By Michael Roberts
Westword (Denver), Oct. 5, 2016
Of the nine amendments and propositions that will be on Colorado’s ballot next month, Amendment 69 is the most sweeping. Also known as ColoradoCare, the proposal would create a Colorado-specific health-care program with a goal of covering every citizen in the state with health insurance. It’s not quite a single-payer plan, since it wouldn’t supersede federal programs such as TRICARE, which focuses on veterans. As such, Owen Perkins, director of communications for the ColoradoCare Yes campaign, calls it “Medicare for all.”
Below is a transcript of our conversation with Perkins.
Westword: What are the reasons that folks should vote for Amendment 69?
Owen Perkins: Different people have different priorities about what they think is best about ColoradoCare. For me, it’s about getting us to the threshold where we can make sure everybody’s covered, everybody’s got access to health care. The Affordable Care Act did a good job of getting us closer. We went from over 800,000 uninsured to under 400,000. But that’s still kind of disgraceful to have nearly 400,000 people uninsured and uncovered in Colorado. So the ability to get everybody covered and everybody into the system is essential, I think, for a prosperous society like the United States and for Colorado. And to fall short of that is unacceptable.
The fact that we can do it while maintaining the benefits and saving billions of dollars a year is a tremendous bonus. And I think for a lot of people, the cost savings is the number-one reason. Ultimately, a lot of people look at their pocketbook, and for an individual or family in Colorado, they’ll be saving anywhere from thousands to tens of thousands of dollars. The overwhelming majority of Coloradans will be saving under ColoradoCare. That’s a big point for a lot of people — a good reason to pass ColoradoCare.
One things we’ve discovered, somewhat to our surprise, is that the frustration with the current system is nearly universal. I don’t think I’ve heard anyone try to make the case for the current system — the corporate-insurance, industry-based model. Everyone knows that it doesn’t work and that there are all kinds of problems with it. I think the only debate is about whether this is the right solution or not. A lot of us get tired of people who profess to want to make change but resist making the change when [they] actually have a viable solution in front of [them]. And I think that’s where we are now. I’m hoping Coloradans will take that opportunity to act on it.
How will ColoradoCare be instituted? What kind of Colorado-specific structure will be put in place?
It is a structure that will be entirely Colorado-specific, and it’s a big structure. It ends up involving thousands or tens of thousands of jobs that will be created. ColoradoCare becomes a payment system, basically. The exchange (Connect for Health Colorado, the health-insurance marketplace created under AFA) would go away, and you’d anticipate that a lot of people who’ve grown skilled at working for the exchange, if interested, would be well qualified to work for ColoradoCare.
The amendment creates a board of trustees, and then the board begins hiring the staff and putting an entire system into place: CEO, CFO, a staff, health-service information people. But it’s all on the coverage end of things as opposed to the provider end of things. ColoradoCare doesn’t encompass the providers; they don’t work for ColoradoCare. They stay in their private practices or work for hospitals or groups.
The process will take a couple of years. If it passes in November, the anticipation is that it will go into effect in January 2019. You get that time to build up, and there are a few things that are important that happen during that time. It could pass with 90 percent of the vote — I don’t anticipate that, but it could pass with an overwhelming majority — and end up not going into effect if it doesn’t get waivers from the federal government.
One of the things that happens in 2017 is, that’s the earliest anyone can apply for a waiver from the Affordable Care Act. The Affordable Care Act, I think very intelligently, created a mechanism that allows states to opt out of the act if they can create their own system. That encourages their innovation in finding a more efficient and cost-effective way to deliver and cover health care in states.
So we would be among the first states, if not the first state, to apply for a waiver from the Affordable Care Act, and that standard is very challenging. We need to show we can cover as many people or more as the Affordable Care Act at the same price or lower, with the same benefits or better. That’s, I think, an appropriately challenging standard, and to me, it’s encouraging that we’d have to meet that standard. It would have to be approved by the federal government — by the Health and Human Services Department — in order to move forward. That’s why I say we could get 90 percent of the vote, but if we’re not approved for the waivers by virtue of meeting those standards, we don’t move forward at all.
I never used to mention this, since I think it’s sort of a ridiculous situation — the idea that the federal government would grant the waivers but not give us the full funding. It seems ridiculous. They are encouraging states to be innovative and pursue the waivers through the Affordable Care Act, and it would seem bizarre to encourage states and approve the waiver and then not give the funding to make it work. But if that happens, which the Colorado Health Institute is supposing it would — and which I think that’s an irresponsible supposition — and we didn’t get full federal funding, it would not move forward. It has to get that approval and that funding from the federal government to be implemented. It requires about $13 billion of federal funding that Colorado currently gets; it requires that we get that funding in order to move forward. (Click to read the Colorado Health Initiative analysis of ColoradoCare.)
