By Casey Selix
Monday, June 22, 2009
Dr. Oliver Fein, president of the 16,000-member Physicians for a National Health Program, thinks the civil rights movement of the 21st century will be health care.
As health policy reform moves up the domestic agenda of the president and Congress, a single-payer, government-run program appears to be off the table. But Fein, who was in the Twin Cities last week to launch the Hazardous to Your Health! series at St. Catherine University, thinks the single-payer concept is gaining momentum in the United States.
He urges skeptics to think of a single-payer system as Medicare 2.0 or a new and improved Medicare for All. Fein, an internist and professor at Weill Medical College of Cornell University, explained his reasoning in a Q&A with MinnPost.com.
MinnPost: One report says that those at either end of the health policy spectrum — a single-payer, government-run plan on one end, a free-market approach on the other — are being marginalized in Congress and the administration. Is there any way to revive a single-payer proposal at this point and how would your group go about doing that?
Dr. Oliver Fein: We have been very active in attempting to do that over this period, and what we would say, frankly, is that actually we’ve gotten more visibility during this time, more discussion of single payer over the last six months than we’ve had before. So whether people say that we’re marginalized or not, the fact of the matter is there seems to be more actual discussion of single payer. What I think is really interesting is that although Sen. [Max] Baucus says that single payer is off the table, at the minimum, we’re the elephant under the table. Everybody is referring to us.
So, you have someone like [Health and Human Services Secretary Kathleen] Sebelius now saying we’ll create a public option that will not go to single payer. You have Republicans saying that the thing they fear is single payer; you have a whole variety of discussion that’s going on that keeps referring to this thing called single payer. Probably one of the real problems is there’s not enough of a definition for the public to make an assessment about what that really is.
MP: Would you like to explain that?
OF: I think there are certain principles that really define what single payer is. The first is automatic enrollment in a national plan, which would lead to universal coverage. What we have now are discussions of universal coverage favored by the health insurance industry — provided that there’s a mandate to buy their product. There’s every evidence that that is not going to lead to universal coverage.
Principle two is that benefits ought to be really comprehensive. There’s a lot of discussion that single payer should be a basic package. We think it ought to be a comprehensive benefit package going from prevention, doctor, hospital, pharmaceuticals, to dental, mental health — all medically necessary services.
Principle three is that these things should be publicly financed; that means one would not use insurance premiums for financing. Premiums are really regressive because the president of a company pays the same as the secretary of a company. That seems to us grossly unfair because the incomes of those two parties are so different. So, we would propose either a payroll tax the way the Medicare program, Part A, is funded, or a mix of payroll and income taxes so that you have a progressive way of paying for health insurance. The only way you can do that is through public financing.
The fourth principle is single payer, and what that means is we’re really able to eliminate the administrative waste that occurs when you have multiple payers. The Medicare program has an overhead of about 3 percent in contrast to private health insurance which, on average, has an overhead of 20 to 30 percent. It’s not just the insurance overhead, but every hospital has to have a large billing department to deal with the multiple payers. In my personal office, I have to hire extra people to deal with prior approval, denials of claims, each insurance company having different regulations and different things that I have to fill out.
Single payer would eliminate all of that. A study published in the New England Journal shows that $300 billion could be redirected if we went from a multi-payer system to a single-payer system. That would cover everyone who’s uninsured and many of the people who are underinsured because they have high deductibles — without costing the overall system more. And that’s the real dilemma that the Obama administration is facing right now with their notion of mandates.
The fifth principle is maximizing choice. Under our present private insurance system, health plans limit you to their network of doctors and network of hospitals and you have to pay more if you go out of network or not get covered at all. Many employers offer only one plan — 42 percent of employees in America are offered only one plan. That doesn’t increase choice. The program in the country now with the most choice is Medicare. You have a choice of physician, a choice of hospital; so, again, single payer would lead to increased choice.
The final principle is essentially that this system would be delivered through a nonprofit, privately controlled system. Doctors would not be employed by the government; hospitals would not be owned by the government. What you have is public financing and collection of money by the single payer, but the private delivery system would continue.
