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Single-payers crashing the gates

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Single-payers crashing the gates

By Marcy Winograd
L.A. Progressive
June 30, 2009

One of the many frustrations for advocates of single-payer health care is the relentless drive to marginalize us, not only by conservatives but also by members of our own party.

Case in point: the accounting arm of Congress, the Congressional Budget Office, has yet to perform a financial analysis of the cost of implementing single payer, a system whereby taxpayers — businesses and individuals — pay into a single general fund which covers everyone’s health care for the rest of their lives, regardless of job or health status.

Studies in California and Colorado have shown that a single-payer system would save money for businesses, families, and government by eliminating private insurance overhead and creating enormous purchasing power that would drive down the costs of care.

I wanted to know why we don’t have federal government cost projections for single payer, so I called the Congressional Budget Office — and reached an answering machine.

Two days later, Melissa Merson, the communications director with the CBO, called me back and left a polite message, explaining that the CBO takes its orders from Congress, specifically the leadership (House Speaker and Senate Majority Leader), as well as the chairs of various committees:

– Finance (H-Barney Frank, D-Mass.; S-Max Baucus, D-Mont.)
– Health, Education, and Labor (S-Ted Kennedy, D-Mass.)
– Budget (H-John Spratt, D-S.C.; S-Kent Conrad, D-N.D.)
– Appropriations (H-David Obey, D-Wis.; S- Daniel Inouye, D-Hawaii)
– Ways and Means (H-Charles Rangel, D-N.Y.)
– Energy and Commerce (H-Waxman, D-Calif.)

“We are fully aware there are members of the public who would like us to provide a cost estimate of single payer,” said Merson, “but we are inundated with requests from committees of jurisdiction. The priorities are set for us by the Congress.”

Now single-payer activists, rallying behind Progressive Democrats of America and the California Nurses Association, are demanding the congressional leadership request a CBO analysis of single payer. Not projecting the costs is another way to marginalize the growing single-payer movement.

On the other hand, we do know the cost projections for the current proposal, the Affordable Choices Act, a hybrid concoction of private insurance and the so-called “public option” which funnels billions into private for-profit insurance companies. In a June 15th letter to Senator Kennedy, the primary sponsor of this legislative effort, Douglas Elmendorf, the director of the CBO, estimated the proposal would result in a trillion-dollar federal deficit over a 10-year period. And that amount could only be offset by increased taxes, payment penalties for the uninsured, and cuts in Medicaid — hardly the way toward health care for all.

Instead of taxpayer money paying for actual health care under the public option, most of it, according to the CBO letter, would pay insurance companies to pay for health care. To make matters worse, this subsidy to the insurance industry requires dramatic cuts in Medicare, a program that should be expanded, not curtailed.

But here’s the real kicker. At the end of the decade, in 2019, under a private insurance/public option proposal, 36 million Americans, as opposed to the current 45 million, would still be uninsured, according to the CBO.

Because the draft legislation includes an “individual responsibility” clause, anyone who couldn’t afford to pay for coverage could face steep fines. Much like mandated drivers’ insurance, this system would be a boon to private insurers reaping the benefits of the new law requiring everyone to get health coverage.

On top of that there would be more marginalization. Cancer patients who couldn’t get private insurance coverage on their own would be pushed onto the public rolls, thereby saddling taxpayers with having to subsidize insurance policies for the seriously ill.

In time, the public option, weighed down by this tax burden and unable to fully exercise bulk purchasing power, would collapse amidst a fiery congressional storm over the cost of the public option, thus legitimizing arguments that publicly funded health care is a failed idea.

Which begs the question, why is the health insurance industry pushing back if the public option would be such a bonanza? Is it because the insurance industry is scared of the unknown or is it because the industry would prefer to narrow the debate to two choices: the public option or business as usual?

I would argue the industry’s biggest fear is a frank and open discussion about the merits of single payer — a system that would put health insurers out of business. Hence, the insurance industry, in Academy-award winning style, paints the public option as the false bogeyman and bores in for the kill — the death of anything public.

Health Care for America Now (HCAN) television commercials pitching the public option urge Americans to embrace this hybrid solution — a moderate, reasoned approach –because others “would like the government to take over health care.” We know who those marginalized “others” are — the single payer advocates who can tell a snow job when they see one.

For those hoping the “public option” will be a vehicle for getting single payer, Health and Human Services Secretary Kathleen Sebelius recently set us straight.

From National Public Radio: “Asked if the administration’s program will be drafted specifically to prevent it from evolving into a single-payer plan, Sebelius says, ‘I think that’s very much the case and again, if you want anybody to convince people of that, talk to the single-payer proponents who are furious that the single-payer idea is not part of the discussion.'”

Fox News, the Republican Party, and the insurance industry charge the public option is an attempt to “socialize” health care.

Please.

Last time I checked we had publicly funded the fire department, police department, national parks, libraries, universities, and the highways of America. Though the government pays the bills for these services, fire departments are still free to purchase equipment made by private vendors; libraries purchase books from for-profit publishing houses. The same would be true under a single-payer system, which though funded by taxpayers would allow for individual choice: choose any doctor, hospital, lab, or clinic you wish. Ironically, a free-market approach in the delivery of health care.

So, let us not adopt the Republican Party’s talking points to marginalize the oracles; instead, we must marginalize those who make a killing off of health care.

If politicians in Washington pass a bill that precludes single payer on the federal level, so be it. If those same lawmakers, however, pass a bill that pre-empts the states from forming their own single-payer systems or multistate single-payer consortiums, then we’re in real trouble.

But we are not defeated. Losing patience with the congressional runaround, single-payer advocates are not just getting arrested in Washington, but also planning in-your-face actions in their districts.

