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Doctors prescribe Medicare-for-All: Single payer reform endorsed by America’s largest medical specialty society and recommended in open letter from thousands of physicians

Doctors prescribe Medicare-for-All: Single payer reform endorsed by America’s largest medical specialty society and recommended in open letter from thousands of physicians

Advocates call the endorsement a “sea change” for the medical profession

Contact: Steffie Woolhandler, M.D., M.P.H., steffie_woolhandler@hms.harvard.edu
Adam Gaffney, M.D., M.P.H., agaffney@cha.harvard.edu
Clare Fauke, Physicians for a National Health Program, clare@pnhp.org

Physicians for a National Health Program (PNHP) today welcomed the American College of Physicians’ (ACP) endorsement of single-payer Medicare for All. The ACP, a national organization of 159,000 internists, is the largest medical specialty society and second-largest physician group in the U.S. after the American Medical Association (AMA). 

The ACP announced its endorsement of Medicare for All in a special supplement to its official journal, the Annals of Internal Medicine, where the group also endorsed a “universal public choice” reform model. 

The ACP endorsement coincides with the publication of an open letter signed by more than 2,000 physicians “prescribing” Medicare for All, an effort organized by advocates separately from the ACP. Among the “prescribers” are towering figures in American medicine, including Dr. Marcia Angell, former editor-in-chief of the New England Journal of Medicine; Dr. Bernard Lown, developer of the defibrillator; Dr. Paul Farmer, infectious disease expert and founder of Partners in Health; and Dr. Mary Bassett, former New York City Health Commissioner. The letter will appear as an advertisement in the New York Times on January 21. 

Along with the ACP’s position paper, the Annals of Internal Medicine published an editorial by PNHP co-founders Drs. Steffie Woolhandler and David Himmelstein. Drs. Woolhandler and Himmelstein, noting that organized medicine had opposed national health insurance for a century, called the ACP’s new position “a sea change for the medical profession.”

The ACP’s endorsement of Medicare for All and the publication of the open letter reflects growing support for single-payer reform among physicians. Recent surveys have found that half of all doctors now favor national health insurance. Last June, the AMA’s House of Delegates only narrowly defeated a resolution that would have rescinded its long-standing opposition to Medicare for All. Under pressure from Medicare for All supporters, the AMA then resigned from the dark money group Partnership for America’s Health Care Future, which opposes single-payer reform. 

“As physicians, we see daily the harm that our fragmented, private-insurance based system does to our patients,” noted Dr. Adam Gaffney, President of PNHP and a pulmonary and critical care physician at Harvard Medical School and the Cambridge Health Alliance. “Patients go without the care they need, and physicians squander time and resources on wasteful billing and clerical tasks. Medicare for All would be a much better way — for patients and doctors both.”  

According to Dr. Woolhandler, a Distinguished Professor at the City University of New York at Hunter College and Lecturer in Medicine at Harvard Medical School, “When we started PNHP, doctors who supported single-payer reform were considered radicals, and reporters likened us to ‘furriers for animal rights’.  Now we’re squarely in the mainstream of the medical profession. More and more doctors have realized – often from talking to our Canadian colleagues – that single payer is the only way to cut insurers’ paperwork and profits that siphon hundreds of billions annually from care in the U.S.” Dr. Woolhandler is a Fellow of the ACP, but not an official spokesperson for that organization.

PNHP is a nonprofit research and education organization whose more than 23,000 members support single-payer Medicare for All reform. PNHP’s physician members have been working for single payer since publication of its policy proposal in the New England Journal of Medicine in 1989.

The following documents are available to credentialed media professionals upon request:

Second-Largest Doctor Group Endorses National Health Insurance (Of Some Kind)

Internal medicine association signals it would support either “Medicare for All” or a strong public option.

By Jonathan Cohn
HuffPost, January 20, 2020

The campaign to create a government-managed, truly universal health care system may have just picked up an important new ally: the nation’s second-largest physician organization.

The American College of Physicians, which represents 159,000 doctors with training in internal medicine, on Monday said the federal government should assert more control over national health spending and guarantee insurance for all Americans, either by covering everybody directly (through what advocates call “Medicare for All”) or by creating a new public program that can compete with private plans (through what’s come to be known as a “public option”).

ACP’s announcement could prove to be a milestone in the century-long quest to make health care a universal right, considering how frequently and effectively physicians have resisted ambitious reforms. And it comes at a time when such reforms are once again a focus of national debate, because so many Americans are still struggling with the cost of medical care and because the two political parties are calling for such radically different responses.

Republicans, led by President Donald Trump, are still trying to repeal or roll back the Affordable Care Act, which dramatically reduced the number of uninsured people and established key principles of universal coverage such as guaranteed insurance for people with preexisting conditions. Insofar as Republicans support new initiatives, they have in mind reforms that would relax or eliminate these regulations on insurance companies and shrink government insurance programs on which tens of millions rely.

Democrats want government to do more than it does today ― by reaching the remaining uninsured, providing everybody with more protection from medical bills, and addressing health care spending more aggressively. Inside the party, the debate is all about whether Medicare for All or the public option is the best way to achieve those goals.

What They Are Saying About Government And Health Care

After more than a year of study and internal deliberations, ACP’s governing boards and policy committees have concluded that either Medicare for All or a strong public option could work, though it doesn’t use those terms. The overriding goal, the organization says, should be to give the government much more sway over health care, like other developed countries have long done, rather than to rely on some combination of patchwork reforms and the free market.

And in a series of articles that appear in the new Annals of Internal Medicine, ACP officials and affiliates make a detailed case for why. The package includes a thorough review of national health systems abroad, along with summaries of what American politicians are now proposing.

