PNHP

“Why Not Single Payer?” Parts 1-4

“Why Not Single Payer?” Parts 1-4

Part 1: Response to Paul Krugman and the Leading Democratic Presidential Contenders

Miles Mogulescu
The Huffington Post
Posted October 10, 2007 | 03:10 AM (EST)

Faster than you can say the word “Sicko” and turn around 3 times, the Democrats’ promise of health care for all has gone from “Universal Medicare For All” to “Individual Insurance Mandate”. In Monday’s New York Times, Paul Krugman defends that reversal in an article entitled “Why Not Single Payer?”

The possibility, after the 2008 elections, of a Democratic-controlled Congress which could pass Medicare For All (a/k/a Universal Single Payer Health Insurance) and a Democratic President who would sign it, could bring about the best chance to enact Medicare For All since Harry Truman first proposed it in 1948.

Yet without firing a shot and with no debate, the leading Democratic Presidential Contenders—Hillary Clinton, John Edwards and Barack Obama—as well as a good part of the Washington progressive infrastructure of think tanks and lobbying groups—have given up the fight for Medicare For All. Instead they propose variations of an Individual Mandate plan developed over the past 15 years by the “moderate” corporate wing of the Republican Party, a version of which Mitt Romney enacted in Massachusetts and which Arnold Schwarzenegger is proposing in California as an alternative to the single payer plan which the Democratic California legislature passed last year that he vetoed.

The thing is, I can’t quite figure out why the Democrats are in such rapid retreat from Medicare For All before the first battle has even been joined. Is it another example of the political cowardice by which the only Iraq resolutions that can pass the Democratic controlled Senate are a Republican-driven bill condemning MoveOn.Org. and praising Gen. Petraeus and another declaring the Iranian Revolutionary Guards a terrorist organization? Is it because the Democratic candidates are afraid of being accused by Republicans of supporting socialized medicine? (If so, it won’t help because Giuliani, Thompson, and Romney—whose Massachusetts plan Hillary largely imitates—all quickly claimed that Hillarycare 2.0 is socialized medicine, anyway.) Is it because they’ve been bought off by insurance companies and drug companies or fear that too many other Congress and Senate members have?

Or is it because they think that the insurance companies and drug companies are just too politically powerful to take on: Therefore the only way to insure most Americans is to make a deal with the devil that requires profit-making insurance companies to waive pre-existing conditions and charge everyone similar premiums regardless of age or health, in exchange for Congress delivering them 50 million guaranteed new profit-making customers, partly subsidized by the government?

Paul Krugman’s NY Times column is one of the first direct attempts by a liberal former supporter of single payer to try to make the case for adopting the Individual Mandate approach instead. According to Krugman, “basically it looks like something that could actually happen in the next administration, while enacting a single-payer plan…excellent as those plans are, might take a very long time.”

First, Krugman argues than an Individual Mandate would not require a big tax increase, although he admits (thus defeating his own argument) that taxes which most people would pay for single payer would most likely be lower than premiums that an Individual Mandate would require them to pay out of their pockets to buy insurance. Second, he argues than an Individual Mandate won’t make people feel that they’re “being forced into a government plan”. But the essence of an Individual Mandate plan is that the federal government forces the uninsured to buy health insurance. It involves even more government coercion than Medicare For All.

Finally, he argues that the Democrats’ proposals generally include a Medicare-like public insurance alternative which individuals may buy into and which “would evolve into single-payer over time.” Krugman never quite explains how this piece of alchemy will occur. Moreover, he admits that this is the part of the Democrats’ plan that the insurance industry will fight “tooth and nail”. If the Democrats have already surrendered on Medicare For All without firing a shot, isn’t it likely that the public alternative (the “socialized medicine” part) will be the first part of the plan to be compromised away when the legislative battles start in Congress and the insurance lobby starts exercising its muscle with its hundreds of lobbyists and tens of millions of dollars in campaign contributions?

In short, I find Krugman’s notion that an Individual Mandate is somehow more politically pragmatic than Medicare For All unconvincing and I don’t buy his argument that it’s a backdoor way to eventually get there. I even wonder how strongly he believes his own arguments. Only last January, in critiquing Schwarzeneggers’s Individual Mandate plan for California as a complicated “Rube Goldberg” device, Krugman argued that “the plan requires a much more intrusive government role than a single-payer system. Instead of reducing paperwork, the plan adds three new bureaucracies: one to police individuals to make sure they buy insurance, one to determine if they’re poor enough to receive aid, and one to police insurers to make sure they don’t discriminate against the unwell.” If you then add a public Medicare-like alternative that individuals can buy into, you need a fourth bureaucracy to administer that system.

Thus, when Hillary Clinton claims that her plan requires no new government bureaucracy, she’s not being candid with the voters. That lack of candor will quickly be exploited by the Republicans and the insurance and drug lobbies. While Republicans are wrong that her plan amounts to “socialized medicine”, such charges will still ring true since, in fact, her plan will require intrusive government regulation of the private insurance industry and coercive action to be sure that all citizens are obeying the individual mandate to buy health insurance. That’s one of the big reasons why, once the debate really starts, an Individual Mandate will not necessarily be a popular plan with the voters—Using the political pragmatism test, it stands a better chance of being rejected by the public and meeting the same fate as Hillarycare 1.0 than does Medicare For All, for which the political arguments are simple and clean.

Whatever Clinton might claim, Hillarycare 2.0 in fact requires a highly intrusive government presence in the lives of both businesses and individuals. As with Hillarycare 1.0, this is likely to be the biggest club that Republicans and their insurance company allies will use to defeat her or another Democrat as they did in 1994, unless so many compromises are made to water down the plan that insurance and drug companies decide it’s in their interest to accept the 50 million new mandatory government subsidized customers to pad their bottom lines. (Remember that with private insurance, approximately 30% of the healthcare dollar goes to administration, executive salaries and profits, compared to 2%-3% for Medicare; when all the political deals are finally cut, the private insurance and drug industries might find a new government subsidy for their bottom line an attractive deal.) If an Individual Mandate plan is more politically expedient than Medicare For All, it’s not for any of the reasons which Krugman cites and not because it’s likely to be more politically popular with the voters. The real reason is that with a few backroom political compromises, it could become a that plan the insurance and drug industries could learn to love.

END OF PART 1

Part 2: What’s Wrong With The Clinton / Obama / Edwards Health Care Plans

Miles Mogulescu
The Huffington Post
Posted November 2, 2007 | 04:23 AM (EST)

In Part 1 of this multi-part Huffpost series on the health care debate, I criticized the leading Democratic candidates — Hillary Clinton, Barack Obama, and John Edwards — for surrendering, without firing a shot, to the insurance and drug companies by opposing universal single payer health care.

In this second installment, I elaborate on the difference between universal single payer health care and the Clinton/Obama/Edwards universal insurance mandate plans and argue that universal mandates are bad social policy.

First, let’s define our terms:

“Universal Single Payer Health Care” (aka “Medicare For All”): From the moment that you’re born until the moment that you die, you will be covered by single quasi-public non-profit health insurer that will pay for both preventative care and for all necessary medical procedures and medications. You choose whatever doctor you want to see and you and your doctor decide on the care you need. It won’t matter whether you’re employed or not or whether your employer offers health coverage. You can never be denied insurance.

“Universal Insurance Mandate:” If you like your employer’s health plan, you can keep it. If your employer doesn’t provide health insurance and you don’t qualify for Medicaid, the government will make you pay for your own health insurance out of your own pocket. If you’re too poor to afford the premiums, at tax time every year the government will give you a credit to reimburse you for part of last year’s premiums. If you’re middle class, the government tax credits may be too small to make the insurance really affordable, or you may have to buy a less expensive high deductible policy in which you have to pay for your doctor visits out of your own pocket, unless you get really sick and need major surgery or an extended hospital stay. You and your doctor will still have to fight with your insurance company on whether it will cover procedures your doctor thinks are necessary. If you try to avoid buying your own insurance or think you can’t afford it, the government will penalize you.

To be fair, the Clinton/Obama/Edwards plans have some positive points. By banning “pre-existing conditions”, they would allow people to buy insurance who are simply uninsurable now. By requiring insurance companies to charge the same premiums regardless of age or health, they would make insurance more affordable to middle aged people. (Conversely, they would make insurance more expensive for younger people.) By providing tax credits, they would help lower middle class people afford at least lower priced, high deductible “catastrophic” policies. Most of the plans include a Medicare-like public alternative that individuals may purchase and whch competes with private insurance.

But overall, a universal insurance mandate is bad public policy compared to universal single payer health care. Some of the reasons:

1. It’s a colossal waste of money. While the administrative cost of Medicare is about 2-3 percent, approximately 30 percent of private insurance premiums go to overhead, profits and executive salaries. In 1999, the last year for which I could find numbers, health care administrative costs totaled $294.3 billion or $1,059 per capita, compared to $307 per capita in Canada. With insurance premiums having climbed 87 percent in the past decade, it would be a fair guess that administrative costs now exceed $400 billion per year. That’s more than enough to cover all of the uninsured without raising taxes.

2. Universal mandates punish the middle class who make too much to receive government subsidies, but too little to afford the cost of health insurance that the government will coerce them into buying. Massachusetts passed a state universal mandate program in 2006 which proponents of a universal mandate point to as the model for a national plan. According to recent a study by the Greater Boston Interfaith Organization, the premium for the minimum insurance plan is unaffordable for households earning between 300%-500% of the poverty level. Premiums for the minimum plan are free for those earning up to 150 percent of the federal poverty level of $10,210 for individuals and $13,960 for couples. Premiums are reduced for those earning up to three times the poverty level. Those earning more than that (i.e more than $30,630 for individuals, $41,880 for couples) must pay 100 percent of the premiums themselves. Premiums range from $1464 per year for young adults to $9600 per year for those over 55. So a 55-year-old couple earning $42,000 a year would have to pay $19,200 a year in premiums, nearly 46 percent of their pre-tax income, for a plan with deductibles of $2,000 per individual and $4,000 per family and out-of-pocket expenses of up $5,000 per year for individuals and $7,500 for families. A government mandate requiring people to pay these kinds of premiums, even if a national plan had somewhat higher subsidies, is effectively a huge hidden tax increase for the middle class and a huge boondoggle for the private insurance companies to whom the government delivers large numbers of new customers.

3. The universal mandate plans assume that most people will continue to be covered by their employers and therefore they won’t have to reach into their pockets to pay the full cost of meeting the government mandate. But employer-based health insurance is a dying dinosaur. Each year fewer employers offer insurance. Between 2000 and 2006, the percentage of employers offering some type of health insurance declined from 64.2 percent to 59.7 percent and it continues to decline. Even many people whose employers now provide health insurance are underinsured — according to a Consumer Reports survey, 29 percent of people with health insurance are “under-insured,” with coverage so meager that they often postpone medical care because of cost. Moreover, as insurance premiums escalate at a far greater rate than inflation or wage increases, more and more employers increase their employee’s share of premiums, raise deductibles and co-pays and reduce benefits. If you lose your job, you lose your insurance. In the larger picture, leaving the burden of health insurance on employers makes American companies less competitive in the world economy, compared to other capitalist democracies where the government pays for health care. Recently, Toyota named the savings in health care costs as the main reason for deciding to open a new auto plant in Canada rather than the U.S.

