By Jeoffry B. Gordon, MD, MPH
Any doctor with a brain and a heart who practices medicine these days has daily experiences with the many disastrous shortcomings of our medical system. As the graph below shows we spend nearly $8000 per person per year on health services involving 18% of our GDP and we have worse out comes. We all know that medical care in the United States is poorly distributed, has less than optimal outcomes, and is hugely expensive.
In the last year we have witnessed a vociferous and prolonged public debate about health care reform – the most vigorous and comprehensive in 50 years. This has had the beneficial effect of bringing knowledge of the failings of our health care system into the daily discussions and awareness of large numbers of Americans. While passage of the resulting legislation seems imminent, the process and the outcome in the public square, while often passionate, have been greatly askew – one could even say deceitful, distorted and ineffective. We all know it is shocking to see the proposed reform revolve around tax subsidized premiums to health insurance companies – which are the source of huge administrative  complexity and inefficiencies, thus wasted monies. It is shocking to listen to national experts tell us that more emphasis on information technology and preventive medicine will go a long way to cure our systemic problems. It is shocking not to hear about the excess burden of disease and mortality born by minority citizens. It is shocking not to hear about the expanding deficit of primary doctors, of the shortage of trained nurses, of the huge debt burden of many medical students, or the excessive proliferation of MRI machines and other profit producing technologies. At the same time it is even more shocking, one might say even repulsive, to hear the shrill and distorted rhetoric of the opponents of health reform – focusing on topics like “love of my insurance company,” “insurance required abortions,” “death panels,” “socialism” and government takeover, denial of care due to recommendations of expert panels using evidenced based medicine studies, and the declaration that the United States can be proud of its exemplary health outcomes. For those of us committed to health reform, it is imperative to review and understand the events and the process of the past year in order to formulate a better strategy for accomplishing the reforms  which will improve the health of Americans at a reasonable cost.
Any analysis of contemporary national public policy on health reform must be based on the insight that the health insurance companies had successfully structured the process in their interest before it even began. Single payer health reform, the elimination of the private health insurance sector, was firmly and totally “off the table” from the very start. President Obama was so opposed to the idea that none of the 140 luminaries invited to the First White House Conference on Health Reform were single payer proponents – until 2 were invited at the last minute after protests were being organized outside. It is important to get past the statistics of the huge amounts of money spent by the health insurance industry on lobbying and campaign contributions, of the many former Congressional, White House, and government officials who became health reform lobbyists. Insight comes when you realize that the chief health aide to Senator Max Baucus, Chairman of the Senate Finance Committee is Elizabeth J. Fowler, JD, PhD, who after serving many years as Health and Entitlements Counsel to the Committee left to become a Vice President of Wellpoint Health Insurance and then returned to the Senate Committee to literally write Senator Baucus’ bill. It would also be prudent to recognize that Senator (fmr D, Conn) Joe Lieberman’s wife was a former health insurance company lobbyist and Senator (D, Indiana) Evan Bayh’s wife was on the Board of Directors of Wellpoint insurance, and so on. All the activists’ efforts to educate, confront or otherwise influence Washington principals, all the think tanks, academics, and accumulated data had a vanishing little impact on the final legislative proposals. It is important to remember that the so-called “public option” was first introduced as a pro-competitive, cost-cutting government program as a practical compromise short of single payer and preserving the private insurance market. This could have had an improved competition in the system and based on market principles had the potential to be a real cost saver. When a study showed that up to 135 million Americans might be eligible and able to choose it, it was quickly disparaged and the insurance lobby saw to it that it was whittled away to an impotent remnant that might cover 5 to 8 million people, and then eliminated. Now we have “Health Insurance Exchanges” which especially if done on the state level will be impotent as well. A brief enthusiastic compromise effort to expand Medicare to age 55 was snuffed out quietly and quickly by the same insurance lobbyists as soon as it was realized that it could be the first step to universal Medicare.
Toward the fall, the health insurance industry was still anxious about the direction of the legislation and showed its anxiety by conducting and releasing several reports predicting the failure and excessive costs of the then proposed reforms. These reports were so obviously self serving that there was a brief, vociferous backlash. This brought to light the previously neglected, extraordinary fact that the insurance industry, along with baseball, is exempt from federal regulation and anti-trust law. This was due to the McCarran-Ferguson Act (15 U.S.C. 1001) which was passed by Congress in 1945 to nullify a Supreme Court ruling that insurance could be regulated by the federal government via the Commerce Clause of the Constitution and the Sherman Anti-Trust Act as interstate commerce. This law naturally covered developing health insurance products leaving them to state regulation and supervision. This law also forced health care financing to be subjected to the perversities of ERISA law and to intra-state monopolies by health insurance companies. For a brief moment of anger and insight repeal of McCarran-Ferguson was included in the draft health reform legislation. Then it was quickly and quietly removed.
