PNHP

Quality of Care Lower in For-Profit Nursing Homes than in Non-Profits

Quality of Care Lower in For-Profit Nursing Homes than in Non-Profits

University of California/Harvard Study Finds Investor-owned Homes Skimp on Nursing, Frequently Cited for Deficient Care

A study published in today’s American Journal of Public Health (Full article in Adobe PDF format) finds that investor-owned nursing homes are much more likely to be cited for deficient quality than non-profit homes. The study analyzed data from 1998 government inspections of 13,693 nursing homes, virtually every nursing home in the U.S.

Inspectors cited investor-owned facilities for deficient care 46.5% more frequently than non-profits (and 43.0% more frequently than public nursing homes.) Investor-owned homes also had significantly higher rates of severe quality problems, situations in which patients were actually harmed by poor quality. Quality was particularly poor at facilities owned by nursing home chains.

Nurse staffing was also lower at investor-owned homes. Licensed nurse (Registered Nurse or Licensed Practical Nurse) staffing per patient at investor-owned facilities was 31.7% lower than at non-profits and 22.8% lower than at public facilities; nurses’ aide staffing was 11.9% and 16.0% lower respectively.

Almost two-thirds of all U.S. nursing homes are investor-owned, though tax-dollars pay for more than four-fifths of all nursing home bills. Periodic public scandals in the past have raised concerns that for-profit facilities may be skimping on care in order to make a profit, but the UC/Harvard study is the first nationwide study to document that investor-owned homes deliver worse quality care.

The research is the latest of a series of studies documenting that for-profit health providers compromise quality. For instance, investor-owned HMOs are known to deliver lower quality care than non-profits; investor-owned hospitals are more expensive, and have death rates 6% higher than their non-profit counterparts; and investor-owned kidney dialysis clinics have 21% higher death rates than non-profit facilities paid identical amounts.

“Nursing home advocates, discharge planners and the public need to be aware of the lower quality in investor-owned facilities and take this into account when selecting a nursing home.” said Professor Charlene Harrington of the University of California, San Francisco.

“When investor-owned chains understaff their facilites and underpay their workers, the chain makes money but quality suffers” said Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard and one of the authors of the study. “For the 1.6 million Americans who reside in nursing homes, the quality of care largely determines the quality of life. Nursing homes care for many people too frail, too sick, and too powerless to choose or even protest their care. It is immoral to put such vulnerable patients at the mercy of profit-hungry firms.”

“Our decade-old experiment with market medicine is a failure,” said study co-author Dr. David U. Himmelstein of Harvard, who also serves as National Spokesperson for Physicians for a National Health Program. “It’s time to end our race to the bottom in health care and implement national health insurance, including universal coverage for high quality long term care.”

National Survey on Consumer Experiences With and Attitudes Toward Health Plans

The Kaiser Family Foundation/Harvard School of Public Health
August, 2001

3. Now I’m going to read you some different health care issues. As I read each one, please tell me how important you think it is for the President and Congress to deal with this issue – very important, somewhat important, not too important, or not at all important.

d. Increasing the number of Americans covered by health insurance

72 % – Very important 20 % – Somewhat important 4 % – Not too important 2 % – Not at all important 1 % – Don’t know or refused to answer

http://www.kaisernetwork.org/health_cast/uploaded_files/Consumer_Experience_Toplines.pdf

Comment: 92 % of Americans believe that it is important for the President and Congress to increase the number covered by health insurance. Yet we are being guided by policies supported by 2 % of the people. What will it take to overcome the political gridlock?

HMOs hailed for easing the rules

The Boston Globe
August 29, 2001
by Liz Kowalczyk

“Managed-care plans have responded to growing political and consumer pressure by loosening their restrictions for everything from elective surgeries to lengthy hospital stays.”

“But the shift – which some industry executives are going so far as to call the ‘new era of managed care’ – is coming with a price: Insurance premiums in Massachusetts will rise another 8 percent to 15 percent next year, and even more nationally, an increase that HMO executives attribute partly to the greater freedoms granted to members.”

“But Larry Levitt, a policy director at Kaiser, says he doesn’t buy the argument that greater freedoms for members are driving up costs. The only reason that HMOs are scrapping prior approval and referral policies in the first place, he said, is that they found members rarely sought surgeries and tests they didn’t need. In other words, the restrictions had little impact on the amount of care members received, but created frustration among doctors and patients.”

Larry Levitt, a policy director at Kaiser Family Foundation:

”There is no question that HMOs have loosened up on a whole range of issues, but the idea that it’s the culprit in rising costs is way overstated. These things were not saving them any money.”

http://www.globe.com/dailyglobe2/241/nation/HMOs_hailed_for_easing_the_rules+.shtml

Comment: Managed care health plans were effective in slowing the increase in health care costs by imposing fee controls in their contracts with providers. That was a one-time benefit that can be maintained, but cannot be used to prevent the expansion in health care services that is the real reason that rate of increases in health care costs continues to exceed that of inflation. Now we see that managed care plans are totally incapable of controlling utilization, and double digit increases will continue until we reach the threshold of bankruptcy, an effective but inhumane form of cost containment and rationing. Rationing is absolutely inevitable and is currently practiced in the health care systems of every other nation, but by utilizing much more humane methods. Only our system uses the unique method of rationing based on the ability to pay for health care, a cruel system that is now expanding to include working families. But we can contain costs much more humanely by changing to a system of funding health care costs that has a mission of optimizing allocation of our abundant health care resources. Public administration of a globally budgeted, universal health insurance program would fulfill that mission. Isn’t it time to take a serious look at that model of reform?

HMOs eyeing surcharge for high-end care

Boston Globe
August 28, 2001
by Liz Kowalczyk

“Several managed-care companies, including Tufts Health Plan in Massachusetts, will introduce plans in 2002 that level a surcharge on consumers who choose to visit more expensive (teaching) hospitals. Aetna is planning a similar product in Massachusetts next year and the HMO giant PacifiCare in California will introduce a surcharge on certain hospitals in eight states. The charges, or co-payments will be in the range of several hundred dollars per visit.”

Kevin Counihan, Tufts senior vice president for sales and marketing:

“This is what our employers want. They’re looking for a greater level of consumer engagement.”

Jon Kingsdale, Tufts senior vice president for planning and development:

“We’re not talking about bankrupting people here.”

http://www.boston.com/dailyglobe2/240/nation/HMOs_eyeing_surcharge_for_high_end_care+.shtml

Comment: “Greater level of consumer engagement,” but short of bankruptcy… at the same time that premiums will be rising 8 to 15 percent next year in Massachusetts. Cost containment has not been possible under the current model of marketplace health plans. Both employers and insurers are shifting more and more of the costs to the benificiary-employee-patient. In a personal communication, a very prominent professor of public policy and economics wrote, “My guess is that around 2004-5 all hell will break loose in American health care, if current cost trends continue.” It is imperative that we immediately place before the American public the plan that will contain costs while bringing equity to our health care system: a globally budgeted, publicly administered, universal program of health insurance. We may not be able to enact it until “all hell breaks loose,” but, if we are not prepared, the scavengers will move in and devour what is left.

