The right hates the new healthcare law because they think its reach will be universal. The problem is the opposite.

By Adam Gaffney, M.D.
Salon, Oct. 10, 2013

The battle for universal healthcare is not over. This is not because of the reason you might suspect – that Republicans will obstinately endeavor to obstruct Obamacare in every way they can (though that seems to be the case). Instead, even after the smoke clears from the government shutdown (presumably with the law intact), the battle over universal healthcare will still not be over, but for a more fundamental reason: Obamacare, whatever its advantages (and despite the right’s worst fears), does not create a system of universal healthcare.

Now first, to be clear, this is not to say that Obama’s Affordable Care Act won’t help many people. The uninsured who become eligible for coverage through the expansion of Medicaid, for example, will of course be better off – assuming they don’t live in one of the 20 or more states that have callously elected to deny them this potentially lifesaving opportunity. Additionally, many uninsured who were previously unable to afford private health insurance may now be able to do so, for instance through the new income-based premium subsidies. And most of us will benefit from many of the law’s insurance reforms, like the one that prevents insurers’ from denying us coverage because we are sick.

And at the same time, have no doubt: The various Republican alternatives for American healthcare would be disastrous. Consider the most recent GOP healthcare proposal H.R. 3121, which would gut state insurance regulations, eliminate popular ACA reforms like the ban on “preexisting conditions,” end the Medicaid expansion, and provide tax benefits that would preferentially benefit the wealthy, among other unhelpful proposals that would do nothing to help the uninsured. Conservative “consumer-driven” healthcare dreams, more generally, would in truth be nightmares, radically furthering the transformation of healthcare into yet another commodity, bought by “consumers” in proportion to their means, not provided to patients on the basis of their needs.

Yet these facts don’t change the fundamental fact that the ACA will not create what so many of us want, what the right so fervently fears, and – most important – what so many people really need: true universal healthcare. Why?

First, on a basic level, the ACA is not universal healthcare because though it will reduce uninsurance, it won’t provide universal coverage. According to the Congressional Budget Office’s May 2013 estimates, even by 2020 some 30 million Americans will be left uninsured under the ACA, a number that can only be partially attributed to intransigent Republican state governments that have blocked the expansion of Medicaid in their states.

But even putting aside those 30 million people, the ACA is insufficient because it will not deliver what most of us think of as universal healthcare: a system of equitable and comprehensive care for all, with full protection against the cost of illness. Indeed, on the contrary, underway already is a “quiet revolution” in American healthcare, in the words of Dr. Drew Altman of the Kaiser Foundation, that moves us “from more comprehensive to less comprehensive” health insurance, with patients paying more and more out of pocket every time they get sick. Ironically, even with the ACA going into full effect, “the vision of insurance that they’ve [conservatives] always favored,” as Altman told the New York Times, “with more skin in the game, is the one that’s coming to dominate in the marketplace.”

The data clearly show, for instance, that with each passing year, more and more of the insured are already paying higher and higher deductibles, co-pays, and co-insurance whenever they actually need to use their expensive insurance (despite unsurprising evidence that rising out-of-pocket expenses can deter people from seeking needed medical care). In another disturbing trend, major employers – including Walgreens, Sears and Darden restaurants – seem to be moving away from “fixed benefit” health insurance to “fixed contribution” plans, in which employees receive a lump sum to buy a healthcare plan, with no guarantee that these contributions will keep up with the cost of health insurance in future years. It should be noted that this “quiet revolution” toward higher out-of-pocket expenses and more limited benefits is not of the ACA’s making. At the same time, however, the ACA will do little to reverse it (and, in the case of the new excise tax on “Cadillac” healthcare plans, may even exacerbate it).

