The 31st Constitutional Convention of the United Steelworkers of America (USWA) held in Las Vegas August 5-8, attended by 2,500 union leaders from across the US and Canada, was convened under the banner “Fighting to Win.” It took up issues connected with collective bargaining, organizing, global justice and political activism. The convention adopted a special resolution calling for a new universal and comprehensive healthcare system. The resolution, titled “For a Single Payer Healthcare, Publicly-Funded, Not-for-Profit Health Plan” and passed as an “emergency measure,” was referred to the convention by action of USWA Local 1375.

The resolution reads in part:

WHEREAS, every person residing or employed in the United States is entitled, as a matter of right, to accessible, affordable and quality health care; and

WHEREAS, this Union, the United Steelworkers of America recognizes that there is a growing crisis in health care in the United States of America manifested by massive layoffs, a steep increase in premiums, co-payments and deductibles, and the closing of many health care facilities serving low-to-middle income residents; and

WHEREAS, 44 million people in the United States have no health insurance coverage and that number is increasing rapidly; and

WHEREAS, 42 million people having only limited insurance are one catastrophic illness away from bankruptcy; and

WHEREAS, insured persons now commonly experience unacceptable and sometimes life-threatening delays in obtaining approval for needed health care services by private, for-profit health insurers; and

WHEREAS, it is estimated that the complex and redundant bureaucracy arising from the existence of multiple, for-profit insurance plans, each with its own distinct program of coverage and benefits, its own costly administrative and executive structure, and its own system of processing managed care approvals, and payments of benefits and/or reimbursements, wastes up to 30% of medical coverage premiums paid for by employers and private citizens; resources which otherwise could be used to provide benefits; and

WHEREAS, the bureaucratic structure and its inefficiencies distract health care providers from providing efficient and effective medical services to patients and places a drain on the financial resources of taxpayers; and

WHEREAS, this Union contends that a single-payer, publicly-funded, not-for-profit health plan will: eliminate the redundant bureaucracy caused by numerous insurers; greatly reduce administrative costs associated with providing medical care; free-up additional financial resources; allow medical providers to focus their efforts on providing quality care; and reduce the cost of health care coverage for residents and employers; and

WHEREAS, this resolution constitutes an emergency measure providing for the immediate preservation of the public health; now therefore,

BE IT RESOLVED BY THE UNITED STEELWORKERS OF AMERICA:

Section 1. That the Delegates to the Thirty-First Constitutional Convention of the United Steelworkers of America urges the United States House and Senate to commit to enact a comprehensive, publicly funded, not-for-profit health insurance program covering: (a) all residents of the United States of America as well as all dependents of United States residents, whether residing within the United States or elsewhere; and (b) all persons employed in the United States, regardless of residence within or outside of the United States, as well as their dependents.

Section 2. That this Thirty-First Constitutional Convention urges the prompt passage of Single Payer Health Insurance System so that upon its effective date:

i. Health insurance will be provided to all persons employed in the United States and their dependents by or through their federal, state and local public and private employers, including all health insurance previously provided by the federal, state and local government to its employees, thereby relieving these employers of the cost and administrative burden of providing health insurance coverage; and        ii. Every person will be covered by one uniform program of health insurance benefits, including prescription drug coverage, dental care, vision care, long-term care and coverage for mental illness on full parity with coverage for all other types of illnesses; and        iii. A Commission will be created, as an independent agency of the federal government, to implement and administer the Single Payer Health Insurance program; and        iv. The Single Payer Health Insurance benefit program will be designed and maintained so as to guarantee health care services of excellent quality, timely delivered and accessible to all; full support for ongoing medical research, medical education and training; full choice of providers; and access to comprehensive, preventive and long-term care; and     v. All federal, state and local funds allocated for health care purposes by Medicare, Medicaid, Veterans Administration, and other programs will be directed to the Single Payer Health Insurance benefit program, after obtaining the necessary waivers; and        vi. Any person who while covered by the Single Payer Health Insurance benefit program requires health care services anywhere in the world will be entitled to Single Payer Health Insurance program benefits to pay for such services to the extent payment has not otherwise been provided; and        vii. Any resident displaced from employment by the private health insurance industry in this United States as a direct result of the enactment of Single Payer Health Insurance benefit program will be eligible to receive, at state expense, retraining and temporary financial assistance to facilitate reemployment without significant loss of income, and will receive preference for hiring for employment by the Single Payer Health Insurance benefit program Commission in any position for which the displaced resident is qualified; and viii. Single Payer Health Insurance benefit program will be funded by utilizing federal, state and local monies that currently are used to fund existing federal, state and local health care programs, and any additional funding mechanism deemed necessary to ensure that Single Payer Health Insurance benefit program is fully funded with adequate reserves.