The idea that the problems with medical care outcomes, or even with health care financing, could be solved by the currently proposed legislation falsely follows the Massachusetts model which is currently demonstrating its lack of cost control, lack of restraint on insurance company behavior, and strain on primary care. The politicians have grabbed a model that optimizes the outcomes for the health insurance companies. L. Randall Wray, an economist at the University of Missouri-KC put it best last October 11, 2009:
“Here’s Wall Street’s newest and bestest gamble: there is a huge untapped market of some 50 million people who are not paying insurance premiums—and the number grows every year because employers drop coverage and people can’t afford premiums. Solution? Health insurance “reform” that requires everyone to turn over their pay to Wall Street. Can’t afford the premiums? That is OK—Uncle Sam will kick in a few hundred billion to help out the insurers. Of course, do not expect more health care or better health outcomes because that has nothing to do with “reform”. …They’ll collect the extra premiums and deny the claims. This is just another bailout of the financial system, because the tens of trillions of dollars already committed are not nearly enough.
“You might wonder about the connection between insurance and Wall Street finance. They are two peas in a pod. Indeed, we threw out the Glass-Steagall Act that separated commercial banking from investment banking and insurance with the Gramm-Leach-Bliley Act of 1999 … that let Wall Street form Bank Holding Companies that integrate the full range of “financial services” such as loans and deposits, that sell toxic waste mortgage securities to your pension funds, that create commodity futures indexes for university endowments to drive up the price of your petrol, and that take bets on the deaths [and health] of firms, countries, and your loved ones. “
In fact, it should have been apparent to anyone who was watching that any movement toward real health reform would peter out and fail after there was a wholly inadequate institutional, political, cultural, and media response to the economic debacle in the fall of 2008. The only major public figure who confessed to a failure of ideology was Alan Greenspan. No other main stream political leader or public institution diagnosed the financial collapse as a total failure and repudiation of the government de-regulated, laissez faire, market driven, profit making, financial institutional dominance political philosophy (facilitated by both the Republican and the Democratic Parties)which had sucked our country into a dark hole. Without a clear and strategic, articulate insight into the nature and breadth of the economic crisis and courageous leadership, real financial and health reform and remediation have been impossible. President Obama selected his financial and economic team from the very Wall Street players who were intimately part of the debacle. Then, as the Republicans have properly observed, unconscionable amounts of tax payer money have been thrown into the banking and finance system with astonishingly little targeting, oversight or fiduciary supervision. And even to this day there has been no legislative reform of the regulation of the financial system, nor substantive governmental intervention in its functioning. In this context, the barriers to real health reform are only a side show. White House town halls, brief visits to the Cleveland or Mayo Clinics, noting the cost of medical education, discussions about electronic medical records, or primary care deficiencies, or obesity or touting the medical home or preventive medicine were all media enticing diversions and mere window dressing. As finance capital continues to control all 3 branches of our national government, it was to be expected that public policy about health care reform would end up seeking to maximize profits by the insurance industry. As Michael Moore has said, “There has been a coup d’etat in this country and Goldman Sacks won.”
Due to the dominant importance of the financial interests of the health insurance industry (and our politicians’ subservience to them) all of the hard facts, rational analysis, objective national and international data, and all of the reform planning and policy projects – whether in the clinical realm or in the areas of administration and finance – done by the many government agencies, private foundations, academic institutions, grass roots organizations, and think tanks have been basically impotent and irrelevant. The political movers of public policy and, especially, the opponents of reform have studiously avoided dealing with any of the tragic hard facts about the contemporary provision of medical care and its financing. It was painful to hear Senate Minority Leader (R-Kentucky) Mitch McConnell declare, “We have the best health care system in the world.” Or Senator (R-Iowa) Chuck Grassley complain in August that “(You) should not have a government run plan to decide when to pull the plug on grandma.” Or to hear House Minority Leader, Congressman (R-Ohio) John Boehner tell the press, “I’m still trying to find the first American to talk to who’s in favor of the public option….This is about as unpopular as a garlic milkshake.” The Republicans are clearly handicapped by their one note ideological opposition to government agency to solve any problem short of war or protection of the unborn, even in the face of a total objective failure of their philosophy. And the Democrats have become equally impotent by their refusal to acknowledge the fundamental foundational significance and origins of the economic crisis and by their attempts to accommodate and build bipartisanship with the obstreperous Republicans. The Republicans are patently absurd to propose income tax refunds or health savings accounts as the public policy for optimal funding of health insurance for the working poor or the unemployed. It is tragic to see the political leadership of our country so purposefully turning a blind eye to the hardship and suffering of millions of their constituents. It is certainly demoralizing for involved citizens to see our elected officials, whether in support or in opposition, promote rhetorical name calling, deceitful analyses and avoid honest debate on the issues.
