By Stacey Singer
Palm Beach Post, Nov. 3, 2013 As consumers begin to comparison shop “Obamacare” health plans, a new problem has emerged: The cheapest plans may have such limited provider panels that the nearest in-network hospital could be about 30 miles away for people living in northern and western Palm Beach County. Consumers shopping for health insurance plans typically focus on price, understandably, experts say. But this year, more than ever, they need to hold a magnifying glass to plans’ networks, the doctors and hospitals willing to accept their coverage. It’s true for people buying plans for the first time through the Affordable Care Act marketplace. It’s also true for seniors who are long-time users of Medicare Advantage, the privatized Medicare benefit option. Both sectors are embracing what the industry refers to as “narrow networks” to cut their costs this year, analysts said. The reason? Starting in January, health insurers can no longer charge more for people with pre-existing health conditions. Meanwhile, there are caps on consumers’ out-of-pocket costs. So insurers have less “wiggle room” to manage costs, said health marketplace analyst Allan Baumgarten. “In the effort to meet a lower price point, they have to find another tool to use. That tool is network design,” Baumgarten said. Humana’s HMO marketplace plans leave out two-thirds of area hospitals, those run by HCA and Tenet Healthcare. Someone from Jupiter would face a minimum 27-mile trip, with tolls, to the closest in-network hospital. It’s Wellington Regional Medical Center. In case of emergency, they can use the nearest hospital, Humana spokesman Mitchell Lubitz said. Humana buyers in Belle Glade and Pahokee face an even longer drive to stay in the network. That same Wellington Regional, the nearest in-network hospital, is a 35-mile drive away from the Glades. The CoventryOne Carelink HMO catastrophic plan, from Aetna, also includes no HCA hospitals, a spokesman said. It leaves out JFK Medical Center in Atlanta, Palms West Hospital in Loxahatchee and West Palm Hospital, cutting out a large share of the limited in-patient psychiatric beds here. Enrolling through the federal marketplace web site healthcare.gov continues to be difficult, although it’s gotten easier to see plans and prices. Those price lists show that Humana wins the cost contest on most scores. But Humana’s lower premiums may come with inconvenience that’s harder to spot. Healthcare.gov doesn’t yet link to the insurance plans. If consumers do manage to use an Internet search engine like Google to find the provider panels, they may be surprised. Humana offers marketplace shoppers just four choices of in-network hospitals, all of them in central or south Palm Beach County. They include Bethesda’s two Boynton Beach hospitals, as well as Boca Raton Regional Hospital and Wellington Regional. “We are trying to ensure the exchange plans in Florida are affordable, and so that has meant a smaller network of hospitals doctors and specialists to keep costs down,” Lubitz said. Florida’s deputy insurance commissioner for health, Wences Troncoso, said the network issue is one more reason that insurance brokers remain important partners for consumers. “Reach out to your local agents. They can help provide that information, they are well-trained at it,” Troncoso said. It’s the job of CMS – the U.S. Centers for Medicare and Medicaid Services – to make sure that networks have adequate hospitals and doctors for both Medicare Advantage and marketplace plans. Humana has concluded that different rules are in place for each market, though federal officials weren’t willing to agree late Friday. Medicare Advantage reviewers at CMS interpret “adequate network” to mean within a 30-mile or 30-minute drive, in most cases. “I checked with our provider team for South Florida, and the 30-minute, 30-mile rule does not apply to commercial and individual health insurance plans, only to Medicare,” Lubitz said. While narrow networks mean less choice for consumers and longer drives for care, they do allow for lower premiums. But to come out ahead, consumers must be savvy, remembering to stay within their plan’s panel, and follow all of its rules, including getting referrals for specialists for HMO plans. It will be a steep learning curve for the uninsured, insurance experts predict. Baumgarten predicted further that it may be the hospital industry absorbing the brunt of the troubles, as they struggle to collect thousands of dollars from low-income patients who can’t easily pay. Medicare beneficiaries who use the privatized Medicare Advantage plans have grown used to the tough in-network rules of their HMOs. But the churn of providers is a newer trend. This fall, UnitedHealth Group’s popular AARP-branded Medicare Advantage plan cut thousands of physicians from its networks in Florida, Connecticut, Rhode Island, Indiana and New Jersey. A spokesman said the move enables the plan to be more efficient, and control quality and costs. It’s the plan of choice for about 20 percent of Palm Beach County Medicare Advantage customers. Those consumers need to check in with their doctors, said Jennifer Vander May, the local coordinator for the Area Agency on Aging’s SHINE project, which stands for “Serving Health Insurance Needs of Elders.” The Medicare Advantage open enrollment period ends Dec. 7. Thousands of seniors have recently received letters about the change from UnitedHealth Group, she said. “Some are very frustrated,” Vander May said. “Every year we encourage them to find out what’s in their plans, ask what their doctor accepts.” West Palm Beach dermatologist Dr. Howard Green recently learned his large dermatology group had been dropped by UnitedHealth Group’s AARP plan. He’s livid. “We are losing patients with whom we have cared for continuously for two decades,” he said of Dermatology Associates of the Palm Beaches. “This is nothing more than rationing for profit. This is pure politics. They are grabbing profits under the anarchy of Obamacare.” Stacey Singer is a staff writer at the Palm Beach Post. http://www.mypalmbeachpost.com/news/lifestyles/health/beware-health-insurers-shaving-networks/nbfpc/?icmp=pbp_internallink_textlink_apr2013_pbpstubtomypbp_launch