Meanwhile, for those not insured by their employer and who buy health insurance on the state exchanges that opened on Oct. 1, “underinsurance” may very well become the norm. The plans on the exchanges will be offered in tiers, with the lowest level – the Bronze plan – only required to have an actuarial value of 60 percent (that is to say, the percent of your average annual healthcare expenses that insurance actually pays for), with out-of-pocket annual expenses (after your premium is paid) reaching as high as $12,700 a year for families (depending on income). Moreover, to keep premiums in check, many of these plans will have significantly limited networks of doctors and hospitals, bringing back memories of 1990s managed care. In Missouri, for instance, the Anthem BlueCross BlueShield Plans sold on the exchange will exclude one of the state’s top hospital systems, thereby denying access to the state’s primary academic medical center and its prominent children’s hospital.

Finally, the ACA most likely won’t significantly bend the overall cost curve of healthcare, mainly because it will more or less leave our existing, fragmented and inefficient system in place. According to the most recent projections, for instance, once the economy recovers, the rate of growth of national health expenditures is expected to rebound to about 6 percent annually. This is better than in some previous years, and in an expanding economy in which growth was being distributed throughout the pay scale, might be entirely acceptable. But insofar as these rising costs continue to be passed on to the average working person – while at the same time gains in economic gro wth continue to accrue solely to the most affluent among us – these rising expenses will simply translate into tighter and tighter household budgets, and therefore even more inequality.

So while what the right says about Obamacare is generally wrong, paranoid or both, and though their own proposals would clearly make things much worse, we can’t pretend that Obamacare will create universal healthcare in the sense that most of us imagine it. We won’t have, that is to say, truly comprehensive healthcare for all, with free choice of doctor and hospital, and without a “sickness tax” in the form of out-of-pocket expenses every time we become ill.

What would a system of true universal healthcare look like?  The most feasible and best-studied system for the United States is a form of national health insurance called “single payer,” in which care would be provided by the same mixture of private and public hospitals and physicians that is already in place, but in which a single entity – the government – insures everyone in the country. Medicare is one example of an existing single-payer system, but under a national single-payer system, everyone – not only the elderly – would be covered. Uninsurance would thereby be finally, and entirely, eliminated.

From a quality perspective, the evidence suggests that universal systems perform better – not worse, as is frequently alleged.  A January 2013 report from the National Research Council, for instance, showed that the U.S. has essentially the worst health outcomes among 16 wealthy “peer nations,” despite spending about twice as much on healthcare.

Such a system would have other advantages as well. For instance, it would drastically reduce our massive and rising expenditure on healthcare administration, which in 1999 accounted for an estimated 31 percent of all healthcare spending in the U.S., as opposed to a mere 7 percent in Canada.  This difference is the predictable result of our highly complex and fragmented system of billing and insurance, which is particularly a problem of the private health insurance industry, which has such additional costs as product design, marketing and profits. Indeed, as much as 85 percent of excess spending on “health administration and insurance” is attributable to the private health insurance system. How, exactly, the health insurance industry contributes to actual healthcare – putting aside its extracting role as unnecessary middleman – remains among the great mysteries of the modern age.

The potential windfall from simplifying this mess could therefore be enormous. According to one recent study, a single-payer system could save the federal government about $592 billion a year. These savings could be used to pay for the cost of eliminating both uninsurance and underinsurance, with everyone receiving comprehensive healthcare without onerous co-pays and deductibles every time they got sick.

Such a system might sound like a dream for some, but it’s not only a dream worth fighting for, but also one that can – with time and determination – be won. The fight for universal healthcare, it is clear, is still far from over: A new stage of that fight, in fact, has only just begun.

Adam Gaffney is a physician and writer in Massachusetts.

http://www.salon.com/2013/10/10/republicans_biggest_misunderstanding_about_obamacare/

