PNHP

Current political status on reform

Current political status on reform

Great Expectations — The Obama Administration and Health Care Reform

By Jonathan Oberlander, Ph.D.
The New England Journal of Medicine
January 22, 2009
Health care reform is back. For the first time since 1993, momentum is building for policies that would move the United States toward universal health insurance. President Barack Obama has made health care a central part of his domestic agenda, and key members of Congress have promised to introduce ambitious health care reform legislation in 2009.
The lessons of 1993 and 1994 are also well understood in Congress. Two key Senators — Max Baucus (D-MT), chair of the Finance Committee, and Edward Kennedy (D-MA), chair of the Health, Education, Labor, and Pensions Committee — are developing legislation that largely tracks the Obama plan. Consequently, this time around, congressional Democrats may be more unified around a health care reform strategy. Baucus’s support for reform is crucial, given the importance of financing issues, and Kennedy’s staff has been holding meetings with stakeholders in an effort to build consensus. Both senators are determined to move quickly, fearing that delay could dissipate momentum, as it did in 1993.
Financing health care reform in this fiscal climate will be an extraordinary political challenge, deep divisions persist in Congress, and many thorny problems are nowhere near resolution. Throughout the past century, reformers pursuing comprehensive change in the U.S. health care system have failed to overcome similar barriers. But the fact that reform has failed before does not mean it is fated to fail forever. As the election of Barack Obama vividly reminds us, history is not always repeated. Sometimes it is made.
http://content.nejm.org/cgi/content/full/360/4/321

And…

Which Way to Universal Healthcare?

By Ezra Klein
In These Times
January 19, 2009
Ezra Klein: Your opening statements demonstrate a congruency in values, but obviously your approaches are different. It seems to me you each balance the politics and the policies of the issue differently. So, let me start with you, Steffie: How does single payer pass the Senate Finance Committee?
Steffie Woolhandler (PNHP): Well, you build a popular movement among the American people, much in the way that Obama was able to succeed by building a popular movement. If you’d asked me five years ago, what was more likely, passing single-payer or electing a black president, I probably would’ve said single-payer and you probably would’ve, too. But the thing that changed was a kind of populist sentiment in this country, and that’s what it’s going to take.
Ezra Klein: Richard, a lot of what you said today has been reliant on the idea of the public plan, but my congressional reporting suggests that one plausible outcome for your plan is that when you try to get to 60 votes in the Senate, the public plan gets bargained away. Is the public plan a bottom line? If the public plan vanishes, but the rest of the plan is structurally similar to your principles, is that a plan that’s beneath the level of acceptability? Is that a plan that therefore merits opposition?
Richard Kirsch (HCAN): We haven’t as a coalition had a discussion yet about how we look at this whole plan when it passes, and what’s acceptable and what is not.
We’re a long way policy-wise and politically — although maybe not that long on the calendar, potentially only nine or so months — of seeing something enacted. But we’re not there yet, so we’re just going to fight in every way for the best system that is achievable.
http://www.inthesetimes.com/article/4159/which_way_to_universal_healthcare/

Jonathan Oberlander is one of the nation’s more astute observers of the politics of health care reform. After a long dry spell of pessimism, he is finally able to justify a very cautious note of optimism, though it still risks being a fleeting message. The most reassuring component of his message is that Congressional Democrats, especially Sen. Baucus and Sen. Kennedy, are rapidly moving forward with comprehensive reform in a process designed to prevent as much as possible the errors of the past.
So the politics is in motion, but with which policies?
Although there is a growing populist sentiment for single payer reform, that has not translated into political action. Congress is moving forward with reform based primarily on covering more individuals with private health plans. Many of those supporting public insurance have decided that the politics require that we must follow the lead of the Washington politicians regardless of the Medicare-for-all populism. Thus they are pushing for a public insurance option in a market of private plans.
Ezra Klein is quite correct when he states that “my congressional reporting suggests that… when you try to get to 60 votes in the Senate, the public plan gets bargained away.” And what is the strategy to prevent this outcome? Richard Kirsch of the HCAN coalition states, “We haven’t as a coalition had a discussion yet…” and “We’re a long way policy-wise and politically…” and “we’re not there yet…”
The boat has left the dock and is leaving behind the better-than-Medicare option, and the HCAN coalition hasn’t solidified either the policies or the politics, other than to agree on abandoning single payer.
Is there any way that we can convert Medicare-for-all populism into political action? In his NEJM article, Professor Oberlander states, “Finally, in Barack Obama, health care reform has a president who could effectively use the bully pulpit to rally the public behind change.” Populism got President Obama to where he is. Can’t we take it one step further?

Current political status on reform

Great Expectations -- The Obama Administration and Health Care Reform

By Jonathan Oberlander, Ph.D.
The New England Journal of Medicine
January 22, 2009

Health care reform is back. For the first time since 1993, momentum is building for policies that would move the United States toward universal health insurance. President Barack Obama has made health care a central part of his domestic agenda, and key members of Congress have promised to introduce ambitious health care reform legislation in 2009.

The lessons of 1993 and 1994 are also well understood in Congress. Two key Senators — Max Baucus (D-MT), chair of the Finance Committee, and Edward Kennedy (D-MA), chair of the Health, Education, Labor, and Pensions Committee — are developing legislation that largely tracks the Obama plan. Consequently, this time around, congressional Democrats may be more unified around a health care reform strategy. Baucus’s support for reform is crucial, given the importance of financing issues, and Kennedy’s staff has been holding meetings with stakeholders in an effort to build consensus. Both senators are determined to move quickly, fearing that delay could dissipate momentum, as it did in 1993.

