By Ralph Nader
The Nader Page, Nov. 1, 2013 With the Tea Partiers relentless attacks on each of the troubles besetting Obamacare since its complicated, computer glitch-ridden startup on October 1, 2013, the compelling question is: Why aren’t the Congressional sponsors of H.R. 676 – full Medicare for all with free choice of physician and hospital – speaking out as strongly on behalf of this far superior universal health care coverage? There are fifty-one members of the House who openly favor the single-payer solution for many good reasons. Legislators behind H.R. 676, such as Reps. Robert Brady (D-PA), Michael Capuano (D-MA), Donna Christensen (D-VI), Judy Chu (D-CA), Yvette Clarke (D-NY), Wm. Lacy Clay (D-MO), Steve Cohen (D-TN), Elijah Cummings (D-MD) and Danny Davis (D-IL) know that single-payer insurance with private delivery is by far more efficient, saving $400 billion a year just on administrative simplification. Physician, scholar and advocate, Steffie Woolhandler, co-founder of Physicians for a National Health Program (PNHP) says that, “complexity is baked into Obamacare.” What does “complexity” mean beyond thousands of pages of legislation and many more pages of regulations? Over forty years ago, Canada’s single-payer system was enacted with a 13 page bill that covers everyone for less than half of the cost per capita than the U.S.’s waste-ridden, profiteering, corrupt medical-industrial complex that drives honest practitioners up the wall. And, the Canadian system produces better health outcomes at this reduced cost. Unfortunately complexity means endless opportunities for insurance companies to game the system with fine print, tricks, confusing pricing and lobbying to get out of requirements and standards through waivers. Complexity means ongoing confusion for consumers and patients who go into these exchanges, either because they’ve been thrown out of their existing but substandard insurance policies or do not have any insurance. Every year, these same consumers have to figure out whether their income has changed enough so that they can report any difference to get a higher or lower subsidy. Moreover, the public insurance option – Obama dropped that even before he was elected, anxious to not antagonize the powerful insurance companies and their allies – is missing. In West Virginia there is only one insurance seller! Other states have either one, two or more companies that will soon begin confusing consumers in different ways. So far, the young consumers aren’t signing up at anywhere near the number necessary to actuarially balance off the more costly older consumers. The expected signup rate for middle-aged consumers is way behind projections. And the fine print trap doors keep getting discovered week after week. Contrast this when Medicare was launched in 1966, as Dr. Woolhandler writes: “Using index cards,” (they didn’t have computers then), Medicare,     “enrolled over 20 million people in six months. And because it was a simple system based on Social Security records, you didn’t have hundreds of people programming in the state of Oregon, thousands of different plans, tons of different co-pays, restrictions and deductibles. You had one single payer plan, which is what we need for all Americans to give Americans the choice they want – which is not a choice between insurance company A and insurance company B. They want the choice of any doctor or hospital like you got with traditional Medicare.” Additional co-sponsors of H.R. 676 know all this. They include Reps. Michael Doyle (D-PA), Donna Edwards (D-MD), Keith Ellison (D-MN), Eliot Engel (D-NY), Sam Farr (D-CA), Chaka Fattah (D-PA), Al Green (D-TX) Raúl Grijalva (D-AZ), Luis Gutiérrez (D-IL), Alcee Hastings (D-FL), Rush Holt (D-NJ), Michael Honda (D-CA), Jared Huffman (D-CA) and Eddie Bernice Johnson (D-TX). All the co-sponsors, including the lead sponsor, Cong. John Conyers (D-MI), know that the great majority of the American people, as well as the majority of physicians and nurses prefer the single-payer, full Medicare – everybody in, nobody out – system. Most doctors want to practice medicine, not bookkeeping with page after page of computerized bills loaded with hospital overcharges and code manipulations. Most Canadians never see a bill. Other co-sponsors of H.R. 676 know how much fraud is concealed in these complex, inscrutable bills that people and insurers receive. The leading expert on health care billing fraud and abuse, Harvard’s Malcolm Sparrow (author of License to Steal), conservatively estimates that 10 percent of all health care expenditure is drained away by billing fraud. That’s over $270 billion this year! Additional co-sponsors of H.R. 676 including Reps. Henry Johnson (D-GA), Barbara Lee (D-CA), John Lewis (D-GA), Zoe Lofgren (D-CA), Alan Lowenthal (D-CA), Carolyn Maloney (D-NY) and Jim McDermott (D-WA), like their colleagues, know that 45,000 Americans (according to a Harvard Medical School peer reviewed study) die every year because they cannot afford health insurance to get diagnosed and treated in time. Nobody dies in Canada, Germany, France, Sweden, Italy and other western countries due to no insurance; because everybody is insured from the moment they are born at half the per capita cost of that in the U.S. All the co-sponsors, including Reps George Miller (D-CA), Gwen Moore (D-WI) Jerrold Nadler (D-NY), Richard Nolan (D-MN), Eleanor Holmes Norton (D-DC), Chellie Pingree (D-ME), Mark Pocan (D-WI), Charles Rangel (D-NY), Lucille Roybal-Allard (D-CA), Bobby Rush (D-IL), Linda Sanchez (D-CA), Loretta Sanchez (D-CA) and Janice Schakowsky (D-IL) know that most of their Democratic colleagues favor single-payer, but have not signed on due to their reluctance to embarrass President Obama (who used to favor single-payer) or their avoidance of lobbying hassles from their contributors for a bill they believe has no chance of passing. How’s that for leadership? So the spotlight has to shine on the lawmakers who have stood publically for H.R. 676, but have not taken on the Tea Partiers and their corporatist backers with this superior alternative. Consequently, the media just reports on the Tea Partiers vocal opposition and nothing on the silent backers of full Medicare for all. Around the country, there are groups pressing for full Medicare (visit www.singlepayeraction.org). This weekend, the Physicians for a National Health Program, (with over 15,000 physician-members) is meeting in Boston to debate whether they should mount an offensive for full Medicare in the midst of the Obamacare imbroglio. Their revered mentor, Dr. Quentin Young, a former Chicago friend of Obama’s, argues in his new autobiography, “Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause,” why Obamacare is worse than nothing. All the H.R. 676 co-signers, including “Bobby” Scott (D-VA), José Serrano (D-NY), Mark Takano (D-CA), Paul Tonko (D-NY), Peter Welch (D-VT), Frederica Wilson (D-FL) and John Yarmuth (D-KY), should press Senators Bernie Sanders, Sherrod Brown, Elizabeth Warren, Barbara Boxer and others to introduce in the Senate a similar single-payer bill to H.R. 676. Senator Sanders’ office informs me he is finally ready to do so in a couple of weeks. With over 100 Americans dying each day due to lack of insurance, there’s no time to lose. Please call your members of Congress at 202-224-3121. http://nader.org/2013/11/01/silence-sponsors-superior-full-medicare/