Section 3. That the Secretary-Treasurer of the United Steelworkers of America is hereby requested to forward a copy of this resolution to the members of the United States House and Senate.

Authors of a new study published today on the Health Affairs Web site say that higher drug cost-sharing saves money for retiree health plans, but enrollees pay more; drug utilization isn’t necessarily reduced. The authors conclude that policymakers should consider how copayments change use when designing a Medicare drug benefit. To view the article, go to www.healthaffairs.org/WebExclusives/Thomas_Web_Excl_120402.htm.

BETHESDA, Md.—Employer health plans that charge retirees higher copayments for retail pharmaceuticals saved themselves 18.7 percent per member on average in 2001, but their enrollees on average had 59.4 percent higher out-of-pocket costs ($389 versus $244), according to a new study published as a Health Affairs Web exclusive.

The study demonstrates the effects that plan design might have on costs and drug use under any Medicare prescription benefit, write authors Cindy Parks Thomas, Stanley S. Wallack and colleagues from Brandeis University’s Schneider Institute for Health Policy. The authors write that the study shows that higher copayments lead to the use of less-expensive drugs and fewer retail purchases, although they argue that Medicare should consider using copayment strategies in combination with other cost-containment mechanisms such as encouraging generics, mail-order delivery of prescriptions, prior authorization, and provider education.

The authors studied prescription drug claims made by more than 29,000 retirees age 65 and older enrolled in 96 employer plans managed by one pharmacy benefit management firm. They compared prescription drug use and costs in a number of plan designs, including those with multiple “tiers” of benefits and cost-sharing requirements.

They compared plans with cost sharing categorized as “more-aggressive” and “less-aggressive,” defined by whether they required an above- or below-average copayment for brand-name drugs, or whether they required coinsurance of more or less than 30 percent for brand-name drugs. The “more-aggressive” cost-sharing plans had average per-enrollee costs to the plan of $1,155 and average enrollee out-of-pocket costs of $389 in 2001. The “less-aggressive” plans had average per-enrollee plan costs of $1,421 and average enrollee out-of-pocket costs of $244 in 2001.

Enrollees in the more-aggressive plans had on average overall costs of $1,544 in 2001, compared to less-aggressive plans, which had fewer 30-day equivalent prescriptions and overall costs of $1,665 per enrollee. The study attributes half of the difference in costs to the higher cost-sharing in the more-aggressive plans, but says the greater use of generics, less expensive brands, and more mail-order delivery lowers the costs of drugs in those plans.

Across all the plan designs studied, average annual spending per enrollee was $1,571 in 2001, with average member out-of-pocket cost-sharing of 18 percent. The plans that had the highest member cost-sharing were the single-tiered plans with at least 50% member coinsurance for retail purchases, combined with mail order incentives, and the three-tier plans that charged between 10 percent and 40 percent member coinsurance, depending on the type of drug. Those plans had total member out-of-pocket cost sharing of 28 percent and 22 percent, respectively.

The study also found that enrollees are more likely to use generics when they fill their prescriptions at retail pharmacies under plans that have the greatest spread in copayments between brand-name and generic drugs. This is particularly true in plans that make use of coinsurance, which as a percentage of the total cost is variable based on the total price of the drug and not a flat copayment. For example, the authors found that in three-tier plans with a maximum 30 percent coinsurance for retail purchases and an actual copayment difference of $15 between generic and brand-name drugs, 44.5 percent of prescriptions were generic. In a three-tier plan with a $5 to $10 difference between tiers, only 36.1 percent were generic.

In addition, the study found that use of generic medications and use of mail order can save money both for enrollees, through lower copayments, and plans, through lower overall costs. The average mail-order price for all prescriptions was 16.4 percent less than retail. However, use of generics saved the most, with the average price of a generic prescription over 70 percent less than the average brand, at the pharmacy or through mail order.

The study can be read at www.healthaffairs.org/WebExclusives/Thomas_Web_Excl_120402.htm.

The research was funded by the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation.

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research.

By NUPGE Research

Since the beginning of our campaign to protect and build Canada’s Medicare, the National Union of Public and General Employees has recommended that the different levels of government work together to reach ten objectives. We believe that these ten objectives are not only about the health of Canadians, they are also about the economic health ofCanada. Achieving these ten objectives is the best way to ensure that we have a sustainable health care system that reflects Canadian values and lives up to Canadian standards for efficiency. We also believe that these ten objectives draw on the courage of the original vision put forward by the pioneers ofCanada’s Medicare and fulfill that vision by restoring, rethinking, and reinvesting in public Medicare and the people who provide health services. This report card is intended to evaluate how well the final report of the Romanow Commission stacks up against the National Union’s ten objectives.