“The U.S. health care system is like a chronically ill patient, and ACP is proposing a new prescription,” three of the group’s officials say in the lead essay. “Simple market solutions have been unsuccessful elsewhere, and we do not believe that health care is a commodity.”

ACP, which supported the Affordable Care Act and has fought efforts to repeal it, has always been among the most liberal physician organizations. But this is the first time the organization has formally called for the government to create a new insurance program, be it mandatory or optional, and to exert so much more power over health care spending, according to Robert McLean, an internist and the group’s president.

“We have said in the past, ‘Hey, maybe we need to consider or look at single-payer financing as an option,’ but we didn’t fully come out and boldly endorse it,” McLean told HuffPost. “We are doing that now. This is a really assertive endorsement with much more detail on how this approach has been shown to be effective for these various reasons. … That is new for us.”

What It Means For The 2020 Election

The ACP articles assiduously avoid endorsing any politician or party. But ACP’s positions line up with some well-known advocates.

Sen. Bernie Sanders (I-Vt.) is Medicare for All’s most visible champion, having written the damn bill, as he likes to say, and endorsed it for nearly his entire life in politics. Sen. Elizabeth Warren (D-Mass.) has also endorsed Medicare for All, though she has said she would seek to get there through a two-step process, starting with a law to create a public option.

Other 2020 Democratic presidential candidates ― including former Vice President Joe Biden; former South Bend, Indiana, Mayor Pete Buttigieg; and Sen. Amy Klobuchar (D-Minn.) ― have warned that Medicare for All represents too dramatic a change. They have said they would prefer simply to pass public option reforms, at least for now, although the specific initiatives those candidates have put forward would appear to be less ambitious than what ACP has in mind.

In its review of public option proposals, ACP cited plans from the Center for American Progress and Yale political scientist Jacob Hacker. The closest analogue to those plans is proposed ”Medicare for America” legislation from Reps. Rosa DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.) that would envision, among other things, more federal intervention to control prices.

And that element of the ACP endorsement, the interest in letting government get more involved with the price of health care through either Medicare for All or a public option, may ultimately be the most important part of its endorsement.

How And Why Physician Opinion May Be Shifting

Physicians, like most providers of health care, have a long history of fighting ambitious reforms, going back to the Progressive Era when state medical societies fought the first, embryonic efforts at “compulsory health insurance.” Thirty years later, the American Medical Association, which was and remains the largest U.S. organization representing doctors, led the fight to defeat Harry Truman’s universal coverage plan.

Since that time, however, physician opposition to sweeping health reforms has softened.

The AMA, like the ACP, supported the Affordable Care Act and has opposed efforts to repeal it. Last year, the AMA’s House of Delegates came within a few percentage points of voting to rescind its historic opposition to single-payer schemes like Medicare for All. It also withdrew from the Partnership for America’s Health Care Future, a health industry group that has fought both Medicare for All and the public option.

The evolution of physician sentiment likely reflects a variety of factors, including a generational shift. Older physicians came into the profession with expectations of operating in solo practices or as small groups, with minimal outside interference.

Younger doctors are more accustomed to working in large organizations and in many cases see government as a necessary, even welcome force to counter the influence of insurance companies and guarantee access in a way that private plans do not.

“First, there is widespread recognition of the harm that our health care financing system inflicts on our patients’ health,” said Adam Gaffney, a pulmonology specialist who is president of Physicians for a National Health Program. “But second, there’s also growing recognition of the ways that the system fails physicians too — endless hours glued to the electronic medical record, enormous amounts of time, energy, and resources expended on billing, documentation, and other onerous clerical tasks. We’re recognizing more and more that patients and doctors are in this together.”

What The Endorsement Doesn’t Say

PNHP is a longtime champion of Medicare for All and recruited more than 2,000 doctors to sign an open letter, set to run as an advertisement in The New York Times on Tuesday, endorsing the idea. Together with ACP’s announcement, the letter suggests that Medicare for All is gaining mainstream credibility.

“The fact that the largest medical specialty society in the country explicitly and officially endorsed Medicare for All is a huge deal — even if they also endorsed another option,” Gaffney said.

ACP’s support of both Medicare for All and strong public option reforms comes with warnings that limiting provider payments too aggressively could hurt doctors and hospitals that operate with low margins, ultimately hurting patients. This is no small thing.

Actual legislation to create either a Medicare for All or ambitious public option system could entail limits on provider income that many physicians would find objectionable. Yet without enough control over health spending, the math of reform gets tricky and it’s difficult to deliver the benefits advocates promise.

But though it’s a tough problem to solve, as policy and politics, McLean says more and more physicians understand it’s worth the effort. “We can do better, our patients deserve better,” he said. “No system is perfect but we can get a lot closer than we are.”

https://www.huffpost.com…

Labor should not bargain against itself on Medicare for All

By Dr. Martin Luther King, Jr.
Illinois AFL-CIO Convention, October 1965

“At the turn of the century women earned approximately ten cents an hour, and men were fortunate to receive twenty cents an hour. The average work week was sixty to seventy hours. During the thirties, wages were a secondary issue; to have a job at all was the difference between the agony of starvation and a flicker of life. The nation, now so vigorous, reeled and tottered almost to total collapse. The labor movement was the principal force that transformed misery and despair into hope and progress. Out of its bold struggles, economic and social reform gave birth to unemployment insurance, old age pensions, government relief for the destitute, and above all new wage levels that meant not mere survival, but a tolerable life. The captains of industry did not lead this transformation; they resisted it until they were overcome. When in the thirties the wave of union organization crested over our nation, it carried to secure shores not only itself but the whole society.”

https://www.afscme.org…

The Labor Movement Must Fight for Medicare for All — Not Employer-Based Plans

By Mark Dudzic
Jacobin, January 17, 2020

Unions have been at the forefront of almost every progressive policy advance for a century. So why are AFL-CIO president Richard Trumka and American Federation of Teachers president Randi Weingarten denouncing Medicare for All by parroting talking points crafted by health care industry lobbyists?

