PNHP

Employer-sponsored health plans under the Affordable Care Act

Employer-sponsored health plans under the Affordable Care Act

Health Policy Brief: Employers and Health Care Reform

Health Affairs/Robert Wood Johnson Foundation
March 9, 2011

To expand access and strengthen the employment-based health system, the Affordable Care Act of 2010 will require midsize and large companies to make payments to the federal government if they do not offer health insurance to their employees and dependents starting in 2014.

What’s in the law?

Under the Affordable Care Act, beginning in 2014 employers with at least 50 full-time employees (or equivalent full- and part-time workers) will have to provide “qualified” health insurance coverage to their full-time employees and their dependents. Qualified coverage means that plans are comprehensive (pay at least 60 percent of health care expenses) and affordable (cost less than 9.5 percent of employees’ household incomes).

If employers don’t offer qualified coverage, and if their employees purchase coverage instead through a new state insurance exchange with the assistance of federal subsidies, companies will have to make an “assessable payment” of up to $2,000 for every full-time employee beyond the first 30 employees. The amount of the assessment will be adjusted annually to reflect the growth in national insurance premium costs.

If employers do offer coverage, but the coverage does not meet certain parameters, they may still have to pay assessments. First, employers will be assessed if a plan is judged not to be comprehensive. This means the coverage must have an “actuarial value” of at least 60 percent. In other words, the employer pays on average at least 60 percent of health care expenses and the employee pays on average 40 percent of these expenses through deductibles and copayments.

Second, employers will be assessed if the employees’ premiums are considered unaffordable relative to their household incomes. Specifically, the employee’s share of the premium must not exceed 9.5 percent of his or her annual household income.

Starting in 2014, if either of these two conditions is not met, the employer must pay a $3,000 annual assessment for each employee who declines his or her employment-based insurance and obtains government-subsidized coverage through an exchange.

Small businesses with fewer than 50 full-time employees (or equivalent full- and part-time workers) don’t have to meet the requirement and are exempt from having to offer health insurance.

Many companies face payments:

A study by the Mercer consulting firm found that 38 percent of US employers may face paying assessments starting in 2014, because their coverage might not be considered affordable for at least some of their employees.

“Free-choice vouchers”:

Employees who earn less than four times the federal poverty level (in 2011, $43,560 for an individual and $89,400 for a family of four) and whose share of the premium is between 8 percent and 9.5 percent of his or her household income, can choose to enroll in an exchange instead of the employer plan. The employer must issue the employee a “free-choice voucher” equal to the amount the employer would have paid under the employer’s plan.

Tax on high-value health plans:

Beginning in 2018, “Cadillac” or high-value health plans will be subject to a 40 percent excise tax on premium amounts exceeding $10,200 for single coverage and $27,500 for families.

What’s the likely impact?

The Congressional Budget Office (CBO) and the Joint Committee on Taxation estimated that provisions of the Affordable Care Act, including the employer requirement, will result in 3 million fewer people having employer-provided coverage in 2019. This would be the net result of a series of big changes.

First, the CBO estimates that 6–7 million people would acquire employer coverage for the first time because the requirement would increase workers’ demand for coverage through their jobs. Second, another 1–2 million who currently have employment-based coverage would instead move to the exchanges because the coverage would be more affordable. Third, about 8–9 million others covered under an employer plan under current law would lose employer coverage because firms would choose to no longer offer coverage. These firms are likely to be smaller companies employing lower-wage workers who would be eligible for exchange subsidies.

In addition, according to the CBO, employers will pay about $52 billion in additional assessments between 2014 and 2019. Under the law, that money will be put toward the new subsidies for millions of workers and their families to defray the cost of purchasing health coverage through the exchanges.

“Pay and walk away”:

Among companies of all sizes currently offering benefits, 76 percent reported they would continue to do so in January 2014. Of the rest, 15 percent reported they would offer coverage to at least some full-time employees, and 9 percent said they would stop offering coverage altogether. Among firms with 200 or more full- and part-time equivalent employees, 7 percent planned to drop coverage. “For some large firms, in particular, there is a desire to pay and walk away,” said Susan McIntyre, senior vice president of Market Strategies International’s health care division, in a statement.

Tempted to drop coverage:

The math could make the idea to drop coverage tempting. In 2010, the average annual premium cost for employer-based coverage was $5,049 for a single person and $13,770 for a family, although employers generally do not pay the entire cost. Many employers might consider paying $2,000 or $3,000 in assessments to be more cost-effective. On the other hand, many large employers say they view offering health coverage to be an important part of their overall compensation strategy, and necessary to attract the best workers.

It is possible that employers will watch closely to see how their peer companies respond. In a July 2010 survey by Fidelity Investments, 65 percent of large employers said they were not seriously considering eliminating health care benefits because of the new law. But when asked what they would do if others dropped coverage, 36 percent said they too would consider eliminating coverage. Another 36 percent said they would not drop coverage and the remaining employers were unsure.

http://www.healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_42.pdf

Comment: 

By Don McCanne, MD

What will happen to employer-sponsored coverage under the Affordable Care Act? Perhaps one of the most alarming provisions of the Act is that plans with a 60 percent actuarial value (patients pay an average of 40 percent of their health care bills) qualify to fulfill the employers’ obligations to provide coverage or pay an assessment. Thus the Act is establishing under-insurance as the new standard.

Premiums on more generous plans are approaching a level that will trigger a a 40 percent excise tax. One way to avoid that tax would be to reduce the actuarial value of the plans to the minimum requirement. With employers’ aversion to taxes, many will surely consider that.

With these low actuarial value plans, employees will surely complain about the high out-of-pocket costs they will face when they need health care. Since employers won’t want to make their employees unhappy, they will be motivated to drop their plans altogether and pay t
he much lower assessments required by the Act. We already know that most employers may not want to lead on this, but a great many will certainly follow once a few do it, and they have said so.

It is frequently stated that employers will want to continue to offer plans in order to attract more qualified employees, but this argument seems rather disingenuous. Employers now have an out.

When employers drop their health plans, there is no assessment on the first 30 employees, and then only $2000 for each beyond the 30. Employers can use some of the savings for pay raises, and then the employees, most of whom will be eligible for government subsidies, can select their own plans in the exchanges. Why would employers use health plans as an enticement – plans that are otherwise readily available in the exchanges – when they can use higher wages to compete in the labor markets?

Our experience shows that plans with low actuarial values – usually high-deductible plans – still frequently have premiums that are unaffordable for many. Combining unaffordable premiums with low actuarial values, it won’t be long before middle-income Americans realize that the private insurers have foisted off on us a highly defective product: UNAFFORDABLE UNDER-INSURANCE. You go broke if you buy it, and you go broke if you need to use it!

Single payer, anyone?

Employer-sponsored health plans under the Affordable Care Act

Health Policy Brief: Employers and Health Care Reform

Health Affairs/Robert Wood Johnson Foundation
March 9, 2011

To expand access and strengthen the employment-based health system, the Affordable Care Act of 2010 will require midsize and large companies to make payments to the federal government if they do not offer health insurance to their employees and dependents starting in 2014.

What’s in the law?