Financing health care reform in this fiscal climate will be an extraordinary political challenge, deep divisions persist in Congress, and many thorny problems are nowhere near resolution. Throughout the past century, reformers pursuing comprehensive change in the U.S. health care system have failed to overcome similar barriers. But the fact that reform has failed before does not mean it is fated to fail forever. As the election of Barack Obama vividly reminds us, history is not always repeated. Sometimes it is made.

http://content.nejm.org/cgi/content/full/360/4/321

And…

Which Way to Universal Healthcare?

By Ezra Klein
In These Times
January 19, 2009

Ezra Klein: Your opening statements demonstrate a congruency in values, but obviously your approaches are different. It seems to me you each balance the politics and the policies of the issue differently. So, let me start with you, Steffie: How does single payer pass the Senate Finance Committee?

Steffie Woolhandler (PNHP): Well, you build a popular movement among the American people, much in the way that Obama was able to succeed by building a popular movement. If you’d asked me five years ago, what was more likely, passing single-payer or electing a black president, I probably would’ve said single-payer and you probably would’ve, too. But the thing that changed was a kind of populist sentiment in this country, and that’s what it’s going to take.

Ezra Klein: Richard, a lot of what you said today has been reliant on the idea of the public plan, but my congressional reporting suggests that one plausible outcome for your plan is that when you try to get to 60 votes in the Senate, the public plan gets bargained away. Is the public plan a bottom line? If the public plan vanishes, but the rest of the plan is structurally similar to your principles, is that a plan that’s beneath the level of acceptability? Is that a plan that therefore merits opposition?

Richard Kirsch (HCAN): We haven’t as a coalition had a discussion yet about how we look at this whole plan when it passes, and what’s acceptable and what is not.

We’re a long way policy-wise and politically — although maybe not that long on the calendar, potentially only nine or so months — of seeing something enacted. But we’re not there yet, so we’re just going to fight in every way for the best system that is achievable.

http://www.inthesetimes.com/article/4159/which_way_to_universal_healthcare/

Comment:

By Don McCanne, MD

Jonathan Oberlander is one of the nation’s more astute observers of the politics of health care reform. After a long dry spell of pessimism, he is finally able to justify a very cautious note of optimism, though it still risks being a fleeting message. The most reassuring component of his message is that Congressional Democrats, especially Sen. Baucus and Sen. Kennedy, are rapidly moving forward with comprehensive reform in a process designed to prevent as much as possible the errors of the past.

So the politics is in motion, but with which policies?

Although there is a growing populist sentiment for single payer reform, that has not translated into political action. Congress is moving forward with reform based primarily on covering more individuals with private health plans. Many of those supporting public insurance have decided that the politics require that we must follow the lead of the Washington politicians regardless of the Medicare-for-all populism. Thus they are pushing for a public insurance option in a market of private plans.

Ezra Klein is quite correct when he states that “my congressional reporting suggests that… when you try to get to 60 votes in the Senate, the public plan gets bargained away.” And what is the strategy to prevent this outcome? Richard Kirsch of the HCAN coalition states, “We haven’t as a coalition had a discussion yet…” and “We’re a long way policy-wise and politically…” and “we’re not there yet…”

The boat has left the dock and is leaving behind the better-than-Medicare option, and the HCAN coalition hasn’t solidified either the policies or the politics, other than to agree on abandoning single payer.

Is there any way that we can convert Medicare-for-all populism into political action? In his NEJM article, Professor Oberlander states, “Finally, in Barack Obama, health care reform has a president who could effectively use the bully pulpit to rally the public behind change.” Populism got President Obama to where he is. Can’t we take it one step further?

Which Way to Universal Healthcare?

Two leading reformers debate the role of private insurers

By Ezra Klein
In These Times
January 19, 2009

Steffie Woolhandler and Richard Kirsch talk it out.

The numbers have never been this grim. Almost 50 million Americans are uninsured. The average annual premium for a family is nearing $13,000, and racing upward at rates that wages can’t hope to match. If nothing changes, by 2050, government healthcare spending will consume 37 percent of the gross domestic product, and private health spending will be far more. There will be little left for education or wages or leisure.

Economists have a dictum they call Stein’s Law, and it is simple: If something cannot go on forever, they say, it won’t.

Our health system cannot go on in this fashion forever. It will break the back of the federal budget and crush individual consumers. But between “cannot” and “will not” lies an ocean of impediments and questions.

Some of those barriers seem to be dissolving before the moral force of the issue. For the last eight years, our government lacked either the will or the interest to act on health reform. After Jan. 20, 2009, that will no longer be true.

President-elect Barack Obama has not only stated his intention to reform healthcare, he has also staffed his administration with eager reformers, notably former Senate Majority Leader Tom Daschle, who has written a book calling for comprehensive healthcare reform and who will serve as the administration’s “health czar,” as well as its Health and Human Services secretary.

But if the incoming administration has the will, few are sure of the way. It’s an old debate, and a consequential one. As the saying goes, the status quo is everyone’s second choice. And when you have reformers squabbling over what they want, and industry uniting to defeat what they don’t want, the outcome is never progressive.

In an attempt to encourage dialogue in advance of the legislative battles to come, In These Times invited representatives from two leading reform groups–Steffie Woolhandler, co-director of Physicians for a National Health Program, and Richard Kirsch, the national campaign manager for Health Care for America Now (HCAN)–to talk out their differences. An edited transcript of their conversation follows.

Why don’t we begin with each of you giving us the “elevator pitch” of what your groups are advocating for? Steffie?

Steffie Woolhandler: Our group of more than 15,000 physicians supports single-payer national healthcare insurance. We support that because it’s the only way to affordably cover all Americans. That’s because single-payer allows you to generate huge administrative savings by going to a more simplified payment structure.

If you don’t go with single-payer and you continue with the current system of multiple-payers and the participation of private insurance, you continue to have tremendous administrative waste. And then the only way to get more coverage is to spend more money, and that quickly becomes economically unfeasible.