The spectacle of national labor leaders defending a system that is the biggest cause of strikes, lockouts, and concession bargaining is mind-boggling. For an entire generation now, unions in the United States have traded wages and other benefits for shrinking coverage by employer-provided health insurance (or for the ever-increasing employer contributions required to maintain similarly shrinking benefits from union-sponsored health and welfare funds).

Like it or not, employment-based health care is simply unsustainable. The Milliman Medical Index reports that the 2018 total health care costs for a family of four with decent employment-based coverage exceed $28,000 per year. That is $14 per hour worked for a full-time employee — almost twice the federal minimum wage. The employer pays $15,000 of that, and $13,000 is paid by the worker through co-insurance, out-of-pocket charges, co-pays, deductibles, and all the other myriad ways that the medical-industrial complex extracts money from our pockets. These amounts already exceed the average hourly wage in food services and retail occupations and are increasing two times faster than the rate of wage increases for all workers, putting them on track to exceed average wages in manufacturing and other core industries within the next decade. The percentage of total health care costs paid by the worker has gone up nearly every year since it was first tracked in the 1990s.

Employment-based health care is also a major driver of wage stagnation. Every worker trades wages for health care.

And even the best employment-based health care is not there when we need it the most: when we lose our jobs, change jobs, go on strike, or struggle with long-term illness.

Medicare for All would take health care off the bargaining table and increase union bargaining leverage in nearly every negotiation. It would allow union-sponsored health and welfare funds the opportunity to reallocate revenues currently sunk into the world’s most expensive and inefficient health care system. Savings could be applied to new “union advantage” programs such as enhanced disability benefits, supplemental unemployment benefits, tuition and training programs, legal services, child- and eldercare, and others. Some revenues could also potentially be reallocated to shore up endangered pension plans.

Medicare for All would also provide better coverage than any employment-based plan in existence today. Opponents of Medicare for All often conflate the constricted benefits offered under today’s Medicare program after more than fifty years of underfunding and privatization attempts with the greatly expanded and improved benefits proposed under Medicare for All – HR 1384 — Rep. Pramila Jayapal’s Medicare for All Bill.

I challenge any advocate of employment-based coverage to show me a plan that matches the level of comprehensive services, freedom of choice, and absence of out-of-pocket costs proposed by HR 1384.

Union members should be justly proud of the long battle that unions have waged to protect their right to access affordable, quality health care, and the Labor Campaign for Single Payer stands in solidarity with all workers everywhere who fight to protect these hard-won gains. But our movement is at an historic juncture. Now is not the time to muddy the waters or bargain against ourselves. We need labor to lead as we work to make this a key issue in the 2020 elections and to hold politicians accountable in 2021 and beyond. And we have the right to expect that the union leaders who represent us and the politicians that we support will do more than just parrot the talking points crafted by health care industry lobbyists.

Mark Dudzic is coordinator of the Labor Campaign for Single Payer.

https://jacobinmag.com…

Comment:

By Don McCanne, M.D.

On this day we should consider what Martin Luther King, Jr. would have to say about the fact that workers’ health care benefits are not universal, and, for those who have them, that they have displaced wages that otherwise could help many more achieve the American Dream that King believed should be freely available to all.

Our brothers and sisters in the unions should join with the rest of us in the campaign to see that they and all others can be assured that health care will always be there when needed without having to sacrifice other elements of the American Dream. We can have it all.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Major Doctors’ Group Calls for US to Assure Coverage for All

By The Associated Press

WASHINGTON — With health care an election-year priority, a major doctors’ organization on Monday called for sweeping government action to guarantee coverage for all, reduce costs and improve the basic well-being of Americans.

Declaring that the U.S. health care system “is ill and needs a bold new prescription,” the American College of Physicians endorsed either of the two general approaches being debated by Democratic presidential candidates: a government-run “single-payer” system that would cover everyone, or a new “public option” government plan that would offer comprehensive coverage to compete with private insurance.

But the group’s president, Dr. Robert McLean, said his organization is not signing on to specific proposals, such as Vermont Sen. Bernie Sanders’ “Medicare for All” bill or former Vice President Joe Biden’s combination of a public option, improvements to “Obamacare” and deputizing Medicare to negotiate prescription drug prices.

Instead, he said, the group arrived at its recommendations by analyzing available evidence on what might best address the nation’s problems with high costs, gaps in insurance coverage, uneven quality, and mind-boggling complexity.

“We think there is a realistic chance that either of these two approaches could get us to a much, much better place,” said McLean. “It is not looking to be partisan, but I would say it is unavoidably political because policy is political.”

One problem Sanders’ plan poses for McLean’s group is its reliance on Medicare rates, which are well below what private insurance pays.

Although less well known than the American Medical Association, the group represents doctors who are critical in the health care system. Its 141,000 members in the U.S. are internal medicine specialists, focusing on adults from Medicare recipients to people in their working years covered by employer plans.

Doctors have traditionally been central in the nation’s health care debates. The AMA’s approval helped President Barack Obama pass the Affordable Care Act, and physicians’ groups were a core element of the coalition that blocked President Donald Trump’s efforts to repeal it.

About half of U.S. adults support a national Medicare for All plan, according to recent polling by the nonpartisan Kaiser Family Foundation. A public option garners more support, with about two-thirds backing it. Both ideas face strong opposition from health insurance companies and other industry players.