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‘Medicare for all’ isn’t perfect, but it does what the ACA can’t: Guarantee better healthcare and a simpler system

By David Sirota
Salon, Oct. 31, 2013 Whenever scandal arises in Washington, D.C., the fight between the two parties typically ends up being a competition to identify a concise message in the chaos — or, as scientists might say, a signal in all the noise. This week confirms that truism, as glitches plagued the new Obamacare website and as insurance companies canceled policies for many customers on the individual market. Amid the subsequent noise of congressional debate and cable TV outrage, Republicans argued that the signal is about government — more specifically, they claim the controversies validate their age-old assertions that government can’t do anything right. Democrats countered that the signal in the noise is about universal healthcare — Obamacare is a big undertaking, they argue, and so there will be bumps in the road as the program works to provide better health services to all Americans. This back and forth is creating an even more confusing cacophony — and further obscuring the signal that neither the two parties nor their health industry financiers want to discuss. That signal is about the need for single-payer healthcare, otherwise known as Medicare for all. One way to detect this signal is to consider the White House guest list. In trying to show that he was successfully managing the Obamacare rollout, the president last week staged a high-profile White House meeting with private health insurance executives — aka Obamacare’s middlemen. The spectacle of a president begging these middlemen for help was a reminder that Obamacare did not limit the power of the insurance companies as a single-payer system would. The new law instead cemented the industry’s profit-extracting role in the larger health system — and it still leaves millions without insurance. The second way to see this single-payer signal is to behold the Obamacare-related congressional hearings. During the proceedings, you’ve been hearing a lot about the insurance enrollment website that the government is paying millions to insurer UnitedHealth Group to build. But you’re not hearing much about actual health care.  That’s because the insurance industry wrote the Affordable Care Act, meaning the new statute’s top priority isn’t delivering health services. Obamacare is primarily about getting the insurance industry more customers and government contracts, whether or not that actually improves health services. The third way to see this single-payer signal is to simply experience the confusion about Obamacare for yourself. If you’ve managed to successfully navigate Healthcare.gov, you probably have been treated to a wave of perplexing information about different kinds of private insurance plans and premiums. In other words, you haven’t seen a simple, standardized and guaranteed form of healthcare coverage like the kind provided by the single-payer government-administered Medicare system. You’ve likely seen the same maddeningly labyrinthine private insurance system that works to ration — and often deny — access to healthcare. It didn’t have to be this way. Back when Obamacare was being negotiated, Congress could have circumvented the private insurance industry by simply expanding Medicare to cover everybody. Medicare isn’t perfect, of course, but it remains one of the most popular institutions in America because its single-payer model guarantees access to decent, cost-effective health care rather than just meager health insurance. It also does a good job of preventing profit-taking middlemen from getting between patients and their physicians. Obamacare doesn’t do all that. It certainly includes some important reforms, but it doesn’t do what a single-payer system does — it doesn’t guarantee better healthcare or a more simple health system. Those Democrats who pretend it does are just as dishonest as the Republicans who ignore Medicare and pretend government cannot effectively manage healthcare. All of them are making noise to drown out the single-payer signal. David Sirota is a nationally syndicated newspaper columnist, magazine journalist and the best-selling author of the books “Hostile Takeover,” “The Uprising” and “Back to Our Future.” http://www.salon.com/2013/10/31/single_payer_health_care_vs_obamacare/