Just so we’re clear on terms, when you say “single payer,” how stringent are you being? Are you talking just what Canada and England do, or are you also considering Germany and France, which have nonprofit involvement? Do they count as single-payer?

SW: Germany clearly would not count as single-payer. They have multiple payers. But there are other nations that have, or have had, some form of single-payer systems, not just Canada or England. For a while, Australia had single-payer, for instance, and Taiwan has a single-payer system.

Richard?

Richard Kirsch: Health Care for America Now’s goal is to have a guarantee of quality, affordable healthcare for everyone in the nation. And we’ve come together as a coalition that includes 480 organizations that represent community groups, labor, healthcare providers and faith-based groups, among a whole variety of organizations on a common set of principles: That everyone should be covered. That the coverage should be affordable based on people’s income. That the benefits should meet people’s needs. That the coverage should be affordable to employers. And that, in order to do this, we need to have really strict regulation of the private health insurance industry, so that it can’t continue to have a business model that drops people when they need healthcare.

We also need to give people a choice of healthcare coverage. So, in addition to keeping their own healthcare coverage, they have the choice of a public health insurance plan. Private insurance isn’t the only choice. The primary goal is to look at healthcare as a public good.

The reason healthcare in this country costs so much more than in any other country is because we’re the only country that treats healthcare as a commodity.

Your opening statements demonstrate a congruency in values, but obviously your approaches are different. It seems to me you each balance the politics and the policies of the issue differently. So, let me start with you, Steffie: How does single payer pass the Senate Finance Committee?

SW: Well, you build a popular movement among the American people, much in the way that Obama was able to succeed by building a popular movement. If you’d asked me five years ago, what was more likely, passing single-payer or electing a black president, I probably would’ve said single-payer and you probably would’ve, too. But the thing that changed was a kind of populist sentiment in this country, and that’s what it’s going to take.

So, Richard, what’s your response? In particular, why do you let corporate insurers remain in your system?

RK: First of all, our goal is to get all folks covered. A lot of people in America have their healthcare taken care of by private insurers.

My wife’s a cancer survivor. She got really good care and some not-good care, and none of that had to do with the insurance. The not-good care had to do with a doctor who wasn’t so good, but the insurance covered both the good doctor and the bad doctor.

There are a lot of problems with the health insurance industry and the way it functions, but it can be regulated. It’s not private insurance that makes it impossible to provide access to care to people. We should remember that, even with all the frustrations that people have with it.

SW: These private-public types of plans fail. The TennCare plan [Tennessee’s Medicaid managed care program] in 1992 did include a big public plan, so it’s not correct to say that none of these efforts have included a public plan.

Similarly, the Massachusetts reform in 1988, the Oregon reform in 1992, and the Washington reform in 1993 all included substantial employer mandates. They were never fully implemented because the economics didn’t work. If you don’t get the administrative costs under control, you can’t get advanced care.

But these proposals fail at the state level because healthcare is a countercyclical cost. States cannot deficit spend. When recessions hit, their revenues drop. But when recessions hit, more people lose their insurance and need subsidies. So at the exact moment revenues go down, costs go up. That’s why the plans unravel. But it’s not necessarily applicable to the federal level.

SW: That’s certainly true about the state level and the inability of states to deficit spend. But what the countercyclical argument doesn’t get to is the explosion of healthcare costs. And that is much more the cause of their failure, and not a specific issue about money flowing into state coffers.

RK: As Steffie may recall, I was a leader of the single-payer movement in the early ’90s. I actually co-wrote with Assemblyman Dick Gottfried–who was, and still is, the chair of the Assembly Health Committee in New York–the only fully financed single-payer bill to pass a state legislative body. (Most of the other ones that passed punted on the financing.)

I did the fiscal analysis that showed the financing. So I understand the arguments against state plans. But there is an enormous difference if we do this at the federal level. You have broad-based taxes, you can deficit spend. The financing is totally different.

Richard, one of the arguments that Steffie is making about your proposal is that of cost-control. I’m not as concerned about the administrative costs as she is, but single-payer certainly has a very coherent argument about cost-control. It’s essentially that we will use the market share of a single payer to force the system into being more cost-effective. There’s a lot of research backing this up. What is the cost-control theory of the HCAN plan?

RK: There are two things: First, having a public plan that has 100 million people in it will give you a lot of the cost-control.

But what if you don’t have that? That seems to me a very speculative part of your plan. Are there any other aspects of the plan that will control costs?

RK: Well, to say that the public plan is speculative is to say that any of this stuff is speculative, regulating the insurance industry, etc. But there are other things that control costs that might even be bigger lifts than the public plan.

We need to ask, “How do we start doing the other kind of changes in the system that we need, to control costs?” Part of it is, obviously, how do we get everybody in the system with prevention? How do we get better chronic care management? How do you create a system where providers have different incentives? How do you have a system where there’s better value?

So, yes, let’s use the public plan for its ability to have better prices for drug companies, better prices for hospitals, not have medical specialists get paid the outrageous amounts of money that they do get paid in this country–all the things Medicare tries to do.

But also, let’s start having a public discussion about the really hard decisions about what we pay for. Should we be having doctors perform lots of services that have no value? Should we be paying for drugs that have no value? Those are the hard decisions that the hospitals, the doctors, the drug companies, the medical device manufacturers are going to fight tooth and nail in both a private system and in a public system, and that’s ultimately where the price savings are going to have to come from.

Steffie, let me ask you about what is maybe the most fundamental disagreement between you two. Do you think the American people might be disturbed to lose the private healthcare they currently have and move toward a government system?

SW: Medicare is one of the most popular social programs of all time in the United States. So it’s very easy to talk in terms of Medicare, and to win people over by explaining that what we are proposing is an expanded and improved Medicare for all. Winning people over is not he problem.