McLean said his group is seeking comprehensive solutions that address coverage, cost, quality and complexity. Tackling one area and not the others won’t suffice, he said. He said Republican proposals to encourage patients to be better consumers of health care fall short because they don’t address coverage gaps or guarantee comprehensive benefits.

His organization’s framework was outlined in a series of papers published in its journal, Annals of Internal Medicine.

https://www.nytimes.com…

The Labor Movement Must Fight for Medicare for All — Not Employer-Based Plans

Unions have been at the forefront of almost every progressive policy advance for a century. So why are AFL-CIO president Richard Trumka and American Federation of Teachers president Randi Weingarten denouncing Medicare for All by parroting talking points crafted by health care industry lobbyists?

By Mark Dudzic
Jacobin, January 17, 2020

At the June 2019 House Ways and Means Committee Hearing on Medicare for All, Texas Republican Kevin Murphy lamented, “That great health care plan that your union negotiated for you? It’s gone. Banned under Medicare for All.”A right-wing congressman with a 7 percent lifetime voting score from the AFL-CIO crying crocodile tears for great union health care plans can be easily dismissed as just another absurdity of the increasingly dysfunctional American political system. But when Joe “the workingman’s friend” Biden repeats the charge almost word for word and when AFL-CIO president Rich Trumka insists — on Fox News no less! — that “if there isn’t some way to have our plans integrated into the system, then we would not support [Medicare for All],” something is certainly happening out there. Talking points, after all, don’t just come out of thin air. They are carefully crafted and disseminated by a coterie of lobbyists and publicists often working on behalf of shadowy corporate and political interests.

Trumka was shortly joined by American Federation of Teachers (AFT) president Randi Weingarten, who just six months earlier had delivered a full-throated endorsement of the Medicare for All Act at a rally celebrating its introduction. In her September 23, 2019, Politico article, Weingarten walked back that support in favor of a fictitious system in which “employer-based insurance would be allowed to exist to the extent that plans met or exceeded the standards set by the Medicare plan.” Such a system “would allow people who like their current employer-based plan — which seven in ten Americans claim to (although it’s likely they like their doctor, not the plan itself) — to keep it, allow for a gradual transition from one plan to another when necessary, and effectively improve on the model originally created by the Affordable Care Act.”

The spectacle of national labor leaders defending a system that is the biggest cause of strikes, lockouts, and concession bargaining is mind-boggling. For an entire generation now, unions in the United States have traded wages and other benefits for shrinking coverage by employer-provided health insurance (or for the ever-increasing employer contributions required to maintain similarly shrinking benefits from union-sponsored health and welfare funds).

An Accident of History

The US health care system’s linkage to employment is unique among industrialized countries. It emerged as an accident of history in the years just following World War II when Roosevelt’s promise to enact a “Second Bill of Rights” in the postwar period was stopped dead in its tracks by resurgent capital. In 1946, the American Medical Association led the fight to defeat the Wagner-Murray-Dingell Bill that would have created a publicly funded national health insurance program. The following year saw the passage of the Taft-Hartley Act, which, combined with an orgy of anticommunism and race-baiting, set the powerful postwar labor movement into a long retreat.

Unable to expand the social wage by treating public goods such as health care as a basic right available to all, labor helped craft a “second-best solution” of making access to health care a benefit linked to employment. Corporate America piled on and offered elaborate benefits to recruit and retain employees and to keep unions out. This system was flawed from the beginning. It created tiers of coverage that reinforced employment-based racial and gender disparities and massive amounts of “churn” that disrupted continuity of care for even the best insured. Particularly after the expansion of for-profit health insurance and health care providers beginning in the 1970s, more and more administrative inefficiency was built into the system to facilitate profit-taking, until, by the early twenty-first century, the US health care system was twice as expensive as the OECD average.

Nonetheless, in the post-World War II period of high union density and employment stability, many unions were able to negotiate a robust “private welfare state” that provided health care security for tens of millions of working-class Americans. These benefits were almost never handed to workers. Unions had to wage long and unremitting fights to expand and defend employer-based health care. By the 1980s, almost every contract negotiation was faced with employer demands for reductions in coverage and transfer of costs from the employer to the worker. Nonunion workers fared even worse as they were forced to accept whatever the employer offered. And, unlike attempts to cut social insurance benefits like Social Security or Medicare that almost always fail due to massive popular opposition, cuts to employment-based health care benefits take place company by company under cover of night and arouse little or no popular opposition. Today, even those few union members who have been able to preserve good benefits find themselves as islands in a sea of inadequate and precarious health care coverage.

A System in Crisis

Like it or not, employment-based health care is simply unsustainable. The Milliman Medical Index reports that the 2018 total health care costs for a family of four with decent employment-based coverage exceed $28,000 per year. That is $14 per hour worked for a full-time employee — almost twice the federal minimum wage. The employer pays $15,000 of that, and $13,000 is paid by the worker through co-insurance, out-of-pocket charges, co-pays, deductibles, and all the other myriad ways that the medical-industrial complex extracts money from our pockets. These amounts already exceed the average hourly wage in food services and retail occupations and are increasing two times faster than the rate of wage increases for all workers, putting them on track to exceed average wages in manufacturing and other core industries within the next decade. The percentage of total health care costs paid by the worker has gone up nearly every year since it was first tracked in the 1990s. Employment-based health care is coming up upon the limits of Stein’s Law, formulated by economist Herbert Stein in 1985: “If something can’t go on forever, it will stop.”

Employment-based health care is also a major driver of wage stagnation. Every worker trades wages for health care. A recent Gallup poll found that 61 percent of Americans would be willing to trade 10 percent of future wage increases for a guarantee that their health care costs would not go up for five years. This puts workers and their unions at a huge bargaining disadvantage and goes a long way toward explaining why wages continue to stagnate at a time of low unemployment and growing corporate profits.

