Health Care For America Now

What will prevent the for profit insurance companies from “cherry picking” the young and well and leaving the sick to the public plan - or how will adverse selection be addressed?

by Dave Bean - 07/15/08

Part of our goals is to create rules for coverage, no matter if you are on the public or private plan, to make sure a certain level of quality coverage is there for you no matter what.

by jason - 07/16/08

The core of Richard Kirsch’s argument is that reformers should forego advocacy of a proven and effective reform – single-payer – in favor of policies which have already been demonstrated to be failures, because the latter are politically expedient. In other words, because failure is politically achievable, failure should be advocated.

The great wealth of literature and experience – both foreign and domestic – should leave us with no doubt that Kirsch and HCAN’s proffered reforms will not only fail to achieve anything approaching universal coverage, they will almost certainly make things worse. As Dr. David Himmelstein of Harvard Medical School points out, we’ve already heard promises that strict regulation of private insurers, placed in competition with a public plan, will demonstrate the public plan’s superiority. But the experience in Medicare has been quite the opposite – private insurers still managed to game the system and attract the healthy and profitable, to the detriment of the public system. This storyline is not confined to the United States: the private health insurer BUPA recent left the Irish market after a judge determined the company had unfairly skimmed healthier patients from the public system, and ordered the company to make adjustment payments.

The definition of insanity is to continue to repeat the same actions, expecting a different result. Yet this is exactly what Kirsch and HCAN advocate, and the results with be predictable. Their response to evidence that the medicine they peddle is nothing more than a placebo is simply to commission more pollsters to produce charts and graphs emphasizing its political feasibility.

In contrast, single-payer national health insurance works both on paper and in practice. Kirsch purports to dispel the “myth” that all European nations have single-payer by replacing it with a new one: that these systems preserve – as he and HCAN would – a substantial role for U.S.-style private insurance. Nothing could be further from the truth. In reality, all of these systems work only because they have regulated U.S.-style insurance companies out of existence. Even in the most privatized system, insurers are required to be non-profit, have their benefits and premiums dictated by the government, and must make “risk equalization” payments if one profits at the expense of another. We need not commission a poll in order to discern whether U.S. insurance companies are going to find such an arrangement more politically acceptable than single-payer.

After many years in the darkness, there is a groundswell of popular support for single-payer. “The U.S. National Health Insurance Act” (HR 676) has 92 co-sponsors in the U.S. House of Representatives. The U.S. Conference of Mayors has just voted unanimously to endorse it. Twenty-five state labor federations and hundreds of union locals have backed single-payer through a grassroots campaign. The majority of physicians and two-thirds of the American public say they support single-payer when polled. To raise the white flag of surrender and retreat to a position more favorable to insurance industry interests at precisely the time when popular support and grassroots energy are on the side of true reform is the real political miscalculation.

by Nicholas Skala - 07/16/08

I am a retired physician and, although I have heard horror stories re: universal health care in places like England and Canada, I am a firm proponent of Universal Health Care. At the present time only some of the people that have employer subsidized insurance, or those that qualify for State Insurance (the indigent) have access to medical care. In the mean time Insurance Companies make Billions of dollars as in the case of United Health Care - obviously they made enough in 2006 to PAY THEIR CEO $1.6 BILLION dollars just for ONE YEAR’S WORK.  In Arizona the head person of the State program for indigent patients got paid $1.1 million for 2006 - money that came out of tax payer’s pockets. How can we justify paying so much to such few people. THERE IS NO JUSTIFICATION. I would like to know what MIRACLES did those two people worked to be worth that much money; money that came out of the pockets of their enrollees. In the mean time reimbursement to Doctors, Hospitals, and other medical care facilities keeps going down. In my practice overhead expenses kept growing while insurance reimbursement kept being reduces every so many months, and it got to the point where I had to close my practice. Like everyone else I have a mortgage, utilities, groceries, medical expenses, etc. and the income was not sufficient to provide for present and future needs. And it is not like a have a mansion and a high rolling life style. I live in a track home, drive a 10y old Honda Accord, and for my vacations I usually drive to see the children and grand children (no cruises or foreign travel). Therefore, Insurances and not the Doctors are the problem. Also, we should not forget the malpractice suit lotery and its effect on doctors income (the lowest rate in my field - Internal Medicine is $120 a year. Therefore I have to make at least twice that amount just to match an engineer’s salary, and they do not work over 12 hours a day, have paid vacations and benefits, and have no liability.

