What does Vermont’s failed single-payer plan tell us about future reform efforts?

By A.W. Gaffney, M.D.
Jacobin magazine, Jan. 8, 2015

Has the tide of health care justice turned — in the wrong direction? Last month, Vermont Governor Peter Shumlin announced that he could no longer “responsibly support” a funding plan for his long-awaited “single-payer” plan for the state. It wasn’t long before some on the Right claimed a historic victory.

“As crises of faith go,” the Wall Street Journal editorial board gloated, “this is Mikhail Gorbachev circa 1991 territory.” After all, single-payer health care, according to the Journal, is not merely “the polite term for socialized medicine,” but nothing less than “the ultimate goal of the political left.”

Now, inapt historical analogies aside, it is fair to concede the Journal’s point that universal health care has long been on the left and progressive agenda, from the “[f]ree medical care, including midwifery and medicines” called for by the 1891 Erfurt Program onward.

But the meaning and roots of Vermont’s about-face are more complicated than the dominant narrative now emerging in the mainstream media — as is even characterizing the Vermont plan as “single-payer.” For those of us who see real universal health care as foundational to an egalitarian society, a deeper analysis of the still-evolving events in Vermont is critical. So what has happened in the Green Mountain state, what has changed, and where do we go from here?

To some extent, events in Vermont can be seen as yet another chapter in the long story of failed efforts at health care reform in this country. The “state-based” approach to reform is also nothing new: in the 1910s, Progressives sought to pass “compulsory health insurance” laws in several state legislatures, which would have created insurance systems restricted mainly to industrial workers.

This effort was ultimately defeated by the “convergence of economic and political power with the ideological force of the Red Scare,” as the historian Beatrix Hoffman puts it (analogous forces have arguably forestalled progress ever since).

Skipping ahead to 2010, the Affordable Care Act (ACA) was passed with much celebration (and apocalyptic groaning). However, as 2015 unfolds with the law largely in full force, a right to health care remains only an aspiration in America.

It’s not just the estimated thirty-one million who will be left uninsured by the ACA in coming decades — it’s the many, many more who face rising out-of-pocket health care costs (e.g. copays and deductibles), premium increases that are outpacing meager wage growth, and ever-looming “medical bankruptcy.” Such facts only amplify the calls for true universal health care, in Vermont and across the country.

A single-payer health program would accomplish this goal by replacing our current fragmented system with a public system of universal national health insurance, eliminating uninsurance together with out-of-pocket health care expenses. But the daunting political obstacles to enacting such a system at the federal level (including the potent insurance and pharmaceutical lobbies) have led many to work towards reform at the state level.

The Canadian road to single-payer is frequently invoked as a possible model in this regard: after the leftist Co-Operative Commonwealth Federation (CCF) came to power in the province of Saskatchewan in 1944, it enacted a system of universal hospital insurance — “the first important step,” as political scientist Jacob Hacker calls it, to the nationwide, provincial-based Canadian single-payer system.

Elsewhere, change came differently: after the Labour Party took control of the British Parliament in the wake of World War II, it legislated the National Health Service into existence in one fell legislative swoop.

More recently, in Vermont, it was years of determined advocacy — from the single-payer organizing of physicians like Deborah Richter to the “tireless activism” of the Vermont Workers’ Center and some unions — that set the stage for serious state-level health care reform. In conjunction with the Vermont Progressive Party — which, according to historian Molly Worthen, “promised not to play spoiler [in the 2010 gubernatorial election] if the Democratic candidate supported single-payer health care” — such work helped contribute to the election of pro-single-payer Democrat Peter Shumlin in 2010, followed by the passage of Act 48 in 2011.

This legislation was supposed to put Vermont on the road to a “universal and unified,” publicly funded system. But it also left much undone, most notably a mechanism for financing.

