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Congress Health Care Is Not Real Reform
Posted on Jan 28, 2010
PNHP: Some people say we should embrace a highly regulated system like Switzerland or Germany has instead of adopting single payer. Others suggest gradually lowering the eligibility age for Medicare as a stepping stone to single payer.
DH: These proposals are based on the presumption that politically it’s easier to do lesser measures than single payer. I think the behavior of the insurance industry in the current round of debate suggests that’s actually a false precept. Even the most minor regulations have evoked enormous opposition from the insurance industry.
So, for example, the view that we can completely change the nature of the insurance industry but leave them in the health care system and that that’s going to mollify them – that we’re going to turn them into extraordinarily tightly regulated, not-for-profit organizations whose executives can’t be paid extraordinary sums, whose shareholders receive no compensation, whose behavior is really completely different than their behavior today and that somehow that will attenuate their political opposition – I mean even the most minor regulations in the current bill have been enough for them to come out and oppose it, despite getting an extra $500 billion from it.
I think the view that, politically, we head off their opposition in this way is demonstrably incorrect. This gives rise to two additional questions. First, if the opposition from the insurance industry to these lesser measures is every bit as strong as it is to single payer, are we likely to enlist a much larger number of people to win that sort of reform? I think answer to that is, probably not. There’s not a strong principled group of people saying, “We want a German-style system rather than national health insurance.”
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The second question is: Does it work better as policy? That is, which system ultimately works better once you get it in place? There I think the answer is demonstrably clear that in a single-payer system you get more and better care for people than any given amount of money you spend than under one of these regulated systems like what T.R. Reid has been speaking about, for example the German system or the Swiss or Dutch systems.
The political compromise that some people suggest doesn’t get you very far politically, and the policy compromise gets you a worse health care system.
On reducing the Medicare eligibility age to 55, where it’s done automatically for everyone in that group (as opposed to a so-called buy-in, which would create very big problems), in some ways it’s a similar calculus. Do you really substantially reduce the political opposition? I would say probably not. The policy is a little different, because it’s a better policy than going to a regulated system, but the problem there is that until you get everybody in, you don’t get many of the financial advantages of a single-payer system. And as you phase it in, you’re adding money in order to keep the system afloat and only at the end of that process do you get the savings that make it financially viable. So the phase-in is really a big problem.
PNHP: What should supporters of single-payer health reform be doing during this period?
DH: One very important task for single-payer people is to make it clear to others that this bill is not ours, and that this reform is not real health reform. Then, when it’s passed and fails, we need to make it clear that Congress and the administration never did health reform, not that health reform didn’t work.
Until the bill is finished being debated, the one piece of salvage that would be worthwhile at this point would be for Congress to adopt an amendment allowing individual states to experiment with their own single-payer systems should they choose to do so. Rep. Dennis Kucinich is trying to get his state single-payer amendment back into the bill; Sen. Bernie Sanders has something similar on the Senate side. The message to our lawmakers would be something like, “We think this is a horrible bill. Can’t you at least get the option for our state to do better?”
PNHP: Are you worried that the single-payer movement will turn away from national legislative efforts and instead focus on state-based campaigns?
SW: I don’t worry about that because the state work and national work are complementary. I think we do need a national single-payer bill, so I hope people don’t think we should abandon the idea of national reform. But working at the state level can help build the knowledge and movement that can get us to single payer nationally.
DH: Steffie is from Louisiana and, as she’s fond of reminding me, if Louisiana is ever going to have decent health care program, we can’t do it state by state.
PNHP: How would you assess PNHP’s and the single-payer movement’s efforts in this round of reform? What has been most effective in advancing cause – lobbying, testimony before Congress, civil disobedience, rallies? What lessons do you draw?
DH: All of those things have been effective, except for the testimony, to be honest. The testimony is the result, not the cause, of such activity. When Congress asks people to come testify, that’s a signal that they’ve been getting pressure from below.
The mobilization in communities around the country, particularly some of the dramatic activities like civil disobedience and the Mad as Hell Doctors’ caravan – especially when they attracted media attention – have been quite effective.