WellPoint is savvy but… doctors are wary

American Medical News
September 3, 2001

“At a time when many managed care companies are losing money and rethinking capitation, health care analysts point to WellPoint Health Networks as the industry leader that has broken from the pack. WellPoint, analysts say, stands out from the crowd because it consistently makes a profit and is well ahead of the curve in providing the flexibility and choice that consumers want from their health plans.”

“WellPoint, which focuses on the small- and mid-size employer market, is able to price its products to make a profit, while avoiding alienating employers with steep premium increases, France said. It does that by fine-tuning health plans — raising co-payments or deductibles and adjusting benefits.”

Joe France, an analyst with Credit Suisse First Boston:

“They are very forward looking. Leonard Schaeffer (WellPoint CEO) is the single most respected executive in the industry.”

http://www.ama-assn.org/sci-pubs/amnews/pick_01/bisa0903.htm

Comment: Forward looking – smaller benefit package, and higher out-of-pocket expenses. And price the product to compete within the employer’s panel of defined contribution plans. With WellPoint leading the way, working families will soon be faced with health care cost sharing that will consume all of their disposable income. It has been said repeatedly that we cannot have health care reform until the average American is hurting. Well, they’ll be hurting real soon.

Excerpt from a communication received from a concerned member of Physicians for a National Health Program (PNHP)

“If we focused on universal access instead of single payer, we would have a much greater chance of dealing productively with these problems. If the resources, intelligence, and good will of PNHP were applied to formulating a universal access scheme incorporating the principles we espouse with the political and social realities that exist, we could move forward. We should even draft concrete proposals for universal access and present them to the political hopper. I do not believe that single payer per se has any real chance of occurring in this country. People who have dedicated their political lives (like Rep. McDermott and Sen. Wellstone) to single payer now admit that it won’t be accepted.

“They have moved on – why can’t we? I happen to believe that it is an error to have only one insurance vehicle, because there will be no choice for the consumer. Medicare can be as rigid and unfair as HMO’s and we ought to have alternatives. The American people often blindly fear and reject government control of their lives; can we expect less of their health? We need to support a balance of power, not 100% centralization.”

“Don, I am asking you to send this commentary out on your email list, so that the ideas therein have a chance to be aired and commented on. There out to be room in PNHP for dissent, and time is passing without a solid hope of improving this situation.”

Comment: It has been a dozen years since the New England Journal of Medicine published the landmark article, “A National Health Program for the United States: A Physicians’ Proposal,” by David U. Himmelstein, M.D., Steffie Woolhandler, M.D., M.P.H. and The Writing Committee of the Working Group on Program Design (https://pnhp.org/publications/NEJM1_12_89.htm).

In that article it was stated:

“Most significant, the great majority of Americans support a universal, comprehensive, publicly administered national health program, as shown by virtually every opinion poll in the past 30 years. Indeed, a 1986 referendum question in Massachusetts calling for a national health program was approved two to one, carrying all 39 cities and 307 of the 312 towns in the commonwealth. If mobilized, such public conviction could override even the most strenuous private opposition.”

So, why do we not have reform? We continue to ask ourselves that question. Inevitably, we question our own proposal, and now I am speaking as a board member of PNHP. Some suspect that our proposal must be defective, and look for alternative solutions. Today’s quote is from a member who is genuinely concerned about the failure of the movement for reform. He very legitimately wants to bring up other options that may seem to be politically feasible. Before I was actively involved in PNHP, although a member, I myself devised a “brilliant” alternative plan, which proposed basic care, elective care, and excluded care as categories for different coverage options. I sent it to Claudia Fegan, M.D., then president of PNHP, and she returned an extensive critique, which, in retrospect, indicated to me that I was quite ill-informed on fundamental issues of health policy. But, foremost, she taught me a lesson that she learned from her father in his negotiations on behalf of unions, and that is that you do not ever put anything on the table at the start of negotiations. Never, never start from a compromised position. I am deeply indebted to Claudia redirecting me down the right path towards reform.

Although I presented only a couple of excerpts from the concerned physician’s communication, some of the other options he proposed will be evident from my response. His concerns are very genuine, and his proposals seem to be logical extrapolations from possible explanations for the failure to achieve reform. I present my response both because many others have had similar proposals and we wish to present our concerns about these types of proposals, and also because we want to explain why we must stay the course.

Response to a concerned PNHP Member:

Dear Dr.

Ellen Shaffer concludes this series:

Recent exchanges have raised important issues regarding how to assess, analyze and address the public’s views on health care reform, as well as what might change the equation. It would be great to have a forum that does not overload The Quote of the Day list where these ideas could be pursued. As it is, we can all refer to cited publications, and look forward to promised new ones.

Uwe raised some questions with you all about me, and about my remarks regarding his comments. I have written a detailed note to him, responding to the questions he asked. I don’t believe that passing along my new round of comments publicly would clarify much that wasn’t clear in my first message, or that others have not subsequently said better. I stand by every word I wrote, and the purpose for which I wrote it. I’ve sent Don a copy of my message to Uwe, and would be happy to have him pass it along to any of you who are interested, and to hear back from you if you want. A short summary of the point I consider most important follows:

A central concern remains with the policy implications of identifying and addressing in isolation the role of widespread insurance in insulating the public from the brunt of the problem, and undermining activism. It is true that most Americans are healthy, most are insured. This makes the fight for universal coverage in some ways a fight to win over the majority in support of the minority; or, in a different light, to forge an understanding of common concerns about the health care system shared by insured and uninsured alike. This is not impossible, but poses particular challenges. Many economists with powerful supporters use exactly this argument, however, to actively propound as a solution inflicting greater economic hardship on individuals, by making them pay more for health care. To borrow from an earlier writer, there is not a 1:1 relationship between intensifying economic hardship, and activating political resistance. Many people, when confronted with high health care charges, either pay the bill if they can, or go without if they can’t. It is gratifying to know that Uwe does not support, for example, defined contributions. Hopefully others who read this list will also be suspect of these sorts of proposals.

Note 1: As mentioned above, Dr. Shaffer sent a detailed message to Dr. Reinhardt, responding to his comments. If you would like to read her response, we can send you a copy. Merely respond to this message with your request.

Note 2: We greatly appreciate the contributions to this discussion, and the responses indicate that this view is widely shared. Our greatest regret is that we were unable to distribute many other excellent responses since that would have violated our self-imposed rule to avoid contributing to information overload for the very busy members of this list. We had considered an open chat room, but we decided that most of you could not participate because of your schedules, not to mention that the open discussions tend to be inundated with non-productive messages from extremists. We will continue to post a limited number of your messages that we believe would be of interest to the members of this list.

Our profound thanks to all of those that have contributed,

Don

Scarce Funds Imperil Bush Health Goals

Los Angeles Times
August 24, 2001
by Robert Rosenblatt

“Health and Human Services Secretary Tommy G. Thompson signaled Thursday that the Bush administration is backing away from its commitment to extend health insurance coverage to some of the nation’s 39 million uninsured.”