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By Margaret Flowers, M.D.
Talk Nation Radio, Oct. 30, 2013 

PNHP note: The following is an unofficial transcript of an interview given by Dr. Margaret Flowers to David Swanson of Talk Nation Radio on the Pacifica Network on Oct. 30. An audio version can be listened to at this link.

David Swanson: Welcome to Talk Nation Radio. I’m David Swanson. I’m delighted to have on Talk Nation Radio this week Dr. Margaret Flowers. Margaret is a Maryland pediatrician who served as the congressional fellow for Physicians for a National Health Program and who is on the board of Healthcare-Now. She’s an organizer with PopularResistance.org, co-director of ItsOurEconomy.us and co-host of Clearing the Fog radio. Margaret Flowers is the secretary of health in the Green Shadow Cabinet and is one of our leading advocates for universal health care: single-payer, Medicare for All. Margaret Flowers thank you for joining us. 

Margaret Flowers: Thank you David for inviting me.

DS: I guess the big question is, how is Obamacare working out?

MF: Well, it’s interesting – all of these computer glitches and things they’re having as the health insurance exchanges roll out. To me this speaks to the real complexity of it when you’re trying to create a system that maintains our current very complex system of all these different insurances and different criteria that people have to meet in order to get subsidies or be excused from getting insurance. It’s even a more complicated system than what we already have and really begs for the simplicity of what we advocate for, which is Medicare for All, or a single-payer health care system.

DS: Is it actually true that they started Medicare using 3” x 5” cards?

MF: That’s what I understand from Dr. Philip Caper in Maine, who worked for Sen. Ted Kennedy and who was there when Medicare was rolling out. I think he said 20 million people were enrolled in six months with index cards. I think the beauty of a Medicare for All is that you wouldn’t even actually have to enroll right away to get care, because when you have a universal system that means that every single person in the country is in that system. Whether or not you’ve filled out the paperwork right away, if you have to go to receive care, the first question would be, “What do you need?” and you would receive the care you need. They could deal with the paperwork later. That’s the opposite of the type of system we have now. 

DS: I’ve gotten sick in Europe and not been a resident and gone to a hospital and simply gotten care by being a human being, and there was no computer work or paperwork involved.

MF: It’s a completely different environment, isn’t it, where health care is considered to be a public good and people who need care get that attention and that’s what the focus is on – what a person needs, how to help them to get better. 

DS: So, apart from the website fiasco, your critique of Obamacare, as I understand it, includes that many people are actually not going to be covered, and that other people are going to be inadequately covered. How is that possible? We’ve heard so many great things about this program.

MF: I know. It’s amazing that in a country where we have such a health care crisis there has to be so much marketing of a health reform – for something that people need and want but that we didn’t actually get through this plan. That’s one my biggest critiques, fundamentally, about this – that it’s a market-based plan, unlike other countries, like I said, where health care is considered a public good. And so that kind of [market-based] system, in our environment, just could never become a universal system. At best, it could possibly decrease the number of people who are without insurance by half. Right now we have 48 million people who have no insurance at all. It’s expected right now under this law when it’s fully implemented in five more years there will still be 31 million people with no insurance at all. And what are the rest of the people going to have? Well, a provision of this law says insurance coverage that covers only 60 percent is completely fine. And that’s lowering the bar on what we consider to be adequate coverage, because when somebody only has 60 percent coverage that means they have to pay a lot out of pocket, up front, they have to pay a lot of the cost if they have something significant happen and people just don’t have that kind of money. They can’t afford to do that. So we’ll still have tens of millions who are uninsured when it’s fully implemented and many tens of millions with inadequate insurance who, when they have a serious problem, they’ll find it’s not there for them.

DS: And the tens of millions without any coverage, are these the people who famously will have to pay a fine for not purchasing the product, or is this a different category?

MF: Well, it’s interesting. About 24 million people are expected to qualify for a waiver, allowing them to be uninsured without having to pay a penalty for being uninsured. Millions will have to pay that penalty who don’t purchase insurance and don’t qualify for waivers. And you qualify if you don’t have documents in this country; you’re not allowed to purchase insurance through the health insurance exchanges, so you don’t have to pay a penalty for being uninsured. If the cost of the premium is a certain percentage of your income, you’ll also be excused. Most of the people who are going to be uninsured are working people who just can’t afford the insurance premium.

DS: And then again, many people will be quote-unquote insured, but it will be inadequate insurance that will cover certain things and not other things and they’ll have to pay up-front when they go for a doctor’s visit. So it won’t actually be creating preventive, universal health coverage for those people.

MF: Right. And there are a couple of interesting things. One is that people in this country who already have insurance are really struggling to meet those out-of-pocket costs. We’ve seen a decrease in the amount of health services people are using. We call this self-rationing: It’s when people just don’t go to the doctor when they should, or they don’t get their prescriptions filled when they need to because they don’t have the money on hand to do that. Another interesting aspect about the number of people who are going to be underinsured is that we have not changed the behavior of the insurance industry. So we’ve written some new regulations to try to get them to behave and actually pay for the care that people need, but they still have to make money for their investors, so they’re doing that by not only creating these plans that have low percentage of coverage but they’re also restricting their networks. So somebody may have insurance that covers 60 percent of their covered costs but the major hospital centers in their area are not included in that plan, or the number of doctors who are included in that plan are not sufficient. What these do is drive people out of their plans for care and people end up having to pay more of the cost or all of the cost of that care when they go out of network. So the insurance companies are finding ways to work around all these regulations – that’s the bottom line.

