PNHP

Quentin Young and Cory Franklin on Medicare for all

Quentin Young and Cory Franklin on Medicare for all

Excerpts from Pro and Con op-eds on Medicare for all

Chicago Tribune
August 4, 2010

Pro: Rx for Medicare’s birthday: Expand it

By Quentin Young
I was in active medical practice on July 30, 1965, when Medicare was signed into law by President Lyndon B. Johnson. Its impact on older Americans and their families was swift and spectacular. I saw the results with my own eyes.
Almost overnight, millions of Americans age 65 and older had the doors to health care opened to them that had hitherto been closed. They streamed into our doctors’ offices seeking long-deferred and sometimes urgently needed medical attention.
Simultaneously, the specter of crushing medical debt was lifted from the shoulders of tens of millions of America’s seniors and their children. You could almost hear a collective sigh of relief.
In fact, Medicare stands like a rock in a troubled sea of waste, inefficiency and disarray in the rest of our health care system, dominated as it is by big, corporate insurers whose paramount goal is to maximize profits, often by enrolling the healthy, avoiding the sick, raising premiums and denying claims.
Medicare is not without its problems, of course. Its benefits package could be richer. It lacks authority to negotiate lower prices with drug companies. The reimbursement rate to physicians could be enhanced and stabilized, instead of depending on an annual cat-and-mouse game with Congress (the “doc fix”) over a flawed accounting formula that only erodes physician confidence in the program.
But the best way to remedy these problems — and to bring down skyrocketing health care costs at the same time — is to improve the program and, most important, to expand it to cover every person in the United States.
That’s right: Extend Medicare to everyone. By replacing our crazy-quilt, inefficient system of private health insurers with a streamlined, publicly financed single-payer program, we would reap enormous savings.
First, we would save about $400 billion annually that is presently wasted on unnecessary paperwork and bureaucracy. That’s enough money to cover everyone who is currently uninsured and to upgrade everyone else’s coverage without increasing overall U.S. health spending by a single penny.
Patients could go to the doctor and hospital of their choice. They’d be covered for all medically necessary services and medications, with no co-pays or deductibles.
Second, we’d acquire powerful cost-control tools like the ability to purchase medications in bulk, negotiate fees, develop global budgets for hospitals and coordinate capital investments. Such tools would rein in costs and help assure the program’s sustainability over the long haul.
It’s never too late to do the right thing. So when naysayers urge cuts to Medicare, don’t buy it. Tell them to ask Congress to enhance Medicare and to extend it to all.
Dr. Quentin Young is national coordinator of Physicians for a National Health Program.
http://www.chicagotribune.com/news/ct-oped-0805-pro-20100804,0,2770491.story

Con: Patients will end up receiving less care

By Cory Franklin
No physician in the United States has been a more articulate spokesman for the medically disenfranchised in the last half century than Quentin Young; his ideas on health care merit our attention. But he is simply mistaken that the best remedy for our health care problems is to expand Medicare to every American.
Medicare, adopted in 1965, has been a success — albeit a qualified one. Many of its advantages are indisputable, but some are oversold.
Medicare expansion raises the untested arguments of single-payer advocates — savings accrued through lower administrative costs, negotiating fees, global budgets, centralized planning and purchasing.
The biggest problem in expanding Medicare is essentially solving what economist Greg Mankiw calls the trilemma, the three problems of health care delivery — cost, access and quality. Any two might be achieved but the third necessarily suffers. Expanding Medicare could certainly improve access but no one has figured out how to prevent escalating costs or diminishing quality (e.g. less subspecialty care). The question must be asked: Under universal Medicare might the country pay more and see patients receive less?
Dr. Cory Franklin is a physician with NorthShore University HealthSystem.
http://www.chicagotribune.com/news/ct-oped-0805-con-20100804,0,5728796.story

Supporters of Medicare for all are already familiar with the Pro position expressed so well by Quentin Young, but you may want to download the full article anyway to share it with others who may be less informed.
The full article on the Con position, written by Cory Franklin, also provides passive support for the Medicare for all position. He argues that 1) Medicare is going broke, 2) physicians are unhappy with Medicare reimbursement rates, 3) there have been many extensive technological advances in the past 45 years, 4) aging and obesity would put a strain on Medicare, 5) patients no longer pay 50 percent of total costs out of pocket, and that 6) there are unintended consequences in a massive government assumption of costs.
The reason that his arguments support Medicare for all is that he provides no alternative to address these issues other than the “untested” policies of the single payer model. In fact, the policies listed have been tested extensively in other nations and proven to be effective in both controlling costs and ensuring health care access for everyone.
A word needs to be said about the oft-repeated common wisdom that cost, access and quality are interdependent and that an improvement in one automatically results in an impairment of one or both of the others. Improve access and costs will go up and quality will go down, they say. This meme has been repeated so often that it is no longer questioned. Even Cory Franklin advances it with his statement: “Expanding Medicare could certainly improve access but no one has figured out how to prevent escalating costs or diminishing quality.”
What is the truth? As a universal program, Medicare for all would eliminate financial barriers to access for everyone. Expanded coverage would be paid for initially by the recovery of the profound administrative waste that uniquely characterizes our dysfunctional, fragmented system of financing health care. Not only would costs not increase, but single payer policies that would be put in place would slow the growth in costs to sustainable levels far into the future. A single payer system is also much more adept at identifying and incentivizing beneficial health care practices, thereby improving the quality of care delivered.
The opponents of Medicare for all are locked into the framing of the three-legged stool of cost, access and quality – reinforce one leg and the other two destabilize. We can show them how we can use Medicare for all to reinforce all three legs – proving universal access to higher quality care while controlling costs – to provide a solid, permanent structure of affordable, high quality care for everyone.

Rx for Medicare’s birthday: Expand it

By Quentin Young
Chicago Tribune, August 5, 2010

Medicare, one of our nation’s most cherished social programs, turned 45 last week.

I was in active medical practice on July 30, 1965, when Medicare was signed into law by President Lyndon B. Johnson. Its impact on older Americans and their families was swift and spectacular. I saw the results with my own eyes.

Almost overnight, millions of Americans age 65 and older had the doors to health care opened to them that had hitherto been closed. They streamed into our doctors’ offices seeking long-deferred and sometimes urgently needed medical attention.

Simultaneously, the specter of crushing medical debt was lifted from the shoulders of tens of millions of America’s seniors and their children. You could almost hear a collective sigh of relief.

That was only the beginning. Through the years, Medicare dramatically reduced poverty among the elderly. It added new benefits like preventive care. It reduced racial and income-based disparities. It extended its coverage to the severely disabled. It laid the basis for nationwide, comparative health studies that have improved the quality of care for everyone.

In short, Medicare, a government-sponsored program that now covers over 45 million Americans, has been a triumphant success.

However, instead of celebrating, Medicare is facing ominous rumblings from President Obama’s debt commission and not-so-veiled threats from other quarters.

“Medicare’s going broke,” its market-obsessed critics say. “It’s dragging down the economy.”

Such alarms have been sounded about every six or seven years since Medicare began, but in real life it continues to thrive. Either the economy prospers, yielding greater tax revenues, or Congress tweaks the payroll tax by a tiny fraction of a percentage point, and immediately the projected shortfall disappears. (The last adjustment was in 1985, when the rate was increased to 1.45 percent from 1.30 percent.)

While it’s true aging baby boomers will make bigger demands on Medicare, again, modest adjustments today will assure its financial solvency tomorrow.

In fact, Medicare stands like a rock in a troubled sea of waste, inefficiency and disarray in the rest of our health care system, dominated as it is by big, corporate insurers whose paramount goal is to maximize profits, often by enrolling the healthy, avoiding the sick, raising premiums and denying claims.