Wake up America, fewer people are going into Medicine and even fewer are going for Family or Internal Medicine. You may wake up tomorrow and find out that there is no one to care for your health, except maybe “foreign graduates” that did not make the cut for a USA based Medical School. Think about it, ater all IT IS ONLY YOUR HEALTH. It is time we had a revolution.

by SEIGRELLA - 07/16/08

We agree on many points, for example, we agree that the Goverment’s role is to provide a guarantee of quality, affordable health care. However, we disagree that the Government necessarily needs to be that Health Care provider.

I think we need to stay focused on the real fight, as Richard puts it,“the real debate is between those of us who believe that health care is a public good where government has to guarantee quality, affordable coverage and those who think that the problem with the health care system is that the market’s not working, and if we gave people a voucher to buy unregulated private insurance, it would solve everything.”

by Levana - 07/16/08

If you’re not for single-payer, you’re still part of the problem, not the solution, to the health care crisis.  The system is broken, and no amount of tinkering is going to fix it.  The only real fix is to remove private insurers from the equation altogether.  I will not support any group or candidate that does not call for single-payer.

by Kyla Klein - 07/16/08

Nicholas Skala, above, points out that the kind of system HCAN is supporting only works when the private insurance industry is regulated in a truly radical way that would turn them into completely different animals than they are today in America:

“Even in the most privatized system, insurers are required to be non-profit, have their benefits and premiums dictated by the government, and must make “risk equalization” payments if one profits at the expense of another. We need not commission a poll in order to discern whether U.S. insurance companies are going to find such an arrangement more politically acceptable than single-payer.”

But Mr. Kirsch’s article, “Winning Quality Affordable Health Care for All”, explains that HCAN’s goal is not to avoid antagonizing the insurance industry, but to win the support of a public that isn’t ready to trust what they see as “government-run” (i.e., single-payer) healthcare in the wake of the Bush administration’s botching of Katrina, etc.

My challenge to Levana or Mr. Kirsch:

Given the fact that prior attempts to regulate the insurance industry have, as Mr. Skala notes, utterly failed to prevent them from gaming the system to attract the healthy and profitable, will you declare that HCAN plans to insist on truly radical reforms of private insurance industry regulations, such as those described by Mr. Skala above, in order to have at least some chance of achieving HCAN’s stated goal of assuring that “risk is fairly spread among all health care payers and that insurers do not turn people away, raise rates or drop coverage based on a person’s health history or wrongly delay or deny care” where all other regulations have failed at this in the past?

If so, I think I could support HCAN.

by N. Olson - 07/17/08

The objection to HCAN’s approach, by at least some Single Payer advocates, is the combination of appropriating the single paqyer message and then not even including us at your table.

We who are advocates for the Single Payer (aka: expanded and improved Medicare for all) approach to acheving real universal health coverage in the United States are often accused of being zealots opposing the supposedly acheivable good (pre-compromising proposals like HCAN’s) for the an idealistic unacheivable best. A more balanced then most version of this argument appears under the title Single Minded by Jon Cohn in the New Republic.  PNHP has a response on their blog. 

But as a one of those who has supported the obvious need for some sort of “universal health care” since I was first learned about the issue as a college and medical student in the 1980s, and only came to single payer per se recently, I have a few of my own points to make:

1: Strong or Weak?

Ironically, we single payer advocates are apparently so weak that we should be dismissed out of hand and not even have a seat at the negotiating table? But then again we are also strong enough to be warned not to wreck “doable reform”?