“Wear your hospital gown and bring your gurney” protests in front of the Los Angeles office of Congressman Henry Waxman are planned for July 11th. Waxman, chair of the House Energy and Commerce Committee, was a previous co-sponsor of H.R. 676, Conyers’ bill for single payer, but has since reneged. A few weeks ago Waxman steadfastly refused to hold hearings on single payer, but that changed when Conyers called out Waxman publicly and single-payer activists crashed Waxman’s Health Care for America Now (HCAN) forum at UCLA on the public option. Since then, Waxman’s Energy and Commerce’s Subcommittee on Health held hearings with single- payer advocates, such as Congressman Conyers and representatives from Harvard Medical School and the Physicians for a National Health Program, testifying for a more comprehensive overhaul.

Politics, of course, is the art of compromise. So I call on Congressman Waxman — my former representative, Congresswoman Harman — my current representative and the one I am challenging in 2010, and Congressman Conyers — the sponsor of H.R. 676, to join forces to introduce a new health care bill that immediately enrolls every American in Medicare while allowing for those who prefer private insurance to opt out, pay their taxes, and cough up the added cost of boutique health care if they so choose.

One of the main reasons I am running for Congress is to get single-payer health care for all Americans. To push for it, I am running primetime cable ads round-the-clock on CNN and MSNBC, including spots on Keith Olbermann’s Countdown and the Rachel Maddow show, challenging my opponent, longtime incumbent Jane Harman (D-Calif.), to sign on to Congressman John Conyers’ bill, H.R. 676, for single payer.

Perhaps someone else, another primary candidate, will issue the same challenge in a different race, so that together, through district-targeted cable ads, we can amplify the message to not only put single payer on the table, but to make it the main course.

Marcy Winograd is a 2010 congressional candidate running to unseat Jane Harman in southern California’s 36th district, a 30-mile stretch that spans West Los Angeles to the harbor. For more on the campaign, visit www.winograd4congress.com or Marcy Winograd for Congress on Facebook.

http://www.laprogressive.com/2009/06/30/single-payers-crashing-the-gates/

Dr. Sidney Wolfe's Testimony before the House Committee on Energy and Commerce at Hearing on Health Insurance

June 24, 2009

Testimony of Sidney M. Wolfe MD
Acting President, Public Citizen and Director, Health Research Group at Public Citizen
Before the Subcommittee on Health
House Committee on Energy and Commerce
Hearing on Health Insurance

What if you picked up the morning paper tomorrow and saw the following headline: “50 People Died Yesterday Because they Lacked Health Insurance”? The next day, the same headline–and the next as well. This is the average number of people in the United States who, according to a 2004 report by the Institute of Medicine of the National Academy of Sciences, die each day–more than 18,000 a year–because they lack health insurance. How should we respond to this unacceptable and embarrassing finding?

Not by saying, as President Obama has said that if we were starting now from scratch, we would have a single-payer, but it’s too disruptive or, as the health insurance industry recently said, having the public option would be too “devastating”. What could be more disruptive and devastating than being one of 45+ million people who are uninsured, from whose ranks come 18,000 people who die each year because of this dangerous status?

The real question is why should we tolerate the fragmented, highly profitable, administratively wasting private health insurance industry any longer? In this regard, the public is way ahead of either President Obama or the Congress in its distrust of the health insurance industry.

A recent national Harris Poll (October, 2008) asked the following question: “Which of these industries do you think are generally honest and trustworthy — so that you normally believe a statement by a company in that industry?” Only one out of 14 people (7%) thought that the health insurance industry is honest and trustworthy. The only industries in the survey that were even more distrusted than the health insurance industry were HMO’s (7%), oil (4%) and tobacco (3%).

The Congress, on the other hand, trusts the health insurance industry and feels compelled to come up with a “solution” that avoids a big fight with them, not only writing them into the legislation but assuring further growth of that industry. The Congress wants to believe that the health insurance and pharmaceutical industries will be good citizens and voluntarily lower their prices to save some of the money that is necessary to fund health insurance. Several weeks ago, the collective forces of the health industry promised that they could voluntarily save two trillion dollars over the next 10 years

But the amount that can be saved over the next ten years by just eliminating the health insurance industry and the $400 billion of excessive administrative costs it causes each year is $4 trillion, in one fell swoop. This would be enough to finance health care for all without the additional revenues the Congress and the Administration is desperately seeking.

As an example of administrative waste, over the last 30 plus years there have been maybe two and a half, three times more doctors and nurses, in proportion with the growth in population. But over the same interval, there are 30 times more health administrators. These people are not doctors. They’re not nurses. They’re not pharmacists. They’re not providing care. Many of them are being paid to deny care. So, they are fighting with the doctors, with the hospitals to see how few bills can be paid. That’s how the insurance industry thrives by denying care, paying as little out as it can, getting the healthiest patients.

There is no question that we have a fragmented health insurance industry. And it thrives on being fragmented, avoiding any kind of serious centralized examination or control. The drug companies make much more money with this insurance fragmentation, because there’s no price control. The insurance companies make much more money because they can push away people who aren’t going to be profitable, let public programs take care of these patients who are “unprofitable”.

What the President and the Congress are really, realistically advocating–since there is absolutely no possibility of having enough money to cover all people in this country as long as the private, for-profit health insurance industry is allowed to exist –is more incremental reform, not National Health Insurance. It is now 44 years since Medicare and Medicaid came into existence. In the interim, there have been many experiments in this country and abroad to try to provide universal health coverage.

Other countries have uniformly rejected the private for-profit insurance industry and have adopted National Health Insurance. Is everyone else wrong and only the US is right?

A recent study by the international OECD (Organisation for Economic Co-operation and Development)[1] provided health insurance data from its 30 member countries (Europe, Korea, Japan, Mexico, Canada, the U.S. and others including Australia, New Zealand and Iceland). The latest data from those countries showed that 27 of the 30 had health insurance coverage for more than 96% of the population, with only Germany having any non-public coverage (10.3%). The other three were Mexico with 60.4% covered–all with public coverage, Turkey, with 67.2% covered, also with public coverage and the U.S. with 84.9% covered 57.5% with private and 27.4% with public coverage.