DS: So the much-trumpeted new requirements that they not turn people away because of a pre-existing condition and that young people can stay on their parents’ policies, and so forth – are the insurance companies finding ways around those requirements?

MF: Yes, they are. Not so much the young people being able to stay in their parents’ plans till they turn 26, but what many people are finding is that even though their sons or daughters can stay on their plans they can’t afford to pay the premiums on those plans. So we really saw a very small drop over the last few years in the number people in the age group of 19-26 who are uninsured. It was 48 percent who were uninsured before that and now it’s 41 percent. There’s still 41 percent of that age group who are uninsured. And regarding pre-existing conditions, there are a number of ways the insurance companies can get around that. One is restricting their networks, so that people who have significant health care needs can’t find plans that cover the places they need to go for care. Another, and we’ve seen this with privatized Medicaid plans too, is when they identify people who have a lot of health problems, the insurance companies just start kind of making things more difficult for them – not processing their claims as well, providing poor service – and that often pushes people to move to other plans. So that’s how they get people with health problems to go elsewhere. And then they will still be able to draw these geographic areas so that the prices of these plans are going to vary by geography instead of by an individual’s health care needs. So if an insurance company has a certain plan in an area and they find that too many people in that area are having significant health problems and the company is not able to make a profit off of their plan, they’ll just drop it. That’s what it is to them: an insurance plan is just a product, like a cell phone, or a TV, on the shelf.

DS: We’re speaking with Dr. Margaret Flowers, who among other things is the secretary of health in the Green Shadow Cabinet. It’s incredible, Margaret, that they market this as benefiting from the wisdom of the invisible hand of the market economy, and yet the companies as you’ve just described are doing the exact opposite of what is supposedly done in a market economy. They’re trying to lose customers by providing poorer service than some other health insurance company that they might be willing to switch to. And as you’ve described and what I’ve read, the impact of Obamacare, it’s going to result in a lot more privatization, a lot more of our health care dollars going to private companies. Is that right?

MF: That’s correct. The reason that a market-based health system doesn’t work is because private insurers make their profit by charging high premiums and then not paying for services. It’s not like they’re trying to sell TVs or cell phones, they’re trying to not have to pay any money out after they’ve collected it. So it’s the complete opposite of what you want. You want a system that actually pays for the care that you need when you need it. And that’s why privatization doesn’t work and the Affordable Care Act, or Obamacare, is actually further privatizing our system. We’re seeing more of these large hospital corporations buying up practices; we’re seeing insurance companies starting to buy up medical practices. Public insurances are becoming more privatized. Already, 75 percent of Medicaid – that’s the program for people with lower incomes – 75 percent of Medicaid patients are in a privately managed Medicaid plan. And regarding Medicare, which is traditionally our standard for a single-payer-like program in this country, President Obama, when the law was being put together, said he was going to get rid of Medicare Advantage, which is the privatized portion of Medicare. But instead he’s given the Medicare Advantage plans even more money, and we’ve seen a 30 percent increase in people enrolling in those privatized plans. So this is the wrong direction from where we need to be going.

DS: And this is at the state level as well as the federal level that money is going more into private health care.

MF: Correct. Here in Maryland, where I live, we have these privatized managers that handle much our state Medicaid plans, and they skim off probably 15-20 percent, maybe even as much as 40 percent of the money for salaries, profits and administrative costs, and things like that. And that’s money that then can’t go to pay for health care. We had to create a system in Maryland that was completely managed by the state that takes care of our sickest patients because the doctors were having so much trouble fighting with these privatized Medicaid providers to get the care for patients who really needed it. They insisted that the state create a completely public Medicaid for patients with chronic illnesses. This is the problem when you privatize a system and it’s about hanging on to that money and making a profit as opposed to providing the best care, making a system that works for everyone.

DS: So its sounds like one of the big flaws in the U.S. health care system is not getting fixed at all by Obamacare and that is the costs. If we were already paying twice as much as other countries for health care and not necessarily getting it, much less getting twice as much, and nothing is being done to bring down costs, what’s going to happen, is that going to continue to be the case, is it going to get worse? Are there any measures in Obamacare aimed at actually reducing costs?

MF: That’s the really sad thing. As you said, we’re already spending enough money in this country – two to two and a half times more than the other industrialized countries spend per person each year on health care – so we’re spending enough to provide high-quality, comprehensive care to every person living in the country right now, but because we have this very complicated system of all these insurances, and all these different kind of rules in these plans, at least a third of our health care dollars are going just toward administration, which is way more than other countries spend. In the Medicare plan, we spend less than 5 percent on administration. That means more dollars can actually go to care. We’re just wasting this money that could actually go to health care services. And the Affordable Care Act, Obamacare, actually increases the complexities, to create these exchanges. Now the IRS has to be able to determine whether people have insurance or not, whether they have to pay a penalty or not, adding more regulation to try to get the insurance companies to behave. We have now added more administrative costs. And the law did not use any other standard cost controls that we know of that work; instead, they’re kind of they’re saying “experiment with anything that might work and we’ll see what works” for them, when we already know what works to keep health care costs down. So costs will continue to rise, premiums will continue to rise. What we’re finding in Massachusetts is that as the premiums go up, benefits go down. People will continue to have trouble with rising health care costs, and ultimately I imagine the ACA will fail, but in the meantime we’re going to see people continuing to self-ration, to deny themselves necessary care when they don’t have the money out of pocket to pay for the care they need.

DS: So is your take on the creation of the Affordable Care Act, Obamacare, that the net effect is negative because it’s a missed opportunity to enact a real solution, despite the good bits in it, or is it your take that there really aren’t any good bits in it, that it’s all negative?

MF: Some people will get onto Medicaid who weren’t on it before and will be able to get some care. I’m not going to argue with that as being a positive. Some more money was given to some community health centers – that’s definitely a positive. But overall, what this law has done is that it has taken us in the wrong direction. It’s not based on good health policy. There’s so much evidence out there that shows us what kind of a system we could have and that could meet our health care needs in this coun try. It’s not a question of whether we can do that: We can absolutely do that. And this law was not based on good policy, there was no interest in the process of putting it together in Congress of including those kinds of policies. Instead, it’s really the industry, using this opportunity of a health care crisis to pass legislation that further enriches them. I just see it as taking us in the wrong direction and delaying us putting in place a system that will work in this country.

