By HELEN REDMOND
Counterpunch, December 8, 2009

If you join a fight for social justice you many win or lose, but just by being part of the struggle, you win, and your life will be better for it.

–Howard Zinn

Already defenders and apologists for the Democrat’s health care legislation are busy at work. In the next few weeks they will be working overtime to persuade, cajole, shame and ruthlessly attack if necessary, anyone opposing health care legislation. They’ll reserve special hysteria, invective and contempt for those of us who continue to support a single-payer, national health care system.  And because it is the holiday season, we will be called heartless health care Grinches and silly, single payer, Bernie Sanders Scrooges. There will be accusations: “If you don’t support health care reform legislation, you support the status quo.” Implicit in the indictment is single-payer advocates, with their pie-in-the-sky idea that health care is a human right for all, will be responsible for the continued impoverishment and immiseration of the American people if a bill doesn’t pass.

Joshua Holland, an editor and senior writer for AlterNet and Uwe E. Reinhardt, an economics professor at Princeton, have begun the onslaught.
In a piece posted on AlterNet November, 24th titled, “Is the House’s Health Bill Really Worse than Nothing?” Holland attacks Dr. Marcia Angell, author, former editor of the New England Journal of Medicine and a leader of Physicians for a National Health Program (PNHP.) Dr. Angell opposes the House bill and believes it’s “worse than nothing.” For that she earns the disdain of Joshua who just can’t accept there isn’t something in the bill worth supporting, even though he agrees with her trenchant criticism of the bill’s gaping defects. He claims she ignores the “primary thrust of the legislation” which for Holland is “the fact that the House legislation would do quite a bit for millions of real Americans struggling through a very real health care crisis.” “Real” Americans, a “real” health care crisis? The insinuation is Angell, and by affiliation PNHP, isn’t operating in the real world of real suffering if they don’t support whatever bill Congress delivers to the Oval Office for a signature. That’s interesting. An organization of 16,000 doctors that conducts research on major aspects of the health care crisis and have been on the frontlines for real reform for decades doesn’t understand what’s real?

Holland argues Angell negates her original thesis when she writes, “The bill has a few good provisions (expansion of Medicaid, for example) but they are marginal.” It doesn’t. Her central contention is even with an expansion of Medicaid and a few other “good” provisions, the bill is a bomb because on balance, it entrenches the power and profits of the private insurance industry – the source of the health care crisis.

This isn’t the first time an expansion of Medicaid has been offered as a partial panacea for the health care crisis. And it has to be said: It isn’t necessary to create a huge, complex and expensive piece of national legislation in order to expand the Medicaid Program. Any state can decide at any time to change eligibility rules and insure more residents (Massachusetts did in 2006.) But the overall trend has been the opposite.

According to a study published in the Annals of Family Medicine, “Medicaid programs in all 50 states implemented cost-savings strategies, including benefit reductions, cost sharing and tightened administrative rules during the recent economic downturn.” Medicaid operates within the dysfunctional, multi-payer health care system and has suffered from an expand-contract cycle since its inception. It’s a favorite target for blame-the-victim politicians who want to get poor people off welfare (and health care) and into the workforce with no health care. Under the Clinton Administration’s “welfare reform,” hundreds-of-thousands of mostly women and children lost Medicaid coverage. The Medicaid program is not an entitlement or a right. An onerous redetermination is done every year in most states. And in fact, losing Medicaid coverage for a variety of reasons is the norm.

It’s true – the expansion of Medicaid would help millions of low-income Americans, but for how long? Expansion of Medicaid is a short-term, incremental fix, not a permanent one. And that should be the goal of legislation – a permanent fix to the health care crisis so there is no longer a health care crisis. 

Holland thinks the subsidies are “rather generous.” It’s curious he isn’t asking these questions: If the government were truly reforming health care, why would millions of people need subsidies? Shouldn’t the cost of coverage come down so much its affordable without government assistance?

Here’s the conundrum – if you support subsidies to help people buy insurance and the expansion of Medicaid, you are forced to support the transfer of billions of taxpayer dollars into the coffers of the investor-owned insurance industry and a mandate that criminalizes and punishes people. You also have to accept the Stupak Amendment and the denial of health care to millions of undocumented workers.

There are more poison pills to swallow. Holland thinks it’s fine insurance will still be linked to employment – tell that to the millions who are unemployed and being laid off by the thousands every day. In the House bill, if employers offer insurance, they must pay at least 72.5 percent of the premium for individuals and 65 percent for families. That’s too low and gives companies who pay a higher percentage an incentive to shift costs onto employees until they hit the government-mandated limit. Workers will then be dumped into the insurance exchange because it will be cheaper for employers and once there, because of the mandate, forced to buy stripped down plans with no limits on premiums.