In Canada, back in 1970, they were spending the same percentage of their gross national product as we were on health. They also had millions of uninsured people and many of the same insurance companies such as Blue Cross, Blue Shield. They decided to just get rid of the health insurance industry. They had experimented with it in Saskatchewan ten years earlier and it had worked so well, they couldn’t wait to do it nationally. So, where there’s a will, there’s a way. There is no way we are ever going to get to having good health insurance for everyone, as long as there’s a health insurance industry, in the way, obstructing care.

Other more recent experiments abroad include Taiwan. In 1995, Taiwan had said, we don’t like the fact that 40 percent of our people are uninsured. They passed, essentially, single-payer plan and within a few years 90-95 percent of the people were covered.

In the U.S. we have had experiments as well with seven states having instituted various versions of the public/private combination that this legislation seeks to provide. In none of these states has this worked, once several years had elapsed, despite initial enthusiasm and short-lived decreases in the uninsured.

So as we consider what to do, which experiments do we follow? The ones that were successful, all of which, for all practical purposes eliminated the private for-profit insurance industry, or the failed U.S. state examples, all of which were built on this industry?

If instead of saying that a single payer program is not politically possible, the President and the Congress need to say, “It is not only politically possible, politically feasible, but it’s the only practical way national health insurance will ever happen. Anything short of that is essentially throwing tens of billions of dollars at the insurance industry. And if you’re afraid of the insurance industry, than you’re afraid of doing the right thing: Having everybody in, and nobody out of having health insurance.

[1]OECD Health Working Papers: Measuring Disparities in Health Status and Access and Use of Health Care in OECD Countries. 3/9/09

http://www.citizen.org/publications/release.cfm?ID=7672

Medicare: Made In America

Rally and Lobby Day

Thursday, July 30th, 2009 | Washington, DC

Celebrate Medicare’s 44th Birthday by showing Congress and President Obama that unions, doctors, nurses, seniors, faith groups, and Americans of every stripe support national, single-payer healthcare.

The best way to save this system is to expand it and make it a truly single-payer system by removing the for-profit interests and guaranteeing healthcare as a right for all.

We’ll also be celebrating Rep. John Conyers, Jr. (D-MI) and his leadership on improving and expanding Medicare for all (HR 676).

Click here to download the flyer for this event

On Eve of Healthcare Rallies, Forums

Nurses, Progressive Democrats Seek Stepped Up Action for Real 'Robust' Reform--Single-payer, Medicare for All, as Best Solution to Crisis

For immediate release:

June 24, 2009
For more information contact:

Tim Carpenter, PDA Executive Director
Tim@pdamerica.org

Charles Idelson, CNA/NNOC Communications Director

WASHINGTON, DC–With action heating up in Washington for enactment of comprehensive healthcare reform, the nation’s largest RN union and professional association joined with progressive Democratic Party activists today in calling for the most “robust” reform of all to repair the nation’s healthcare crisis, by enacting a single-payer system in the form of expanded and updated Medicare for all.

In a joint statement, the National Nurses Organizing Committee/California Nurses Association and Progressive Democrats of America announced they are stepping up calls and other lobbying efforts to urge Congressional leaders to include discussion of the single-payer option in upcoming deliberations on the healthcare reform legislation now advancing in Congress.

As President Obama holds several public healthcare events, major committees in Congress unveiling legislation, and some liberal constituency groups set to rally in Washington Thursday, NNOC/CNA and PDA said that a single-payer/Medicare for all approach is “the best way to achieve goals of universality, effective cost controls, and improving the quality of care for all Americans.”

All other proposals, the groups said, suffer the same limitations. They:

* Leave the insurance industry, with its emphasis on generating profits and revenues rather than providing care, in control of our health.
* Fail to assure financial security of American families by not cracking down on insurance pricing practices.
* Avoid the strongest cost controls that are achieved in a single-payer system with one shared risk pool that covers everyone, eliminates the administrative waste associated with private insurers, and uses the power of the public entity to negotiate lower costs.
• Does not protect choice of doctor, hospital and other providers, as occurs in a single-payer system, because insurers can still limit choice to their own approved network of doctors and providers.

Even the public option favored by the President and leading Democrats would not achieve these goals, said NNOC/CNA and PDA. Private insurers would still be able to cherry pick healthier patients through their aggressive marketing techniques, with sicker patients likely being dumped into the public plan. The result is the public plan would face higher costs and the likelihood of having to cut or ration services to stay financially afloat.

PDA and NNOC/CNA are asking people to continue to call Congress and the White House to insist that single-payer healthcare, and the single-payer bills in Congress, HR 676 in the House and S 703 in the Senate, be given equal consideration in the legislative review process this summer.

The two organizations have worked together since early last year on a variety of healthcare projects, including passing an amendment to the Democratic National Party platform in “support of guaranteed health care for all” at the national convention in Denver, campaigns on behalf of single-payer candidates across the country in the fall, and rallies and forums in cities throughout the U.S.

“The time is ripe for real reform–for our personal well-being and for the sake of our great nation–now is the time to institute a real healthcare system instead of tweaking the patchwork of corporate non-care that now envelopes us,” said /CNA Co-President Geri Jenkins, RN.

Jenkins attended the ABC White House Town Hall meeting with President Obama on healthcare reform last night, along with Patty Eakin, RN, President of the Pennsylvania Association of Staff Nurses and Allied Professionals and a NNOC/CNA Board member.

“As long as a profit-motive is the centerpiece of our system, as it is and will be with healthcare corporations calling the shots, we entertain no notion that a public option will be the fix that so many Americans desperately need and want,” Jenkins said. “Medicare-for-all is the only solution to what ails us.”

