generation: Baby Boomers Facing a Perfect Storm, with permission from the publisher, Common Courage Press.  Order link
1,096 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

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From Jeoffry Gordon, M.D., M.P.H. (San Diego, CA)

We had a good Medicare birthday rally on July 30th.

Next week is busy for me.
Sunday: Single payer presentation at Mission Hills United Church of Christ.
Tuesday: Medical Grand Rounds on Single Payer Reform at Sharp Coronado Hospital
Wednesday: I will represent PNHP and single payer on local PBS affiliate KPBS’s “These Days” show (you can get a podcast) which is presenting a four day series on problems with the health care and reform proposals.

From Wendy Ring, M.D., M.P.H. (Bayside, CA)

A group of us have been performing The Sound of Moolah, a show about health reform and why we need single payer, around southern Oregon and Northern CA recruiting new single payer activists wherever we go. There have been several newspaper articles and radio interviews.

From David A. Cimino, M.D. (St. Petersburg, FL)

I have had two letters to the editor published in the St. Petersburg Times in the past 4 months. The most recent was on July 22 and was a push for a Single Payer System. Tomorrow July 31 I have been asked to appear on a local news program on Channel 13 WTVT Fox News at 12:30 PM to discuss health care reform. I again will push for a Single Payer System as the only way to achieve affordable, quality health care for all. I am a semi-retired general pediatrician and for the past 20 years limited my practice to adolescents.

From Cynthia Haq, M.D. (Madison, WI)

Dr. Cindy Haq on Wisconsin Public Radio:
http://www.wpr.org/hereonearth/archive_090722k.cfm

Health Care Reform Rally 7/25/09 in Madison in Memory of Lindy Farley, MD

http://www.youtube.com/watch?v=TOc-2wwQYKk

Dr Jeff Patterson at the Farmer’s Market in Madison 6/28/09

http://www.youtube.com/watch?v=QaMU4-IYESc

Dr Gene Farley at the Farmer’s Market in Madison 6/28/09

http://www.youtube.com/watch?v=KeUjrW-UMZs

Farmer’s Market Madison 6/28/09
http://www.channel3000.com/health/19884995/detail.html

Poisoning thought with words

Posted by on Friday, Jul 31, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

“American Values” — A Smoke Screen in the Debate on Health Care Reform

By Allan S. Brett, M.D.
The New England Journal of Medicine
July 29, 2009

Amid all the rhetoric about health care reform, one claim has emerged as a trump card designed to preserve the current patchwork of private and public insurance and to stop discussion of a government-sponsored single-payer system in its tracks: the claim that single-payer health care — a Canadian-style Medicare-for-all system — is antithetical to “American values.” The idea that American values dictate a particular approach to health care reform is often stated explicitly, and it is implicit in the generalization that “Americans want” a particular system. The underlying premise is that an identifiable set of American values point incontrovertibly to a health care system anchored by the private insurance industry. Remarkably, this premise has received very little scrutiny.

Americans have been misled by the rhetoric about choice. In contrast with the single-payer option, a system with multiple private insurers would continue to restrict one dimension of choice (selection of physicians) and perpetuate a choice most people would consider irrational (wasteful spending on administrative overhead).

A closely related rhetorical device — the idea that Americans or American values are “unique” — also deserves attention… What is relevant is whether a solution works, not whether it is unique. Indeed, the aspect of the current U.S. system that is truly unique among developed countries is its failure to cover everyone — hardly something to brag about.

Policymakers debating health care reform should stop hiding behind the smoke screen of “American values.” Discussions dominated by references to uniquely American individualism, uniquely American solutions, or narrowly defined conceptions of choice tell us more about the political and economic interests of the discussants than about the interests of the Americans they claim to represent. In an increasingly diverse country that has a widening gap between rich and poor, a more promising approach is to start with the questions that matter to everyone: Will the system care for us when we’re sick and help prevent illness when we’re well? Will we have access to medical care throughout our lives without risking financial ruin? Will we be able to navigate the system easily, without jumping through unnecessary hoops or encountering excessive red tape? Will health care spending be managed wisely? Health care reformers owe Americans a system that best addresses these questions — not one that merely pays lip service to ill-defined “American values.”

http://healthcarereform.nejm.org/?p=1245

Click on the link above now. At the bottom of this article you will find another link to the full PDF version (2 pages). Download it now. It will be a very important resource during the August recess when tens of millions of dollars will be spent to keep our thought processes suppressed by the poisonous rhetoric of carefully-crafted nice words – a process that has permeated our national dialogue on health reform. It is ideas, not words, that count.