Currently, there are over twenty-five million people underinsured. The majority of people who declared medical bankruptcy started out with insurance. That is the wave of the future. The government will claim more people are insured and technically they will be, but are you really insured if you have a $5000 deductible, high co-pays and less than one-hundred percent coverage for hospitalizations, expensive medication and diagnostic tests?

And what about the much ballyhooed public option which was supposed to keep the rapacious insurers honest and give millions quality, inexpensive health care that Joshua argued for at the expense of advocating for single-payer which he is a supporter of? Eviscerated, not robust at all, and what Paul Krugman now calls “medium-strength.” It’s not even that. The “progressive” Democrats abandoned Holland and his ilk and voted in favor of the bill after they swore not to if it didn’t contain a robust public option with rates tied to Medicare. These are the same “regressive” Democrats that voted in favor of the Stupak Amendment. Holland argues if the final legislation contains Stupak it can’t be supported. But if “Progressive-Regressive” Democrats voted for it the first time, they will vote for it a second time because they don’t have the spines to stand up to President Obama, or for abortion rights.         

Toward the end of his assault on Dr. Angell’s position, Holland writes, “…drawing the line at the House bill is privileging ideology over getting something done in the short-term, however imperfect it might be overall.” But that is precisely the problem. For decades short-term, imperfect reforms are offered that inexorably lead right back to the crisis. Then more short-term, imperfect reforms are offered and the cycle continues. Instead of attacking the p
rivileged ideology of for-profit, corporate controlled health care, Joshua attacks single-payer ideology and argues to abandon it in order to get something, anything done.

Single-payer supporters also reject his false choice of “trying to push for the best package possible or leaving a disastrous status quo in place…” The not so subtle message is if a bill doesn’t pass we will be responsible for the disastrous status quo that is the state of health care in this country. Sorry Joshua, but that responsibility will rest with the Obama Administration that at every turn placated the profit hungry, parasitic insurance and pharmaceutical industries.

And if a bill does pass this year, we can hurry up and wait 4 years because that’s when it will be enacted! So, disastrous status quo for 4 more years, then in 2013 implementation of a disastrous bill that will continue to leave 20 million uninsured. I can hardly wait. 

Uwe E. Reinhardt dismisses and disrespects Dr. Don McCanne, another leader of PNHP, for arguing current health care legislation can’t be supported and instead the fight for a single-payer health care system must continue.

Reinhardt wrote in response to Dr. McCanne’s comments on the letter he and 22 other prominent economists sent to President Obama: “Don is a mensch, but a dreamer. Let’s face it, this very limited bill, should it pass into law, is the very best Americans can hope for. This country will never have a sensible, efficient health care system, and perhaps not even a totally humane one. For better or worse, we must get used to it.”

Reinhardt’s work is full of contradictions. He writes extensively on health care and understands that a government-run, single-payer system is the best way to control the cost of health care and insure everyone. Like in Taiwan. But Reinhardt is thoroughly pessimistic the political movement that is necessary to bring about that kind of system can be built and can win. So he tells us we have to get used to 45 thousand people dying every year for lack of health care. We have to get used to millions of families being bankrupted from medical bills. It’s the very best Americans can hope for and if you don’t hope for that you are a stupid dreamer. I couldn’t disagree with Dr. Reinhardt more. We cannot and will not get used to that barbarism.
Obviously Reinhardt hasn’t been paying attention to the movement for single-payer and what we have accomplished during this round in the health care debate.  

Reinhardt needs to come down from his Ivy Tower and join the movement for single-payer. It’s really not so bad down here at the grassroots level, Uwe. There is PNHP with 16,000 members. The California Nurses Association (CNA) supports single-payer and has thousands of members, too. Sections of the labor movement support single-payer. There are grassroots, single-payer organizations in almost every state with committed members who got arrested in acts of civil disobedience at insurance company headquarters. And poll after poll consistently shows the majority of Americans want government-run, guaranteed and financed health care.

If Reinhardt came over strongly and unequivocally to the side of single-payer, he could help the movement take a giant step closer to winning a humane, efficient health care system. He could use his prodigious talents of number crunching and economic analysis to demonstrate the superiority of single-payer and to demoralize and defeat The Powers That Be who listen to his economic prognostications on health care reform. Reinhardt could be a founding member of an organization of economists for single-payer and name it Economists for Single-Payer Network (ESPN.) He could be a proud member of a social movement struggling to make health care a human right in the richest capitalist country in the world.