“Regardless of the claims that the majority of people want a “public option,” what most people really want is a system of healthcare that covers everybody, and they believe the government can do a better job of it than the healthcare corporations can. It’s time for Congress to stop nibbling around the edges of reform and provide real leadership toward enacting healthcare reform for the people, instead of yet another windfall for wealthy corporations,” said Tim Carpenter national director of PDA.

The Healthcare NOT Warfare campaign presses forward with a “Week of Action for Medicare-for-All–H.R. 676.” Participating organizations will make calls to Congress asking representatives to provide leadership in the healthcare debate. On July 30, the 44th anniversary of Medicare will be celebrated with a rally and lobby day in Washington DC.

Does US Chamber soft talk hide their agenda?

Checking In With James Gelfand, U.S. Chamber of Commerce

By Jenny Gold
Kaiser Health News
July 1, 2009

The Chamber of Commerce is not mincing words. The senior manager of health policy for the Chamber, James P. Gelfand, says: “The problem is instead of focusing on the 90% of issues that everyone can agree on, we’re getting stuck on the 10% ideological, uncompromisable, unworkable provisions… like creating a government-run insurance plan, forcing employers to provide health insurance. That’s the kind of stuff that reads like a poison pill.”

Q: In congressional testimony, the Chamber’s senior vice president Randel Johnson said the [employer mandate] pay-or-play proposal “holds a Sword of Damocles over the necks of America’s job creators.” Do you believe it represents that kind of threat?

A: You [have to] pare this down to the simplest form — what does this employer mandate do? It makes people who don’t make a lot of money worth less to their employers. Say to yourself, I want to hire someone. I want them to do a simple task. It’s probably worth about $7 an hour. And then you realize, oh wait, because of a new law, I’m going to have to provide gold-plated health insurance. So instead of $7 an hour, it’s going to be more like $20 an hour. Let me tell you something, that person is not getting a job. So we’re just trying to make Congress understand this is a bad, bad policy. It’s gonna hurt the people they want to help.

Q: Many people say the plans on the table right now help lower income people the most. Why does the employer mandate hurt those people who are unable to get insurance?

A: Let’s look at the plan as a whole and what it’s going to do for people who don’t make a whole lot of money. If they’re lucky enough to keep their jobs, which many of them will not be — in fact, a model developed by the president’s own chair of the Council of Economic Advisers found that 4.7 million jobs would be lost based on this employer mandate — well, their benefits are going to be taxed. We’re going to tax them when they buy Coca-Cola. We’re gonna tax them when they buy alcohol. We’re going to force them, if they have a small health plan that they can afford and that appeals to them, to buy a big, rich, expensive health plan. Yeah, I think they’re getting the shaft here.

Q: So far, advertising on health care has been fairly restrained. At what point is it time to ramp up opposition? And what might it look like?

A: You don’t start a battle with nuclear weapons. First thing we’re going to do is try to work inside the system, try to work especially with Sen. Baucus to fix this thing. We don’t want to launch nukes. We don’t want to have a war. We want to support legislation. What will happen at the end of the day? Will Charlie Rangel work with us? I don’t know. I can tell you that at the hearing, he specifically, clearly said, we need the Chamber to get this done. He’s right. And I think as Congress slowly comes to the realization, oh wait, we can’t jam this down America’s throat, we can’t roll employers, we can’t roll the U.S. Chamber, I think the process is going to improve, and hopefully we won’t have to do any of these war tactics of buying air time and stuff like that. Just keep in mind, though, that we could if we had to. We have a massive grassroots network. We put out one e-mail asking people to write letters to Congress about the employer mandate and about the public plan, and we generate somewhere around 50,000 letters to Congress. So I think Congress is realizing that it’s gonna be trouble if they try to roll us.

We really do need reform, and I’m sorry that things have gotten to the point where we’re having to beat up on members of Congress who are proposing wacky schemes instead of pragmatic legislation.

http://www.kaiserhealthnews.org/Checking-In-With/Gelfand.aspx

Wal-Mart, SEIU, CAP letter to President Obama:
http://www.kaiserhealthnews.org/Daily-Reports/2009/June/30/~/media/Images/KHN%20Features/2009/June/30/CAPwalmartSEIU.ashx

Comment:

By Don McCanne, MD

“So I think Congress is realizing that it’s gonna be trouble if they try to roll us,” and “I’m sorry that things have gotten to the point where we’re having to beat up on members of Congress.” Was this guy nurtured on “The Sopranos,” or is he the real thing?

Regardless, are the owners of America’s businesses really as heartless as this jerk implies? Do they really believe that their workers would be “getting the shaft” by having health insurance with adequate benefits?

Even Wal-Mart can’t stomach this anymore. In a letter to President Obama yesterday, they stated, “We are for shared responsibility. Not every business can make the same contribution, but everyone must make some contribution. We are for an employer mandate which is fair and broad in its coverage, but any alternative to an employer mandate should not create barriers to hiring entry level employees. We look forward to working with the Administration and Congress to develop a requirement that is both sensible and equitable.”

Employer-mandated insurance is a primitive, inefficient and inequitable method of financing health care. Maybe Wal-Mart and the other business interests are ready to consider a model that is fair for all, efficient, and really does ensure that everyone has affordable access to health care. And if they walk away from the U.S. Chamber of Commerce, they will find advocates that can show them that they don’t even have to break any kneecaps to achieve that.

Democratic party chairman favors single-payer health care

The Associated Press
June 30, 2009

HELENA — The head of the Montana Democratic Party, also a candidate for Congress, is coming out in favor of universal health coverage.

The announcement comes at a time when senior Montana U.S. Sen. Max Baucus is getting more pressure from liberal activists to include a government option in his health care plan.

But McDonald says his intention is only to let people know where he stands on the issue.

McDonald says the current proposals in Washington D.C. are far too complicated.