By Amy Goodman
Truthdig, October 9, 2013 “We apologize for the inconvenience. The Marketplace is currently undergoing regularly scheduled maintenance and will be back up Monday 10/7/3013.” You read it right, 3013. That was the message on the homepage of the New York state health insurance exchange website this past weekend. Yes, the Affordable Care Act (ACA), popularly known as Obamacare, is going through difficult birth pains, as the marketplace websites went live only to crash. The government is not giving out numbers, but informed observers speculate that very few people have succeeded in signing up for any of the plans so far. The ACA rollout occurred as Republicans shut down the government in their attempt to defund Obamacare. But their strategy backfired. Had there been no shutdown, all of the attention would have been on the disastrous rollout. The fundamental issue, at the core of the health-care dispute, is typically ignored and goes unreported: The for-profit health-insurance industry in the United States is profoundly inefficient and costly, and a sane and sustainable alternative exists—single-payer, otherwise known as expanded and improved Medicare for all. Just change the age of eligibility from 65 to zero. “When Medicare was rolled out in 1966, it was rolled out in six months using index cards,” Dr. Steffie Woolhandler told me Monday. “So if you have a simple system, you do not have to have all this expense and all this complexity and work.” Woolhandler is professor of public health at CUNY-Hunter College and a primary-care physician. She is a visiting professor at Harvard Medical School and the co-founder of Physicians for a National Health Program, or PNHP. PNHP is an organization with 17,000 physicians as members, advocating for a single-payer health-care system in the U.S. What is single-payer? Critics denounce it as “socialized medicine,” while ignoring that single-payer is already immensely popular in the U.S., as Medicare. A 2011 Harris poll found that Medicare enjoyed 88 percent support from American adults, followed closely by Social Security. Woolhandler explained that with a Medicare-for-all system, “you would get a card the day you’re born, and you’d keep it your entire life. It would entitle you to medical care, all needed medical care, without co-payments, without deductibles. And because it’s such a simple system, like Social Security, there would be very low administrative expenses. We would save about $400 billion [per year].” Dr. Woolhandler went on, rather than “thousands of different plans, tons of different co-payments, deductibles and restrictions—one single-payer plan, which is what we need for all Americans to give the Americans really the choice they want … not the choice between insurance company A or insurance company B. They want the choice of any doctor or hospital, like you get with traditional Medicare.” Monthly premiums in most cases are expected to decrease with Obamacare’s health-exchange systems, which will enhance the transparency and ease of comparison for people shopping for a health-insurance policy. If and when the technical problems are eliminated from the online health insurance exchanges, and people can easily shop, there will likely be a huge number of people buying policies for the first time. The ACA offers important advances, which even single-payer advocates acknowledge: subsidies for low-income applicants will make insurance affordable for the first time. Medicaid expansion also will bring many poor people into the umbrella of coverage. Young people can stay on their parents’ insurance until the age of 26. People with so-called pre-existing conditions can no longer be denied insurance.

While the ACA was deemed constitutional by the Supreme Court, the opinion gave states the option to opt out of the Medicaid expansion, which 26 states with Republican governors have done. A New York Times analysis of census data showed that up to 8 million poor people, mostly African-Americans and single mothers, and mostly in the Deep South, will be stranded without insurance, too poor to qualify for ACA subsidies, but stuck in a state that rejected Medicaid expansion. So, while partisan bickering (between members of Congress who have among the best health and benefits packages in the U.S.) has shut down the government, the populace of the United States is still straitjacketed into a system of expensive, for-profit health insurance. We pay twice as much per capita as other industrialized countries, and have poorer health and lower life expectancy. The economic logic of single-payer is inescapable. Whether Obamacare is a pathway to get there is uncertain. As Dr. Woolhandler summed up, “It’s only a road to single-payer if we fight for single-payer.” Denis Moynihan contributed research to this column. Amy Goodman is the host of “Democracy Now!,” a daily international TV/radio news hour airing on more than 1,000 stations in North America. She is the co-author of “The Silenced Majority,” a New York Times best-seller.