Helen Redmond, LCSW, is a medical social worker in Chicago. She can be reached at redmondmadrid@yahoo.com. She blogs at http://helenredmond.wordpress.com  

http://www.counterpunch.org/redmond12082009.html

By Philip Caper
Published on Wednesday, December 2, 2009 by CommonDreams.org

As health care reform legislation enters a critical phase in Congress, it’s important to keep our eye on the ball — elements essential to the success of any reform effort. In order to define those elements, we must have a clear understanding of the nature of the pathology in our dysfunctional health care system.

Modern high tech health care is a right of the residents of most wealthy countries in the world — except the United States. America is exceptional in this regard. It is also exceptional in being the only wealthy nation where health care is considered to be a business.

Prior to about the mid-1970s, American health care institutions like those in other developed countries were overwhelmingly non-profit locally controlled entities driven by their mission — comforting the sick, curing illness, and promoting healing.

Most physicians practiced independently or in small groups, free to carry out their Hippocratic oath. Hospitals were community based non-profit institutions governed by local volunteer boards. Private insurance companies were also mostly non-profit, and rarely crossed state lines. Pharmaceutical companies were small, often family owned and mostly driven by George Merck’s ethic: “If we develop medicines that cure disease, the money will take care of itself.”

In the mid-1970s, leaders in American health care fell in love with business. They began to believe that management could be improved and costs controlled by a stiff dose of good old American business know-how. As a result, first MBAs and then full-fledged corporatism began to engulf and transform medical care. Hospital administrators became CEOs, services became product lines, patients became market share and so on.

Hospitals consolidated and became part of larger networks. Local control was weakened or lost. Insurance companies consolidated across state lines, and ownership was transferred from non-profit local corporations to for-profit multi-state and national corporations. As pharmaceuticals became a larger part of medical care pharmaceutical companies grew, became more profitable and merged, eventually creating huge multi-national conglomerates. Ownership was transferred from private (often family) hands to distant shareholders through lucrative public offerings. Health care products and services became just another commodity to be traded on the stock exchange — their value judged only in terms of return on shareholder on investment.

The practice of medicine, the bedrock of any modern health care system, changed too. Doctors went from being independent professionals, bound only by their Hippocratic oath, to being employees of increasingly large corporate entities, many of them also for-profit. As a result, physicians have come under growing pressure to tailor their clinical decisions to the revenue and profit demands of their corporate employers. These demands often conflict with the profit driven demands of insurers, attempting to maximize their profits by minimizing their “medical losses.” Revenue driven medical care was born. This profit-driven micromanagement of physicians’ decisions about how to treat their patients exists nowhere else in the world. It too is uniquely American.

As a result of these structural changes, the mission of the American health care system changed. Increasing shareholder value became the driving force in the financing and provision of medical services. In the process, the healing mission of medical care has been diminished and sometimes lost altogether. This too is a uniquely American phenomenon.

In order to resuscitate the healing mission of medicine, a few very important changes must be made to drive the profit motive out of the financing and direct provision of health care. They must be a dominant part of any successful reform effort.

The first step must be the strengthening of our publicly controlled non-profit system of financing medical care. From a policy perspective, the simplest and most direct way to do that would be to gradually expand Medicare. Medicare is effective, efficient and popular. The eligibility age could initially be dropped to 55, and then gradually lowered to eventually encompass the entire population. Unfortunately this fair, simple and elegant solution is also the most politically difficult due to the enormous influence of the medical-industrial complex on our politicians.

The second step must be to remove the profit motive from the direct provision of health care services by changing the way doctors, hospitals and other providers are paid. We must eliminate the fee for service system, and move toward global budgets for hospitals, and salaries and bonuses for doctors. This would remove the influence of fees for individual services on clinical decisions and would eliminate the single largest driver of exploding costs in American health care. It would also allow the incomes of primary caregivers to be brought closer to those of specialists and stem the exodus of doctors out of primary care practice. Higher incomes for primary caregivers relative to specialists would be justified by their role in managing the use of specialists and expensive tests and procedures.

Third, we must greatly strengthen the ability of our public insurance system to control the prices of pharmaceuticals and medical devices to bring the US more in line with all other developed countries. These companies are entitled to a fair profit but not the windfalls they are currently receiving due to the market protection they enjoy from federal patents, protection from price negotiations by Medicare and the massive public investment in biomedical research that often forms the basis of pharmaceutical products.

Health care reform without these basic changes is probably not worth doing, as it would simply reinforce the existing dysfunctional system. If these changes are part of reform, we will be on the way to joining other civilized countries in making health care a right of all our people. If not, it will continue to be an increasingly expensive commodity that only the wealthy can afford.