Certainly, if Richard and HCAN went out with rhetoric about Medicare, they’d have no trouble signing up voters who are interested in it. But if they go out there with, “Here’s our principle: We have to have private insurance,” that’s not going to move us forward.

Okay, but to follow up: HCAN, for better or for worse, is a response to a long history of failure on the U.S. left to achieve universal healthcare. And that’s been a failure to achieve it on a single-payer basis, which is what Truman was looking at, a failure on a hybrid basis, which is more what Clinton was looking at. I agree that HCAN is a policy compromise that is suboptimal, but it does have a certain political logic behind it.

SW: Who got Obama elected? That’s obviously not the same coalition that we’d need to build a movement for national health insurance, but it shows what is possible. We’ve had a civil rights movement that completely changed the way we think about race. We’ve had a women’s movement that has won all sorts of victories. We had an antiwar movement that ended the war in Vietnam. So I don’t understand your cynicism here about how there couldn’t be a movement.

I’m not saying that there can’t be one, but I’m wondering why hasn’t there been one? The catalytic figure for the movement of Barack Obama was Barack Obama. What would be the catalytic moment or figure for your movement? Single-payer as an idea has been around for an extremely long time, but the movement hasn’t achieved a sufficient amount of power to pass it. So what has been wrong in the past that will be right in the future? Why can it succeed now when it has failed before?

SW: Right before the Clinton plan, the thing that changed was the election of Sen. Harris Wofford (D-Pa.). He was elected on a single-payer platform almost by accident. It was only one aspect of his plan, and then his opponent, Dick Thornburgh, decided to attack him as being a single-payer supporter, and Wofford was elected to the Senate based on Thornburgh’s attacks.

Now, that I could not have predicted. But in a general way, I can predict that when important elections are won and lost on this issue, then it’ll be like a lightning bolt coming from the sky. The political scene can change very, very rapidly.

RK: But Steffie, what you just said totally makes an HCAN point. Because Barack Obama was elected on a promise to fix healthcare in a certain way. One of his ads showed two extremes–government health insurance at one extreme, all private health insurance at the other extreme–and he said, “I’m not at either extreme, I’m in the middle.” What he said in his messaging at every debate was, “Under my plan, you can keep your own health insurance or you can have a choice of other health insurance.” He was elected on exactly the kind of mandate Steffie’s talking about.

That’s what the election was all about. It wasn’t for single-payer. It was for this bold promise to the American public to have a guarantee of quality, affordable healthcare from a choice of either private or public insurance and know that you’re going to get good benefits that are affordable. That’s the mandate we have.

Steffie, is there any intermediate proposal between here and single-payer that would be a step in the right direction?

SW: If you’re going to do something incremental, I would start with single-payer for hospital care. All hospitals would get their budget from a single-payer, and hospitals would no longer send bills or do health accounting to individual patients, but would be budgeted. That at least gets you a substantial amount of administrative savings and increases the fairness of the system. It also allows you to do better health planning.

There’s not a lot of talk about that as an incremental step, but that’s the one incremental step that makes sense.

Richard, a lot of what you said today has been reliant on the idea of the public plan, but my congressional reporting suggests that one plausible outcome for your plan is that when you try to get to 60 votes in the Senate, the public plan gets bargained away. Is the public plan a bottom line? If the public plan vanishes, but the rest of the plan is structurally similar to your principles, is that a plan that’s beneath the level of acceptability? Is that a plan that therefore merits opposition?

RK: We haven’t as a coalition had a discussion yet about how we look at this whole plan when it passes, and what’s acceptable and what is not.

We’re a long way policy-wise and politically–although maybe not that long on the calendar, potentially only nine or so months–of seeing something enacted. But we’re not there yet, so we’re just going to fight in every way for the best system that is achievable.

We’re glad we got President-elect Obama and more than half the newly elected members of Congress to sign our principles. Our goal is to build this movement for the set of principles that are achievable and that the President-elect got a mandate for, and to see that in law in 2009.

Ezra Klein is a staff writer at the American Prospect who blogs regularly at www.ezraklein.com.

Health care system needs help

JACK BERNARD
Atlanta Journal Constitution
Letter to the Editor
January 22, 2009

Given the upcoming stimulus package, it is the perfect time to do something about our irrational health care system. What better way to stimulate the economy than to spend funds on those in need of medical services vs. more bridges to nowhere.

The time has come to put to rest the old catchphrase “socialized medicine.” A universal single-payer system is no more socialistic than the Veterans Administration, Medicare (seniors), Medicaid (low-income) or SCHIP (kids).

We are taking care of everyone except the middle-class working stiff, who often is uninsured because his employer does not carry insurance or (due to the economy) he is between jobs, laid-off, involuntarily retired and so forth.

Commonwealth on the Swiss and Dutch systems

The Swiss and Dutch Health Insurance Systems: Universal Coverage and Regulated Competitive Insurance Markets

By Robert E. Leu, Frans F. H. Rutten, Werner Brouwer, Pius Matter, and Christian Rütschi
The Commonwealth Fund
January 2009
Universal coverage attained through a mandate that every individual purchase a basic insurance plan
Building on a previous system of social and private insurance, the individual mandate in the Netherlands took effect in 2006. The Swiss have operated with a mandate since 1996. In both countries uninsured rates are low (estimated at about 1.5 percent of the population in the Netherlands and below 1 percent in Switzerland).
Enforcement of mandatory health insurance
Switzerland
On the other hand, some people who are nominally covered are not paying their premiums. Since 2005, insurers have been permitted to suspend payments on behalf of such people, meaning that providers are left with unpaid bills or consumers are denied services. These suspensions can last 8 to 24 months, because of the time it can take to ascertain whether a consumer is unable to pay the premium (in which case cantons or communities will often assume financial responsibility) or is simply unwilling to pay. About 120,000 people, or 1.6 percent of the population, were affected by suspensions in 2006.
Netherlands
Before the new Health Insurance Act, there was a fear that, despite the mandate, many individuals would opt not to obtain coverage. In fact, the number of uninsured at the end of 2006 was about the same as before the new mandate took effect — 241,000 people, or 1.5 percent of the population.
Almost an equal number of people — 240,000 as of the end of 2007 — were enrolled with an insurer but were not paying their premiums. Beginning July 1, 2007, insurers were allowed to expel enrollees who have not paid premiums, but these enrollees simply switched to other insurers and failed to pay them as well. To prevent this, the government has forbidden people from switching plans when they are behind in paying their premiums. There is also a proposal to allow garnishing of wages or unemployment or disability benefits.
http://www.commonwealthfund.org/usr_doc/Leu_swissdutchhltinssystems_1220.pdf?section=4039