By Garrett Adams, M.D., M.P.H. The following text reflects the prepared remarks given to a session of the Healthcare-NOW strategy meeting in Nashville, Tenn., on Oct. 5. Dr. Adams, a pediatrician, is immediate past president of Physicians for a National Health Program. The United States has the greatest wealth gap of all industrialized countries and the gap is surging. We also have the worst health and societal outcomes. As Richard Wilkinson and Kate Pickett demonstrate in their book titled “The Spirit Level, Why Greater Equality Makes Societies Stronger,” income inequality is divisive and socially corrosive. As income inequality increases, the range of social problems increases. The Reverend Dr. Martin Luther King Jr. once said, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.” A national, publicly financed single-payer health plan would be the best thing that could ever happen to this country. In one fell swoop on at least one level – health – everyone becomes the same. We not only improve the nation’s health status, we seriously commit ourselves to a true democracy with liberty and justice for all, and we build the better society that more equality can bring. What exactly is single payer? “The Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance” (JAMA, August 2003) and Congressman John Conyers’ House Resolution 676, the Expanded and Improved Medicare for All Care Act, are the road maps to single payer. The message is that single payer replaces the health insurance industry and substitutes cost-efficient central planning for market-based health care profiteering. The term “single payer” means that one fund, administered by a nonprofit government agency accountable to the public, would make payment for all medical services. Period. Is single payer politically feasible? Yes. When asked if they would support “a universal health insurance program in which everyone is covered under a program like Medicare, run by the government and financed by taxpayers,” two-thirds of Americans say they would. Tell me a politician that wouldn’t be thrilled to have that level of approval. That’s political feasibility. In 2007, 5,000 physicians randomly selected from the AMA Masterfile were asked, “In principle, do you support or oppose government legislation to establish national health insurance?” Fifty-nine percent said yes. In some specialties, 83 percent supported national health insurance. Why the disconnect between popular opinion and congressional voting? Corporate power and campaign financing. We must shine a spotlight on the profiteering of the medical-industrial complex. Single payer is politically feasible; but it has been blocked by medical profiteers. Is single payer financially feasible? Yes. Professor Gerald Friedman recently showed that if H.R. 676 were in force in 2014, the U.S. could save an estimated $592 billion by slashing the administrative waste associated with the private insurance industry ($476 billion) and reducing pharmaceutical prices to European levels ($116 billion). The savings would be enough to cover all the uninsured and upgrade benefits for everyone else. “No other plan can achieve this magnitude of savings on health care,” he said. What do we do now? We advocate and educate for single payer, so that when the Affordable Care Act crumbles, people understand there is a solution. While the ACA has positive points, it is fatally flawed because of its inability to control costs and profiteering. Paradoxically, because of the ACA, single payer now has more and more recognition in the general public. We should take advantage of this inflection point in single-payer awareness. As my dear friend and courageous single-payer activist the Rev. David Bos said, “We need to keep our eyes on the prize.” Healthcare-NOW is the original single-payer coalition, founded by Marilyn Clement from the civil rights movement and Dr. Quentin Young of PNHP as the “Campaign for a National Health Program.” Importantly, the original coalition also included an African American leader of Pastors for Peace – repeat: an African American leader of Pastors for Peace. Well over 900 groups have endorsed H.R. 676. One especially useful group today has a very informative listserv is One Payer States. Public Citizen gives invaluable support. In addition to the many statewide coalitions, a national coalition called the “Leadership Conference for Guaranteed Health Care” functioned quite well in the run-up to the 2010 reform. That coalition included PNHP, Healthcare-NOW, National Nurses United/California Nurses Association, Progressive Democrats of America, the Labor Campaign for Single Payer Healthcare, and the All Unions Committee for Single-Payer Health Care – H.R. 676. Minority groups suffer the most from health inequities and disparities. These disparities are the worst in Southern states. We particularly need to take the single-payer message to them. This movement will not succeed without the enthusiastic support of everyone, white, Black, Asian and Latino.

By Paige Lavender & Nick Wing
Huffington Post, October 8, 2013

Department of Health and Human Services Secretary Kathleen Sebelius was grilled by Jon Stewart on Comedy Central’s “The Daily Show” on Monday, where she appeared to address glitches that have plagued the Obamacare website in its first week since going online.

Stewart challenged Sebelius on why individuals aren’t able to delay Obamacare, even though businesses have been given option.