Additionally, though “Green Mountain Care” could’ve been an improvement, it didn’t go nearly far enough: indeed, as has been noted for some years, the term “single-payer” itself was ultimately omitted from the final legislation. “Vermont’s public failure,” as Sarah Weaton recently put it in Politico, “is especially frustrating to single-payer advocates because, they note, the Shumlin framework… wasn’t really a true single-payer plan.”

Its shortcomings speak, in part, to the constraints imposed by our political structure, as well as the complexities of several federal laws. The potential “roadblocks” to state single-payer-like systems, as outlined in a 2013 report by Public Citizen, can briefly be summarized.

First, the ACA prevents single-payer experimentation on the state level, at least until 2017, when states may apply for waivers from the law (which might be used for good or evil). Similarly, Medicaid requires a waiver from a cooperative administration to be incorporated into a state single-payer system. Medicare, on the other hand, is not authorized to issue such grants, though several alternative approaches might permit some degree of incorporation into a state system.

Finally, the report discusses the difficulty of integrating federal health programs (like TRICARE for military families) into a state program, as well as the somewhat uncertain legal ramifications of the 1974 federal Employee Retirement Income Security Act (ERISA), which limits the ability of states to regulate health insurance offered by businesses.

Why does any of this matter? The Shumlin plan, for instance, didn’t integrate either Medicare or TRICARE into its “Green Mountain Care” plan, and was set to allow “ERISA employers” (big businesses that self-employ their workers) to continue providing private health insurance (albeit while still having to pay taxes for the public system, which they didn’t seem to like).

As a result, Vermont would have still had multiple insurers, or “payers,” and hence, it wouldn’t have “single-payer”; the plan would have additionally accommodated other private plans, like Medicare Advantage and “Part D” drug plans.

Unfortunately, this is a profound problem, for the administrative simplicity of single-payer plans is the crucial source of the large savings these systems can achieve. The Harvard School of Public Health study that put forth the original “public-private single-payer” reform proposal for Vermont, for instance, estimated some $580 million in savings from a Vermont single-payer-like system for 2015, savings which the Shumlin administration now asserts are not “practical to achieve.”

Additionally, a national single-payer program would reduce expenditures on pharmaceuticals by allowing direct negotiations over drug prices, a reform that would be highly problematic at the state level (Medicare, for instance, is currently prohibited by federal law from doing so). Separately, the Vermont plan would also have permitted out-of-pocket “cost sharing” (though reduced compared to the ACA) at the time of health care use.

And yet, the Vermont plan could still have constituted progress. So it came as a major shock to many when, on December 17, after multiple delays, Shumlin announced that his financing plan for the system was finally complete, that the necessary taxes were too high, and that he would be dropping it altogether. As the result of various reductions in expected revenue, he explained that his plan would require what he labeled an “enormous” 11.5% payroll tax, on top of an income tax that would range from 0 to 9.5%.

There seemed to be more at work than simply changed revenue estimates, however. In the wake of Shumlin’s decision, Richter criticized “vested interests,” including “institutions with a commercial interest in health care, out-of-state PAC money and large businesses too miserly to provide decent health care to their employees…”

Vermonters for Health Care Freedom, a conservative group with unclear financial backing, ran ads criticizing the Shumlin “scheme.” During a single-payer fight many years back (as the labor journalist Steve Early reported), some six thousand workers at a Vermont IBM plant were gathered together and warned that employers would have to exit the state if the bill was passed.

Another factor may have been the unpopularity of the ACA itself. Ironically, for conservatives who fear that the ACA is a “slippery slope” to single-payer, the seemingly refractory dysfunction of the ACA exchange website may have actually had the opposite effect in Vermont: as Shumlin described (according to his prepared remarks), “Vermonters have good reason to question the ability of state government to deliver on this [law] after the painful rollout of the exchange.”

And the increasingly recognized onslaught of out-of-pocket health care expenses faced by families across the country — trends accommodated by the ACA — may likewise be increasing the public’s skepticism of government health care initiatives.