Medicare is not without its problems, of course. Its benefits package could be richer. It lacks authority to negotiate lower prices with drug companies. The reimbursement rate to physicians could be enhanced and stabilized, instead of depending on an annual cat-and-mouse game with Congress (the “doc fix”) over a flawed accounting formula that only erodes physician confidence in the program.

But the best way to remedy these problems — and to bring down skyrocketing health care costs at the same time — is to improve the program and, most important, to expand it to cover every person in the United States.

That’s right: Extend Medicare to everyone. By replacing our crazy-quilt, inefficient system of private health insurers with a streamlined, publicly financed single-payer program, we would reap enormous savings.

First, we would save about $400 billion annually that is presently wasted on unnecessary paperwork and bureaucracy. That’s enough money to cover everyone who is currently uninsured and to upgrade everyone else’s coverage without increasing overall U.S. health spending by a single penny.

Patients could go to the doctor and hospital of their choice. They’d be covered for all medically necessary services and medications, with no co-pays or deductibles.

Second, we’d acquire powerful cost-control tools like the ability to purchase medications in bulk, negotiate fees, develop global budgets for hospitals and coordinate capital investments. Such tools would rein in costs and help assure the program’s sustainability over the long haul.

Conventional wisdom suggests we should wait and see how the new health law plays out. But we’ve seen how comparable reforms have fared on the state level: They’ve invariably failed after only a few years, chiefly because they can’t control costs. Meanwhile more millions suffer.

It’s never too late to do the right thing. So when naysayers urge cuts to Medicare, don’t buy it. Tell them to ask Congress to enhance Medicare and to extend it to all.

Dr. Quentin Young is national coordinator of Physicians for a National Health Program.

http://www.chicagotribune.com/news/ct-oped-0805-pro-20100804,0,2770491.story

Rx for Medicare's birthday: Expand it

By Quentin Young
Chicago Tribune, August 5, 2010

Medicare, one of our nation’s most cherished social programs, turned 45 last week.

I was in active medical practice on July 30, 1965, when Medicare was signed into law by President Lyndon B. Johnson. Its impact on older Americans and their families was swift and spectacular. I saw the results with my own eyes.

Almost overnight, millions of Americans age 65 and older had the doors to health care opened to them that had hitherto been closed. They streamed into our doctors’ offices seeking long-deferred and sometimes urgently needed medical attention.

Simultaneously, the specter of crushing medical debt was lifted from the shoulders of tens of millions of America’s seniors and their children. You could almost hear a collective sigh of relief.

That was only the beginning. Through the years, Medicare dramatically reduced poverty among the elderly. It added new benefits like preventive care. It reduced racial and income-based disparities. It extended its coverage to the severely disabled. It laid the basis for nationwide, comparative health studies that have improved the quality of care for everyone.

In short, Medicare, a government-sponsored program that now covers over 45 million Americans, has been a triumphant success.

However, instead of celebrating, Medicare is facing ominous rumblings from President Obama’s debt commission and not-so-veiled threats from other quarters.

“Medicare’s going broke,” its market-obsessed critics say. “It’s dragging down the economy.”

Such alarms have been sounded about every six or seven years since Medicare began, but in real life it continues to thrive. Either the economy prospers, yielding greater tax revenues, or Congress tweaks the payroll tax by a tiny fraction of a percentage point, and immediately the projected shortfall disappears. (The last adjustment was in 1985, when the rate was increased to 1.45 percent from 1.30 percent.)

While it’s true aging baby boomers will make bigger demands on Medicare, again, modest adjustments today will assure its financial solvency tomorrow.

In fact, Medicare stands like a rock in a troubled sea of waste, inefficiency and disarray in the rest of our health care system, dominated as it is by big, corporate insurers whose paramount goal is to maximize profits, often by enrolling the healthy, avoiding the sick, raising premiums and denying claims.

Medicare is not without its problems, of course. Its benefits package could be richer. It lacks authority to negotiate lower prices with drug companies. The reimbursement rate to physicians could be enhanced and stabilized, instead of depending on an annual cat-and-mouse game with Congress (the “doc fix”) over a flawed accounting formula that only erodes physician confidence in the program.

But the best way to remedy these problems — and to bring down skyrocketing health care costs at the same time — is to improve the program and, most important, to expand it to cover every person in the United States.

That’s right: Extend Medicare to everyone. By replacing our crazy-quilt, inefficient system of private health insurers with a streamlined, publicly financed single-payer program, we would reap enormous savings.

First, we would save about $400 billion annually that is presently wasted on unnecessary paperwork and bureaucracy. That’s enough money to cover everyone who is currently uninsured and to upgrade everyone else’s coverage without increasing overall U.S. health spending by a single penny.

Patients could go to the doctor and hospital of their choice. They’d be covered for all medically necessary services and medications, with no co-pays or deductibles.

Second, we’d acquire powerful cost-control tools like the ability to purchase medications in bulk, negotiate fees, develop global budgets for hospitals and coordinate capital investments. Such tools would rein in costs and help assure the program’s sustainability over the long haul.

Conventional wisdom suggests we should wait and see how the new health law plays out. But we’ve seen how comparable reforms have fared on the state level: They’ve invariably failed after only a few years, chiefly because they can’t control costs. Meanwhile more millions suffer.

It’s never too late to do the right thing. So when naysayers urge cuts to Medicare, don’t buy it. Tell them to ask Congress to enhance Medicare and to extend it to all.

Dr. Quentin Young is national coordinator of Physicians for a National Health Program.

http://www.chicagotribune.com/news/ct-oped-0805-pro-20100804,0,2770491.story

The impact of Taiwan's single payer system on amenable mortality

The impact of universal National Health Insurance on population health: the experience of Taiwan

By Yue-Chune Lee, Yu-Tung Huang, Yi-Wen Tsai, Shiuh-Ming Huang, Ken N Kuo, Martin McKee and Ellen Nolte
BMC Health Services Research
August 4, 2010

Background

Taiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwan’s population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care.

Methods

Identification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005.

Results

Deaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64 percent per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. (This result is consistent with our expectations as 77% of the working age population were already covered by the pre-existing social insurance; thus they were inevitably going to be affected less by the introduction of NHI.) NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed.

Conclusions

NHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.

Policy Implications

These findings have implications for other countries that do not have universal health insurance coverage. The implementation of NHI in Taiwan was associated with a sustained reduction in deaths from causes amenable to health care, which surpassed the underlying decline in other causes. It is reasonable to expect that the introduction of universal coverage elsewhere might also have beneficial effects.

Looking ahead, while the Taiwanese NHI has succeeded in terms of cost (3.4% of GDP), satisfaction (77.5% satisfied in 2007), low administrative cost (1.49%), and equitable financial burden, the system is not without problems. For example, as a publicly-managed program, it is difficult to insulate it from political interference, a factor that has contributed to a continuing financial deficit. Thus, the existing budget may be inadequate to sustain the current level of performance.

http://www.biomedcentral.com/1472-6963/10/225/abstract

Full article (provisional):
http://www.biomedcentral.com/content/pdf/1472-6963-10-225.pdf

United States has worst rate of amenable mortality:
https://pnhp.org/news/2008/january/united_states_has_wo.php

Comment: 

By Don McCanne, MD

Taiwan’s 1995 introduction of a single payer system of universal National Health Insurance provides us with a natural experiment on the impact of single payer reform on health outcomes. The results are dramatic. The rate in reductions of deaths due to disorders that are amenable to health care were nine times the reductions in deaths from non-amenable causes. Nine times!

The United States should be especially interested in these results since, in a study of nineteen industrialized nations, we have the worst rate of amenable mortality (link above). We have over 100,000 excess deaths per year due to disorders amenable to health care.

