Single Payer – Gaining Momentum

June 13, 2009

New York Times columnist, Nicholas Kristof, injected some balance into the health care reform discussion on Thursday.  In a forceful counterpunch to conservative criticisms of the Canadian health care system, he reported the “real life story” story of Diane Tucker, an American living in Canada, who has had significant encounters with health care on both sides of the border.  The one in Canada was positive, the one in the US was not.

in his follow on blog, Mr. Kristof writes that

Canada does have health care problems, including waits and escalating costs, but the U.S. has even worse problems – including that we spend twice as much per capita and get significantly worse results.

What is most refreshing is that it quickly became the number one e-mailed article on the New York Times on-line edition.  Comments to both his column and his blog clearly indicate that, at least among Mr.Kristoff’s readers, a Canadian style health care delivery system would be a significant improvement over our current system.

Mr. Kristoff admits that he would prefer a single payer system, but concedes that is unlikely to happen.  A public plan option is an adequate alternative, he argues.

But Mr. Kristoff reflects a creeping awareness among the media establishment that single payer is “on the table.”  This is to the credit of the single payer activists who demanded to be heard beginning with their protest of President Obama’s health care summit and the Senate Finance Committee hearing in May.

Since then single payer voices are being heard on the streets, in the media and in Congress.

On the Streets

In cities across the country, activists have called for a single payer health care system.  There was a rally in San Francisco, Nancy Pelosi’s back yard.  There were rallies in Montana, Sen Baucus’ state.  There was even a rally in my home town, Harrisburg, PA.

In the Media

The main stream media is only slightly less dismissive of single payer than Congress.  Trudy Lieberman, in the Columbia Journalism Review, reminds us just how rare Mr. Krisoff’s voice is.   Ironically the most exposure to single payer seems to be in the home state of Senator Max Baucus.  Bill Moyers, true to form, showed the media how to do it on the Bill Moyers Journal on NPR.  Single payer advocates did appear on the Ed Schultz Show, not main stream yet.  And locally, single payer has had air time on Baltimore public radio and somthing approaching an objective discussion on the Dianne Rehm show on WMAU in Washington DC.  But the media has not shown any great understanding of the issue.

In Congress

Single Payer got a chance to appear before the Senate Health Education and Labor Committee on June 10 and June 11.  Kevin Zeese, an activists with Maryland Health Care Now, reported on the site, Prosperity Agenda.

Yesterday, as Senator Tom Harkin (D-IO) left the health care hearing room he leaned over to me and said:

“I used to sell insurance. The basic rule is the larger the pool the less expensive the health care. Today we have 1,300 separate pools – separate health care plans – and that is why health care is so expensive; 700 pools would be more efficient and less expensive and one pool would be the least expensive. That’s why single payer is the answer.”

Nothing like common sense.

But, common sense was not on display in the Senate yesterday. Instead, the senate is seeking a path to the goal of universal coverage by protecting the least efficient model – the for-profit insurance industry that through waste, fraud, abuse and bureaucracy eats up 31% the cost of health care.

Back to the Streets, the Media and Congress

All of this may come together on Thursday, June 25th when single payer advocates from across the country will converge in Washington DC, 11:30 in Upper Senate Park, to rally and swarm their congressional representatives.

Hopefully the media will notice.


Single Payer Gets a Voice Behind the Table

May 9, 2009

When reason fails shouting prevails.

From Senator Max Baucus, “We need more police.”

Voics from the back of the room

And more voices from behind the table.

Margaret Flowers, MD & Katie Robbins, Healthcare-NOW

Carol Paris, MD, PNHP

Adam Schneider from Health Care for the Homeless

Russell Mokhiber, Single Payer Action

Thanks to the brave organizers of this event!

Healthcare Reform – Why a public plan Option?

April 25, 2009

Some things I don’t understand!

I just don’t quite get the “public plan option” idea.

I read Jacob Hacker’s proposal for a public plan option again.  Professor Hacker is a scholar with his heart in the right place, a rare combination.  He gained my immense respect after I heard him speak about his book, The Great Risk Shift, a couple of years ago.

Professor Hacker makes a compelling case that a public plan is not only administratively more efficient than private plans, but that they have a convincing record of introducing large scale quality initiatives and payment reforms into the marketplace.

He then goes on to describe the dismal record of private insurers in comparison to public plans.