4. Large numbers of people opting for lower-cost, high deductible plans will lead to many middle class people avoiding preventive care and necessary treatment until they are already very sick, leading to worse health outcomes and in the long-run resulting in higher costs from waiting to treat preventable diseases until they become serious. If, after paying thousands of dollars a year in premiums, a middle class family has to pay $2,000-$4,000 in deductibles before their insurance kicks in, many won’t go to the Doctor until it’s an emergency. For example, someone with a chest infection won’t seek care, thus infecting others, and possibly ending up in the hospital with pneumonia. Men won’t get their PSA checked, women won’t get pap smears and breast exams, people won’t get colonoscopies, thus leading to cancers not being found at the early treatable stage.

5. The strongest argument by progressives who support a universal mandate is that the plan would include a Medicare-like public alternative that would compete with private insurance and, because it would so clearly be superior to private insurance, would eventually evolve into a single payer system. If this plan is modeled on Medicare, it would be a fairly generous plan in which you can choose your own doctor, in which most treatments your doctor recommends are covered, and in which deductibles and co-pays are low. This means that, even after greatly reducing the administrative costs associated with private insurance, it will still be expensive compared to high deductible plans. This leads to “adverse selection.” The young and healthy would opt for the cheaper plans. The people who will buy the Medicare-like plan will be those who think their health care costs are likely to exceed their premiums — in other words, the older and sicker. Far from slowly evolving into a single payer system, as its progressive supporters like Paul Krugman argue, the Medicare-like plan is likely to become more and more expensive as time passes, making it less and less affordable and forcing more and more people back to bare bones private insurance.

Part 3: The Clinton/Obama/Edwards Individual Mandates Represent a Losing Political Strategy

Miles Mogulescu
The Huffington Post
Posted December 3, 2007 | 09:59 AM (EST)

Hillary Clinton is busy in Iowa bashing Barack Obama for offering a health care plan that doesn’t punish uninsured people who won’t pony up their own money out of their own pockets to buy their own health insurance. She points out (rightfully) that if, under Obama’s plan, the Federal government doesn’t force everyone to buy health insurance, millions of uninsured people may decide not to pay for their health insurance and remain uninsured—Thus, Hillary charges, Obama’s plan fails to provide for Universal Health Insurance for all Americans.

Meanwhile, John Edwards criticizes Hillary’s plan on the same grounds. Her plan is vague and elusive on the details, calling for a Federal Mandate, but not specifying what the penalty will be on uninsured citizens who ignore the Mandate. If there’s no penalty, or the penalty is small (under Massachusett’s Universal Mandate plan the penalty is currently $295 per year) then Hillary’s plan doesn’t guarantee Universal Health Insurance either. In addition, Hillary’s plan does not cover 12-15 million illegal immigrants who will continue to flood emergency rooms, driving up premiums for everyone else. Even one of Hillary’s principal health care advisers, MIT economic professor Jonathan Gruber, acknowledges that Hillary’s plan will not include everybody, stating that “Any system that does not have a single payer will not have 100 percent coverage.”

At least John Edwards has the political courage to put some teeth into his plan for the federal government to force the uninsured to buy their own health insurance: Citizens will have to provide proof of health insurance when they seek care or file their Federal tax returns. If they don’t have health insurance, the Federal government will sign them up for a minimum basic plan and take the premiums out of their taxes or garnish their wages. However, Edwards, Obama, and Clinton all avoid spelling out what a minimum plan would cover, what the deductibles and co-pays would be, how much the premiums would cost, and how poor you will have to be for your premiums to be subsidized by the government.

The whole dust-up among Clinton, Obama and Edwards makes clear why Individual Mandate plans—far from being more politically pragmatic than Single Payer/”Medicare For All” plans—are likely to end up being as big a political disaster as Hillary’s 1994 health reform fiasco.

When the Republican Presidential candidate starts attacking the Democratic nominee for trying to compel middle class Americans to buy health insurance that they can’t afford, the Democrat’s poll numbers may start to dive. “If you’re a family making over $40,000 a year so you aren’t poor enough for subsidies and you don’t have health insurance, the Democrats will force you to sign up and keep your tax return or garnish your wages for thousands of dollars, since the average policy costs $10,000 for a family of four.” This is what the Washington consultants think is smart, pragmatic politics for Democrats? The health care issue, which should be a big Democratic advantage on the ‘08 elections, could suddenly turn into liability.

Even if a Democrat wins the Presidency, when it comes time to get a specific proposal through Congress, it will become clear to the voters either that their plan only pretends to cover all the uninsured but doesn’t, or it represents a massive backdoor tax on the uninsured middle class who will be forced by the Federal government to pony up thousands of dollars which they can’t afford to buy their own individual insurance policies. The most affordable of these policies, which realistically will still cost thousands of dollars a year, will of necessity have high deductibles and co-pays. This will force policyholders to forego preventive care and delay going to the doctor until they are really sick and may need major and expensive care. It may even lead to their early death from conditions like breast and prostate cancer that could have been treated if diagnosed earlier. (For some of the other serious problems with Universal Mandate plans as social policy, see Part 2 of this series on the Huffington Post.

Getting major health care reform through Congress (particularly the Senate, with 60 votes needed to end a filibuster) will require a massive popular mobilization. If history proves anything, it’s that Washington only enacts major social change if prodded by large scale social movements such as the union movement, the civil rights movement, and the anti-war movement. Without such movements, there would be no social security, no Civil Rights Act, and we might still be fighting in Vietnam. Why should progressives put such an effort into organizing a mass movement around Universal Mandate plans that will prove unpopular, will not really offer Universal Health Care, will put a huge financial burden on the uninsured middle class, and subsidize the private insurance industry? If we’re going to organize the kind of massive mobilization that will be necessary to really change the health care system in America, then let’s do it for a progressive plan that really works.

HR 676, the “Medicare For All” bill introduced in Congress by Rep. John Conyers, already has 78 congressional co-sponsors. It would cover all Americans from birth until death for all medically necessary treatments and drugs, as well as preventive care. As with Medicare, people can chose their own doctor and determine the best course of care in conjunction with him or her. The 30% of the health care dollar—over $400 billion this year—that goes to pay administrative costs of insurance companies, doctors, and hospitals, as well as insurance company marketing cost, executive salaries and profits, would be reduced to less than 5%, which alone would be enough to cover all of the uninsured. Medicare For All would be paid for by taxes, but would cost most Americans less in the aggregate than they are already paying in premiums, deductibles, co-pays, and forgone wages that are used for employer-provided health care. Unlike Clinton’s, Edward’s and Obama’s plans, it would be truly universal.

A mass movement has already begun to organize around Medicare-For-All. HR 676 has been endorsed by over 235 union organizations in 40 states, including 60 Central Labor Councils, as well as many citizens and religious organization. In California, SB 849, which would have provided for a single payer system for the State’s 37 million citizens, passed both houses of the California Legislature, only to be vetoed by Gov. Schwarzennegger. It was backed by over 400 organizations and unions including the League of Women Voters, the Consumers Union, the California Catholic Conference, the California Nurses Association, the California Teachers Association, AFSCME and the SEIU, and numerous cities and counties. Many other states are building large coalitions favoring Medicare For All.

With a mass mobilization still in its infant stages, several polls show that a majority of Americans are ready to support Medicare For All. A CBS News poll on September 14-16, 2007 asked, “Which do you think would be better for the country: having one health insurance program covering all Americans that would be administered by the government and paid for by taxpayers, or keeping the current system where many people get their insurance from private employers and some have no insurance?” 55% chose “One Program For All” (up from 47% in February, 2007) and 29% chose the “Current System” (down from 38% in February). (Back in January, 2007, according to an NBC News/Wall Street Journal Poll, 53% said they would be willing to pay higher taxes so that everyone can have health insurance, while 40% disagreed.)

So why are the leading Democratic candidates afraid to support Medicare For All and are instead offering up inferior, and politically less viable, proposals for Universal Mandates? When it comes to health care, Andrew Sullivan’s recent description of Hillary Clinton, unfortunately seems to apply to Barack Obama and John Edwards as well. “Her liberalism is warped by what you might call a Political Post-Traumatic Stress Syndrome. Reagan spooked people on the left, especially those, like Clinton, who were interested primarily in winning power. She has internalized what most Democrats of her generation have internalized: They suspect that the majority is not with them, and so some quotient of discretion, fear or plain deception is required to advance their objectives”.

As the above polls suggest, the Democratic candidates need not be so fearful when it comes to Health Care. Even if they are, progressives do not need to follow them in their fear and timidity. Only a progressive grassroots movement has the power to help a Democratic President get meaningful health care reform through Congress, given the millions of dollars in campaign contributions and the arm twisting of corporate lobbyists that will be mobilized against real reform by the insurance and drug industries and other corporate special interests.

So here’s the deal for our Democratic frontrunners: Run on your Universal Mandate plans if you must. You’ve probably gotten yourself so locked into them that it’s hard to change course in the middle of a political campaign. At least you’ll keep health care reform on the political front burner. We’ll even give you money and work on your campaign, because the country and the planet cannot afford another 4 years of a Republican in the White House.

But if you’re elected President, we’re not going to lend the force of our progressive movement to supporting your Universal Mandate plans. We’ll be organizing millions of people behind Single Payer Health Care/Medicare-For-All, the only type of plan that can actually guarantee quality, Universal Health Care to all Americans.

Part 4: In Partial Defense of Obama Against Clinton’s Attacks on His Health Care Plan

Miles Mogulescu
The Huffington Post
Posted February 4, 2008 | 01:36 PM (EST)

In this ongoing multipart Huffpo series entitled “Why Not Single Payer?” I’ve written extensively about why Single Payer/Medicare For All represents both better social policy and better political strategy than the healthcare plans advanced by the leading Democratic candidates, including both Hillary Clinton and Barack Obama (whom I enthusiastically support for numerous reasons other than his Healthcare plan. Among these is Obama’s ability to encourage popular movements which could push change beyond his own campaign proposals.).

However, as a single payer advocate, I find Obama’s healthcare plan to be politically superior, and certainly more honest, than Clinton’s.

First, let’s be clear on one thing: Despite the rhetoric, neither Clinton’s nor Obama’s plan guarantees Universal Health Care for all Americans. Hillary is being less than candid when she proclaims “My opponent will not commit to Universal Healthcare. I do not believe we should nominate any Democrat who will not explicitly support universal health insurance.”

Hillary is using a deceptive rhetorical slight of hand. “Universal health insurance,” which is at the heart of Clinton’s plan, is not the same as “Universal Healthcare” which can only be guaranteed by a single payer system under which all Americans are automatically covered for all medical care by a single, taxpayer funded, not for profit health insurer from birth until death. (Even one of Hillary’s top health care advisors, MIT Prof. Jonathan Gruber acknowledges that Clinton’s plan will not include everybody, admitting that “Any system that does not have a single payer will not have 100% coverage”.)