It is the Beltway sensible moderates who have worked hard to ignore the actual presendce of single-payer grassroots and to exclude its advocates from the table, not the other way around. And frankly, it is tiresome to be dismissed upfront (and then be blamed for not participating or getting on board).

We are the ones who actually have a real grassroots movement.  The single payer proposal in Congress, HR-676, has more signed-on co-sponsors then then any other “universal health reform bill.” It has a higher percent of the House then the Wyden bill has in the Senate. HCAN could have included single payer advocates as part of their mix, could have included support for HR-676 “Improved and expanded Medicare for All” as one option still in the mix of possibilities to be promoted; in their language and in their “poll”; etc.). First they exclude us from the table, then they call us rejectionist zealots after the fact.

I first encountered this back in 1992 after Bill Clinton was elected with our support, and they actively kept single payer advocates from the pre-inaugural economic summit.  Similarly we were kept out of participating in the closed door development of the Clinton health plan during 1992-1994. More recently there was the so called Citizens’ Health Care Working Group, where the citizens part supported single payer but the establishment organizers made sure they were ignored. Similarly during the early part of the primaries, during the Clinton listening tour in 2007, citizens for single payer were a majority at many of her gatherings, but were actively ignored.  Most recently, leading up to HCAN, there have been numerous conference call by the “Unity” group at which single-payer advocates are told to be quiet and “get over it”.  At a Health Affairs sponsered press conference in D.C., ostensibly for discussing just the candidates Obama and McCain plans, other folks from AHIP, Wyden, etc., were in fact also invited and spoke. Nobody from Conyers office or single-payer groups was invited ahead of time.

Unlike those with $40 million K-street campaign-cycle-only Ads, we are the ones who have been working at the real grassroots level to inform the public and health care professionals since the last pre-compromise plan went down in flames (not due to us) in 1994. WE have made progress, as noted by the recent survey published in the Annals of Internal Medcine showing a 59% of U.S. physicians would be in favor of a single payer system, up 10%.

2: Strategy of Pre-Compromising with the Insurance Companies?

No matter what “Reform” is proposed the opposition - AHIP, Pharma, the for-profit hospitals, and free market fundamentalists will start off by opposing it. We don’t see the advantage of pre-compromising before the negotiations even begin.  I prefer to keep all my bargaining chips until the real negotiations begin.

3: Politics and Overton Window & Framing?

Putting aside for the moment that we are correct as a matter of pure policy; just as a matter of politics does it make sense for us to shut-up? There is the Overton Window argument.

For those who do argue for pre-compromised mixed plan on the basis of political expediency/feasibility, is it not really better for them to also have folks arguing from their left? Is it not a good thing to have some pull from left, while they are also being fought from the right by AHIP and free market fundementalists?

Is this not part of the success the right had? What was crazy talk in the National Review in the 1950s, and a political failure with Goldwater in 1964, becomes the “success” (tax cuts, supply side, deregulation, government is the problem) of Reagan/Bush.

More recently we see the example of same-sex relationships as a case of moving successfully the goal posts. Crazy talk that becomes acceptable in compromise fashion (civil union; state benefit rights) and slowly (but surely?) marriage.  Historically we can think of ending slavery, and the vote for women. There were always folks calling for half-way compromise. But the more the side that seemed more “extreme” but in fact had truth and reality on their side won in the end.

For those who prefer, and think that one wins, by framing a policy as a clear moral message, the single payer approach also offers the better way.  HCAN starts off by saying that the for-profit private insurance companies are the problem, but then goes on to keep them as wasteful distorting middlemen. Rather then deliberately pre-compromising and keeping keeping the identified problem in the mix, we say who need them, get rid of them. It is similar to the confusing and mixed message the ever so clever moderates came up with of paying for SCHIP expansion with cigarette taxes. A simpler message with moral clarity is what Single Payer offers.