At the same time, whatever the difficulties in achieving state-level reform, we shouldn’t be too quick to agree with those who’ve concluded from all this that funding single-payer through taxation is unattainable. Consider, for instance, some of the figures in the administration’s full fifty-seven-page financing report released last week: even with the new individual tax, and even despite the fact that the Vermont plan was not a single-payer plan, Vermont residents would “over time … have higher net family income on average” as a result of the system — the exception being those making more than $150,000:

Additionally, according to the report, this change in net income was expected to increase over time under the plan.

The new payroll tax would seem to increase the overall health expenditures of private employers. And yet, the report estimates that “[m]ost classes of firms that offer health insurance today would spend less” overall on health care under the plan, the exception being businesses with more than one thousand employees.

Small businesses that currently provide no health benefits would pay significantly more, and the report and Shumlin contended that this was a major problem from the financing perspective. But again, for a system that had some of the costs but basically none of the efficiencies of a single-payer system, none of this sounds particularly earth shattering.

In sum, the discourse that is now emerging in the media — that Vermont has proven that single-payer health care is impractical or unaffordable — must be fiercely countered. Complementary organizing for single-payer on both the state and the national level not only should continue, but can succeed — with the ultimate goal being a single, inclusive program for the country.

Such a system would not resolve all health injustices in the nation. But in its true and full form, it would wholly abolish uninsurance; it would facilitate the rational, equitable allocation of health care capital investments; it would turn back the tide against the ever-encroaching “medical-industrial complex” of corporate health care; and it would — critically — eradicate “underinsurance” by removing all financial barriers to care. In doing so, it would make for a far more just, happy, and equitable society.

For that very same reason, it will not easily be won. No one can precisely predict the pathway to success, but it is clear that progress is only possible if true universal health care remains a principal demand of labor and left political movements. Recent retreats notwithstanding, a national health program remains on the political horizon.

A.W. Gaffney is a physician whose work has appeared in Salon, Dissent, and In These Times.

https://www.jacobinmag.com/2015/01/vermont-single-payer/

By Margaret Flowers, M.D.

For decades healthcare advocates in the state of Maryland worked with state senator Paul Pinsky who introduced a state health bill each year calling for a universal healthcare system that is publicly financed, a single payer system. Even when advocates educated lawmakers, gathered co-sponsors and testified in committees about the dire need for a health system that would solve the current healthcare crisis, one based on solid evidence, the bill fell flat. The closest we came was one vote short of getting it passed in one committee. We had all of the facts on our side, but no political muscle to move the bill.

The people in Vermont took a different approach starting in 2009, and we in Maryland have since followed their lead. The Vermont Workers’ Center and allies started by first building the grassroots movement necessary to provide that muscle. They focused on educating people throughout the state and used a human rights framework to do that.

After years of work to elect a favorable governor, pass legislation and implement it, the people of Vermont were recently spurned by Governor Peter Shumlin when he announced that the state would not go ahead with the health law as planned. This turn of events provides an important lens for examining what happened in the advocacy for health reform and what must be done now. The fight for universal healthcare has been going on for a century in the US and it is certainly not over because of Shumlin’s failure.

I want to say from the beginning that I applaud the people of Vermont. Hindsight is always clearer. The groups on the forefront of this struggle face many critical issues that need attention and lack adequate resources as it is for most groups that are working to change the system. So this article is not a criticism of them, but rather an analysis of the situation and what we can learn from it for current organizing efforts throughout the US as well as next steps in Vermont.

Human Rights Framework is Necessary

There has been hesitancy by some health reform advocates to embrace the human rights framework for single payer organizing. However, the human rights framework is necessary for organizing on all of the social, economic and environmental justice issues that are in crisis today. It helps us see that all of our issues are connected, know when our human rights are being violated and advocate for changes that respect all of our rights.

Many in the US don’t understand that they have human rights, let alone that their rights are being violated. The human rights framework is based on five core principles. Put simply, they are universality, that all people are included; equity, that all are able to participate; transparency, that all have access to information; accountability, that those who make decisions answer to the people; and participation, that all are able to participate in the process. It is the government’s responsibility to guarantee our human rights.