Under the Affordable Care Act, beginning in 2014 employers with at least 50 full-time employees (or equivalent full- and part-time workers) will have to provide “qualified” health insurance coverage to their full-time employees and their dependents. Qualified coverage means that plans are comprehensive (pay at least 60 percent of health care expenses) and affordable (cost less than 9.5 percent of employees’ household incomes).

If employers don’t offer qualified coverage, and if their employees purchase coverage instead through a new state insurance exchange with the assistance of federal subsidies, companies will have to make an “assessable payment” of up to $2,000 for every full-time employee beyond the first 30 employees. The amount of the assessment will be adjusted annually to reflect the growth in national insurance premium costs.

If employers do offer coverage, but the coverage does not meet certain parameters, they may still have to pay assessments. First, employers will be assessed if a plan is judged not to be comprehensive. This means the coverage must have an “actuarial value” of at least 60 percent. In other words, the employer pays on average at least 60 percent of health care expenses and the employee pays on average 40 percent of these expenses through deductibles and copayments.

Second, employers will be assessed if the employees’ premiums are considered unaffordable relative to their household incomes. Specifically, the employee’s share of the premium must not exceed 9.5 percent of his or her annual household income.

Starting in 2014, if either of these two conditions is not met, the employer must pay a $3,000 annual assessment for each employee who declines his or her employment-based insurance and obtains government-subsidized coverage through an exchange.

Small businesses with fewer than 50 full-time employees (or equivalent full- and part-time workers) don’t have to meet the requirement and are exempt from having to offer health insurance.

Many companies face payments:

A study by the Mercer consulting firm found that 38 percent of US employers may face paying assessments starting in 2014, because their coverage might not be considered affordable for at least some of their employees.

“Free-choice vouchers”:

Employees who earn less than four times the federal poverty level (in 2011, $43,560 for an individual and $89,400 for a family of four) and whose share of the premium is between 8 percent and 9.5 percent of his or her household income, can choose to enroll in an exchange instead of the employer plan. The employer must issue the employee a “free-choice voucher” equal to the amount the employer would have paid under the employer’s plan.

Tax on high-value health plans:

Beginning in 2018, “Cadillac” or high-value health plans will be subject to a 40 percent excise tax on premium amounts exceeding $10,200 for single coverage and $27,500 for families.

What’s the likely impact?

The Congressional Budget Office (CBO) and the Joint Committee on Taxation estimated that provisions of the Affordable Care Act, including the employer requirement, will result in 3 million fewer people having employer-provided coverage in 2019. This would be the net result of a series of big changes.

First, the CBO estimates that 6–7 million people would acquire employer coverage for the first time because the requirement would increase workers’ demand for coverage through their jobs. Second, another 1–2 million who currently have employment-based coverage would instead move to the exchanges because the coverage would be more affordable. Third, about 8–9 million others covered under an employer plan under current law would lose employer coverage because firms would choose to no longer offer coverage. These firms are likely to be smaller companies employing lower-wage workers who would be eligible for exchange subsidies.

In addition, according to the CBO, employers will pay about $52 billion in additional assessments between 2014 and 2019. Under the law, that money will be put toward the new subsidies for millions of workers and their families to defray the cost of purchasing health coverage through the exchanges.

“Pay and walk away”:

Among companies of all sizes currently offering benefits, 76 percent reported they would continue to do so in January 2014. Of the rest, 15 percent reported they would offer coverage to at least some full-time employees, and 9 percent said they would stop offering coverage altogether. Among firms with 200 or more full- and part-time equivalent employees, 7 percent planned to drop coverage. “For some large firms, in particular, there is a desire to pay and walk away,” said Susan McIntyre, senior vice president of Market Strategies International’s health care division, in a statement.

Tempted to drop coverage:

The math could make the idea to drop coverage tempting. In 2010, the average annual premium cost for employer-based coverage was $5,049 for a single person and $13,770 for a family, although employers generally do not pay the entire cost. Many employers might consider paying $2,000 or $3,000 in assessments to be more cost-effective. On the other hand, many large employers say they view offering health coverage to be an important part of their overall compensation strategy, and necessary to attract the best workers.

It is possible that employers will watch closely to see how their peer companies respond. In a July 2010 survey by Fidelity Investments, 65 percent of large employers said they were not seriously considering eliminating health care benefits because of the new law. But when asked what they would do if others dropped coverage, 36 percent said they too would consider eliminating coverage. Another 36 percent said they would not drop coverage and the remaining employers were unsure.

http://www.healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_42.pdf

What will happen to employer-sponsored coverage under the Affordable Care Act? Perhaps one of the most alarming provisions of the Act is that plans with a 60 percent actuarial value (patients pay an average of 40 percent of their health care bills) qualify to fulfill the employers’ obligations to provide coverage or pay an assessment. Thus the Act is establishing under-insurance as the new standard.

Premiums on more generous plans are approaching a level that will trigger a a 40 percent excise tax. One way to avoid that tax would be to reduce the actuarial value of the plans to the minimum requirement. With employers’ aversion to taxes, many will surely consider that.

With these low actuarial value plans, employees will surely complain about the high out-of-pocket costs they will face when they need health care. Since employers won’t want to make their employees unhappy, they will be motivated to drop their plans altogether and pay the much lower assessments required by the Act. We already know that most employers may not want to lead on this, but a great many will certainly follow once a few do it, and they have said so.

It is frequently stated that employers will want to continue to offer plans in order to attract more qualified employees, but this argument seems rather disingenuous. Employers now have an out.

When employers drop their health plans, there is no assessment on the first 30 employees, and then only $2000 for each beyond the 30. Employers can use some of the savings for pay raises, and then the employees, most of whom will be eligible for government subsidies, can select their own plans in the exchanges. Why would employers use health plans as an enticement – plans that are otherwise readily available in the exchanges – when they can use higher wages to compete in the labor markets?

Our experience shows that plans with low actuarial values – usually high-deductible plans – still frequently have premiums that are unaffordable for many. Combining unaffordable premiums with low actuarial values, it won’t be long before middle-income Americans realize that the private insurers have foisted off on us a highly defective product: UNAFFORDABLE UNDER-INSURANCE. You go broke if you buy it, and you go broke if you need to use it!

Single payer, anyone?

Single-Payer Supporters Stand Strong in Salem

A rally and emotional hearing for House Bill 3510 put spotlight on single-payer system

By Rebecca Robinson
The Lund Report (Portland, Ore.), March 11, 2011

SALEM, Ore. — Supporters of single-payer healthcare legislation had their day in Salem Friday, with a well-attended hearing on the Capitol steps and an emotional hearing for the single-payer bill, House Bill 3510, before the House Health Care Committee.

“This is not all about the bill,” Rep. Mike Dembrow (D-Portland), the sponsor of House Bill 3510, told supporters at Friday’s noontime rally. “Single-payer is a movement.”
 
Dembrow and other supporters of a single-payer system point to existing programs such as Medicare, Medicaid and the Veterans Administration, as current examples of single-payer healthcare in America: government-run systems with no copays, deductibles or cost-sharing that allow patients to choose their healthcare provider.
 