BREAKING NEWS: Speaker Pelosi promises floor vote on single payer

Posted by on Friday, Jul 31, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Liberals will get single-payer vote on House floor

By Mike Soraghan
The Hill
July 31, 2009

Seeking to dampen liberal anger about deals cut with centrists, Energy and Commerce Committee Chairman Henry Waxman (D-Calif.) said House leaders have agreed to allow a floor vote on a government-run, single-payer system.

“A lot of members on our committee want a vote on that,” said Waxman said in an interview. “I believe their wishes will be accommodated.”

Rep. Anthony Weiner (D-N.Y.) offered a single-payer amendment in the Energy and Commerce Committee on Friday, but withdrew it after Waxman said House Speaker Nancy Pelosi (D-Calif.) had promised a floor vote.

http://thehill.com/leading-the-news/liberals-will-get-single-payer-vote-on-house-floor-2009-07-31.html

The Weiner single payer amendment:
http://energycommerce.house.gov/Press_111/20090731/hr3200_weiner_1.pdf

Call out the troops. We have work to do!

President Obama's hardship waivers

Posted by on Thursday, Jul 30, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

TIME’s Exclusive Interview with President Obama

By Karen Tumulty
TIME
July 29, 2009

Karen Tumulty: But some things have changed. I mean, for instance you were very much against an individual mandate. Could you describe how your thinking has evolved on this issue…

President Obama: I feel pretty good that I’ve been pretty consistent on this. The individual mandate is probably the one area where I basically changed my mind. The more deeply I got into the issue, the more I felt that the dangers of adverse selection justified us creating a system that shares responsibility, as long as we were actually making health insurance affordable and there was a hardship waiver for those who, even with generous subsidies, couldn’t afford it. And that remains my position.

Karen Tumulty: What about — you mentioned that subsidies have to be there. What’s — you’re hearing now — 300% [that the government would provide assistance to people earning up to 300% of poverty]. Is that enough? Is that really –

President Obama: Until I actually see the numbers, I don’t want to give a definitive answer on that. I do think that if we can figure out what is a fair, appropriate percentage of your income that you’re paying on health care, and peg it — peg subsidies so that it’s meeting that test, potentially with some regional variation then we’ll get it right. And I think that the committees are working on that. That’s the kind of detail that we had anticipated working through in conference. If it turns out that Congress just can’t get there and that’s the holdup, then we’ll give a very definitive idea of where we need to go on it.

http://www.time.com/time/politics/article/0,8599,1913410-1,00.html

Detail? Figuring out how to make insurance affordable if it is to protect families from the financial burden of the $16,771 already being spent on average for health care? 300 percent of poverty? 400 percent of poverty?

Play with the numbers all you want. Using the model of reform selected by the President and Congress automatically limits the total subsidies to an amount that will not increase the deficit in the federal budget. Even if the majority of employers continue to displace wage or salary increases in exchange for health benefits, the number of hardship waivers issued will have to be much larger than most are projecting. If employers finally bail out, the majority of us would require hardship waivers.

You don’t believe me? Do the numbers, starting with the amount of money they propose to spend on subsidies.

Steve Burd's magic elixir

Posted by on Wednesday, Jul 29, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

How Safeway Is Cutting Health-Care Costs: Market-based solutions can reduce the national health-care bill by 40%

By Steven A. Burd, CEO of Safeway Inc.
The Wall Street Journal
June 12, 2009

As with most employers, Safeway’s employees pay a portion of their own health care through premiums, co-pays and deductibles. The big difference between Safeway and most employers is that we have pronounced differences in premiums that reflect each covered member’s behaviors. Our plan utilizes a provision in the 1996 Health Insurance Portability and Accountability Act that permits employers to differentiate premiums based on behaviors. Currently we are focused on tobacco usage, healthy weight, blood pressure and cholesterol levels.

Safeway’s Healthy Measures program is completely voluntary and currently covers 74% of the insured nonunion work force. Employees are tested for the four measures cited above and receive premium discounts off a “base level” premium for each test they pass. Data is collected by outside parties and not shared with company management. If they pass all four tests, annual premiums are reduced $780 for individuals and $1,560 for families.