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By Ralph Nader
The Nader Page, Nov. 1, 2013 With the Tea Partiers relentless attacks on each of the troubles besetting Obamacare since its complicated, computer glitch-ridden startup on October 1, 2013, the compelling question is: Why aren’t the Congressional sponsors of H.R. 676 – full Medicare for all with free choice of physician and hospital – speaking out as strongly on behalf of this far superior universal health care coverage? There are fifty-one members of the House who openly favor the single-payer solution for many good reasons. Legislators behind H.R. 676, such as Reps. Robert Brady (D-PA), Michael Capuano (D-MA), Donna Christensen (D-VI), Judy Chu (D-CA), Yvette Clarke (D-NY), Wm. Lacy Clay (D-MO), Steve Cohen (D-TN), Elijah Cummings (D-MD) and Danny Davis (D-IL) know that single-payer insurance with private delivery is by far more efficient, saving $400 billion a year just on administrative simplification. Physician, scholar and advocate, Steffie Woolhandler, co-founder of Physicians for a National Health Program (PNHP) says that, “complexity is baked into Obamacare.” What does “complexity” mean beyond thousands of pages of legislation and many more pages of regulations? Over forty years ago, Canada’s single-payer system was enacted with a 13 page bill that covers everyone for less than half of the cost per capita than the U.S.’s waste-ridden, profiteering, corrupt medical-industrial complex that drives honest practitioners up the wall. And, the Canadian system produces better health outcomes at this reduced cost. Unfortunately complexity means endless opportunities for insurance companies to game the system with fine print, tricks, confusing pricing and lobbying to get out of requirements and standards through waivers. Complexity means ongoing confusion for consumers and patients who go into these exchanges, either because they’ve been thrown out of their existing but substandard insurance policies or do not have any insurance. Every year, these same consumers have to figure out whether their income has changed enough so that they can report any difference to get a higher or lower subsidy. Moreover, the public insurance option – Obama dropped that even before he was elected, anxious to not antagonize the powerful insurance companies and their allies – is missing. In West Virginia there is only one insurance seller! Other states have either one, two or more companies that will soon begin confusing consumers in different ways. So far, the young consumers aren’t signing up at anywhere near the number necessary to actuarially balance off the more costly older consumers. The expected signup rate for middle-aged consumers is way behind projections. And the fine print trap doors keep getting discovered week after week. Contrast this when Medicare was launched in 1966, as Dr. Woolhandler writes: “Using index cards,” (they didn’t have computers then), Medicare,     “enrolled over 20 million people in six months. And because it was a simple system based on Social Security records, you didn’t have hundreds of people programming in the state of Oregon, thousands of different plans, tons of different co-pays, restrictions and deductibles. You had one single payer plan, which is what we need for all Americans to give Americans the choice they want – which is not a choice between insurance company A and insurance company B. They want the choice of any doctor or hospital like you got with traditional Medicare.” Additional co-sponsors of H.R. 676 know all this. They include Reps. Michael Doyle (D-PA), Donna Edwards (D-MD), Keith Ellison (D-MN), Eliot Engel (D-NY), Sam Farr (D-CA), Chaka Fattah (D-PA), Al Green (D-TX) Raúl Grijalva (D-AZ), Luis Gutiérrez (D-IL), Alcee Hastings (D-FL), Rush Holt (D-NJ), Michael Honda (D-CA), Jared Huffman (D-CA) and Eddie Bernice Johnson (D-TX). All the co-sponsors, including the lead sponsor, Cong. John Conyers (D-MI), know that the great majority of the American people, as well as the majority of physicians and nurses prefer the single-payer, full Medicare – everybody in, nobody out – system. Most doctors want to practice medicine, not bookkeeping with page after page of computerized bills loaded with hospital overcharges and code manipulations. Most Canadians never see a bill. Other co-sponsors of H.R. 676 know how much fraud is concealed in these complex, inscrutable bills that people and insurers receive. The leading expert on health care billing fraud and abuse, Harvard’s Malcolm Sparrow (author of License to Steal), conservatively estimates that 10 percent of all health care expenditure is drained away by billing fraud. That’s over $270 billion this year! Additional co-sponsors of H.R. 676 including Reps. Henry Johnson (D-GA), Barbara Lee (D-CA), John Lewis (D-GA), Zoe Lofgren (D-CA), Alan Lowenthal (D-CA), Carolyn Maloney (D-NY) and Jim McDermott (D-WA), like their colleagues, know that 45,000 Americans (according to a Harvard Medical School peer reviewed study) die every year because they cannot afford health insurance to get diagnosed and treated in time. Nobody dies in Canada, Germany, France, Sweden, Italy and other western countries due to no insurance; because everybody is insured from the moment they are born at half the per capita cost of that in the U.S. All the co-sponsors, including Reps George Miller (D-CA), Gwen Moore (D-WI) Jerrold Nadler (D-NY), Richard Nolan (D-MN), Eleanor Holmes Norton (D-DC), Chellie Pingree (D-ME), Mark Pocan (D-WI), Charles Rangel (D-NY), Lucille Roybal-Allard (D-CA), Bobby Rush (D-IL), Linda Sanchez (D-CA), Loretta Sanchez (D-CA) and Janice Schakowsky (D-IL) know that most of their Democratic colleagues favor single-payer, but have not signed on due to their reluctance to embarrass President Obama (who used to favor single-payer) or their avoidance of lobbying hassles from their contributors for a bill they believe has no chance of passing. How’s that for leadership? So the spotlight has to shine on the lawmakers who have stood publically for H.R. 676, but have not taken on the Tea Partiers and their corporatist backers with this superior alternative. Consequently, the media just reports on the Tea Partiers vocal opposition and nothing on the silent backers of full Medicare for all. Around the country, there are groups pressing for full Medicare (visit www.singlepayeraction.org). This weekend, the Physicians for a National Health Program, (with over 15,000 physician-members) is meeting in Boston to debate whether they should mount an offensive for full Medicare in the midst of the Obamacare imbroglio. Their revered mentor, Dr. Quentin Young, a former Chicago friend of Obama’s, argues in his new autobiography, “Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause,” why Obamacare is worse than nothing. All the H.R. 676 co-signers, including “Bobby” Scott (D-VA), José Serrano (D-NY), Mark Takano (D-CA), Paul Tonko (D-NY), Peter Welch (D-VT), Frederica Wilson (D-FL) and John Yarmuth (D-KY), should press Senators Bernie Sanders, Sherrod Brown, Elizabeth Warren, Barbara Boxer and others to introduce in the Senate a similar single-payer bill to H.R. 676. Senator Sanders’ office informs me he is finally ready to do so in a couple of weeks. With over 100 Americans dying each day due to lack of insurance, there’s no time to lose. Please call your members of Congress at 202-224-3121. http://nader.org/2013/11/01/silence-sponsors-superior-full-medicare/