“On defense… the administration faces a struggle to get an $18.4-billion increase in the budget for the next fiscal year. Defense Secretary Donald H. Rumsfeld indicated Thursday the administration is ready for a hard legislative fight but expects to prevail.”

Health and Human Services Secretary Tommy Thompson:

“The reality is the economy is starting to contract, and when it does you don’t have as much money. The $28 billion would be a nice fix toward helping the uninsured, but… I don’t know if it’s going to be there.”

Defense Secretary Donald Rumsfeld:

“The need is so serious and so real, and the president’s commitment is clear, and I’ve generally found that there are always some people that are against defense spending at any level. And yet when the votes tend to be done, they seem to find a majority to support a strong national defense. And I suspect that that will be the case this time.”

http://www.latimes.com/news/politics/la-082401tommy.story

Comment: Do the American people really believe that these are our national priorities? Where are their voices?

Jonathan Oberlander, Ph.D., Assistant Professor of Social Medicine comments

School of Medicine, University of North Carolina – Chapel Hill, comments:

As a political scientist and a teacher of health policy to medical students, I have read Uwe’s comments and the back and forth with much interest.

Uwe has long been an important voice in calling attention to the uninsured and need for health reform–and there are precious few among economists I am afraid. And his tone, which expresses outrage and indignation at the situation, and is no doubt designed to provoke a similar reaction from others, is both effective and in my view, absolutely on target.

I agree with much of what Uwe has written: that there is no basis for optimism on single payer, wishing it were otherwise does nothing to change the political climate; that Americans aren’t exactly enthralled of the idea of making sacrifices for the uninsured right now (thus the policy solution de jour of relatively benign, in terms of their impact on the insured, tax credits); that the politics of health reform is defined by the fact that 85% of us have insurance, not that 15% do not; and that the debate over managed care is much more complex that simple anti-HMO backlash suggests.

However, I think from the exchanges with Ted Marmor and others it is obvious Uwe has hit a few nerves, perhaps unintentionally: Let me comment on one:

The idea that Americans have the health care system they want implies that the public both has no taste for universal insurance and that we have chosen the current system. Without rehashing all the political science on this, lets just say that there is not a 1:1 correlation between public opinion and public policies. In fact, there has for much of the period since 1940 been a permissive majority of Americans for national health insurance. It is too easy, as other commentators have done, typically of the Beltway crowd that includes Norm Ornstein (though I don’t know his views on this), that the public killed the Clinton plan; Larry Jacobs excellent works presents a much more nuanced account.

Nor can the supposed exceptionalism of American political culture explain everything (or even Social Security). We are different in political culture and attitudes than either Germany or Canada. But no two countries that have universal insurance are identical (e.g., try matching Japan and England) and there is the problem with Canada of explaining if they were so different, why no national health insurance fully implemented until 1970?

Equally importantly, there is a temptation for those who oppose universal coverage to dismiss the chances for universal health insurance–and not just single payer–as a cultural impossibility. That is often, I fear, an intentional strategy on the part of providers to protect the status quo, and it needs to be exposed.

Lets be honest, political institutions are central to the story: if we had a parliamentary system, we would have passed national health insurance long ago, as early as the 1940s and no later than 1975, and it would be as popular as it is in other nations, and we would not be having this discussion. This does not mean it is not more difficult to enact such a program given American values and attitudes right now–the residue of anti-government thinking over the past 3 decades is, as the Clintons discovered, difficult to overcome. Single payer in this environment of public opinion is clearly impossible at the moment, though other strategies may certainly be more feasible. But we shouldn’t be too hasty in taking prevailing public opinion and expanding that to define all of American political culture.

Finally, in many ways, insured Americans do have the health care system they want: private insurance, the multiple insurance products and market segmentation that Uwe mentions, the access to latest technologies and drugs. But I would argue that in one fundamental way these preferences–along with those of providers– have inadvertently created a health care system they very much did not want: managed care (and for physicians I too have little sympathy on this score). Yet no one ever asked patients and they never voted on this, whatever the merits or flaws of managed care, it was top down policy imposed by employers and insurers. The current system then, is a long way from public endorsement, though perhaps the erosion of managed care will put things back closer to equilibrium and the golden age for physicians and patients, not an altogether favorable prospect for social goals in health care or the uninsured.

Jon Oberlander , Ph.D.

Dr. Oberlander is co-author, with Dr. Marmor, of “The Path to Universal Health Care” from “The Next Agenda,” cited in yesterday’s message from Dr. Marmor.

Theodore Marmor, Ph.D. responds to Uwe Reinhardt, Ph.D., and suggests the federalist option for health care reform:

I have looked over not only your comments to me, Uwe, but also the exchanges with others. Can we proceed this way? I have enclosed a long essay on reform in American medicine that takes up many of the issues you raise (1). It is not as if it were written with you in mind, but this chapter represents the distillation of my thinking about such matters. I would regard this as one step in our understanding each other. Another would be for me to acknowledge that I have felt as much frustration as anyone in connection with American medical politics. I sometimes think of emigrating–to Canada, to Britain, to Australia–to escape much of the misery of our public debate on matters like universal coverage, managed care and the like. But my analysis of why we face what we do differs substantially from yours, and this essay–along with another on managed care–should make it plain (2). These essays are simply more considered presentations than I could make on the run, just as I am off to Alaska to fish for salmon and then on to the political science meetings in San Francisco.

My hope would be that you might look at these papers and, if you have the time and inclination, look at either Larry Jacobs and Robert Shapiro’s new book, Politicians Don’t Pander, (Chicago U.P., 2000) or any of the books by Ben Page. These are more considered treatments of American public opinion than anything available in Health Affairs. When I get back–the 5th of September–I will take up the particular questions about medical reform politics you raised in the letter to me. They are good questions and I think I have responses that will make some sense to you. To foreshadow my views, just consider what would have happened in l992 if the election of Bill Clinton was at the same time an election of a majority in both houses of Congress for a type of universal coverage. In the US the question of whether, what, and when get conflated and mixed up more than in other institutional settings. And, as you will see in the Next Agenda piece, we think that is fateful, not the level of American other directedness.

Looking forward to getting back to this in early September.

Theodore R. Marmor Professor of Public Policy & Management Professor of Political Science Yale University School of Management

(1) Jonathan Oberlander and Theodore Marmor, “The Path to Universal Health Care,” from “The Next Agenda: Blueprint for a New Progressive Movement,” Robert Borosage and Roger Hickey, editors, Westview Press, 2001.

(2) Jacob Hacker and Theodore Marmor, “How Not to Think about ‘Managed Care’,” University of Michigan Journal of Law Reform, Volume 32, Issue 4, Summer 1999.

Note: Dr. Marmor has made both of these documents available in Microsoft Word format. If you would like to receive either one, or both, please reply to this message with a request specifying (1), (2), or both.

Comment: Quoting from reference (1): “Under (the federalist) option, national legislation would be passed that encourages the states to enact universal coverage, insurance reform, and cost control, but gives the states choice over what types of reform they wish to implement.” “The federalist strategy, referred to by others as a state-federal partnership, offers the prospect of genuine health reform and he advantages of political flexibility.” “We recognize that embracing the federalist option would mean altering the past emphasis of American reformers on enacting the Canadian single payer model. That would by no means be an easy transformation or compromise to make.”