Dembrow’s sentiment was echoed by all in attendance, including his fellow Representative, Jules Bailey (D-Portland), and Dr. Paul Gorman, a physician at Oregon Health and Science University.
 
“All of us are one illness away from bankruptcy in the current system,” said Gorman, who likened the U.S. insurance industry to Big Tobacco.
 
“They [the insurance industry] are selling us a product that’s harmful to all of us, for a profit,” Gorman said.
 
Legislators heard more about House Bill 3510, also known as the Affordable Health Care for All Oregon Act, from both supporters and opponents at a hearing Friday afternoon. Dembrow and Gorman reiterated their endorsement of the bill, and many more came forward to testify in support of a single-payer system.
 
“Payment with a single-payer system will be simpler for everyone to understand, and much less expensive to negotiate,” said Dr. Doug Bigelow, a professor emeritus of psychiatry at OHSU. He spoke of his eight years practicing in British Columbia, Canada, in a single-payer system with universal coverage, no deductibles and free choice of doctors for patients.
 
“I can say that this system works very well, it’s comparatively inexpensive, and very popular,” said Bigelow. “What stymies us here is the deep structural transformation” required to change the current system – work, he argued, that is both necessary and would lead to long-term savings.
 
An independent insurance agent Paco Maribona, said that even though a single-payer system could cost him and other agents their jobs, he still supported the bill, because “the advantage of all Oregonians getting coverage is worth it.”
 
“I asked my [Portland Community College] students if they didn’t have insurance, and two-thirds of them raised their hands,” said Terri Mills, a longtime nurse educator. “It’s so ironic; they don’t have access to the care they themselves will someday be providing.” She called for “evidence-based policy” that would stem the “growing crisis that continues to erode our living standards.”
 
Opponents of the bill pulled no punches.
 
“We shouldn’t rely on top-down solutions” like House Bill 3510, said Steve Buckstein of the Cascade Policy Institute, “but instead bottom-up liberations.” To reduce costs and improve access, Buckstein argued, use the profit motive.
 
“Walmart started offering $4 generic prescription drugs, and Fred [Meyer] matched those prices,” said Buckstein. “Prices dropped quickly, and [the companies] did it for profit.”
 
Eric Fruits, an economist for the state, likened the single-payer system to an “All-you-can-eat health care buffet” with no cost controls.
 
“It’s impossible to simultaneously provide universal insurance coverage, control costs, and maintain provider participation,” Fruits asserted.
 
Individual consumers also expressed their concerns about government-mandated healthcare.
 
“I’m standing today on my fundamental, constitutional right to choose,” said Kate Jaudes of Salem. “I don’t want the government to force me to go to an MD or punish me if I don’t.”
 
No matter the outcome, both sides will continue to work on either side of the issue to, in Rep. Bailey’s words, “get this done.”

http://www.thelundreport.org/resource/single_payer_supporters_stand_strong_in_salem

Oregon House Health Care Committee draws testimony on bill to create single-payer universal health care

By Bill Graves
The Oregonian, Friday, March 11, 2011

A House hearing Friday on a bill to establish a single-payer universal health care plan in Oregon drew testimony from about two dozen people, most in favor of the proposal.

One supporter, Wes Brain of Southern Oregon, held up a wedding photo of his daughter before the House Health Care Committee and described her nine-year battle with her insurance company before she died from leukemia.

“They made her life miserable,” he told the House health committee. “Every step of the way.”

After her teeth fell out from radiation therapy, he said, she was denied help from insurers who said that she needed dental care, not medical care.

“Please remember my daughter,” he said. “I’m going to work on this the rest of my life. We can do better than this.”

Supporters of House Bill 3510, a single-payer health care proposal entitled the Affordable Health Care for All Oregon Act, argued the bill would cut administrative costs, promote efficient primary care and create jobs. But opponents said the plan would foster overuse and underpay, driving away doctors and limiting services.

The bill would create a system that directs all public and private money now spent on health care into a single fund that covers everyone, a single Oregon self-insurance plan. Rep. Michael Dembrow, D-Portland, author of the bill, said it would essentially extend Medicare, the federal health insurance for people 65 and older, to all Oregonians.

The single–payer proposal faces stiff political opposition, particularly in a House that is evenly divided between Republicans and Democrats.

But Dembrow, doctors, nurses and other health professionals argued that a single-payer system would dramatically cut administrative costs and paperwork that arise from health care that depends on a complex private insurance industry. Medicare, by contrast, has low administrative fees, he said.

Oregon could use the money it spends now on health care to extend Medicare to all Oregonians in a system that would contain costs, offer choice and create jobs, supporters said.

Dr. Paul Gorman, a physician and university instructor, said 45,000 people die a year for lack of health insurance.

“We’re all one serious illness away from bankruptcy,” he said.

Dr. Samuel Metz, a Portland anesthesiologist, and Dr. Joseph Eusterman, a retired physician, also testified. They belong to a group of Oregon physicians who campaigned across the country in 2009 for single-payer health care and call themselves the Mad as Hell Doctors.

Dembrow’s bill “is fiscally conservative, socially responsible, morally correct and an urgently needed solution,” said Eusterman.

Opponents argued a government-run health care system would raise taxes and lower the quality and accessibility of health care services.

Two members of the conservative Americans for Prosperity said the plan would lead to a bloated, inefficient bureaucracy that would drive up taxes and create only government jobs. The House Health Care Committee received 280 emails in opposition to the bill from Americans for Prosperity.

 Eric Fruits, an economist and consultant to the Cascade Policy Institute, a Portland market-oriented think tank, said the bill offers Oregonians an “all-you-can-eat” buffet.

“This is a recipe for over consumption of health care,” he said. Create this buffet, he added, and “you’ll find the chef has quit, and the kitchen is out of food.”

http://www.oregonlive.com/politics/index.ssf/2011/03/oregon_house_health_care_commi.html

'Single payer' still their goal

By BENNETT HALL
Corvallis Gazette-Times,  March 12, 2011

Shortly after noon on Friday, state Rep. Michael Dembrow stepped to the microphone and addressed a crowd of about 150 people gathered on the steps of the Oregon Capitol in Salem.

“You look so healthy,” he told his audience. “You must all have good health insurance.”

The line got a big laugh for the Portland Democrat, as he must have known it would. Dembrow is the chief sponsor of House Bill 3510, the Affordable Health Care for All Oregon Act, which would all but eliminate private health insurance in Oregon and replace it with a taxpayer-funded system covering everyone in the state: single-payer health care.

Dembrow’s bill was scheduled for a hearing before the House Health Care Committee on Friday afternoon, and the lunchtime rally on the Capitol steps was a bit of political theater calculated to show support.

Toting signs with slogans such as “Patients Not Profits,” “Single Payer Now!” and “Everybody In, Nobody Out,” the crowd chanted and cheered for more than an hour as speaker after speaker slammed the insurance industry, shared horror stories of Americans bankrupted by medical expenses and called on the legislature to enact Dembrow’s proposal.

The really funny thing was, none of them seemed to think it has a ghost of a chance.

Rep. Jules Bailey, one of the bill’s co-sponsors, exhorted the crowd to settle in for a long fight.