Would people be mandated to use ColoradoCare? Or could they still use private health care, or health care through their business or employer?
They won’t be mandated to use it, but they’ll still be covered. Every Colorado resident will be covered by ColoradoCare, but they can still choose to use private insurance instead, in much the same way that everyone in Colorado has access to public-school education but many choose to go to a private school and pay twice — pay the taxes for the public school and the tuition for a private school.
Everybody will be covered by ColoradoCare. For most people, that will mean they’ll be contributing a portion of their salary or their income. If people are making below the poverty level or if they’re seniors and have exemptions, they might not be paying anything and still be getting ColoradoCare. And if they’re unemployed, they’ll be getting ColoradoCare. But they don’t have to use it, and it doesn’t dictate that the private-insurance industry goes away. The private-insurance industry can stay as long as it wants. I would imagine initially that those who oppose ColoradoCare, many of them may keep paying for private insurance. But I would think that over time, they’ll realize, “I’m paying twice and my neighbor is getting great coverage from ColoradoCare — the same kind of coverage I’m getting. So I think I’ll stop paying twice for it.” And eventually, you might have the private-insurance industry essentially closing up shop in Colorado. But it doesn’t mandate that.
How do you guarantee that ColoradoCare provides service that is equal or better to the current system?
A lot of the coverage that establishes that minimum of meeting the current system — to ensure that it meets that standard — is in the language of the amendment. Some of it is about getting the Medicaid waiver, which is additional to getting the Affordable Care Act waiver, and that’s actually significantly more money than the Affordable Care Act — because ColoradoCare will essentially take over Medicaid here. ColoradoCare would be required to sustain any benefits that Medicaid offers. So anybody who’s eligible for Medicaid benefits would get those benefits under ColoradoCare.
It’s basically written into the language of the constitution. And within the constitution, you essentially want it to be a blueprint for ColoradoCare. I don’t think anyone wants the constitution micromanaging health care. So you want to find this balance of what needs to be covered, but not putting, for example, the cost of that coverage into the constitution when you know that changes over time — or the reimbursement rates, or things like that.
You get as much as is appropriate into the constitution. And I think it’s appropriate to have it in the constitution. That’s where we go to protect our rights. And I’m one of those who feel that health care should be a right, and is a right. Certainly we as a society, and me as a member of the society, I feel we have a responsibility to cover all of our residents, and if our society is taking that responsibility, I think concurrent to that, I believe everybody has a right to care. But micromanaging that in the constitution would be a little overkill.
Your opponents have three major objections to ColoradoCare. Among other things, they see it as risky putting all of this information into the state’s constitution, because that makes it difficult to change. But at the same time, they talk about the lack of specificity in the amendment, which they see as only an outline or a framework for a system — one that leaves too many questions unanswered. Could this have been done in the legislature, through statute? Or does putting it in the constitution make it more of a permanent pledge to the people of Colorado that their health care will be covered?
The latter. You do want that significant pledge. And I think we all know too well how fickle the legislature can be and how it can change as majorities change and how special interests can affect the legislature and result in something unwieldy.
That’s essentially what happened in Vermont. Vermont started with this ideal notion of getting a single-payer, universal plan to cover all their residents and then left it to the legislature to come up with how to do that. And the result, with so many legislators feeling the obligation to represent various special interests with aspects of the legislation, it became unwieldy. The costs escalated because of all the changes they tried to add, and the governor vetoed it. So you had the state accept something and then the legislature screwed it up. (Click for more information about Green Mountain Care, the failed Vermont single-payer plan.)
Those options — for the legislature to mess it up or the governor to veto it — are not an option when the people of Colorado put it into the constitution. It’s a question for them. We strongly believe this right should be defended and put into the constitution.
Obviously, this is making a change to the constitution. But I give the people of Colorado tremendous credit for making good decisions, for the most part, about what goes into the constitution. And if they make the challenging decision to accept this and put it in, I think they’ll be well situated to make changes in the future, if need be.
For example, the board can’t change the payroll-deduction rate without a vote of the people of Colorado. There are those who think they’ll never vote for an increase. But I think if they vote for this in the first place, they’re showing the ability to take on a challenging idea. The ballot language is very challenging for us, and if they can accept that, they can accept the idea of making changes in the future, if need be.
Our constitution, both nationally and in Colorado, has always been a living document. Vitally important things exist as amendments. The Bill of Rights, for example. And it’s essential that things get in when they need to get in.