The Commonwealth Fund is joining the chorus of those who say that we should look to the Swiss and Dutch systems as potential models for universal coverage in the United States. What is meant by universal coverage? It means that everyone is covered (except for the one percent or so who are not, and the one and one-half percent who have been suspended for failure to pay their premiums).
If we were to adopt a “universal” program that left about two and one-half percent without coverage, that means that about 7.5 million U.S. residents would be left out. The population of Switzerland just happens to be 7.5 million. Does anyone else see any irony in adopting a Swiss-like insurance system that would leave out the equivalent of the entire population of Switzerland? Perhaps some might argue that the Swiss population is more worthy of coverage than would be the 7.5 million that we would leave out.
This report is very supportive of the private insurance industry. The lead author, Robert E. Leu, Ph.D., serves as a director on the board of the largest private hospital group and a large health insurance company in Switzerland. Rate of coverage is only one of the many policy issues covered in a favorable light in this report. Those who have been following our national dialogue on health policy will recognize many other sections in this report that seem to be more intent on marketing their model to the United States than to caution us against the deficiencies in their systems.
Their faith in the social value of the private insurance industry is certainly noteworthy. For instance, when discussing the Swiss nonprofit plans for basic coverage, and for-profit plans for supplemental coverage, they state, “There may be synergies between the two lines — for example, in provider relations — and some insurers may use health information from basic coverage when deciding to whom to offer supplementary insurance (this is illegal but difficult to control).” Does isolating this statement parenthetically sterilize it, making it a fundamental business principle?
Private insurers, whether for-profit or nonprofit, are businesses. They will always advance innovations that enhance their business models. No matter how tightly they are regulated, they will engage in activities that are “illegal but difficult to control.” Of course, since not every potential loophole could possibly be covered by laws and regulations, some of the innovative, immoral business behaviors technically might not be illegal, even though they should be.
In a single payer public health program, everyone is covered for life, automatically, including the 7.5 million deemed less worthy (?) than all of the citizens of Switzerland. Not only that, we would also remove from our midst an expensive, superfluous industry that thrives on immoral or illegal (but difficult to control) business practices. Now really, isn’t single payer a better model for the United States?

Commonwealth on the Swiss and Dutch systems

The Swiss and Dutch Health Insurance Systems: Universal Coverage and Regulated Competitive Insurance Markets

By Robert E. Leu, Frans F. H. Rutten, Werner Brouwer, Pius Matter, and Christian Rütschi
The Commonwealth Fund
January 2009

Universal coverage attained through a mandate that every individual purchase a basic insurance plan

Building on a previous system of social and private insurance, the individual mandate in the Netherlands took effect in 2006. The Swiss have operated with a mandate since 1996. In both countries uninsured rates are low (estimated at about 1.5 percent of the population in the Netherlands and below 1 percent in Switzerland).

Enforcement of mandatory health insurance

Switzerland

On the other hand, some people who are nominally covered are not paying their premiums. Since 2005, insurers have been permitted to suspend payments on behalf of such people, meaning that providers are left with unpaid bills or consumers are denied services. These suspensions can last 8 to 24 months, because of the time it can take to ascertain whether a consumer is unable to pay the premium (in which case cantons or communities will often assume financial responsibility) or is simply unwilling to pay. About 120,000 people, or 1.6 percent of the population, were affected by suspensions in 2006.

Netherlands

Before the new Health Insurance Act, there was a fear that, despite the mandate, many individuals would opt not to obtain coverage. In fact, the number of uninsured at the end of 2006 was about the same as before the new mandate took effect — 241,000 people, or 1.5 percent of the population.

Almost an equal number of people — 240,000 as of the end of 2007 — were enrolled with an insurer but were not paying their premiums. Beginning July 1, 2007, insurers were allowed to expel enrollees who have not paid premiums, but these enrollees simply switched to other insurers and failed to pay them as well. To prevent this, the government has forbidden people from switching plans when they are behind in paying their premiums. There is also a proposal to allow garnishing of wages or unemployment or disability benefits.

http://www.commonwealthfund.org/usr_doc/Leu_swissdutchhltinssystems_1220.pdf?section=4039

Comment:

By Don McCanne, MD

The Commonwealth Fund is joining the chorus of those who say that we should look to the Swiss and Dutch systems as potential models for universal coverage in the United States. What is meant by universal coverage? It means that everyone is covered (except for the one percent or so who are not, and the one and one-half percent who have been suspended for failure to pay their premiums).

If we were to adopt a “universal” program that left about two and one-half percent without coverage, that means that about 7.5 million U.S. residents would be left out. The population of Switzerland just happens to be 7.5 million. Does anyone else see any irony in adopting a Swiss-like insurance system that would leave out the equivalent of the entire population of Switzerland? Perhaps some might argue that the Swiss population is more worthy of coverage than would be the 7.5 million that we would leave out.