4: Perceived Political Feasibility Aside, Which Reform Will Work?

PNHP’s role and goal is to advocate for the the actual best plan, the one that can actually work to provide coverage that is not only universal, but also that is comprehensive, affordable to individuals and families, and also acheives system wide control of costs. Single Payer, as embodied by HR-676, Improved and Expanded Medicare for All can do this.

The U.S. already spends as much as Europe and the other developed countries do on it public sector health coverage; they provide universal; we are already in effect paying for it, but don’t get it. Keeping the for-profit private insurance companies in the mix allows them to continue to game the system (e.g. skimming the healthy and wealthy; dumping the sick, poor, old on the public system). Continued subsidizing of the wasteful for-profit private insurance companies forgoes $350 savings billion per year. Administrative waste is a natural byproduct of the private insurance firms that would retain a central role under HCAN’s plan. Private plans’ overhead is 12-fold higher than under NHI; the excess is squandered on marketing, underwriting, utilization reviewers and profits, and for the billions paid to executives. And the multiplicity of insurers envisioned in the plan precludes paying hospitals a global, lump sum budget; such budgets would save additional billions by obviating the need for most hospital billing and much of the internal accounting needed to attribute hospital costs to individual patients and payers.

Alas, HCAN’s proposal duplicates key elements of health reforms that have passed, and then failed, in multiple states: Massachusetts in 1988; Oregon in 1989; Tennessee, Minnesota and Vermont in 1992; Washington State in 1993; and Maine in 2003. In each case, rising costs scuttled the reform effort; none had a durable impact on the number of uninsured. The 2006 Massachusetts law, which incorporates many of the features of HCAN’s plan, is already threatened by rising costs, despite offering skimpy coverage and leaving many uninsured; indeed so far the increase in coverage in the new Massachusetts plan is among to poor who get public coverage, and the effect if any of mandates and regulated private coverage has not been seen yet. And Massachusetts, with its low rate of uninsurance to begin with, and a large fund devoted to care of the uninsured, offered the optimal conditions for trying such a plan.

Single Payer is the one that also control costs!  CBO and GAO have previously scored single payer as most economically feasible. So has Lewin on numerous State single payer proposals. So not only does single payer provide care that is more universal and comprehensive then the other reform proposals, it does so with greater cost saving then HCAN or Obama or Wyden-Bennett or McCain.  We are correct as a matter of policy and economics.

5: Who Wins “I Told You So” After the Next “Reform” Fails?

It is also a matter of who gets to win the “I told you so” argument after the next reform passes, and if it fails as Single Payer advocates believe it will. At the very least we want to be sure that after the next reform does pass, that if it fails, the next step is forward to single-payer (“see you left the private for-profit in as wasteful cheating unneeded intermediaries”), and not backward (“see government tries to reform things and it went badly”) to market fundamentalism. This is very important, since something is likely to pass after the 2008 elections and I fear for what it will and will not bring.

6: We Are Not Spoilers!

How dare others, especially folks not actually working in health care and for those who are underserved, call us spoilers! Like many other single-payer activists, I already work in the frontlines of providing care to those who are uninsured and underinsured. Many of the PNHP’ers and other single-payer advocates that I know have as their real full time day jobs just such work. And guess what? We could be earning a lot more if we worked elsewhere.  Unlike the K-street lobbyists and full time corporate supported think-tanker’s, we are mostly volunteers doing this in addition to the work that pays the bills. Supporters of HR-676, both grassroots, and the 90 co-sponsers in the House, are ALSO the same folks who have always been at the forefront of all the immediate short-term reforms and fights such as those for SCHIP, Medicaid expansion, saving the Medicare from the privatizers, etc. We are hardly rejecting the good/mediocre for the perfect. It sure as heck was not us who shot down the Clinton proposal, even thought they thought they a had a pre-compromised deal with AHIP, in 1994. And frankly, despite some claims, it was not CNA or other single payer advocates who shot down the Schwarzenegger Rube Goldberg-kludge of a plan in California last year. Indeed, case in point, it was the ridiculous economics of that plan which killed it, even though, once again, Lewin had scored California single-payor favorably. 