And even the best employment-based health care is not there when we need it the most: when we lose our jobs, change jobs, go on strike, or struggle with long-term illness.

What was once a source of pride in the “union advantage” has become an anchor around the necks of the US working class. No union leader in their right mind can conjure a scenario where the system of employment-based health care could be stabilized in ways that could provide sustainable health care security for workers and their families. That is why unions representing a majority of organized workers now support HR 1384 — The Medicare for All Act of 2019 and why the AFL-CIO at its 2017 convention unanimously voted to support policies to “move expeditiously to a single-payer Medicare for All system.”

The Medicare for All Solution

Medicare for All would take health care off the bargaining table and increase union bargaining leverage in nearly every negotiation. It would allow union-sponsored health and welfare funds the opportunity to reallocate revenues currently sunk into the world’s most expensive and inefficient health care system. Savings could be applied to new “union advantage” programs such as enhanced disability benefits, supplemental unemployment benefits, tuition and training programs, legal services, child- and eldercare, and others. Some revenues could also potentially be reallocated to shore up endangered pension plans.

Medicare for All would also provide better coverage than any employment-based plan in existence today. Opponents of Medicare for All often conflate the constricted benefits offered under today’s Medicare program after more than fifty years of underfunding and privatization attempts with the greatly expanded and improved benefits proposed under Medicare for All. HR 1384 — Rep. Pramila Jayapal’s Medicare for All Bill with 119 cosponsors — proposes to cover the following benefits without a single co-pay, deductible, or other out-of-pocket cost:

Hospital services, including inpatient and outpatient hospital care, including twenty-four-hour-a-day emergency services and inpatient prescription drugs. (2) Ambulatory patient services. (3) Primary and preventive services, including chronic disease management. (4) Prescription drugs and medical devices, including outpatient prescription drugs, medical devices, and biological products. (5) Mental health and substance abuse treatment services, including inpatient care. (6) Laboratory and diagnostic services. (7) Comprehensive reproductive, maternity, and newborn care. (8) Pediatrics. (9) Oral health, audiology, and vision services. (10) Rehabilitative and habilitative services and devices. (11) Emergency services and transportation. (12) Early and periodic screening, diagnostic, and treatment services, as described in sections 1902(a)(10)(A), 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A); 1396a(a)(43); 1396d(a)(4)(B); 1396d(r)). (13) Necessary transportation to receive health care services for persons with disabilities or low-income individuals (as determined by the Secretary). (14) Long-term care services and support (as described in section 204).

By comparison, the highly touted federal employees’ health benefit plan merely offers the choice of a number of fairly comprehensive private insurance products with the typical array of co-pays, deductibles, and narrow networks. For all of this, federal employees must kick in 28 percent of the weighted average premium for all plans.

Arguably, union employees working for the City of New York might have some of the bestv coverage of any working-class American. They can get fully employer-paid coverage in the default Emblem Health/HIP plan which has almost no co-pays or deductibles (workers may also choose other private insurance plans that do require employee contributions). They also receive generous dental, optical, and prescription coverage. But even here, workers must use a narrow provider network or face substantial co-pays, and the plan falls far short of HR 1384 in its coverage of long-term care, disability services, and community and home-based care. Moreover, every contract negotiation is held hostage to the imperative to hold on to these extraordinary benefits at almost any cost. I challenge any advocate of employment-based coverage to show me a plan that matches the level of comprehensive services, freedom of choice, and absence of out-of-pocket costs proposed by HR 1384. 

Like global warming, the case for replacing our dysfunctional, multi-payer, for-profit health care system with a publicly funded, universal system with a single standard of care for all is so compelling that it has reached the level of scientific fact. Nonetheless, too many national labor leaders continue to sing the praises of employment-based health care benefits, while too many others give merely rhetorical support for Medicare for All — passing resolutions at conferences and conventions to please union activists while continuing to devote the bulk of their union’s mobilizing and legislative efforts to support for incremental and defensive policy fixes. Only a few national unions have begun to commit the kind of resources and organizing capacity that will be needed to defeat the concentrated political and economic power of the medical-industrial complex.

Union Backpedaling

As momentum for Medicare for All builds, we are witnessing more backpedaling within the labor movement. And not all of it is confined to national labor leaders (though it certainly is more pronounced at that level). In New York, a single-payer-style state bill — NY Health — has twice passed the State Assembly and is edging toward passage in the State Senate backed by a growing popular movement. While the bill does have considerable labor support, including from the state’s powerful hospital workers and nurses’ unions, a significant section of the labor movement has gone into open opposition. In June of 2018, James Cahill, the president of the New York State Building and Construction Trades Council, joined the CEO of the Business Council pf New York State in co-authoring an op-ed in Crain’s New York Business opposing the bill and “government-run health care.”

Taken by itself, this expression might be dismissed as another sign of the class collaborationism and conservatism than infects significant sections of the building trades. But they were joined by a number of other unions, including the 380,000-member Municipal Labor Council — whose affiliates include a number of “progressive unions” — which told Politico that they “dread the impact of the single-payer proposal in Albany.” It is true that, unlike national proposals, state-level single-payer-style plans are notoriously complex to design and difficult to fund. But this hostility goes beyond having legitimate questions about implementation. The fact that major sectors of the labor movement refuse to engage in an effort to make health care a birthright in a state with near-Canadian levels of union density is profoundly unsettling for those of us who believe that, in order to succeed, labor must be in the forefront of the fight to win Medicare for All.