This report is very supportive of the private insurance industry. The lead author, Robert E. Leu, Ph.D., serves as a director on the board of the largest private hospital group and a large health insurance company in Switzerland. Rate of coverage is only one of the many policy issues covered in a favorable light in this report. Those who have been following our national dialogue on health policy will recognize many other sections in this report that seem to be more intent on marketing their model to the United States than to caution us against the deficiencies in their systems.

Their faith in the social value of the private insurance industry is certainly noteworthy. For instance, when discussing the Swiss nonprofit plans for basic coverage, and for-profit plans for supplemental coverage, they state, “There may be synergies between the two lines — for example, in provider relations — and some insurers may use health information from basic coverage when deciding to whom to offer supplementary insurance (this is illegal but difficult to control).” Does isolating this statement parenthetically sterilize it, making it a fundamental business principle?

Private insurers, whether for-profit or nonprofit, are businesses. They will always advance innovations that enhance their business models. No matter how tightly they are regulated, they will engage in activities that are “illegal but difficult to control.” Of course, since not every potential loophole could possibly be covered by laws and regulations, some of the innovative, immoral business behaviors technically might not be illegal, even though they should be.

In a single payer public health program, everyone is covered for life, automatically, including the 7.5 million deemed less worthy (?) than all of the citizens of Switzerland. Not only that, we would also remove from our midst an expensive, superfluous industry that thrives on immoral or illegal (but difficult to control) business practices. Now really, isn’t single payer a better model for the United States?

Inaugural Address

President Barack Obama
January 20, 2009
The question we ask today is not whether our government is too big or too small, but whether it works – whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified. Where the answer is yes, we intend to move forward. Where the answer is no, programs will end. And those of us who manage the public’s dollars will be held to account – to spend wisely, reform bad habits, and do our business in the light of day – because only then can we restore the vital trust between a people and their government.
http://www.nytimes.com/2009/01/20/us/politics/20text-obama.html?pagewanted=all

Inaugural Address

President Barack Obama

January 20, 2009

The question we ask today is not whether our government is too big or too small, but whether it works – whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified. Where the answer is yes, we intend to move forward. Where the answer is no, programs will end. And those of us who manage the public’s dollars will be held to account – to spend wisely, reform bad habits, and do our business in the light of day – because only then can we restore the vital trust between a people and their government.

http://www.nytimes.com/2009/01/20/us/politics/20text-obama.html?pagewanted=all

Is Universal Coverage enough?

by Ann Settgast, MD
Twin Cities Daily Planet Jan. 19, 2009

The upcoming change in administration has brought optimism and hope to the American public. Now is the time to demand meaningful healthcare reform rather than a replay of past failures. As a physician, I know that offering a placebo in place of known effective treatment is unethical. Hence, while I applaud the good intentions of Senator Tom Daschle, the Healthcare for America Now (HCAN) coalition, and others, I advise against their proposals to extend a system that is fundamentally flawed. In these times of economic uncertainty and crisis, single payer is the only fiscally responsible option for reform…and it is the only solution that will actually work.

Many physicians agree that the largest limitation to providing quality care to our patients rests in the structure of our current system. In an April 2008 survey in Annals of Internal Medicine, 59 percent of U.S. physicians said they would support government action to establish national health insurance.

Most Americans believe lack of health insurance is a “serious problem” (NPR/KFF survey, Feb 2008). Current reform proposals claim to be the way forward. However, expanding our flawed system will not solve the serious problems we face — rising costs and lack of coverage (for uninsured and underinsured). Unfortunately, having coverage in our system does not guarantee care. One-fourth of the insured go without needed care due to cost; three-fourths of individuals bankrupted by medical bills had insurance when they became ill. Is this a system worth perpetuating?

Reform efforts such as those proposed by HCAN and outlined by Senator Daschle maintain a central role for private insurance companies, and are thus doomed to fail because they cannot control costs. They increase coverage only by increasing cost. These proposals duplicate key elements of reform efforts that have consistently failed: Massachusetts in 1988; Oregon in 1989; Tennessee, Minnesota and Vermont in 1992; Washington State in 1993; and Maine in 2003. In each case, rising costs foiled the reform effort, and none durably decreased the number of uninsured. Similarly, the 2006 Massachusetts law, which represents a mandate model of reform, is threatened by rising costs. While the number of uninsured MA residents has fallen modestly, 14% of residents in 2007 remained uninsured at some point in the year. Many MA residents cannot afford the “required coverage”. A 56-year-old making $30,000 annually must spend $7,164 in premium and deductible alone. Today, hundreds of thousands of MA residents remain uninsured. Relying on government subsidies that cannot be sustained, and requiring people to buy insurance they cannot afford, is no solution. Such “reform” expands the role of wasteful private insurers, does nothing for the tens of millions underinsured, and relinquishes the colossal savings that would be achieved under single-payer.

Administrative costs in the U.S. health-care industry are a whopping 31% — more than double that of most industrialized nations. The administrative costs of our private insurers are drastically higher than those of our current single payer (Medicare administrative overhead is less than 2%). This excess is squandered in medically unnecessary activities such as marketing, underwriting, and profit-making. Providers also have unnecessarily high overhead as they struggle to deal with hundreds of different plans. By eliminating this waste, a single-payer system will save our country an estimated $350 billion a year — enough to provide comprehensive health care for all at no additional cost.

In conclusion, I urge the reader to be wary of doomed efforts that focus on lack of insurance and ignore the broader problems of access, affordability, and skyrocketing costs. Single-payer insurance is not socialized or government-run medicine. Care will be provided by private physicians and hospitals, just as it is now, but patients will have increased choice of providers because there will be no insurance meddling. They will also have comprehensive coverage coupled with freedom from the fear of financial ruin due to illness. H.R. 676, the U.S. National Health Insurance Act, has more than 90 co-sponsors in Congress more than any other health reform proposal. Successful implementation will effectively fix our broken system.

