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by Claudia Chaufan
www.opednews.com
April 3, 2009

With 100,000 monthly foreclosures, 700,000 jobs lost every month, and the number of uninsured, underinsured, and deaths for lack of health insurance not getting any smaller, if the time for healthcare reform is not now, when then? And private health insurers know this too well, which is why they claim to have become “team players”, and to support “change”. But the question remains: which change?

As New York Times reporter Robert Pear recently noted, the only two options receiving any serious consideration in the halls of power of Washington D.C. are a “public option” (Medicare-like plan) or no public option, both within a “tightly-regulated-healthcare-marketplace”. In other words, our house is burning, and Washington, once again, gives us two options, “vanilla or chocolate”, both of which involve “comparative-shopping” (as if with health insurance, much like with Ipods, we could increase our market power if we wait for the next sale!).

That private insurers are fighting the public option on the grounds that competing with government is “unfair” should come to nobody’s surprise: clearly, they are in the business for the money, not to provide a social service to the American people. And they win when they collect premiums and deny payments for health care, and when they dump “bad customers” (sick, old, poor, or “not-wealthy-enough-to-pay-for-our-products”) on taxpayers.

And from their point of view of course, a government-financed, privately-delivered, healthcare plan is “unfair competition:” who can compete against a publicly financed option — whose goal is to eliminate financial barriers to health care — with its demonstrable administrative efficiency, capacity to set high quality standards, and huge market power that could dramatically reduce the absurd prices Americans pay for services and goods (e.g. pharmaceuticals) that cost a fraction elsewhere?

And defenders of the public option, the “other side” of the “chocolate-or-vanilla” equation, are also very familiar with the strengths of publicly-financed systems, such as single payer. Indeed, renowned Berkeley professor Jacob Hacker has extolled the virtues of a Medicare-like plan, and argued that including it is critical to successful healthcare reform.

What is less clear is why Hacker, who clearly understands the advantages of social insurance (what his Medicare-type “option” is) — advantage, that is, from the point of view of prospective patients — when compared to for-profit liability insurance (what private for-profit plans are), would suggest a Medicare-like plan only as an “option”, and in so doing undermine its critical strengths – by chipping away its administrative efficiency, weakening its market leverage, and forcing it to compete against folks whose ultimate goal is not to meet a social need, but to make a buck, the bigger the better.

Why would Hacker not recommend extending the benefits of Medicare to all Americans (what Congressman John Conyers’ HR676 bill proposes for the nation and Senator Mark Leno’s SB 810 proposes for California), while extricating the profit motive, which created the current mess, from health insurance altogether?

To this, Hacker replies that Americans are “deeply divided” when it comes to health insurance — after all, have we not been struggling with this while the rest of the world moved on? — and that “polls” (two exactly, one of them conducted by himself) indicate that Americans prefer “choice”, not only of doctors but also of insurance plans (hmm…does it follow that pushing single payer off the table represents “the people’s will”?). And that anyway, Americans don’t trust government (very well…does it follow that we trust insurance CEOs more than our elected officials?).

This coming Monday April 6th, in Los Angeles, Californians will host the last of five, White-House-sponsored, highly scripted Healthcare Forums. So far, key legislators and their corporate friends have gone out of the way to exclude single payer from the “menu of options” (unsuccessfully as it turned out). It is up to Californians to say “enough:” why settle for less than all other industrialized nations in the world have?

No more “shopping” for our rights. Let us demand single payer. Now.

By RUSSELL MOKHIBER
April 2, 2009

Last year, former Washington Post reporter T.R. Reid made a great documentary for the PBS show Frontline titled Sick Around the World.

Reid traveled to five countries that deliver health care for all — UK, Japan, Switzerland, Germany, Taiwan — to learn about how they do it.

Reid found that the one thing these five countries had in common — none allowed for-profit health insurance companies to sell basic medical coverage.

Frontline then said to Reid — okay, we want you to go around the United States and make a companion documentary titled Sick Around the America.

So, Reid traveled around America, interviewing patients, doctors, and health insurance executives.

The documentary that resulted — Sick Around America — aired Monday night on PBS.

But even though Reid did the reporting for the film, he was cut out of the film when it aired this week.

And the film didn’t present Reid’s bottom line for health care reform — don’t let health insurance companies profit from selling basic health insurance.

They can sell for-profit insurance for extras — breast enlargements, botox, hair transplants.

But not for the basic health needs of the American people.

Instead, the film that aired Monday pushed the view that Americans be required to purchase health insurance from for-profit companies.