Philip Caper is a medical doctor who, in the 1970s, worked on the staff the late Senator Edward Kennedy, when the senator chaired the Senate’s health committee. From that time on, he has been a careful observer of health care politics in the United States.

http://www.commondreams.org/view/2009/12/02-8

By ROB KIEFNER
Concord (N.H.) Monitor, Dec. 4, 2009

Amid chaos, misinformation and misunderstanding, the health care reform bill was nudged through the House of Representatives by the narrowest of margins. By not letting the facts get in the way of their blustering arguments, wacky lawmakers from both sides of the aisle offered lots of hype and heft, at times bench pressing the actual 2,100-page document to underscore the strength of their positions.

I thought, for a time, that outcome would be decided by virtue of which representative’s head exploded first in a display of feigned indignation about one aspect or another of the bill.

As a family physician, I rely upon my patients’ stories for insight into health care reform. Lost in the mind-numbing mumbo-jumbo from Capitol Hill are the stories of real patients who can’t afford insurance and small business owners who can’t offer it. The House legislation might make insurance available to my patient who is a struggling small business owner, but at an impossible cost. To add insult to injury, he’ll be fined if he doesn’t purchase insurance.

And for those patients who have “decent” insurance, there are always the struggles, which we share as their doctors, to obtain the diagnostic testing and therapeutic treatments to which they are entitled. By keeping the for-profit insurance companies happy, the legislation will continue to effect de facto rationing of health services by employing the hassle factor.

Good faith?

The costs associated with this bill are not at all clear. If projections are tied in to the “good faith” cuts promised by the pharmaceutical and insurance industries last summer, we are indeed in trouble.

We spend twice as much on health care, per capita, as any other industrialized nation. Yet by several measures of our collective health and wellness, we rank a piddling 37th in the world.

The House bill, with mega subsidies to the health insurance industry, seems to assure our place as No. 1 in the world – for health care spending that is. Within that 2,000-page tome is a mandate for universal coverage with all sorts of befuddling caveats. While health insurers will have to take on patients with preexisting conditions, they’ll do just fine with the increase in volume of patients and the ability to increase premiums. Those insurance execs are kicking back, popping another magnum of Dom Perignon, and reveling in their ability to influence people in high places. Money well spent.

Now I’m not a rocket surgeon, but I think that we can achieve close to universal coverage by developing a publicly financed, privately delivered system in which the 30 cents of each health care dollar currently wasted on insurance companies is channeled into actual health care. In the context of a single-payer plan, or “Medicare for All,” nobody dies for lack of insurance or goes bankrupt on account of medical bills.

Primary care is key

Health care financing is but one leg of the table of reform. An equally important support is primary care. By enhancing the financing of primary care training programs and assuring that reimbursements are commensurate with the costs of providing services, we’ll close in on the quality gap with countries such as France, Germany and Switzerland. Time and again, studies have shown that regions of the country well served by primary care and preventive medicine experience decreased costs across the board, with fewer expenditures due to excessive testing and hospitalizations.

The final two pillars holding up the table of reform are the general acceptance of evidence-based medicine and malpractice reform. We should not be paying for expensive and ineffective diagnostic procedures and treatments, though I do believe that guidelines, and not mandates, are reasonable to allow physicians some leeway in the management of challenging clinical scenarios.

By definition, evidence-based recommendations are a work in progress. The use of screening mammograms among women under 50 has saved countless lives, and this practice should not be abandoned or even modified until much longer-term studies are available. As with any procedure in medicine, patients need to be fully apprised of the risks versus benefits of cancer screening tests.

By practicing in accordance with good science and not speculation, we should be able to diminish the onerous burden of defensive medicine costs.

This brings me to the fourth leg supporting the table: tort reform, conspicuously absent from the House bill. Honest oversight, or a function of the millions of dollars thrown at Democratic congressional campaigns by trial lawyers? Now that’s a tough one.

Focus on doctors

As our elected officials preen and posture for the next part of reform’s journey through the Senate, it is important to remember that governments and insurance companies don’t deliver health care.

It is health care providers and hospitals, working with patients who are fortified with a sense of personal responsibility, that will ultimately control costs and improve care.

Though I do hope that some form of reform ultimately passes, I am concerned that this bill, like “Hillary Care” so many years ago, is destined to collapse from its own incomprehensible mass.

(Rob Kiefner is a family physician in Concord.)

http://www.concordmonitor.com/apps/pbcs.dll/article?AID=/20091204/OPINION/912040357