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By Margaret Flowers, M.D.
Talk Nation Radio, Oct. 30, 2013 

PNHP note: The following is an unofficial transcript of an interview given by Dr. Margaret Flowers to David Swanson of Talk Nation Radio on the Pacifica Network on Oct. 30. An audio version can be listened to at this link.

David Swanson: Welcome to Talk Nation Radio. I’m David Swanson. I’m delighted to have on Talk Nation Radio this week Dr. Margaret Flowers. Margaret is a Maryland pediatrician who served as the congressional fellow for Physicians for a National Health Program and who is on the board of Healthcare-Now. She’s an organizer with PopularResistance.org, co-director of ItsOurEconomy.us and co-host of Clearing the Fog radio. Margaret Flowers is the secretary of health in the Green Shadow Cabinet and is one of our leading advocates for universal health care: single-payer, Medicare for All. Margaret Flowers thank you for joining us. 

Margaret Flowers: Thank you David for inviting me.

DS: I guess the big question is, how is Obamacare working out?

MF: Well, it’s interesting – all of these computer glitches and things they’re having as the health insurance exchanges roll out. To me this speaks to the real complexity of it when you’re trying to create a system that maintains our current very complex system of all these different insurances and different criteria that people have to meet in order to get subsidies or be excused from getting insurance. It’s even a more complicated system than what we already have and really begs for the simplicity of what we advocate for, which is Medicare for All, or a single-payer health care system.