So, then people usually ask me is there a model for this, any place in the world that does this? And I respond, “Yes, right here in the United States. It’s the Medicare program.” The traditional Medicare program is very much what we’re talking about. It needs improvement and better coverage. Dental care isn’t covered, for instance; nursing home care isn’t covered; the prescription drug benefit is a real problem because you have to use a private insurance company. The Medicare program can’t negotiate directly with pharmaceutical companies. Medicare is structured on an 80-20 rule where the beneficiary has to come up with 20 percent of the cost. I would eliminate that.
So, what we talk about is Medicare 2.0 — an expanded program of Medicare for all and an improved program that deals with many of these other programs. That would be the way a single-payer program would operate in the United States.
MP: What is your best hope — and worst fear — about the health reform proposals floated by Congress and the Obama administration?
OF: I guess our worst fear would be that Congress would pass essentially an individual mandate that everybody had to purchase health insurance AND that there would be nothing like a public option. That would be our worst fear because what that would do is essentially act as a bailout for the private health insurance industry — just like the bailout for Wall Street, frankly. It probably would not benefit patients but benefit the industry. Private health insurers have been losing people who pay premiums because essentially employer coverage has dropped over 10 million people over the last decade. We think they’re out now for this individual mandate so that they can reverse that and have more people buy private health insurance.
When it comes to the public option, we think there are many problems with it potentially. It could become a multi-payer system where private health insurance persists — a system in which the sickest patient would be dumped into the public option. The public option would, in fact on a per-beneficiary basis, become very expensive. People would say, “Oh, the government can’t run a program.” There would be strong attempts to underfund the program; it could become a total fiasco.
The other thing that worries us a little bit is how are we going to pay for this public option and some of the proposals like taxing health benefits — why are we doing such a ridiculous thing? So we really think that’s the major dilemma for the Obama administration at this point.
MP: Your best hope?
OF: It’s really difficult to say what that would be other than that there would be an increasing awareness of the single-payer option and essentially out of all of this, an increasingly large mass movement that really begins to say, “Well, we need this kind of Medicare 2.0 type program in the United States.” I’m not impressed with the idea that that’s impossible.
One has to think of the kinds of things we thought were really impossible. If you were in the 1960s and looking at the segregation that was in our society — separate waiting rooms in bus stations, train stations … in the South, you would come to think it was impossible that segregation would be erased in our lifetimes. But in four short years because there was a civil rights movement, we got the Civil Rights Act.
My best hope is that there would be a growing awareness and mass movement for health care as a right. What I think that means is health care as a single payer. I think that is growing in the country. It’s just not yet being recognized by politicians. Politicians are, to some degree, beholden to various interest groups, and that can change if there is this growing mass movement.
The civil rights movement of the 21st century, I think, is going to be for health care as a right.
MP: Why do you think this nation has resisted universal coverage and/or a single-payer program for so long?
OF: I think it’s an accident of history. During World War II, wages were frozen and unions couldn’t bargain for raises. But they could bargain for fringe benefits. So, what happened is that health insurance got linked to employment and that then began to expand. Government involvement in guaranteeing health care is very young in the world. In Europe, it started in post-World War II. There, the accident of history was that they were in very devastated economies and devastated societies; they were rebuilding. The decision there was we’ve got to offer medical care, in essence, as a right.
Well, we had a different model linking it to employment. Gradually, we got to 1965, the Medicare program was passed; why was that? What happened to most people when they turned 65? They retired. They lost their health insurance because they were no longer working for an employer. So, we instituted single-payer national health insurance for the elderly.
Now, we have many more formidable interest groups that have built up since 1965 — the private health insurance industry, the pharmaceutical industry who really worry that they’re at jeopardy if we go to single payer — and they’re probably right. So I think it’s no mystery why things have moved a little slower here. The problem is it’s not sustainable in a global world, and in a global world, which is really the way things are moving, we’re going to see single payer in the United States. It’s inevitable.
Casey Selix, a news editor and staff writer for MinnPost.com, can be reached at cselix[at]minnpost[dot]com.