During this four-year period, we have kept our per capita health-care costs flat (that includes both the employee and the employer portion), while most American companies’ costs have increased 38% over the same four years.

While comprehensive health-care reform needs to address a number of other key issues, we believe that personal responsibility and financial incentives are the path to a healthier America. By our calculation, if the nation had adopted our approach in 2005, the nation’s direct health-care bill would be $550 billion less than it is today.

http://online.wsj.com/article/SB124476804026308603.html

And…

Preventive health plan may prevent cost increases

By Victoria Colliver
San Francisco Chronicle
February 11, 2007

Safeway chief executive Steve Burd has turned into an evangelist of sorts, spreading the lower-cost, better-health gospel to other business executives around the country.

Starting in January 2006, Safeway began offering a new plan to its 30,000 nonunion employees.

The plan, administered by Cigna Corp., is the lowest-premium option for nonunion employees, but it comes with a high deductible. To encourage enrollment, Safeway offered the plan last year for 22 to 30 percent less than what employees were paying for Cigna’s preferred provider organization option.

The company said its program focuses more on rewards for good behavior than penalties for bad. For example, smokers who agreed to fill out the questionnaire and try to quit smoking saw no increase in their 2007 premiums.

Virtually all the savings generated in the program’s first year came from changing the plan design, Burd said. But even if the company manages to keep spending flat, Burd noted, Safeway will remain ahead of the trend.

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/02/11/BUG02O20R81.DTL

And…

Mr. Burd Goes to Washington

By Kimberley A. Strassel
The Wall Street Journal
June 19, 2009

Mr. Burd explains that the “cure for today’s ills is simply removing the obstacles to a free health-care market.”

The Safeway plan has two main parts that work in tandem. The first involves giving employees a financial stake in the system. Safeway demolished the traditional PPOs and HMOs that encourage consumers to be cavalier about costs. The company deposits $1,000 each year into a “health reimbursement account,” which workers can use to pay for care. The next $1,000 in expenses is the employee’s responsibility. After that, employees pay 20% of costs up to a $4,000 maximum.

The second part of Safeway’s plan… Safeway’s “Healthy Measures” program, which is voluntary. Employees are tested for smoking, weight, blood pressure and cholesterol. Every area they “pass” results in a reduction in their premium, of as much as $1,560 for a family, a year.

When I ask Mr. Burd what he hopes to accomplish here, he is blunt that one goal is to prevent a “public option” that would only “piggyback on the experience of Medicare.” It’s a “Trojan Horse” that will steer people to government and ultimately squeeze out innovative programs like his.

He’s also working to ensure that any health-care bill contains provisions that would replicate or encourage Safeway’s success. That includes changing current law so that he can offer even steeper premium discounts for good behavior.

http://online.wsj.com/article/SB124536722522229323.html

And…

Just Rewards? Healthy Workers Might Get Bigger Insurance Breaks

By Mary Agnes Carey
Kaiser Health News
July 28, 2009

The discounts are being pushed by Steve Burd, the chief executive officer of Safeway Inc., who has met with several lawmakers on Capitol Hill and says that rewarding healthy behavior has helped keep his firm’s health care costs flat while other companies’ have skyrocketed.

Health care overhaul legislation passed by the Senate Health, Education, Labor and Pensions Committee would allow employers to increase those discounts to 30 percent and up to 50 percent if the secretaries of Labor, Health and Human Services and Treasury agree. A House proposal would allow employers to charge workers who participate in wellness programs 50 percent less than workers who don’t.

“If you give one person a discount, someone else is going to end up paying more,” said Paul Cotton, senior legislative representative, federal affairs, at AARP, one of more than 60 groups that’s fighting the provision. “So the people who aren’t able to change their behavior or participate in the program will end up paying more. Our fear is that premiums will become unaffordable for people who can’t change their behavior.”

By Safeway’s calculations, “if the nation had adopted our approach in 2005, the nation’s direct health-care bill would be $550 billion less than it is today,” Burd wrote in a June 12 op-ed in the Wall Street Journal. Critics of Burd’s data have said (that) has not been independently verified. A Safeway spokeswoman acknowledged that there has been no independent analysis, but “we were able to see savings clearly and immediately the first year we implemented the program.”

http://www.kaiserhealthnews.org/Stories/2009/July/28/Prevention.aspx

Safeway’s Steve Burd has been making the rounds in Washington and elsewhere claiming that his program would reduce our national health care bill by $550 billion, even though there is absolutely no verification of that.