DS: Is it actually true that they started Medicare using 3” x 5” cards?

MF: That’s what I understand from Dr. Philip Caper in Maine, who worked for Sen. Ted Kennedy and who was there when Medicare was rolling out. I think he said 20 million people were enrolled in six months with index cards. I think the beauty of a Medicare for All is that you wouldn’t even actually have to enroll right away to get care, because when you have a universal system that means that every single person in the country is in that system. Whether or not you’ve filled out the paperwork right away, if you have to go to receive care, the first question would be, “What do you need?” and you would receive the care you need. They could deal with the paperwork later. That’s the opposite of the type of system we have now. 

DS: I’ve gotten sick in Europe and not been a resident and gone to a hospital and simply gotten care by being a human being, and there was no computer work or paperwork involved.

MF: It’s a completely different environment, isn’t it, where health care is considered to be a public good and people who need care get that attention and that’s what the focus is on – what a person needs, how to help them to get better. 

DS: So, apart from the website fiasco, your critique of Obamacare, as I understand it, includes that many people are actually not going to be covered, and that other people are going to be inadequately covered. How is that possible? We’ve heard so many great things about this program.

MF: I know. It’s amazing that in a country where we have such a health care crisis there has to be so much marketing of a health reform – for something that people need and want but that we didn’t actually get through this plan. That’s one my biggest critiques, fundamentally, about this – that it’s a market-based plan, unlike other countries, like I said, where health care is considered a public good. And so that kind of [market-based] system, in our environment, just could never become a universal system. At best, it could possibly decrease the number of people who are without insurance by half. Right now we have 48 million people who have no insurance at all. It’s expected right now under this law when it’s fully implemented in five more years there will still be 31 million people with no insurance at all. And what are the rest of the people going to have? Well, a provision of this law says insurance coverage that covers only 60 percent is completely fine. And that’s lowering the bar on what we consider to be adequate coverage, because when somebody only has 60 percent coverage that means they have to pay a lot out of pocket, up front, they have to pay a lot of the cost if they have something significant happen and people just don’t have that kind of money. They can’t afford to do that. So we’ll still have tens of millions who are uninsured when it’s fully implemented and many tens of millions with inadequate insurance who, when they have a serious problem, they’ll find it’s not there for them.

DS: And the tens of millions without any coverage, are these the people who famously will have to pay a fine for not purchasing the product, or is this a different category?

MF: Well, it’s interesting. About 24 million people are expected to qualify for a waiver, allowing them to be uninsured without having to pay a penalty for being uninsured. Millions will have to pay that penalty who don’t purchase insurance and don’t qualify for waivers. And you qualify if you don’t have documents in this country; you’re not allowed to purchase insurance through the health insurance exchanges, so you don’t have to pay a penalty for being uninsured. If the cost of the premium is a certain percentage of your income, you’ll also be excused. Most of the people who are going to be uninsured are working people who just can’t afford the insurance premium.

DS: And then again, many people will be quote-unquote insured, but it will be inadequate insurance that will cover certain things and not other things and they’ll have to pay up-front when they go for a doctor’s visit. So it won’t actually be creating preventive, universal health coverage for those people.

MF: Right. And there are a couple of interesting things. One is that people in this country who already have insurance are really struggling to meet those out-of-pocket costs. We’ve seen a decrease in the amount of health services people are using. We call this self-rationing: It’s when people just don’t go to the doctor when they should, or they don’t get their prescriptions filled when they need to because they don’t have the money on hand to do that. Another interesting aspect about the number of people who are going to be underinsured is that we have not changed the behavior of the insurance industry. So we’ve written some new regulations to try to get them to behave and actually pay for the care that people need, but they still have to make money for their investors, so they’re doing that by not only creating these plans that have low percentage of coverage but they’re also restricting their networks. So somebody may have insurance that covers 60 percent of their covered costs but the major hospital centers in their area are not included in that plan, or the number of doctors who are included in that plan are not sufficient. What these do is drive people out of their plans for care and people end up having to pay more of the cost or all of the cost of that care when they go out of network. So the insurance companies are finding ways to work around all these regulations – that’s the bottom line.