Under the federalist option, the states would still be required to enact reforms that guarantee universal coverage, comprehensive benefits, administrative accountability, fiscal viability, and portability. The sharp contrast from single payer proposals is that public administration would not be mandated, allowing any form of administration, including the current competing market plans. Abandonment of the economies and efficiencies of public administration, not to mention the assurance of equity, seems like an unacceptably high price to pay for political expediency, at least in my opinion.

Don

Dr. Reinhardt's US Chamber of Commerce paper:

Don:

I had referenced an angry paper I had once written for the US Chamber of Commerce. Unsure of whether I had sent it to you for distribution, I send it to you now.

I had agreed to appear on one of their panels, but when I saw that our topic was “Why are there so many uninsured, and what does it mean to us, the insured?” I balked. I told them I won’t blow a day to participate in such a panel but I would write them a statement, if they promised to distribute it. They did, I wrote it, and they distributed it. It was written in some haste, as you can tell, but I did want to register a few points with that crowd.

Best,

Uwe

Note: This paper provides a clear explanation for the perpetuation of the deficiencies of our current health insurance system. Because it is inappropriate to send a 180 KB attachment in a mass mailing, it is not included with this message. If you would like to receive this paper (as a Microsoft Word attachment) please respond to this message, and we will send it to you.

Don McCanne

Uwe Reinhardt, Ph.D. responds to Ellen Shaffer, Ph.D.:

(Dr. Shaffer’s previous comments are marked ES, and Dr. Reinhardt’s inserted comments are marked UR.)

UR: Ellen:

I appreciate your comment on our ongoing debate and shall offer some rejoinders in the body of your text. Before doing so, however, I would like to address an issue of methodology.

You write off my and Norm Ornstein’s comments as “cynical” and “unanalytical.” Although I would not characterize Norm Ornstein’s commentary thus, I am prepared to plead vaguely guilty as far as my commentary is concerned, because I had not intended it to be a scholarly, tightly reasoned, analytically rigorous piece. It was a rather quickly written comment, injected into something akin to a chat room–a rather loose statement of a hypothesis which is this: The structure of our government alone, and the power of the elite that uses that structure to its advantage, cannot fully explain the half century of failure to move the US towards universal coverage–let alone toward a single-payer system. The myopia and apathy of the electorate also played a part. Furthermore, unless that electorate can be awakened and mobilized politically, mere appeals to the ruling elite, and finger-pointing in that elite’s direction, are unlikely to bring us closer to your goals.

Now, having said that much, and in view of your professional judgment of my and Norm’s comments, I deem it fair to look to your commentary for an example of “analytical” thinking. Presumably, you would not contribute an “unanalytical” piece to this debate. Therefore I am asking you, quite sincerely in fact, to identify for me just where your commentary is analytical, in the sense that it could be a role model for an economist like me. I do know very well what is and what is not a rigorous analysis within neoclassical economics. I am curious to know what political scientists mean by “analysis,” and I would like you to use your commentary to show me the way.

I shall proceed with my rejoinders, paragraph by paragraph.

ES: Here is why Uwe Reinhardt’s comments, and Norm Ornstein’s, are cynical, unanalytical, demoralizing and wrong:

Whatever nods they may offer to the actual structural political obstacles to achieving universal health care in the U.S., the ultimate villain is the stupid American populace (teenagers, plebes, what have you -surely not the well educated, who read this list).

UR: Is this what you mean by “analysis”, Ellen?

By the way, I would not call the plebs the “ultimate villain.” In fact, I am not sure what “ultimate” means in this context any more than I know which blade in a scissors “ultimately” cuts the paper. My point was merely that the electorate does have more power than it chooses to exercise and that its failure to exercise that power is an integral part of the failure so far of the movement for universal health insurance coverage.

Furthermore, I do believe that the general public suffers from a degree of myopia. In many opinion surveys that I have seen, a large majority of respondents (usually over 80%) declare themselves satisfied with their health care and even with their health insurance. I wonder how many Americans actually worry about being uninsured, while they are employed and well insured. One of President Clinton’s stronger selling points for his plan was that insurance card he waved, “insurance coverage that you cannot lose.” Why did that powerful message not get better political traction with the electorate in 1994? Why did Americans vote as they did in 1994? Did the preferences of the electorate have nothing to do with Newt’s ascendancy?

Let me hasten to concede that I share the economist’s deep suspicion of opinion polls of any kind, even those that might support one of my hypotheses. I am more impressed by actual votes and plebiscites.

ES: And the econometrician’s solution to engaging these dunderheads is: make them pay more! Then they’ll pay attention and we can really get somewhere. Economic shock therapy for the ailing of America. Great news for insurance companies, hospitals, doctors and employers. Defined contribution plans will finally make Americans real consumers, with direct control over their health care choices. Then they can really call up that doctor and tell her to conform to national standards of quality, balancing over- and under-service. Yes indeed. (Or maybe the theory is that once they have realized the futility of becoming individual consumers, Norm Ornstein will lead us in calling for rescinding the tax rebate, and funding federal enforcement of national quality guidelines, as well as universal coverage.)

UR: Is this what you would call rigorous “analysis”, Ellen? Can this serve as a role model for economists who might venture into political analysis?

I should mention to you that econometricians are, basically, positive analysts who usually do not engage in normative economics. You must be thinking of normative economists, such as Mark Pauly or Stuart Butler and many others who tend to think along those lines.

Personally, I have never argued that more cost sharing will make the individual patient a smarter “consumer” of health care. On the contrary, I have written that I do not subscribe at all to that hypothesis. Many economists on the right of the political spectrum, of course, do make that a working hypothesis. They seem to have much sway in the political arena..

On the other hand, it would not surprise me to see greater interest in a single-payer system among the American people if the full fiscal brunt of a defined contribution scheme rained down on them. As you probably know, the percentage of the American health bill that was paid out of pocket actually fell during the 1990s. Using the CMS data, which you can download off the web, I find that total private out-of-pocket spending as a percentage of total national spending on personal health care was 24.1% in 1988, 22.6% in 1990, 17.6% in 1995 and 17.7% in 2000. That is averaged over all Americans, including the uninsured. If one took only insured Americans, the fraction spent out of pocket would be even lower. My point is that, by and large, insured Americans really are not yet hurting, fiscally. The only problem they have is hassle over the interpretation of the myriad of fine-print clauses in their increasingly customized insurance contracts, but that is another issue. The hypothesis that much heavier cost sharing under a defined contribution plan could, conceivably, kindle greater interest in a single-payer system with comprehensive coverage is not, in my view, totally off the wall.

ES: Well, yes, power does flow in many directions between the ruling/corporate elite and the rest of us, and sometimes our side wins. (Medicare. Medicaid. Happened at a time when many of us were inspired and united by the civil rights movement, not demoralized by invective.)