Will the Patient Protection and Affordable Care Act (PPACA) erase this blemish on our health care system? Most of our dysfunctional financing system will remain in place. Some will receive care under an expansion of Medicaid, but as a chronically underfunded program with insufficient numbers of willing providers, access problems are inevitable. Others will receive care under the private plans in the insurance exchanges, but financial barriers to access will remain because of the low actuarial values of the plans and inadequate subsidies. There is little reason to believe that the tweaks of PPACA will have much impact on amenable mortality.

After enacting a single payer system, Taiwan not only greatly reduced amenable mortality, but it was done at a fraction of our spending, with great patient satisfaction, with extremely low administrative costs, and with a financing system that is equitable. Maybe Taiwan needs to spend more, but just think of what we could have with the amount that we are already spending. Besides, saving 100,000 lives a year seems to be a worthy policy goal.

The impact of Taiwan’s single payer system on amenable mortality

The impact of universal National Health Insurance on population health: the experience of Taiwan

By Yue-Chune Lee, Yu-Tung Huang, Yi-Wen Tsai, Shiuh-Ming Huang, Ken N Kuo, Martin McKee and Ellen Nolte
BMC Health Services Research
August 4, 2010

Background

Taiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwan’s population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care.

Methods

Identification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005.

Results

Deaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64 percent per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. (This result is consistent with our expectations as 77% of the working age population were already covered by the pre-existing social insurance; thus they were inevitably going to be affected less by the introduction of NHI.) NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed.

Conclusions

NHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.

Policy Implications

These findings have implications for other countries that do not have universal health insurance coverage. The implementation of NHI in Taiwan was associated with a sustained reduction in deaths from causes amenable to health care, which surpassed the underlying decline in other causes. It is reasonable to expect that the introduction of universal coverage elsewhere might also have beneficial effects.

Looking ahead, while the Taiwanese NHI has succeeded in terms of cost (3.4% of GDP), satisfaction (77.5% satisfied in 2007), low administrative cost (1.49%), and equitable financial burden, the system is not without problems. For example, as a publicly-managed program, it is difficult to insulate it from political interference, a factor that has contributed to a continuing financial deficit. Thus, the existing budget may be inadequate to sustain the current level of performance.

http://www.biomedcentral.com/1472-6963/10/225/abstract

Full article (provisional):
http://www.biomedcentral.com/content/pdf/1472-6963-10-225.pdf

United States has worst rate of amenable mortality:
https://www.pnhp.org/news/2008/january/united_states_has_wo.php

Comment: 

By Don McCanne, MD

Taiwan’s 1995 introduction of a single payer system of universal National Health Insurance provides us with a natural experiment on the impact of single payer reform on health outcomes. The results are dramatic. The rate in reductions of deaths due to disorders that are amenable to health care were nine times the reductions in deaths from non-amenable causes. Nine times!

The United States should be especially interested in these results since, in a study of nineteen industrialized nations, we have the worst rate of amenable mortality (link above). We have over 100,000 excess deaths per year due to disorders amenable to health care.

Will the Patient Protection and Affordable Care Act (PPACA) erase this blemish on our health care system? Most of our dysfunctional financing system will remain in place. Some will receive care under an expansion of Medicaid, but as a chronically underfunded program with insufficient numbers of willing providers, access problems are inevitable. Others will receive care under the private plans in the insurance exchanges, but financial barriers to access will remain because of the low actuarial values of the plans and inadequate subsidies. There is little reason to believe that the tweaks of PPACA will have much impact on amenable mortality.

After enacting a single payer system, Taiwan not only greatly reduced amenable mortality, but it was done at a fraction of our spending, with great patient satisfaction, with extremely low administrative costs, and with a financing system that is equitable. Maybe Taiwan needs to spend more, but just think of what we could have with the amount that we are already spending. Besides, saving 100,000 lives a year seems to be a worthy policy goal.

The impact of Taiwan's single payer system on amenable mortality

The impact of universal National Health Insurance on population health: the experience of Taiwan

By Yue-Chune Lee, Yu-Tung Huang, Yi-Wen Tsai, Shiuh-Ming Huang, Ken N Kuo, Martin McKee and Ellen Nolte
BMC Health Services Research
August 4, 2010
Background
Taiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwan’s population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care.
Methods
Identification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005.
Results
Deaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64 percent per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. (This result is consistent with our expectations as 77% of the working age population were already covered by the pre-existing social insurance; thus they were inevitably going to be affected less by the introduction of NHI.) NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed.
Conclusions
NHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.
Policy Implications
These findings have implications for other countries that do not have universal health insurance coverage. The implementation of NHI in Taiwan was associated with a sustained reduction in deaths from causes amenable to health care, which surpassed the underlying decline in other causes. It is reasonable to expect that the introduction of universal coverage elsewhere might also have beneficial effects.
Looking ahead, while the Taiwanese NHI has succeeded in terms of cost (3.4% of GDP), satisfaction (77.5% satisfied in 2007), low administrative cost (1.49%), and equitable financial burden, the system is not without problems. For example, as a publicly-managed program, it is difficult to insulate it from political interference, a factor that has contributed to a continuing financial deficit. Thus, the existing budget may be inadequate to sustain the current level of performance.
http://www.biomedcentral.com/1472-6963/10/225/abstract
Full article (provisional):
http://www.biomedcentral.com/content/pdf/1472-6963-10-225.pdf
United States has worst rate of amenable mortality:
https://pnhp.org/news/2008/january/united_states_has_wo.php

Taiwan’s 1995 introduction of a single payer system of universal National Health Insurance provides us with a natural experiment on the impact of single payer reform on health outcomes. The results are dramatic. The rate in reductions of deaths due to disorders that are amenable to health care were nine times the reductions in deaths from non-amenable causes. Nine times!
The United States should be especially interested in these results since, in a study of nineteen industrialized nations, we have the worst rate of amenable mortality (link above). We have over 100,000 excess deaths per year due to disorders amenable to health care.
Will the Patient Protection and Affordable Care Act (PPACA) erase this blemish on our health care system? Most of our dysfunctional financing system will remain in place. Some will receive care under an expansion of Medicaid, but as a chronically underfunded program with insufficient numbers of willing providers, access problems are inevitable. Others will receive care under the private plans in the insurance exchanges, but financial barriers to access will remain because of the low actuarial values of the plans and inadequate subsidies. There is little reason to believe that the tweaks of PPACA will have much impact on amenable mortality.
After enacting a single payer system, Taiwan not only greatly reduced amenable mortality, but it was done at a fraction of our spending, with great patient satisfaction, with extremely low administrative costs, and with a financing system that is equitable. Maybe Taiwan needs to spend more, but just think of what we could have with the amount that we are already spending. Besides, saving 100,000 lives a year seems to be a worthy policy goal.

The impact of Taiwan’s single payer system on amenable mortality

The impact of universal National Health Insurance on population health: the experience of Taiwan

By Yue-Chune Lee, Yu-Tung Huang, Yi-Wen Tsai, Shiuh-Ming Huang, Ken N Kuo, Martin McKee and Ellen Nolte
BMC Health Services Research
August 4, 2010

Background

Taiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwan’s population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care.

Methods

Identification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005.

Results

Deaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64 percent per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. (This result is consistent with our expectations as 77% of the working age population were already covered by the pre-existing social insurance; thus they were inevitably going to be affected less by the introduction of NHI.) NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed.

Conclusions

NHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.

Policy Implications

These findings have implications for other countries that do not have universal health insurance coverage. The implementation of NHI in Taiwan was associated with a sustained reduction in deaths from causes amenable to health care, which surpassed the underlying decline in other causes. It is reasonable to expect that the introduction of universal coverage elsewhere might also have beneficial effects.