I can’t speak for any individual other then myself, but at the very end of the day I won’t be the reason a half-decent reform does not pass. But, meanwhile, I will fight for it to be at least three-quarters decent instead. But meanwhile “god forbid” we should actually argue for the actual best policy at the beginning.

Oddly in the Jon Cohn article it is Andy Stern who is cited as asking for our grassroots support to make a differnce. This joiner of every compromising coalition there has been (including with WalMart and AHIP), may not be the best spokesperson for calling out single payer advocates. He has his own separatist and exclusionary agendas with regard to some single payer advocating unions such as CNA and many AFL-CIO affiliates. Actually several SEIU locals have endorsed HR-676.

The real problem is not that Single payer advocates are unwilling to support HCAN. The real problem is that Single Payer advocates have been and still are being actively excluded from all the these other efforts.  It is nice that they have gotten around to co-opting our message after we laid the ground work for them with years of hard work. Although they are using our message that the Insurance companies are the problem, even if they are too invested in pre-compromise to follow through to the conclusion. Maybe if they would be more inclusive of us upfront, we could indeed work jointly, equally, together as true partners.

by DrSteveB - 07/18/08

Hi DrSteveB,

In fact our outreach did include many of these organizations that you refer to. I am sorry that no one contacted you directly. However, some of these organizations that support a single payer plan joined the coaltion, some did not, and some are still thinking about it. We are also open to any organization that would like to join us here: http://healthcareforamericanow.org/page/s/organization/

I am sorry that you felt left out, but we did do a lot of outreach and it is still ongoing. If you or members of your network would like to join on we would be happy to discuss that with you.

by Levana - 07/18/08

My work history very closely resembles Richard Kirsch’s. Like Richard, I began organizing for universal coverage in the mid-1980s with a state chapter of what used to be called Citizen Action. Like Richard, I co-wrote a state-level single-payer bill (I was one of a half-dozen Minnesotans who, in 1990, wrote the single-payer bill that has been introduced in Minnesota’s legislature every year since 1991). But unlike Richard, I never abandoned single-payer.

I need to be blunt: Richard has abandoned single-payer. When you urge Americans not to work for single-payer and to support instead a plan which feeds tax dollars to the insurance industry (a diehard opponent of single-payer), you have abandoned single-payer. It is not a stretch to say you have become an opponent of single-payer. I appreciate the fact that Richard has stayed in community organizing all these years. I can testify to how financially and emotionally difficult that can be. But I strongly disagree with the path Richard has taken on health care reform.

To stress how similar our career paths have been, let me add an anecdote to one Richard tells in Will It Be Déjà vu All Over Again, his 2003 account of the history of the fight for universal coverage. (I thoroughly enjoyed reading the historical portions of this account, as opposed to Richard’s explanations of why history turned out the way it did.) Richard describes a national event involving several caravans of ambulances that traveled cross-country (west to east) in 1991 to dramatize the need for universal coverage. An ambulance in one of those caravans, a three-ambulance caravan that started in Minnesota, broke down just south of Duluth. When word of the breakdown arrived at the Minneapolis headquarters of Minnesota COACT (Citizens Organized Acting Together) where I worked, I dropped everything, took a bus from Minneapolis to Duluth, got the ambulance repaired, and drove it back down to Minneapolis at unlawful speeds in time for the ambulance to catch up with the rest of the “caravan” the next day.

In this post, Richard tells us that “people” (which presumably means a sizable majority of Americans) are fearful of a single-payer system. He claims he discovered this unpleasant fact (to his “surprise”) in 2003 in the course of writing Will It Be Déjà vu…,  and this discovery forced him to “reframe [his] view” and abandon single-payer. But if you read Will It Be Déjà vu…., you will see that Richard abandoned single-payer in 1993 or shortly thereafter, not in 2003.