And the film had a deceptive segment that totally got wrong the lesson of Reid’s previous documentary — Sick Around the World.

During that segment, about halfway through Sick Around America, the moderator introduces Karen Ignagni, president of America’s Health Insurance Plans, the lead health insurance lobby in the United States.

Moderator: Other developed countries guarantee coverage for everyone. We asked Karen Ignagni why it can’t work here.

Karen Ignagni: Well, it would work if we did what other countries do, which is have a mandate that everybody participate. And if everybody is in, it’s quite reasonable to ask our industry to do guarantee issue, to get everybody in. So, the answer to your question is we can, and the public here will have to agree to do what the public in other countries have done, which is a consensus that everybody should be in.

Moderator: That’s what other developed countries do. They make insurers cover everyone, and they make all citizens buy insurance. And the poor are subsidized.

But the hard reality, as presented by Reid in Sick Around the World, is quite different than Ignagni and the moderator claim.

Other countries do not require citizens buy health insurance from for-profit health insurance companies — the kind that Karen Ignagni represents.

In some countries like Germany and Japan, citizens are required to buy health insurance, but from non-profit, heavily regulated insurance companies.

And other countries, like the UK and Canada, don’t require citizens to buy insurance. Instead, citizens are covered as a birthright — by a single government payer in Canada, or by a national health system in the UK.

The producers of the Frontline piece had a point of view — they wanted to keep the for-profit health insurance companies in the game.

TR Reid wants them out.

“We spent months shooting that film,” Reid explains. “I was the correspondent. We did our last interview on January 6. The producers went to Boston and made the documentary. About late February I saw it for the first time. And I told them I disagreed with it. They listened to me, but they didn’t want to change it.”

Reid has a book coming out this summer titled The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care (Penguin Press, August 2009.)

“I said to them — mandating for-profit insurance is not the lesson from other countries in the world,” Reid said. “I said I’m not going to be in a film that contradicts my previous film and my book. They said — I had to be in the film because I was under contract. I insisted that I couldn’t be. And we parted ways.”

“Doctors, hospitals, nurses, labs can all be for-profit,” Reid said. “But the payment system has to be non-profit. All the other countries have agreed on that. We are the only one that allows health insurance companies to make a profit. You can’t allow a profit to be made on the basic package of health insurance.”

“I don’t think they deliberately got it wrong, but they got it wrong,” Reid said.

Reid said that he now wants to make other documentaries, but not for Frontline.

“Frontline will never touch me a again — they are done with me,” Reid said.

Reid says that “it’s perfectly reasonable for people to disagree about health policy.”

“We disagreed, and we parted ways,” Reid says.

It might be perfectly reasonable for people to disagree about health policy.

But it’s not perfectly reasonable to mislead the American people on national television in the middle of a health care crises when Congress is shaping legislation that will mean life or death for the for-profit health insurance industry.

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http://atheonews.blogspot.com/2009/04/something-is-rotten-at-pbs.html

By Mark Binker
Greensboro News & Record
Wednesday, April 1, 2009

GREENSBORO — When she lost her job a decade ago, Kirby Heard joined the N.C. Farm Bureau so she could get health insurance. But when one of her payments arrived late, her coverage was terminated.

That, the High Point graphic designer told the Regional White House Forum on Health Care Reform on Tuesday, was when she joined the growing ranks of uninsured. Between 750 and 1,000 people attended the forum at the N.C. A&T Alumni Foundation Event Center on Benbow Road.

The event was one of five regional health reform forums that the White House says will build on a national gathering in Washington earlier this year.

Since losing her insurance, Heard, 52, said she has gotten treatment from a community care network, a group of local health providers that tries to coordinate medical care for people without insurance. Gov. Bev Perdue, who moderated the event, praised those networks as something the federal government should help expand.

“If you need a specialist, they can’t cover that,” Heard said, adding she was grateful for the care she could get. “I have a lot of achy-painy kind of things that are specialist oriented and I have learned to live with them. … I’ve been on a waiting list to see a dentist after losing a filling for eight months now.”

Also on hand Tuesday was Nancy-Ann DeParle, director of the White House Office for Health Reform. She told the audience that President Barack Obama has set two main health care goals: lowering the cost of services and making sure that everyone has some sort of health insurance coverage.

DeParle and Perdue called on people who had been pre-selected to tell their stories as well as people in the audience such as Heard who raised their hands.

Obama addressed the gathering by video.

“Through your own experience, you know what works, what doesn’t,” Obama said in the message. “I look forward to hearing your ideas.”