DS: It’s confusing to a lot of us what the insurance companies’ attitude really is toward Obamacare. They’re involved in writing it, there are the secret meetings and the lobbying and the control of the process in Washington, one would think that they would love it from the way that you describe it as further entrenching their interests. And yet we hear, over and over again, about how they hate it. Is the reality that they like it better than they would have liked single payer, which would have put them out of existence, or at least radically altered their existence, but they would have preferred nothing and would rather it go away? Do they like the thing and pretend not to like it? What is their real position here?

MF: I think the real position of the insurance companies is that they want to have a completely open market without regulations and so they’re always going to be fighting against any attempts to regulate them. You know, there are regulations in the law, but it simply means extra work for them to try to get around those regulations and still be able to turn a profit. So they may kick and scream a little bit. Yes, they would have really been opposed if we were trying to put together a single payer, a publicly financed health program. But that’s just the reality. That’s been the reality in every country that has moved to a single-payer, publicly financed health care system. They all had private insurers who complained. But at the end of the day, what we’re talking about here – health care – is absolutely fundamental to people and to a society. When you don’t have a healthy society, everybody is affected by that. The risk of infectious diseases in your community, what it does to families in your neighborhood when they have to go through situations of serious illnesses and struggling to be able to get care and, you know, neighbors are having to do fund-raisers to help them get their chemotherapy. These types of things shouldn’t be happening. In mental health, the fact that we don’t provide good mental health in this country really hurts us as a society. So, at the end of the day, you have to say, you know what, we have to take on that opposition, take on those industries, and just realize that they’re not helping us as a society, and that we as people have to demand that they go do something else. There are other kinds of insurance they can sell; they don’t have to sell health insurance, they can sell life insurance, car insurance, that’s fine.

DS: They can get completely other jobs and we can help them.

MF: That would be fine too.

DS: What about the requirement that individuals buy insurance? Do they like that bit?

MF: Oh sure. That was their main “ask” in the process. I went to many of those meetings in Congress and the first thing that the insurance representatives would say is that this plan going forward has got to include an individual mandate. There’s no way that we can cover people with pre-existing conditions if we don’t force everybody – the healthy people who are just not buying insurance – buying our insurance. So that was their requirement all along. And as the legislation was coming to an end, we were saying that’s the provision that should be dropped. Instead of requiring people to buy private insurance, which we know is going to be lousy coverage – in order to make it affordable, it’s going to have to be lousy coverage – and that instead of taking billions of our taxpayer dollars to subsidize the purchase of these lousy health insurance plans, let’s just take that money and build up our public insurances. Let’s expand Medicare, let’s build up Medicaid and make it better. That would actually put us in a better direction. But that isn’t what happened, unfortunately.

DS: Is there a significant precedent set here? Few if any precedents prior to this one of the government requiring that people buy a product from private companies and promoting that product for those companies – is there a danger here of this setting a precedent that will lead to other bizarre legislation? Or is this a one-time thing?

MF: I’m not a legal expert, but we did challenge the individual mandate, a number of us did, and had lawyers who drew up the brief for us and filed an amicus brief to the Supreme Court with our concerns about that individual mandate. You know, it is foreseeable that, say they decide that Social Security is not going to work, but people have to have pensions, so now we’re going to force people to purchase pension plans from Goldman Sachs. That’s a possibility. It does set a concerning precedent.

DS: The other precedent that we’ve set is the failure of the American people to push hard when the occasion arose for a real solution, for single payer. We had many, many activist organizations and labor unions, as you’re all too familiar, pushing for whatever was already going to get done, for the “robust public option,” the solution that wasn’t really a solution. And we had rallies where we were censored because the demand was for the “robust public option,” which of course then didn’t happen. First of all, are all the people who said this is a step toward single payer and then we’ll take another step – are they now out there pushing for single payer? Have I missed that?

MF: No. And the truth is that this is a step in the other direction, toward greater privatization of our health care. That was interesting because we were looking recently as to what does it take to actually con people, to scam people into accepting something. And there are six kinds of stages of a scam, and we looked at the process of the Affordable Care Act and found those six stages. People we’re really fooled. The health care crisis was there, and it still is there. There was definitely a demand for health reform, and so the whole process was kind of scripted in a direction to devise the health reform movement, to tell people that the single-payer system they were asking for was too much, but that we could get this public option thing and if you fight real hard for that, then we’ll use that, it will become a back door to single payer. People who understand health policy and how health reform has worked out in this country at the state level knew this was actually never going to happen. And the other thing that was really sad was when in March 2009, at the Center for American Progress, Sen. Max Baucus made an announcement that the public option was a bargaining chip that was never meant to be in the final legislation: So all of these people were fighting for something that members of Congress and the White House knew they were not going to include in the final bill.

DS: What should we have done, and what should we do now? And how hard would it be to simply lower the age for Medicare in a bill perhaps in a sentence or a paragraph that people can understand? Is such a thing still possible at this point?

MF: I would say it’s possible. It’s interesting that the same Sen. Baucus, who really pushed the bill in the direction of the health industries, he did carve out a portion of his state, in Libby, Montana, where they have some serious health problems from asbestos exposure, he allowed that whole area to be eligible for Medicare, regardless of age.

DS: Incredible.

MF: What we need to do is continue to push for a Medicare-for-All-type system. One of the takeaways from this whole process was that we need to be really clear about what it is that we want, what a single-payer system is and what it isn’t, and not get fooled when they start telling us that something is a back door to single payer or just a label. We need to know whether that is a reality or not. And we need to be independent of political party in our advocacy work. We need to be focused on the issue, on the policy, not on whether this party or that party is doing it, because this legislation became more about Obama’s legacy and the midterm elections rather than actually solving our health care crisis. We have to stop being so willing to compromise. We’re told that politics is a game of compromise, but I think of what Gandhi said, that you can’t compromise on fundamentals. Because it’s all give and no take. Health care is a fundamental. You can’t really compromise on that, especially when we already have the resources in this country to solve our health care crisis. So being clear on what we want and really being uncompromising is the way that we’re going to move forward and get the kind of health care reform that we need.