In 1993, Citizen Action’s national staff and many of the state Citizen Action affiliates, including New York Citizen Action (the organization Richard has directed for two decades), shifted their resources away from the single-payer legislation pending in Congress to lobby for Bill Clinton’s awful Health Security Act, a bill that would have pushed all but wealthy Americans into HMOs. My organization, Minnesota COACT, was among the Citizen Action affiliates that refused to lift a finger to promote the Clinton bill despite considerable lobbying from the national Citizen Action office and AFSCME (another organization that abandoned single-payer to lobby for the Health Security Act). So Richard’s answer to his question, “What happened to me?” doesn’t ring true to me.

Richard’s answer – his current explanation for why he must continue to turn his back on single-payer in favor of the plan promoted by Health Care For America Now (HCAN) – suffers from three big defects: (1) He ignores numerous polls and other evidence indicating two-thirds of the public support a single-payer (or Medicare-for-all) system; (2) he ignores the fact that his “guaranteed affordable choice” proposal has at least as many unsightly warts (from the point of view of the insurance industry and the right wing) as single-payer does; and (3) even assuming his jaundiced view of public opinion about single-payer is correct, he totally ignores the role that courageous and passionate advocacy of single-payer can play in altering public opinion and inoculating the public against false accusations by the right. I’ll describe each defect briefly.

  Defect 1 (turning a blind eye to evidence he disagrees with): Numerous polls and at least two “citizen jury” experiments (one involving Senator Paul Wellstone) indicate approximately two-thirds of Americans support universal coverage with a single-payer. I’ll give you just four examples:

* A 1991 Wall Street Journal-NBC poll found 69 percent support single-payer.
* A 2003 ABC News Poll found 62 percent said yes to the following question (note the bogeyman words “taxpayers” and “government” are in this question): “[Do you support] a universal health insurance program, in which everyone is covered under a program like Medicare that’s run by the government and financed by taxpayers?”
* An AP-Yahoo poll taken at the end of 2007 asked the same question ABC News asked and reported that 65 percent said yes.
* At the end of five eight-hour days of interviewing expert advocates for single-payer, the Clinton plan, and the Republicans’ high-deductible proposal, a 24-person “citizen jury” convened by the Jefferson Project in 1993 voted 17 for single-payer, 5 for the Clinton plan, and zero for the Republican proposal.

Note the high level of support for single-payer exists despite the absence of a well-endowed, highly visible single-payer movement. Of course, the absence of such a movement is due in part to the refusal of the AFL-CIO, SEIU, Health Care for America Now, USAction (the successor to Citizen Action) and other groups Richard works with to put resources into the single-payer movement. Note also that these high levels of public support for single-payer exist despite constant trashing of single-payer systems (like Medicare and Canada’s system) by the insurance industry and other powerful right-wing forces.

Richard offers no evidence in his post nor in Will It Be Déjà vu… that contradicts the evidence that two-thirds of Americans support single-payer. Nor does he offer any evidence to support his claim that a majority of the “people” oppose single-payer and that support for single-payer among citizens is more vulnerable to degradation under right-wing attacks than support for his “guaranteed affordable choice” plan would be. (It is possible to find polls, some with biased phrasing, that indicate that when Americans are given choices between a variety of proposals and asked which they prefer, fewer than half indicate they prefer single-payer. But even these polls do not contradict the statement that two-thirds of Americans will support a single-payer system if asked. They merely indicate “preferences,” not opposition to any particular proposal. In any case, Richard does not cite these.)

(In 2006, a group that Richard helped form called the Herndon Alliance began cranking out junk science that allegedly supports Richard’s claims. Obviously, given the timing of Richard’s decision to abandon single-payer—either 2003 or 1993—the Alliance’s junk science could not have played a role in that decision.)