Objective 1

Adequate and stable public funding
Romanow Report Grade: A

The report recommends the federal government provide “adequate, predictable, and stable public funding for Medicare.” To do so, the report recommends a multi-billion dollar injection of federal funds until it reaches a 25% minimum cash floor of Canada Health Act insured services – $6.5 billion more per year by 2006 – $3.5 Billion in 03/04, $5 billion in 04/05, and $6.5 Billion in 05/06. NUPGE, the CLC, other unions and many of our health coalition partners have called on the federal government to increase its share of health funding to 25% of publicly insured services. The Romanow report clearly reaches this benchmark.

As equally important as proposing increased federal funds, the report recommends that the new federal cash be used to “buy change” by attaching strings (through earmarked funding initiatives) to the new funds. In addition, the report recommends that the CHST be abandoned and replaced with a separate fund for health care transfers to the provinces (called the Canada Health Transfer) with a built-in escalator provision so that federal funding would keep pace with economic growth. This is the kind of accountability and transparency that’s necessary to ensure that any new health dollars actually go to health care services rather than tax cuts or other areas and it is something the labour movement has called for over the last 8 years. 

The Romanow report is much better that the Kirby report when it comes to increased public funding for Medicare. Kirby proposed what amounts to a permanent user fee, payable by all tax payers. Kirby’s proposal would not raise enough funds and it does not meet the test of fairness.

While we could argue that Medicare needs more money than what is being proposed, what is being offered is significant (particularly if the federal government gets to the 25% minimum, using the existing progressive income tax system and its revenues, with a built-in escalator) and this section of the report is positive and comes very close to meeting our Objective.

Objective 2

Never for profit
Romanow Report Grade: B

The report states that: ‘Medicare is a moral enterprise, not a commercial venture. Medicare is a right of citizenship … It is a far greater perversion of Canadian values to accept a system where money, rather than need, determines who gets access to care. ” The report concludes that private, for-profit health care runs the risk of being more expensive, providing worse care and undermining the value of fairness.

The report clearly states that Romanow challenged those advocating private sector solutions to provide the evidence but that evidence was not forthcoming. The answer to Canadian health needs, the report concludes, does not lie in the private sector but in a better funded public system.

The Romanow report also recommends decisive action to curb the growing number of private for-profit MRI and other diagnostic services clinics, concluding that these private clinics lead to queue-jumping and this violates the principles of the Canada Health Act. The report recommends that diagnostic services be explicitly included under the definition of insured services under the Canada Health Act. The report recommends that there be no user fees, facility fees or extra billing for MRIs and CT scans; thus, making it illegal for anyone to be charged an out-of-pocket fee for these services. The report recommends thatOttawapenalize any provinces that allow private delivery of diagnostic services. The report also states that the current status of injured workers (WCB claims) getting preferred access to care and being sent to private clinics violates the principle of equal access. Further, the report proposes a Diagnostic Services Fund of $1.5 billion over 2 years to improve wait times.

The report looks at Public-Private Partnerships and essentially concludes that they’re not a good idea and will end up costing taxpayers more than if the government had simply done the job itself in the first place. The report also notes that these arrangements can have the effect of hospital bed closures and a reduction in staffing levels.

The Romanow report also recommends that user fees, medical savings accounts, deductibles and tax-based co-payments continue to be banned by the CHA.

Clearly, this is much better than the Kirby report which has no problem with further commercialization, private for-profit ownership and delivery.

However, the report does have a major weakness on the issue of privatization. It offers reasons and suggests there is evidence that contracting-out of non-medical services such as food preparation, laundry, maintenance and cleaning is okay. This is not the right thing to recommend or the smart thing to recommend and therefore the report, on this point, is extremely disappointing.

Further, while the report gives strong rationale for opposing private for-profit care, the report is missing a specific recommendation of a specific mechanism for banning private, for-profit delivery of health services. 

In addition, while the report is critical of P3s it stops short of recommending they be banned completely and even suggests that they might be useful in non-direct health areas such as “health information systems.”

This section of the report went far, but could have and should have gone even further. In any health care institution, germ-free environments, properly sterilized laundry and food safety are critical to the well-being of patients – we can’t afford to cut corners with for-profit laundry, dietary and maintenance services. The report should have said this but it didn’t. Therefore, this section of the report does not completely meet our Objective.

