Subject: Shift in strategy
It seems to me that our current world crisis has changed the political playing field and opened the probable opportunity for a swift move to a national health program. We ought to adjust our rhetoric, strategies, and thoughts accordingly.
(1) The terrorist attack has the unintended byproduct of curing the civil society malaise described by Robert Putnam in BOWLING ALONE (an outcome he predicted), and people are not just rallying around the flag, they are esteeming the government, depending on it for safety and solutions. This is a tectonic shift in attitudes.
(2) We are in a recession; businesses are going to be doing poorly and watching their pennies very closely.
(3) Health insurance companies are at a point in their business cycle where, after competitively driven price cuts and consolidation, they will be requiring repeated >10% price increases to maintain viability (Aetna or PacifiCare/Secure Horizons) or profitability.
(4) The health insurance premium costs are going to be very onerous to all businesses who will be passing on costs to employees or dropping benefits or health insurance altogether.
(5) As people are laid off (and have been in huge numbers in the service industries as a result of 9/11), the number of uninsured is going to explode and many of the newly uninsured are going to be middle class.
Thus the stage is set for an as yet publicly unanticipated crisis – the final breaking point – in the health care system in the USA. The federal government is going to have to step in (and can with the rationale of protecting the public welfare during wartime). The simplest solution and easiest to promote is to expand Medicare to everyone (and not to get into much of the details about how the providers organize themselves). This will have great public support from the newly uninsured and unemployed, and maybe even from the AMA, etc., as doctors and hospitals feel even more squeezed by falling income and will be eager for public subsidy for “a physician full employment program,” and by the states who will now be too poor to subsidize their own reformed health systems. As unlikely as it seems, the Republicans (like Bismarck and Lloyd George) are likely to be more successful at pulling off a national health program than the liberals and the Democrats as a way to help the business and corporate classes (except for the health insurance industry) save money (overhead costs) and as a way to reward, support and calm a worried and activated civil society.
PNHP can have a pivotal role in promoting these changes, especially if we anticipate the need, publicize it, and organize around it with a simple implementation strategy. What do you think?
Please circulate this message to whomever you think will be interested.
Jeoffry Gordon, MD, MPH
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You may also wish to contact the following:
Physicians for a National Health Program
Ida Hellander, MD, Executive Director
California Physicians Alliance
Carla Woodworth, Executive Director
Theodore R. Marmor, Ph.D., Professor of Public Policy and Management, Yale University School of Management, responds to Jeoffry Gordon, MD, MPH:
Gordon’s call for a shift in strategy of reformers seems to me eminently sensible. The landscape of American politics has certainly been altered and it is surely the case that the reliance on government has been newly noted and accepted. Furthermore, we are likely to have a crush on health coverage, though it is just as likely that the demand will be for extensions of COBRA as Medicare for all. Nonetheless, if ever there will be a dramatic shift in setting–short of depression and short of a l964 electoral avalanche–this is one of them. And advancing Medicare for all–absent endless details –is certainly more appealing post-9/11 than in August of 2001.
But there is also a need for attention to details–like how to price a premium for voluntary enrollment in Medicare. Does one advocate using the present Part B structure, mostly general revenues and a premium? Or, do we rely on Part A financing? If so, there will be a big shift to Part A from employer-based insurance. In short, the rhetorical opportunity is there, but the incremental steps remain complicated. Pay or Play in the l992 period was one answer.
I do not know how to answer the questions I posed, but I do think them worth posing even as I agree with Gordon about the significance of the change in context.
Theodore R. Marmor, Ph.D.
Professor of Public Policy & Management Professor of Political Science
Yale University School of Management
P. O. Box 208200, 135 Prospect Street
New Haven, CT 06520-8200
Arthur Caplan, Ph.D., director of the Center for Bioethics at the University of Pennsylvania, responds by referring to his opinion article on msnbc.com.
From the msnbc.com article:
“In the past, efforts to create a national health care plan have foundered when private interests have defeated the public good. Americans can no longer afford to put the public good behind private interest. No mother should be worrying about how to pay for her kids’ medical bills because her husband has been killed by terrorists. President Bush and Congress ought to announce a plan to mandate that every American will have access to high quality health care.”
The full article is available at:
Jonathan Oberlander, Ph.D., Assistant Professor of Social Medicine, University of North Carolina – Chapel Hill, responds:
Jeffrey Gordon’s suggestion that in the aftermath of September 11 there is a potential opportunity to pass a Medicare for All program seems quite improbable to me. It is far to early to judge the political implications of what happened as well as the military campaign ahead. I agree that with Dr. Gordon that the development of a communitarian national ethos is one possible outcome. But there is a long way from this to adoption of Medicare for All. The political reality after September 11 is still that you have a president opposed to universal health insurance, a Congress without much appetite for health reform, and most importantly a Republican party fervently opposed to Medicare as a model for public insurance. Moreover, with higher inflation rates, American businesses are less likely to pressure the GOP to pass national health insurance than they are to drop coverage. If momentum does develop to expand health coverage in response to economic woes, it is much more likely to come in the form of the already-on-the-table tax credits or extending CHIP, than Medicare for All or single payer. The most ambitious goal for reformers would be to expand the scope of these instruments; pushing for Medicare for All is simply not feasible for the moment.
Assistant Professor of Social Medicine
University of North Carolina – Chapel Hill
Bioethicist Arthur Caplan, responding to a personal e-mail from Ida Hellander, M.D., Executive Director of PNHP, on single payer reform (prompted by today’s discussion):
“Single payer will not fly. Period. I favor it but it has no chance, none, nada, zero, with Bush in and the Republicans in Congress. It did not even fly with Clinton and an all-Dem Congress.
“The AMA position is as relevant as that of the Taliban on this issue. No one credits their views on this.
“My view is forget about doing best. It is time to do better. Let’s get something. Fifty years of waiting for a national health system has left tens of millions with nothing. Mandate coverage, let the private sector have its piece, and let’s get the damn thing done already.”
Martin Donohoe, MD, Senior Scholar, Center for Ethics in Health Care, Oregon Health and Science University, responds to Arthur Caplan’s comments on single payer:
Major social changes in the US have come about through radical changes, not piecemeal. Otherwise, in the US we would have outlawed slavery but only say for Africans from certain nations or only for first and second generation African-Americans; or we would have given women the vote, but only women making over a certain amount of money or those with a college education; or we would have outlawed child labor but only for kids working in the mines (granted I realize that child labor still exists in the US, particularly in agriculture). I say we need visionary policymakers and ethicists who will go for the whole enchilada – a single payer system, and that physicians and patients say, “For God’s sake, it is about time.”
Martin Donohoe, MD, FACP
Assistant Professor of Medicine and
Senior Scholar, Center for Ethics in Health Care
Oregon Health and Science University
General Internal Medicine (L-475)
3181 SW Sam Jackson Park Road
Portland, OR 97225