Once we have this understanding of our rights, we see the violation of our human rights across a broad sector of issues whether it is the right to housing, education, a job with a living wage, healthcare, clean water and air or other rights. Then we can look more deeply to understand why these rights are being denied and that there are systemic root causes that are the same for all of these issues. All of our struggles face the same obstacles of monstrous industries that are driven by profit through exploitation of people and the planet and that control not only the lawmakers but in most areas, the method by which they are elected.

Several studies were released last year documenting that public policy reflects the desires of the wealthy rather than the needs of the majority of people. We are facing a crisis of democracy. It will take all of us working together strategically to overcome these obstacles and shift the balance of political power to respect our rights.

The human rights framework teaches us that we cannot accept that rights are respected for some and not for others. A core principle is universality. For example, a health law that gains access to care for some but leaves others out does not fulfill the criteria. The human rights framework prevents the tried-and-true tactic of ‘divide and conquer’. It requires that our work is not done until we all have the same rights.

This human rights framework is especially relevant when it comes to health. The US spends the most per capita on health care in the world but our health outcomes are relatively poor. If our goal is a healthier population, then we must recognize that our fight is not only for access to health care, but is also for quality education, housing, a healthy environment, an end to systemic racism and all of the factors that constitute the social determinants of health.

And not only do we need to include all of these factors in our ultimate goal of health, but to succeed in changing the system we need to build a movement of movements that has the political muscle to overcome the for-profit health institutions that are heavily invested in maintaining the status quo. The healthcare movement needs to collaborate with those who are fighting for other rights.

Beyond the Human Rights Framework We Need Clarity

While the human rights framework is necessary for public education and connecting movements, it is not sufficient when it comes down to the details of policy and this is where clarity is key. This is one area that was problematic for the healthcare campaign in Vermont which resulted in the current failure of the health law and greater confusion about single payer health care.

The approach of the Vermont campaign was to first pass a law in 2010 requiring the state to hire a consultant to develop three health systems that meet the five human rights principles. The Health Care is a Human Right campaign organized across the state and built a strong grassroots base that not only led to passage of that law, but made single payer health care a major component of the gubernatorial race that year. Peter Shumlin, who won that election, spoke out strongly and publicly for single payer health care.

Once the law was passed and Shumlin was in office, the grassroots told lawmakers that it was up to them to design a system that met the human rights principles. The grassroots did not demand that it be a single payer system. And the ultimate choice for a health system in Vermont was not a single payer system but a multi-payer system with a tax-funded public option to be available to whomever did not qualify for Medicaid or Medicare and did not have private insurance.

This is where the lack of clarity caused significant problems. First, a single payer healthcare system is the only way to solve the healthcare crisis. The type of healthcare system that Physicians for a National Healthcare Program and other single payer advocacy groups have pushed for would create a unified system in which everyone is included that provides comprehensive benefits and is financed through a progressive tax. These are the essential ingredients that create a system which places health, not profit, as the priority and that has built-in cost savings that make such a system affordable. Because the Vermont plan lacked necessary cost-control features, it was unlikely to succeed.

Another problem has arisen because although the Vermont plan is not a single payer system, some health advocates, the Governor and other lawmakers and the media have been calling it a single payer system. Now that it has failed, the message that the public is hearing is that “single payer is too expensive.” This is the opposite of the truth. Numerous studies and practical experience in the US and abroad have shown that the US’ current market-based system is the most expensive and single payer systems are the most cost effective.

Clarity on the details of what does and does not work is critical because it is common for health laws to be called universal, affordable and guaranteed when the reality is that they are none of those things. We saw this when the Affordable Care Act was signed into law. That is why it is imperative that the grassroots not only understand the human rights principles, but is also clear about what policies will and will not accomplish the end goal.