“If I’m if an individual I’m wondering — well, an individual who doesn’t want this because there are individuals clearly that want this — but if I’m an individual that doesn’t want it, it would be hard for me to look at big business getting a waiver and not having to do it and me having to because I would think, ‘geez, it looks like because I don’t have a lobbying group,'” Stewart said. “I would feel like you are favoring big business because they lobbied you to delay it because they didn’t want to do this year but you are not allowing individuals that same courtesy.”

“Why is it that individuals, though, couldn’t say they didn’t want to do it just for a year?” Stewart continued.

“Well they can. They pay a fine,” Sebelius said. “They pay a fine at the end of the year, but they don’t have to — they can say, ‘I don’t want to do it.’ The theory is they can’t pick and choose if they are hit by a bus or diagnosed with an illness.”

In the second interview segment, Stewart admitted that he had broader concerns about what many saw as “incompetence” in Obamacare’s implementation over the last week.

See part 1 of the segment above, and watch part 2 below (story continues below video):

When Sebelius again defended the importance of making sure more people have health insurance and aren’t relying on treatment at the emergency room, Stewart said he believed this goal would have been best achieved through a single-payer system.

“I don’t understand the idea of staying with a market-based solution for a problem where people can’t be smart consumers. There are too many externalities in health care that I honestly don’t understand, why businesses would jump at the chance to decouple health insurance from their responsibility, and why the government wouldn’t jump at the chance to create a single-payer that simplifies this whole gobbledegook and creates the program that I think America deserves,” Stewart said.

Sebelius said she understood Stewart’s point, but thought “the president did not want to dismantle the health care that 85 percent of the country have and start all over again.” She also noted that the Republican response to Obamacare suggested that they wouldn’t have been too excited about the idea of a single-payer system run by the federal government.