Objective 3

Debunk private health care myths
Romanow Report Grade: A

The report is an eloquent defence of public Medicare. It offers unqualified support for the principles underlying public Medicare. It dismisses the myth that public Medicare is on the brink of collapse. It debunks the myth that public Medicare is unsustainable or unaffordable. It also challenges the myth that private, for-profit care is more efficient, would shorten waiting lines, and provides better care (except when it comes to support services and this is a problem with the report). It also concludes that ‘innovations’ such as user fees, medical savings accounts, P3s etc. are nothing more than standard right-wing nostrums that will do nothing to improve Medicare.

This part of the report is very positive and meets our Objective.
 

Objective 4

A comprehensive national health human resources strategy
Romanow Report Grade: B

The report suggests the need to look at changing the scopes and patterns of practice of health providers.
 
The report argues for a national database to analyze relevant human resource information, and track and forecast trends.

It also suggests that governments stop recruiting health care workers from third world countries.

The report calls for a Rural and Remote Access Fund ($1.5 Billion over 2 years) to attract and retain health care providers, including opportunities for health professionals to train and gain experience.
 
There are not enough substantial recommendations on this subject – i.e. it does not make specific suggestions for training and upgrading skills of existing health professionals and other workers. Most of the details of a national health human resources strategy are left to be developed by a new Health Council of Canada. We were hoping for more substantive recommendations and a national fund for a human resource strategy. We were also looking for a proposal to promote and market the various health professions.
 
On this subject, the Romanow report only partially addresses the Objective we set out. 
 

Objective 5

Primary Care Reform – Develop a system of blended care
Romanow Report Grade: A

The report recommends a common national platform for primary care reform.

It recommends a $2.5 billion investment over 2 years through a Primary Health Care Transfer in order to remove barriers to change and kick-start reform. Of course, service delivery is provincial jurisdiction, so Romanow recommends the federal government link the new funding to provincial pursuit of the community clinic model.

The changes it proposes include: full-service community health clinics where patients can access a team of health professionals 24-7and receive everything from a doctor’s prescription to nutritional advice to physiotherapy and psychiatric help.

There is also an emphasis on the need for cultural diversity and removing language barriers to improve access to care.

The report also talks about the need to put more emphasis on wellness and disease prevention programs – tobacco, obesity and physical activity are good choices to start with for health promotion.

In some ways this section of the Romanow report is similar to Kirby’s proposal of creating primary-care groups of different types of health-care providers. However, Romanow’s recommendation is better in that it calls on the federal government to use any new money to ‘buy the changes needed in primary care reform’ and it talks about wellness and prevention programs being critical to good health.

The focus on primary care reform, integrated with health promotion and disease prevention is long over-due. This section of the report and its related recommendations are very positive and come very close to meeting our Objective.

Objective 6
Add home care to the Canada Health Act
Romanow Report Grade: B

The report recommends that Ottawa kick-start a process (and provide the foundation for) a national home care program by covering all priority home care services – i.e. intervention services, home mental health services, palliative care, post-acute home care – through a Home Care Transfer of $2 billion over 2 years.

It is not clear what the report suggests should be done with home support / personal support services. It has no specific recommendation on bringing these services under the CHA so we must assume it is okay with those services, for the most part, being left out of the Act and therefore becoming out-of-pocket expenses for all intents and purposes. This would not be the right thing to do or the smart thing to do. These are services that allow people to live with dignity in their own homes. That both improves care and saves money by keeping people out of hospitals.

The Kirby report called for a national home care program that would cover only those just released from hospital or those near death.

This part of the report does not go all the way and recommend a new national program immediately, and not mentioning home support services is disappointing, but it does propose a good step forward in the direction of including all home care services under the CHA. It doesn’t completely meet our Objective but it brings us a closer to a national home care program. 

Objective 7
Add long term care to the Canada Health Act
Romanow Report Grade: D

The Romanow report is a dismal failure on this Objective. The report does not make any recommendations at all for institutional care.

It assumes, for the most part, that through home care reform and increased coverage of acute and palliative home care services under the CHA, you would be able reduce the demand for beds in long-term care institutions.

The report does not recommend national standards for long-term institutions and it does not recommend new immediate public funding for long-term care.

The total lack of recommendations in this area is clearly a major win for the huge private corporations involved in the long-term care industry i.e. Extendicare.

 
Objective 8
Add a national pharmacare program to the Canada Health Act
Romanow Report Grade: A-

The report concludes that the short term priority should be to provide public funding for “catastrophic drug costs” with the Canada Health Act eventually covering the cost of prescription drugs.