Human Rights Principles Also Apply to the Political Process

Another obstacle for the health reform process in Vermont is that the process itself did not meet the human rights principles, particularly of transparency, accountability and participation. Early on, as the legislation was being formed in the state house, members of the grassroots were heavily involved and watchful of each change to the bill. When they noticed changes that were negative, they applied pressure on lawmakers to have them changed or dropped. This vigilance and pressure were critical to shaping the law in favor of the people.

Once the law was passed and signed, the next steps were the implementation of the various pieces of it such as the public insurance, called Green Mountain Care, and the financing mechanism, which was to be determined by the governor. It was the process of determining the financing that was problematic. Governor Shumlin ignored requests from the grassroots to include health finance experts that were proponents of a single payer system.

Business leaders and pro-market-based healthcare reform advocates were close advisers. A chief consultant to the health reform process was Anya Rader Wallack, who came directly from the Blue Cross Foundation. Blue Cross is the largest private insurer in Vermont. Rader Wallack is now leaving Vermont to go to Rhode Island to work on the health insurance exchange (essentially the government selling health insurance).

The governor also used a flawed economic model which is known to overestimate health care spending developed by Jonathan Gruber, a former White House adviser during the 2009 national health reform process. Not only does Gruber support the health insurance dominated Affordable Care Act, but he supports privatization of Medicare by pushing the elderly and chronically ill into the insurance exchanges.

The governor delayed his announcement of the financing for the system, ignoring the deadline set by the law that it be completed in 2013, until after the election in 2014. In mid-December, he held a press conference where he said that the cost of the system was too expensive and therefore, it would be impossible. The grassroots movement, led by the Vermont Workers’ Center, immediately responded with a protest of the Governor calling his career “toast” for his failure to meet his obligation established by the health law.

Holding Politicians Accountable

In my experience, lawmakers have an endless supply of excuses to explain why they fail to meet the needs of the people and most of them are manufactured. It is unlikely that Governor Shumlin would have reached the same conclusion about the financing of the health system if he had used an open and transparent process that allowed participation of the grassroots base and health finance experts that are proponents of single payer systems rather than of market-based systems. Even if he did reach the same conclusion, a more open and participatory process would have allowed the public a deeper understanding of the reasons for it.

This is why the grassroots must insist on transparency and participation. And if these demands are not met, then politicians must be held accountable. Secrecy only exists in public policy when the needs and desires of the people are being disregarded.

Political muscle is critical for a progressive legislature which defies the interest of the big industries that are in control of the system. Take the recent fracking ban in New York. That only came about because a strong grassroots demanded studies of the effects of fracking and hounded Governor Cuomo literally everywhere he went for six years.

Randy Shaw, author of “The Activist’s Handbook,” said that the proper relationship between the grassroots and lawmakers is fear and loathing. Too often when activists become close with lawmakers, they are pulled into compromising for a political agenda rather than holding true to their mission. In New York, because protesters showed up with anti-fracking signs everywhere he went, Governor Cuomo reportedly told his staff that he hated them.

Recommendations for Single Payer Healthcare Activists

If we are to succeed in gaining single payer healthcare systems at the state or national level, we need more than the facts on our side. We must have political muscle that we are willing to flex.

After the 2009-10 national health reform process, I wrote an article that outlined three key elements for the single payer movement, calling it “I.C.U.” The “I” stands for independence because the movement must remain independent of political parties and their agendas; “C” for clarity, knowing what policies are real solutions and what are false solutions so that you can evaluate proposed policies; and “U” for uncompromising because as Gandhi said, “You cannot compromise on fundamentals for it is all give and no take.” We will keep getting crumbs if we are willing to take them.

Here is a summary of a few more recommendations:

1. Organize a broad base using the human rights framework with the understanding that the struggle for health care is part of the broader struggle for social, economic and environmental justice.
2. Understand how political power works so that the strategy and tactics that are used are effective. I think of it as a scientific approach that does not apply placebos but uses proven methods for social change.
3. Demand that the reform process is transparent and allows public participation.
4. Cultivate a proper relationship with lawmakers who are opposed to your position, one of persistent pressure on them that creates fear and loathing.
5. Hold politicians accountable for their actions.
6. Don’t be afraid to use your power. If the movement shows weakness, it will be exploited. If it shows strength, it will be respected.