So what is driving this opposition? Perversely, in New York some of it derives from precisely these high levels of union density. Unions still think they have a seat at the table and may sincerely believe that they can bargain better and more secure benefits that would not be subject to the precariousness of annual state budget debates. This parochial perspective ignores the reality that New York unions are only one election or economic downturn away from catastrophe. They only need to look across the Hudson to see what anti-union Governor Chris Christie did to New Jersey public sector workers’ ability to bargain for health care during his administration (aided and abetted, I would add, by Democratic political elements associated with some of the most politically influential building trades locals).

Putting aside the idiosyncrasies of New York labor politics, many union leaders may also believe that “the members aren’t ready” to support Medicare for All. Loss aversion plays a central part in shaping that belief. Behavioral scientists have observed that people are much more likely to be motivated by the fear of losing something they have than by the prospect of gaining something they want. Fear of loss of health insurance is a major driver of working-class insecurity in the United States. It is no surprise, then, that the lobbyists and publicists working on behalf of the medical-industrial complex would focus on this theme in their effort to scare the American people away from a just health care system. Some of that fear has infected union members. The failure to confront such fears, of course, is a classic mistake that anyone who’s ever been through an organizing campaign would know to avoid. The real problem here is union leaders who fail to articulate a vision of working-class politics that will inspire and unify union members.

These concerns are compounded in the wake of the Janus decision, which has made public sector union membership completely voluntary. Many public sector union leaders are convinced that the best way to persuade workers to maintain their union membership is to show how the union adds value in their workplace. Negotiating health insurance benefits that are much better than those enjoyed by most other working-class Americans is one way to do that without necessarily having to engage in risky internal organizing and mobilizing activities that may end up undermining existing union leadership.

Some unions have raised the specter of job loss as a reason to oppose Medicare for All. This is a legitimate concern. Studies have shown that close to two million workers will be displaced due to the administrative efficiencies of Medicare for All. While both the House and Senate bills provide funding for transition benefits for these workers, decades of working-class experience with bearing the cost of environmental-, trade-, and automation-related job losses have made workers rightly skeptical of any promises of economic security. The Labor Campaign for Single Payer has called for centering these worker concerns in the political and legislative battles to come and has warned that a failure to do so will give our opponents the opportunity to divide workers against each other.

Unions have also expressed concern that employers would reap the benefit of all the sunken wages that unions have agreed to divert to maintain decent private insurance coverage. This would assume that, in the transition to Medicare for All, unions would be so weak and/or incompetent that they would be unable to recapture those already bargained monies. Even assuming a worst-case scenario, this objection is tantamount to someone opposing student loan forgiveness because they’ve already paid off a chunk of their loan.

There are also several institutional factors that can work to discourage union support for Medicare for All. Union health and welfare funds often have substantial brick-and-mortar investments in union facilities and provide a range of member services that often strengthen members’ union identification. A vast web of relationships also exists between union officials and health care vendors, brokers, intermediaries, attorneys, and various hangers-on. Some are outright corrupt. Others are more benign, such as the insurance company that subsidizes their stewards training or the broker that they can call to get a member rapid placement in a substance abuse treatment program. Nonetheless, all these relationships are ultimately corrupting because of the entailments of obligation that they engender with players who have a vested interest in maintaining the status quo.

However, the biggest factor by far that drives union opposition to Medicare for All is many union leaders’ fear of disrupting their political relationships. Unions are multi-issue organizations, and many of their bargaining and organizing goals are impacted by local and national political concerns. The ascendancy of a right-wing, anti-labor political regime is an existential threat to the institutional labor movement as well as to a wide range of working-class concerns. Unions routinely pull their punches in the interest of maintaining these relationships. For example, with a few notable exceptions, unions were nowhere to be seen in the 2016 Democratic Party platform fight around Medicare for All and other issues of central concern to the working class led by Bernie Sanders supporters. Enmeshed in the two-party system and with diminishing leverage, unions often see no alternative. Every election cycle is the most important one in the history of the nation, and, whatever the outcome, unions nearly always emerge weaker from each round.

This political practice engenders cynicism and apathy among union members and provides the space for right-wing populism to take root within some sections of the working class. The past decade has seen the reemergence of a refreshing political independence in some of the most dynamic sections of the labor movement. By challenging the status quo, they have inspired their members to take risks and have forced important concessions from the political establishment. Medicare for All, because it seeks to reclaim a public good on behalf of the entire working class, can be an important wedge issue in building out an independent working-class politics.

The Path Forward

Our experience in the Labor Campaign for Single Payer has shown that support for our cause is greatest at the front lines of the labor movement, where leaders and staffers have to deal on a daily basis with the consequences of private, for-profit health care. Our goal has been to work with those activists as they find ways to constructively engage with national labor leadership. After AFL-CIO president Trumka’s Labor Day appearance on Fox News, for example, we asked unionists to write him to remind him that support for Medicare for All is the official policy of America’s largest labor federation. Over 2,500 people answered the call. These are the leaders who will drive change in our movement and ultimately bring the formidable political and mobilization resources of institutional labor into the battle to make health care a right for everyone in America. When that happens, we will win.

As Washington State Labor Council president Larry Brown stated, “Unions do not serve their members well by trying to circle the wagons around an unsustainable model of employment-based health care.” Our labor movement will thrive when we express the aspirations of all workers and speak on behalf of the entire working class.

Union members should be justly proud of the long battle that unions have waged to protect their right to access affordable, quality health care, and the Labor Campaign for Single Payer stands in solidarity with all workers everywhere who fight to protect these hard-won gains. But our movement is at an historic juncture. Now is not the time to muddy the waters or bargain against ourselves. We need labor to lead as we work to make this a key issue in the 2020 elections and to hold politicians accountable in 2021 and beyond. And we have the right to expect that the union leaders who represent us and the politicians that we support will do more than just parrot the talking points crafted by health care industry lobbyists.