UR: Just a question: were you, Ellen, personally part of the movement that brought us Medicare and Medicaid? I ask, because I believe that an important factor at the time was that America was then run by a generation that had suffered the Great Depression together and had gone through W.W.II together–a generation that understood that luck is just luck and not (as many of my students seem to think, deserved), and a generation that had experienced first hand that government can be benevolent and get things done. Government organized the Allied victory. I wonder whether that generation of Americans did not emerge from its travails with a greater sense of social solidarity (and greater faith in government) than is typical of the younger generations–a lingering racism at that time notwithstanding.

ES: Specific analysis of particular political events needs to inform us, and determine when we are mistakenly blaming the victim, and when instead we can rightly blame a stratum of society for intentional and heartless pursuit of self-interest.

UR: Do you consider this statement rigorous analysis, Ellen? I sense a distinct prejudgment here.

ES: People are regularly abused and treated unfairly by those with more power, whether raped and slaughtered, unfairly fired, or given a bad grade; some fight back, many don’t, usually successful organizing and intelligent leadership helps.

UR: Is this analysis or a polemic?

ES: The prevailing rules and institutions societies develop over time (very long periods of time) to safeguard justice also play a role.

UR: Precisely what do you mean here?

ES: Without dwelling on some lapses in bonhomie among certain Europeans during the 20th century …

UR: I’m glad you don’t, Ellen, but it really does not have any bearing on the issue of universal health insurance coverage. On the other hand, it is a nice personal dig in this debate, I’ll grant you that. Touché!

ES: … it is important to recognize that in the case of the failure of universal coverage in the U.S., the problem lies not primarily in failures in the national character of the American population, however amusingly this elitist view of our people is served up.

UR: Is this a statement of fact, your opinion, or analysis, as you understand that term?

ES: If Uwe wishes to make the case that this is really the central problem, he might present some evidence that links cause and effect, or at least a logical line of argument beyond observations about spoiled stockbrokers in the Hamptons.

UR: I don’t know what will pass muster, Ellen. I cite the sorry American voting record by income class to shore up my point; but apparently that does not count. I cite the fact that in a clear-cut plebiscite on the single-payer system, in a generally progressive state, the majority of those citizens who did bother to vote voted against the single payer system. I make the logical inference that failure on the part of the poor to vote more heavily in presidential or Congressional elections (cause) has as one of its consequences (effect) that the poor will be disregarded in the political process, especially when candidates (such as Bill Bradley) who do take up the cause of the disenfranchised lose at the ballot box for want of political support. In my view, this is a legitimate hypothesis about cause and effect.

ES: (If the American people really were that stupid I’m not sure that yelling at them to get off their duffs would be very effective.)

UR: Yelling at them when they are basically comfortable probably won’t work. Yelling at them when they are in great discomfort might work.

ES: Uwe has already well described the failures of our systems of financing and organizing politics and politicians. Will imposing further financial hardship, e.g. through defined contribution plans, truly mobilize the populace to overcome these obstacles?

UR: As noted, it might.

ES: What is the evidence that this would be the best or even one effective stimulus to political activity in the case of health care?

UR: As I mentioned above, the evidence may be lacking because the bulk of Americans have been reasonably well insured and the bulk of them declare themselves satisfied with their coverage in Humphrey Taylor’s and others’ surveys. But is it surely acceptable, even in political science, to entertain the hypothesis that greater financial hardship associated with brittle and shallow insurance might kindle among the electorate a greater interest in comprehensive, permanent health insurance. Are hypotheses off limits in political science?

ES: (If it were, we should be seeing armies of the uninsured waving their hospital bills in the faces of policymakers, rather than retreating into defeat, homelessness and bankruptcy.)

UR: Perhaps you will explain to us, Ellen, why they just retreat–why it is so hard to mobilize their voting power? A little analysis here might help.

ES: What is even the analytical connection? Is there precedence for this in the US or elsewhere?

UR: You ask me: is there precedence in the US for cases where widespread among the electorate perceived hardship led to remedial political action? Maybe someone else can answer it better than I can. But I believe Social Security is such a case, as is Medicare and Medicaid. There was plenty of suffering there among the people, and fiscal duress among providers, and things did begin to click politically.

ES: Truly, Americans have a proclivity towards individualism. Additionally, many of us do not vote, (As Jim Hightower has noted, if God intended us to vote she would have given us candidates.)

UR: Is this, then, an analytical statement, Ellen? There is no difference at all between Al Gore and George W. Bush that might bestir a citizen to vote? Bill Bradley was not a candidate?

ES: How does this factor balance against the immense financial and political power of the private insurance industry, with its attendant ability to command publicity and the fealty of politicians? No other nation has had to face and overcome this force.

UR: Other nations do have these forces, too. But, as Ted Marmor points out, and I fully agree, these powers do not hold nearly the sway in parliamentary systems as they do in our system.

ES: This is not a reason to give up; it has to be done. It is a difference between the US and other countries that we must acknowledge and address. Further, health care is a difficult stand-alone organizing issue in industrialized countries, absent other national crises: most people are healthy, poor people have other pressing priorities, sick people are sick; both problems and solutions are complex, and the industry has far greater access to the media than do reformers.

What is the actual position of the American people on universal health care, through single payer or any other means? Uwe tells us the vote against single payer in California was definitive; in this case the electorate was swayed by a last-minute, well-financed campaign by the insurance industry alleging huge resulting cost increases.

UR: Are you simply asserting this, or is that a fact? And if you were right, does it not underscore a point I made about the fickle American voter with a short attention span who is easily swayed, one way or the other? Why is it that the proponents of the single-payer system could not apprise California voters of the empirical record all around us, which shows that single payer systems generally cost less per capita and as a percentage of the GDP than does our system? Why were these facts disregarded by the California electorate?

ES: This was a false allegation, this kind of tactic is not unexpected, and activists need to be able to confront this kind of thing.

UR: Yes, indeed. Why haven’t you?

ES: But it is far from the last word. Kip and others point out alternative results through polls, the Maine legislature, the Jefferson Jury, and countless local ballot initiatives.

UR: Like Massachusetts recent ballot initiative? Did the single-payer movement prevail? I thought it had not.

ES: The answer is murky, and often depends on the point the presenter is trying to make.

UR: I sincerely do wish you and yours luck, Ellen, but I won’t hold my breath. In the meantime, I support ugly ducklings, such as the Families USA–HIAA two-pronged approach the reduce the number of uninsured. Ideological purity is not my shtick. I’d just like to see the number of uninsured reduced by as much as is politically feasible, by whatever means.

ES: I like to ask people whether they would prefer the current for-profit, market-driven, inequitable system of health care that leaves 45 million people without coverage; or a fair, publicly financed, publicly delivered and equitable system of universal coverage that would provide high quality health care to all. Usually gets a pretty good response.

UR: Talk some time to pollsters, Ellen. I recommend Humphrey Taylor of Lou Harris, or Bill McInturf, the Republican pollster–both as straight as they come. Pollsters will tell you that the response you get from respondents in surveys depends significantly on the way you ask your question. Look at how you phrase your question. Are you at all surprised to receive the answers that you get? A pollster engaged by the HIAA or AAHP, surveying the very same people, but phrasing the question differently, could most likely extract the conclusion that the respondents would not like a “government run, single-payer, one-size fits all etc etc” system and prefer our “free-enterprise system that stresses innovation etc etc.” In short, Ellen, I hardly consider what you offer here hard data or even analysis. Do you?