It has been even more provocative and threatening to have experienced – as we did this summer – the angry hatred of the so-called Tea Party protesters, the Palin People and their friends. It is crucially important to understand the origin and implications of this phenomenon in order to plan for success in the future. In fact, it is only by understanding their forceful energy and beliefs that we can make any sense of this phenomenon at all. Clearly the issues and fears of these citizens are not based on the facts nor any reality concerning clinical medical care, actual government policies,  or its proposed administration and financing. Furthermore it must be recognized that these protests have been mobilized and magnified with hundreds of millions of dollars from the same well documented vast array of very wealthy donors and foundations (Including the health insurance industry) which have undertaken to destroy good government over the past twenty years. In addition, their vehement disruptiveness and distain for civil discourse has been explicitly and eagerly endorsed by and participated in by the Republican Party itself. One can accept the legitimacy of the vehemence of their energies, even if it is impossible to agree with the actual content of what they are saying. The content of their fears, and the source of their opposition, is both emotional and ideological. The emotional issues are serious and very important because they fuel their anger and its threat of violence. Their fervor has two sources: (1) the perceived disruption of personal security and the natural order of things created by the election of a Black President and (2) the huge economic dislocations and economic insecurity our country and each family are experiencing at this time. Only by understanding how threatening and tumultuous these circumstances are to those involved can we make sense of the forceful deceived rhetoric and the mass psychology of this summer’s protests. While the racism of these folks has its origin in their primal immaturity and class culture and cannot be excused, frankly it is important to respect their economic fears – and this is crucial for successful health care reform. As will be demonstrated below, the President, both political parties, major cultural leaders and commentators, and most main stream media as well as most bloggers and critics, both currently and in the past, have been desperately trying to get the country to ignore or minimize the economic and social painful transformation and decline of the United States over the past few decades and the tragic harm-multiplier of last year’s economic collapse and its continuing impact. This neglect of our true economic circumstances is analogous the past President’s attempts to minimize the costs of war by forbidding photographs of returning dead soldiers.
GROUPS 1, 2, AND 3 (the top 10% of all income producers) ADD TO A TOTAL OF 50% 0F TOTAL NATIONAL FAMILY INCOME
We must now delve into the suppressed economic circumstances of the contemporary United States. As you can see from the figures above, from 1943 through 1983 our country had a stable sharing and distribution of incomes – and prosperity – which carried us forward from a recovery after a horrible war through the awakening and the challenges of the civil rights movement and beyond. It was this period which created and supported our cultural self image of a generous, pluralistic, idealistic, humanistic, equitable civil American society. First, note that this graph ends before the additional impact of the current depression. Second, note that the period since 1998 has created a concentration of wealth among the top 1% of families unseen since the years immediately preceding the Great Depression. And third note that this transformation in our society started in 1983 with the Presidential election victory of Ronald Reagan and the ascendency of the deregulating, laissez faire, anti-government economic philosophy of the Republic Party. Yes, the Tea Party and Palin People folks have every right to be angry. The economic evolution of our country has stolen their birthright and the current economic mess has put the nail in the coffin of their hopes. And it is more than their problem: while we have been looking the other way, the economic catastrophe of the last 18 months has been destroying the middle class. Today about 20% of Americans are unemployed, underemployed, or stopped looking for work. In the past decade the United States economy has had zero net job creation. Almost 10% cannot make the minimum payment of their credit cards; 12.5% are on food stamps (over 37 million people). A total of 10,000,000 Americans may lose their homes (6.2% of mortgages are in default). The current economic depression has wiped out $5 trillion in pensions and savings assets and another $13 trillion in housing assts. In 2008 median household income, adjusted for inflation, fell 3.6% to $50,303, the steepest drop in 40 years. The poverty rate in 2008 rose to 13.2%, the highest since 1997. And about 700,000 more Americans did not have health insurance in 2008 than in 2007. It goes without saying that the data for 2009 when it is in will be much worse.
If this shocking description does not motivate you to want to join the outrage of the Tea Party and Palin People, let me introduce you to a statistic called the Gini coefficient. This is a statistical index which can be used to quantify the level of income or wealth inequality in a country. It is compiled by such organizations as the United Nations and the CIA. Sweden captures the “world’s best” title (with an index of 23 (CIA) or 25 (UN). It keeps company with countries like Denmark (24), Austria (26) and Belgium (28). The average EU index is 31; Canada has an index of 32; and Great Britain has an index of 34. Before the current economic turmoil the United Sates had an index of 47 (its highest ever) and it keeps company with countries like Cameroon (44.5), Jamaica (45.5), Mexico (46.1), and the People’s Republic of China (46.9). Yes, while you weren’t looking our country has been turned into a banana republic. The ascendency of Wall Street, the crash of 2008 and the failure of health reform are prime symptoms of a much bigger problem. One way to look at the angst created by the gap between President Obama’s charisma and rhetoric and his performance in office is to see that it reflects our gut feeling that our Country has been taken in the wrong direction into a period of massive decline. We are responding to his abject failure to acknowledge these tragic facts and lead us in a better direction. Even worse – and his paradigm of health care reform proves it – he has chosen to kowtow to the interests of the financial sector.