The healthcare crisis and many crises continue in the United States. Our struggles will continue despite temporary setbacks. We must not give up. Let’s continue the conversation about next steps in our work for healthcare justice.

Dr. Margaret Flowers is co-director of It’s Our Economy, co-host of Clearing the FOG Radio and an organizer of the occupation of Freedom Plaza in Washington, DC. She is also with the Health Care is a Human Right campaign in Maryland.

Rather than pay so much out-of-pocket, many skip checkups, scrimp on care

By Laura Ungar and Jayne O’Donnell
USA Today, Jan. 2, 2015

Physician Praveen Arla is witnessing a reversal of health care fortunes: Poor, long-uninsured patients are getting Medicaid through Obamacare and finally coming to his office for care. But middle-class workers are increasingly staying away.

“It’s flip-flopped,” says Arla, who helps his father run a family practice in Hillview, Ky. Patients with job-based plans, he says, will say: ” ‘My deductible is so high. I’m trying to come to the doctor as little as possible. … What is the minimum I can get done?’ They’re really worried about cost.”

It’s a deep and common concern across the USA, where employer plans cover 60% of working-age Americans, or about 150 million people. Coverage long considered the gold standard of health insurance now often requires workers to pay so much out-of-pocket that many feel they must skip doctor visits, put off medical procedures, avoid filling prescriptions and ration pills — much as the uninsured have done.

A recent Commonwealth Fund survey found that four in 10 working-age adults skipped some kind of care because of the cost, and other surveys have found much the same. The portion of workers with annual deductibles — what consumers must pay before insurance kicks in — rose from 55% eight years ago to 80% today, according to research by the Kaiser Family Foundation. And a Mercer study showed that 2014 saw the largest one-year increase in enrollment in “high-deductible plans” — from 18% to 23% of all covered employees.

Meanwhile the size of the average deductible more than doubled in eight years, from $584 to $1,217 for individual coverage. Add to this co-pays, co-insurance and the price of drugs or procedures not covered by plans — and it’s all too much for many Americans.

Full story, with charts and graphs: http://www.usatoday.com/longform/news/nation/2015/01/01/middle-class-workers-struggle-to-pay-for-care-despite-insurance/19841235/

By Claudia Chaufan, M.D.
Labor Notes, Dec. 31, 2014

Supporters of a single-payer, Medicare-for-all health care system in the U.S. were puzzled September 27 when Swiss voters rejected a reform proposal by 62 percent.

The new law would have replaced the current system, where about 60 insurance companies offer mandatory health coverage, with a single insurer, the government. It would have offered all medically necessary care, paid for by taxes adjusted to each person’s ability to pay.

To Americans who’ve worked for such a system here, nationally and state by state, it was a blow. What’s not to like about single payer?

Swiss and American media, academia, and business sectors rushed to interpret the results. Virtually all crowed that the Swiss people had rejected government-run national health insurance because they preferred private insurers.

But these convenient interpretations rely on false assumptions to justify a model of health insurance that is unraveling—less conspicuously in Switzerland, but dramatically in the U.S.

Let’s look at what’s wrong with these pro-business interpretations, and see what lessons the Swiss referendum has for single-payer advocates here.

Mainstream Answers

Washington Post “policy wonk” Jason Millman wrote that the Swiss rejection shows that single-payer has little chance of gaining popular support in the U.S.

He notes that in 1996, the Swiss voted for an individual mandate that compels everyone to buy a basic package of health services. That law eliminated discrimination for pre-existing conditions, meaning companies have to sell equal plans at equal prices to all customers. The government subsidizes low-income people. In Millman’s view, the resulting Swiss system is very much like Obamacare.

Another policy reporter, Avi Roy from Forbes, asserted that Obamacare (and Romneycare before it) was modeled on the Swiss system: people shopping among competing private plans with little government interference.