Mark Dudzic is coordinator of the Labor Campaign for Single Payer.

https://jacobinmag.com…

Health care inflation? It’s the insurer administrative costs, stupid.

Energy and Health Insurance Drive Inflation Higher in October

By Dean Baker
Center for Economic and Policy Research, November 13, 2019

Over the year, the overall CPI is up 1.8 percent, while the core index is up 2.3 percent. There is some modest evidence of accelerating inflation in the core CPI.

The major item driving the core inflation rate higher is medical care, with the index rising by 4.3 percent over the last year and at an annualized rate of 6.6 percent, comparing the last three months with the prior three months. This index accounts for more than 11.0 percent of the core CPI.

Within the medical care index, by far the biggest problem is health insurance. This index has risen 20.1 percent over the last year and at a 22.9 percent rate, comparing the last three months with the prior three. It is important to remember that this is just the administrative costs and profits of insurers, this index is not measuring premiums.

The index for hospital and related services is also rising rapidly, increasing by 3.4 percent over the last year and rising at a 7.8 percent annual rate, comparing the last three months with the prior three months. The rapid inflation in this sector likely reflects increased consolidation in the industry. By contrast, the index for professional medical services rose by just 0.1 percent in October and is up 1.6 percent over the last year.

Inflation in most other sectors is well contained.

Overall, this report shows that inflation remains well-contained almost everywhere, with the major exception of the health care sector.

http://cepr.net…

Comment:

By Don McCanne, M.D.

Everyone is concerned about health care costs, except maybe the insurers. We continue to debate what to do about it. This report should give us some guidance.

Currently inflation is well contained, except in medical care. Professional medical services are not contributing to health care inflation. But because of consolidation in the industry, hospital and related services are contributing somewhat to the increase in the medical care index.

But by far the biggest problem is health insurance. This index has risen over 20 percent in the past year, and that is just for the administrative costs and profits of the insurers, not for premiums.

So what solutions are we debating? Conservatives want market solutions, but they have been unable to come up with any proposals that would not make the situation worse. Moderates want to add to the current system a public option Medicare for Some that would preserve the role of the private insurers who are largely responsible for these inflationary administrative costs and profits. Only those advocating for the single payer model of an improved Medicare for All are supporting a proposal that would eliminate most of these administrative excesses and their unmerited profits.

The perpetual delay in enacting and implementing single payer Medicare for All has wasted trillions of dollars that we could have recovered over the past couple of decades. Are we going to continue with inaction while we have these silly debates over Medicare for All, Medicare for Some, or Medicare for None? Too many are experiencing preventable financial hardship, physical suffering, and even death. Shame on us!

For those who need a reminder of what we could have:

Landmark administrative waste study updated:
https://pnhp.org…

Projected costs of single payer in the United States:
https://pnhp.org…

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Use polls as a tool, not as a deterrent

Should Medicare for All be Democrats’ top priority?

By Alvin Powell
The Harvard Gazette, January 14, 2020

Health care, climate change, and political reality collided this week, when experts discussing national single-payer health insurance clashed over the question of whether Democrats should make it their top priority if the party manages to retake both the White House and Congress this year.

John McDonough, a professor of the practice of public health who played a role in the design and passage of the Affordable Care Act, shook his head, arguing that recent history suggests health-care overhaul debates tend to crowd out all other issues and to exact a high political price.

“Health care is vitally important, but so is climate change, so is voting rights, so is gun control,” he said. “When health reform is on the agenda, it sucks up all the political oxygen in the room, and there’s very little room or space for anything.”

Adam Gaffney, an instructor in medicine at Harvard Medical School and president of Physicians for a National Health Program, disagreed, citing Franklin D. Roosevelt’s New Deal and Lyndon B. Johnson’s Great Society as examples of packages of progressive initiatives that passed despite multiple controversial parts.

“If you look at American history, many times many important reforms can be sought and achieved at the same time and that’s what we’re hoping for,” Gaffney said.

The exchange came during The Forum at Harvard T.H. Chan School of Public Health. The webcast, “The Future of National Health Insurance: Debates During a U.S. Presidential Election Year,” also featured Robert Blendon, professor of health policy and political analysis at the Chan School; Sara Collins, vice president of health care coverage and access for The Commonwealth Fund; and Phil Ellis, president of Ellis Health Policy Inc. and former analyst, adviser, and deputy assistant director at the Congressional Budget Office.

McDonough reminded the panel what happened to Democrats the last two times they took on health care. The party has won the coveted “trifecta” of the House, Senate, and White House just twice in the last 40 years. The first was during the first two years of the Clinton presidency and the second was during the first two years of the Obama presidency. Both times, he said, health-care restructuring topped the agenda — unsuccessfully for Clinton and successfully for Obama. And both times Democrats lost control of Congress in the midterm election.

“Each of them made heath reform their signal, main issue, and very little else happened,” McDonough said. “I think we have to be pragmatic … because the consequences are severe, not just for health but for everything else we care about.”

He also said that even under Democrats’ most favorable election scenario, mustering the votes for Medicare for All or another single-payer national health plan is unlikely, because a Democratic Senate majority, if achieved, is unlikely to approach the 60 votes needed to forestall a Republican filibuster.

National polls show that voters care deeply about health care and Democratic presidential candidates have made the issue central to their campaigns. But Blendon cautioned that a closer look at polling responses shows that Democrats and the general public aren’t necessarily talking about the same thing. While Democrats are dedicated to making the health-care system more efficient overall, the public is more narrowly focused on personal costs, such as co-pays and other out-of-pocket expenses. They’re skeptical that they’ll see savings from any plan aimed at system-wide efficiencies.