It recommends the establishment of a National Drug Agency and a National Drug Formulary as a national strategy for dealing with soaring drug costs, providing comprehensive coverage and objective and accurate information on drugs.

The Romanow report also calls for a review of current drug patent laws inCanada.

The Romanow recommendation is better than Kirby’s proposal which calls for public coverage after $5,000 and does nothing to address the root causes of soaring drug costs (patent law). 

This recommendation falls short of our Objective of a National Pharmacare Program but it offers a huge step in the right direction, especially on the recommendation to review patent laws. 

Objective 9
Exclude health services from all international trade deals
Romanow Report Grade: A

The Romanow report offers a strong message on this issue. The report issues a ‘warning flag’ on globalization and trade deals and their impact on the future expansion of public health care.

It recommends that governments must not delete from trade deals any of the current protections and exemptions for health care and it states thatCanadashould work with other nations to protect public health care from trade agreements.

It also states that any future efforts to expand public Medicare must also be protected from trade deals. 

It also states that the right to regulate health policy should not be subject to claims from foreign companies.

The Romanow recommendation is better than the Kirby report which ignores altogether the risks posed by NAFTA and other trade agreements that further privatization of health services would open the door to US and other foreign corporations to penetrate our Medicare and take over its services.

The report could have called for a renegotiation of trade deals which would provide even stronger protection for public health services. There should have been a recommendation that the Canadian government take TeleHealth technology off any trade negotiation table.

On the whole, the Romanow report is strong on this subject and comes very close to meeting our Objective.

 
Objective 10
Women’s equality in health care
Romanow Report Grade: A

The report recommends that governments provide some kind of financial aid to those (overwhelmingly women) who have to stay at home to care for sick, elderly or disabled relatives. On principle this is an excellent recommendation and it takes us into any area governments have not yet ventured. Of course, the devil will be in the details with respect to how the assistance is provided – likely through the EI system

The recommendation of increased public funding and reversing the trend of privatization is also very helpful for health care workers the majority of whom are women. Contradicting this, however, is the section of the report that offers reasons for contracting-out support services. This would unevenly affect women workers and so this aspect of the report could have been better.

The report does not offer enough to address the unique health needs of women and related access issues.

The Romanow recommendation is much better than the Kirby report which ignores the uneven burden faced by women when it comes to unpaid care giving in the home. Further the Kirby endorsement of private for-profit ownership of facilities and services would actually exacerbate the uneven burden and unequal access to health services faced by women.

The report goes further than any other to address the uneven burden faced by unpaid care-givers (mostly women) and comes close to meeting our Objective.

Other Important Recommendations

· A new Canadian Health Covenant is proposed to express Canadians collective vision for health care and updating the Canada Health Act.

· A New Health Council of Canada to foster collaboration amongst governments and stakeholders.

· The report recommends that a 6th principle of “accountability” be added to the Canada Health Act.

 
FOR MORE INFORMATION:
Contact Mike Luffat
Phone: 613-228-9800
Fax: 613-228-9801
Email: mluff@nupge.ca
Visit:   www.nupge.ca
www.savemedicare.com  
www.youthformedicare.ca

Health care reform is back in the news. This time, does it stand a chance?

By Jonathan Cohn, 12/1/2002

WHEN SENATOR EDWARD Kennedy announced on Nov. 21 that he would soon propose a plan for universal health insurance, it barely qualified as news. Kennedy has been a member of Congress for 40 years now, and in that time he’s introduced major health care bills at least a dozen, maybe two dozen times. But for once, Kennedy’s timing seemed exquisite. In the past, the senator has been a lonely champion of health care reform, fighting not only Republicans but even more cautious members of his own party. This time around, Kennedy has company in his crusade. And lots of it.

Just days before Kennedy made his announcement, Al Gore surprised reporters with his announcement that he will call for the creation of a ”single-payer” health insurance system in the United States – that is, a system in which the government provides every citizen with health insurance directly, just as it does in Canada. Almost immediately, two of Gore’s would-be rivals for the 2004 Democratic presidential nomination, Senators John Edwards and John Kerry, indicated they’d soon be unveiling health care plans of their own. Assuming all three men make good on their promises, they’ll be following the lead of a fourth Democratic presidential contender, Vermont Governor Howard Dean, who long ago made universal health insurance the centerpiece of his upstart candidacy.

And Democrats running for president aren’t the only ones talking about big changes in health care. The National Academy of Sciences has placed a starkly worded report on the desk of President Bush. ”The American health care system is confronting a crisis,” it reads. ”The health care delivery system is incapable of meeting the present, let alone the future, needs of the American public.” The academy went on to recommend that the federal government allow a handful of states to experiment with different schemes for achieving universal coverage, a message the Bush administration said it would take to heart. And while Bush doesn’t exactly have the budget space to enact a major health reform right now – frittering away $1.7 trillion on a tax cut for the wealthy will do that – he has been talking up a more modest initiative to help the uninsured buy coverage for themselves.