So what is his program? It has two parts: 1) changing from traditional coverage to a high deductible plan with 20 percent coinsurance, and 2) premium reductions for better health.

Changing to consumer-directed high-deductible plans, with coinsurance replacing copays, reduces the amount that Safeway pays for its health benefit programs, but it does so by shifting more costs to the employees in out-of-pocket expenses, and by reducing the amount of health care received, no matter how beneficial. Since most health care spending is not subject to the negative impact of deductibles, the impact on our total national health spending would be negligible. So where is the $550 billion savings?

Reducing premiums for healthier employees automatically results in higher premiums for employees with health problems who are in the same risk pool. Hypertension, hypercholesterolemia, and a higher body mass index are problems that are much more complex than simple lifestyle choices. Health insurance is already unaffordable for the majority of us, and pushing premiums higher for those who have have greater health care needs is unsound policy, assuming that our goal is affordable health care for everyone.

Even if financial incentives were capable of reversing hypertension, hypercholesterolemia, and obesity, it would take many years – decades – to see a benefit in the form of lower national health care spending. Steve Burd’s claim that he has dramatically reduced costs in just a couple of years by shifting more out-of-pocket expenses to the less healthy employees is a crock!

Let’s say it like it is. When Steve Burd says that his program would save the nation $550 billion, he is lying. And he needs to be called on it.

His primary goal is to convince Congress that it needs to block the public option. The Senate Finance Committee decided this week that the reform bill will exclude the public option. Score one for Burd.

His other goal is to take care of his lower-cost healthy employees while punishing those with health care problems. Both the Senate HELP bill and the House Tri-Committee bill would shift even more of the premiums from the healthy to those with health problems than has Burd with his Safeway program. Score two for Burd!

It’s seems like a waste of time to even talk about Burd’s dishonest bull. But we have to, because Congress is converting his bull into our policy. At the same time, Congress is pushing aside the policies that would enable all of us to have affordable access to health care.

I only wish my anger were more contagious. The nation needs a massive epidemic of anger right now.

by Kip Sullivan

It has become obvious that the Democratic leadership in Congress will not fight for a large “Medicare-like” program or “public option,” to use the lingo adopted early in 2009 by advocates of this idea. As I reported in an article posted on this blog on July 20, “public option” advocates originally claimed they stood for a “Medicare-like” program that would enroll 130 million non-elderly Americans, but somewhere along the line they got comfortable selling the “public options” proposed in legislation introduced by Senate and House Democrats a few weeks ago that will, at best, enroll 10 million people.

A “public option” that small will have no effect on the cost of health care in the U.S., which means it cannot bring us closer to universal health insurance. I noted in my July 20 article that neither the original proponents of the “public option,” nor Democrats in Congress, have warned the public that the “public options” contained in the Democrats’ legislation are tiny and powerless compared with the original model.

It is difficult to understand why “public option” advocates outside Congress would conceal this from the public. It is even more difficult to comprehend why members of Congress – people who actually have something tangible to lose (namely, power and a livelihood) if the “public option” turns out to be a joke – have remained silent about the degradation of the “public option.”

If you were asked to think of one group of Congress members who should be leading the campaign to warn America that the “public option” in the Democrats’ legislation is not what it’s been cracked up to be, you would think of the Congressional Progressive Caucus (CPC).

With 82 members (according to CPC’s latest count), representing the most progressive members of the House of Representatives, the Congressional Progressive Caucus is the largest caucus. The CPC has said not a word about the incredible shrinkage of the “public option” that occurred between the time the concept was originally proposed by Jacob Hacker (the man “who is credited with developing the public-plan idea”) and the time it was written into the Democrats’ bills. This omission might be justifiable if the “public option” were a small afterthought in the Democrats’“reform” legislation. But it is not. According to its proponents, it is “the heart” of the Democrats’ proposal and an essential plank in the Democrats’ cost-containment platform.

Nevertheless, the CPC has been silent about the remarkable transformation the “public option” has suffered during the course of the campaign that propelled it to center stage. What explains this behavior? To answer that question, it helps to take a close look at the statements the CPC has made about the “public option” in recent months.