DS: Great advice. We’ve been speaking with Margaret Flowers. She is a Maryland pediatrician, she served as congressional fellow for Physicians for a National Health Program, and she’s on the board of Healthcare-Now. Margaret Flowers, thank you very much for coming onto Talk Nation Radio. 

MF: Thank you for having me on, David.

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By Margaret Flowers, M.D.
The Indypendent (New York City), Oct. 30, 2013 The battle lines have been drawn and the Inside-the-Beltway media circus is underway. As the Affordable Care Act (or “Obamacare,” as it is popularly known) gets off to a rocky start, Republicans are bellowing that the new health care law should be jettisoned, even though it is modeled on ideas hatched 20 years ago by the conservative Heritage Foundation and originally backed by the likes of Newt Gingrich and Mitt Romney. Meanwhile, the Obama administration insists that once a few computer “glitches” are resolved in the healthcare.gov website by the end of November, everything will turn out swimmingly. “Don’t worry, these plans will not sell out,” President Obama said in late October. “Everyone who wants insurance in the marketplace will get it.” Lost amid the noise is the fact that not only could we adopt a simpler, more effective single-payer system that is common to other industrialized nations — more about that below — but also that we are witnessing perhaps the greatest corporate scam ever. Not only did the health insurance corporations write the Affordable Care Act in 2009-2010 to enhance their profits, but now they also have the government and non-profit groups doing the work of marketing their shoddy products. The foundation of Obamacare, the mandate that uninsured individuals purchase private insurance if they do not qualify for public insurance, goes into effect in 2014. The state health insurance exchanges where people can purchase that private insurance opened on October 1. A new organization called Enroll America was created to organize and train grassroots activists to seek out the uninsured (they even provide maps) and assist them in using the exchanges. The Uninsured Can you imagine this scenario with any other industry? Billions of public dollars and tremendous efforts are being spent to create new health insurance markets, advertise them, subsidize their products and actively solicit buyers for them. This is being done with the belief that the solution to our health care crisis is to reduce the number of people who are uninsured. But our health care crisis runs deeper than that. And having health insurance in the United States isn’t the same as having access to necessary care. Obamacare does not resolve the fatal flaw in our health system — that it is a market-based system rather than a public health-based system, as is the case in all other industrialized nations. Market competition does not improve health outcomes because it consists of health insurance corporations competing for profits by selling policies to those who are the healthiest and denying and restricting payment for care. And regulation of insurers doesn’t work either. Although rules in Obamacare give the appearance of changing insurance company behavior, insurers are already working around them. Remember, the health insurers wrote the rules. This illusion that the health insurance corporations are regulated under Obamacare is one of the reasons that progressives have been seduced to accept a market- based health system rather than continuing to push for the system most of them desire, a single-payer Medicare-for-all national health program. Defenses of Obamacare ignore the long history of private insurance domination and are based on the hope that this time things will be different. But Obamacare has not changed the fact that private insurance companies view their plans as products and have no more allegiance to human health than does Big Energy, which will stop at nothing to drill, frack and blow up the planet for profits. Experience at the state level with similar reforms and a look at current health trends show that Obamacare will leave tens of millions without insurance, will increase the percentage of people who are underinsured, will increase financial barriers to necessary care and will further privatize health care. Cutting out the multitudes of insurers and creating a single publicly-financed universal health care system is the only way to solve our health care crisis. Tweaking the System During and after the health reform process, the President explained that since most people were happy with their health insurance, we should work with the present health system to improve it. This was the reason given for not enacting a Medicare-for-all system. From the outset, it is important to realize that 80 percent of the population is generally healthy and that this is the population that private insurers prefer to enroll. People may believe that their coverage is satisfactory, until they have a serious health problem and discover that the out-of-pocket costs and restrictions on their care make necessary care unaffordable. Is it wise to try to tweak the current system? Will that bring us to universal coverage? The answer is no. About the best that has been achieved by tweaking the present system at the state level is reducing the number of uninsured people by half. That is what happened in Massachusetts, where legislation similar to Obamacare was passed in 2006. There are currently 48 million uninsured people in the United States. At its best, the Congressional Budget Office estimates that Obamacare will leave 31 million people without health insurance when it is completely rolled out. And even that estimate may be too low. Experience at the state level showed that none of the plans that were similarly hailed as comprehensive met their coverage goals before they failed fiscally. Without effective cost controls, care remains unaffordable. Shifting the Costs As health care costs have soared in the United States, the trend in health insurance coverage has been to shift more of the costs onto the individual. This has primarily been done through what are called Consumer-directed Health Plans (CDHPs), which require co-pays, deductibles and co-insurance. This means that patients have to pay thousands of dollars in addition to their premiums before and after their insurance kicks in. These up-front costs are barriers to care. Considering that 76 percent of Americans are living paycheck to paycheck without significant savings, the money simply isn’t there to pay for visits to the doctor, tests or prescriptions. A health survey by the Commonwealth Fund last year found that 80 million people reported not getting care due to cost, 75 million were having difficulty paying medical bills and four million (over two years) went into bankruptcy as a result. The result of CDHPs is that patients self-ration by avoiding or delaying necessary care. And so many people are currently self-rationing that the rise in health care spending in the United States has slowed over the past five years. Reducing access to necessary care is not the kind of cost-control that should be promoted, but Obamacare does just that. The health insurance exchanges sell four tiers of coverage, identified by metals. The lowest levels, silver and bronze, will pay for 70 and 60 percent of covered services once deductibles are met. “Covered services” is the key phrase. Health insurers are restricting their provider networks for plans sold on the exchanges to exclude places where sick people go, large health centers and safety-net hospitals, and to limit the number of doctors. This will force people to go out of the network and bear more or perhaps all of the cost of their care. The silver and bronze plans have lowered the bar on what is considered coverage. These are levels that will leave people at risk of financial ruin if they have a serious accident or illness. And these are the levels that most people will purchase. Subsidies are available for those who qualify based on the price of a silver plan, and because the subsidies are inadequate, peop le will migrate to the cheapest plans. This model means that people will still get the care they can afford rather than the care they need. It means that more people will have insurance but will not be able to afford care. In Massachusetts, eight out of 10 people who see themselves as “sick” report that health care costs are a serious problem for them. That’s quite a gift to the insurance companies. Millions of new customers will pay premiums, and because of the out-of-pocket costs, may not actually use health services. A cap on out-of-pocket costs was included in Obamacare, but has been delayed for a year because insurers said their computer systems were not ready to manage the caps. Thousands of Waivers The delay on out-of-pocket spending caps is one of the tricks that insurers are using to protect their profits. They have used many others, and we can expect more. Obamacare