Feel like you’ve heard this all before? That’s because you have. In the early 1990s, as health care costs skyrocketed and a deep recession drove up unemployment, large numbers of Americans began to fear losing their insurance coverage and having to face serious medical bills, much as they do today. Panels of experts began churning out dire warnings of systemwide collapse and, before long, health care reform was the dominant topic in politics. During the 1992 campaign, the popularity of Bill Clinton’s health care pitch even forced the incumbent president, Republican George H.W. Bush, to craft a modest reform package similar in broad outlines to what his son offers today.

Of course, all the talk about health care reform in the early 1990s didn’t exactly make it happen. On the contrary, in 1994 Clinton’s ambitious health care proposal died an ignominious death: Even though the Democrats controlled both the House and the Senate, the plan never came up for a vote on the floor of either chamber. Ultimately, it unleashed such furious political opposition that the Democrats lost control of the House for the first time in a generation. So while it seems pretty obvious that another national dialogue about health care is beginning, the real question is where that discussion will go. Will it produce meaningful change? Or will it produce exactly what the last great health care debate produced – namely, nothing?

Certainly, there are reasons to doubt that large scale health care reform will take place soon. A major reason that the Clinton plan ran afoul of public opinion was that substantially expanding the reach of health insurance coverage inevitably requires substantially expanding the reach of government. The voters were pretty ambivalent about that prospect then, and they still are now. What’s more, you can bet the special interests who fought reform so vigorously in the 1990s – particularly the small business lobby and portions of the insurance industry – will do so again.

But even if those conditions remain largely the same, one key barrier to reform may be gone: the sense among middle-class Americans that their current insurance policies are sacrosanct. If you remember the fight over the Clinton health care plan, then you probably remember the ”Harry and Louise” ads on television. Those spots featured a middle-class couple sitting around their kitchen table, purportedly reading aloud from the Clinton plan and recoiling at its provisions. As Harry and Louise explained it, under the Clinton plan Americans would lose their choice of doctor, their access to life-saving treatments, and so on. The advertisements echoed what would become the main line of attack against the Clinton plan: that middle-class Americans stood to lose more from government intervention in health care than they stood to gain.

Such an argument is unlikely to be so persuasive today. When government reform failed in 1994, employers took it upon themselves to restrain costs through managed care – a method that, although effective, rankled most consumers. Suddenly, all of the dire predictions of Harry and Louise were coming true anyway, even without the dreaded Clinton plan. Health maintenance organizations and other forms of managed care limited patients to selected groups of physicians, second-guessed treatment decisions, and created longer waits for those treatments that were approved. Whether or not these changes were necessary for the sake of containing costs, the fact is they made the status quo a lot less appealing to the average American. According to the Harris Poll, for example, the number of people who said health insurance companies do a ”bad job” of serving consumers jumped from 47 percent to 57 percent from 1998 to 2001 alone. That’s one reason regulating HMOs, a cause that burst onto the scene in the mid-1990s, became so popular so quickly. It’s also one reason that enthusiasm for a total overhaul of health care has quietly crept back to its pre-1992 levels.

Another traditional obstacle to health care reform has been the cost. Any successful program to extend health coverage to the uninsured is going to require raising taxes, and one might expect voters to resist, even if it’s just a matter of redirecting money they’d be spending on insurance premiums anyway.

But will they resist? Here is where today’s reformers can unleash some scare tactics of their own, thanks to another side-effect of the managed care revolution. During the late 1990s, as insurance companies slashed the money they paid doctors and hospitals, the providers of health care responded by downsizing and making their operations more efficient. They largely succeeded – it’s one reason hospitals like Beth Israel Deaconess and Massachusetts General, which were in so much financial trouble just a few years ago, are climbing back into the black – but only by compromising their ability to deal with surges of patients. The most visible result of this shift has been a nationwide epidemic of overcrowded emergency rooms, a crisis Boston knows only too well. As recently reported in the Globe, Massachusetts ERs are now diverting ambulance traffic twice as often as they did just two years ago. And once patients do make it into the ER, they must frequently wait hours – even days – before getting admitted.