Clinton’s “Universal health insurance” is a plan under which, if your employer doesn’t provide health insurance or you don’t have a job, the government mandates that you must buy health insurance out of your own pocket. If your income is less than a certain level (which level Hillary’s plan glaringly does not specify) you will retroactively receive a tax refund or tax credit, on a sliding scale, after April 15th of the following year to reimburse you for part of the premium which you already laid out in the prior year. If you fail to buy your own health insurance, the federal government will penalize you.

Again, glaringly, Clinton’s plan does not spell out what the penalties will be. It should be noted, however, that if the penalties are small, the plan will not be Universal because many people will take the penalty, rather than pay thousands of dollars in insurance premiums that they cannot afford. That’s what is happening in Massachusetts under the Romney plan on which Hillary is modeling her plan. If the penalties are large — for example, if the government can garnishee your wages, keep your tax refund, or charge you a large fine — many middle class people who make too much to receive subsidies but too little to afford the premiums will see their standard of living go down.

While, notably, Clinton has not specified an enforcement mechanism in her plan, on Sunday she stated that “I think there are a number of mechanisms” [for enforcing a mandate, including] “going after people’s wages”. Clinton plan punishes the uninsured middle class which makes too much money to qualify for a tax subsidy but too little to afford a meaningful insurance policy which averages $5,000 for an individual and $12,000 for a family of four.

Obama responds, “It’s not that people don’t want health care, it’s that can’t they can’t afford it”. Unless and until health insurance costs come down to a level that everyone can afford, Obama would not punish people for not buying insurance.

Obama circulated a mailer last week which criticized Hillary’s plan, showing a photo of a couple sitting at a kitchen table, stating truthfully “Hillary’s health care plan forces everyone to buy insurance, even if you can’t afford it”. In response, the Clinton campaign convened a conference call of health care policy advisors to denounce the mailer. One of the advisors, Len Nichols, denounced the leaflet and photo, stating, “It is as outrageous as having Nazis march through Skokie, Illinois. I just find it disgusting that this kind of imagery is being used to attack the only way to get to universal coverage.”* (The Clinton campaign and Nichols later apologized for the remark.)

In fact, Obama’s mailer demonstrated why Clinton’s individual mandate plan is a political loser for Democrats. If Clinton’s campaign freaks out so badly at relatively mild criticism from Obama, imagine what it will face from Republicans if Hillary is the nominee in the fall. Already, the Republican National Committee put out a press release saying “Hillary Clinton wants to garnishee your wages”. Here’s what the Republicans will be saying in the fall: “If you’re an uninsured family making over $40-$50,000 a year so you aren’t poor enough for subsidies but can’t afford insurance, Hillary will garnishee thousands of dollars of your wages since the average policy for a family of 4 is around $12,000.” That should be enough to scare off millions of middle class families earning less than $100,000, and make them think twice about voting for a Democrat.

The growing failure of Romney’s Massachusetts plan will give ample evidence to back these Republican charges. In Massachusetts, premiums are subsidized for people earning up to 3 times the poverty level (i.e. up to $30,630 for individuals and $41,880). If you make more than that, you have to pay the full cost of insurance, which ranges from $1464 a year for young adults to $9600 a year for those over 55. At those prices, it’s no surprise that only 7% of the 244,000 uninsured Massachusetts citizens who are mandated to buy unsubsidized insurance had signed up by last Dec. 1, although fines for each uninsured individual will be $2,000 in 2008.

So Obama is right to criticize Clinton for putting forward a plan that would penalize the uninsured middle class, unless and until the cost can be brought down to an affordable level. Hillary’s plan is morally wrong, and it’s a political loser.

Obama’s plan is in most other ways similar to Clinton’s. Both plans would prevent insurance companies from denying coverage based on pre-existing conditions, provide community rating under which risk is shared by limiting the premium difference between the healthy and less healthy and the young and old, and provide subsidies for the less well off to buy insurance. They also both provide for a public plan to compete with private insurance. If enacted by Congress (absent the mandate), these plans will help millions of people obtain health insurance who don’t now have it. Obama’s plan has an additional provision that will lower premiums more than Clinton’s plan would. 80% of health care costs cover the care for the sickest 20% of the population. Obama’s plan provides for the Federal government to reimburse insurers for part of the cost of catastrophic care if they use that reimbursement to lower premiums.

Nevertheless, neither Obama’s nor Clinton’s plan will provide truly Universal Healthcare for all Americans. At a cost of a little more than $100 billion a year each, financed largely through letting Bush’s tax cuts for the wealthy lapse, neither plan can make health insurance affordable for all Americans. That can only be done through a single payer/Medicare For All plan which would save approximately $350-$400 billion dollars a year by eliminating the nearly 1/3 of health care costs that go to paying the overhead, advertising, executive salaries, and profits of private health insurers, and the cost of employees in Doctor’s offices and hospitals required to process claims from multiple insurers (as opposed to 3%-4% overhead for Medicare.)

That’s why I still find it disappointing that Obama — who has a sophisticated understanding of the single payer concept — did not have the political courage to join the 78 Congressional co-sponsors of HR 676, the Medicare For All bill introduced in Congress by Rep. John Conyers. But unlike Clinton, at least Obama is not hostile to single payer. In the South Carolina debate, Clinton angrily accused Obama of having once been a supporter of single payer, as though he had once been a Communist. Obama responded that if he were designing a health care system from scratch, he would support single payer, but that since many people are happy with their current health insurance, he thought it was better for the time being to build on the present system. I disagree with Obama. The present system of employer-based health insurance is collapsing under its own weight and an attempt to build on this shaky foundation will also collapse, if not right away, then within a few years.

Despite Obama’s political calculation to the contrary, the combination of a President with Obama’s extraordinary leadership skills and a budding mass movement already supporting HR 676 (which includes over 235 union organizations in 40 states, including 60 Central Labor Councils, as well as many citizens and religious organizations) the American people can be convinced to support Medicare For All. A CBS News poll in September asked “Which do you think would be better for the country: Having one health insurance program covering all Americans that would be administered by the government and paid for by taxpayers, or keeping the current system where many people get their insurance from private employers and some have no insurance?” 55% chose “One Program For All” and 29% chose the “Current System”.

If Obama is elected President, there will be a strong and serious mass movement supporting HR 676. A President Obama is less likely to meet such a movement with hostility than would a President Clinton. Morever, if Obama manages to pass something resembling his plan, when it fails to provide Universal Healthcare, and when increasing numbers of employers drop or reduce their health benefits within a few years, it is conceivable that Obama could support an evolution towards a single payer system in his second term.

Moreover, in California, a similar coalition just defeated an individual mandate plan proposed by Gov. Schwarzenneger and the Democratic Speaker of the California Assembly with only a single State Senator supporting the bill in Committee. In contrast, a year ago both houses of the California Legislator passed SB 840 which would have created a single payer system for the state’s 37 million citizens, had it not been vetoed by Gov. Schwarzenneger. If California gets a Democratic Governor in 2010, it could be the first state to enact single payer healthcare on a state level. To succeed, it will need a series of waivers from the Federal government and the ability to use Federal healthcare funds towards the cost of the State system. Whatever the fate of Obama’s national plan, it is unlikely that a President Obama would try to block a state from experimenting with its own single payer system which, if successful, could provide the model for the rest of the country. (Canada’s single payer system started first in the Province of Saskatchewan under a Conservative government, before expanding to cover the entire country.)

So, as a supporter of single payer/Medicare For All, I find it disappointing that Obama did not have the audacity to support single payer. Nevertheless, his program is better than Hillary’s coercive individual mandate plan. It will certainly be easier to run on against the Republicans in the fall, and to potentially gain enough popular support to get through Congress without too many crippling compromises. Maybe I’m being naïve, but, in the long-run, the fact that Obama understands single payer and is not hostile to it as a concept, gives me hope that we might get there, or close to there, over the course of an 8 year Obama Presidency.

For that to happen, it will take a mass movement in support of single payer health. Obama speaks eloquently of the fact that real social change is hard and starts from the bottom up through organized movements, not from the top down from a government that institutionalizes fundamental social change only when forced to from below. A mass movement for single payer healthcare has already begun to take shape. My hope is that an Obama Presidency will help give it the space to flourish, and to push Universal Healthcare beyond the bounds of Obama’s more modest proposals.

*Nichols is head of the Health Policy Program of the New America Foundation, which helped advise Romney, Schwarzennegger and Clinton on their health plans. His predecessor at NAM was Laurie Rubiner, a former aide to Bob Dole who was assigned by Dole in 2003 to devise a competing plan to Hillary Clinton’s first health reform plan. She developed the idea of individual mandates, which had roots in conservative economist Milton Friedman, Richard Nixon’s attempts to counter Democratic efforts to enact single payer, and the conservative Heritage Foundation. After leaving her Senate posts, she went to NAM where she further developed the individual mandate idea and helped lay the basis for Romney’s Massachusetts plan. In 2005, Rubiner became Hillary Clinton’s legislative director (a post she just left) where she was instrumental in developing Hillary’s individual mandate plan. In the next installment of this “Why Not Single Payer?” Huffpo series, I will trace the history of individual mandates as a conservative Republican idea that has ironically been adopted by leading Democrats, including Hillary Clinton.

Focusing on coverage, or costs?

The Cost-Coverage Trade-off

Ezekiel J. Emanuel, MD, PhD
JAMA
February 27, 2008

According to recent polls, many Americans consider health care reform the No. 1 domestic issue. Presidential candidates, other politicians, health policy experts, labor leaders, business groups, and others have responded with numerous reform proposals. And somehow in the clamoring, health care reform has become equated exclusively with expanding coverage to the 47 million uninsured Americans.

This is a mistake. As serious as it is, the problems of the uninsured and lack of coverage are symptoms, not the underlying problem. …the diagnosis and treatment need to focus on health care costs. The fundamental problem arises because of a cost-coverage trade-off. Without controlling health care costs, any attempt at universal coverage will be transient.

Warnings that costs are too high and cannot go higher are a perennial and recurrent theme dating back to at least the 1970s. But costs always increase, and the system has thus far accommodated them. This time, however, things may be different.

…employers and workers are simply finding premiums too high. Providing family health care coverage to 1 worker is like hiring a second worker at minimum wage. A cost of approximately $12 000 per year for family health insurance–about a quarter of the median income–seems to constitute a cost “brick wall” that begins to make health insurance coverage unaffordable despite other positive economic factors.

The cost-coverage trade-off does not mean that cost control and universal coverage should occur sequentially. Waiting to cover all Americans until costs are controlled is like blaming the victim. The uninsured are not driving health care cost increases. Moreover, lack of insurance adversely affects their health and economic well-being. Cost control and universal coverage must occur simultaneously. Expanding coverage and then worrying about controlling costs, as was done in Massachusetts, is not a tenable policy. Without policies to restrain cost increases over time, universal coverage will not be sustainable.