By Scott McLarty
CommonDreams, Oct. 6, 2013 Sure, the government shutdown and Republican demands regarding the Affordable Care Act (ACA) are reprehensible, but let’s not delude ourselves about the ACA itself. It’s needlessly complex. It preserves medical treatment as a commodity rather than a right: low-cost policies will provide low-quality insurance. It imposes a direct public subsidy to feed the insurance industry, which helped write the legislation. It isn’t universal. Millions of people who lacked it will now have health insurance, but the coverage they get won’t approach the level of health-care access guaranteed to every citizen in every other democratic nation. Obamacare is a Republican idea. It’s based on the individual mandate, an idea introduced by the conservative pro-business Heritage Foundation, promoted by Republican leaders, and enacted in Massachusetts by Gov. Romney. Republicans only began to detest it circa 2009 when President Obama and Democrats made it part of Obamacare. Conversely, progressives only began to support it when the ACA was introduced. Barack Obama opposed it during his presidential campaign but changed his mind in 2009. Is it obnoxious to suggest that the dispute over Obamacare was always more about partisan loyalties than substance? The shutdown will probably end when establishment Republicans convince Sen. Ted Cruz (R-Tex.) and his fellow Tea Partiers that they’ve had their fun and now it’s time to let adults run the show again. The main GOP objection to Obamacare is the “Obama” part. The legislation’s real defects aren’t important to the GOP. GOP Agenda and Obamacare Republicans are expert at aggravating crises and using instability to ram through their agenda: destroying social programs, privatizing resources and services, deregulating big business, recreating the dismal economic conditions of the Robber Baron Era. (Naomi Klein described this in her book “Shock Doctrine.”) Republicans can usually count on Democratic presidents and congressional leaders (who are subject to the same lobby and campaign-contribution influences as the GOP) to capitulate or compromise, sometimes without a fight, as President Obama did during the summer 2011 budget talks that resulted in sequestration. They often rely on Dems to pursue GOP agenda without GOP help. President Obama’s secretly negotiated Trans-Pacific Partnership trade pact, proposed Social Security reductions, and debt-expanding military actions would have been recognized as Republican ten years ago — as would the ACA. The ACA became a capitulation from the moment Sen. Max Baucus (D-Mont.), Chair of the Senate Finance Committee, declared single-payer national health care “off the table” during health-care reform panels in 2009. Single-payer advocates were barred from the panels, while insurance and other health-care industry representatives were invited to make sure their own interests were protected in the new legislation. Even the public option was dropped. The capitulation has serious consequences, a few of which I mentioned above. One consequence was reported in the New York Times on October 2: “A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help…. Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help.” By sacrificing universal health care, the new law accommodated Republican disregard for the poor in the 26 states that have rejected Medicaid expansion. The ACA isn’t a victory for the millions, maybe tens of millions of Americans for whom insurance and medical costs will remain beyond reach or require a hefty percentage of their income. Or for those who will still face financial ruin over a medical emergency. (For a more detailed critique, see Scott Tucker’s interview with Dr. Don McCanne of Physicians for a National Health Program.) These consequences won’t be disturbed when the shutdown ends and immediate funding for the ACA prevails. The ACA was designed to be partial solution to the crisis of skyrocketing medical costs that bankrupt working Americans, even those with insurance, and the lack of insurance for millions more. Useful Idiots The context of the government shutdown is a dispute within the GOP between traditional types and “kill the government” fundamentalists associated with the Tea Party. Are we witnessing an implosion of the GOP? We can only hope so, but it’s more likely we’ll see a return to bipartisan business as usual: two factions of a corporate-money party arguing over the best way to satisfy the country’s One-Percenters. (See “The Shutdown Game” by Glen Ford in Black Agenda Report, Oct. 2) One Percent aren’t really interested in shrinking government. They prefer laws and government that more efficiently and generously serve their interests. They want Washington to remove barriers to markets, profits, and consolidation into monopolies and cartels, even when it means destroying the middle class and plunging working Americans into helplessness. Plutocracy’s sole interests are money and power. Ideologies and economic theories are for little people, endowed academic seats, bow-tie wearing newspaper columnists, and other suckers. To the plutocrat, the Tea Party libertarian is a useful idiot. The plutocrat is grateful that the libertarian supports Walmart as a beacon of free-market competition and prosperity, while Walmart crushes small-business competitors and hires employees at wages that force them to rely on social services. The plutocrat thanks the libertarian for demanding deregulation of Wall Street derivatives in the name of free movement of capital, while ordering pet politicians to insure derivatives trading with taxpayers’ money against multi-billion and multi-trillion dollar losses. Plutocrats (with some exceptions, like the Koch brothers) transcend party and can live with any law or policy that allows them to boost the bottom line. The health-care debate between Dems and Repubs was rigged from the beginning by the One Percent, which made sure that insurance companies would continue to make a killing whether the ACA was passed or defeated. What About Medicare For All? Let’s imagine another scenario. A bloc of Democratic Congress members is willing to shut down government rather than vote yea on a budget with funding for another war like the 2003 invasion of Iraq. Good or bad? What if several Congress members had risked a shutdown in 2009 over the declaration that Medicare For All was “off the table” and that pro-single-payer physicians and consumer advocates would be banned from the health-care reform panels? These are fantasies. Anti-war and progressive Democrats in Congress are too timid to consider such actions. In contrast, Tea Partiers in Congress, fueled by the generosity of billionaire plutocrats, have no reservations about how they accomplish their goals. The only solution for America’s dismal health-care delivery system is Medicare For All — a single-payer plan that guarantees universal care. We’ll only win Medicare For All with a movement that goes beyond polite lobbying, with street protest as vigorous as Occupy Wall Street and a concerted effort to replace politicians in office. The latter requires a voter rebellion and campaigns that are independent of the two corporate-money parties. It means resisting the predictable claim o f Democratic leaders, after the shutdown ends, that the GOP’s retreat on the ACA is a victory for everyone who opposes the Tea Party and we shouldn’t complicate that victory by demanding Medicare For All. If we lose sleep during the government shutdown, I hope it’s because we’re pondering ways to surpass the Tea Party in asserting our own political power. Scott McLarty serves as media coordinator for the Green Party of the United States and for the DC Statehood Green Party. He can be reached at mclarty@greens.org. http://www.commondreams.org/view/2013/10/06