was written with the help of large insurance corporation lobbyists and others from health industries. The reform process was led in the Senate Finance Committee by Liz Fowler, a former WellPoint executive and Senate staffer. After Obamacare was signed into law, Fowler was transferred to the Department of Health and Human Services (HHS) to oversee the regulations. Insurance representatives have also played an active role at the state level in forming the exchanges. It is no secret that most state insurance commissioners have close ties to the industry. The effect that this level of industry influence has had is that thousands of waivers have been issued by HHS to water down provisions in the bill and the industry has participated in writing definitions of terms to their advantage. For example, one area of tension concerned the requirement that insurers spend 80 to 85 percent of what they collect in premiums on health care (called the Medical Loss Ratio, MLR). This requirement simply led to a redefinition of care, and the term was interpreted so broadly as to include insurance brokers. Dr. John Geyman of Physicians for a National Health Program writes, “The insurance lobby won a number of concessions, including counting expenses of quality assurance as medical costs, allowance to deduct many of their taxes from their total premiums before calculating their MLR, and the ability to appeal for a lower MLR standard for up to three years in states where ‘there is a reasonable likelihood that market destabilization could harm consumers.’” Perhaps one of the most egregious examples of insurance company behavior took place six months after Obamacare was signed. At that point, by law, insurers were no longer allowed to deny new policies to children on the basis of pre-existing conditions. Faced with a potential reduction in profit margins, many health insurers simply stopped selling new policies for children. In essence, they pulled the product from the shelf. HHS was able to entice the insurers to sell policies again by offering increased premiums and limiting open enrollment periods. This is one of the ways that insurance corporations cherry pick only the healthiest people. Under Obamacare, some large insurers are avoiding most of the insurance exchanges and are focused instead on offering plans to employers or serving as benefit administrators. Another method is restricting networks to avoid facilities that care for the sickest or by reducing the number of providers in a plan. And the third will be to pull out of geographic areas if they prove to be money-losers. Insurers are not allowed to charge more for people with pre-existing conditions, but they are allowed to charge more for smokers, up to three times more based on age and more in geographic areas where health care costs are high or the population has greater medical needs. As it is with markets, health insurers will sell their products where they can make the most profit. We will watch and see what insurers do over the coming years. We can expect them to justify charging higher premiums. In the past, they have reduced premiums temporarily to lure people in or avoid government intervention and then raised them later. We can expect them to push for lower levels of coverage or fewer required services. And we can expect that HHS and state insurance commissioners will be compliant, as they have been. Towards Greater Privatization Another myth used to lure progressives to support Obamacare is to say that it is a step in the right direction, meaning towards universal coverage. But Obamacare is actually a step towards greater privatization of our entire health system. It lacks provisions to stop the consolidation of ownership of health facilities by large for-profit entities, something that large insurers are doing more. It cuts funding to safety-net hospitals. And under Obamacare, public insurances are becoming more privatized. Medicaid is state health insurance for people with low incomes. More states are moving their Medicaid patients into managed care organizations (MCOs). MCOS, such as Amerigroup which was bought by WellPoint after Obamacare passed, are for-profit administrators that compete with each other to cover the healthiest patients and are incentivized to cut care. Currently 75 percent of Medicaid patients are in MCOs and that number is expected to increase further under Obamacare. Medicare is public insurance for people 65 years of age and older and who are disabled. One of the early goals of Obamacare was to cut back on Medicare Advantage plans, which are essentially private insurance plans paid for through Medicare. The Advantage plans primarily insure the healthiest seniors and cost more than traditional Medicare. Instead of cutting back, the Obama administration boosted payment to the Advantage plans. And enrollment in the plans has increased by 30 percent since 2010. There is good reason to suspect that Medicare may be completely privatized in the coming years by being turned into a defined premium plan rather than the defined benefit plan that it is now. This means that seniors would receive a certain amount of money each year to purchase private insurance instead of knowing each year that they would have Medicare with its required benefits. This is the plan being pushed by Republican Congressman Paul Ryan. The idea came out of the National Commission for Fiscal Responsibility and Reform created by President Obama in 2010. Not the Reform We Need Looking at Obamacare from a distance, it is difficult to see it as anything more than a law designed by and for the health industries that profit from the current health system. The regulations can be circumvented or waived. The insurers can continue to find innovative ways to avoid the sick and not pay for care. And overall the system is becoming more privatized, which is the opposite direction from the real solution, Medicare for all. Medicare for all, also called single-payer, would create a health system that treats health care as a public good rather than as a commodity. The system would be paid for up front through progressive taxation. There would be no premiums or out of pocket costs, so while taxes would be higher, people would be able to get the health care they need rather than being limited to what they could afford. In a Medicare-for-all system, every person in the United States would be in the system from birth to death and it would cover all necessary care. It would be much simpler to use because there would be one set of rules and all health professionals would be included. People would have more choices of where to go for care and would be able to change jobs or travel freely without worrying about not being covered. Barriers to receiving care would be removed. There would be no more worries about whether a person qualifies for this or that because everyone would have access to the same standard of care. Current health care spending in the United States is more tha n adequate to pay for a Medicare-for-all system. This has been proven time and again in studies at the state and national levels. In fact, a Medicare-for-all system would allow better management of our health care dollars and the ability to negotiate for fair prices for medications and services. And Medicare for all would have a broader impact on our public policy because the bottom line would be public health rather than profits. Clean air and water, access to healthy food and fewer toxins in consumer products would reduce health care spending rather than padding the pockets of the health industry. The work for Medicare for all continues. There is a bill, HR 676, in the House of Representatives that is collecting co-sponsors and which outlines a Medicare-for-all plan. Single-payer groups throughout the country continue to press forward. And Physicians for a National Health Program will continue to document the problems with our health system and educate about Medicare for all. It’s crucial that single-payer supporters continue to articulate what a real solution to our health care crisis would look like and not silence themselves out of a misguided desire to shield Obama and the Democrats and the poor decisions they have made from attacks by Republican demagogues. We cannot cross our fingers and hope that Obamacare “works.” That attitude means hundreds of thousands will suffer and die from preventable causes and millions of families each year will continue to go bankrupt because of medical illness and costs. The moral imperative is to realize that health care never has been and never will be a commodity and to stop treating it as such by taking it out of the marketplace altogether. Margaret Flowers is a pediatrician and co-chair of the Maryland chapter of Physicians for a National Health Program. She serves on the board of Healthcare-Now and of the Maryland Health Care is a Human Right campaign. She is also an editor at popularresistance.org. https://indypendent.org/2013/10/30/health-care-market-madness