What is a serious cost control plan? True cost control means reducing how much health care cost increases from year to year, to about 1% more than overall economic growth. Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records, and improving quality are merely “lipstick” cost control, more for show and public relations than for true change. Reducing the waste from insurance underwriting, sales, and marketing costs is valuable but constitutes a 1-time savings. Furthermore, because these costs are in large part a consequence of selling insurance individually to more than 6 million businesses, they can be achieved only by completely revamping employer-based insurance. Cost control will require comprehensive reform of both employer-based insurance and the dysfunctional health care delivery system that will take years of sustained effort.

…there are real political advantages from focusing on costs. The politically powerful constituencies whose support is integral to any health care reform really care about rising health care costs. Employers worrying about global competition, state governors handcuffed by rising Medicaid bills, and the 85% of insured Americans all care about rising premiums, deductibles, co-payments, and prescription drug prices. Because of self-interest, costs can motivate these groups in ways that covering the uninsured has not. In the strange calculus that is American politics, the more politically salient issue of costs may provide a better way to achieve the comprehensive reforms necessary to cover the uninsured than the hitherto futile direct moral appeal.

http://jama.ama-assn.org/cgi/content/full/299/8/947

Comment:

By Don McCanne, MD

Ezekiel Emanuel is certainly correct when he states that we must focus on health care costs as we expand health care to everyone. He is also correct when he implies that current political proposals such as electronic medical records, wellness programs, quality incentives, and disease management programs would not have any significant impact on controlling spending. But he is wrong when he implies that there is no reform proposal that would both control costs and cover everyone.

A single payer national health program is specifically designed to include everyone automatically, and to slow the rate of growth in spending, while shifting funds from wasteful administrative services to more beneficial health care services.

He concedes that reducing the waste of the insurance industry is “valuable,” but then he dismisses it as a “1-time savings.” Since it is a fundamental structural change in the health care financing system, it is not a one-time savings, but rather it is a change that shifts the curve of the health care spending down to a new lower trajectory – permanently. All of the other cost-saving features of the single payer model each have the effect of further lowering this trajectory.

Although he mentions that cost control will require comprehensive reform, his own model, which he developed with Victor Fuchs, doesn’t seem to address the cost issue that he says (and we agree) is so important. They would establish a voucher system for purchasing private insurance and fund it with a regressive value-added tax (VAT). They would control spending by providing only a “basic” plan for everyone, but allow individuals to purchase services or coverage beyond the basic plan.

Victor Fuchs and I participated in a panel debate at Stanford. I asked him if providing a walker would be a basic service for a patient with disabling osteoarthritis of the hip, whereas hip replacement surgery would be an option for those willing (and able) to pay for it. He emphatically insisted that hip replacement surgery is a basic benefit, even though it is an elective surgery. My point is that all reasonable beneficial health care services should be covered, and we should not be distracted by the fictional concept that there is an inexpensive, lower tier of services that would satisfactorily address the health care needs of all of us, with an opt-up for extra services. That lower tier includes most of our health care services and products (excluding vanity cosmetic surgery and the like), and it is very expensive.

Dr. Emanuel also states in his article, “…health reform proposals by presidential candidates or others should be critically evaluated primarily on whether they establish a financing structure and incentives for the delivery system reform that really control costs. If they lack a serious plan, they are not credible reforms.”

Physicians for a National Health Program (www.pnhp.org) has advanced a highly credible reform proposal. Anyone else?

AHIP's recommendation for rescissions

Health Insurers Address Issue Of Nixed Policies

By Rhonda Rundle
The Wall Street Journal
February 27, 2008

The health-insurance industry is racing to defuse a growing furor over retroactive policy cancellations that have saddled some patients with big medical bills and sparked lawsuits.

America’s Health Insurance Plans, an industry group, is pushing a proposal with state regulators that would give consumers the right to appeal such policy cancellations, known as rescissions, to an external panel, whose decisions would be binding.

But some critics say that the practice of unfair policy rescissions suggests that private health insurers aren’t up to the task of ensuring that sick people maintain coverage.

“We are often viewed as having very different views from the insurance industry, but on this particular matter we think this is a step in the right direction,” said Ron Pollack, executive director of Families USA, a Washington nonprofit organization.

http://online.wsj.com/article/SB120408088594795743.html.html

Comment:

By Don McCanne, MD

Our goal is to bring everyone under the health care financing umbrella, including those with significant health care needs. The goal of the insurance industry is to bring the healthy under their umbrella, while excluding those with health care needs.

The insurers find that some do sneak in who need health care. When the underwriting process fails to exclude these individuals in the first place, they still want one more chance to throw them out. Because of the black eye they’ve received over their excessively aggressive, cruel cancellation activities, they now wish to establish a process by which they can receive an independent stamp of approval for these rescissions.

It is no surprise that the insurance industry’s response is merely to attempt to relieve themselves of the obligation to cover these individuals, when the real problem that needs to be addressed is to provide these individuals with health care.

Ron Pollack of Families USA has repeatedly rejected single payer as a model of reform, insisting that reform must be achieved in incremental steps instead. We’ve been following that incremental path for the last couple of decades, and all parameters are worse. He claims that the stamp-of-approval process is a step in the right direction, but granting private insurers authoritative approval to jerk insurance coverage from under those who need it sounds like another step backwards to me.

'Socialized medicine' loses much of its stigma

Most people no longer fear the term that has turned people off since the days of FDR

By Susan Brink
Staff Writer
Los Angeles Times
February 25, 2008

The term “socialized medicine” may be losing its boogeyman status, according to a survey of voting-age adults. Long uttered in warnings against any sort of government involvement in healthcare, today the term has largely lost its scare power.

That’s according to a study led by Robert Blendon, professor of health policy and political analysis at the Harvard School of Public Health.

“This is a term from the 1940s,” Blendon says. “We wondered if anyone even knew what it meant anymore.” To find out, his team, along with pollsters at Harris Interactive, asked more than 2,000 people in two surveys what they knew about the term. Among the findings, released Feb. 14:

* Of the respondents, 67% said they understood what “socialized medicine” meant. Of those, 79% said the term means that the government makes sure everyone has health insurance. Only 32% said it means that the government tells doctors what to do.

* Of those who said they understand the term, 45% said that if America had socialized medicine, the health care system would be better, while 39% said it would be worse.

* Not surprisingly, opinions differed according to respondents’ politics. Among Republicans, 70% thought socialized medicine would make the healthcare system worse. Among Democrats, 70% thought it would make things better.

Independents were split more evenly, with 45% saying that socialized medicine would be an improvement, and 38% saying it would be worse than the country’s current healthcare system.

“It’s still an emotionally charged term for Republicans. The phrase itself gets them very angry,” Blendon says. “But Democrats and independents don’t see it as a term that drives them away.”

The words “socialized medicine” have turned up at just about every discussion of government-sponsored health insurance in America’s history going back to Franklin D. Roosevelt, who, after unemployment insurance and Social Security passed, wanted to develop a national health insurance program. The term was used at that time by the American Medical Assn. to attack the idea.

President Truman followed in FDR’s footsteps with a national health insurance plan that once again was attacked by the AMA and some politicians using the phrase; that plan died too. The phrase had its heyday in the post-World War II years and through the 1950s and 1960s, when it was tightly linked to the threat of the Soviet Union and the postwar Red Scare.

The pejorative and loaded term almost killed the famous Framingham Heart Study, which began in the late 1940s and ultimately uncovered major risk factors for heart disease.

Dr. Thomas Dawber, then director of the study in Framingham, Mass., later said he had to work hard to convince volunteers and the town’s doctors that the study was not a form of creeping socialized medicine. He held meetings to assure them that government wasn’t going to snoop into medical records, steal patients or tell physicians how to practice their profession.

The term raised its head again through the 1960s as the American Medical Assn. used it in attempts to discredit government proposals to insure the elderly and the poor. Those proposals, Medicare and Medicaid, were finally signed into law in 1965, 20 years after Truman proposed national health insurance. Symbolically, Truman was the first to sign up for Medicare.

More recently, advertisements have warned against the prospect of government encroachment into healthcare without the actual use of the words “socialized medicine.”

The Harry and Louise ads, funded by the Health Insurance Assn. of America, showed a couple despairing over what they claim to be a government takeover of healthcare. The couple in the ads, which ran in 1993 in opposition to President Clinton’s proposed health care plan, conclude: “They choose. We lose.”

Blendon said it came as a surprise to him and other pollsters to again hear, during the 2008 presidential campaign, what sounded to them like an antiquated phrase.

Former Republican candidate Mitt Romney, talking about Sen. Hillary Rodham Clinton’s new healthcare proposal, labeled it “socialized medicine.”

And former Republican candidate Rudolph Giuliani said, “Whether it’s HillaryCare or ObamaCare or EdwardsCare, the idea that it’s not socialized medicine is a trick. It’s a massive growth of government control of medicine.”

The phrase, says Blendon, is no longer frightening to most people. “It has sort of morphed in the American mind into making sure everyone has coverage.”

susan.brink@latimes.com

What's wrong with individual health insurance mandates?

by Claudia Chaufan
San Francisco Bay Area Indymedia
Tuesday Feb 26th, 2008 5:01 PM

Individual health insurance mandates have lately been hailed as the solution to the health care crisis in America. Mandates to purchase health insurance have been included in legislative proposals at the state level — for instance, by Gov. Schwarzenegger and Speaker Nunez, in their “Health Care Security and Cost Reduction Act”, or at the federal level, by Hillary Clinton in her “American Health Choice Plan”. Can mandates achieve universal access to health care and control rising costs of medical care? This article explains why they can’t.

Lately, legislation including a universal mandate — a legal obligation that everybody purchase a health insurance policy — has been hailed as the solution to the health care crisis in America. At the state level, mandates have been included, for instance, in Gov. Schwarzenegger and Speaker Nunez’s “Health Care Security and Cost Reduction Act”, and at the federal level, by Hillary Clinton in her “American Health Choice Plan”. Yet many of us remain skeptical. Why? After all, if everybody is forced to buy a health insurance plan — maybe with a subsidy if you are “poor enough” — would this not resolve the problem of uninsurance? Maybe so. But the real question is: would mandating universal health insurance guarantee universal access to medical care? And the short answer is no.

A longer answer would include that many health reform proposals promising heaven on earth rely on fantasy numbers, not facts: for instance, there is reason to believe that Swcharzenegger’s stillborn legislation would have run out of money by the fifth year of operation (http://www.lao.ca.gov/2008/Webcasts/hcr_1-23-08/flashversion/hcr_flash.aspx). Indeed, often these proposals offer no numbers at all, fantasy or otherwise: a sound study estimating the capacity of “Hillary Care” to guarantee that those who “like” their current health insurance “will be able to keep it”, as Hillary promises (http://www.hillaryclinton.com/feature/healthcareplan), has yet to be produced. But worst of all is the tendency, popular among many health care experts, including M.I.T. professors (http://www.nber.org/papers/w13758) to commit the capital sin in health policy: confusing universal health insurance with universal access to comprehensive medical care.