“Don’t stop,” Bailey said. “If we don’t get there right away, we will get there eventually. We will get there.”

As Dembrow himself put it, “It’s not all about the bill. Single payer is a movement.”

‘A long-term effort’

For hardcore health care reformers, single payer is the holy grail, a system that would rein in out-of-control medical costs while extending coverage to everyone. But they face determined and well-financed opposition from insurers, pharmaceutical companies and tea party Republicans, who deride the idea as socialized medicine.

HB 3510 is not the first attempt to create a single-payer health care system in Oregon. That distinction belongs to Senate Bill 1066, which was introduced in 1995 — and promptly faded into obscurity.

The issue was resuscitated in 2002, when Health Care for All-Oregon mounted a statewide signature-gathering campaign that succeeded in placing Measure 23 before the voters — who shot it down by a 700,000-vote margin.

Now it’s back, and while Dembrow has no illusions that his bill will pass, he’s crossing his fingers that it will stay alive long enough to generate some genuine discussion in the legislature. He has two co-sponsors on the Senate side, where he’s hoping the proposal could get additional hearings.

If he can get enough lawmakers interested in the concept, they might be willing to commission an in-depth cost analysis, a step that could build additional support. And even if 3510 dies this session, as expected, he’ll push to send it to Oregon voters again as a referendum, possibly in 2013.

“The likelihood of this bill passing and us having a single-payer system in the next year or two is remote,” Dembrow acknowledged in an interview last week.

“I see the effort for single payer as being a long-term effort,” he added. “There is still a lot of education that has to happen and a lot of organizing that has to happen, and this bill is a vehicle for that.”

Coalition-building

As health care costs continue to rise faster than American incomes, more and more people are flocking to the single-payer banner. In Oregon as in other states, the coalition that has formed around the issue includes labor unions, doctors and nurses, churches and social justice organizations, all of which were well represented at Friday’s rally in Salem.

Peter Shapiro was the master of ceremonies, introducing the speakers and setting the tone for the event with his rabble-rousing commentary.

A retired mailman who now works as an organizer for Portland Jobs With Justice, Shapiro urged the audience to fight back against the attacks on public employee unions around the country.

“I have one of those gold-plated plans,” he told the crowd. “I’m one of those people you’re supposed to hate. And 25 percent of my federal annuity goes to insurance premiums.”

In an interview, Shapiro talked about organized labor’s shift toward single payer after years of fighting to protect hard-won insurance benefits — often achieved at the cost of significant concessions on wages.

“It’s a difficult transition for union members to make. It’s a mark of how badly our health care system has deteriorated,” he said.

“More and more unions are realizing we’re living on borrowed time as far as benefits are concerned, and they’re paying a greater and greater price to keep those benefits at the bargaining table.”

Portland Jobs With Justice has thrown itself into the campaign for single payer, reaching out to other labor organizations to broaden the coalition supporting HB 3510. So far, nine Oregon unions have officially endorsed the measure — including two that represent teachers, often targeted for having Cadillac health benefits.

In January, Shapiro helped organize a highly successful conference on single payer in Portland. More than 400 people turned out for the event, which featured keynoters such as Dr. Margaret Flowers of Physicians for a National Health Program and Michigan Rep. John Conyers, one of the champions of single payer in Congress.

And on Friday, Shapiro brought a dose of fiery union rhetoric to the rally for HB 3510.

“We have the most profit-driven health care system in the world, and you see where that gets us,” he reminded the crowd as the event came to a close.

“The fact of the matter is, health care is not a commodity, it is a human right. And we are not consumers of health care, we are human beings!”

Mad as hell

Radiation oncologist Mike Huntington of Corvallis has devoted himself to health care reform since retiring in 2006. He became convinced of the need for change after seeing too many of his patients delay treatment because they lacked insurance coverage, with disastrous results.

“I saw it happen so often that it made me sick and then sad and then mad,” Huntington said.

In 2009 Huntington and fellow Corvallis physician Paul Hochfeld helped launch the Mad as Hell Doctors, an Oregon offshoot of Physicians for a National Health Program. The group mounted a cross-country tour, holding raucous single-payer rallies in more than two dozen cities en route to a demonstration on the White House lawn in a bid to influence the congressional debate on health care reform.

No trace of single payer made it into the federal health care reform law, which failed to include even the “public option” initially promoted by President Barack Obama.

But the Mad as Hell Doctors are still on the case. Last year they staged a California road trip to promote a single-payer measure in that state, and they’ve been touring Oregon for several weeks in support of the Dembrow bill.

On Friday, a white-coated contingent of Mad Docs was on hand for the Capitol rally, including Huntington.

The way he sees it, the financial logic of single payer is simply inescapable.

“Even health insurance CEOs privately say it. How can health care expenses keep increasing 25 percent a year? Eventually they’ll run out of customers,” Huntington said in an interview before the rally.

“It’s a false reality, and I’m going to stick around until the real reality is too hard to ignore.”

In it for the long haul

Betty Johnson is a battle-scarred veteran of the fight for sin
gle-payer health care in Oregon. She got involved in health care reform in 1991 through her church, and her faith continues to inform her work for the cause.

“It is a moral imperative to ensure that everyone has the health care they need,” she said.

The Corvallis resident, a widely respected leader in the state’s Health Care for All chapter, was a key player in the campaigns for SB 1066 and Measure 23 and now is pushing hard for HB 3510. In fact, she had a hand in writing all three proposals.

Johnson attended the rally, too, but before that she led a small cadre of Corvallis and Albany health care activists through the Capitol corridors on a mission to lobby as many lawmakers as possible to support HB 3510.

The group started on the House side of the building, stopping by the offices of Sara Gelser, Jim Thompson and Andy Olson before crossing over to the Senate wing in search of Frank Morse.

None of the legislators was in, so the mid-valley activists spent their time chatting up secretaries and aides, passing out copies of testimony to be given in the afternoon hearing and laying the groundwork for future meetings.

At Olson’s office, Johnson and Edie Orner, a retired schoolteacher who heads the Albany chapter of the Archimedes Movement, won a small victory: the promise of a breakfast meeting early next month.

Olson, an Albany Republican, is not known as a supporter of single payer, but he is willing to listen. Orner considers it progress.

“Everything that you do is building momentum,” she said, “and you just have to keep doing what you’re doing and hope that eventually there will be a tipping point.”

Johnson agrees. Like Dembrow, she has no expectations that 3510 will actually pass this session. And like him, she takes the long view of the fight for single payer.

The campaigns for SB 1066 in 1995 and Measure 23 in 2002, she said, started the conversation about single payer in Oregon, and Dembrow’s bill has created the opportunity to take the discussion one step further.

“The world is a different place than it was in 2002 — and I can’t help but think that it’s a different place, at least here in Oregon, in part because of what we did in 2002. We informed a lot of people,” Johnson said.

“That was a building block. This is a building block. And this campaign is not going to die.”

http://www.democratherald.com/news/local/article_38a88e7a-4d46-11e0-9f0e-001cc4c002e0.html

One Payer States conference calls keep movement alive

By BENNETT HALL
Corvallis Gazette-Times, March 12, 2011

It’s 8 o’clock in the morning, and Betty Johnson and Mike Huntington are huddled around a cordless phone set up on a folding table in Johnson’s Corvallis living room. The two veteran health care activists listen intently to the voices coming over the speaker.