After the forum, DeParle said the federal government was in the “sausage-making process” of trying to craft a new national health care strategy, a task that has befuddled presidents going back more than a century.

When asked how forums such as Tuesday’s would play into that crafting, DeParle said it was important for the administration to see different ways states are helping to provide health coverage to those without.

“The personal stories are really something you take back,” she said, recalling Heard’s story as something that would stick with her. “You don’t lose that story, so it makes you understand the problem better. … On the good side, I heard more first-hand and saw more first-hand about the community care network and how that is working.”

As participants made their way to the forum, about a dozen protesters waved signs and chanted slogans in favor of a single-payer health care system, one that would be run by the federal government.

“Because the people say so, insurance companies got to go,” protester Marcia Everett, 46, yelled into a bullhorn.

“We are trying to encourage them to take a serious look at single payer,” Everett said. Advocates for that viewpoint felt they were initially excluded from the first White House forum and still say it’s an option the Obama administration should consider more closely.

“Single payer is the only way we can provide health care for everyone and save money,” said Jonathan Kotch, who heads Health Care for All N.C.

That viewpoint had sympathy inside the forum, and at least one presenter explicitly made the point. In the audience, Albertina McGirt said she wasn’t sure single-payer was the way to go but said something needed to be done.

A breast cancer survivor who describes herself as fiftyish, McGirt said she had health insurance when she got ill. But she still had to pay 20 percent of what it cost to beat back her disease.

“That 20 percent was monumental. After treatment, I was teetering,” she said. “Instead of being poor I was just ‘po.’ ”

McGirt said she hoped changes could be made to help people avoid those kind of financial trials.

“Whatever we do, we need to approach it carefully,” she said. “You must talk to those people who are in it, who have been affected by it.”

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Contact Mark Binker at (919) 832-5549 or mark.binker@news-record.com

By Gregory P. Marchildon
Literary Review of Canada, April 2009

BOOK REVIEW

“National Health Insurance in the United States and Canada: Race, Territory and the Roots of Difference”

By Gerard W. Boychuk
Georgetown University Press, 234 pages, softcover

The word “race” divides us ­– primarily according to skin colour and secondarily according to ethnicity. While the concept of race lacks a biological basis, categorization by race continues to shape relations within societies, particularly in those countries where slavery was a central institution for centuries or where settlement involved the displacement of large numbers of indigenous peoples. For example, because of the legacy of slavery, the racial division between African Americans and white Americans is the single most important theme in the national narrative of the United States. In his famous speech on race in March 2008 in Philadelphia, Barack Obama said it was time for America to confront the accumulated anger, resentments, stereotypes and distortions in order to get beyond the race divide. Only then, he said, would it be possible to fix the most broken parts of American public policy, including health care.

I suspect that this connection between race and healthcare policy must seem a little peculiar to most Canadians. In his new book, National Health Insurance in the United States and Canada: Race, Territory and the Roots of Difference, Gerard Boychuk, a political science professor at the University of Waterloo, explains why the politics of race prevented the introduction of universal health care in the United States. He also introduces a bold new hypothesis as to why Canada did the opposite. Boychuk’s surprising explanation for the introduction of universal health care in Canada, while not rooted in race, is nonetheless based on the politics of identity and the competition between the federal government and the provinces (particularly Quebec) for the hearts and minds of its citizens.

The different paths taken by the two countries have fascinated and perplexed commentators and social scientists on both sides of the 49th parallel for decades, particularly given the fact that the two countries once had congruent health systems. However, after universal hospitalization was implemented in Canada in the late 1950s and universal medical care insurance in the 1960s, two things changed.[1] First, access to health care (or at least that portion deemed medically necessary) would now be based on need rather than ability to pay. Second, payment for such services would now be administered through provincial and territorial single-payer systems, thereby avoiding the overhead associated with private health insurance carriers and their need to assess risk, calculate premiums and administer claims.

As a consequence of this change, Canadians increasingly perceived health care as a collective right rather than an individual benefit, a social service rather than a commodity to be bought and sold on the marketplace. This policy divergence produced a different way of viewing the world, a difference reflected in everyday language—health care is generally described as an industry by Americans and as social policy by Canadians. However, the consequences of this policy divergence go beyond the philosophic. Before medicare, Canadians spent almost as much as Americans on health care. After medicare, Canadians began to spend less than Americans on both private and public health care thanks in part to the cost control exerted by single-payer administration in Canada and the escalating cost of public and private health care insured by private insurance carriers in the United States. Today, we spend less than one half of what Americans spend on private and public health care combined. Even when it comes to public health care alone, we spend less per capita, prompting some to ask why American taxpayers pay for European-style universality but get only partial coverage in return.