Now, it could very well be that these experts are not confused, and only hope that ordinary citizens won’t be smart enough to tell the difference — that we will all be convinced if only they repeat “universal” enough times. Whichever the case may be, as political analyst Robert Kuttner recently pointed out, there is a fundamental difference between “universal” social health insurance, such as proposed by single payer health care reform, and a “universal” health insurance mandate (http://content.nejm.org/cgi/content/full/358/6/549). And it is not merely semantic, because clearly in both approaches “universal” means “everybody”. It is a difference of substance.

In a social health insurance system everybody gets insurance by virtue of being a citizen or a resident, everybody contributes to the system according to ability to pay, and everybody is guaranteed an amount and type of services. This is possible because the system, whose ultimate goal is to provide the most and best care to all participants with whatever budget it has, counts on a predictable influx of money, has as sole incentive finding the most efficient ways to spend it, is able to estimate the needs of participants, and can utilize their collective purchasing power to bargain for best prices of services and goods.

In contrast, in a system based on mandates, nobody “gets” anything, really. Rather, everybody is compelled to buy a policy, by law. Hence guaranteeing a decent amount of medical care to the population at large, that many consider a social problem, is turned into a “problem” of “every” individual or “every” family, who are forced to comparative-shop for affordable policies, while second-guessing current or future medical needs as they decide which is the best investment for their resources — a more comprehensive health policy, rent, or food.

A key assumption underlying individual mandates is that forcing an influx of “customers” into the health insurance marketplace, flooded with private insurers’ “products” made to suit a range of personal preferences will, through the powerful and reveered “invisible hand”, improve the quality of medical goods and services and bring their prices down, such that on average they will be affordable to everybody. This of course would be true, if shopping for medical services were functionally equivalent to shopping for designer shoes. Faced with an offer, you are always free to take it or leave it, depending on how good the deal is. If it is not good enough, you can always wait until the next Christmas sale. Or you can decide that you are not so crazy about those shoes after all, and shop for something else, until those recalcitrant shoe sellers realize that if they want your dollars, they have to behave reasonably, and offer the best they can at the least possible price.

But of course nobody needs a doctoral degree to understand that the need for medical care cannot be compared with the want for designer shoes. Nor does one need a doctoral degree to understand that a mandate to buy, for instance, drivers’ insurance, does not guarantee full protection against the expenses incurred if one gets into a car accident. While some policies might cover those expenses, they are unlikely to be cheap. What the current mandate to buy drivers’ insurance “guarantees”, if the word makes sense at all, is that, given the law, we won’t get in trouble with it if we are stopped by the police. Which is why nobody claims we have “universal drivers’ insurance”. Likewise, whichever health insurance policies we may afford to buy, if there is a mandate, it will only “guarantee”, aside from a steady pool of clients for private insurers, that we are in compliance with the law when we file our taxes (assuming this is how the mandate is enforced).

Under our current system, which relies heavily on private insurance, paying for medical care is insurers’ greatest “cost”. Now, like any other business, insurers’ ultimate goal is to control the costs of running their business while maximizing profits. Hence the increasingly bewildering range of “choices” of “insurance products” that make sure that insurers will not have to pay more for medical care than they collect in premiums and that there remains enough spare change to keep CEOs and shareholders happy.

And because profit is the essence of business, however much “mandate” fans boast they will force insurers to not turn people down on the basis of “pre-existing conditions”, they will not — they cannot — force them to sell policies that will not meet insurers’ profit maximizing goals. So mandate supporters remain conveniently vague whenever asked how much “consumers” will have to pay for policies offering more than minimum coverage or even what will count as minimum coverage, hoping that we won’t notice when they fail to compute out-of-pocket costs to “consumers” — deductibles, co-pays, co-insurance — as “costs”.

Or worse, they hope that by repeating scare stories backed by fanciful (and distorting) statistics Americans will end up believing that the only alternative to the current mess is a mandate’s version of “universal health coverage” and that a social insurance system will inevitably cause an invasion of alien Reds, with long lines in cold winter mornings in which everybody is given the same loaf of bread (substitute “sees the same doctor” or “receives the same medicine”), however far this scenario is from the daily reality of Canadians, Brits, Germans, Spaniards, and so forth.

Now, the point is not to force business to do business at a loss. The point is why, when it comes to health care, we should insist on a model that confuses health care with designer shoes and that has failed to deliver the goods. Because it is clear that choices that are meaningful, not of health policies but of doctors and services when and to the extent we need them are increasingly out of reach for ordinary Americans.

Which is why only a system based on the principle of social insurance, that spreads the risk over a large pool — all Californians, or even better, all Americans — to which all participants contribute an affordable proportion of their income, and where individuals are guaranteed real choice, not of policies but of medical services, constitutes meaningful universal health care reform.

And sound legislation exists: it is the single-payer model proposed by SB840, the California Universal Healthcare Act, vetoed by Schwarzenegger, who appears to dislike “big government bureaucracies” (http://www.youtube.com/watch?v=asgUP31Vf8o) but can live with the 30% mark-up of the bureaucracy of private insurers. It is also HR676, the expanded and improved Medicare for All Act, conveniently made invisible every time the major media or policy thinktanks report on the health care crisis, and disqualified by Hillary as “difficult to achieve” (http://www.democracynow.org/2008/2/8) for reasons that we are never given.

Now, will a social insurance system resolve all the problems in American medicine? Of course not. “Financing” and “delivery and organization” of medical care are different analytic categories, so securing the first will not miraculously resolve, for instance, the problems of over-reliance on expensive medical technologies, lack of uniformity of medical records, or insufficient emphasis on preventive care (or the never-settled question of whether Americans are as dutiful as others when it comes to eating our veggies). Those are internal to the system — to any health care system — and require separate attention. But a sound financial structure is a prerequisite to making improvements in the delivery and organization of a medical system possible.

At any rate, as Kuttner said, the “debate” about whether or not to have a mandate misses the point that the financial structure of the system, built on false assumptions and perverse incentives, is sick (http://www.democracynow.org/2008/2/8). The real issue is whether or not major presidential candidates are willing to “do it right” and use their formidable political power, social prestige, and precious media time to bring “public opinion around” (http://www.democracynow.org/2008/2/8), assuming they haven’t yet been informed about the increasing public support for single payer among the electorate (http://abcnews.go.com/images/pdf/935a3HealthCare.pdf), including physicians (http://www.philly.com/philly/business/20071204_Doctors_endorse_single-payer.html).

As Kuttner, supporters of single payer wish our politicians and opinion leaders “got it right” this time, stopped trying to reinvent the wheel, and stood for the only type of reform that can bring affordable and comprehensive health care to all Americans.

Claudia Chaufan teaches sociology of health and medicine and health policy at the University of California at Santa Cruz. She has written extensively on social inequalities in the diabetes epidemic, for general and specialized audiences, nationally and internationally. She is the Vice President of California Physicians Alliance, the Californa Chapter of Physicians for a National Health Program, an organization that supports single-payer health care reform.

AHIP’s recommendation for rescissions

Health Insurers Address Issue Of Nixed Policies

By Rhonda Rundle
The Wall Street Journal
February 27, 2008

The health-insurance industry is racing to defuse a growing furor over retroactive policy cancellations that have saddled some patients with big medical bills and sparked lawsuits.

America’s Health Insurance Plans, an industry group, is pushing a proposal with state regulators that would give consumers the right to appeal such policy cancellations, known as rescissions, to an external panel, whose decisions would be binding.

But some critics say that the practice of unfair policy rescissions suggests that private health insurers aren’t up to the task of ensuring that sick people maintain coverage.

“We are often viewed as having very different views from the insurance industry, but on this particular matter we think this is a step in the right direction,” said Ron Pollack, executive director of Families USA, a Washington nonprofit organization.

http://online.wsj.com/article/SB120408088594795743.html.html

Comment:

By Don McCanne, MD

Our goal is to bring everyone under the health care financing umbrella, including those with significant health care needs. The goal of the insurance industry is to bring the healthy under their umbrella, while excluding those with health care needs.

The insurers find that some do sneak in who need health care. When the underwriting process fails to exclude these individuals in the first place, they still want one more chance to throw them out. Because of the black eye they’ve received over their excessively aggressive, cruel cancellation activities, they now wish to establish a process by which they can receive an independent stamp of approval for these rescissions.

It is no surprise that the insurance industry’s response is merely to attempt to relieve themselves of the obligation to cover these individuals, when the real problem that needs to be addressed is to provide these individuals with health care.

Ron Pollack of Families USA has repeatedly rejected single payer as a model of reform, insisting that reform must be achieved in incremental steps instead. We’ve been following that incremental path for the last couple of decades, and all parameters are worse. He claims that the stamp-of-approval process is a step in the right direction, but granting private insurers authoritative approval to jerk insurance coverage from under those who need it sounds like another step backwards to me.

‘Socialized medicine’ loses much of its stigma

Most people no longer fear the term that has turned people off since the days of FDR

By Susan Brink
Staff Writer
Los Angeles Times
February 25, 2008

The term “socialized medicine” may be losing its boogeyman status, according to a survey of voting-age adults. Long uttered in warnings against any sort of government involvement in healthcare, today the term has largely lost its scare power.

That’s according to a study led by Robert Blendon, professor of health policy and political analysis at the Harvard School of Public Health.

“This is a term from the 1940s,” Blendon says. “We wondered if anyone even knew what it meant anymore.” To find out, his team, along with pollsters at Harris Interactive, asked more than 2,000 people in two surveys what they knew about the term. Among the findings, released Feb. 14:

* Of the respondents, 67% said they understood what “socialized medicine” meant. Of those, 79% said the term means that the government makes sure everyone has health insurance. Only 32% said it means that the government tells doctors what to do.

* Of those who said they understand the term, 45% said that if America had socialized medicine, the health care system would be better, while 39% said it would be worse.

* Not surprisingly, opinions differed according to respondents’ politics. Among Republicans, 70% thought socialized medicine would make the healthcare system worse. Among Democrats, 70% thought it would make things better.

Independents were split more evenly, with 45% saying that socialized medicine would be an improvement, and 38% saying it would be worse than the country’s current healthcare system.

“It’s still an emotionally charged term for Republicans. The phrase itself gets them very angry,” Blendon says. “But Democrats and independents don’t see it as a term that drives them away.”

The words “socialized medicine” have turned up at just about every discussion of government-sponsored health insurance in America’s history going back to Franklin D. Roosevelt, who, after unemployment insurance and Social Security passed, wanted to develop a national health insurance program. The term was used at that time by the American Medical Assn. to attack the idea.

President Truman followed in FDR’s footsteps with a national health insurance plan that once again was attacked by the AMA and some politicians using the phrase; that plan died too. The phrase had its heyday in the post-World War II years and through the 1950s and 1960s, when it was tightly linked to the threat of the Soviet Union and the postwar Red Scare.

The pejorative and loaded term almost killed the famous Framingham Heart Study, which began in the late 1940s and ultimately uncovered major risk factors for heart disease.

Dr. Thomas Dawber, then director of the study in Framingham, Mass., later said he had to work hard to convince volunteers and the town’s doctors that the study was not a form of creeping socialized medicine. He held meetings to assure them that government wasn’t going to snoop into medical records, steal patients or tell physicians how to practice their profession.