The CPC’s endorsement of the “public option”

Between early April and early June of this year, the CPC aggressively promoted the “public option” in the same vague terms many of the groups associated with Health Care for America Now have promoted it – as if it were a slogan on a bumper-sticker unaccompanied by position papers and data one could turn to find out what it meant. On April 2, long before either house had drafted “public option” provisions, the Progressive Caucus sent a letter to Senate Majority Leader Harry Reid and House Speaker Nancy Pelosi stating:

Regarding the upcoming health care reform debate, we believe it is important for you to know that virtually the entire 77-Member Congressional Progressive Caucus (CPC) prefers a single-payer approach to health care reform. Therefore, it will come as no surprise as you work to craft comprehensive health care reform legislation, that we urge the inclusion of a public plan option, at a minimum, in the final legislation. We have polled CPC Members and a strong majority will not support legislation that does not include a public plan option that is supported on a level playing field with private health insurance plans.

In an April 28 press release, the CPC again expressed its strong support for a “public option” and threatened a no vote on the entire “reform” bill if a “public option” was not in the final bill:

[O]ur support for enacting legislation this year to guarantee affordable health care for all firmly hinges on the inclusion of a robust public health insurance plan like Medicare.

Although the CPC’s press release placed the word “robust” before “public option,” they did not define what that term meant to them. Is it not odd for any legislator, much less dozens, to “hinge” their support for an entire (and very important) bill on the inclusion in that bill of an entity they have not defined?

The CPC’s criteria for a “public option”

It was not till early June that the CPC got around to identifying criteria that had to be met in order for the CPC to define a “public option” as “robust.” In a June 5 letter to House Speaker Nancy Pelosi, which laid out these criteria, CPC’s co-chairs, Reps. Raul Grijalva and Lynn Woolsey, warned the Speaker that these criteria “must be included” in the final bill in order to win CPC support.

The CPC’s list of criteria includes about a dozen “principles.” The principles are an odd mix. Although the letter to Speaker Pelosi repeated the “public option” proponents’ mantra that the “public option” should be “robust … like Medicare,” the criteria enunciated in the letter were far weaker than the criteria Jacob Hacker originally proposed for his version of the “public option,” a version which would have enrolled 130 million people. The CPC’s criteria refer to only one of the features of the “Medicare-like” program that Hacker called for, namely, the one calling for giving all non-elderly Americans access to the public program (as opposed to limiting access to uninsured people and employees of small businesses). Missing from the CPC list of criteria are these four features of Hacker’s original proposal:

• the public program must be pre-populated with tens of millions of
people;
• subsidies must go only to Americans who enroll in the public program;
• the program must be authorized to use Medicare’s payment rates; and
• the insurance industry must be required to offer the same benefits
the public program is required to offer.

One CPC criterion would actually reverse one of Hacker’s: The Progressive Caucus insists on paying the insurance industry the same subsidies the public program gets.

The CPC document containing these criteria does not explain why the CPC adopted them, nor why the CPC thinks their criteria are sufficient to guarantee the “public option” will survive and have any influence on the insurance industry and the number of uninsured and underinsured. Of the CPC’s “criteria,” only two would have a direct, positive influence on the public program’s ability to set its premiums below those of the insurance industry. They require the “public option” to:

• Consist of one entity, operated by the federal government, which sets policies and bears the risk for paying medical claims to keep administrative costs low and provide a higher standard of care.

• Be available to all individuals and employers across the nation without limitation.

Significantly, the CPC would prohibit the “public option” from attempting to “compete” with private insurers by limiting patient choice of provider. This standard reads: “Allow patients to have access to their choice of doctors and other providers ….”

For two reasons this criterion will almost certainly make it harder for the “public option” to undersell the insurance industry (or even keep its premiums from being above those of the industry).

First, people in poor health are more likely to value freedom to choose their own doctor and hospital. If the “public option” is the only insurer in a multiple-insurer setting that is not limiting choice of provider, the “public option” is likely to suffer “adverse selection,” which means it winds up enrolling a disproportionate number of sick people. “Public option” premiums would go up and premiums of the insurance industry would go down.