ES: Ok, how do we address the myriad obstacles to health care reform in the US, including developing support among our fellow citizens, besides further impoverishing them? Whoever knows this for sure is likely to be rich or assassinated but here are a few points of departure: 1. It may take some time.

UR: Agreed. Half a century down without success. How many more decades to go? Give me a guestimate!

ES: 2. Undermine the credibility and power of the opposition (why the fight over the patients’ bill of rights is a good thing).

UR: As you know, I would debate that, and so would many other detached observers. You are stating your opinion here, which is all right. It is not a statement of fact, and surely not analysis. How far, do you think, would that PBOR movement have gotten without the coffers and the lobby of the AMA, which has its own agenda, and that is surely not enforcement of insurance contracts between insurers and the insured. The AMA, by the way, favors MSAs, not a single-payer system. So you won’t have the AMA on your side in the next round.

ES: 3. Incremental programs like Healthy Families are failing to recruit and retain members; call for states to pay the full premiums, for good.

UR: By all means, call for it. But will the fiscally hard pressed states comply? I’ve seen them make a mush of Medicaid.

ES: 4. Link the fight for a just health care system to other calls for social justice, and thereby ally with political movements with some clout. Opposing “free” trade in health care via GATS and FTAA would be a start.

UR: Has such linkage worked in the past? Honestly, I don’t know.

ES: 5. Point the finger at powerful forces like businesses that prefer to give away their profits to the insurance industry rather than turn the enterprise over to the government as enlightened capitalists do abroad.

UR: Good heavens! You think this will work any better tomorrow than it has in the past? But, ok, point the finger and see the elite blush. Point it at Jack Rowe, M.D. of Aetna, Inc. and see him blush! Point it at Karen Ignani of the AAHP and see her blush. Having unsuccessfully tried to shame members of the elite on many occasions–openly, in my testimony before Congress–I would not expect much from the strategy. No one ever did blush.

ES: 6. Demand some rigor from ourselves and our leaders in analyzing successes and failures, and figuring out which forces are required to and likely to do what in order to advance the issue.

UR: By all means! Agreed!

ES: (Did Bill Bradley’s campaign really fail because he championed a tepid proposal to expand health insurance coverage? Is that what scared the Democrats into the arms of Al Gore? Fascinating!)

UR: I am not sure what you are asking us here. “Tepid”? Bill Bradley offered by far the most generous and far-reaching proposal on the uninsured among the candidates last year. In fact, Al Gore’s health insurance proposal was hardly more generous than Bush’s. A bit of Medicaid and SCHIP expansion, some tax credits to employers, and so on, all on the back of a paltry budget. Anyone who really cared about the uninsured should have favored Bradley.

ES: 7. Get Uwe to write us a polemic from time to time.

UR: OK, Ellen, let’s specialize. I’ll do the polemics, and you do the cool analysis, like the present one.

ES: Apparently some readers found his comments bracing and challenging. It’s a good opportunity to think through why they are misleading, though appealingly presented.

It’s frustrating to have been propounding an intelligent and effective solution like single payer for all these years, and not to be getting very far.

UR: Yes, indeed, As you said, you will need some rigorous analysis to explore why you have failed.

ES: It is worth examining why not, and what we might do differently. I look forward to seeing us all move forward.

UR: I’d like to see it, too. But I don’t expect much.

UR: Let me repeat that I challenge you, Ellen, to explain to me in what way your commentary is more “analytical” and less “polemical” than mine, or than Norm Ornstein’s commentary. I insist upon it, because I am not well pleased by debates in which arguments one does not like are simply written off with adjectives like “cynical” or “unanalytical” or “polemic” and so on. The proper approach is to engage on the substance and I encourage you henceforth to follow that route.

Dr. Reinhardt’s US Chamber of Commerce paper:

Don:

I had referenced an angry paper I had once written for the US Chamber of Commerce. Unsure of whether I had sent it to you for distribution, I send it to you now.

I had agreed to appear on one of their panels, but when I saw that our topic was “Why are there so many uninsured, and what does it mean to us, the insured?” I balked. I told them I won’t blow a day to participate in such a panel but I would write them a statement, if they promised to distribute it. They did, I wrote it, and they distributed it. It was written in some haste, as you can tell, but I did want to register a few points with that crowd.

Best,

Uwe

Note: This paper provides a clear explanation for the perpetuation of the deficiencies of our current health insurance system. Because it is inappropriate to send a 180 KB attachment in a mass mailing, it is not included with this message. If you would like to receive this paper (as a Microsoft Word attachment) please respond to this message, and we will send it to you.

Don McCanne

Uwe Reinhardt, Ph.D. responds to Ellen Shaffer, Ph.D.:

(Dr. Shaffer’s previous comments are marked ES, and Dr. Reinhardt’s inserted comments are marked UR.)

UR: Ellen:

I appreciate your comment on our ongoing debate and shall offer some rejoinders in the body of your text. Before doing so, however, I would like to address an issue of methodology.

You write off my and Norm Ornstein’s comments as “cynical” and “unanalytical.” Although I would not characterize Norm Ornstein’s commentary thus, I am prepared to plead vaguely guilty as far as my commentary is concerned, because I had not intended it to be a scholarly, tightly reasoned, analytically rigorous piece. It was a rather quickly written comment, injected into something akin to a chat room–a rather loose statement of a hypothesis which is this: The structure of our government alone, and the power of the elite that uses that structure to its advantage, cannot fully explain the half century of failure to move the US towards universal coverage–let alone toward a single-payer system. The myopia and apathy of the electorate also played a part. Furthermore, unless that electorate can be awakened and mobilized politically, mere appeals to the ruling elite, and finger-pointing in that elite’s direction, are unlikely to bring us closer to your goals.

Now, having said that much, and in view of your professional judgment of my and Norm’s comments, I deem it fair to look to your commentary for an example of “analytical” thinking. Presumably, you would not contribute an “unanalytical” piece to this debate. Therefore I am asking you, quite sincerely in fact, to identify for me just where your commentary is analytical, in the sense that it could be a role model for an economist like me. I do know very well what is and what is not a rigorous analysis within neoclassical economics. I am curious to know what political scientists mean by “analysis,” and I would like you to use your commentary to show me the way.

I shall proceed with my rejoinders, paragraph by paragraph.

ES: Here is why Uwe Reinhardt’s comments, and Norm Ornstein’s, are cynical, unanalytical, demoralizing and wrong:

Whatever nods they may offer to the actual structural political obstacles to achieving universal health care in the U.S., the ultimate villain is the stupid American populace (teenagers, plebes, what have you -surely not the well educated, who read this list).

UR: Is this what you mean by “analysis”, Ellen?

By the way, I would not call the plebs the “ultimate villain.” In fact, I am not sure what “ultimate” means in this context any more than I know which blade in a scissors “ultimately” cuts the paper. My point was merely that the electorate does have more power than it chooses to exercise and that its failure to exercise that power is an integral part of the failure so far of the movement for universal health insurance coverage.