Sometimes, there’s a baffling dichotomy on the opposite side of objecting to the idea that this is any way connected to government, by putting it into the constitution and collecting taxes, but at the same time also objecting to what they see as there not being enough government involvement or government oversight. But when the voters are educated about the issue — when they take the time to learn about it — they’ve shown the ability to make really wise, responsible choices. I’m comfortable with them doing it again in this case. But it is a challenge to get them educated about it, letting them know about it.
Your opponents say the measure calls for $25 billion in new taxes, and to provide some context, they note that the entire state budget is around $27 billion. They also say the new taxes would result in Colorado having the highest income-tax rate of any state in the country. Is that accurate, or an exaggeration?
It’s kind of a half-truth. The full truth is that it is $25 billion. That’s what’s called for in the language on the ballot. But the part they’re leaving out is that the $25 billion replaces the $30 billion we currently pay for health care in Colorado. That’s vitally important to understand.
I mentioned Vermont and the way they started with the ideal. Where Colorado started was with the practical, with the real. We looked at what we currently spend on health care, which is $30 billion. Families, firms, businesses, individuals currently pay that much on health care in premiums, deductibles, co-pays. We said, “Okay, $30 billion is what we spend. How do we create a better system with that budget?” And in part, when you go to a real universal health care system and get everybody into the pool, you end up saving money. We were able to find the more efficient model — take away the corporate-insurance-industry for-profit model and replace it with a Medicare-for-all model, which is based on Medicare, and takes the 20 percent administrative cost that’s associated with the corporate-insurance industry model and cuts that down to the 4 percent administrative cost Medicare uses. That eliminates 16 percent of the budget right there. It’s not where all the savings come from, but the overall savings are about $4.5 billion a year.
To talk about a $25 billion tax increase, that’s what the language of the ballot asks for — so there’s certainly truth in that. But to leave out the fact that we’re replacing the $30 billion we currently spend on health care is grossly negligent.
Our total cost of health care and income tax would be significantly less with ColoradoCare in place than it is now. That’s what we really need to look at. We’re eliminating insurance premiums, deductibles, co-pays for primary and preventive care and lowering them for other care and setting up the ability to waive them for financial-hardship co-pays. So you’re eliminating a lot of costs and replacing it with another cost that ends up being $4.5 billion less.
Your opponents also talk about a 10 percent payroll tax, which they describe as an important piece of the financing mechanism. A tax on all payroll incomes, two-thirds to be paid by the employer, one-third to be paid by the employee. But there’s also an additional 10 percent tax on non-payroll items, which would include things like savings, investments and capital gains. Is that accurate? And if so, why does that make sense in the context of the overall plan?
Yes, for most people, it’s a 3.33 percent payroll deduction, with the employer kicking in 6.67 percent. And for most people — and we’re talking about over 80 percent of Coloradans — that’s less than they’re paying now. The average Coloradan is paying closer to 12 percent — considerably higher than 3.33 percent. And the average employer is kicking in around 13.5 percent for employee health care. So both of those costs that people are currently enduring are replaced at what, for most people, is a lower cost of 3.33 percent. And that’s where the $25 billion comes from.
That’s part of the simplification process of eliminating a system that is bogged down in bureaucracy, because there are all the insurers and all the different plans each insurer has, which can add up to hundreds of options, and which create this unbelievable bureaucracy in medicine. And the number of bureaucrats in health care has skyrocketed since 1970, as opposed to the number of providers, which has stayed fairly consistent, growing at a smaller, more natural pace. But this explosion of bureaucratic entanglement in health care has created a kind of cottage industry for bureaucrats in health care. You eliminate that and go to a Medicare model where it’s all going to one place and they’re reimbursing without that profit motive — and when you eliminate the profit motive, you eliminate the incentive for denying coverage that so much of the insurance industry is consumed with right now. You get, essentially, an independent, nonprofit cooperative that’s owned by the people of Colorado and doesn’t profit from it — that exists to make a good environment for patients and providers. Their goal ends up costing less when you take out that profit motive that corporations are focused on.
We’re seeing millions of dollars going to the Coloradans for Coloradans campaign, and the vast majority of their funding comes from corporations — and most of that’s related to the health-care industry. Big Medicine, Big Pharma — and a huge percentage of that is coming from out of state. (Figures from September 19 show that $3,935,950 of $4,003,067 contributed to opposition group Coloradans for Coloradans came from corporations and business entities. The top four, whose contributions exceed $2 million, are from Ohio, California, Connecticut and Tennessee, respectively.) And that’s natural, because that’s their profits we’re talking about, and which they’re trying to defend. But those profits come at the expense of patient care in Colorado. So this is a real commonsense attempt to put patients over profits in the same way that Medicare does it. And Medicare has, for a long time, been considered the most popular and efficient government program out there. To use that as a tried-and-tested model makes immense good sense….