A caller from Portland is talking about an upcoming hearing for a single-payer health care bill in the Oregon Legislature.

Someone from Minnesota reports on the prospects for a similar measure there.

A man from Colorado discusses some of the other health care reform bills that are competing with a single-payer plan in his state.

Johnson, who’s been jotting notes on a steno pad, puts down her pen and jumps into the conversation.

“We need to stay on top of the legislature and try to get the best we can out of whatever bill comes out, with the understanding that single payer is what we’ll have eventually,” she suggests. “So we’re on two tracks all the time.”

For almost a year now, scenes like this have been playing out all across the country as health care reformers get together once a week via long distance to compare notes on the fight  in their home states — and to dream of a day when the whole country might be covered by a publicly financed health care program.

The loose-knit coalition — dubbed the One Payer States — sprang from a meeting last April in Wayne, Pa., where single-payer activists had gathered to strategize in advance of a progressive political conference.

Bitterly disappointed in the massive federal health care bill signed just days earlier by President Barack Obama, the participants agreed that the best hope for progress toward single-payer health care now resides with the states. They formed an online discussion group to stay in touch, and soon they were holding conference calls every Friday morning.

The calls have evolved into a lively forum for the U.S. single-payer movement. In addition to providing updates on single-payer legislation (nearly 20 states could consider some variation on the theme this year), callers trade war stories on lobbying lawmakers, swap suggestions on converting skeptics and exchange ideas on everything from mobilizing volunteers to managing donor databases.

The number of participants varies from week to week, as does the topic, but Huntington said he always learns something worthwhile.

“There’s lots of knowledge and not much overhead control,” said the former radiation oncologist, who has devoted himself to health care reform since retiring in 2006.

“We gather the pearls as people mention them from Colorado or Hawaii or Illinois and do what we can with them.”

While the immediate goal of the One Payer States is to promote single-payer bills in individual states, the group has also caught the attention of organizations still working toward a nationwide single-payer system.

Donna Smith, an organizer for National Nurses United, the country’s largest nurses union, was one of the people who helped launch the group, and she’s a regular participant in the weekly calls.

“I think the maximum number of states we’ve had (represented) at any one time is 23 or 24, which is remarkable,” she said. “There are a lot of flowers blooming out there right now.”

Despite the efforts of diehards like Michigan’s John Conyers, who recently reintroduced his Medicare for All bill in the House, single payer has been all but forgotten in Congress. And with President Obama endorsing a move to let states enact their own reforms as early as 2014, many activists believe that’s where change will have to happen.

“There are those who really feel that a state-by-state effort is the way to go,” Smith said.

Mark Almberg, communications director for Physicians for a National Health Program, said state bills help keep single payer in the national health care reform conversation. They also play a crucial educational role, chipping away at some of the lingering objections in the public mind.

“Personally, I view the state single-payer efforts as contributing to the larger goal,” Almberg said.

But he also thinks state-level reforms could serve as a bridge that ultimately leads to a national single-payer health care system.

As an example, he points to Canada. Our neighbor to the north has had a national single-payer health care system since 1984 — but it only came about after each of the country’s 13 provinces and territories passed single-payer plans of their own.

Katie Robbins, a national organizer for Healthcare Now, is hoping the U.S. follows the Canadian template.

It could start with Vermont, where a sympathetic governor and Democratic-leaning legislature just might be on the verge of passing the country’s first true single-payer bill.

If it works there, Robbins said, it could work anywhere.

“I really think that a single-payer system passed at the state level could be a model,” she said.

http://www.democratherald.com/article_0c722690-4d46-11e0-ab28-001cc4c002e0.html

Health Care is a Basic Human Right — Almost Everywhere but Here

By Ronald Pies, M.D.
OpEdNews, March 13, 2011
 
In a recent piece in the Boston Globe, David Abel described a 52-year-old woman named Ona Stewart. Despite being deaf and blind, she is able to live independently, and earn a living by making pottery. Ona Stewart has no family in the area, and relies on a state-funded program that provides aides who help her communicate, shop, and run errands.
 
But now, the proposed Massachusetts budget for 2012 eliminates funding for this program — threatening to leave the DeafBlind Community Access Network high and dry. For people like Ona Stewart, this could mean “dangerous risks to safety,” possible hospitalizations due to failing health, “and institutionalizations,” according to Sharon Applegate, executive director of Deaf, Inc., which oversees the aid program.
 
Ona Stewart’s plight is just one forlorn strand in the unraveling fabric of the American health care system — if “system” is not too generous a term. Despite our tremendous progress in medical research and technological innovation, our health care system is not taking care of those who need it most: the very poor and sick, whose friends, family, or community cannot or will not help them.
 
Far from having “the best health care system in the world” — as some politicians persistently claim — our system is failing in the most basic measures of medical care.   For example, according to a 2002 study by the Institute of Medicine, 18,000 Americans die every year because they don’t have health insurance. And, in a recent Commonwealth Fund-supported study comparing “preventable deaths” in 19 industrialized countries, researchers found that the United States placed last.
 
Our failures in health care are not for lack of spending. As Victor Fuchs, Ph.D., of Stanford University recently noted in the New England Journal of Medicine (Dec. 2, 2010), the U.S. government currently spends more per capita for health care than eight European countries spend from all sources on health care. And yet, life expectancy at birth in every one of these eight countries is higher than that in the U.S. The huge amount of money spent on administrative costs in the U.S. — rather than on direct care — is a major factor in these cross-national disparities.
 
Furthermore, as the Center for Economic and Social Rights notes, “Although the United States offers coverage for the very poorest Americans through Medicaid, this fails to reach millions of Americans who do not qualify as the ‘poorest’ but still have far too little money to afford purchasing their own health insurance and do not have access to it through employment.”
 
Yes, emergency rooms are obligated to provide critical care to all — but poor patients with cancer or chronic renal failure cannot be safely and effectively treated in emergency rooms. And the “free” care provided to indigent patients in the ER simply means that costs are shifted to some other part of the system. The organization Physicians for a National Health Program — consisting of 18,000 physicians, medical students and health professionals — have put the economic issues in a harsh but realistic light:
 
“Sooner rather than later, our nation will have to adopt a single-payer national health insurance program, an improved Medicare for all. Only a single-payer plan can assure truly universal, comprehensive and affordable care to all. By replacing the private insurers with a streamlined system of public financing, our nation could save $400 billion annually in unnecessary, wasteful administrative costs. That’s enough to cover all the uninsured and to upgrade everyone else’s coverage without having to increase overall U.S. health spending by one penny.”
 