The term raised its head again through the 1960s as the American Medical Assn. used it in attempts to discredit government proposals to insure the elderly and the poor. Those proposals, Medicare and Medicaid, were finally signed into law in 1965, 20 years after Truman proposed national health insurance. Symbolically, Truman was the first to sign up for Medicare.

More recently, advertisements have warned against the prospect of government encroachment into healthcare without the actual use of the words “socialized medicine.”

The Harry and Louise ads, funded by the Health Insurance Assn. of America, showed a couple despairing over what they claim to be a government takeover of healthcare. The couple in the ads, which ran in 1993 in opposition to President Clinton’s proposed health care plan, conclude: “They choose. We lose.”

Blendon said it came as a surprise to him and other pollsters to again hear, during the 2008 presidential campaign, what sounded to them like an antiquated phrase.

Former Republican candidate Mitt Romney, talking about Sen. Hillary Rodham Clinton’s new healthcare proposal, labeled it “socialized medicine.”

And former Republican candidate Rudolph Giuliani said, “Whether it’s HillaryCare or ObamaCare or EdwardsCare, the idea that it’s not socialized medicine is a trick. It’s a massive growth of government control of medicine.”

The phrase, says Blendon, is no longer frightening to most people. “It has sort of morphed in the American mind into making sure everyone has coverage.”

susan.brink@latimes.com

What’s wrong with individual health insurance mandates?

by Claudia Chaufan
San Francisco Bay Area Indymedia
Tuesday Feb 26th, 2008 5:01 PM

Individual health insurance mandates have lately been hailed as the solution to the health care crisis in America. Mandates to purchase health insurance have been included in legislative proposals at the state level — for instance, by Gov. Schwarzenegger and Speaker Nunez, in their “Health Care Security and Cost Reduction Act”, or at the federal level, by Hillary Clinton in her “American Health Choice Plan”. Can mandates achieve universal access to health care and control rising costs of medical care? This article explains why they can’t.

Lately, legislation including a universal mandate — a legal obligation that everybody purchase a health insurance policy — has been hailed as the solution to the health care crisis in America. At the state level, mandates have been included, for instance, in Gov. Schwarzenegger and Speaker Nunez’s “Health Care Security and Cost Reduction Act”, and at the federal level, by Hillary Clinton in her “American Health Choice Plan”. Yet many of us remain skeptical. Why? After all, if everybody is forced to buy a health insurance plan — maybe with a subsidy if you are “poor enough” — would this not resolve the problem of uninsurance? Maybe so. But the real question is: would mandating universal health insurance guarantee universal access to medical care? And the short answer is no.

A longer answer would include that many health reform proposals promising heaven on earth rely on fantasy numbers, not facts: for instance, there is reason to believe that Swcharzenegger’s stillborn legislation would have run out of money by the fifth year of operation (http://www.lao.ca.gov/2008/Webcasts/hcr_1-23-08/flashversion/hcr_flash.aspx). Indeed, often these proposals offer no numbers at all, fantasy or otherwise: a sound study estimating the capacity of “Hillary Care” to guarantee that those who “like” their current health insurance “will be able to keep it”, as Hillary promises (http://www.hillaryclinton.com/feature/healthcareplan), has yet to be produced. But worst of all is the tendency, popular among many health care experts, including M.I.T. professors (http://www.nber.org/papers/w13758) to commit the capital sin in health policy: confusing universal health insurance with universal access to comprehensive medical care.

Now, it could very well be that these experts are not confused, and only hope that ordinary citizens won’t be smart enough to tell the difference — that we will all be convinced if only they repeat “universal” enough times. Whichever the case may be, as political analyst Robert Kuttner recently pointed out, there is a fundamental difference between “universal” social health insurance, such as proposed by single payer health care reform, and a “universal” health insurance mandate (http://content.nejm.org/cgi/content/full/358/6/549). And it is not merely semantic, because clearly in both approaches “universal” means “everybody”. It is a difference of substance.

In a social health insurance system everybody gets insurance by virtue of being a citizen or a resident, everybody contributes to the system according to ability to pay, and everybody is guaranteed an amount and type of services. This is possible because the system, whose ultimate goal is to provide the most and best care to all participants with whatever budget it has, counts on a predictable influx of money, has as sole incentive finding the most efficient ways to spend it, is able to estimate the needs of participants, and can utilize their collective purchasing power to bargain for best prices of services and goods.

In contrast, in a system based on mandates, nobody “gets” anything, really. Rather, everybody is compelled to buy a policy, by law. Hence guaranteeing a decent amount of medical care to the population at large, that many consider a social problem, is turned into a “problem” of “every” individual or “every” family, who are forced to comparative-shop for affordable policies, while second-guessing current or future medical needs as they decide which is the best investment for their resources — a more comprehensive health policy, rent, or food.

A key assumption underlying individual mandates is that forcing an influx of “customers” into the health insurance marketplace, flooded with private insurers’ “products” made to suit a range of personal preferences will, through the powerful and reveered “invisible hand”, improve the quality of medical goods and services and bring their prices down, such that on average they will be affordable to everybody. This of course would be true, if shopping for medical services were functionally equivalent to shopping for designer shoes. Faced with an offer, you are always free to take it or leave it, depending on how good the deal is. If it is not good enough, you can always wait until the next Christmas sale. Or you can decide that you are not so crazy about those shoes after all, and shop for something else, until those recalcitrant shoe sellers realize that if they want your dollars, they have to behave reasonably, and offer the best they can at the least possible price.

But of course nobody needs a doctoral degree to understand that the need for medical care cannot be compared with the want for designer shoes. Nor does one need a doctoral degree to understand that a mandate to buy, for instance, drivers’ insurance, does not guarantee full protection against the expenses incurred if one gets into a car accident. While some policies might cover those expenses, they are unlikely to be cheap. What the current mandate to buy drivers’ insurance “guarantees”, if the word makes sense at all, is that, given the law, we won’t get in trouble with it if we are stopped by the police. Which is why nobody claims we have “universal drivers’ insurance”. Likewise, whichever health insurance policies we may afford to buy, if there is a mandate, it will only “guarantee”, aside from a steady pool of clients for private insurers, that we are in compliance with the law when we file our taxes (assuming this is how the mandate is enforced).

Under our current system, which relies heavily on private insurance, paying for medical care is insurers’ greatest “cost”. Now, like any other business, insurers’ ultimate goal is to control the costs of running their business while maximizing profits. Hence the increasingly bewildering range of “choices” of “insurance products” that make sure that insurers will not have to pay more for medical care than they collect in premiums and that there remains enough spare change to keep CEOs and shareholders happy.

And because profit is the essence of business, however much “mandate” fans boast they will force insurers to not turn people down on the basis of “pre-existing conditions”, they will not — they cannot — force them to sell policies that will not meet insurers’ profit maximizing goals. So mandate supporters remain conveniently vague whenever asked how much “consumers” will have to pay for policies offering more than minimum coverage or even what will count as minimum coverage, hoping that we won’t notice when they fail to compute out-of-pocket costs to “consumers” — deductibles, co-pays, co-insurance — as “costs”.

Or worse, they hope that by repeating scare stories backed by fanciful (and distorting) statistics Americans will end up believing that the only alternative to the current mess is a mandate’s version of “universal health coverage” and that a social insurance system will inevitably cause an invasion of alien Reds, with long lines in cold winter mornings in which everybody is given the same loaf of bread (substitute “sees the same doctor” or “receives the same medicine”), however far this scenario is from the daily reality of Canadians, Brits, Germans, Spaniards, and so forth.

Now, the point is not to force business to do business at a loss. The point is why, when it comes to health care, we should insist on a model that confuses health care with designer shoes and that has failed to deliver the goods. Because it is clear that choices that are meaningful, not of health policies but of doctors and services when and to the extent we need them are increasingly out of reach for ordinary Americans.

Which is why only a system based on the principle of social insurance, that spreads the risk over a large pool — all Californians, or even better, all Americans — to which all participants contribute an affordable proportion of their income, and where individuals are guaranteed real choice, not of policies but of medical services, constitutes meaningful universal health care reform.

And sound legislation exists: it is the single-payer model proposed by SB840, the California Universal Healthcare Act, vetoed by Schwarzenegger, who appears to dislike “big government bureaucracies” (http://www.youtube.com/watch?v=asgUP31Vf8o) but can live with the 30% mark-up of the bureaucracy of private insurers. It is also HR676, the expanded and improved Medicare for All Act, conveniently made invisible every time the major media or policy thinktanks report on the health care crisis, and disqualified by Hillary as “difficult to achieve” (http://www.democracynow.org/2008/2/8) for reasons that we are never given.

Now, will a social insurance system resolve all the problems in American medicine? Of course not. “Financing” and “delivery and organization” of medical care are different analytic categories, so securing the first will not miraculously resolve, for instance, the problems of over-reliance on expensive medical technologies, lack of uniformity of medical records, or insufficient emphasis on preventive care (or the never-settled question of whether Americans are as dutiful as others when it comes to eating our veggies). Those are internal to the system — to any health care system — and require separate attention. But a sound financial structure is a prerequisite to making improvements in the delivery and organization of a medical system possible.

At any rate, as Kuttner said, the “debate” about whether or not to have a mandate misses the point that the financial structure of the system, built on false assumptions and perverse incentives, is sick (http://www.democracynow.org/2008/2/8). The real issue is whether or not major presidential candidates are willing to “do it right” and use their formidable political power, social prestige, and precious media time to bring “public opinion around” (http://www.democracynow.org/2008/2/8), assuming they haven’t yet been informed about the increasing public support for single payer among the electorate (http://abcnews.go.com/images/pdf/935a3HealthCare.pdf), including physicians (http://www.philly.com/philly/business/20071204_Doctors_endorse_single-payer.html).

As Kuttner, supporters of single payer wish our politicians and opinion leaders “got it right” this time, stopped trying to reinvent the wheel, and stood for the only type of reform that can bring affordable and comprehensive health care to all Americans.

Claudia Chaufan teaches sociology of health and medicine and health policy at the University of California at Santa Cruz. She has written extensively on social inequalities in the diabetes epidemic, for general and specialized audiences, nationally and internationally. She is the Vice President of California Physicians Alliance, the Californa Chapter of Physicians for a National Health Program, an organization that supports single-payer health care reform.

Health care spending for 2008

Health Spending Projections Through 2017: The Baby-Boom Generation Is Coming To Medicare

By Sean Keehan, Andrea Sisko, et al (Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group)
Health Affairs
February 26, 2008

Projected spending for 2008

$2,394.3 billion – National Health Expenditures (NHE)

$7,867.7 – NHE per capita

16.6% – NHE as percent of GDP

Over the projection period in this paper (2007-2017), growth is anticipated to remain steady at around 6.7 percent per year, yielding an estimated $4.3 trillion in health spending in 2017.

Gross domestic product (GDP) growth is expected to average 4.7 percent per year over the projection period. Therefore, health spending growth is expected to outpace economic growth by an average of 1.9 percentage points annually.