Ann Settgast, MD, is the co-chair of Physicians for a National Healthcare Program — Minnesota Chapter. Originally published on 1/19/09 http://www.tcdailyplanet.net/blog/2009/01/18/universal-coverage-enough.html

New Albany City Council relays confidence in universal health care

House Resolution 676 remains in congressional committee

By DANIEL SUDDEATH
The Evening News and Tribune (IN)
Published: January 16, 2009

The most expensive health care in the world provides only run-of-the-mill results.

That’s how Dr. Rob Stone, an emergency room doctor in Bloomington and director of Hoosiers for a Commonsense Health Plan, described America’s health care system during a New Albany City Council workshop Thursday.

He said Americans spend more on health care, less time in the hospital and live shorter lives than all countries that have a universal system.

Stone has been traveling around Indiana since 2005 drumming up support for House Resolution 676, a bill currently in committee in the U.S. House of Representatives that would provide universal health care.

He stated his case to the council in hopes of inducing it to lend its favor to the bill.

New Albany joined Bloomington and Indianapolis as the only cities in the state that have passed a resolution supporting the House measure. The council voted 7-1 in favor of it with Kevin Zurschmiede the lone member opposing.

Louisville has also passed a similar measure.

Why does universal health care matter to a local governing body?

That question was asked of the council by New Albany resident Jeff Roudenbush.

“It’s not a waste of time,” said John Gonder, defending the council’s decision to vote on the issue. His reasoning was simple: The city pays nearly $3 million a year for health care for its employees, so Gonder asked how could they not act?

With President-elect Barack Obama set to take office next week coupled with 91 House co-sponsors of the bill, Stone said now is the time to make universal health care a national dialogue.

The evidence he provided contrasted America’s health care system with other countries that have a universal system. Stone likes Canada’s system, which he paralleled to Medicare.

Canada has a single payer system where hospitals and doctors remain privately employed but the only payer of medical bills is the government. He said this is different than a socialized system where everything is owned by the government.

There are 18,000 deaths a year in America that are the result of lack of insurance, according to Stone.

“It’s an epidemic” that’s “totally preventable,” Stone said. People could seek preventative measures to ward off illnesses if everyone had health care, he added.

Part of the H.R. 676 proposal is eliminating what is known as the Bush tax cuts for people making more than $200,000 a year, and using a seven percent payroll tax to flip the health care bill.

This would provide everyone with health insurance and could actually save money, Stone said. Employers who provide adequate insurance for their workers usually spend more than seven percent, according to Stone.

The payroll tax would be split between the worker and employer, but all would save by not having to pay high insurance premiums, Stone said.

Stone obviously isn’t fond of health insurance companies and stated several times that passing H.R. 676 would lead to the termination of some jobs.

He blames insurance companies for high rates that are in part responsible for so many being uninsured.

Stone said he deals with the situations everyday: a patient comes to the emergency room with an illness that could have been prevented, but that person canceled their health coverage so they could buy groceries and gasoline.

Stone said the financial aspect of health insurance companies is also failing.

“I think we should phase them out before we have to bail them out,” Stone said.

The cost for covering all of the uninsured in America is $120 billion, according to Stone. He said that need trumps the $700 billion approved by Congress for a financial bailout.

Opponents of universal health care say the waits to see a physician can be lengthy. Stone countered that when health care is cheap and inclusive, people try to find something to complain about.

He said that in Canada, you can go online and find out the exact wait to see any doctor you wish, making the system more transparent than in America where you have no idea how long you’ll be waiting.

A representative from Congressman Baron Hill’s office attended the workshop and subsequent council meeting where the supporting measure was passed.

Hill has said he’s open to the idea of universal health care but has not voiced a decision on H.R. 676 publicly.

Gonder said hopefully more cities will pass a supporting resolution to show Hill and other members of Congress that the need for a change is great.

So you know: In 1883, Germany became the first industrialized country to establish a universal health care system.
— www.hchp.info

Tackling Union Opposition to Single-Payer

Medicare for All!

By MISCHA GAUS
Labor Notes
January 16-18, 2009

Labor activists from 31 states gathered in St. Louis last weekend, solidifying their strategies to push “Medicare for all”–and to oppose the half-hearted health care plans circulating in Washington.

The meeting launched Labor for Single-Payer Healthcare, a campaign whose reform would cut the insurance industry out of health care and expand an improved Medicare system to everyone. The single-payer concept has been endorsed by 39 state AFL-CIO federations, 100 central labor councils, and more than 400 local unions.

Yet some major unions that have endorsed single payer, including AFSCME and the Service Employees, in practice are backing plans that would preserve private insurers. Both union federations, the AFL-CIO and Change to Win, already have lined up behind compromise plans.

“There’s another agenda out there. It’s not what’s best or what’s right, but what’s opportune,” said Sandy Eaton, a regional president of the Massachusetts Nurses Association.

Heavy hitters in D.C., including Senators Edward Kennedy and Max Baucus, are pushing mixed public-private reform ideas. AFL-CIO President John Sweeney praised the plan Baucus floated in November, calling it a “giant step.”

But their approach is fatally flawed, said Martha Livingston of Physicians for a National Health Program. Because it leaves the profit-making insurance companies as major players, it can’t control spiraling costs and does nothing to prevent insurers from denying care.

The new campaign was launched to make clear to policy-makers that a substantial section of the labor movement sees through the flawed proposals and believes the moment is right to embrace truly universal health care.

In contrast, Democrats are likely to put forward a Massachusetts-style plan, adopting an approach the state initiated in 2006. It mandated that each resident purchase health insurance, yet Eaton said tens of thousands in his state are still uninsured because they can’t afford premiums but don’t qualify for subsidies.

GRASSROOTS PRESSURE

Representatives from 13 central labor councils and four state federations attended the kick-off meeting.