  Defect 2 (seeing the mote but not the log): Richard has an eagle eye for the controversial features of single-payer and a blind eye (or at least a very forgiving eye) for the controversial features of his proposal. Richard is eager to tell readers how “scary” single-payer is, but he is unwilling to help readers understand the enormous obstacles his “guaranteed affordable choice” plan faces. He is unwilling, in other words, to help his readers think about whether the obstacles to his proposal are less daunting than those he sees for single-payer. The most serious of the obstacles to his proposal will be the high cost of universal coverage under his plan and the need for costly and stringent regulations on the insurance industry that will infuriate the insurance industry and the right wing.

There is no cost containment in the proposal promoted by Richard and HCAN. In fact, as Richard and his allies flesh out their proposal (which at this date it is little more than ten bullet points on the HCAN Web site), I expect we will see provisions that will actually raise costs (such as the cost of the bureaucracy that will decide which health insurance companies get more money for insuring sicker people, the cost of detecting and investigating abuses of patients by insurance companies, the cost of switching from paper medical records to electronic medical records, and the cost of hiring more nurses to do “disease management”). By contrast, numerous studies, including those done by the US GAO and the Congressional Budget Office, demonstrate that a single-payer plan will achieve universal coverage for a lot less than Richard’s proposal or any other proposal that leaves the insurance industry in the mix.

Another huge impediment to Richard’s proposal is the need to impose regulations on the insurance industry to make his proposal work.(The most essential regulations will never be sufficiently effective, but I don’t need to get into that here.) The insurance industry and the right wing will fight these regulations with as much ferocity as they will fight single-payer.

A fair and useful discussion of the political feasibility of Richard’s proposal versus single-payer, then, would ask (among other questions) whether Richard’s proposal really is more feasible than single-payer when you take into account the high cost of his plan versus the lower cost of single-payer, and the intense resistance the insurance industry will put up against both plans. Richard doesn’t do that.
Defect 3 (leadership doesn’t matter): In his post and in his article, Richard has nothing to say about the role that enthusiastic support for single-payer from a large coalition of politicians and citizen, labor, and religious organizations could play in antidoting the corrosive effect of anti-single-payer propaganda. He is not only cynical about where public opinion is today, but he treats public opinion as if it were movable only in the anti-single-payer direction, never in the pro-single-payer direction.

That is, obviously, nonsense. If HCAN were to devote the $40 million they plan to spend on “guaranteed affordable choice” to a Medicare-for-all system (either implemented overnight or in stages), and if politicians like Senators Obama and Clinton would start talking about extending Medicare to everyone, the combined effect might well be to offset, and possibly even more than offset, insurance industry propaganda, which is to say, to maintain public support for single-payer at two-thirds or even increase it.

Richard’s “guaranteed affordable choice” plan is so poorly described in HCAN’s and Richard’s publications that it is a bit risky to predict what will happen to it. But here I go anyway. Odds are very high it will suffer a fate similar either to Clinton’s bill (it will never be enacted) or to the current Massachusetts “individual mandate” law (it will be enacted but it won’t achieve universal coverage because it will be too expensive and the insurance industry won’t be prevented from rationing). My fervent hope is that it will never be enacted.

My worst fear is that if it is enacted the Medicare-like public program that HCAN wants to create to “compete” with the insurance industry will be destroyed by the antisocial behavior of the insurance industry that simply can’t be regulated away. The public program will behave honestly while the insurance industry will keep doing what it does best – it will deny services and frustrate its enrollees and thereby drive the sickest of them into the public program – thereby pushing the public program’s costs up and its own costs down, and eventually driving the public program from the market. If that happens, the right wing will chortle, “See, we told you single-payers aren’t efficient, and now we’ve got proof.” It will be difficult for single-payer advocates, or HCAN for that matter, to explain that what actually happened was that the bad destroyed the good. The result could be prolonged damage to the public’s opinion of single-payer and further delay in establishing universal coverage.