Furthermore, I do believe that the general public suffers from a degree of myopia. In many opinion surveys that I have seen, a large majority of respondents (usually over 80%) declare themselves satisfied with their health care and even with their health insurance. I wonder how many Americans actually worry about being uninsured, while they are employed and well insured. One of President Clinton’s stronger selling points for his plan was that insurance card he waved, “insurance coverage that you cannot lose.” Why did that powerful message not get better political traction with the electorate in 1994? Why did Americans vote as they did in 1994? Did the preferences of the electorate have nothing to do with Newt’s ascendancy?

Let me hasten to concede that I share the economist’s deep suspicion of opinion polls of any kind, even those that might support one of my hypotheses. I am more impressed by actual votes and plebiscites.

ES: And the econometrician’s solution to engaging these dunderheads is: make them pay more! Then they’ll pay attention and we can really get somewhere. Economic shock therapy for the ailing of America. Great news for insurance companies, hospitals, doctors and employers. Defined contribution plans will finally make Americans real consumers, with direct control over their health care choices. Then they can really call up that doctor and tell her to conform to national standards of quality, balancing over- and under-service. Yes indeed. (Or maybe the theory is that once they have realized the futility of becoming individual consumers, Norm Ornstein will lead us in calling for rescinding the tax rebate, and funding federal enforcement of national quality guidelines, as well as universal coverage.)

UR: Is this what you would call rigorous “analysis”, Ellen? Can this serve as a role model for economists who might venture into political analysis?

I should mention to you that econometricians are, basically, positive analysts who usually do not engage in normative economics. You must be thinking of normative economists, such as Mark Pauly or Stuart Butler and many others who tend to think along those lines.

Personally, I have never argued that more cost sharing will make the individual patient a smarter “consumer” of health care. On the contrary, I have written that I do not subscribe at all to that hypothesis. Many economists on the right of the political spectrum, of course, do make that a working hypothesis. They seem to have much sway in the political arena..

On the other hand, it would not surprise me to see greater interest in a single-payer system among the American people if the full fiscal brunt of a defined contribution scheme rained down on them. As you probably know, the percentage of the American health bill that was paid out of pocket actually fell during the 1990s. Using the CMS data, which you can download off the web, I find that total private out-of-pocket spending as a percentage of total national spending on personal health care was 24.1% in 1988, 22.6% in 1990, 17.6% in 1995 and 17.7% in 2000. That is averaged over all Americans, including the uninsured. If one took only insured Americans, the fraction spent out of pocket would be even lower. My point is that, by and large, insured Americans really are not yet hurting, fiscally. The only problem they have is hassle over the interpretation of the myriad of fine-print clauses in their increasingly customized insurance contracts, but that is another issue. The hypothesis that much heavier cost sharing under a defined contribution plan could, conceivably, kindle greater interest in a single-payer system with comprehensive coverage is not, in my view, totally off the wall.

ES: Well, yes, power does flow in many directions between the ruling/corporate elite and the rest of us, and sometimes our side wins. (Medicare. Medicaid. Happened at a time when many of us were inspired and united by the civil rights movement, not demoralized by invective.)

UR: Just a question: were you, Ellen, personally part of the movement that brought us Medicare and Medicaid? I ask, because I believe that an important factor at the time was that America was then run by a generation that had suffered the Great Depression together and had gone through W.W.II together–a generation that understood that luck is just luck and not (as many of my students seem to think, deserved), and a generation that had experienced first hand that government can be benevolent and get things done. Government organized the Allied victory. I wonder whether that generation of Americans did not emerge from its travails with a greater sense of social solidarity (and greater faith in government) than is typical of the younger generations–a lingering racism at that time notwithstanding.

ES: Specific analysis of particular political events needs to inform us, and determine when we are mistakenly blaming the victim, and when instead we can rightly blame a stratum of society for intentional and heartless pursuit of self-interest.

UR: Do you consider this statement rigorous analysis, Ellen? I sense a distinct prejudgment here.

ES: People are regularly abused and treated unfairly by those with more power, whether raped and slaughtered, unfairly fired, or given a bad grade; some fight back, many don’t, usually successful organizing and intelligent leadership helps.

UR: Is this analysis or a polemic?

ES: The prevailing rules and institutions societies develop over time (very long periods of time) to safeguard justice also play a role.

UR: Precisely what do you mean here?

ES: Without dwelling on some lapses in bonhomie among certain Europeans during the 20th century …

UR: I’m glad you don’t, Ellen, but it really does not have any bearing on the issue of universal health insurance coverage. On the other hand, it is a nice personal dig in this debate, I’ll grant you that. Touché!

ES: … it is important to recognize that in the case of the failure of universal coverage in the U.S., the problem lies not primarily in failures in the national character of the American population, however amusingly this elitist view of our people is served up.

UR: Is this a statement of fact, your opinion, or analysis, as you understand that term?

ES: If Uwe wishes to make the case that this is really the central problem, he might present some evidence that links cause and effect, or at least a logical line of argument beyond observations about spoiled stockbrokers in the Hamptons.

UR: I don’t know what will pass muster, Ellen. I cite the sorry American voting record by income class to shore up my point; but apparently that does not count. I cite the fact that in a clear-cut plebiscite on the single-payer system, in a generally progressive state, the majority of those citizens who did bother to vote voted against the single payer system. I make the logical inference that failure on the part of the poor to vote more heavily in presidential or Congressional elections (cause) has as one of its consequences (effect) that the poor will be disregarded in the political process, especially when candidates (such as Bill Bradley) who do take up the cause of the disenfranchised lose at the ballot box for want of political support. In my view, this is a legitimate hypothesis about cause and effect.

ES: (If the American people really were that stupid I’m not sure that yelling at them to get off their duffs would be very effective.)

UR: Yelling at them when they are basically comfortable probably won’t work. Yelling at them when they are in great discomfort might work.

ES: Uwe has already well described the failures of our systems of financing and organizing politics and politicians. Will imposing further financial hardship, e.g. through defined contribution plans, truly mobilize the populace to overcome these obstacles?

UR: As noted, it might.

ES: What is the evidence that this would be the best or even one effective stimulus to political activity in the case of health care?

UR: As I mentioned above, the evidence may be lacking because the bulk of Americans have been reasonably well insured and the bulk of them declare themselves satisfied with their coverage in Humphrey Taylor’s and others’ surveys. But is it surely acceptable, even in political science, to entertain the hypothesis that greater financial hardship associated with brittle and shallow insurance might kindle among the electorate a greater interest in comprehensive, permanent health insurance. Are hypotheses off limits in political science?

ES: (If it were, we should be seeing armies of the uninsured waving their hospital bills in the faces of policymakers, rather than retreating into defeat, homelessness and bankruptcy.)

UR: Perhaps you will explain to us, Ellen, why they just retreat–why it is so hard to mobilize their voting power? A little analysis here might help.

ES: What is even the analytical connection? Is there precedence for this in the US or elsewhere?

UR: You ask me: is there precedence in the US for cases where widespread among the electorate perceived hardship led to remedial political action? Maybe someone else can answer it better than I can. But I believe Social Security is such a case, as is Medicare and Medicaid. There was plenty of suffering there among the people, and fiscal duress among providers, and things did begin to click politically.