Roy says the referendum demonstrates the “political popularity” of universal coverage via private insurance. He concludes that because the Swiss have rejected single payer, there’s good reason to believe Americans will reject it, too.

What’s Wrong with the ‘Official View’?

These interpretations are based more on ideology than on facts. Why?

First, Swiss health care is not a version of Obamacare. The differences are critical to understanding the implications of the Swiss referendum for health care reform here.

Second, Swiss health care, though far superior to ours in terms of access, quality, and equity, has critical problems that threaten the system. Those problems illustrate why, four years after Obama signed the Affordable Care Act into law, health care access, quality, and equity are increasingly threatened here too. The Swiss is a model to reject, not to embrace.

Third, the referendum does not prove that the Swiss don’t want government involvement in health care, nor that they like private insurance companies. Quite the opposite.

Indeed, an analysis of a series of referendums over several years shows that, like the U.S. population, the Swiss are increasingly unhappy with treating health care as a business, rather than a social good.

1) Obamacare is not a version of the Swiss system.

The current National Health Care Law, known as LaMal, requires that everybody living and working in Switzerland carry health insurance—we call this an “individual mandate.” So the Swiss are required to purchase insurance for a uniform, comprehensive package of medical services.

But the national government operates at every level to make everything run smoothly. To more than 50 percent of the population, the government offers full or partial subsidies to purchase insurance. So more than 99 percent of the population is covered.

The government also compels insurers to sell policies to everybody at the same price, irrespective of health status, medical history, gender, age, or location (within each canton, the administrative equivalent of a U.S. state). A 25-year-old and an 80-year-old pay exactly the same premium for the same plan. The only exception: those under 25 pay substantially less.

If your income changes, or job changes, or marital status changes, your doctor need not change.

The government also enforces a “basic” package that is very comprehensive—in the U.S., some call it “Cadillac,” as if only spoilt Americans would dare demand it! Thus basic insurance, Swiss-style, includes outpatient care—essentially whatever a doctor prescribes—hospital care, mental health, all pharmaceuticals on the government’s list, some rehabilitation services, some dental care, some herbal medicine, and acupuncture.

Importantly, the government forbids insurers to make a profit from the sale of the mandatory package, and it compels them to contract with every single health care provider in Switzerland.

The government also imposes a system of risk equalization. It compensates companies that enroll individuals with more expensive medical needs, taking the money from companies that enroll healthier users.

The government also compels mechanisms to deal with prices. Within each canton, prices must be negotiated between associations of providers and insurers, and everybody must abide by them. So providers within a canton are paid equal amounts for equal services, regardless of which plan the patient has.

Finally, the state also enforces limited deductibles (about $300 U.S.) in all plans, and a maximum out-of-pocket cost of about $700.

Users can choose to purchase cheaper policies as a trade-off for higher deductibles (up to 2,500 Swiss francs, or about $2,500 U.S., for adults, and 600 francs, or about $600 U.S., for children). They can also choose policies with restricted provider networks, though few do.

As you can see, this looks nothing like “no government interference.”

Obamacare: A Reality Check

Nor does it look like a version of Obamacare. A few comparative points:

• Obamacare does not cover 100 percent of the population. In fact, more than 30 million people living in the U.S., the majority of them citizens or legal residents, will remain uninsured by 2024, according to the Congressional Budget Office.
• Obamacare does not guarantee a homogeneous, generous basic package of services.
• It does not guarantee equal prices for equal services—hence all these calls for greater transparency of prices so “consumers” can shop more productively! Prices vary according to age—older people pay up to three times as much—geographical location (over 18 different ones only in California!), even gender composition of the workforce insured.
• Providers under Obamacare are paid differently depending on the patient’s plan—which is unheard of, and would be scandalous, in Switzerland.
• Obamacare does not guarantee access to every provider in your state—only to providers in your plan, and only as long as your plan does not change.
• As to maximum out-of-pocket, we’re not even close to the Swiss.
• As to the celebrated choice of plans, it hardly applies to the 160 million Americans with employer-sponsored coverage (now 60 percent of the non-elderly population; it was close to 70 percent back in 2000), who are stuck with whatever “choices” their employers offer (assuming they offer any).
• Last and not least, insurers in the U.S. can and do make a profit for selling you insurance for medically necessary care. Which is the only reason they are in the business of selling insurance!