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GOP base doesn’t understand right wants to turn Medicare, Social Security and more into a very similar program

By Michael Lind
Salon, Oct. 28, 2013 The smartest thing yet written about the botched rollout of the Affordable Care Act’s federal exchange program is a post by Mike Konczal of the Roosevelt Institute at his “Rortybomb” blog at Next New Deal.  Konczal makes two points, each of which deserves careful pondering. The first point is that to some degree the problems with the website have been caused by the overly complicated design of Obamacare itself.  Instead of being a simple, universal program like Social Security or Medicare, the Affordable Care Act system is designed as if to illustrate Steven Teles’ notion of “kludgeocracy” or needless, counterproductive complexity in public policy.  By using means-testing to vary subsidies among individuals and by trying to match individuals with private insurance companies, the ACA requires far more information about people who try to sign up than do simpler public programs like Social Security and Medicare.  If Congress had passed Medicare for All, the left’s preferred simple, universal alternative to the kludgeocratic ACA mess, signing up would have been a lot easier and the potential for website snafus correspondingly less. Konczal’s second point is even more important — the worst features of Obamacare are the very features that conservatives want to impose on all federal social policy: means-testing, a major role for the states, and subsidies to private providers instead of direct public provision of health or retirement benefits.   This is not surprising, because Obamacare’s models are right-wing models — the Heritage Foundation’s healthcare plan in the 1990s and Mitt Romney’s “Romneycare” in Massachusetts. This point is worth dwelling on. Conservatives want all social insurance to look like Obamacare.  The radical right would like to replace Social Security with an Obamacare-like system, in which mandates or incentives pressure Americans to steer money into tax-favored savings accounts like 401(k)s and to purchase annuities at retirement, with means-tested subsidies to help the poor make their private purchases.  And most conservative and libertarian plans for healthcare for the elderly involve replacing Medicare with a totally new system designed along the lines of Obamacare, with similar mandates or incentives to compel the elderly to buy private health insurance from for-profit corporations. If you don’t like Obamacare, you should really, really hate the proposed conservative alternatives to Social Security and Medicare.  Konczal writes:     “Conservatives in particular think this website has broad implications for liberalism as a philosophical and political project. I think it does, but for the exact opposite reasons: it highlights the problems inherent in the move to a neoliberal form of governance and social insurance, while demonstrating the superiorities in the older, New Deal form of liberalism. This point is floating out there, and it turns out to be a major problem for conservatives as well, so let’s make it clear and explicit here.” Building on an insightful discussion of public policy by means of subsidies or “coupons” published by the New America Foundation’s Next Social Contract initiative, Konczal contrasts the indirect, market-based, state-based  neoliberal/conservative approach to social insurance that inspired Obamacare with the kind of universal federal social insurance preferred by liberals in the tradition of FDR and LBJ:     “So this tells a story. Let’s refer to these features of social insurance, which are also playing a major role in the rollout problems, as ‘Category A.’ Now, what would the opposite of this look like? Let’s define the opposite of this as ‘Category B’ social insurance. And let’s take these two categories and chart them out.” Konczal speculates that the flaws of Obamacare may undermine public support for proposed conservative replacements of Social Security and Medicare:     “However, the smarter conservatives who are thinking several moves ahead (e.g. Ross Douthat) understand that this failed rollout is a significant problem for conservatives. Because if all the problems are driven by means-testing, state-level decisions and privatization of social insurance, the fact that the core conservative plan for social insurance is focused like a laser beam on means-testing, block-granting and privatization is a rather large problem. As Ezra Klein notes, ‘Paul Ryan’s health-care plan — and his Medicare plan — would also require the government to run online insurance marketplaces.’ Additionally, the Medicaid expansion is working well where it is being implemented, and the ACA is perhaps even bending the cost curve of Medicare, the two paths forward that conservatives don’t want to take.” Will the flaws of Obamacare really hurt the right and help center-left supporters of universal social insurance?  I doubt it. To begin with, this implies a willingness of the right to acknowledge that Obamacare, in its design, is essentially a conservative program, not a traditional liberal one.  But we have just been through a presidential campaign in which Mitt Romney, who as governor of Massachusetts presided over the creation of the most important model for Obamacare, rejected any comparison of Romneycare with Obamacare.   What is more, instead of agreeing with Konczal that the flaws of Obamacare are shared by most conservative entitlement reform proposals, conservatives are likely simply to denounce Obamacare as “socialism” or “collectivism” while promoting their own, Obamacare-like replacements for Social Security and Medicare, with blithe indifference to their own inconsistency. Nor are progressives likely to press the point in present or future debates.  Unlike conservatives, who are right-wingers first and Republicans second, all too many progressives put loyalty to the Democratic Party — most of whose politicians, including Obama, are not economic progressives — above fidelity to a consistent progressive economic philosophy.  These partisan Democratic spinmeisters are now treating Obamacare, not as an essentially conservative program that is better than nothing, but as something it is not — namely, a great victory of progressive public policy on the scale of Social Security and Medicare. In doing so, progressive defenders of Obamacare may inadvertently be digging the graves of Social Security and Medicare. If Obamacare — built on means-testing, privatizing and decentralization to the states — is treated by progressives as the greatest liberal public policy success in the last half-century, then how will progressives be able to argue against proposals by conservative Republicans and center-right neoliberal Democrats to means-test, privatize and decentralize Social Security and Medicare in the years ahead? I predict that it is only a matter of time before conservatives and Wall Street-backed  “New Democrats” begin to argue that, with Obamacare in place, it makes no sense to have two separate healthcare systems for the middle class — Obamacare for working-age Americans, Medicare for retired Americans.  They will suggest, in a great bipartisan chorus:  Let’s get rid of Medicare, in favor of Lifelong Obamac are!  Let’s require the elderly to keep purchasing private insurance until they die! I’m sure a number of token “centrist” Democrats will be found, in due time, to support the replacement of Medicare by Lifelong Obamacare.  And with neoliberal Democratic supporters of the proposal as cover, the overclass centrists of the corporate media will begin pushing for Lifelong Obamacare as the sober, responsible, “adult” policy in one unsigned editorial after another. Once Medicare has been abolished in favor of Lifelong Obamacare, perhaps by a future neoliberal Democratic president like Clinton and Obama, Social Security won’t last very long. The conservative Republicans and centrist Democrats will argue that the success of Obamacare, in both its initial version and the new and improved Lifelong Obamacare version, proves that a fee-based, means-tested, privatized and state-based system is superior to the universal, federal, tax-based Social Security program enacted nearly a century ago in the Dark Age known as the New Deal.  We will be told that, in a world with computers and globalization and apps or whatever, simple, universal, one-size-fits all social insurance is obsolete.  In the “new economy,” public policy needs to offer as many baffling choices as airlines or gyms, like the ridiculous bronze, silver, gold and platinum plans of Obamacare. At some point in the future, the right will introduce a plan to replace Social Security with a system of individual mandates and fines to compel working-age Americans to invest in for-profit Wall Street mutual funds during one’s working years, and to compel them to buy annuities from for-profit money managers at retirement (which with the help of centrist Democrats will be postponed to 70 or beyond).  The genuine progressives will respond with a defense of Social Security.  Whereupon the faux-progressives, the neoliberal heirs of Carter, Clinton and Obama, will reject the option of preserving Social Security — why, that’s crazy left-wing radical talk! — but insist that the subsidies for the poorest of the elderly be slightly increased, as the price for their adoption of the conservative plan to destroy Social Security.  Throughout the process, the right-wing Republicans and neoliberal Democrats will ask, “How can progressives object to means-testing, privatization and 50 state programs, when those are the very features of the Obamacare system that our friends on the left celebrate as a great achievement?” Think about it, progressives.  The real “suicide caucus” may consist of those on the center-left who, by passionately defending the Affordable Care Act rather than holding their noses, are unwittingly reinforcing the legitimacy of the right’s long-term strategy of repealing the greatest achievements of American liberalism. Michael Lind is the author of “Land of Promise: An Economic History of the United States” and co-founder of the New America Foundation. http://www.salon.com/2013/10/28/what_the_tea_party_misses_if_you_hate_obamacare_youll_really_hate_what_the_right_wants_to_do_to_social_security/