Looking ahead, while the Taiwanese NHI has succeeded in terms of cost (3.4% of GDP), satisfaction (77.5% satisfied in 2007), low administrative cost (1.49%), and equitable financial burden, the system is not without problems. For example, as a publicly-managed program, it is difficult to insulate it from political interference, a factor that has contributed to a continuing financial deficit. Thus, the existing budget may be inadequate to sustain the current level of performance.

http://www.biomedcentral.com/1472-6963/10/225/abstract

Full article (provisional):
http://www.biomedcentral.com/content/pdf/1472-6963-10-225.pdf

United States has worst rate of amenable mortality:
https://pnhp.org/news/2008/january/united_states_has_wo.php

Taiwan’s 1995 introduction of a single payer system of universal National Health Insurance provides us with a natural experiment on the impact of single payer reform on health outcomes. The results are dramatic. The rate in reductions of deaths due to disorders that are amenable to health care were nine times the reductions in deaths from non-amenable causes. Nine times!

The United States should be especially interested in these results since, in a study of nineteen industrialized nations, we have the worst rate of amenable mortality (link above). We have over 100,000 excess deaths per year due to disorders amenable to health care.

Will the Patient Protection and Affordable Care Act (PPACA) erase this blemish on our health care system? Most of our dysfunctional financing system will remain in place. Some will receive care under an expansion of Medicaid, but as a chronically underfunded program with insufficient numbers of willing providers, access problems are inevitable. Others will receive care under the private plans in the insurance exchanges, but financial barriers to access will remain because of the low actuarial values of the plans and inadequate subsidies. There is little reason to believe that the tweaks of PPACA will have much impact on amenable mortality.

After enacting a single payer system, Taiwan not only greatly reduced amenable mortality, but it was done at a fraction of our spending, with great patient satisfaction, with extremely low administrative costs, and with a financing system that is equitable. Maybe Taiwan needs to spend more, but just think of what we could have with the amount that we are already spending. Besides, saving 100,000 lives a year seems to be a worthy policy goal.

Threat of destabilization of the private insurance market

Covering New Ground in Health System Shift

By Robert Pear
The New York Times
August 2, 2010

Administration officials are eager to demonstrate and deliver what they see as the benefits of the new law (Patient Protection and Affordable Care Act). But they face a delicate task: they do not want to destabilize or disrupt the existing market in a way that makes insurance less available or more expensive to consumers.

For the moment, President Obama has the upper hand. Congress gave him sweeping power to regulate the industry for the benefit of consumers. Administration officials said they would be tough on the industry, but, for the law to succeed, they need large numbers of insurance companies to compete in the new regulated marketplace.

Sabrina Corlette, a research professor at the Health Policy Institute of Georgetown University, said: “In 2014, we can say good riddance to bottom-feeder insurance plans, which have built a business around selling policies to healthy young people. They often provide inadequate coverage when people get sick. But if these plans pull out of the market before 2014, we want to be sure that viable alternatives are available.”

http://www.nytimes.com/2010/08/03/health/policy/03insurance.html?hp

Comment: 

By Don McCanne, MD

“…bottom-feeder insurance plans, which have built a business around selling policies to healthy young people (and which) often provide inadequate coverage when people get sick…” That quotation describes the products being sold in the individual insurance market by WellPoint, the largest insurer in the nation.

Imagine WellPoint improving those plans so that they do provide adequate benefits, with a choice of physicians and hospitals, without excessive cost sharing, and that they would include everyone regardless of preexisting conditions. Imagine the premiums that they would have to charge. Then imagine many companies developing similar quality insurance products to create a robust market of plan choices within the insurance exchanges.

Keep imagining because these products will have to exist only in our minds since the private insurance industry will never again be able to make them a reality if they are going to cover everyone with premiums we can afford.

For those who have employer-sponsored plans that seem to be working, keep in mind that these plans have cherry picked the large but highly select group of the inexpensive healthy workforce and their young healthy families. Also keep in mind that the employee cost of these plans is not only the payroll deduction, but also the forgone wage increases that pay for the employer contribution, and now to be added are the taxes that will be paid to support the subsidies for those who purchase their plans through the exchanges. Nobody is getting off cheap.

If the Obama administration is going to “regulate the industry for the benefit of consumers,” then they can’t help but “destabilize or disrupt the existing market in a way that makes insurance less available or more expensive to consumers.”

Why should we worry about a destabilized market of private plans, when our real concern is how are we going to pay for the health care that any of us might need? The obvious solution would be to replace the private plans with a single payer national health program – an improved Medicare for all. The fate of the private insurers should be the least of our concerns.

On the Anniversary of Medicare Comes a Renewed Call for 'Medicare for All'

By John Nichols
The Nation, Aug. 1, 2010

Forty-five years ago today, on July 30, 1965, President Lyndon Johnson flew to Independence, Missouri, to mark a milestone in the long struggle to establish healthcare as a right, not a privilege, for all Americans.

With reporters and photographers surrounding them, Johnson took a place beside former President Harry Truman, who the sitting president thanked for “planting the seeds of compassion and duty which have today flowered into care for the sick and serenity for the fearful.”

With that, Johnson completed the signing of the Social Security Act of 1965 [1], and establishing the universal, single-payer public insurance programs for the elderly and low-income Americans that we know as Medicare and Medicaid.

Truman was delighted to be part of the celebration. But he and Johnson knew that they had not completed the work Truman began when, as part of a “Fair Deal” program developed to complete the work of Franklin Roosevelt’s New Deal, he had proposed a national healthcare program for all Americans.

That work is still unfinished, which is why Congressman Dennis Kucinich [2], D-Ohio, says: “I celebrate Medicare’s birthday by pledging to continue the fight to implement Medicare for All nationally and at the state level, where there is so much promise.”

Congressman John Conyers [3], D-Michigan, says: “As we honor Medicare’s 45th birthday today, I am proud to say that the movement for Medicare for All remains strong and vibrant. I look forward to working with my colleagues, activists, and my other friends in the single payer community to improve H.R. 676 over the next few months, before reintroducing it in the 112th Congress. While we must continue to work for the passage of a true universal health care bill, we must also be vigilant in our efforts to protect the health care benefits many Americans count on today. Over 47 million older adults and people with disabilities look to Medicare as a source of health and financial security. During this period of increased concern over the size of the federal deficit, Medicare and other social insurance programs are increasingly at risk of being targeted for benefit cuts. I pledge to work with my colleagues in the Congress to defeat any proposal that threatens any of these critically important programs.”

And Senator Bernie Sanders [4], I-Vermont, says of the “Medicare for All” model that Truman imagined and Johnson began to implement: “In my view, the single-payer approach is the only way we will ever have a cost-effective, comprehensive health care system in this country. One of the reasons our current health care system is so expensive, so wasteful, so bureaucratic, so inefficient is that it is heavily dominated by private health insurance companies whose only goal in life is to make as much money as they can.”

Kucinich, Conyers and Sanders fought frustrating battles during the recent healthcare reform debate to get Congress and the Obama administration to focus on the right fix for a broken system. They were thwarted more frequently than they succeeded, although Kucinich forced the House to confront the issue and Sanders got some critical funding for clinics that will provide care to those most in need.

Now, on the forty-fifth anniversary of the moment when Truman and Johnson celebrated a major move in the right direction, however, the trio has renewed the “Medicare for All” call.

In a letter, Sanders, Conyers and Kucinich write [4]: “Now that a new health care bill has been signed into law, it has never been more important to have a strong movement behind Medicare for All.”

At the same time they warn that: “The truth is not enough. We already know that such a health care system has repeatedly proven to control costs more effectively, cover everyone or almost everyone, and deliver care of significantly higher quality than health care systems that tolerate the presence of private health insurance companies. Now we must make it so that the truth can no longer be ignored.”

Harry Truman had another way of saying it. Complaining about the conservatives in Congress who had beaten him on more than a few economic issues in the first few years of his presidency, Truman decided he was going to explain to the American people exactly what was going on when his partisan rivals tried to raised all sorts of false arguments to divide workers and farmers: “It’s an old political trick: ‘If you can’t convince ’em, confuse ’em,’ he explained during the 1948 campaign he was supposed to lose. “But this time it won’t work.”