In the United States, opposition to universality went well beyond an ideological preference for the market and hostility to the state. As Boychuk shows, the more deep-rooted issue was the threat posed by health reform proposals to segregated health services. Southern congressional representatives, the majority of whom were Democrats, were viscerally opposed to reforms that might have required white people to be treated in hospitals, nursing homes and medical clinics alongside black patients. Segregationist sentiment was also a pronounced feature of organized labour, and the unions worked with conservative Democrats as well as the most vocal opponent of universal health care, organized medicine. The American Medical Association was itself a segregated organization and opposed universal public health care for racial as well as political and economic reasons in the 1940s and ’50s.

It was only after the Civil Rights Act of 1964 forced the desegregation of all public programs funded by the American government that the racial objections to universality receded and the political and economic objections to universality and government intervention took priority. One year later, a three-layer policy cake had been baked by Lyndon B. Johnson, assisted by Democrats and Republicans in Congress. The first layer, part A of Medicare, was designed to please Democrats. It involved extending federal social security (first introduced by Franklin D. Roosevelt in the 1940s) as health insurance for contributing seniors. Republicans endorsed the second layer, part B, which introduced government-subsidized private insurance for physician care. The final layer was Medicaid, covering the poor as well as seniors who had not made sufficient social security contributions to qualify for Medicare. It was understood by all that these three layers were to supplement, not replace, employment-based private health coverage, which Democrats and Republicans, industry and labour, still viewed as the core of American health care.

Of course, this bipartisan policy did not, and could not, deliver universality. Instead, it further entrenched a system of entitlements based on employment, age and income—an old-fashioned passenger ship with clearly demarcated classes, to introduce a different metaphor. In first class, you have Medicare and comprehensive private health insurance. In second class, you have Medicaid and private health insurance plans with less than comprehensive coverage. In steerage, you have the chronically underinsured, while those without any coverage—the working poor without private insurance and seniors without Medicare benefits—are always under threat of being thrown overboard. In eschewing universality, the U.S. displayed its exceptionalism, at least relative to the majority of wealthy nations in Europe, Australasia and Canada that have adopted some form of universal health care.

Aside from the lack of universality, the downside of the three-layer policy is the inability of federal and state governments to control the cost of Medicare and Medicaid, a constant thorn in the side of the American body politic. This generates a perpetual crisis. As private health insurance costs rise, companies cut or eliminate their employee health insurance benefits. As Americans lose benefits, they depend more heavily on the public safety net, but the more they rely on public benefits, the higher public costs grow. Not surprisingly, Americans regularly call upon their elected officials to address this recurring crisis in health care. In 1993, in response to public outcry, Bill Clinton told Congress that “this health care system of ours is badly broken, and it is time to fix it” only to see his administration’s efforts go down to spectacular defeat.

As Barack Obama begins his presidency, expectations are high that health care will finally be repaired if not reformed. This is so despite an eco
nomic crisis that is beginning to bear a striking resemblance to the Great Depression. If 50 percent of all personal bankruptcies in more prosperous times were a consequence of the inability to pay medical bills, just imagine the situation that faces the working poor, many of whom are African American, in the next two years. Obama is also aware that 95 percent of African Americans voted for him hoping for some improvement in their lives, including the constant worry whether the next hospital visit will push them into welfare and poverty.

In contrast, health care in Canada seems less of an issue in these hard economic times in large part because medicare has eradicated the spectre of medical bankruptcy. I would go even further than Boychuk in arguing that national medicare was an inspired act of nation building, and in this sense was much more than a reaction to province building—but I am almost sure that this is a view of history not shared by Stephen Harper and most members of his government today in Ottawa. Nation building is what Boychuk calls territorial integration, a term he borrows from Canadian social policy scholar Keith Banting, from whom he quotes:

Social programs controlled by the central government can become instruments of nation-building, helping to mediate regional tensions and strengthen the state against centrifugal forces rooted in territorial politics. Alternatively, social programs designed and controlled at the regional level can become instruments for strengthening regional cultures and enhancing the significance of local communities in the lives of citizens, thereby reinforcing differentiation and centrifugal tendencies at the centre.