A lot of national organizations have been encouraging their supporters to support ColoradoCare, including Bernie Sanders and Our Revolution (a political organization created in late August). I think that’s a huge chunk of donations to ColoradoCare. It’s something we’ve anticipated coming for a long time. Bernie endorsed at the end of August. We anticipated he would as soon as he was through with his race. And he put it as a priority for the political-action group that he started. It’s one of I think seven ballot issues they’ve targeted around the country — things that fulfilled his vision and were in sync with his platform…. It’s one of the two or three biggest platform planks that has a chance to be enacted, and it’s here in Colorado.
Bernie Sanders knows and has said that if Colorado passes it, it will have an effect beyond Colorado. The reason the insurance industry is pouring millions of dollars into defeating it is not because of the money it will lose in Colorado, but because of the fear that other states will begin following that trend, just as they did with women’s suffrage, with child-labor laws, with minimum wage, with marriage equality, with interracial marriage, with recreational marijuana, and on and on. These things start at the state level and then reach a tipping point nationally as they become accepted.
The same thing happened in Canada with universal health care. It started in one province there — Saskatchewan — and then everyone saw how well it worked there. But rather than everyone moving to Saskatchewan, as the opposition claims will happen in Colorado if ColoradoCare passes, they moved that great idea from Saskatchewan to their own provinces and adopted it, and very soon had national universal health care. That’s what a lot of people expect will happen if Colorado passes it. And I think that’s what the insurance industry fears — getting a national, single-payer system. (Click to read more about the history of health care in Canada.)
To clarify, we’re not single-payer. Because Medicare still runs, and so does TRICARE for veterans, that keeps this from being purely a single-payer plan. But it’s similar. It’s understandable that people get it confused. But basically, it’s a Medicare-for-all program that does for Colorado what Medicare does for seniors. If you live here, you’re covered.
Are you pitching ColoradoCare not only as something that’s good for Colorado, but also as something that could go national? Or is it more important from your perspective that voters here look at how it will benefit them?
I think it’s more important for voters to look at how it benefits them in this state. So we probably don’t pitch the national aspect. But they’re one and the same. What’s good for Colorado is good for the nation. It makes the same economic sense; it’s the same moral-responsibility argument. It doesn’t really need to be separated. A lot of detractors say, “I’d like to see it on the national level, but I don’t want Colorado to start it on the state level.” But that’s how it’s going to happen. It’s going to start on the state level, and all the arguments for doing it nationally pretty much apply to starting it on the state level. It’s good for Colorado in terms of fulfilling our moral imperative as a society and saving us billions of dollars as a state and thousands or tens of thousands for individuals and families. It’s good any way you look at it.
As you’ve noted, your opponents are very well financed. Has it been a challenge to get your message out in the face of their resources? Or are you finding that word of mouth is working? And are you optimistic about the outcome?
It is a challenge. I think we’re all optimistic in that we know from polling that when people know about ColoradoCare, they like it and would vote to support it. The challenge is making sure they know about it. We have done a pretty good job all the way through in keeping up. It’s been a phenomenal grassroots effort. Our budget has been minuscule compared to the opposition…but the bottom line is, we need to make sure people know about it and understand it.
I think as we’ve gotten into the home stretch and those millions of dollars from the opposition have come into play with on-air ads, on TV for the most part, it’s been more challenging to keep up with. But the recent influx of donations will allow us to get on the air. We haven’t been on the air yet, but we’ve had something like 485 past and future presentations and speaking engagements and debates all over Colorado. I think about 125 of those have been debates. Reaching out, speaking to groups anywhere from a dozen to 500, has been effective. We’ve certainly been on the ground, knocking on doors and making phone calls. Every kind of grassroots tactic we can use to get the word out we’ve used, including a real aggressive volunteer effort to write letters to the editor and also to earn a lot of media attention. That’s helped us keep pace with the opposition, which has ten times the funding we have.
These last weeks, TV ads play such a big part — and it’s always tricky to figure out how they’re going to play. I think we’ve seen a lot of elections where TV advertising backfires. And certainly, I’ve heard from a lot of people who say the more they see of these ads, the less they trust them.
So, yes, it’s a challenge. But we know that when people know about it, they like it. And that gives us the drive to keep going, keeping doing everything we can to make sure Coloradans know the facts about it.
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PNHP has published a brief evaluation of the ColoradoCare ballot initiative, here.