It worked. Truman was re-elected in what remains the definitional political upset of the past century.

The conservatives did not back off. They played the “confuse ’em” card again during the debate over health care.

But Truman promised that America would eventually “adopt a comprehensive and modern health program for the Nation.” [5]

The healthcare “reform” America got this year may take the country a few steps in the right direction. But as Sanders, Conyers and Kucinich note: “Many health care experts have expressed concern that the Patient Protection and Affordable Care Act does not adequately contain costs for American families and businesses. If they are correct, and we believe they are, additional legislative cost-containment measures will be necessary in the future.”

“When it is time for Congress to try and control health care costs again,” the senator and congressmen argue, “the demand for Medicare for All must be undeniable.”

To Sanders, Conyers and Kucinich, Harry Truman would undoubtedly say: “Give ’em hell!”
Source URL: http://www.thenation.com/blog/43140/anniversary-medicare-comes-renewed-call-medicare-all

Links:
[1] http://en.wikipedia.org/wiki/Social_Security_Act_of_1965
[2] http://kucinich.house.gov/
[3] http://conyers.house.gov/
[4] http://sanders.senate.gov/
[5] http://www.trumanlibrary.org/anniversaries/healthprogram.htm

http://www.thenation.com/blog/43140/anniversary-medicare-comes-renewed-call-medicare-all

On the Anniversary of Medicare Comes a Renewed Call for ‘Medicare for All’

By John Nichols
The Nation, Aug. 1, 2010

Forty-five years ago today, on July 30, 1965, President Lyndon Johnson flew to Independence, Missouri, to mark a milestone in the long struggle to establish healthcare as a right, not a privilege, for all Americans.

With reporters and photographers surrounding them, Johnson took a place beside former President Harry Truman, who the sitting president thanked for “planting the seeds of compassion and duty which have today flowered into care for the sick and serenity for the fearful.”

With that, Johnson completed the signing of the Social Security Act of 1965 [1], and establishing the universal, single-payer public insurance programs for the elderly and low-income Americans that we know as Medicare and Medicaid.

Truman was delighted to be part of the celebration. But he and Johnson knew that they had not completed the work Truman began when, as part of a “Fair Deal” program developed to complete the work of Franklin Roosevelt’s New Deal, he had proposed a national healthcare program for all Americans.

That work is still unfinished, which is why Congressman Dennis Kucinich [2], D-Ohio, says: “I celebrate Medicare’s birthday by pledging to continue the fight to implement Medicare for All nationally and at the state level, where there is so much promise.”

Congressman John Conyers [3], D-Michigan, says: “As we honor Medicare’s 45th birthday today, I am proud to say that the movement for Medicare for All remains strong and vibrant. I look forward to working with my colleagues, activists, and my other friends in the single payer community to improve H.R. 676 over the next few months, before reintroducing it in the 112th Congress. While we must continue to work for the passage of a true universal health care bill, we must also be vigilant in our efforts to protect the health care benefits many Americans count on today. Over 47 million older adults and people with disabilities look to Medicare as a source of health and financial security. During this period of increased concern over the size of the federal deficit, Medicare and other social insurance programs are increasingly at risk of being targeted for benefit cuts. I pledge to work with my colleagues in the Congress to defeat any proposal that threatens any of these critically important programs.”

And Senator Bernie Sanders [4], I-Vermont, says of the “Medicare for All” model that Truman imagined and Johnson began to implement: “In my view, the single-payer approach is the only way we will ever have a cost-effective, comprehensive health care system in this country. One of the reasons our current health care system is so expensive, so wasteful, so bureaucratic, so inefficient is that it is heavily dominated by private health insurance companies whose only goal in life is to make as much money as they can.”

Kucinich, Conyers and Sanders fought frustrating battles during the recent healthcare reform debate to get Congress and the Obama administration to focus on the right fix for a broken system. They were thwarted more frequently than they succeeded, although Kucinich forced the House to confront the issue and Sanders got some critical funding for clinics that will provide care to those most in need.

Now, on the forty-fifth anniversary of the moment when Truman and Johnson celebrated a major move in the right direction, however, the trio has renewed the “Medicare for All” call.

In a letter, Sanders, Conyers and Kucinich write [4]: “Now that a new health care bill has been signed into law, it has never been more important to have a strong movement behind Medicare for All.”

At the same time they warn that: “The truth is not enough. We already know that such a health care system has repeatedly proven to control costs more effectively, cover everyone or almost everyone, and deliver care of significantly higher quality than health care systems that tolerate the presence of private health insurance companies. Now we must make it so that the truth can no longer be ignored.”

Harry Truman had another way of saying it. Complaining about the conservatives in Congress who had beaten him on more than a few economic issues in the first few years of his presidency, Truman decided he was going to explain to the American people exactly what was going on when his partisan rivals tried to raised all sorts of false arguments to divide workers and farmers: “It’s an old political trick: ‘If you can’t convince ’em, confuse ’em,’ he explained during the 1948 campaign he was supposed to lose. “But this time it won’t work.”

It worked. Truman was re-elected in what remains the definitional political upset of the past century.

The conservatives did not back off. They played the “confuse ’em” card again during the debate over health care.

But Truman promised that America would eventually “adopt a comprehensive and modern health program for the Nation.” [5]

The healthcare “reform” America got this year may take the country a few steps in the right direction. But as Sanders, Conyers and Kucinich note: “Many health care experts have expressed concern that the Patient Protection and Affordable Care Act does not adequately contain costs for American families and businesses. If they are correct, and we believe they are, additional legislative cost-containment measures will be necessary in the future.”

“When it is time for Congress to try and control health care costs again,” the senator and congressmen argue, “the demand for Medicare for All must be undeniable.”

To Sanders, Conyers and Kucinich, Harry Truman would undoubtedly say: “Give ’em hell!”
Source URL: http://www.thenation.com/blog/43140/anniversary-medicare-comes-renewed-call-medicare-all

Links:
[1] http://en.wikipedia.org/wiki/Social_Security_Act_of_1965
[2] http://kucinich.house.gov/
[3] http://conyers.house.gov/
[4] http://sanders.senate.gov/
[5] http://www.trumanlibrary.org/anniversaries/healthprogram.htm

http://www.thenation.com/blog/43140/anniversary-medicare-comes-renewed-call-medicare-all

Single Payer Isn't Dead: How States Are Keeping the Movement Alive

By Michael Corcoran
truthout | Op-Ed
Monday 02 August 2010

The grassroots single-payer movement in Vermont reflects the growing belief that the fight to make health care a human right must come from the states. But will the passage of federal reform get in the way?

When Barack Obama signed the Patient Protection and Affordable Care Act  in March, many thought the long and tedious stretch of legislative wrangling and endless debates about health care reform had come to an end and the prospects for further meaningful reform would be shelved for years or decades.

But while the country was consumed with the incredibly narrow debate  in DC, dictated largely by drug and insurance lobbyists, anti-abortion politicians and a collection of conservative Democratic senators with close ties to the insurance and drug industries, another significant health care battle was taking place hundreds of miles to the north, in the tiny little state of Vermont, population, 600,000. By the time Obama signed a federal health care bill into law, the Vermont Workers’ Center was almost two years into its “Healthcare is a Human Rights campaign,” which had the unambiguous goal of abolishing for-profit health care in the state and passing a statewide, single-payer health care system that guarantees health care as a right to all Vermonters. In May, the Vermont Legislature, under constant pressure from this growing people’s movement, passed a bill that could possibly lead to Vermont being the first state to pass a single-payer health care system, setting up what could be a crucial phase of the fight for health care justice.