Baucus’ is putting together a proposal that is considered a front-runner as he tries to reach bipartisan agreement with Republicans on the issue.

McDonald is an announced Democratic candidate for Congress in the 2010 elections, hoping to beat incumbent Republican U.S. Rep. Denny Rehberg.

Starr, Reich and Kuttner on the public option

Debating the Public Option

Paul Starr, Robert B. Reich and Robert Kuttner
The American Prospect
June 29, 2009

In “The Perils of the Public Plan,” Paul Starr warns that a public-insurance option could turn into exactly the opposite of what progressives want. Here he discusses the problems with the Prospect’s two other co-founders, Robert Kuttner and Robert Reich.

Paul Starr:

The public plan will likely end up as a dumping ground for high-cost, mostly low-income people if the exchanges are open only to the individual and small-group market and have inadequate power to risk-adjust premiums or to regulate private insurers’ marketing and benefit design.

In other words, we could get a public plan that instead of “disciplining” private insurers, as the president said last week, actually buttresses their dominance of the system. Watch what you wish for.

Robert Kuttner:

The public option, as it is evolving, is even more dubious than Paul Starr’s apt critique suggests. Under the House leadership bill, people who have coverage through their employers are ineligible. So the proposed, head-to-head competition between the public plan and private competitors is left to employers, not individuals.

Politically, protecting the public option from industry mischief is no less a heavy lift than single-payer. It’s a pity that all the progressive energy that’s gone into defending the public option hasn’t gone to advocate national health insurance.

Robert Reich:

I’d prefer a single-payer, but it’s got no skin in the game. The only practical hope we have for expanding coverage and taming health-care costs lies with the public option. That’s why it’s the epicenter of the current fight. The House is supportive, but the Senate is backing off because Republicans and Blue Dog Democrats have been told it’s a Trojan horse for single-payer. And the medical-industrial lobbies are hard at work convincing the public that the public option will lead to a wholesale government takeover of the health-care system.

Yesterday the president said he might sign a health-care bill that did not include a public option. That’s exactly the wrong message. If progressives fail to work hard for a public option because it’s not a single-payer, or we allow the other side to demagogue a public option, we miss the moment.

Paul Starr:

The public option has gotten all the political attention, but the real “crux” of reform is the system of rules that govern all competing plans. If the Democrats can’t get a strong public plan through the Senate but can get a strong design of the exchanges by trading off a weak public plan, they should take that deal and pass the bill.

Robert Kuttner:

It’s interesting and significant that the three co-founders of the Prospect are reprising the three major strands of progressive views on health reform. Robert Reich is arguing that the Obama plan, with the public option, is the best practical brand of reform available. Paul Starr, holding out for something that looks a lot like the Clinton plan, argues (convincingly in my view) that the most likely form of the public option will backfire. And I continue to be the single-payer guy. We’ve been having different versions of this friendly argument for two decades, as has the progressive community.

Reich says that single-player has “no skin in the game.” Well, let’s put some there, rather than being apologists for a threadbare cloak of a public option.

Where Starr and I disagree is on both his diagnosis of Medicare for All, and on his optimism that “exchanges” could be designed in a way that would meet his hopes (the exchanges sound a lot like the purchasing pools of the Bill Clinton plan that Paul Starr helped devise).

Although Starr and Reich seem to disagree, they have one thing in common. They are both somewhat wishful about what it would take politically to legislate the crucial details of either the Obama public option (Reich) or the exchanges (Starr) necessary to achieve meaningful reforms. In order for the fine print in either approach to do the job, progressives would need first to crush the industry influence in Congress that is very likely to hobble either strategy. And both Reich and Starr are right that a weakened version of the Obama plan could well be worse than nothing.

The political reality is that Medicare for All is no harder politically than a version of the Obama plan that would meet all the tests that Reich and Starr apply. And it would be far simpler and more cost effective.

The regulatory and political nightmare of doing everything that Starr insists is necessary to get a system of insurance exchanges to work efficiently is actually far more of a daunting challenge than having a single system under direct public control. And the odds are that the Obama administration, by the time it is done reassuring Max Baucus, the health insurance industry, the drug companies, and the Blue Dogs, will settle for far less than Starr’s formula.

Reich may say that if we just work hard enough, we can prevent that fate and still get a good program. But Obama began with less than what we need, and he has not painted this as a battle of the people against the interests. The bill gets weaker with each succeeding round. I suspect that by the time there is finally legislation for him to sign, Reich and Starr will both feel that it falls way short. It is high time for progressives to stop settling for badly flawed second bests and to throw their energy into a first best that could rally popular support and produce a system that serves everyone.

To read the full article:
http://prospect.org/cs/articles?article=debating_the_public_option

Comment:

By Don McCanne, MD

To rephrase the very important point that Paul Starr brings to this debate, it is not the design of the public option that is crucial to successful reform under the model being advanced in Congress, but rather it is that the design of the insurance exchanges must be absolutely compliant with the rules of social insurance. If the exchanges are poorly designed, the public option would become a Medicaid-like dumping ground for low-income people with high-cost problems, and would suffer from a lack of willing providers because of chronic underfunding. And poorly designed exchanges could never meet the test of social insurance.

Robert Reich would have us design an empowered public option that could shape up the private insurers by exerting full competitive pressure within the exchanges. That’s a nice wish, but all Republicans and an insurmountable number of Democrats in Congress have already made an irrevocable decision that an empowered public option will never survive the legislative process. It is possible that the “public option” label might survive, but only if applied to a private market-type plan, public in name only.

So can the insurance exchanges function as a bona fide social insurance program? Look at some of the decisions that have already been made.

Social insurance programs based on private plans require an individual mandate for everyone to purchase the plans, except those whose incomes are too low and therefore qualify for public programs. Congress and the state governors are very concerned about the costs of the Medicaid program and want it to be limited to the poor, especially since Medicaid is crippling many state budgets. Medicaid will not be expanded to include average-income individuals.