So why are the private plans an option if the public plans are superior?

That’s what I don’t get! Read the rest of this entry »

The COBRA Maze

April 18, 2009

Today, April 18, 2009, is COBRA Subsidy Notice Day -the deadline imposed by the American Recovery and Reinvestment Act to send COBRA notices to those involuntarily terminated after September 1, 2008.

Not exactly the same as Paul Revere’s ride, the event 234 years memorialized by Henry Wadsworth Longfellow’s poem and remembered in Massachusetts with Patriot’s Day.  With apologies to Hank, I offer this little ditty to memorialize the event occurring this year..

Listen my public and you shall cuss
About the COBRA part of the stimulus
Twas the eighteenth of April in twenty O nine
When out was tossed a feeble life line

Those who imagine that a “government run” health care system might mean more bureaucracy should spend some time familiarizing themselves with COBRA.

Certainly since the ARRA law was signed on February 19th and the regulations and additional “guidance” were released on March 30th, there has been ample opportunity.  Our office has been flooded with solicitations for seminars and webinars, and guidance form assorted professional organizations.

It is a sad reflection on the values of our society that an event as disruptive as job loss is compounded by the loss of health insurance.  COBRA was designed to alleviate that somewhat by permitting people to continue on their employer’s plan as long as they paid the full cost.  Very few – only those with expensive on going treatments – take advantage of it.  Read the rest of this entry »

Does Congresswoman DeGette Really Get It?

April 11, 2009

Congresswoman Diana DeGette (D-CO) is the Chief Deputy Majority Whip for the Democrats in Congress.  She is serving her seventh term representing the 1st congressional district in Colorado, succeeding Pat Schroeder  who represented that district and advocated for progressive causes for many years.

Diana DeGette (D-CO)

Diana DeGette (D-CO)

On April 7th of this year Congresswoman DeGette offered a powerful and personal critique of health care in the United States in a speech before the City Club in Denver.  

…Americans – including 800,000 Coloradans – have no health insurance and when thousands more Americans are losing their coverage every day. That means they’re less likely to get the medical care they need, more likely to develop chronic and life-threatening diseases and more likely to die prematurely, causing more than 20,000 preventable deaths in America every year.

It is unacceptable when the uninsured population includes 9 million children – 180,000 here in Colorado …

It is unacceptable when even families with health insurance struggle to keep up with skyrocketing premiums and co-pays only to have to fight their insurance companies for the coverage they thought they had.

They’re families like my sister’s-insured, middle-class family with two kids, paying monthly premiums of $1,100. And when my nephew had a skateboarding accident-a compound fracture of his wrist-what did her insurance company say? “Sorry. You didn’t get pre-approved for the emergency room service.”…

But she didn’t stop there

Americans often think we have the best health care in the world. But consider this. In terms of women’s health – compared to other countries – the United States ranks 24th. In infant mortality, we rank 29th. In life expectancy, we rank 31st. And for health outcomes overall we rank 37th – below the Dominican Republic and Costa Rica. Put simply, when it comes to health care, Americans pay so much more but get so much less.

This is not only morally unacceptable, it is financially unsustainable…

And she offered change

That’s why the new Congress and President Obama have moved swiftly to confront the most pressing short-term challenges….

Reform must reflect this fundamental truth: affordable, quality health care is not the privilege of the fortunate few, it is the right of every American.

Reform must achieve key goals: reduce costs, expand coverage to those who lack it and improve the quality of care.

Reform must preserve the values we cherish as Americans: choice – of doctors, providers and plans; strong doctor-patient relationships – free from government interference, and; accountability-to avoid profiteering and discrimination based on pre-existing conditions…

But she she fell on her face

And reform must reflect what is politically possible. There are those who favor a single-payer, government-run health care system. But let’s be clear: such an approach has neither public nor political support at this time despite that, we must not lose sight of our goal of providing health care for every American.

Guided by these principles, I believe a reformed system should have three essential pillars. It must cover every American; it must be affordable; and it must be portable.

For starters, she is wrong that that a single-payer system has no public support.  Polls consistently demonstrate broad support for a single-payer system.  Recently a CBS poll found that 59% of americans support a national health insurance program and 49% of Americans  believe it should cover all of their medical problems.  Other polls show similar results.  And the single payer proposal HR 676 has more co-sponsors than any other proposal.