If Vermont is able to break this ground, the implications could reverberate well past the borders of the Green Mountain State. The fight for statewide single-payer here reflects a growing belief among health care activists that the path to a universal public system, will not take place in Washington, DC, where moneyed interests have a death grip on the legislative process, but through state houses across the country. Further, the effort in Vermont may prove to be the first test case of the “state innovation” language in the federal reform bill and could indicate if Obamacare will ultimately serve to enable statewide single-payer systems or if it will kill them. Finally, the movement in Vermont also highlights a fascinating debate over the rhetoric of health care reform. Should advocates point to the significant savings associated with single-payer health care and the unsustainability of the current system? Or should the primary emphasis view the fight for public health care as a matter of basic human rights?

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Federal Reform: A “Distraction” to the Fight for Health Care Justice

For the last year, James Haslam, long-time director of the Vermont Workers’ Center, paid only scant attention to the massive fight in Washington over health care reform. “In many ways the argument in Washington was something of a distraction for us,” he said in an interview with Truthout, from his home in Burlington Vermont. “The debate gave some people the impression that healthcare would be fixed. But to us it was clear that what they did in Washington does not address the crisis, because they preserved the current profit system. We thought it was important to define healthcare as a human right.”

Indeed, the reform that eventually passed in DC is memorable not only for its scale – some $900 billion in federal spending over ten years – but also the fact that it failed to fundamentally change the private, for-profit basis of the United Sates woeful health care system, which leaves more than 46 million without insurance and is the most expensive in the world. Not only did Congress fail to even consider some kind of public, guaranteed, universal system, the likes of which exists in every developed nation on the planet, but progressives could not even muster through Congress a minuscule “public option,” that had been understood as the major consolation prize that would ensure liberal/left support for Obama’s health care reform.

So the Workers’ Center, unlike many progressive organizations, chose not to rally on behalf of federal reform and instead dutifully set out to “get people to think about healthcare as a human right,” as Haslam describes it. The first year of the campaign began ever so cautiously. Rather than narrowly focus on a specific piece of legislation, or even the details of single-payer health care, organizers simply made their way across the state, passing out surveys and listening to stories from those who had been left behind by the health care system. Many of them were from the tens of thousands of uninsured Vermont men, women and children.

The group held hearings in every corner of the state – from St. Albans to Brattleboro – and heard gut-wrenching story after gut-wrenching story: women who stayed in abusive relationships so their children would not lose health insurance; a hobbled logger who continued to work one of the world’s most dangerous jobs on a bad knee with no insurance (“life is scarier when you step out of the woods,” he said); families with insurance still facing bankruptcy, because the coverage did not protect them from financial ruin.

“From talking to people, we came to learn that people in Vermont really did believe that healthcare was something that everyone should have and that it should not be treated as a commodity,” Haslam said, noting that 95 percent of those polled by the Workers’ Center, believed health care to be a human right.

A Different Approach

At the core of every action and statement made by the Workers’ Center, was its emphasis on human rights. It is noteworthy just how much this approach differed from reform efforts in Washington. While Democrats in DC were obsessing over “bending the cost curve,” cutting the deficit, and other technical (though vitally important) elements of health care reform, in Vermont, the bulk
of the rhetoric used avoided that approach. The Workers’ Center often cited the Universal Declaration on Human Rights and held events to correspond with its anniversary.

Anja Rudiger, the Right to Health Program coordinator for the National Economic & Social Rights Initiative, has assisted with health care campaigns in Vermont and elsewhere. She says the language of human rights is being adopted by an increasing number of organizations and individuals as they attempt to build movements.

“A human rights focus puts humans at the center. It is about people’s experiences and about people’s needs and it is a very powerful approach to get people in all kinds of communities involved,” she said in an interview with Truthout.

This approach may seem simple, but it does take discipline. After all, the finances of statewide single payer remain persuasive. According to a study commissioned by the Vermont Legislature in 2006, Vermont would save $51 million a year if it switched to single payer. Still, Haslam insists, the focus should not be on cold economics. “It’s important that the debate over healthcare reform not only be about how to finance a system,” he said.

The difference in rhetoric – and policy goals – is not the only reason why reform in Vermont is so different than in DC. While reform in Washington was largely hammered out in closed-door meetings between politicians and industry officials, in Vermont, the drive for change has come from the bottom up – at rallies, committee hearings and parades. “In Vermont, a few hundred votes can make the difference for a politician,” Haslam said. “The people have a much larger voice on what goes on than in Washington … we had people from our campaign at almost every single related committee meeting, telling their stories.”

Building the System

Even in Vermont – home to a self-identified socialist senator and Ben and Jerry’s ice cream – passing single payer will be no easy task. A bill that could have been a stepping stone to single payer was passed in 2005, only to be vetoed by Gov. Jim Douglas. This led to a private-public compromise, Catamount Health, that has been hampered by state budget issues, ever-rising premiums and low enrollment.

With Governor Douglas not seeking re-election, single-payer activists are no doubt keeping a close eye on the 2010 Vermont gubernatorial race, which is expected to be a battle between Vermont’s conservative Lt. Gov. Brian Dubie and the winner of a hotly contested democratic primary. Organizers express optimism that any of the Democratic front-runners will be favorable to their position. Senate President pro-tempore. Peter Shumlin, who in July received a key endorsement from former president of Physicians for a National Health Program Deb Richter,  may be the most friendly to the cause. In a letter to the Barre Montpelier Times Argus, Richter and other health professionals called Shumlin, “the only candidate who has shown unwavering support for a publicly financed universal health care system in Vermont.” (A similar dynamic exists in California, where the Legislature has passed single-payer bills twice in recent years to have them met with vetoes from Gov. Arnold Schwarzenegger, who is termed out in 2010).

“Whoever is the governor, we think we can work with them to pass a bill,” Haslam says, confidently. Nonetheless, others have lingering fears that the Legislature will punt by passing another half-measure, or using federal reform as an excuse to hold off on anything dramatic. Others fear Dubie, who polls ahead of all the Democrats, may win the election and simply veto any meaningful reform.

But despite the many political obstacles, the Workers’ Center continued to fight, and at the end of the 2009 legislative session, got behind S.88, which calls for three health care systems – all to be based on human rights principles – to be designed. Among the three systems to be designed will be a single-payer system and organizers’ hope is that S.88 will lead to a new health care system in the near future.

While the grassroots movement may be focused on human rights, designing a system will require a hard look at the economics of dramatic reform. And to handle this task, the Vermont Joint Fiscal Committee (which handles legislative business when the session is out), has assigned Dr. William Hsiao, the creator of the much-praised Taiwanese health care system, which has dramatically lowered costs and increased coverage since it was implemented in 1996.

Single-payer activists have celebrated this selection as a sign that the Legislature is serious about reform. “We are at the door step of history,” noted Walter Carpenter, a volunteer for the Workers’ Center.

For Carpenter, a Montpelier resident who nearly died at the hands of the system when he suffered liver disease, the issue is personal. “In the last of my four operations for liver disease, I had lost my job, was turning yellow again and had to negotiate the price of my own life,” he told Truthout.

Will Obamacare Derail Statewide Single-Payer Efforts?

Perhaps, the worst possible conclusion would be if a movement in Vermont managed to secure a historic health care victory, only to be killed by the very federal health care reform that some overzealous commentators praised as “the greatest social achievement of our time.”

But this is entirely plausible. One major element of planning a new system is dealing with the federal government. The final version of federal reform includes “state innovation” language that address the ability of states to create their own health care systems. These systems, according to a memo by the Center for Policy Analysis, “could delay implementation of state single-payer plans.” Igor Volsky, writing for Think Progress, says the federal reform might be “a major set back for single-payer advocates”:

“States that still chose to pursue their own plan, will have to reconcile their programs with the federal requirements for Medicare, Medicaid, FEHBP, Indian Health Service and, most importantly ERISA – a 1974 law that, among other things, preempts states from enacting legislation that is “related to” employee bene
fit plans … States will have to go to Congress if their reform affects the health insurance offered by large employers.”