In other words, in response to the secessionist forces within Quebec as well as the expansionist tendencies of nationalist Quebec governments, the federal government inserted itself into healthcare policy in order to “create a direct connection” with Quebec residents and “foster a sense of attachment between them and the national polity.” Boychuk argues that the federal government’s desire to exert a degree of territorial integrity is a better explanation for why Canada differs in its healthcare policy from the United States than the more commonly offered alternatives. One of these alternatives is the different ideology and values of the two countries, what Boychuk calls political culture. We can see this in terms of the social democratic ideology that led Tommy Douglas’s government in Saskatchewan to pioneer medicare, as well as the Red Tory influences in the old Progressive Conservative Party that allowed its members eventually to go along with medicare, however grudgingly. Another explanation is that Canada’s political institutions facilitated the adoption of universal health care while America’s diffused checks-and-balances structure prevented (and may continue to prevent) a similar reform. The fusion of the legislative and executive in Canada allows for majority governments to make major policy changes without compromise while a decentralized federation permits major experiments in areas of provincial jurisdiction, thus Saskatchewan’s innovations in hospitalization and medical care insurance could easily be adopted in other provinces with the encouragement of cost-share financing by the federal government.

A third common explanation is “path dependency” and its accompanying notion that timing is everything in public policy. Policy pathways are notoriously difficult to break from, in large part because of the financial, intellectual and ideological capital invested by individuals, organizations and institutions in the status quo. As difficult as it is, however, there are moments—critical junctures—when dissatisfaction with the status quo is powerful enough, or when the investments have not yet triggered a “lock-in” of the policy status quo, when change becomes possible. These windows of opportunity are rare. If not taken advantage of, policy change may be permanently blocked. Saskatchewan, for example, introduced universal hospital and medical care before private health insurance covered the majority of the population, although the same argument seems to fall flat for most urbanized provinces, such as Ontario, that had quite high rates of public coverage before medicare was introduced.

In the United States, the window of opportunity was 1965, but legislators chose incremental improvements over universality, making major change in the future even more difficult. As Jacob Hacker explained about American health care in the New England Journal of Medicine, the sad truth is that “most Americans—even the underinsured and soon-to-be-insured, the potentially uninsurable and the one-illness-from-bankrupt—can be frightened into believing that changing this entrenched and inadequate system means paying more for less.” While race may not seem relevant to this explanation, the fact is that a disproportionate number of the underinsured and uninsured are African Americans. They have the most to lose in this economic downturn and therefore are the most at risk from medical bankruptcy. They have the most to lose if President Obama and Congress do not finally fix the healthcare mess, but some, as Hacker identified in 2007, may object to any major change to the status quo for fear of losing what little they have under the current system.

Returning to Canada, I must admit that I still find aspects of the path dependency explanation more compelling than Boychuk’s argument concerning territorial integrity. In the second half of the 1950s, the Duplessis government in Quebec was opposed to government involvement in health care, so it hardly seems logical that the St. Laurent and Diefenbaker governments would have been attempting to steal a march by establishing a connection with Quebec residents through universal hospitalization. The argument holds a little more water in the 1960s during the Quiet Revolution in Quebec, but even here it seems to me that Boychuk has not made the case. In fact, it seems that successive nationalist governments in Quebec were only too willing to accept federal principles in return for tax room and cash for universal medical care.

It is possible to reject Boychuk’s argument yet accept his conclusion that the policy has become linked with national identity because health care has become one of the key differences between the two countries. This may be for a variety of reasons, including the very simple fact that in terms of ideology, Canada continues to be influenced by a set of social democratic values that are very much in the minority south of the border, although it remains to be seen whether Obama’s election marks a move toward more liberal communitarian values. Still, a more collectivist approach to health care in the U.S. seems to fly in the face of the more highly individualistic ethos that underpins both major political parties as well as civil society. On the other hand, the American emphasis on individual rights combined with the legacy of the civil rights movement may lead to health care being declared a fundamental right by the courts. This would strengthen the hand of those political leaders who feel that it is time, finally, for all Americans to have universal access to essential health care. Race once prevented this from occurring, and now, the intersection of race and rights may allow it to happen. As Roosevelt demonstrated during the Great Depression, a crisis can actually provide the opportunity for a new policy direction, if not a new social contract.

ENDNOTE

1. Although the word “medicare” in Canada was originally a contraction of “medical care insurance,” it soon became shorthand for both universal hospital and medical (physican) care coverage. It should not be confused with American “Medicare,” which is not universal.

Gregory P. Marchildon is the former executive director of the Romanow Commission, the Canada Research Chair at the Johnson-Shoyama Graduate School of Public Policy at University of Regina and a member of the Health Evi
dence Network of Canada.

What’s Race Got to Do with It?