ES: Truly, Americans have a proclivity towards individualism. Additionally, many of us do not vote, (As Jim Hightower has noted, if God intended us to vote she would have given us candidates.)

UR: Is this, then, an analytical statement, Ellen? There is no difference at all between Al Gore and George W. Bush that might bestir a citizen to vote? Bill Bradley was not a candidate?

ES: How does this factor balance against the immense financial and political power of the private insurance industry, with its attendant ability to command publicity and the fealty of politicians? No other nation has had to face and overcome this force.

UR: Other nations do have these forces, too. But, as Ted Marmor points out, and I fully agree, these powers do not hold nearly the sway in parliamentary systems as they do in our system.

ES: This is not a reason to give up; it has to be done. It is a difference between the US and other countries that we must acknowledge and address. Further, health care is a difficult stand-alone organizing issue in industrialized countries, absent other national crises: most people are healthy, poor people have other pressing priorities, sick people are sick; both problems and solutions are complex, and the industry has far greater access to the media than do reformers.

What is the actual position of the American people on universal health care, through single payer or any other means? Uwe tells us the vote against single payer in California was definitive; in this case the electorate was swayed by a last-minute, well-financed campaign by the insurance industry alleging huge resulting cost increases.

UR: Are you simply asserting this, or is that a fact? And if you were right, does it not underscore a point I made about the fickle American voter with a short attention span who is easily swayed, one way or the other? Why is it that the proponents of the single-payer system could not apprise California voters of the empirical record all around us, which shows that single payer systems generally cost less per capita and as a percentage of the GDP than does our system? Why were these facts disregarded by the California electorate?

ES: This was a false allegation, this kind of tactic is not unexpected, and activists need to be able to confront this kind of thing.

UR: Yes, indeed. Why haven’t you?

ES: But it is far from the last word. Kip and others point out alternative results through polls, the Maine legislature, the Jefferson Jury, and countless local ballot initiatives.

UR: Like Massachusetts recent ballot initiative? Did the single-payer movement prevail? I thought it had not.

ES: The answer is murky, and often depends on the point the presenter is trying to make.

UR: I sincerely do wish you and yours luck, Ellen, but I won’t hold my breath. In the meantime, I support ugly ducklings, such as the Families USA–HIAA two-pronged approach the reduce the number of uninsured. Ideological purity is not my shtick. I’d just like to see the number of uninsured reduced by as much as is politically feasible, by whatever means.

ES: I like to ask people whether they would prefer the current for-profit, market-driven, inequitable system of health care that leaves 45 million people without coverage; or a fair, publicly financed, publicly delivered and equitable system of universal coverage that would provide high quality health care to all. Usually gets a pretty good response.

UR: Talk some time to pollsters, Ellen. I recommend Humphrey Taylor of Lou Harris, or Bill McInturf, the Republican pollster–both as straight as they come. Pollsters will tell you that the response you get from respondents in surveys depends significantly on the way you ask your question. Look at how you phrase your question. Are you at all surprised to receive the answers that you get? A pollster engaged by the HIAA or AAHP, surveying the very same people, but phrasing the question differently, could most likely extract the conclusion that the respondents would not like a “government run, single-payer, one-size fits all etc etc” system and prefer our “free-enterprise system that stresses innovation etc etc.” In short, Ellen, I hardly consider what you offer here hard data or even analysis. Do you?

ES: Ok, how do we address the myriad obstacles to health care reform in the US, including developing support among our fellow citizens, besides further impoverishing them? Whoever knows this for sure is likely to be rich or assassinated but here are a few points of departure: 1. It may take some time.

UR: Agreed. Half a century down without success. How many more decades to go? Give me a guestimate!

ES: 2. Undermine the credibility and power of the opposition (why the fight over the patients’ bill of rights is a good thing).

UR: As you know, I would debate that, and so would many other detached observers. You are stating your opinion here, which is all right. It is not a statement of fact, and surely not analysis. How far, do you think, would that PBOR movement have gotten without the coffers and the lobby of the AMA, which has its own agenda, and that is surely not enforcement of insurance contracts between insurers and the insured. The AMA, by the way, favors MSAs, not a single-payer system. So you won’t have the AMA on your side in the next round.

ES: 3. Incremental programs like Healthy Families are failing to recruit and retain members; call for states to pay the full premiums, for good.

UR: By all means, call for it. But will the fiscally hard pressed states comply? I’ve seen them make a mush of Medicaid.

ES: 4. Link the fight for a just health care system to other calls for social justice, and thereby ally with political movements with some clout. Opposing “free” trade in health care via GATS and FTAA would be a start.

UR: Has such linkage worked in the past? Honestly, I don’t know.

ES: 5. Point the finger at powerful forces like businesses that prefer to give away their profits to the insurance industry rather than turn the enterprise over to the government as enlightened capitalists do abroad.

UR: Good heavens! You think this will work any better tomorrow than it has in the past? But, ok, point the finger and see the elite blush. Point it at Jack Rowe, M.D. of Aetna, Inc. and see him blush! Point it at Karen Ignani of the AAHP and see her blush. Having unsuccessfully tried to shame members of the elite on many occasions–openly, in my testimony before Congress–I would not expect much from the strategy. No one ever did blush.

ES: 6. Demand some rigor from ourselves and our leaders in analyzing successes and failures, and figuring out which forces are required to and likely to do what in order to advance the issue.

UR: By all means! Agreed!

ES: (Did Bill Bradley’s campaign really fail because he championed a tepid proposal to expand health insurance coverage? Is that what scared the Democrats into the arms of Al Gore? Fascinating!)

UR: I am not sure what you are asking us here. “Tepid”? Bill Bradley offered by far the most generous and far-reaching proposal on the uninsured among the candidates last year. In fact, Al Gore’s health insurance proposal was hardly more generous than Bush’s. A bit of Medicaid and SCHIP expansion, some tax credits to employers, and so on, all on the back of a paltry budget. Anyone who really cared about the uninsured should have favored Bradley.

ES: 7. Get Uwe to write us a polemic from time to time.

UR: OK, Ellen, let’s specialize. I’ll do the polemics, and you do the cool analysis, like the present one.

ES: Apparently some readers found his comments bracing and challenging. It’s a good opportunity to think through why they are misleading, though appealingly presented.

It’s frustrating to have been propounding an intelligent and effective solution like single payer for all these years, and not to be getting very far.

UR: Yes, indeed, As you said, you will need some rigorous analysis to explore why you have failed.

ES: It is worth examining why not, and what we might do differently. I look forward to seeing us all move forward.

UR: I’d like to see it, too. But I don’t expect much.

UR: Let me repeat that I challenge you, Ellen, to explain to me in what way your commentary is more “analytical” and less “polemical” than mine, or than Norm Ornstein’s commentary. I insist upon it, because I am not well pleased by debates in which arguments one does not like are simply written off with adjectives like “cynical” or “unanalytical” or “polemic” and so on. The proper approach is to engage on the substance and I encourage you henceforth to follow that route.