Factors Contributing To Growth

The primary drivers of personal health care spending growth during the projection period are medical prices and utilization, followed by smaller impacts from population growth and the age-sex mix.

Since 1995, widespread selective contracting associated with the expansion of managed care has mitigated growth in medical price inflation. During that time, this output price inflation has averaged slower growth than the CMS index of medical input prices. The slower growth in medical price inflation relative to growth in input costs also reflects declines in real physician incomes relative to those of other professional and technical occupations.

Utilization, which includes both the volume and intensity of services, is primarily influenced by trends in real household income and, to a lesser extent, the substitution effect associated with relative medical price inflation and shifts in insurance coverage. …the expectation of slower disposable income growth from 2008 to 2017 is the primary driver for the slowing growth in utilization toward the end of the projection period.

The impact of the population aging is expected to account for a relatively small share of future health care spending growth on a per enrollee basis but to have a substantial influence on the public share of spending growth, as the leading edge of the baby-boom generation becomes eligible for Medicare.

Over the remainder of the period and in response to projected slowing economic growth, employers could shift more costs to employees through benefit buy-downs and increased cost sharing, resulting in a convergence of the growth rates for out-of-pocket and private insurance spending. The impact of consumer-directed health plans on out-of-pocket spending has been, and is expected to remain, minor.

http://content.healthaffairs.org/cgi/content/full/hlthaff.27.2.w145/DC1

Comment:

By Don McCanne, MD

The projected numbers for 2008, listed above, are the most reliable estimates of our current health care spending. They are the numbers you should use in your advocacy work.

There are no surprises in this projection. Heath care costs/prices continue to increase at rates well in excess of inflation, and continue to outpace GDP growth by about two percent. The latter is of concern to many since they would rather spend more in other sectors of our economy.

Much attention will be directed to the shift of Baby Boomers from private to public financing. As a result, there will be increased political pressure to halt the “unsustainable” spending growth in entitlement programs – Medicare and Medicaid. But compared to the total NHE, this shift is quite small. Over the next decade projected growth in NHE is expected to be 6.7 percent, whereas growth in public spending is expected to be 7.2 percent, and Medicare specifically, 7.4 percent. Medicare should not be singled out as an isolated problem that needs to be fixed, while ignoring the rest of our health care spending.

The pseudo-hysteria that we will see is exemplified by the statement of Rep. Paul Ryan (R-WI) posted on the Health Affairs blog simultaneously with this report. Rep. Ryan states, “…these are not signs that the health care market has failed. In fact — and it is crucial to understand this — they are the predictable results of vast distortions imposed on the market over decades. The government is the single greatest contributor to this problem…”

Obfuscation of the issues based on personal ideology is the last thing we need right now from our political leaders. The problems of our high-cost but mediocre health care system cannot be repaired without appropriate government action. We need to elect politicians who understand this, and then they need to get to work.

Mythbusting Canadian Healthcare, Part II: Debunking the Free Marketeers

By Sara Robinson
OurFuture.org
February 11th, 2008

In the previous post, I looked at ten of the most common myths that get bandied about whenever Americans drag Canada into their ongoing discussions about healthcare. In this follow-up, I’d like to address a few of the larger assumptions that Americans make about health care that are contradicted by the Canadian example; and in the process offer some more general thinking (and perhaps talking) points that may be useful in the debates ahead.

Government-run health care is inherently less efficient — because governments themselves are inherently less efficient.

If anything could finally put the lie to this old conservative canard, the disaster that is our health care system is Exhibit A.

America spends about 15% of its GDP on health care. Most other industrialized countries (all of whom have some form of universal care) spend about 11-12%. According to the WHO, Canada spends a bit over 9% — and most of the problems within their system come out of the fact that it’s chronically underfunded compared to the international average.

Any system that has people spending more and getting less is, by definition, not efficient. And these efficiency leaks are, almost entirely, due to private greed. There is no logical way that a private system can pay eight-figure CEO compensation packages, turn a handsome a profit for shareholders, and still be “efficient.” In fact, in order to deliver those profits and salaries, the American system has built up a vast, Kafkaesque administrative machinery of approval, denial, and fraud management, which inflates the US system’s administrative costs to well over double that seen in other countries — or even in our own public systems, including Medicare and the VA system.

Not incidentally: one of the benefits of single-payer health care is that it largely eliminates the entire issue of “fraud.” You can only “cheat” a system that already views its primary business as rationing and withholding care. In Canada, where the system is set up to deliver health care instead of profits, and medical access is considered a right, this whole oversight machinery is far cheaper and more compact. In general, the system trusts doctors and patients to make the right choices the first time. As a result, people generally don’t have to lie, cheat, and grovel to get the system to deliver the care they need. They just go and get it — and walk out without a moment’s dread about the bills.

Shareholder profit, inflated CEO salaries, and top-heavy administration — all of which serve to work against the delivery of care, not facilitate it — are anti-efficiencies that siphon off 20-25% of America’s total health care spending. These are huge sums; yet it’s mostly money down a gold-plated rathole. In the end, it doesn’t provide a single bed, pay a single nurse or doctor, or treat a single patient.

We’ll have rationed care

Don’t look now: but America does ration care. And it does it in the most capricious, draconian, and often dishonest way possible.

Mostly, the US system rations care by simply eliminating large numbers of people from the system due to an inability to pay. Last year, one-quarter of all Americans didn’t go to a doctor when they needed one because they couldn’t afford it. Nearly that many skipped getting a test, treatment, prescription, or follow-up appointment recommended by a doctor. In Canada, those same numbers are in the 4-5% range; in the UK, 2-3%. Also: nearly 20% of all Americans had a hard time paying a medical bill last year; and these stresses now trigger over half of all personal bankruptcies in the country.

Furthermore, nominally having health insurance is no guarantee against financial ruin, as Sicko amply illustrated. Being cut off or denied by your insurance company is rationing, too. And there are vast numbers of fairly well-off Americans — many of them middle-aged, and too young for Medicare — who have pre-existing conditions that render them uninsurable at any price. They’re one heart attack, one diabetic event, or one bad turn away from financial disaster. Please don’t insult these people by telling them that the American system doesn’t ration care.

Another persistent (and ridiculously mendacious) rationing myth about the Canadian system is that old people are cut off from treatment and left to die. I’ve never heard about a single case of this in Canada; but it happens routinely to Americans on Medicare and many private policies, which have strict limits on how long you can stay in the hospital with an acute illness. When the benefits run out, ready or not, they send you home. If you die, you die. The Canadian plan has no such limits: you stay for as long as you need to. But in the US, these limits fit the very definition of “rationed care.”

Effectively shutting one-quarter of the population out of the medical system entirely, and putting many of the rest on short rations, certainly does make things so much nicer for those happy few who are still in it. In fact, Americans have these missing millions to thank for their system’s impressively short wait times. Only 4% of American have to wait more than six months for non-elective surgeries, while 14-15% of Canadian and Britons do. (Don’t blame this on government care, though: in Germany and the Netherlands, the number is closer to 2%.) When conservatives start bellowing about Canada’s terrifying wait times (which, by the way, are carefully triaged: it’s rare for people to die waiting, though it happens), we need to remind them that there are 75 million Americans who have been wait-listed forever. If my friend’s Aunt Millie gets her emergency hip surgery today because I’m willing to hobble along for an extra couple months before getting my knee surgery — well, for any morally serious person, that choice should be a complete no-brainer.

You can’t have medical innovation without the incentives provided by the free market.

As in the US, Canada’s government funds major medical research that has led to a continuous stream of new medical breakthroughs. (And as this link shows, the rate of innovation didn’t slow down in the least when Canada moved to single-payer in the 1960s.) All of the country’s medical schools are located within public research universities. The university that houses my local medical school, the University of British Columbia, ranked ninth in North America last year — in league with UC, Stanford, and other powerhouses — in total public and private research grants received by its labs. Among other things, it leads the way in genetics (David Suzuki is emeritus faculty), and stem-cell research (having attracted a handsome roster of American scientists whose research was thwarted by the political situation at home).

Because the Canadian health care system is driven by delivering care instead of profits, the focus of research is sometimes different — and often wider-ranging. While there’s plenty of pursuit of patents and innovations, there’s also considerable research put into questioning whether new treatments are really more effective than older ones; and in pursuing possible treatments that may not be patentable by anyone. The system is focused first on what works; and after that, on what might make someone some money.

Single-payer health care will make America less competitive.

I can’t believe people still have the gall to argue this point, but apparently, they do. There are several reasons this is flat-out wrong:

Jobs, Jobs, Jobs — It’s no secret that public health care is making Canada a more attractive business environment for large manufacturers, who typically have very high insurance overhead. Toyota and GM have both moved plants to Canada in recent years, in large part to avoid the spiraling costs of insuring American workers. (Toyota also cited Canada’s better-educated workers, but that’s another issue for another day.) As long as $900 of every car GM makes is going to supply health care to the people who make it, the US’s current system of employer-based health care is going to continue to drive skilled jobs out of the country.

A Smarter, More Entreprenurial Workforce — Being relieved of insurance worries also makes individual citizens more competitive. How would your life choices change if you didn’t have to worry about health care? Would you go back to school and get your PhD in lepidoptery? Start a blog — or a small business? Work part-time and travel? Tell your boss where he can stick it? Spend a few years at home with your kids?

Countries with universal coverage free up their citizens to take advantage of personal development opportunities that, in the long run, stimulate the economy and create a more skilled, traveled, educated, and fulfilled workforce. Americans, on the other hand, routinely stay chained to jobs they hate — and are forced to pass up on chances to expand their horizons and their fortunes — because they can’t afford to jeopardize their health care coverage. Our health care mess has reached a point where it jeopardizes not only our lives, but also our liberty and our ability to pursue happiness — as well as the long-term strength of the economy as a whole.

Increased Financial and Social Capital — When families are bankrupted by medical bills, or are thrown into poverty when a working member is disabled because they can’t afford proper care, or simply break down and fall apart under the stress of debt and illness, it’s not long before the country’s entire social fabric begins to show the wear and tear — along with the sense of optimism and the common good required for a democracy to function.

Part of what makes a country competitive is its own commitment to the common good. I’ve often been impressed by the very tangible sense of civic pride and shared effort my Canadian neighbors have in the fact that they’re taking the best possible care of their own, regardless of status, age, or ethnicity. Every encounter with the medical system reminds them that they’re all in this together. A medical system that routinely drives families into bankruptcy or divorce court is actively destroying, rather than adding to, the essential social capital that makes the whole society function.

No Deferred Maintenance — Decades of foregone medical care are starting to catch up with Americans. We’re seeing serious declines on many fronts: infant mortality, lifespan, cancer rates, heart disease rates, and increased diabetes. On most of the major markers of public health, America is nowhere near the top tier anymore. In some areas, there are a few small former Communist countries doing better than we are.

Business relies on healthy workers who aren’t distracted by their own illness or that of a family member. America’s uninsured, increasingly unhealthy workforce is in no position to compete on equal terms with the strong, healthy workers of other countries who are getting the care they deserve.