But I think that the lesson is that we haven’t built nearly a big and strong enough movement. And it’s not just in health care, frankly – we need a movement that takes back the country in many respects and that goes beyond health care. Health care is going to be an important part of it, but I think having organizations throughout the nation that are pressuring our political leaders in a much more serious way than we’ve even been able to do in this round of pushing for single payer is clearly going to be essential. That’s the message for us now, and if the next debate about health reform is five or seven years from now, that’s how long we have to really build a movement five times as large as what we have.
SW: It will take a much bigger movement to take back power from the corporations, who are now actually running the country.
DH: The nation’s political process needs to be responsive not just to corporate power. And at some level single-payer forces should unite with folks who say we need much more regulation of the financial sector, for example, and of many other aspects of life.
PNHP: Has PNHP been growing and if so, why?
DH: PNHP has been growing. Doctors have a different perspective on this than politicians. We’re in this for our whole careers, and the fact that the health reform debate may die down for a couple of years doesn’t actually mean we go on to another issue.
We’re in this issue for life, and if the health care system would let us do our work and accomplish with our patients what we want to accomplish then the need for PNHP would evaporate and we would close down. But unfortunately that need continues to mount. That means that doctors – more and more of us – feel the need to be active. And that’s not going to go away when the Congress stops debating this issue actively.
Yes, there will be some disappointment if a bad bill is passed, and a feeling of regret that the issue is not being debated as actively as one would want, but I think within the medical profession it’s clear that the urge for reform is going to continue and likely strengthen through time because the situation is continuing to get worse for our patients and our work.
PNHP: What’s behind PNHP’s tenacity for these 20-odd years?
SW: I think the health system’s problems have continued and in some ways mounted, but our members are people who actually work every day in health care, so it’s not like people move on to some issue like world peace, however valuable that might be. These are people whose lives are in the health care system, trying to take care of patients.
DH: We actually don’t have alternatives. One can work on world peace and on issues we face in our everyday work, but unless you’re going to say, “Well, I spend 55 hours a week in a terrible health care system and I’m going to ignore that,” I think doctors of conscience increasingly feel driven to do something about the distortion and corrosion of their work.
PNHP: You’ve been extremely prolific in your research this year, publishing seven or eight studies, including one showing that 62 percent of personal bankruptcies are linked to medical bills or illness, and another showing that 45,000 deaths annually are linked to lack of health insurance. How do you evaluate the impact of this work?
DH: The research is the product of a research team that includes several colleagues — Andy Wilper, David Bor, Danny McCormick and (for the bankruptcy study) Deborah Thorne and Elizabeth Warren. Obviously the circumstance of the nation being very actively focused on health reform is part of the reason why the research has received so much media attention.
But while we’re gratified that the work has been useful in helping to open debate, the actual use of the findings by politicians – the arguments that they’ve made with the data – have often been very disappointing.
I think Steffie has remarked that the work has helped push the wagon of health reform forward, but someone else has been steering the wagon in a very different direction than we would want it to go.
We’ve tried to highlight the major problems in the health care system and some of the reasons why the alternatives to single payer won’t work. The pieces that highlight the irrationality and the problems of the health care system have gained attention, but the pieces that speak to why the alternatives won’t work have been selectively ignored.
SW: Some politicians love to bring in the left or the left-liberals to create research and create a movement and create some energy, but that’s pretty different from then putting you in charge of things and letting you make decisions.
PNHP: Are there any final comments you’d like to make?
DH: One thing that has been striking in this year’s push for single payer has been the tremendous degree of cohesion and the sense of camaraderie within PNHP. That’s somewhat different than the feeling during the 1993 round of health policy debate, where there was more controversy within PNHP and, frankly, within the single-payer movement. At that time, some colleagues were saying we had to stop pushing for single payer and hop on board the Clinton health plan.
There’s been a very clear-eyed sense and consensus within the organization that our role is to say what’s right in this debate and to bring forward a principled stance and not to play political games that end up with disastrous consequences.
It’s also gratifying to see how PNHP has helped create a platform for people to speak in their communities and speak in public and really use their creative energies in a progressive way on health policy, as has been amply demonstrated in this round of debate. There’s no way we could have raised enough money to do the work that PNHP members have done on a volunteer basis. The organization is there to provide resources and opportunities to work, and our members have taken advantage of those opportunities in extraordinary ways.
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