Rep. Dennis Kucinich (D-Ohio) had pushed hard to include an ERISA waiver, but it was dropped from the final bill – yet another painful example of progressive impotence in this legislative process. More trouble for statewide single-payer advocates occurred when the date for when states could opt out and make their own systems was pushed back from 2014 to 2017 – three years after statewide exchanges will go into effect.

This, according to Michael Briggs, communications director for Sen. Bernie Sanders, (I-Vermont), was an unfortunate and inexplicable tweak to the final bill. “Bernie (Sanders) has encouraged statewide single-payer for years. He was the one who pushed for and implemented provisions that would allow states to experiment. But, for complicated reasons I don’t fully understand, the date that these states could start experimenting was pushed back until 2017,” he said in an interview with Truthout.

This could mean that even if Vermont is able to pass through a single-payer bill in one of the next legislative sessions, it may require an act of Congress – a place notorious for not even giving single payer a passing glance – to allow such a transformation to take place. It is hard to grasp what a cruel irony it would be if Obama’s health care legislation became the death nail for statewide single-payer movements across the country.

But not all are so pessimistic. Dr. Hsiao, in an interview with Truthout, said he felt the new federal legislation, “left quite a bit of room for state innovations,” and was confident the state could secure the needed waivers should Vermont push legislation through.

Senator Sanders, too, has encouraged Vermonters to push through a bill. “As a long-time advocate of single-payer I’m glad the state is going to have a study,” Senator Sanders told The Nation. “I think the result of it will show that the most cost-effective way to provide universal, comprehensive health care to every Vermonter is through a single-payer approach. What the Vermont legislature has done is very important, very positive and I strongly support their efforts.”

Sanders added that he “will be going right into the President’s office and making the fight on the floor of the Senate that Vermont should be able to become a laboratory and go forward with a single-payer program. And I think if it works in Vermont many other states will want to do the same thing.”

Could Vermont Lead the Way?

Sanders has a point. Washington has proven to be entirely unwilling, or incapable, of truly standing up to entrenched special interests. Indeed, the Canadian single-payer health care system was created in much the same way as Sanders envisions for the United States, with one province taking the lead and others following in turn as the positive impacts became obvious. “Vermont, being a smaller state could be a demonstration site. And it can show states across the country how we can bend the cost curve,” said Hsaio.

“The battle for healthcare as a human right in Vermont is also really a battle for healthcare for people all over the country,” Haslam said.

This is precisely why the battle for single-payer health care in Vermont ought to be seen as a national struggle. The reform talks in Vermont may not involve close to a trillion dollars, but the type of change that could come out could represent a fundamental change in the way a state delivers and finances health care. And if it works, it could spread.

In fact, formidable statewide single-payer movements are forming all over the country and making the case that health care should be a human right – in Montana, Pennsylvania, New Mexico, Minnesota, Maryland, California,  and elsewhere. It is clear that private, for-profit health care is unsustainable and that Washington, DC, is not capable of addressing the issue. So, the responsibility to end this crisis now falls on grassroots movements across the states. Will Vermont be the first domino to fall?

This work by Truthout is licensed under a Creative Commons Attribution-Noncommercial 3.0 United States License.

Single Payer Isn’t Dead: How States Are Keeping the Movement Alive

By Michael Corcoran
truthout | Op-Ed
Monday 02 August 2010

The grassroots single-payer movement in Vermont reflects the growing belief that the fight to make health care a human right must come from the states. But will the passage of federal reform get in the way?

When Barack Obama signed the Patient Protection and Affordable Care Act  in March, many thought the long and tedious stretch of legislative wrangling and endless debates about health care reform had come to an end and the prospects for further meaningful reform would be shelved for years or decades.

But while the country was consumed with the incredibly narrow debate  in DC, dictated largely by drug and insurance lobbyists, anti-abortion politicians and a collection of conservative Democratic senators with close ties to the insurance and drug industries, another significant health care battle was taking place hundreds of miles to the north, in the tiny little state of Vermont, population, 600,000. By the time Obama signed a federal health care bill into law, the Vermont Workers’ Center was almost two years into its “Healthcare is a Human Rights campaign,” which had the unambiguous goal of abolishing for-profit health care in the state and passing a statewide, single-payer health care system that guarantees health care as a right to all Vermonters. In May, the Vermont Legislature, under constant pressure from this growing people’s movement, passed a bill that could possibly lead to Vermont being the first state to pass a single-payer health care system, setting up what could be a crucial phase of the fight for health care justice.

If Vermont is able to break this ground, the implications could reverberate well past the borders of the Green Mountain State. The fight for statewide single-payer here reflects a growing belief among health care activists that the path to a universal public system, will not take place in Washington, DC, where moneyed interests have a death grip on the legislative process, but through state houses across the country. Further, the effort in Vermont may prove to be the first test case of the “state innovation” language in the federal reform bill and could indicate if Obamacare will ultimately serve to enable statewide single-payer systems or if it will kill them. Finally, the movement in Vermont also highlights a fascinating debate over the rhetoric of health care reform. Should advocates point to the significant savings associated with single-payer health care and the unsustainability of the current system? Or should the primary emphasis view the fight for public health care as a matter of basic human rights?

Click here to get Truthout stories like this one sent straight to your inbox, 365 days a year.

Federal Reform: A “Distraction” to the Fight for Health Care Justice

For the last year, James Haslam, long-time director of the Vermont Workers’ Center, paid only scant attention to the massive fight in Washington over health care reform. “In many ways the argument in Washington was something of a distraction for us,” he said in an interview with Truthout, from his home in Burlington Vermont. “The debate gave some people the impression that healthcare would be fixed. But to us it was clear that what they did in Washington does not address the crisis, because they preserved the current profit system. We thought it was important to define healthcare as a human right.”

Indeed, the reform that eventually passed in DC is memorable not only for its scale – some $900 billion in federal spending over ten years – but also the fact that it failed to fundamentally change the private, for-profit basis of the United Sates woeful health care system, which leaves more than 46 million without insurance and is the most expensive in the world. Not only did Congress fail to even consider some kind of public, guaranteed, universal system, the likes of which exists in every developed nation on the planet, but progressives could not even muster through Congress a minuscule “public option,” that had been understood as the major consolation prize that would ensure liberal/left support for Obama’s health care reform.

So the Workers’ Center, unlike many progressive organizations, chose not to rally on behalf of federal reform and instead dutifully set out to “get people to think about healthcare as a human right,” as Haslam describes it. The first year of the campaign began ever so cautiously. Rather than narrowly focus on a specific piece of legislation, or even the details of single-payer health care, organizers simply made their way across the state, passing out surveys and listening to stories from those who had been left behind by the health care system. Many of them were from the tens of thousands of uninsured Vermont men, women and children.

The group held hearings in every corner of the state – from St. Albans to Brattleboro – and heard gut-wrenching story after gut-wrenching story: women who stayed in abusive relationships so their children would not lose health insurance; a hobbled logger who continued to work one of the world’s most dangerous jobs on a bad knee with no insurance (“life is scarier when you step out of the woods,” he said); families with insurance still facing bankruptcy, because the coverage did not protect them from financial ruin.

“From talking to people, we came to learn that people in Vermont really did believe that healthcare was something that everyone should have and that it should not be treated as a commodity,” Haslam said, noting that 95 percent of those polled by the Workers’ Center, believed health care to be a human right.

A Different Approach

At the core of every action and statement made by the Workers’ Center, was its emphasis on human rights. It is noteworthy just how much this approach differed from reform efforts in Washington. While Democrats in DC were obsessing over “bending the cost curve,” cutting the deficit, and other technical (though vitally important) elements of health care reform, in Vermont, the bulk of the rhetoric used avoided that approach. The Workers’ Center often cited the Universal Declaration on Human Rights and held events to correspond with its anniversary.