Secondly, if the “public option” is not allowed to channel patients to a small network of providers, it will be more difficult for the “public option” to extract discounts from those providers, let alone match the big discounts large insurers typically get. Again, that would drive “public option” premiums up vis a vis those of the industry.

But as weak as the Congressional Progressive Caucus criteria are, they are better than nothing. But to be better than nothing, weak criteria have to be enforced. What has the CPC done?

The CPC avoids its first test

The first test of how seriously the Progressive Caucus would take its own weak principles arose on June 19. On that day, the House leadership unveiled a “reform” bill, a bill they would introduce a month later as HR 3200. The “public option” in this bill failed to meet all but one of Hacker’s criteria and nearly all of the important CPC criteria.

The CPC’s initial statement included a promise to evaluate the “public option” provisions in the bill. But even at this date (more than a month later), the CPC’s website contains no evidence that the CPC has published an evaluation of HR 3200’s “public option” provisions. The CPC has apparently endorsed those provisions anyway.

Here is what the CPC said in a press release published the same day (June 19) as the House draft bill was published:

We welcome the draft [bill] and will evaluate the language in the upcoming days. In our evaluation, we will pay close attention to the language outlining the public option. The Congressional Progressive Caucus has already submitted principles for a public plan that provides a guarantee of healthcare coverage … and which lowers costs for all consumers…. As we work with our colleagues toward a final bill, the CPC will be vigilant in ensuring that the bill’s public option is robust and is linked to the existing infrastructure of Medicare, in order to maintain transparency and provide consumer protection in its administration…..

The statement closed with this plaintive remark:

[W]e hope that our evaluation of the language in this draft bill upholds our principles.

The CPC dodges its second test

When HR 3200, America’s Affordable Health Choices Act, was formally introduced on July 14 (with “public option” language virtually identical to the draft language), the Congressional Budget Office released a copy of its “preliminary” assessment of the bill. The CBO said the “public option” might enroll 9 to 10 million people and would leave 16 to 17 million uninsured. This was a very different assessment from that promised by Hacker and the “public option” movement – 130 million enrolled in the public program and only 2 million people left uninsured. The CBO’s report should have been an immense red flag for the CPC. If it was, the CPC didn’t let on. The Progressive Caucus
press release, issued the same day (July 14), consisted of a short, cryptic remark. Here is the entire text:

The Co-Chairs of the Congressional Progressive (CPC), Reps. Lynn Woolsey (D-CA) and Raúl M. Grijalva (D-AZ), issued the following statement in response to the release of the introduction of America’s Affordable Health Choices Act: The public option is central to our support of health care reform. The Congressional Progressive Caucus is confident that the final legislation will retain a robust public option linked to Medicare that will cut costs, promote quality care and offer coverage to all.

There was no reference in this statement to the CPC’s “principles,” no indication whether the CPC had performed the “evaluation” of the bill’s “public option” provisions promised a month earlier, nor any indication whether an evaluation would be forthcoming.

On July 22, by which time HR 3200 had cleared the Ways and Means Committee and the Education and Labor Committee, the CPC sent a letter to President Obama in which they seemed to say that, yes, after all, they were endorsing HR 3200’s “public option.” The letter read:

As the health care proposal continues to move forward in the House and Senate, we ask that you continue your commitment to the inclusion of a strong public option and do not weaken the language that has already passed through two committees. Let us be clear: A strong public option is already a compromise for the CPC. Many of us strongly supported a single-payer approach. We will not support a weakened public option.… [emphasis added]

What does “a weakened public option” mean? Compared to what? Where were the CPC’s “principles”? Where was the evaluation of the bill’s “public option” provisions promised a month earlier?

The CPC released a similar statement two days later in the form of a letter to Nancy Pelosi. In it, the CPC objected for the first time to an actual provision in HR 3200, in this case, to the provision allowing providers to opt out of the “public option.” (As I noted in my July 20 article, this provision in HR 3200 inflicts a crippling injury on the “public option’s” ability to get started.) The CPC’s letter to the House Speaker stated:

We want to assure you that for our continued support, the public option …. must be on a level playing field …. And, it must be connected to the Medicare infrastructure, including the provider and payment system. Allowing providers to opt out of the public option has already created a loss of $91 billion in savings. We cannot tolerate further weakening of the public option.

What does “further weakening” mean? Compared to what? To Hacker’s criteria? To the CPC’s “principles”? When the long-awaited evaluation of HR 3200’s “public option” is published, will it answer these questions?