“Single payer is the only reform in health care that has a constituency,” said Rose Ann DeMoro, executive director of the California Nurses Association (CNA). “We have to light the fire that builds the movement to get single payer.”

The 150 delegates discussed how to grow support for single payer in their unions and communities. They’ll be coordinating actions, from plant gate and parking lot rallies to lobby days to more dramatic confrontations at insurance companies.

They believe they will have some breathing room, as Obama will likely not attempt a full overhaul of the system in his first year. They anticipate instead that the administration will focus immediately on smaller changes, such as expanding medical insurance for poor children and reining in excessive costs from private insurers that lure healthy seniors out of Medicare.

TACKLING UNION OPPOSITION

Conference-goers said one problem within labor is that unions that run their own welfare funds tend to oppose single-payer. These funds, which typically skip insurers and administer health care plans directly to union members, are common in the building trades and Teamsters. Union officers there generally argue that their members are happy with the status quo.

But whether plans are union-run or not, others said, the price of private health care is climbing, eating into salary gains and eroding members’ benefits.

Some attendees foresee even the strongest unions being dragged into health care concessions.

“We don’t want to be the ones going back to members, saying, ‘it’s going to be more expensive this year,'” said Mark Dudzic, the campaign’s coordinator. “Suddenly we become the agent of retreat for our members.”

Dudzic added that activists need to challenge union leaders to think about what unions could do with the savings that national health care could achieve.

“You could convert a $6 per hour cost into a $2 per hour cost,” Dudzic said, “and do incredible things–subsidized childcare, educational benefits–with the surplus we create as workers.”

Indeed, single payer could pull the U.S. economy out of its quagmire by injecting $317 billion in public and private funds into the economy and creating 2.6 million new jobs, according to the CNA’s research arm. A study the union previewed at the St. Louis conference said the spending would pump $100 billion in wages into the economy and create almost as many jobs as the economy lost last year.

Many activists raised a big, unanswered question: How to approach union supporters of the mediocre health care reforms competing for attention in Washington?

Essentially, they won’t–for now. Unions and coalitions that support combined private-public plans will go their own way, while activists raise the profile of single payer and pressure Congress members back in their home districts.

“If everybody puts this plan into play,” said Al Cholger, a Steelworkers staffer in Detroit, “this train won’t leave the station without us.”

Mischa Gaus is editor of Labor Notes, where this story originally appeared.

Let's hope Obama doesn't blow it

By HELEN THOMAS
Seattle Post-Intelligencer
January 19, 2009

WASHINGTON — Barack Obama has the crushing burden of meeting some mile-high expectations that the American public has built up for his presidency.

Even before taking office, Obama has evoked more national support, excitement and high hopes than many of his predecessors. On the other hand, few have faced more problems at the outset of his presidency — two wars and a depressed economy with 7.2 percent jobless rate.

Lawmakers are reeling under the staggering projection of a $1.2 trillion annual budget deficit.

America is also involved in the mayhem in Gaza because of its support of Israel at the U.N. and by providing it heavy weapons.

It’s still a mystery on how Obama intends to approach these problems. He has been silent on most key issues on the ground that we have only one president at a time.

Fair enough, but it seems he could have spoken out against the slaughter in Gaza and embellished his credentials as an incoming peacemaker — and perhaps even saved lives.

If nothing else, the words that describe Obama’s political profile are “super-cautious” and “careful.”

He is treading slowly into the highest office in the land, trying to touch all bases and make new friends. He calls himself a “progressive” but he comes across as center-right, perhaps fearing to be called a “liberal.”

Obama seems intent on leaving his renowned “audacity” to the campaign trail rather than bring it to the White House.

Although there is pressure for a full-scale inquiry into the Bush administration’s use of torture techniques like water-boarding against suspected terrorists, Obama has indicated he has no interest in blaming President Bush or Vice President Dick Cheney for their roles in these despicable policies.

Obama said a week ago Sunday on ABC-TV that if someone has broken the law they should be prosecuted but that his legal advisers were still evaluating interrogation issues and past practices of the Bush intelligence agencies.

During the campaign, Obama sang a different tune, condemning the administration’s harsh interrogation practices. But that was yesterday. Now he says “we need to look forward” as opposed to “looking backwards.”

That flip flop is par for the course. Why should he offend the CIA, which was only following the president’s orders? Incidentally, the following-orders defense was rejected during the post-World War II Nuremberg war crime trials.

The American people certainly deserve to know why we have lost our moral standing in the world — or whether our new president is already in a protective mode of the nation’s dubious national security practices.

Obama acts as if he doesn’t have a dog in this fight. But as president these issues cannot be ignored.

Obama is being wooed by the ultra conservatives, apparently those still hoping they will retain their power position in Washington. Conservative columnist George Will gave a dinner in his honor and invited fellow right-wing columnists and commentators. Reports from insiders say he charmed them.

Obama later met with liberal journalists but not in a fancy social setting.

There is a lot on the incoming president’s plate — to put it mildly. Health care reform is one thing. With the economy in the tank and 47 million people without insurance, Obama should take a bold step and support a single-payer plan a la Social Security. It makes sense — and better still — it works.

Obama should also tear a page out of Franklin D Roosevelt’s book in leading our economic recovery during the Great Depression.

Public works put people to work. Welfare checks were available for the indigent to feed their families and to cope with hard times.

Like today the big problems were traced to Wall Street.

Many current government restrictions and oversight on banks and business were born of FDR’s “New Deal,” which unfortunately were ignored by the free marketers in recent years who apparently thought that prosperity would last forever.

In other words, Obama has a lot to prove. Let’s hope he doesn’t blow it.

Helen Thomas is a columnist for Hearst Newspapers. E-mail: helent@hearstdc.com. Copyright 2009 Hearst Newspapers.