Stories like this scare people, as well they should. And because everybody, not just the poor, might someday need care in an emergency room, concern about ER crowding can motivate otherwise complacent, relatively comfortable voters into supporting expensive health care initiatives. Just consider what happened in Southern California this Election Day, where voters in Los Angeles – cradle of the antitax movement – overwhelmingly approved a property tax increase in order to support local trauma care. A major reason they did so was a series of television ads portraying paramedics desperately seeking emergency rooms that would accept their patients. The ads were dramatizations, but they weren’t fiction: In LA, emergency rooms now divert ambulance traffic 40 percent of the time.

To be sure, it’s a long way from enacting a local ER tax to making health insurance a right of citizenship, as many reformers now propose to do. And as if to demonstrate the extent of that distance, on the same day voters in Los Angeles approved their new property tax the voters in Oregon, about as progressive a state as you’ll find on health care issues, overwhelmingly rejected a ballot initiative that would have required the creation of a universal health care program in the state.

But today’s reformers have learned a key tactical lesson from Clinton: don’t try to reinvent the entire health care system at once. That’s why Howard Dean, who once proposed a Clinton-like scheme for Vermont, has said he’ll work on insuring children up to the age of 22 first and worry about the adults afterward. Ted Kennedy may have a reputation as a radical, but his plan actually calls for leaving our current employer-based system intact. He’d simply require that businesses give their workers benefits and cover three-quarters of the cost themselves; employees would pick up the rest of the bill, with government subsidizing low-income workers who can’t afford their share of the premiums. Then there is the National Academy of Sciences approach to health reform: letting a few states experiment with universal coverage until somebody gets it right.

Al Gore’s proposal would appear to be the odd one out: The adoption of Canadian-style national health insurance would represent a sweeping change of Clintonlike proportions. But Gore may have learned a key lesson from Clinton, too. Clinton’s determination to produce a workable compromise ultimately produced a convoluted scheme that, however elegant on paper, was impossible to defend from Harry and Louise’s kitchen table jabs. Gore, by contrast, can describe his plan with one simple slogan, ”Medicare for All,” thereby linking it to one of the most popular and successful government programs of all time.

Admittedly, it will take more than simplicity to sell large-scale health care reform right now. If Congress can’t even pass HMO reform, a relatively modest measure that would merely regulate the way insurance companies make decisions about treatments, the prospects for more sweeping measures would seem pretty slim. But the plight of the uninsured and the anxieties of the currently insured are getting worse, and this means the political appetite for health care reform is likely to increase. Ted Kennedy obviously thinks it will. And judging by all his newfound political soulmates, he’s not alone.

This story ran on page D1 of the Boston Globe on 12/1/2002.
© Copyright 2002 Globe Newspaper Company.

DAILY EXPRESS
The Single Guy
by Jonathan Cohn
Only at TNR Online | Post date 11.22.02

It looks like Al Gore wasn’t kidding two weeks ago when he let slip his intentions to propose a single-payer health care system for the United States. In a piece about Gore published earlier this week, Ron Brownstein of the Los Angeles Times reports that Gore told him the very same thing–and in considerably more detail. Specifically, Gore told Brownstein that he would unveil his plan early next year, and that the plan would observe three principles: The actual practice of medicine would still be done through the private sector; Americans would have “choices”; and the plan would reduce spending by streamlining bureaucracy. “The system as a whole has reached a point of no return,” Gore said. “It is collapsing. It is beyond saving in its current design.”

Is Gore nuts? Not on policy grounds. In a single-payer system, the government becomes the nation’s health insurance company. Instead of paying premiums to an insurer (either directly or through an employer), each American would pay that money to the government; in turn, the government would pay the providers of medical care–i.e., mostly private doctors and hospitals–in the same way insurance companies now do.

Make no mistake: It’s a radical overhaul. But single-payer also has clear virtues: As a general rule, the more people who belong to an insurance pool, the more thinly you spread the financial burden of illness, which can be devastating if you face it alone or within a small group. By definition, single-payer spreads the risk pool across the largest number of people possible–namely, everyone in the country. In addition, while people may associate government with excessive bureaucracy, single-payer systems devote far less money to administrative overhead than private insurance. (Among other things, insurance companies spend a ton of money on advertising.)

Typically, opponents of single-payer insist it’s better to have a private insurance system that promotes more “choice.” But one of the chief advantages of single-payer is that it gives patients the kind of choice that matters–not choice of insurance plan, but choice of doctor. For example, if you switch plans today, you may discover your favorite physician doesn’t take your new insurance. But in a single-payer system, virtually every physician would take government insurance, so that would no longer be an issue.

And, of course, single-payer systems by definition make coverage universal–i.e., they give insurance to every citizen as a birthright, regardless of employment status. This isn’t just fair: It may also be more efficient, since it would allow people more freedom to change jobs and pursue better opportunities.