DS: So the much-trumpeted new requirements that they not turn people away because of a pre-existing condition and that young people can stay on their parents’ policies, and so forth – are the insurance companies finding ways around those requirements?

MF: Yes, they are. Not so much the young people being able to stay in their parents’ plans till they turn 26, but what many people are finding is that even though their sons or daughters can stay on their plans they can’t afford to pay the premiums on those plans. So we really saw a very small drop over the last few years in the number people in the age group of 19-26 who are uninsured. It was 48 percent who were uninsured before that and now it’s 41 percent. There’s still 41 percent of that age group who are uninsured. And regarding pre-existing conditions, there are a number of ways the insurance companies can get around that. One is restricting their networks, so that people who have significant health care needs can’t find plans that cover the places they need to go for care. Another, and we’ve seen this with privatized Medicaid plans too, is when they identify people who have a lot of health problems, the insurance companies just start kind of making things more difficult for them – not processing their claims as well, providing poor service – and that often pushes people to move to other plans. So that’s how they get people with health problems to go elsewhere. And then they will still be able to draw these geographic areas so that the prices of these plans are going to vary by geography instead of by an individual’s health care needs. So if an insurance company has a certain plan in an area and they find that too many people in that area are having significant health problems and the company is not able to make a profit off of their plan, they’ll just drop it. That’s what it is to them: an insurance plan is just a product, like a cell phone, or a TV, on the shelf.

DS: We’re speaking with Dr. Margaret Flowers, who among other things is the secretary of health in the Green Shadow Cabinet. It’s incredible, Margaret, that they market this as benefiting from the wisdom of the invisible hand of the market economy, and yet the companies as you’ve just described are doing the exact opposite of what is supposedly done in a market economy. They’re trying to lose customers by providing poorer service than some other health insurance company that they might be willing to switch to. And as you’ve described and what I’ve read, the impact of Obamacare, it’s going to result in a lot more privatization, a lot more of our health care dollars going to private companies. Is that right?

MF: That’s correct. The reason that a market-based health system doesn’t work is because private insurers make their profit by charging high premiums and then not paying for services. It’s not like they’re trying to sell TVs or cell phones, they’re trying to not have to pay any money out after they’ve collected it. So it’s the complete opposite of what you want. You want a system that actually pays for the care that you need when you need it. And that’s why privatization doesn’t work and the Affordable Care Act, or Obamacare, is actually further privatizing our system. We’re seeing more of these large hospital corporations buying up practices; we’re seeing insurance companies starting to buy up medical practices. Public insurances are becoming more privatized. Already, 75 percent of Medicaid – that’s the program for people with lower incomes – 75 percent of Medicaid patients are in a privately managed Medicaid plan. And regarding Medicare, which is traditionally our standard for a single-payer-like program in this country, President Obama, when the law was being put together, said he was going to get rid of Medicare Advantage, which is the privatized portion of Medicare. But instead he’s given the Medicare Advantage plans even more money, and we’ve seen a 30 percent increase in people enrolling in those privatized plans. So this is the wrong direction from where we need to be going.

DS: And this is at the state level as well as the federal level that money is going more into private health care.

MF: Correct. Here in Maryland, where I live, we have these privatized managers that handle much our state Medicaid plans, and they skim off probably 15-20 percent, maybe even as much as 40 percent of the money for salaries, profits and administrative costs, and things like that. And that’s money that then can’t go to pay for health care. We had to create a system in Maryland that was completely managed by the state that takes care of our sickest patients because the doctors were having so much trouble fighting with these privatized Medicaid providers to get the care for patients who really needed it. They insisted that the state create a completely public Medicaid for patients with chronic illnesses. This is the problem when you privatize a system and it’s about hanging on to that money and making a profit as opposed to providing the best care, making a system that works for everyone.

DS: So its sounds like one of the big flaws in the U.S. health care system is not getting fixed at all by Obamacare and that is the costs. If we were already paying twice as much as other countries for health care and not necessarily getting it, much less getting twice as much, and nothing is being done to bring down costs, what’s going to happen, is that going to continue to be the case, is it going to get worse? Are there any measures in Obamacare aimed at actually reducing costs?