Richard opens his article, Will It Be Déjà vu All Over Again, with this question: “Is this time really the time for universal health care? …. Or will the political process invent other half-measures rather than provide a government guarantee of affordable, quality health care for all?” Richard has answered his own question. He and others who abandoned single-payer in 1993 to support Clinton’s awful plan are repeating the mistakes they made 15 years ago. In 2008, as in 1993, they are urging Americans to abandon single-payer to support yet another “half measure” – a plan that can’t work but which, on the basis of superficial and biased analysis, seems to be more “politically feasible” than single-payer. Talk about déjà vu!

Kip Sullivan

by Kip Sullivan - 07/19/08

I am with PNHP so that is why I guess I fel left out. Speaking just for myself, I wish we could be working together better, but that would mean that HCAN did not take single payer off the table a priori, and single payer advocates would not insist that it be the only item on the table. So far it is quite unfortunate the way it has played out.

Something interesting is happening. First, “Health Care for America Now” (HCAN) announced their $40 million K-street-based grand coalition, that had many good points to it, but tried to take Single Payer off the agenda. Then they put up a Blog on their website, and it promptly filled up with the real grassroots supporting Single Payer and calling them out on it. Then one of their coalition partners, the AFL-CIO put up a Blog supporting HCAN… five out of five commenters supported Single Payer… and then they closed comments!

While the beltway and people “who knew better” did little after 1994, it has been Single Payer advocates who continued more then anybody to do the hard work of actually building a grassroots infrastructure and support.

As Jon Cohn admitted:

You can see it in the press coverage, as reporters, myself included, hype the work of lawmakers like Senator Ron Wyden, who has been pushing a bipartisan bill that would give everybody private insurance. Meanwhile, almost nobody bothers to interview Representative John Conyers, even though his single-payer bill has 90 co-sponsors—not enough to earn it passage, perhaps, but surely enough to earn it a place in the conversation.

Actually HR-676 now has 91 co-sponsers, having added one more just this past week.

HR-676 has been endorsed by over 417 union organizations in 48 states including 107 Central Labor Councils and Area Labor Federations and 33 state AFL-CIO’s (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO,MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA & AK).

It has the vigourous support of the largest Nurse’s Union (CNA/NNOC), and the largest Nurses professional association (ANA). And the National Association of Social Workers.

It was endorsed last year by largest physician specialty group, the American College of Physicians which represents Internists, and in a recent editorial in their professional journal (.pdf).

And of course Physicians for a National Program (PNHP) with organized activists in most States.

It has been recently endorsed by the U..S. Conference of Mayors.

Oh yes… HR-676 has also been endorsed by the Assembly of the Urban Caucus of the Episcopal Church, General Board on Global Ministries of the United Methodist Church and the Presbyterian Health, Education and Welfare Association of the Presbyterian Church (USA).

We have explained why as a matter of policy it is a mistake to take Single Payer off the table and to ignore John Conyers HR-676.

So, just maybe it is not a good idea to ignore us or tell us shut up.  We have explained why it is wrong as a matter of strategy, politics and real coalition building.

None of us wants there to be no real reform (even if it is a first step) in 2009-2010!

But do not ignore us.
Do not tell us to shut up.
Do not tell us to go away.
Do not ask for our support after the fact.

So here is a deal… you leave single payer in as an option, and I won’t insist on it as the only option. This is just the beginning of the fight with AHIP, Pharma, the for-profit hospitals… there’s no need to take any of our chips off the table.

So how about including Single Payer as part of the range of options, include us at table from the beginning, and let us organize and fight together?

by DrSteveB - 07/19/08

Levana’s comments are so skimpy. That is because she does not have any true answer. HCAN obviously needs to change back to single payer. Let the burned out person, Richard Kirsch, retire or take a break and leave the rest to us. The reason 59% of doctors favor single payer is that we see the data which has obvious conclusions and solutions. We have seen medicine deteriorate because of the rule of the private insurance company, which is employer based.

by Shelley Trazkovich MD - 07/19/08