Polls show Americans clearly split between keeping and tweaking the Affordable Care Act, scrapping the current system in favor of Medicare for All or other similar national health insurance, or Republican-sponsored changes that would reduce federal mandates and devolve more power to the states.

That split, Blendon said, shows that despite years of debate so far, the discussion about health care isn’t close to finished.

“This is what polarized looks like,” Blendon said.

Demographically, Blendon said, some changes are likely over the next 10 years. The wing of the Democratic Party that is most disaffected with today’s institutions and most willing to scrap the current health-care system is also its youngest, which means that support for fundamental change is likely to grow over the next decade.

Despite differing outlooks, panelists agreed that further action on health care is needed. Currently 27 million to 30 million Americans are uninsured, and another 44 million are underinsured, with high co-pays and out-of-pocket expenses. Though the ACA brought the nation’s uninsured below 9 percent for the first time, other developed countries have rates between 0 and 1 percent.

“That’s not nearly good enough. That’s important to keep in mind,” McDonough said of U. S. progress.

Recent studies show that Medicare for All may save money, Gaffney said. The U.S. spends $812 billion annually just for administration of its health-care system, twice what Canada pays. That indicates that even if the cost of care itself doesn’t change under Medicare for All, there may be administrative savings.

Panelists said it is difficult to predict the impact of a Trump reelection on health care, but the general trend of Republican action has been to make health insurance cheaper by reducing coverage and relaxing mandates that insurers cover preexisting conditions. If insurers are again allowed to refuse those with preexisting conditions, Ellis said it’s likely that markets would be split between healthy people paying lower premiums and the sick, who may be forced into high-risk pools with higher premiums. McDonough said it’s also likely we’d see a continued rise in the number of uninsured, whose ranks have risen by 2 million in recent years.

https://news.harvard.edu…

Forum – Harvard T.H. Chan School of Public Health, “The Future of National Health Insurance” – 1 hour video:
https://theforum.sph.harvard.edu…

Comment:

By Don McCanne, M.D.

Clearly the single payer model of Medicare for All is vastly superior to other models of reform under consideration. It would provide all essential health care services to everyone at a cost close to that of our current highly dysfunctional financing system, while ensuring affordability for each individual by implementing equitable tax policies.

But the public is more concerned about their individual costs. They are concerned about the high cost of drugs, about high deductibles, about surprise medical bills, and about high insurance premiums if they are not covered by employer-sponsored plans. They want to see these issues addressed directly, though they are divided between whether the best way would be through expansion of the Affordable Care Act perhaps with a Medicare for All public option added, or if they would prefer more flexibility in private insurance products and in the health care marketplace.

Polls currently show that the nation is fairly evenly split in support of these three options. The neoliberals have apparently decided that we should improve ACA by adding a public option, and then try to bring the single payer supporters into their camp. The conservatives are still floundering with their efforts to patch together market solutions that simply won’t work for most individuals.

The polls are partly responsible for this effort to perpetuate ACA with a public option added. Opponents of single payer have been trying to convince the public that they should have the right to keep their private plans. Since most of those plans are employer-sponsored, beneficiaries believe that their personal costs will be less since they generally do not see the portion of the premium paid by the employer and they are quite unaware of tax expenditures for the deductibility of the plans for which we taxpayers are responsible. They contrast that with the prospect of paying for Medicare for everyone through a massive increase in their Medicare payroll taxes, or the equivalent in income taxes, or whatever, not considering that they would be equitable, progressive taxes

Since we really can’t improve on the single payer Medicare for All model, we should not use the poll results to compromise the single payer policies just to preserve choice of private plans. Instead we should use the poll results to show how single payer much more effectively addresses the individual concerns that the public actually has – controlling drug costs, eliminating surprise bills, eliminating insurance premiums and deductibles, eliminating provider networks that take away their choices of physicians and hospitals, and ensuring that they would be covered for life. Right now the opponents of single payer Medicare for All are using the polls as a deterrence by threatening loss of choice of private health plans.

Polling expert Robert Blendon: “For the average voter, they want to vote for someone who will deal with medical bills… This is a meat and potatoes issue for the average person not voting in the Democratic primary – ‘I want to see something done about these insulin costs, etc., etc.’.. And that’s what scares them about Medicare for All. If you could just talk about – ‘I’ll pay less next year’… But when you get into the trillions, people can’t deal with it – People say ‘I don’t know what a trillion is, but at the end of the day I’m going to be paying more.’ In reality if you can say your fees will go down, your delivery costs will go down, your drug costs will go down, that would be a debate the others would like to have, but that is lost in the aggregate numbers.”

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This is why I prescribe Medicare for All

By Joan A. MacEachen, M.D., M.P.H.
The Journal (Cortez, Colo.), January 16

Health insurance is supposed to protect us from debilitating medical bills. But many of my patients find that when they need care, commercial insurance does not provide adequate protection. Even though they paid thousands of dollars in premiums and deductibles, patients still get stuck with huge surprise bills after a hospital visit.

This is real money for working families: The average surprise bill for emergency care is $628, and more than $2,000 for hospital admission. The vast majority of households filing for medical bankruptcy had commercial insurance at the time of treatment.

It doesn’t have to be this way. Single-payer Medicare for All would eliminate both networks and bills by giving patients free choice of virtually any doctor or hospital, and by paying providers directly for the full cost of care. It really is that simple.

Some politicians think we should settle for a Band-aid plan like a public option, which would only preserve the waste and complexity of our health system, not to mention the scourge of surprise bills and medical bankruptcy.

My patients deserve better. As a doctor, I prescribe Medicare for All.

https://the-journal.com…