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The New York Times
March 27, 2008

Q: Let’s talk for a minute about the formulation of your plan. I’m interested in how seriously you considered proposing a single payer system and at what point in that discussion did you decide to propose an individual mandate?

MRS. CLINTON: You know, I have thought about this, as you might guess, for 15 years and I never seriously considered a single payer system. Obviously, I listened to arguments about its advantages and disadvantages, and many people who I have a great deal of respect for certainly think that it is the only way to go. But I said, as you quoted me, that we had to do what would appeal to and actually coincide with what the body politic will and political coalition building was. So I think if you look at most public opinion surveys, even from groups of people who you would think would be pretty positive towards single payer, Americans have a very skeptical attitude. They don’t really know that Medicare is a single payer system. They don’t really think about that. They think about these foreign countries that they hear all these stories about, whether they’re true or not, which they’re often not. And so talking about single payer really is a conversation ender for most Americans, because then they become very nervous about socialized medicine and all the rest of this. So I never really seriously considered it.

Q: Last question. You talked earlier in the interview about how your plan maintains the private insurance system. But in October, at the forum of the Kaiser Family Foundation, you were asked whether your plan to make government insurance, a Medicare-type plan, available to all was a backdoor route to a single payer system, and you said, “What are we afraid of? Let’s see where the competition leads us.” So is it okay with you if the market ultimately dictates that the U.S. system sort of morphs into a single-payer system? And if so, doesn’t that arm the Republicans with exactly what you were talking about, this claim that it’s socialized medicine?

MRS. CLINTON: No, because I think what we would be offering would be a Medicare-like system, which is something people are familiar with, and you know whether we would call it Medicare 2.0 or whatever we would call it. And we’d see whether people want that or not. And where it morphs to, I think this whole system will morph. I mean, look at where Medicare started and where it is today. In large measure, some of the problems we have are because of the way it evolved. But I think from my perspective, having this Medicare-like alternative really does answer the desires of people. And there’s a significant minority who want quote a single-payer system. It at least gives them the feeling it’s not for profit, they’re not paying somebody a billion dollars for raising their premiums 200 percent and all the rest of the problems that we face with the for-profit system. You get the costs of overhead and administration down as much as possible. I believe in choice. Let Americans choose and what better way to determine that than letting the market have some competition and you know see where it does lead to.

Q: And if the choice is a single-payer system, that’s fine by you?

MRS. CLINTON: You know, I think that would be highly unlikely. I think that, you know, there’s too many bells and whistles that Americans want that would not be available in kind of a bare-bones Medicare-like system but I think it’s important to have that competition.

http://www.nytimes.com/2008/03/27/us/politics/27text-health.html

Comment:

By Don McCanne, MD

Competition between a bare-bones Medicare-like plan versus private bells-and-whistles insurance? What kind of framing is that!?

In her proposal, is she really advocating for a public Medicare-like option that provides only bare-bones coverage? That’s certainly not the model that single payer advocates propose.

Is she suggesting that the private insurance industry will be able to provide us with an insurance product that includes all of the bells and whistles at a premium that is affordable? If such a plan were to be offered it would have a very small market limited to only the wealthiest of us. Insurers typically shun small markets.

It’s not like she doesn’t understand the numbers. Let’s look at what else she said in this interview:

****

MRS. CLINTON: The average family policy cost in America today is $12,000. That is, you know, considerably, you know, that’s like 25 percent of the median income in the country, right? So people are paying a lot of money. Now, employers defray a lot of that cost but it comes out of wages so you’ve got this unfortunate situation where we’ve had flat wages, declining incomes, rising health care costs, so even though your share of that $12,000 family policy might be say 50 percent, or whatever it would be, you’re doubly paying for it because you’re also paying for it in lost wages.

Q: You’ve also said you would cap premiums. But you haven’t said where you would cap them.

MRS. CLINTON: You know, I think we could do it somewhere between five and 10 percent of income.

****

Or maybe she doesn’t understand the numbers. If she does, she has implied that most of the premium will have to be paid through the tax system.

If we’re going to use the tax system anyway, then why waste resources on our fragmented, multi-payer system that falls far short on most of our goals for reform? That would be a terrible misuse of public funds.

What health care financing system would be a better use of public funds? A single payer national health program is specifically designed to provide comprehensive health care for absolutely everyone at a cost that is affordable for each individual, and with an efficiency that would be much more appropriate for a publicly-funded program. That’s where we need to go.

Tabulation and analysis by Peter D. Hart Research Associates
AFL-CIO

Over a period of just seven weeks, from Jan. 14-March 3, a total of 26,419 people took the online 2008 Health Care for America Survey sponsored by the AFL-CIO and Working America. Most are insured and employed. Most are college graduates. More than half are union members.

These are the people, it would seem, most likely to have positive experiences with America’s health care system. Instead, their responses tell a sobering story about the breadth of the problems with health care in America. They say our system has fundamental problems that must be fixed.

* The demand for change in today’s health care system is based primarily on deep concerns about costs.

* The failures of America’s health care system, the survey reveals, are a significant factor in broader economic problems facing working families today.

* Having insurance coverage is not insulating families from problems, concerns and dissatisfaction with today’s health care system.

* But people who lack insurance–and those who have children younger than 18 who are not covered–report particularly troubling problems getting the care they need because of cost.

* More than half of survey takers say their health insurance does not cover all the care they need at a price they can afford.

* Medicare is not a shield against unaffordable prescription drug prices.