So the belief that Swiss health care and U.S. health care after the ACA are “more or less the same” is quite misguided.

At the center of the ACA is a well-oiled money-making machinery for the medical-industrial complex: insurance companies, Big Pharma, and for-profit (and many non-profit) medical establishments.

2) Over the last decade corporate interests have hijacked the Swiss system, despite the strong government oversight.

This has led to increasing overall and out-of-pocket costs, making the Swiss system the third most expensive in the world.

To control costs, the Swiss government has promoted managed-care options and encouraged users to comparison-shop. So in addition to the classic comprehensive plans, insurers are offering narrower provider networks and higher deductibles and co-pays, and users are prompted to choose plans annually.

However, the Swiss appear not to like all these “new choices” after all, because in a 2012 referendum more than 70 percent voted against a dramatic expansion of managed care, proposed as a key mechanism to “control costs and improve the system.” And only a very small minority chooses to change plans every year.

Last, a growing number find health care unaffordable and are failing to pay their premiums.

Simply put, all the problems the Swiss are grappling with are rooted in the for-profit nature of the companies that participate in the system. As these companies become more financially successful, and hence more powerful, they get harder to tame—and their influence on the politicians who decide health policies grows stronger and stronger.

Clearly, even in the best-case scenario—the highly regulated environment of Swiss private insurers—entrusting them with the provision of health care is assigning a fox to guard the henhouse. The attempt to achieve justice in health care via competing private insurers is a pipe dream.

3) The defeat of the single-payer referendum does not mean the Swiss people reject a government-run system and support private insurance.

The Swiss have rejected almost all referendums since 1891—only 20 out of 191 have succeeded, even when issues were popular.

Critically, one successful referendum was LaMal, the 1996 health insurance law that banned profit from the sale of medically necessary care. It also allowed the government to pass on money from companies spending less on patient care, to those spending more—certainly not an indicator that the Swiss shun “government interference” on behalf of ordinary people, nor that they trust private insurance to do well by them without supervision.

Also worth noting: in 2007 single payer was rejected by 71 percent, but the figure fell to 62 percent in 2014. Maybe the Swiss are beginning to cut through the anti-single-payer propaganda?

Lessons Learned

Why, then, was single payer defeated? What can we learn?

First, we need to grant that the state of Swiss health care may be of concern for the Swiss (they seem to have lower tolerance than we do!), but it is still not as bad as in the U.S. People who experience the greatest barriers to care in Switzerland are the most politically disenfranchised—the young, poor, women, immigrants, much like here—so the problem has yet to affect the so-called middle class enough to pass a referendum.

Second, we can see the extraordinary power of corporate propaganda. The scare tactics deployed by corporate interests in Switzerland were quite extraordinary, both in 2007 and this year. Likewise, their interpretation of the results was designed to discourage supporters of public health care—to make us think we’re more alone than we really are.

The Swiss referendum teaches us that:

• We need to sharpen our understanding of what the ACA is really about, who our enemies are, and what our alternatives could be.
• We must increase our outreach to the disenfranchised, to those who don’t think their voices make a difference.
• And we must work on improving our political education of those we wish to reach—rather than watering it down to sound bites that fit within the boundaries of the “politically feasible.”

Claudia Chaufan, MD, PhD, is an associate professor at the University of California San Francisco and a member of Single Payer Now and of Physicians for a National Health Program.

http://labornotes.org/blogs/2014/12/why-did-swiss-voters-reject-single-payer-health-care#sthash.glvmCeoR.dpuf