Adequate health insurance plans are no longer affordable for average-income individuals and families. Some form of tax subsidies will be required to assist with the mandated purchase of these plans. The amount of tax funds that would be required for everyone to be able to purchase coverage has proven to be far more than members of Congress are willing to budget. Consequently, it has been decided that hardship waivers must be a part of any reform legislation, effectively providing tens of millions of individuals with a government permission slip to remain uninsured.

Just to try to pull a few more in, the government will require insurers to provide multiple tiers of coverage. The lowest tier will be designed to be affordable, even though affordable plans, by design, are underinsurance products that fail to protect those who need health care.

Then the government would regulate the insurance exchanges, but look at the results in the most highly regulated states. No state has escaped the problems that are driving our current efforts at reform. No matter how many regulations are passed, the private insurers have always introduced innovations that relieved them of any real responsibility to address the severe deficiencies in our dysfunctional health care system.

Paul Starr may want well designed insurance exchanges, but this Congress has already rejected them. Robert Reich may want an empowered public plan, but this Congress has already rejected that.

As Robert Kuttner states, “progressives would need first to crush the industry influence in Congress that is very likely to hobble either strategy.”

But then, “It is high time for progressives to stop settling for badly flawed second bests and to throw their energy into a first best that could rally popular support and produce a system that serves everyone.”

And, “The political reality is that Medicare for All is no harder politically than a version of the Obama plan that would meet all the tests that Reich and Starr apply. And it would be far simpler and more cost effective.”

Puerto Rican doctors rally at White House, urge Obama to create pilot single-payer system on island

Public Citizen
News release
June 30, 2009

WASHINGTON — The Puerto Rico College of Physicians and Surgeons urged President Obama today to create a single-payer pilot program on the island, saying it is the best way to provide universal coverage to all of Puerto Rico’s 4 million residents.

Members of the organization, which represents all 11,000 physicians on the island, joined other health professionals and representatives from community groups this morning to demonstrate their support for single-payer health reform. The advocates rallied in Lafayette Park in front of the White House and are also meeting with congressional representatives during their visit to Washington.

“This is a matter of both health and social justice,” said Dr. Eduardo Ibarra, president of the College of Physicians and Surgeons. “We can create a system in which access to health care is recognized as a basic right for all, and does not depend on ability to pay, age, race, gender or health status. Puerto Rico stands ready to take the lead in health reform.”

The physicians’ group has petitioned Obama to support a pilot program that would create a single-payer system administered by the government that would provide universal health coverage to all Puerto Rico residents.

The proposed program would end the island’s multi-tiered system, under which those who need the most coverage receive the least health care. Puerto Rico has enough hospitals, clinics and private physicians to adequately care for its population if there a single-payer health program, Ibarra said.

The proposed pilot project would:

* Address the current inequities, and bring social justice to its citizens,
* Remedy the current erosion of employer-based health insurance, the result of growing unemployment, and
* Centralize all billing, leading to administrative efficiencies.

In addition, the single-payer system would be able to collect up-to-date data on health care consumption patterns, unmet needs, and costs. This information database would also allow for more effective allocation of resources, and would identify potential overutilization of services.

Uninsured by choice

Wealth, Income, And The Affordability Of Health Insurance

By Didem M. Bernard, Jessica S. Banthin and William E. Encinosa
Health Affairs
May/June 2009

There have been debates over how many uninsured people can afford insurance but refuse to purchase it.

The difference in purchasing power between the insured and the uninsured is not fully revealed by income comparisons. Median income of the privately insured was 2.9 times the median income of the uninsured in 2002-03 ($53,130 versus $18,404). However, median net wealth among those with private insurance was 23.2 times that of the uninsured ($78,472 versus $3,384). This discrepancy is even larger when we focus on families in the individual market. Median net wealth among those with nongroup insurance was 34.6 times that of the uninsured without access to employer coverage ($105,819 versus $3,057). Our results suggest that assets are an important determinant of effective affordability, undermining the notion that many people are uninsured by choice.

http://content.healthaffairs.org/cgi/content/abstract/28/3/887

Comment:

By Don McCanne, MD

By now you must be annoyed by those on the right who repeatedly claim that we do not have a problem with uninsured individuals. They say that the actual problem is that we are not counting them properly. Most of the uninsured would be insured, if only they showed a little more personal responsibility.

Many of the uninsured have incomes that are low enough to establish their eligibility for public programs. But those denying the problem would exclude these individuals from the count because they are “technically insured,” but merely too lazy to enroll. This ignores the multiple logistical barriers that make it impossible to enroll everyone who is eligible.

Many others without insurance are “illegals” who do not have their immigration papers in order. As long as we continue with national policies that include these individuals in our workforce, regardless of immigration status, then we have to accept the fact that they are part of our intrinsic economy and will access our health care system. Excluding them from the count would understate the issues we face when trying to figure out how to finance the care of uninsured individuals.

Although these undercounters dismiss most of the uninsured as failures of personal responsibility, they do remain conflicted on higher-income individuals who elect not to purchase insurance. Some consider these to be individuals who are exercising their right to freedom of choice – the freedom to self-insure instead of purchasing an insurance plan. Others consider these to be free riders who transfer the risk of catastrophic costs to the rest of us who are already paying our share.

But are these really individuals who are simply declining to purchase coverage they can afford? With health care costs now averaging $16,700 for an employed worker with a family of four, that takes quite a bit out of a typical income of $60,000. Many of theses families have little in the way of assets, living paycheck to paycheck, and really don’t have enough money to purchase a reasonable health plan.

This Health Affairs study demonstrates that not only income but also net wealth are important determinants of whether or not health insurance is affordable. Expanding net wealth requires both a higher level of discretionary income and a longer interval to accumulate assets. Thus both income margins and time are variables that influence the affordability of health insurance.