We have more important matters to tend to — like national security and the war.

Getting everyone insured is, unequivocally, a clear matter of national security.

Our every-man-for-himself attitude toward health care is a security threat on a par with unsecured ports. In Canada, people go see the doctor if they’re sick for more than a day or two. It was this easy access to early treatment, along with the much tighter public health matrix that enables doctors to share information quickly, that allowed the country’s health care system to detect the 2003 SARS epidemics in Toronto and Vancouver while they were still very localized, act within hours to stop them before the disease spread any further, and track down and treat exposed people before they got too sick to be helped. In both cases, the system worked flawlessly. The epidemic was stopped within days and quashed entirely in under a month, potentially saving of millions of lives.

In the U.S., that same epidemic might easily have gone unnoticed for critical days and weeks. If the first people to get sick were among those 75 million without adequate insurance, they probably would have toughed it out a few extra days before finally dragging their half-dead carcasses into an ER somewhere. Not only would they be much farther along in the course of the disease — and thus at greater risk of death themselves — every one of them could have infected dozens or even hundreds of other people in the meantime, accelerating the spread of the epidemic.

Worse: America’s underfunded public health system might have taken several days to piece together the whole picture of an epidemic; and perhaps another week or two might have passed before the E. Coli conservatives in charge (having thrown out the science-based management plans thoughtfully developed by the bureaucracy) cooked up some kind of half-assed ideology-driven decision about how to proceed. (It would, of course, involve spectacular amounts of lying to the public.) By that point, tens of millions could have been infected, leading to a death toll that would make 9/11 and Katrina look like minor statistical blips.

Think about superbugs and the ongoing waves of immunological imports from the world’s swamps and jungles. Think about terrorists with bioweapons. And then think again about the undeniable fact that every single underinsured American is a gaping hole in the safety net that protects us all from a catastrophic epidemic. This really is one of those cases in which none of us are safe as long as even one of us is left at risk. And from a purely economic standpoint: would you want to invest in a country where there was a significant risk that an epidemic or a bio-attack, managed by incompetent officials, might force you to shut down your business at a moment’s notice?

As for the war: Bush’s Folly will generate upwards of half a million veterans, many of whom will require some kind of sustaining care for the rest of their lives. VA funding ebbs and flows with the national political will, and veterans often fall behind other priorities. But if they can enter the same health care system every other American depends on, then we can only forget their interests by forgetting our own as well.

I feel a lot better knowing my taxes are taking care of my fellow Canadians rather than buying bombs to drop on Iraqi towns, supporting a fully-equipped CIA gulag, or funding Baghdad pizza deliveries via Halliburton. It’s hard to become a worldwide empire when you’re putting half your tax revenue into hospitals and doctors, as Canada does. But, on the other hand, it’s hard to insure your citizens when half your tax revenue is going to feed your war machine.

In a very real sense, America has chosen to secure its oil supply at the cost of its own citizens’ health. The more we spend on the former, the less we have for the latter. And our own relative health — both physical and economic — is starting to show the consequences of that choice. Ultimately, all these things are connected: by making ourselves energy independent, we might not only make ourselves more secure, we’ll also finally be able to invest in the kind of health care that will make us truly competitive in the world community.

The Bottom Line

In America, a lucky employee with gold-plated employer-based coverage may well get access to A-level care (though that level of coverage becoming rarer by the month, even among the professional classes). On the other hand, about 50 million under-insured Americans are barely scraping by with C or D-level care; and the nearly 50 million with no insurance at all get next to no care whatsoever. Worst of all: 18,000 Americans die every year due to lack of access to healthcare. That’s one every 30 minutes, around the clock, every day of the year — the equivalent death toll of six 9/11s every single year that passes.

In Canada, everybody gets at least B-level care, pretty consistently across the board — and, on occasion, quite a bit better than that. You might not like those odds if you’re one of the shrinking handful of Americans who’s used to A-level care; but if that’s not you, you’d be getting a much better deal in Canada.

The private sector has had 20 years to prove that it could deliver low-cost, quality care using those vaunted business-style efficiencies; and it has failed us utterly and completely. This fact should be the ultimate nail in the coffin of the old conservative canard that “the free market always does it better.” If that was true, privatizing health care would have been the shining example that proved it once and for all. Instead, all we got was a colossally expensive national disaster that’s denying full coverage to a third of the country — and putting our health, competitiveness, financial and social capital, and national security at risk in the process. It’s also devastating the aspirations of our entire middle class, which is being hollowed out by our current health policies.

A famous Hebrew prophet once advised his followers to take the log out of their own eyes before trying to remove the splinter from someone else’s. As much as it hurts American pride to admit it, Canada and the rest of the industrialized world has us roundly beat on this one. Those who are so quick to criticize the Canadian system might be better off holding their fire until they’ve shown us they can do better. America, and the world, is waiting.

Bush's privatization agenda for Medicare

By LAURA S. BOYLAN
Sacramento Bee
Wednesday, February 13, 2008

The Bush administration is eating away at the heart of Medicare.

The first assault was the Medicare Modernization Act of 2003. And the second assault is the budget that President Bush just submitted to Congress.

Before looking at these two, we should recognize that Medicare is one of our nation’s most efficient, successful and popular public programs. Under this single-payer program for the elderly, people report less hassle, easier access, lower out-of-pocket expenses and more satisfaction than those with private insurance.

Let’s face it: Medicare is a public oasis in the private desert that is the health care marketplace in America. We spend more than twice as much on health care, on average, as other developed nations, all of which provide universal coverage through predominantly public financing. What’s more, their health outcomes are usually superior to ours.

Market-based health care is a minefield of “perverse incentives:” Procedures are rewarded over prevention and administrative costs are enormous. It is estimated that one-third to one-fifth of U.S. medical expense outlays don’t improve health.

As a doctor, I know that my time with patients is at the core of a humanistic practice of medicine. And it’s also the most cost-effective way to deliver primary care. It is, however, the least reimbursable of all medical events. Physicians are more likely to order questionable tests and specialty referrals when in a rush. It provides a sense of thoroughness, a hedge of bets and, frankly, a patient-pleasing way to close the visit when the lines are getting too long. But it adds immensely to the costs of health care.

The waste and inefficiency are, well, un-American.

In a triumph of ideology over fiscal sobriety, of special interests over public health, the Bush administration is trying to privatize Medicare rather than expand it.

The Medicare Modernization Act of 2003 offered prescription drug coverage, but exclusively through private companies. Bizarrely, it prohibited the government from negotiating price discounts from the drug companies. As a result, Medicare Part D drug prices are more than 80 percent higher than the prices negotiated by Medicaid and Veterans Affairs.

One important but obscure component of the Medicare Modernization Act will soon come to haunt us. And that is the creation of an arbitrary 45 percent general revenue cap, which, when reached, will trigger program cutbacks, higher premiums or further privatization. Medicare financing comes from various sources including general revenue, payroll taxes, trust fund interest, and beneficiary premiums. The cap has yet to kick in, but the drug company giveaway was funded mostly through general revenue, so it will come soon.

Then there’s the current Bush budget. It proposes reducing payments to doctors and hospitals while preserving subsidies to inefficient and sometimes corrupt private insurance middlemen, who offer plans through the Medicare Advantage program. These middlemen cost up to 19 percent more per beneficiary than traditional Medicare despite selective enrollment of the healthy.

Fiscal sobriety and public health demand that Medicare be kept affordable by getting rid of inefficient subsidies and giveaways to industry, which add cost but not value to health care.

Don’t let the Bush Administration fool you: We can afford Medicare. The $6 billion it would cut next year from public Medicare is less than the cost of two weeks of the war in Iraq.

Medicare is the proud kernel of a single-payer America, where health care is a right and not a commodity, and everyone has the same health care coverage as their president.

We can’t let the Bush administration continue to gouge it.

About the writer: Dr. Laura S. Boylan is an assistant professor of neurology at New York University and a board member of Physicians for a National Health Program (www.pnhp.org).

Bush’s privatization agenda for Medicare

By LAURA S. BOYLAN
Sacramento Bee
Wednesday, February 13, 2008

The Bush administration is eating away at the heart of Medicare.

The first assault was the Medicare Modernization Act of 2003. And the second assault is the budget that President Bush just submitted to Congress.

Before looking at these two, we should recognize that Medicare is one of our nation’s most efficient, successful and popular public programs. Under this single-payer program for the elderly, people report less hassle, easier access, lower out-of-pocket expenses and more satisfaction than those with private insurance.

Let’s face it: Medicare is a public oasis in the private desert that is the health care marketplace in America. We spend more than twice as much on health care, on average, as other developed nations, all of which provide universal coverage through predominantly public financing. What’s more, their health outcomes are usually superior to ours.

Market-based health care is a minefield of “perverse incentives:” Procedures are rewarded over prevention and administrative costs are enormous. It is estimated that one-third to one-fifth of U.S. medical expense outlays don’t improve health.

As a doctor, I know that my time with patients is at the core of a humanistic practice of medicine. And it’s also the most cost-effective way to deliver primary care. It is, however, the least reimbursable of all medical events. Physicians are more likely to order questionable tests and specialty referrals when in a rush. It provides a sense of thoroughness, a hedge of bets and, frankly, a patient-pleasing way to close the visit when the lines are getting too long. But it adds immensely to the costs of health care.

The waste and inefficiency are, well, un-American.

In a triumph of ideology over fiscal sobriety, of special interests over public health, the Bush administration is trying to privatize Medicare rather than expand it.

The Medicare Modernization Act of 2003 offered prescription drug coverage, but exclusively through private companies. Bizarrely, it prohibited the government from negotiating price discounts from the drug companies. As a result, Medicare Part D drug prices are more than 80 percent higher than the prices negotiated by Medicaid and Veterans Affairs.

One important but obscure component of the Medicare Modernization Act will soon come to haunt us. And that is the creation of an arbitrary 45 percent general revenue cap, which, when reached, will trigger program cutbacks, higher premiums or further privatization. Medicare financing comes from various sources including general revenue, payroll taxes, trust fund interest, and beneficiary premiums. The cap has yet to kick in, but the drug company giveaway was funded mostly through general revenue, so it will come soon.

Then there’s the current Bush budget. It proposes reducing payments to doctors and hospitals while preserving subsidies to inefficient and sometimes corrupt private insurance middlemen, who offer plans through the Medicare Advantage program. These middlemen cost up to 19 percent more per beneficiary than traditional Medicare despite selective enrollment of the healthy.

Fiscal sobriety and public health demand that Medicare be kept affordable by getting rid of inefficient subsidies and giveaways to industry, which add cost but not value to health care.

Don’t let the Bush Administration fool you: We can afford Medicare. The $6 billion it would cut next year from public Medicare is less than the cost of two weeks of the war in Iraq.

Medicare is the proud kernel of a single-payer America, where health care is a right and not a commodity, and everyone has the same health care coverage as their president.

We can’t let the Bush administration continue to gouge it.

About the writer: Dr. Laura S. Boylan is an assistant professor of neurology at New York University and a board member of Physicians for a National Health Program (www.pnhp.org).