MF: That’s the really sad thing. As you said, we’re already spending enough money in this country – two to two and a half times more than the other industrialized countries spend per person each year on health care – so we’re spending enough to provide high-quality, comprehensive care to every person living in the country right now, but because we have this very complicated system of all these insurances, and all these different kind of rules in these plans, at least a third of our health care dollars are going just toward administration, which is way more than other countries spend. In the Medicare plan, we spend less than 5 percent on administration. That means more dollars can actually go to care. We’re just wasting this money that could actually go to health care services. And the Affordable Care Act, Obamacare, actually increases the complexities, to create these exchanges. Now the IRS has to be able to determine whether people have insurance or not, whether they have to pay a penalty or not, adding more regulation to try to get the insurance companies to behave. We have now added more administrative costs. And the law did not use any other standard cost controls that we know of that work; instead, they’re kind of they’re saying “experiment with anything that might work and we’ll see what works” for them, when we already know what works to keep health care costs down. So costs will continue to rise, premiums will continue to rise. What we’re finding in Massachusetts is that as the premiums go up, benefits go down. People will continue to have trouble with rising health care costs, and ultimately I imagine the ACA will fail, but in the meantime we’re going to see people continuing to self-ration, to deny themselves necessary care when they don’t have the money out of pocket to pay for the care they need.

DS: So is your take on the creation of the Affordable Care Act, Obamacare, that the net effect is negative because it’s a missed opportunity to enact a real solution, despite the good bits in it, or is it your take that there really aren’t any good bits in it, that it’s all negative?

MF: Some people will get onto Medicaid who weren’t on it before and will be able to get some care. I’m not going to argue with that as being a positive. Some more money was given to some community health centers – that’s definitely a positive. But overall, what this law has done is that it has taken us in the wrong direction. It’s not based on good health policy. There’s so much evidence out there that shows us what kind of a system we could have and that could meet our health care needs in this coun try. It’s not a question of whether we can do that: We can absolutely do that. And this law was not based on good policy, there was no interest in the process of putting it together in Congress of including those kinds of policies. Instead, it’s really the industry, using this opportunity of a health care crisis to pass legislation that further enriches them. I just see it as taking us in the wrong direction and delaying us putting in place a system that will work in this country.

DS: It’s confusing to a lot of us what the insurance companies’ attitude really is toward Obamacare. They’re involved in writing it, there are the secret meetings and the lobbying and the control of the process in Washington, one would think that they would love it from the way that you describe it as further entrenching their interests. And yet we hear, over and over again, about how they hate it. Is the reality that they like it better than they would have liked single payer, which would have put them out of existence, or at least radically altered their existence, but they would have preferred nothing and would rather it go away? Do they like the thing and pretend not to like it? What is their real position here?

MF: I think the real position of the insurance companies is that they want to have a completely open market without regulations and so they’re always going to be fighting against any attempts to regulate them. You know, there are regulations in the law, but it simply means extra work for them to try to get around those regulations and still be able to turn a profit. So they may kick and scream a little bit. Yes, they would have really been opposed if we were trying to put together a single payer, a publicly financed health program. But that’s just the reality. That’s been the reality in every country that has moved to a single-payer, publicly financed health care system. They all had private insurers who complained. But at the end of the day, what we’re talking about here – health care – is absolutely fundamental to people and to a society. When you don’t have a healthy society, everybody is affected by that. The risk of infectious diseases in your community, what it does to families in your neighborhood when they have to go through situations of serious illnesses and struggling to be able to get care and, you know, neighbors are having to do fund-raisers to help them get their chemotherapy. These types of things shouldn’t be happening. In mental health, the fact that we don’t provide good mental health in this country really hurts us as a society. So, at the end of the day, you have to say, you know what, we have to take on that opposition, take on those industries, and just realize that they’re not helping us as a society, and that we as people have to demand that they go do something else. There are other kinds of insurance they can sell; they don’t have to sell health insurance, they can sell life insurance, car insurance, that’s fine.

DS: They can get completely other jobs and we can help them.

MF: That would be fine too.

DS: What about the requirement that individuals buy insurance? Do they like that bit?