Since current proposals for reform would use tax subsidies to help individuals and families purchase private health plans, does this mean that we need to establish an eligibility grid that includes both income and net assets as variables? If we did, we might see an epidemic of personal failure based on the inability of so many to master the logistical requirements of the eligibility grid. (Have you tired calculating your precise net wealth recently?)

Why do we keep playing these games with all of the variables that go into determining our insurance status? Why don’t we simply make it automatic for everyone? If you exist, you’re covered.

Health care vs. sick care

A significant difference

By Dr. M. Joycelyn Elders
United Methodist News Service
6/25/09

LITTLE ROCK, Ark. (UMNS) — The United States has the best “sick-care” system in the world, but our “health-care” delivery system is lacking. We have the best doctors, the best hospitals, best academic health centers, best nurses, the best drugs, and we are leaders in research.

Our problem is that the system is not available to all of our citizens. In addition, our health care is not equitable, coherent, comprehensive and cost-effective, nor do we have choice. The United States has 5% of the people of the world and 25% of the world’s wealth. We are the richest country in the world and the only industrialized country that does not provide health care for its entire people.

Health care now consumes 17% of the U.S. Gross Domestic Product, or $2.4 trillion in 2007. Health care continues to grow in its appetite for our economic resources. At the same time, the United States continues to fall in overall health care for its citizens in comparison with the remainder of the industrialized world.

We do not have the best health, ranking 46th in life expectancy, 42nd in infant mortality and 57th in overall goodness and fairness as compared to 192 other members of the Organization for Economic Development & Cooperation.

If the rest of the industrialized world can manage to serve all its citizens on less, why can we not?
Lives at risk

The lack of access to health care for so many is literally bankrupting our people and endangering all our lives.

Lack of access to health care for so many is literally bankrupting our people and endangering all our lives.

We have depended upon employers to carry much of the burden of health insurance over the years. Now we find in this global economy, however, that they are at a disadvantage trying to compete with countries that have a public health-care system.

Health insurance expenses are the fastest-growing cost component for employers. Unless something changes dramatically, health insurance costs will overtake profits.

President Obama desires a health-care plan that improves coverage for the 45 million to 50 million uninsured citizens, contains costs, and offers high-quality, cost-effective, equitable, portable and affordable care for everyone.

We must simultaneously address, integrate and solve the three major components of health-care reform: financing, organizing the delivery system, and educating patients and community, in order to facilitate behavioral and lifestyle changes.

Quality of care would improve if every patient had access to a medical home and an accountable care organization with electronic medical records where care was patient-centered, coordinated and cost-effective.

Monitoring of many of our procedures, techniques, new technologies and drugs needs to be evaluated. We need to replace our inefficient, inequitable financing system with one that works. It needs to include everybody with subsidies for the young, poor and sick. It must require all to pay their fair share.

Physicians must have the information (electronic medical records), infrastructure and incentives they need to improve quality and control cost.
Physicians, heal this system

Physicians must become involved in population health, which is influenced by factors in five domains: genetic, social circumstances, environmental exposures, behavioral patterns and health care. The single greatest opportunity to improve health and reduce premature death lies in personal behavior.

We can do more to improve our own health than all the medical discoveries in the past 100 years.

On an individual level, we can do more to improve our own health than all the medical discoveries in the past 100 years.

We must dream big: Our vision is for healthy people in healthy communities with a health-care system that is right for all of our citizens. It needs to be available, affordable, accessible, patient-centered, prevention-focused, purpose-driven and solution-oriented. It must empower individuals to take care of themselves, foster responsibility and human dignity, improve health and enhance quality of life.

Any new health-care system must contain a provision for a public health-care policy: This is a single-payer system. People who prefer private insurance can always purchase it instead of purchasing a public health-care policy. In this public health-care policy, we must provide every person with access to basic health care, including physical and cultural access through transportation and language sensitivity.

We also must provide education to promote health maintenance, preventive measures in order to thwart disease, basic dental health care, mental health care, emergency services and necessary medicines.
A public option

Ask Medicare patients if they would like to give up their insurance. I think few would answer in the affirmative. Public health care is well liked in the United States.

A public health-care policy would likely be similar to purchasing Medicare.

People who do not receive Medicare may not know that each person pays almost $100 per month for the insurance, which is deducted from Social Security checks automatically. After a yearly deductible, Medicare pays 80% of most medical care but not dental care. There is a prescription Medicare (Part D) that is separate from other Medicare and has a variety of plans.

A public health-care policy would likely be similar to purchasing Medicare. With Medicare, about 98 cents of every dollar paid in payroll taxes are spent on actually providing health care. When you look at the private insurance companies, it is more like 80 cents. The rest goes to administrative expenses and profits.

There are many additional costs imposed on the doctors and health-care providers themselves. They must deal with a fragmented, complex system in which they have to negotiate, amend, or cajole payment from many different insurers.

Both business and individuals are breaking under the strain of our very expensive health-care system. We must overhaul our system now; its condition is beyond tweaking to make it function for our people.

We have tried to tweak the way we perform health care for many decades with disastrous results. We have tried HMOs, PPOs, indemnity with an assortment of public health systems to catch some of our people who fall between the cracks. It has failed while costing us precious lives, health and money of our people along the way.

We need an overhaul of the health-care system to save lives, money and U.S. business.

Let Medicare cover all Americans

Letter to the Editor
St. Petersburg Times
Friday, June 26, 2009

Re: What health reform must do | June 21, editorial

The three guiding principles espoused in your editorial are certainly laudable, but our current direction toward health care “reform” will not, unfortunately for the American people, make any of them come to pass.