That said, the core issue underlying the plight of American health care is not economic, but moral: rather than regarding health care as a basic right, the U.S. sees it as a privilege — one available only to those who can afford it, or who are fortunate enough to have adequate insurance coverage. This view flies in the face of many religious teachings and traditions. Thus, Rabbi Elliot Dorff, a pre-eminent authority on Jewish medical ethics has written:
 
“The fact that more than 40 million Americans have no health insurance is, from a Jewish point of view, an intolerable dereliction of society’s moral duty. The Torah, the Prophets, and the Rabbis of our tradition all loudly proclaim that God commands us to take care of the poor, the starving and the sick. We are duty-bound to find a way for all American citizens to be able to afford health care, for all American citizens.”
 
To be sure, some right-wing Christian groups have castigated health care reform as a betrayal of “God’s plan,” and as an impious embrace of an over-expansive government. Yet the Catholic Church has been unequivocally on the side of health care as a basic human right. Cited in the National Catholic Reporter (9/18/09), Bishop William Murphy, chair of the U.S. Bishops’ Committee on Domestic Justice and Human Development, writes:
 
“Reform efforts must begin with the principle that decent health care is not a privilege, but a right and a requirement to protect the life and dignity of every person. … The bishops’ conference believes health care reform should be truly universal and it should be genuinely affordable” (italics in original).
 
Indeed, the teaching that health care is a right rather than a privilege was articulated by Pope John XXIII in his encyclical, Pacem in Terris (Peace on Earth), published in June 1963.   And just three years later, at a Convention of the Medical Committee for Human Rights held in Chicago, the Rev. Martin Luther King Jr. declared: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
 
Whatever the religious controversies, it is beyond dispute that the U.S. stands virtually alone among wealthy and industrialized nations, in failing to consider health care as a basic right.   Ironically — and some might say, hypocritically — the United States is a signatory to the Universal Declaration of Human Rights, adopted by the General Assembly of the United Nations, and signed by 48 countries. Article 25 of the UDHR stated that “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care.”
 
Indeed, in October 2008, President Obama affirmed that health care should be a right, not a privilege, consistent with the principles of the UDHR, as well as with those of Amnesty International and numerous international covenants.
 
Of course, even basic, human rights are not absolute, and health care must be provided in accordance with sound medical judgment and fiscal realities. A right to basic health care means that the government is morally obligated to do all within its means to ensure that medically necessary care is accessible and affordable to all. It does not obligate the government, or physicians, to provide free face-lifts and tummy tucks on demand.
 
Indeed, there is really no such thing as “free” health care; rather, universal health care is made feasible through shared societal responsibility, in the form of a publically financed, single-payer insurance system.
 
It is impossible to “prove” that health care is a basic human right. There is no empirical investigation or experiment that can demonstrate the truth of this claim. Rather, it comes down to the kind of nation and world we wish to live in.
 
As physician and anthropologist Dr. Paul Farmer has said:   “I can’t show you how, exactly, health care is a basic human right. But what I can argue is that no one should have to die of a disease that is treatable.” It is time for the U.S. to embrace Dr. Farmer’s view, and
to enact a health care policy worthy of this country’s highest moral principles.
 
Ronald Pies, M.D., is professor of psychiatry and lecturer on bioethics at SUNY Upstate Medical University, Syracuse, N.Y., and clinical professor of psychiatry at Tufts University School of Medicine in Boston. He is the author of several textbooks, a short story collection, a collection of poems and books on philosophy and ethics.
 
http://www.opednews.com/articles/Health-Care-is-a-Basic-Hum-by-Ronald-Pies-110313-363.html

Privatize Medicare? No thanks!

By Dr. James Mitchiner
AnnArbor.com, March 13, 2011

Well, Karl Rove has done it again. In a recent opinion piece in The Wall Street Journal (“The Politics of Saving ‘Granny,’” Feb. 3), the former Bush presidential adviser sings the praises of replacing traditional Medicare with a federal voucher system.

Under this plan, as proposed by House Budget Committee Chairman Paul Ryan, R-Wis., and former Clinton Budget Director Alice Rivlin, American seniors would receive a federal subsidy to purchase private health insurance policies from competing insurers of their choosing. In other words, Medicare would become privatized, and seniors could select from among hundreds of for-profit commercial or Blue Cross plans across the country, based on their benefit structures, provider networks and premium costs.

Is this a good idea? I think not, for the following three reasons.

The first has to do with the meaning of “choice.” When it comes to choice in health care, I believe that what Americans really want is the ability to choose their own doctors and their own hospitals, rather than their health insurer. In fact, I honestly believe that the average citizen could care less about who their employer’s insurance company is, as long as the ability to pick their own health care providers is preserved.

Under the present system, that is virtually impossible. Most working Americans get their health insurance through their jobs, and their insurance is chosen for them by their employers’ human resources department, generally on the basis of premium cost. And along with that assigned insurer comes a fixed network of providers – doctors, hospitals, outpatient labs, physical therapists, etc. – chosen by their insurer. If a worker chose an out-of-network provider, he/she would have to pay the full cost of seeing that provider, or at least incur a higher co-pay than would be the case if the chosen provider was in-network.

To explore this further, consider how you might currently choose a hospital on the basis of publicly available information. Right now, you can visit the website www.hospitalcompare.hhs.gov and, by typing in your zip code, you can compare up to three local hospitals on the quality of medical care they provide to inpatients with pneumonia, heart attack or congestive heart failure. For each hospital, you can find the typical cost and 30-day mortality rate for each of these diseases. You can also check to see how each hospital performs in preventing surgical infections and blood clots. And you can rank each hospital in terms of creature comforts, like noise level, cleanliness, doctors’ communication skills, and treatment of pain.

All of this is obviously of interest to an educated consumer, and it certainly comports with the public’s desire for more transparency in health care. But here’s the catch: What good does it do for you to know if Hospital A is better than Hospital B, if your insurance plan does not cover the costs if you go to Hospital A (or, if it does, you’d have to pay more out-of-pocket than if you went to Hospital B)? If the purpose of insurance is to limit your out-of-pocket costs for the medical care you value, why should you have to pay more to see a higher quality provider? Clearly, cost is a prime factor in personal healthcare decision-making, even more so for individuals and families of limited financial means. As a practical matter, our current system guarantees that their “choice” will be constrained by the cost of care as seen by their insurer.

The second reason is based on the proposed amount of the Medicare vouchers. Mr. Ryan’s plan, as spelled out in his “Roadmap for America’s Future”, is for those who are now under the age of 55 to receive a payment – as they become Medicare-eligible in 10 years or more – of $11,000, with adjustments for income and disease burden. With the current annual family premium for a private insurance policy averaging $14,000 and climbing, it seems obvious the proposed payment is insufficient for the typical middle-class senior to purchase an insurance policy that would provide meaningful coverage at the time of retirement.

And the third reason for opposing Medicare vouchers is the fact that privatizing Medicare would presumably remove the option of continuing the status quo. As has been the case with attempts to privatize Social Security, there are millions of Americans who prefer government financing of social insurance programs over control by profit-oriented Wall Street firms, thank you very much.

Rather than deconstructing Medicare as we know it, perhaps we should try another tack. Let’s work instead to expand and improve the Medicare we have now, so that everyone – not just seniors – would have access to the health care providers of their choice, without the financial barriers that are characteristic of for-profit health plans. Let’s make health care truly universal, for all people and for all conditions, regardless of where they live, who they work for, or how much they earn.