MF: Oh sure. That was their main “ask” in the process. I went to many of those meetings in Congress and the first thing that the insurance representatives would say is that this plan going forward has got to include an individual mandate. There’s no way that we can cover people with pre-existing conditions if we don’t force everybody – the healthy people who are just not buying insurance – buying our insurance. So that was their requirement all along. And as the legislation was coming to an end, we were saying that’s the provision that should be dropped. Instead of requiring people to buy private insurance, which we know is going to be lousy coverage – in order to make it affordable, it’s going to have to be lousy coverage – and that instead of taking billions of our taxpayer dollars to subsidize the purchase of these lousy health insurance plans, let’s just take that money and build up our public insurances. Let’s expand Medicare, let’s build up Medicaid and make it better. That would actually put us in a better direction. But that isn’t what happened, unfortunately.

DS: Is there a significant precedent set here? Few if any precedents prior to this one of the government requiring that people buy a product from private companies and promoting that product for those companies – is there a danger here of this setting a precedent that will lead to other bizarre legislation? Or is this a one-time thing?

MF: I’m not a legal expert, but we did challenge the individual mandate, a number of us did, and had lawyers who drew up the brief for us and filed an amicus brief to the Supreme Court with our concerns about that individual mandate. You know, it is foreseeable that, say they decide that Social Security is not going to work, but people have to have pensions, so now we’re going to force people to purchase pension plans from Goldman Sachs. That’s a possibility. It does set a concerning precedent.

DS: The other precedent that we’ve set is the failure of the American people to push hard when the occasion arose for a real solution, for single payer. We had many, many activist organizations and labor unions, as you’re all too familiar, pushing for whatever was already going to get done, for the “robust public option,” the solution that wasn’t really a solution. And we had rallies where we were censored because the demand was for the “robust public option,” which of course then didn’t happen. First of all, are all the people who said this is a step toward single payer and then we’ll take another step – are they now out there pushing for single payer? Have I missed that?

MF: No. And the truth is that this is a step in the other direction, toward greater privatization of our health care. That was interesting because we were looking recently as to what does it take to actually con people, to scam people into accepting something. And there are six kinds of stages of a scam, and we looked at the process of the Affordable Care Act and found those six stages. People we’re really fooled. The health care crisis was there, and it still is there. There was definitely a demand for health reform, and so the whole process was kind of scripted in a direction to devise the health reform movement, to tell people that the single-payer system they were asking for was too much, but that we could get this public option thing and if you fight real hard for that, then we’ll use that, it will become a back door to single payer. People who understand health policy and how health reform has worked out in this country at the state level knew this was actually never going to happen. And the other thing that was really sad was when in March 2009, at the Center for American Progress, Sen. Max Baucus made an announcement that the public option was a bargaining chip that was never meant to be in the final legislation: So all of these people were fighting for something that members of Congress and the White House knew they were not going to include in the final bill.

DS: What should we have done, and what should we do now? And how hard would it be to simply lower the age for Medicare in a bill perhaps in a sentence or a paragraph that people can understand? Is such a thing still possible at this point?

MF: I would say it’s possible. It’s interesting that the same Sen. Baucus, who really pushed the bill in the direction of the health industries, he did carve out a portion of his state, in Libby, Montana, where they have some serious health problems from asbestos exposure, he allowed that whole area to be eligible for Medicare, regardless of age.

DS: Incredible.

MF: What we need to do is continue to push for a Medicare-for-All-type system. One of the takeaways from this whole process was that we need to be really clear about what it is that we want, what a single-payer system is and what it isn’t, and not get fooled when they start telling us that something is a back door to single payer or just a label. We need to know whether that is a reality or not. And we need to be independent of political party in our advocacy work. We need to be focused on the issue, on the policy, not on whether this party or that party is doing it, because this legislation became more about Obama’s legacy and the midterm elections rather than actually solving our health care crisis. We have to stop being so willing to compromise. We’re told that politics is a game of compromise, but I think of what Gandhi said, that you can’t compromise on fundamentals. Because it’s all give and no take. Health care is a fundamental. You can’t really compromise on that, especially when we already have the resources in this country to solve our health care crisis. So being clear on what we want and really being uncompromising is the way that we’re going to move forward and get the kind of health care reform that we need.

DS: Great advice. We’ve been speaking with Margaret Flowers. She is a Maryland pediatrician, she served as congressional fellow for Physicians for a National Health Program, and she’s on the board of Healthcare-Now. Margaret Flowers, thank you very much for coming onto Talk Nation Radio. 

MF: Thank you for having me on, David.

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