HR 3200’s “public option” does not meet the CPC’s criteria

If the CPC ever gets around to conducting an evaluation of HR 3200, they will have to report that the “public option” section fails to meet several of the CPC’s more important criteria. To begin with, there is nothing in HR 3200 that requires or guarantees that the “public option” will be “robust … like Medicare.” Medicare enrolls 45 million Americans, and pays about 20 percent of all U.S. health care costs. According to the Congressional Budget Office July 14 report, HR 3200’s “public option” might enroll 10 million non-elderly people, which means, it will pay 1 or 2 percent of the entire U.S. health care bill.

One reason the CBO concluded the “public option” would be so small is that HR 3200 bars the vast majority of Americans from buying insurance from it and from getting the subsidies that would make buying health insurance from any source financially feasible for most Americans. HR 3200 thus clearly violates another CPC criterion, the one requiring the public program to be “available to all individuals and employers across the nation without limitation.”

Finally, there is nothing in the bill requiring the “public option” to permit enrollees to use any clinic or hospital they want. How could it be otherwise when this bill explicitly states that providers don’t have to participate in the “public option”? In fact, the bill states the “public option” is subject to the same rules the insurance industry is subject to, including “provider network requirements.” How can enrollees in the “public option” have complete freedom of choice of provider if the “public option” is setting up “provider networks”?

The CPC must take a principled stand immediately

Two of the three health care “reform” bills that will be introduced in this Congress by Democrats have now been introduced. They are HR 3200 and the bill written by the Senate Health, Education, Labor and Pensions (HELP) Committee. As debilitated as HR 3200’s “public option” is, it is not as degraded as the one called for in the Senate HELP Committee bill.

The “public option” in the HELP Committee bill is weaker for two reasons. First, it calls for “community health insurance options,” and then defines these things as “health insurance coverage” which can vary by state. That implies there will be no single national “Medicare-like” program, but rather dozens, perhaps hundreds, of insurance companies sponsored by the federal government, each of which will be called “a community health insurance option.” Second, the bill does not authorize these “options” to pay providers rates below those paid by insurance companies as HR 3200 does. It was mainly for this latter reason that the CBO reported to Congress that the “options” in the HELP Committee bill would be unable to keep their premiums below those of the insurance industry.

The third bill – the one being written in the Senate Finance Committee – promises to be even worse than the Senate HELP Committee bill. It may not include provisions for a “public option,” or if it does, it will not call for a federal program like Medicare, but instead will probably call for the establishment of small, privately run cooperatives. Slinging little insurance co-ops into the insurance market will be like dumping a bucket of minnows in a shark tank.

So unless something changes, the Democrats’ bill writers have set in motion a process that will inevitably result in either no “public option” or a very weak one. And a very weak “public option” means nearly all of the $1 trillion in payments to insurers projected for the next decade will go to the insurance industry and very little will go to the “public option.” Is that what the CPC wants?

If an intervention within Congress is going to occur, one might expect it to come from the CPC. But so far the CPC’s strategy appears to be to do nothing to strengthen the puny “public option” in HR 3200. The CPC appears to have adopted a strategy of (a) insisting that the final bill contain a “public option”, and (b) begging other Democrats not to let anyone degrade HR 3200’s “public option” any further. If this observation is accurate, and if the Senate Finance Committee bill turns out to be as bad as everyone expects it to be, then it is safe to say the bill Congress sends to Obama will contain either no “public option” or a very, very weak “public option.” And if that’s the case, the bill will be a pure, or 99-percent pure, health insurance industry bailout.

The CPC needs to remind itself that the goal of most of its members is comprehensive, universal health insurance under a single-payer system. CPC members need to ask themselves whether their current strategy is moving America toward or away from that goal. They should take immediate steps to compare the “public option” in HR 3200 with their own principles, or better yet Hacker’s original principles, and then issue a report telling the public what they found. To facilitate this report, I propose to the CPC that it adopt the following resolution:

Proposed resolution for the Congressional Progressive Caucus

WHEREAS the Congressional Progressive Caucus has evaluated the “public option” in HR 3200;

WHEREAS the CPC has determined that the “public option” in HR 3200 is not “robust”;

WHEREAS HR 3200, therefore, is just another Massachusetts-style bailout for the health insurance industry;

WHEREAS a Massachusetts-style debacle on a national scale will set back the movement for universal coverage under a single-payer system;

WHEREAS the CPC has repeatedly put Democratic leaders on notice that they intend to vote against legislation with a weak “public option”; therefore be it

RESOLVED that the Congressional Progressive Caucus members will instead support an amendment to HR 3200 that replaces HR 3200′s language with that in HR 676, The United States National Health Care Act.