* Concerns about today’s health care system span all ages, races, education levels and affect the insured as well as the uninsured.

http://www.aflcio.org/issues/healthcare/upload/healthcaresurvey_report.pdf

Comment:

By Don McCanne, MD

This twenty-eight page reports provides statistical data in tables and graphs that demonstrate the level of dissatisfaction with our health care system. Two of the more revealing numbers are that “ninety-five percent say they are somewhat or very concerned about being able to afford health insurance in the coming years,” and “ninety-five percent of respondents say America’s health care system needs fundamental change or to be completely rebuilt.”

If the politicians can’t hear this call for action, they must be deaf.

By Jane Zhang
The Wall Street Journal
March 25, 2008

Covering the uninsured is a central issue in this year’s political campaign. Yet while politicians debate how best to cover the growing ranks of the uninsured, the federal government — by outsourcing service jobs — quietly is adding to those numbers. “As federal employees, we get great insurance,” says (Dr. William Rogers, a medical officer at the Department of Health and Human Services). “People who work as contractors often don’t enjoy those benefits.”

Federal contract employees, including cafeteria workers, security guards and cleaning crews, work on Capitol Hill and in federal agencies across the country. Under a 1965 law, called the McNamara-O’Hara Service Contract Act, most contractors with service contracts of more than $2,500 are required to pay locally prevailing wages, plus fringe benefits or the cash equivalent — $3.16 an hour this year, under a government formula.

Yet some contract employees don’t get either the health insurance or the extra cash. Under the law, employers in industries where health insurance typically isn’t offered are exempt. Other employers don’t comply with the law because they don’t understand it or assume they won’t get caught, say lawyers and consultants who work in the field.

Some contract workers who get the $3.16 in extra cash use it for rent, food or other things rather than health insurance. Federal contract workers — even if they wanted to pay for it — aren’t eligible for coverage offered to regular federal employees.

Outsourcing of federal-government jobs reflects the same cost-cutting imperatives that drive private businesses to outsource. The U.S. government keeps tabs on how much it pays contractors, but no government agency keeps a tally of the workers who are employed or how many have health insurance. Paul Light, a political scientist at New York University’s Wagner School of Public Service and a specialist on government employees, estimates that in 2005, there were 5.4 million federal service-contract workers, double the number in 1990.

About 80% of those, he says, are lower-wage workers, the ones less likely to be offered or to obtain health insurance. “A substantial number of lower-level white-collar and blue-collar contract workers do not have health insurance,” Mr. Light says. “Either they don’t purchase it or aren’t provided it through their employer,” he says.

http://online.wsj.com/article/SB120640675912461079.html

Comment:

By Don McCanne, MD

We won’t get it right until we’re ready to automatically enroll absolutely everyone in a single national health program. Until then, even the government will game the system.

By Michael A. Fletcher
The Washington Post
March 24, 2008

Recent history has not been kind to working-class Americans, who were down on the economy long before the word recession was uttered.

The main reason: spiraling health-care costs have been whacking away at their wages. Even though workers are producing more, inflation-adjusted median family income has dipped 2.6 percent — or nearly $1,000 annually since 2000.

Employees and employers are getting squeezed by the price of health care. The struggle to control health costs is viewed as crucial to improving wages and living standards for working Americans. Employers are paying more for health care and other benefits, leaving less money for pay increases. Benefits now devour 30.2 percent of employers’ compensation costs, with the remaining money going to wages, the Labor Department reported this month. That is up from 27.4 percent in 2000.

“It is clear that benefits have been the biggest issue on collective bargaining tables and in company compensation calculations,” said Thomas A. Kochan, an economist at the Massachusetts Institute of Technology. “They eat up scarce dollars, and that limits the amount of money firms feel they can put on the table for wage increases.”

http://www.washingtonpost.com/wp-dyn/content/article/2008/03/23/AR2008032301770.html

Comment:

By Don McCanne, MD

This report is further confirmation that increases in health care costs are not being absorbed by employers but are being passed on to employees in the form of forgone wage or salary increases. Since the percentage of compensation in the form of health insurance is inversely related to the income of the employees, this is a regressive method financing health care. Furthermore, higher-income individuals also receive a greater tax subsidy for employer-sponsored coverage than do lower-income individuals. Thus employer-sponsored health care financing is doubly regressive. Lower-income individuals pay a much higher percentage of income for their health care benefits than do higher-income individuals.

The employer role in most current proposals for reform ranges from a mandate for employers to provide private coverage for their employees, to removing the employer from any role while shifting the responsibility for obtaining coverage to the individual. These proposals are flawed for many reasons, but one of the most important is that the premium for private plans is determined by the benefits provided and not by the income of the beneficiaries. Whether paid directly by the employee or nominally by the employer, health care financing remains regressive.

Some proposals would attempt to correct this by providing refundable tax credits on a sliding scale based on income. But this would produce an administrative nightmare. The tax credit eligibility for each individual and family would be in a constant state of flux because of changes in employment status, income, family size, plan availability, eligibility for public programs such as Medicare, and numerous other potential factors that might be considered to improve equity. Adding more administrative complexity to a system already overburdened with profound administrative excesses doesn’t make sense from a policy perspective.

Rather than assigning a fee (insurance premium) to an individual or family based on an insurance product, it would be much simpler and much more equitable to assign a tax or combination of taxes, based on ability to pay, that is contributed to a universal risk pool that covers everyone. Plus the administrative savings would go a long way toward financing care for those currently left out of our system. And isn’t it really our goal to provide affordable care for everyone?