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By David Freudberg
The Huffington Post, Oct. 28, 2013 Advocates of a single-payer health system have long touted what they see as its cost-saving advantages. In light of the recent Obamacare rollout, they would be justified in citing another benefit as well: simplified sign-up. An easy shorthand for single-payer is Medicare for All. The concept is to take a health coverage system that is highly popular and generally works well and just expand it. Without reinventing the wheel, simply lift the age restriction for Medicare eligibility. Instead of covering only seniors, single-payer champions urge allowing everyone to be covered by a federal system — the way health care is provided in basically every other industrialized nation. For example, in Canada’s single-payer system, you select your own doctor (and if unsatisfied, you pick a new one). There are some limitations on what services a patient can get when, but they’re apparently not seen as too drastic: A Gallup Poll showed a majority of Canadians to be “satisfied” or “very satisfied” with their system. And for Americans, of course, there are limits to coverage from private insurers as well. Just ask anyone who has recently braved healthcare.gov and studied the fine print of competing private policies offered on the new exchanges. Or anyone who has had the unpleasant experience of being denied medical care by an American insurer. I’m not sure which is more incomprehensible: the ham-handed launch of registration for the Affordable Care Act (ACA) or the system’s mind-numbing complexity. But the two are related. Failing to beta-test a national site with this many moving parts til two weeks before the liftoff date would strike most IT professionals I know as webmaster malpractice or at least dereliction of management at HHS. But that doesn’t clarify why so many moving parts were needed in the first place. What explains the system’s convolution is the numerous powerful health care industry lobbies. Their behind-the-scenes influence before the ACA was passed by Congress in 2010 produced one of the least healthy foods on the planet: legislative sausage. With about 50 million Americans, including many children, uninsured at the time of President Obama’s first election, the time had come to do something to foster greater fairness in health care. But the awkward compromise reached, dubbed the Affordable Care Act, left no one fully satisfied. As the legislative machinery kicked into gear in the spring of 2009, Senate finance committee chair Max Baucus, who led the deliberations, famously declared that single-payer coverage was “off the table.” On two occasions in March of that year, Baucus even ejected single-payer activists from Senate hearings. Yet single-payer was widely popular. A New York Times poll published the previous month found that “59 percent [of Americans] say the government should provide national health insurance, including 49 percent who say such insurance should cover all medical problems.” But there is powerful opposition to single-payer from a corporate sector that stands to lose billions — the health insurance industry. Last year health insurers invested $243 million in lobbying. The ACA, with its individual mandate to buy coverage, was passed by Congress partly because health insurers went along with it. After all, they were eying tens of millions of new customers. And competition for those customers, projected to yield billions in profits, has brought us the new health care exchanges, which are so complicated that the federal ACA website has been unable to put the pieces together, at least thus far. Imagine what the rollout this month would have looked like if single-payer had carried the day in Washington instead. Undoubtedly, there’d be some computer glitches as happen with all website launches. And Congressional opponents of the law probably would still be griping loudly. But rather than sorting through a bewildering maze of plans, the burden on health care consumers would likely be a far simpler registration for guaranteed health care. And by many calculations, the economies of scale from including more patients would slash the nation’s per capita health costs, a boon to federal deficit reduction. Says Marcia Angell, former editor of the New England Journal of Medicine, “The underlying problem with our health care system, the thing that makes it such a mess, is that it is based on seeking profits and not on providing health care.” David Freudberg is host of the public radio series “Humankind.” http://www.huffingtonpost.com/david-freudberg/the-other-reason-for-health_b_4169711.html

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