Universal coverage is essential to any true reform, but the current plans being debated in Congress fall woefully short of that goal. As you note, the Congressional Budget Office estimates that current plans in the Senate come with a price tag of $1 trillion over the next 10 years, while still leaving 36 million without any coverage.

We already spend enough to insure everyone right now and it’s 2 1/2 times what the average industrialized country spends. To pump additional monies into a system that over the last 50 years has proven itself wasteful, expensive, complicated and which produces poorer health outcomes than other countries is as absurd as it is reckless.

Medical cost increases dramatically outpace inflation and wages year after year. The only way we will ever control these costs is to utilize the purchasing power of the federal government to negotiate with suppliers, pharmaceutical companies, doctors and hospitals on behalf of all taxpayers and demand quality, efficiency and effectiveness for our health care dollars.

We currently lose more than 30 percent of each dollar spent for private insurance companies’ overhead, profits and bonuses. That’s $600 billion annually that should be spent on providing health care. The current plans look to cutting Medicare and Medicaid funding and taxing the health benefits of workers to pay for more private plans. Those “solutions” can only exacerbate the current problems and inequities in our system.

I agree that we need to build on what works in our current system, but that is not private insurance. It’s Medicare, a program that already provides care to more than 44 million seniors with higher satisfaction ratings than employer-sponsored private insurance plans. Medicare enrollees have more choice of doctors and hospitals than those in “network” limited private plans. And with only a 3 percent overhead, the savings of a “Medicare for All” program would be more than enough to cover all of the uninsured without any additional benefit cuts or spending.

Greg M. Silver, M.D., Clearwater

State cuts its health coverage by $115m

Board to slow enrollment in Commonwealth Care

By Kay Lazar
Boston Globe
June 24, 2009

Overseers of Massachusetts’ trailblazing healthcare program made their first cuts yesterday, trimming $115 million, or 12 percent, from Commonwealth Care, which subsidizes premiums for needy residents and is the centerpiece of the 2006 law.

The board of the Connector Authority made the cuts as officials confronted two side effects of the recession: the state budget crisis and a surge in enrollment by the recently unemployed.

The largest share of the savings will come from slowing enrollment. An estimated 18,000 poor residents who qualify for full subsidies, but who forget to designate a health plan, will no longer be automatically assigned a plan and enrolled and thus could face delays in getting care.

Savings will also come from eliminating dental coverage for the poorest residents enrolled in Commonwealth Care, roughly 92,000 people who currently are the only ones in the program who receive that care. This $10 million cut was included in Governor Deval Patrick’s revised budget proposal, but then was restored in the budget lawmakers approved last week. It now falls to the governor to decide the program’s fate.

Also hanging in the balance is the health insurance status of 28,000 legal immigrants whose Commonwealth Care coverage was dropped in the budget lawmakers approved for the fiscal year that begins July 1. Patrick has until Monday to decide whether to veto any of that budget, which set aside $116 million less for Commonwealth Care than he proposed.

“No decision has been made’’ on restoring immigrant coverage, said Leslie Kirwan, chairwoman of the Connector Authority board and Patrick’s secretary of administration and finance. “It’s certainly going to be at the top of our list’’ of items the governor is considering adding back to the budget, she said.

But Kirwan said the $115 million in cuts the Connector Authority board approved yesterday were merely to deal with shrinking state revenues and the rapid growth in enrollment in Commonwealth Care, which has 177,000 members and was projected to grow to 212,000 in the next year.

These cuts do not provide any wiggle room for adding back the 28,000 immigrants who are facing elimination. If the governor decides to restore coverage for the immigrants, Kirwan said, he would have to find other areas to cut in the already razor-thin budget.

Patrick Holland, the Connector Authority’s chief financial officer, said enrollment spiked during the last three months, from 165,000 to nearly 177,000 members, because so many workers are losing their jobs and, with that, employer-provided health insurance.

The progress of the Massachusetts healthcare initiative is being closely watched in Washington, where Congress is crafting national legislation to extend coverage to more Americans. The Massachusetts law, cited as one model in the national debate, requires nearly everyone to have health insurance or pay a tax penalty.

The residents affected by yesterday’s cuts earn too little to be subject to the penalty. They also would be eligible for free emergency care for three months under the state’s Health Safety Net.

Leaders of Health Care for All, one of the state’s largest consumer groups, said the changes will be especially hard on residents whose first language is not English and who have difficulty understanding the complex enrollment paperwork.

But the group said state officials appear to have made the best of a bad situation. “There’s no other place to go for money,’’ said Lindsey Tucker, the organization’s healthcare reform manager. “. . . My concern is people will not get the care that they need.’’

While the group’s leaders are resigned to that cut, they said they will continue to lobby the governor to restore coverage for legal immigrants. Lawmakers said they cut this class of legal immigrants because they do not qualify for matching federal subsidies. Thus, they are more expensive for the state to insure. The move has enraged advocates for the immigrant community.

Much of the rest of the $115 million in savings, $32 million, comes from slowing payments to the managed-care health insurance companies that won bids to offer insurance through the Commonwealth Care program. Regulators said that by slowing enrollment growth, the companies would receive less money than they had banked on when they submitted their bids earlier this year.

Kirwan stressed that when the economy improves, the changes made by the authority can be revisited. She also said the changes still protect the basic eligibility rules for the program and benefits that members receive, but put the brakes only on enrollment growth during an “unprecedented time.’’

While the emergency changes approved by the Connector Authority go into effect July 1, Kirwan said the board will schedule a hearing, probably in late July, to seek public comments on the issues.

Kay Lazar can be reached at klazar@globe.com.

Correction: Because of a reporting error, a Page One story yesterday incorrectly described the decision to cut dental coverage for the poorest residents enrolled in the Commonwealth Care subsidized health insurance program. Dental care for this population was eliminated in Governor Deval Patrick’s revised state budget proposal but was restored in the budget lawmakers approved last week. The Connector Authority board did not vote to cut this coverage.