Because these economic circumstances are so different from the prosperity of the sixties, contemporary political activism must use different strategies and tactics to achieve our aims. It is myopic and fraught with failure to merely pursue health reform in the era of what Kevin Phillips calls the rule of the plutocracy. This country needs a more fundamental transformation. Many Americans do not yet feel the anguish and failure in their gut like the Tea Party and Palin People folks but there is every reason we should. If we look at the Palin People and Tea Party as alien, we can see the seeds of fascism in their alienation and anger, similar to that experienced in Germany, Italy and Argentina before their takeover by the far right. On the other hand, if we identify with their distress – and get past our still relatively comfortable circumstances – we will have allies in taking our country back. We cannot be limited to our rational, professional analyses. Facts and data will not rule the day. There is no rational, beneficent debate going on. It has become clear and evident that all the foundation work, all the macro and micro system modeling, all the vital statistics of health outcomes and service maldistribution, all the shocking case studies, all the bankruptcies, and the morbidity, not to mention, mortality statistics have had little impact on the outcome of last year’s health reform process.
These observations lead to two complimentary paths which will help further the achievement of real health reform. For make no mistake about it, it is highly likely that the currently proposed federal legislation, if it is passed, will not greatly improve medical outcomes, will be an unacceptable financial burden both on individual families and on individual state and federal governments, and will not eliminate the horribly expensive administrative inefficiencies of our current private health insurance based system. Thus it is likely to become highly unpopular and its impact will further erode faith in government agency and the Democratic Party. Our approach to the current circumstances needs to be more strategic, more tightly organized, facilitated by better communication and coordination, and directed toward mobilizing a broader army of reform activists. First, working within the political system, we should focus on the strategy of creating state based initiatives to legislate state single payer systems. The practical fact is that at this time of economic contraction each and every state will be desperate for truly budget saving measures – and because of Medicaid and public employee health costs, real health reform will have major beneficial outcomes. The specific goal should be an amendment to the federal ERISA law to permit states to develop their own single payer systems. This focus will both continue to highlight the fundamental target in the health system debacle – the insurance companies – and energize political action at a level that is more strategically amenable to grass roots impact.
The second path of action lies in dramatically changing the tactics of progressive reform advocates. To put it plainly we must transcend our reliance on facts and data and get out there with an emotional message and captivating activities. As health care providers doctors and other practitioners are taught to maintain a professional demeanor and to maintain an emotional distance from their patients’ suffering and, furthermore, at the core our technical skills are based on analytical knowledge. It is obvious that carrying these habits into the political arena has not been effective. We have to catch up to our opponents – first in the passionate expression of the anguish and suffering that is abroad in the land and secondly in the enthusiastic demand for political attention. It is evident that physicians and nurses alone cannot create the momentum for change. We must actively recruit our own patients who have suffered the shortcomings of the system in large numbers as well as the staffs of institutions serving the underserved, such as municipal hospitals and free and community clinics, and those religious who will stand up for social justice. This outreach must occur in an on-going organized way so that we can create a critical mass. We cannot effectively bring our insights to the public square without a broader coalition at our side. Along with those mentioned above, the Tea Party and Palin People are, in fact, our allies and constituents, for it is they – whether rural plain folk, farmers, manual service workers, employed poor, family shopkeepers, restaurant servers and so on – who are most severely impacted by the expensive, poorly functioning health care system and by our failing national economy. And you can bet they are about to be joined by hordes of former middle class folk. Their conventional wisdom, that government is the problem, just happens to be wrong. We are now in an era of catastrophic decline and disarray generated by 30 years of the dominance of that political philosophy. It has dramatically failed. The alternative conservative or libertarian model of Individual and independent initiative surely will not be enough to solve these problems. We must reach out to fundamentalist churches, talk radio and other conservative media, for example, to respect their anxieties and debate their political paradigm. We need to broadly mobilize as many of these disaffected citizens as we can. We must directly challenge the conservative religious activists morally devoted to protecting the life of an unborn child to see that their morals must encompass and give priority to the duty to relieve the suffering of the living. Collective communal action through an effective democratic government is the major prerequisite for successfully solving our economic problems as well as the expensive dysfunction in health services. The only way forward on health reform is to correctly diagnose the massive economic disaster that has befallen our country and create an integrated, energized broad coalition to implement political change. Those professional groups, those labor unions, those in progressive political organizations must not only unite, but also reach out to enroll and involve the disaffected among us. Then we will be successful.