None of this means single-payer is ultimately the best way to go on health care. In fact, there are some pretty valid objections to it, though not necessarily the ones its critics are making today. But its virtues make it a credible alternative, one that deserves a major role in the debate over our health care system’s future.

But what about the politics? No sooner had Gore introduced the plan than conservative critics pounced on him, calling him an extreme leftist and noting that this endorsement represented another Gore “flip-flop,” given his opposition to Bill Bradley’s health care plan in 2000. “This is … Gore, the radical,” Michael Kelly wrote in his Washington Post column. He then defined single-payer as “the idea [Gore] savaged his 2000 Democratic primary opponent, Bill Bradley, for supporting.”

But the criticism about Gore’s apparent reversal on Bradley actually shows why endorsing single-payer has a certain political logic to it. Bradley didn’t propose a single-payer plan in 2000. On the contrary, the essence of Bradley’s plan (which, by the way, this author lauded at the time) was to help uninsured Americans buy into the same system that now serves federal employees. In that system, federal employees choose from among a menu of private insurance plans, then pay premiums based on what the plans offer. Yes, lots of people attacked that plan for expanding the role of government. But, if anything, it actually reduced government’s role, by getting rid of Medicaid (under which government insures the poor directly) and having those people buy private insurance instead.

The lesson is that even if you don’t actually propose a radical overhaul of the health care system, critics from the right will still have an easy time denouncing it as medical socialism. Indeed, critics from the right have been known to level that charge at even piecemeal health reform measures–from the State Children’s Health Insurance Program (S-CHIP), which merely allows states to subsidize coverage for kids living at or near the poverty line, to HMO reform, which doesn’t expand coverage at all but simply regulates the way insurance companies make treatment decisions.

So if you’re going to propose a large-scale change to the health care system and invite the “socialized medicine” charge anyway, you might be better off endorsing a single-payer system, which at least has the virtue of being easy to explain. Unlike, say, a hybrid public-private system, which involves all sorts of convoluted regulations, which then require all sorts of tortured explanations, the essence of single-payer can be reduced to three simple words: “Medicare for all.”

After all, Medicare is essentially a single-payer system, only one that operates exclusively for senior citizens. While its lack of prescription drug coverage remains a major flaw–albeit one that both parties have now sworn to fix–it is also incredibly popular with the people who have it. And why not? If you’re on Medicare, you never worry about losing your insurance. If you’re on Medicare, you can see most any doctor you want–and get most treatments the doctors recommend. Medicare has a large bureaucracy, but most physicians today will tell you it’s a more reliable payer–and a less onerous overseer–than private managed care companies. Indeed, far from true “socialism,” Medicare allows doctors and hospitals to remain privately employed.

If there’s a big problem with Medicare these days, it’s the program’s lack of long-term financial viability. But that’s a flaw of the entire health care system, and will require resolution with or without major health care reforms. Indeed, single-payer advocates argue that their system makes that resolution easier, by introducing a more efficient system and allowing people to make trade-offs democratically. Enacting single-payer wouldn’t necessarily mean expanding Medicare per se (although plenty of Democrats have proposed such schemes before). But a would-be reformer could certainly explain it that way.

This isn’t to say single-payer is an easy sell. Quite frankly, it may be impossible to sell sweeping health care reform–any sweeping health reform–right now, given the nation’s political mood and power of special interests with a stake in the status quo. But among the proposals out there, single-payer has compelling political advantages. Al Gore may turn out be wrong. But he isn’t nuts.

Jonathan Cohn is a senior editor at TNR and a 2002-2003 Kaiser Family Foundation media fellow.

From MassCARE:

The Massachusetts Health Care Trust will be resubmitted on December 4, 2002.  Activists will be in the State House gathering signatures of legislative cosponsors on:
           
Tuesday, December 3rd – 10am to 4pm – call the office at 800-383-1973 if you would like to join us.  We will meet at the 4th Floor cafeteria

Wednesday, December 4th – 9am to 1pm in Room 222 at the State House. Join us if you can.

Senator Steve Tolman (D-Brighton) and Representative Frank Hynes (D-Marshfield) are the new lead sponsors for the bill.  Both legislators agree that the best strategy is to file the bill only in the Senate, this makes it easier to move.  Frank Hynes will be listed as the lead House sponsor and will sign right under Steve Tolman.  Representatives can sign onto a Senate bill, I am assured that Reps are used to doing this.

CALL YOUR STATE SENATOR AND STATE REPRESENTATIVE AND TELL THEM THAT YOU EXPECT THEM TO SIGN ON AS A COSPONSOR.

THANK YOU.