But maybe the reason she doesn’t get it is that she is so 1990’s.  There is little new in her critique of health care.

What has changed is the work force

The in-term now is the multi-generational work force. Older people are working longer and they are generally not interested in working full time.   It is even even clearer since last September.  Younger people are entering the workforce later.  People are leaving their jobs in mid-career to go back to school, to take care of aging and sick parents, or sometime to take care of their own children.  There are more part time employees.  There are more free lance employees.  The increase is the number of free lancers and part timers is an employer response to the high cost of health care.  Each of these groups need health care.

It is nice to argue for portability.  But how to you make portability happen when people transition in and out of employment.  Concurrent with that change is a change in income status.  A genuine “affordable” reform effort that accommodates the 21st century work force is one that assures continuous coverage regardless of employment status.  The cost of the plan to individuals must reflect their ability to pay.  Only a single payer system can accomplish that.

And then there are certain sectors that have always have been difficult to insure.  Farmers and people living in rural areas have their own unique issues that make that make “free market” solutions irrelevant.

What has changed is the competitiveness of the American economy

Most politicians give lip service to the notion that health care costs impeded the ability of American companies to compete internationally. But health care costs distort domestic competition as well.  Companies that offer inurance are a competitve disadvantage against companies that don’t.  In addition,  the cost of health insurance is a significant market entry barrier for entrepreneurs considering a new idea to take to the marketplace.  If we want to encourage innovation and competitiveness, the cost of health insurance to employers needs to be equitable.

I do hope that Congresswoman DeGette will acknowledge the public support for a single payer system, the compelling policy argument for single payer, and take the lead in translating that into broader political support.

Docs talk about health care reform – sort of

March 18, 2009

Two weeks ago, The Annals of Internal Medicine posted three articles on health reform and invited readers to comment.  The three articles highlight the perspective of physicians, more specifically internists who generally fit into the category of primary care physicians.  As one commenter notes, the three articles read like committee reports.

There are some pretty heavy hitters among the authors to the three reports so I offer my comments with some trepidation.  Bottom line, they miss the mark.  I have this image of trying to land an airplane when the altimeter is 10,000 feet too high.  The plane just doesn’t seem to touch down.

Except for the details outlined in the EMBRACE program, there is little to disagree with, it is just as if the the wheels just don’t reach the ground.

Read the rest of this entry »

COBRA – Stimulus or Bureaucracy?

March 14, 2009

Does Congress really think they are doing anyone a favor with the new COBRA subsidy provision in the recently enacted stimulus package? capitol_art_160_20080314161058

Why can’t they make it simple?

Conservatives who fear “socialized” medicine because it will make medicine more bureaucratic should acquaint themselves with COBRA regulations. Litigation over COBRA keeps lawyers and judges busy all over the country.  And what does any of it have to do with the delivery of care?

What is COBRA anyway?  The Consolidated Omnibus Budget Reconciliation Act of 1986 was one of those huge (thus the word omnibus) budget bills that included everything from tobacco price supports to fishing fees for foreign fishing vessels.   But it will be remembered because Title X (of XX) included provisions to permit those who lose their health insurance under an employer sponsored health plan to continue their health insurance under certain conditions (called qualifying events) and provided they pay the full cost of the coverage.

Because, the person without coverage is also usually without a job, and because the person must pay the full cost (actually 102%) of the coverage, very few people elect the coverage and those that do are more likely chronically ill individuals.  In insurance parlance, that’s called adverse selection.  The plan sponsor will usually end up paying more than they receive in premiums.

So what did Congress and President Obama do with COBRA? 

The new law makes the cost of COBRA premiums slightly more affordable.  Normally, a 65% discount would seem pretty attractive.  But the average cost of one of our family plans exceeds $1,000.  $350 – 450 per month for a family with one less breadwinner is still a stiff price. images_2 Imagine selling a Lamborghini at 65% off!  $70,000 for a $200,000 car is a huge bargain.  But for someone without a job?

The new law allows those terminated between September 1,2008 and February 17, 2009 and who initially declined their COBRA election, another opportunity to elect the coverage at the reduced rate.  And they can begin their coverage March 1 instead of the date of the qualifying event.

Unlike regular COBRA, the subsidy is limited to those who are “involuntarily” terminated and their family members.  The plan sponsor can rely on the employees’ attestation that they were involuntarily terminated. Read the rest of this entry »