Anja Rudiger, the Right to Health Program coordinator for the National Economic & Social Rights Initiative, has assisted with health care campaigns in Vermont and elsewhere. She says the language of human rights is being adopted by an increasing number of organizations and individuals as they attempt to build movements.

“A human rights focus puts humans at the center. It is about people’s experiences and about people’s needs and it is a very powerful approach to get people in all kinds of communities involved,” she said in an interview with Truthout.

This approach may seem simple, but it does take discipline. After all, the finances of statewide single payer remain persuasive. According to a study commissioned by the Vermont Legislature in 2006, Vermont would save $51 million a year if it switched to single payer. Still, Haslam insists, the focus should not be on cold economics. “It’s important that the debate over healthcare reform not only be about how to finance a system,” he said.

The difference in rhetoric – and policy goals – is not the only reason why reform in Vermont is so different than in DC. While reform in Washington was largely hammered out in closed-door meetings between politicians and industry officials, in Vermont, the drive for change has come from the bottom up – at rallies, committee hearings and parades. “In Vermont, a few hundred votes can make the difference for a politician,” Haslam said. “The people have a much larger voice on what goes on than in Washington … we had people from our campaign at almost every single related committee meeting, telling their stories.”

Building the System

Even in Vermont – home to a self-identified socialist senator and Ben and Jerry’s ice cream – passing single payer will be no easy task. A bill that could have been a stepping stone to single payer was passed in 2005, only to be vetoed by Gov. Jim Douglas. This led to a private-public compromise, Catamount Health, that has been hampered by state budget issues, ever-rising premiums and low enrollment.

With Governor Douglas not seeking re-election, single-payer activists are no doubt keeping a close eye on the 2010 Vermont gubernatorial race, which is expected to be a battle between Vermont’s conservative Lt. Gov. Brian Dubie and the winner of a hotly contested democratic primary. Organizers express optimism that any of the Democratic front-runners will be favorable to their position. Senate President pro-tempore. Peter Shumlin, who in July received a key endorsement from former president of Physicians for a National Health Program Deb Richter,  may be the most friendly to the cause. In a letter to the Barre Montpelier Times Argus, Richter and other health professionals called Shumlin, “the only candidate who has shown unwavering support for a publicly financed universal health care system in Vermont.” (A similar dynamic exists in California, where the Legislature has passed single-payer bills twice in recent years to have them met with vetoes from Gov. Arnold Schwarzenegger, who is termed out in 2010).

“Whoever is the governor, we think we can work with them to pass a bill,” Haslam says, confidently. Nonetheless, others have lingering fears that the Legislature will punt by passing another half-measure, or using federal reform as an excuse to hold off on anything dramatic. Others fear Dubie, who polls ahead of all the Democrats, may win the election and simply veto any meaningful reform.

But despite the many political obstacles, the Workers’ Center continued to fight, and at the end of the 2009 legislative session, got behind S.88, which calls for three health care systems – all to be based on human rights principles – to be designed. Among the three systems to be designed will be a single-payer system and organizers’ hope is that S.88 will lead to a new health care system in the near future.

While the grassroots movement may be focused on human rights, designing a system will require a hard look at the economics of dramatic reform. And to handle this task, the Vermont Joint Fiscal Committee (which handles legislative business when the session is out), has assigned Dr. William Hsiao, the creator of the much-praised Taiwanese health care system, which has dramatically lowered costs and increased coverage since it was implemented in 1996.

Single-payer activists have celebrated this selection as a sign that the Legislature is serious about reform. “We are at the door step of history,” noted Walter Carpenter, a volunteer for the Workers’ Center.

For Carpenter, a Montpelier resident who nearly died at the hands of the system when he suffered liver disease, the issue is personal. “In the last of my four operations for liver disease, I had lost my job, was turning yellow again and had to negotiate the price of my own life,” he told Truthout.

Will Obamacare Derail Statewide Single-Payer Efforts?

Perhaps, the worst possible conclusion would be if a movement in Vermont managed to secure a historic health care victory, only to be killed by the very federal health care reform that some overzealous commentators praised as “the greatest social achievement of our time.”

But this is entirely plausible. One major element of planning a new system is dealing with the federal government. The final version of federal reform includes “state innovation” language that address the ability of states to create their own health care systems. These systems, according to a memo by the Center for Policy Analysis, “could delay implementation of state single-payer plans.” Igor Volsky, writing for Think Progress, says the federal reform might be “a major set back for single-payer advocates”:

“States that still chose to pursue their own plan, will have to reconcile their programs with the federal requirements for Medicare, Medicaid, FEHBP, Indian Health Service and, most importantly ERISA – a 1974 law that, among other things, preempts states from enacting legislation that is “related to” employee benefit plans … States will have to go to Congress if their reform affects the health insurance offered by large employers.”

Rep. Dennis Kucinich (D-Ohio) had pushed hard to include an ERISA waiver, but it was dropped from the final bill – yet another painful example of progressive impotence in this legislative process. More trouble for statewide single-payer advocates occurred when the date for when states could opt out and make their own systems was pushed back from 2014 to 2017 – three years after statewide exchanges will go into effect.

This, according to Michael Briggs, communications director for Sen. Bernie Sanders, (I-Vermont), was an unfortunate and inexplicable tweak to the final bill. “Bernie (Sanders) has encouraged statewide single-payer for years. He was the one who pushed for and implemented provisions that would allow states to experiment. But, for complicated reasons I don’t fully understand, the date that these states could start experimenting was pushed back until 2017,” he said in an interview with Truthout.

This could mean that even if Vermont is able to pass through a single-payer bill in one of the next legislative sessions, it may require an act of Congress – a place notorious for not even giving single payer a passing glance – to allow such a transformation to take place. It is hard to grasp what a cruel irony it would be if Obama’s health care legislation became the death nail for statewide single-payer movements across the country.

But not all are so pessimistic. Dr. Hsiao, in an interview with Truthout, said he felt the new federal legislation, “left quite a bit of room for state innovations,” and was confident the state could secure the needed waivers should Vermont push legislation through.

Senator Sanders, too, has encouraged Vermonters to push through a bill. “As a long-time advocate of single-payer I’m glad the state is going to have a study,” Senator Sanders told The Nation. “I think the result of it will show that the most cost-effective way to provide universal, comprehensive health care to every Vermonter is through a single-payer approach. What the Vermont legislature has done is very important, very positive and I strongly support their efforts.”

Sanders added that he “will be going right into the President’s office and making the fight on the floor of the Senate that Vermont should be able to become a laboratory and go forward with a single-payer program. And I think if it works in Vermont many other states will want to do the same thing.”

Could Vermont Lead the Way?

Sanders has a point. Washington has proven to be entirely unwilling, or incapable, of truly standing up to entrenched special interests. Indeed, the Canadian single-payer health care system was created in much the same way as Sanders envisions for the United States, with one province taking the lead and others following in turn as the positive impacts became obvious. “Vermont, being a smaller state could be a demonstration site. And it can show states across the country how we can bend the cost curve,” said Hsaio.

“The battle for healthcare as a human right in Vermont is also really a battle for healthcare for people all over the country,” Haslam said.

This is precisely why the battle for single-payer health care in Vermont ought to be seen as a national struggle. The reform talks in Vermont may not involve close to a trillion dollars, but the type of change that could come out could represent a fundamental change in the way a state delivers and finances health care. And if it works, it could spread.

In fact, formidable statewide single-payer movements are forming all over the country and making the case that health care should be a human right – in Montana, Pennsylvania, New Mexico, Minnesota, Maryland, California,  and elsewhere. It is clear that private, for-profit health care is unsustainable and that Washington, DC, is not capable of addressing the issue. So, the responsibility to end this crisis now falls on grassroots movements across the states. Will Vermont be the first domino to fall?

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