In other words, let’s cut out the middlemen and their inherent inefficiencies, put people before profits, and push for a single-payer health insurance program instead.

Dr. James C. Mitchiner is an Ann Arbor physician and the former president of the Washtenaw County Medical Society.

http://annarbor.com/news/opinion/privatize-medicare-no-thanks/

Reform stops short of what we need

Letters
Memphis Commercial Appeal, March 13, 2011

As always, I enjoy reading Dr. Manoj Jain’s health care posts in The CA. His March 6 Viewpoint article correctly stated some of the points in the University of Memphis’ study “The Impacts of Health Reform in Shelby County Tennessee.”

Yes, we will be able to expand health insurance coverage to 74,234 non-elderly residents of Shelby County, but 71,200 will be left uninsured. Across Tennessee, 600,000 people will gain access to either private insurance or TennCare when the Patient Protection and Affordable Care Act is fully implemented. These will be modest successes, but should be defended as the best we could get at this time.

As the U of M study notes, however, significant challenges will remain: the inadequate professional work force (doctors and nurses in primary care), the need for continued funding for substantial uncompensated care, the projection of ever-rising health care and insurance costs, reduced private and public payment rates for both health care providers and hospitals, and the strain on state funding for TennCare as more people enter the system. All of these challenges will make our health care market even more complex and dysfunctional.

The U of M study states that PPACA was “health” care reform. It was not. The PPACA law is health “insurance” reform, not meaningful and moral health care reform.

Our health system is really a health care market that is not “free” and has many distortions. PPACA is flawed because it continues our nation’s reliance on an inefficient, wasteful and costly private insurance model of financing health care. Nationally we deny health care access to millions, bankrupt patients and families, ratchet up costs and frustrate efforts to improve quality.

We need a national health program with uniform standards based on medical evidence of best care, plus effective regional planning and implementation so the “challenges” outlined in the U of M study can be overcome.

Physicians for a National Health Program calls for real and sustainable solutions to our health care woes as we work through the political process. PPACA is the law of the land and should not be repealed without anything better to take its place, but it should be superseded in time by quality, affordable care to everyone in our country — single-payer national health insurance, an improved “Medicare for All.”

Dr. Arthur J. Sutherland III
Tennessee coordinator and national board member Physicians for a National Health Program
Memphis

http://www.commercialappeal.com/news/2011/mar/13/letter-reform-stops-short-what-we-need/

Physicians and patients want greater compensation for moving to coordinated care

Swiss Experiment Shows Physicians, Consumers Want Significant Compensation To Embrace Coordinated Care

By Peter Zweifel
Health Affairs
March 2011

Policy makers in several industrial countries are seeking to limit the rise in health care cost growth by supporting coordinated or integrated care programs, which differ from most prevailing forms of medical organization in how physicians are paid and how they work in groups. However, as long as fee-for-service payment systems remain an option, general practitioners will be reluctant to embrace coordinated care because it would give them less autonomy in how they practice. A study in Switzerland indicates that general practitioners will require a pay increase of up to 40 percent before they are willing to accept coordinated care, and a similar study found that Swiss consumers wanted a substantial reduction in premiums to accept it. These findings suggest that provisions of US health care reform designed to encourage the growth of coordinated care — such as accountable care organizations and medical homes — may face a challenging future.

http://content.healthaffairs.org/content/30/3/510.abstract

Comment: 

By Don McCanne, MD

This Swiss discrete choice experiment, evaluating willingness to pay, indicates that both physicians and patients want greater compensation if they are to shift from the traditional fee-for-service arrangement to a coordinated care program.

Although HHS has not yet released the proposed rules for accountable care organizations, they will be coordinated care entities. The release of the regulations has been delayed because of internal disagreements. The question is, will accountable care organizations be such a turnoff that physicians and patients will want to be compensated if they have little choice but to participate in them?

Physicians and patients want greater compensation for moving to coordinated care

Swiss Experiment Shows Physicians, Consumers Want Significant Compensation To Embrace Coordinated Care

By Peter Zweifel
Health Affairs
March 2011

Policy makers in several industrial countries are seeking to limit the rise in health care cost growth by supporting coordinated or integrated care programs, which differ from most prevailing forms of medical organization in how physicians are paid and how they work in groups. However, as long as fee-for-service payment systems remain an option, general practitioners will be reluctant to embrace coordinated care because it would give them less autonomy in how they practice. A study in Switzerland indicates that general practitioners will require a pay increase of up to 40 percent before they are willing to accept coordinated care, and a similar study found that Swiss consumers wanted a substantial reduction in premiums to accept it. These findings suggest that provisions of US health care reform designed to encourage the growth of coordinated care — such as accountable care organizations and medical homes — may face a challenging future.

http://content.healthaffairs.org/content/30/3/510.abstract

This Swiss discrete choice experiment, evaluating willingness to pay, indicates that both physicians and patients want greater compensation if they are to shift from the traditional fee-for-service arrangement to a coordinated care program.

Although HHS has not yet released the proposed rules for accountable care organizations, they will be coordinated care entities. The release of the regulations has been delayed because of internal disagreements. The question is, will accountable care organizations be such a turnoff that physicians and patients will want to be compensated if they have little choice but to participate in them?

Vermont's Struggle for Single-Payer Healthcare

By Steve Early
The Nation, March 10, 2011

After years of political frustration, Earl Mongeon had to see it to believe it. Often, when he finishes his twelve-hour night shift at IBM in Essex Junction, Mongeon heads home for breakfast and a few hours of brush clearing on his sixty-acre lot in Westford. In mid-January, the 55-year-old microprocessor assembler and workers’ rights advocate hopped into his car and drove in the opposite direction, to Montpelier. There, at the state Capitol, Mongeon and other supporters of single-payer healthcare gathered to hear Senators Bernie Sanders and Patrick Leahy, Congressman Peter Welch and new Democratic Governor Peter Shumlin explain that last year’s national healthcare bill — a costly mix of subsidies to private medical plans, some insurance market reforms, Medicaid expansion and a mandate that people buy coverage if they don’t already have it — isn’t good enough for the Green Mountain State. The top state and federal officeholders pledged to work together for something better. “We firmly believe we can be the state that passes the first single-payer system in the country,” Shumlin declared.

Mongeon and other supporters of single-payer have marched and lobbied for years, most recently under the banner of the Vermont Workers’ Center and its “Healthcare Is a Human Right” campaign. Their tireless activism had a lot to do with spurring Vermont’s singular display of independence and political unity. Two weeks earlier, several hundred VWC supporters descended on the legislature on its opening day. State House and Senate leaders, including some recent converts to the single-payer cause, paid fealty to the grassroots movement. Before a boisterous crowd of union members and community activists, 71-year-old Peg Franzen, a VWC leader and disability rights advocate, hailed the “people power” that had persuaded legislators to commission a detailed study of options for universal healthcare last year. In late January a joint session of the Democrat-dominated legislature received a 203-page report from Dr. William Hsiao, the Harvard healthcare economist hired to develop a road map for reform. Hsiao’s research team identified fifteen hurdles to creating the system they recommended: universal coverage with equal access and a common benefit package that includes community-based preventive and primary care, as well as control in the escalation of health costs.