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

Georgia PNHPer on local NBC affiliate

Posted by on Tuesday, Jul 28, 2009

Submitted by Henry Kahn, MD (Atlanta, GA)

I appeared live in a 5-minute segment of a Sunday morning TV public affairs program on WXIA (11-Alive, the local NBC affiliate). The producers called me 2 days earlier to ask me to come in for an on-air “discussion” with another local physician (unidentified) who had a “different point of view about the president’s HC reform plan.” I agreed, and attempted to explain to the producer that my view was critical of Mr Obama for not moving more boldly toward a single-payer solution. That was obviously too subtle for his attention.

After arrival at the station I learned that my opponent was the president of the Medical Association of GA (MAG). He and I were seated in separate, isolated cubicles. There was no pre-interview with the show’s hostess/moderator (in a 3rd studio) whom I never saw or met. Although I was well prepared with several pointed arguments, I was caught off guard when she began the on-air segment by introducing me as a supporter of the president’s plan.

“There IS a problem with HC,” I began, trying to develop a short argument to say that Mr Obama and congress were not doing enough. 2 or 3 sentences later I was cut off as the moderator turned to the MAG president. His presentation, far to the right of the larger AMA, was that there was no place for government intrusion in HC. Decisions should be left entirely to the patient and doctor. This allowed me to return with the obvious challenge that market-based commercial insurers were already extremely intrusive in medical relationships.

Then it was over !! I doubt I received more than 90 seconds of air time. I had no opportunity to mention PNHP although I had intended to do so. I was even prepared to wave a copy of the PNHP brochure that I had brought along in my back pocket. C’est la guerre!

John Geyman's "The Cancer Generation"

Posted by on Tuesday, Jul 28, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The Cancer Generation: Baby Boomers Facing a Perfect Storm

by John Geyman
Common Courage Press

You can be sure that cancer will be a part of your life. You’ll either get it – nearly half of all men and more than a third of women will. Or you’ll have a close friend who gets it, or be the child of someone who gets it, or the spouse of someone who has it, or in the worst case scenario, be the parent of a child struggling with cancer. You cannot help but stand on the battlefield of the war against cancer. How America wages this war is leaving an indelible mark on your life.

Cancer is now on track to replace heart disease as America’s leading cause of death within the next few years. This is a fight we have to win. Are we winning? And if we are off target, what changes are imperative for victory? Everything we discuss here focuses on these two questions.

So What Will Happen?

Lives hang in the balance on the answer to this question. The future down our current path is crystal clear – and devastating. Deregulated markets and the corrosive effects of profits over service over many years have brought U.S. health care to a crisis point. Because of soaring costs, patients with cancer are finding effective care increasingly unaffordable. Health care has entered a perfect storm, and it is certain to get much worse without real reform. Our primary care infrastructure is collapsing. ERs are overwhelmed, the ranks of the unemployed are rising quickly, adding to the numbers of uninsured. The economy has tanked, the federal deficit is massive, many states are forced to cut Medicaid to the bone, and our presumed safety net is falling apart.

Meanwhile, market stakeholders increase their efforts to maintain the status quo. The private insurance industry calls for the government to change tax policy and keep the subsidies flowing so that insurers can continue to rake off their profits from the system while offloading sicker and lower-income patients onto public programs.

http://www.commoncouragepress.com/index.cfm?action=book&bookid=398

No topic could serve as a better proxy for the deficiencies in the financing and delivery of health care in the United States than the ever increasing prevalence and expense of cancer. In The Cancer Generation, John Geyman describes the tragic and costly impact of the cancer burden, but then provides us with hope by describing a plan that would reduce these burdens of cancer.

His eight-point plan for one-tier cancer care stresses not only the importance of single payer national health insurance, Medicare for all, but also describes the great power that our own public national health program would have to strengthen our health care system, enabling everyone to have affordable access to high-quality cancer care if and when needed.

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Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.

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