Undaunted by the roadblocks ahead, Shumlin’s special assistant for healthcare, Anya Rader Wallack, went before a joint legislative committee on February 8 to unveil H. 202, “An act relating to a single-payer and unified health system.” Wallack spelled out a three-stage reform process, spanning at least four years but beginning with the creation of a Vermont Health Reform Board to control costs and streamline payment methods. Wallack described Vermont’s current system of multiple private and public payers as “too complex and misguided,” noting that it leaves “more than a quarter of the state’s population potentially facing healthcare bills that send them to bankruptcy.” On behalf of the governor, she insisted that “this craziness must stop. We have to get insurers out of managing medicine and allow providers to use technology and appropriate quality oversight to get waste out of the system.”

The perfect storm for fundamental reform seems to have arrived in America’s second-smallest state, but the wind is blowing rightward elsewhere in the country, with the new Republican majority in the House voting to repeal the Patient Protection and Affordable Care Act, which they brand “Obamacare.” Red-state attorneys general and their GOP governors are challenging the constitutionality of PPACA by focusing on its controversial individual mandate. Healthcare reformers in Vermont aren’t happy with President Obama’s scheme either. That’s why they’re trying to create a social insurance system that would sever the connection between coverage and employment and make access to medical care a “human right” for the state’s more than 625,000 citizens. Marketplace competition and profiteering — given a renewed lease on life nationally by PPACA — would be phased out locally as soon as possible. If single-payer works in Vermont, its backers envision the state becoming the Saskatchewan of America, just as Canada’s thinly populated but left-led prairie province paved the way for Medicare-for-all north of our border fifty years ago.

Getting from here to there will not be easy. The Green Mountain State’s single-payer initiative could be delayed unnecessarily by the implementation timeline of PPACA. Under that law, every state must have health insurance exchanges in order to get the hundreds of millions in new federal dollars to subsidize private benefits. Unless PPACA is amended — as President Obama recommended on February 28 — any pilot projects headed in a single-payer direction would be delayed until 2017. In the now GOP-dominated House, Representative Welch has introduced a bill authorizing the federal waivers needed for Vermont to become “a laboratory for innovation and excellence” in three years, rather than six. As the New York Times reported on March 1, Welch’s bill has “no Republican co-sponsors, making its prospects for passage uncertain at best.”

Single-payer also faces resistance from big business, inside and outside the state. (A taste of that was provided six years ago by antiunion IBM, which held in-plant meetings for 6,000 workers to warn them that a single-payer bill, then pending before the legislature, would require $1 billion in new taxes and force businesses to leave.) A former state legislator from Putney, Governor Shumlin is also part owner of a family business that made him a multi-millionaire. In the face of blunt opposition from his fellow employers, he has pitched single-payer as a way to make Vermont more “business friendly” by curbing healthcare costs, which have doubled in the past decade. Many of the entrepreneurs affiliated with Vermont Businesses for Social Responsibility do seem to favor decoupling health insurance from employment, although not necessarily via a single-payer system. The more mainstream and politically influential Associated Industries of Vermont displays little enthusiasm for moving to a publicly funded plan financed by payroll taxes.

Speaking at a union conference in Burlington over Martin Luther King Day weekend, Mark Dudzic of the Washington, DC–based Labor Campaign for Single Payer Health Care warned about a deluge of anti-single-payer propaganda. “There will be a massive mobilization of corporate power to smash any state single-payer initiative,” he predicted. “Vermont is going to be one of the first battlefields in that fight.” In unionized workplaces — including those represented by the state’s two largest unions, the Vermont Education Association (VEA) and the Vermont State Employees Association (VSEA) — some single-payer advocates worry not enough is being done to educate and mobilize members, whose own negotiated medical benefits are currently at risk. In Vermont, as in other states, there’s growing taxpayer resentment at paying for coverage that most private-sector workers don’t have anymore, whether unionized or not.

At every teachers union bargaining table in Vermont, management is seeking bigger premium contributions, part of a larger giveback trend that has triggered several strike threats. No group of union members has a bigger stake in building a viable tax-supported system of universal coverage than public employees — because their healthcare is already publicly funded by state, county or municipal governments. Nevertheless, as VWC activist and VSEA member Leslie Matthews notes, her own union has not been leading the struggle because some workers are “apprehensive that healthcare reform could lead to erosion of hard-won benefits.” In reality, Matthews arg
ues, “it’s the rising costs, increasing inequities and cost shifts in our current healthcare system that will ultimately bring us down. As union members, our access to affordable healthcare will only be secure when all working people have access to affordable healthcare.”

Workers’ Center director and lead organizer James Haslam does report that the American Federation of Teachers, the Communications Workers of America and the AFL-CIO have all increased their funding of VWC activity. Other national groups, like the Universal Health Care Action Network, have created a “Help Vermont Win! Campaign Fund” to channel more resources into the fight. In late March Physicians for a National Health Program will send nursing and medical students to Vermont to rally support for single-payer. And on May 1 the Jobs with Justice–affiliated VWC will sponsor its biggest May Day “March on Montpelier” ever — to adopt the strongest possible version of Shumlin’s plan.

The new governor’s commitment to the cause is a case study in how Democrats could behave elsewhere — on healthcare and other issues — if their party faced more challenges from the left. Before his run last fall, Shumlin’s only previous bid for statewide office was a failed campaign for lieutenant governor in 2002. His candidacy, as a Democrat, was undermined when 25 percent of the electorate backed Anthony Pollina, a Progressive Party member and longtime single-payer backer who now serves in the State Senate. In last year’s crowded Democratic gubernatorial primary, all the candidates played a game of healthcare reform one-upmanship that helped solidify support for single-payer. Shumlin won the free-for-all by just over 200 votes, even though he was not the preferred nominee of the VEA, VSEA or state AFL-CIO.

In the general election, Shumlin’s opponent was Brian Dubie, an affable Republican who garnered some labor support based on his membership in the Air Line Pilots Association. In the last month of the campaign, the race was very close. That’s when the state’s big-foot independent socialist stepped into the ring. Rallying his own grassroots base, Bernie Sanders held a series of GOTV events for Shumlin that helped the Democratic candidate gain favor among working-class Vermonters who might otherwise have drifted toward Dubie. Shumlin ended up winning by less than 2 percent of the vote.

At a Nation book-signing event in Boston in February, Shumlin’s white-haired, 69-year-old helper was welcomed by local activists. In his discussion with them, Sanders noted that single-payer has become “absolutely mainstream” in Vermont because “we’ve been talking about the issue for thirty years.” But he warned that further grassroots organizing was needed because “this is by no means a done deal.” Back home, the Vermont Workers’ Center and allied groups are taking nothing for granted either, as they gear up for a spring offensive in Montpelier to keep single-payer from getting bogged down in the public policy equivalent of Vermont’s fabled “mud season,” which has never been kind to new models seeking traction, much less the fast track.

This article appeared in the March 28, 2011 edition of The Nation.

http://www.thenation.com/article/159158/vermonts-struggle-single-payer-healthcare