Health Care for All: Why We Need a New Prescription

The right-wing assault on Obamacare is a distraction, but the “progressive” (or rather party line) defense of the Affordable Care Act is also a dead end. While the tea party and MoveOn descend to mud wrestling, Dr. Don McCanne of Physicians for a National Health Program is not just staking out the moral high ground in the debate on health care. He is also making the practical case for the kind of health care we, the people, both deserve and can afford.

McCanne quotes passages from the daily news, political debates, and medical journals, and adds his running commentary. These columns are collectively titled Quote of the Day, and can be found archived at the website of PNHP. His columns are also available by email subscription.

McCanne’s daily comments on health care range over both present policies and the possibilities of comprehensive reform. He is helping to build the bridge from here to there, but he is not pointing to some utopian island over the horizon. Medicare, for example, offers one flawed but real foundation for health care justice. We need a single payer system, but we also need a wider network of community health clinics, and health maintenance programs in schools, neighborhoods and workplaces. If we limit our vision of health care reform only to the programs that career politicians deem “pragmatic,” then we are placing their careers above our own lives.

McCanne’s decency and public spirit shine through his work, though he was almost self-effacing when I first asked him to consider an interview. For myself, and many others, McCanne is our translator of choice when we try to orient ourselves in health care policy debates. He received his B.A. at the UC Riverside in 1959 and his M.D. from the UC San Francisco in 1963. He served two years as a medical officer in the U.S. Army, and then practiced as a family physician for more than 30 years in San Clemente, Calif. He has served as chief of staff of his community hospital and as chairman of the board of a community bank. He served as president of PNHP for two terms, in 2002 and 2003, and is currently senior health policy fellow for PNHP. Every good cause involves a division of labor, and McCanne is a daily laborer for health care justice through PNHP and through his public talks and writing.

I first met McCanne during the founding meetings of the Santa Monica chapter of PNHP, and on Sept. 1 of this year my husband and I joined Don McCanne and his wife, Sandy, for lunch at their home in San Juan Capistrano. We had a long talk about public health, private wealth and politics. Don and I continued the conversation by exchanging emails. Our points of disagreement are plain enough, but so is our common ground. We encourage all supporters of health care for all to carry this conversation from kitchen tables to union halls, and from community clinics to public elections.

My first work in health care activism began as a member of the Reproductive Rights National Network, and continued with the AIDS Coalition to Unleash Power (ACT UP) in Philadelphia. Moving to Los Angeles 10 years ago has taught me new lessons in how the present health care system is both formed and fractured by a class divided society. I was diagnosed HIV positive in 1986, and political activism is one among many reasons for my survival. I have witnessed the malign neglect and direct brutality this political system inflicts on workers, the unemployed, the poor and the ill. In my view, the hope of removing politics from the struggle for health care is like the hope of removing the profit motive from the ruling class.

The fact that doctors are also creatures of our class culture is unsurprising. Unfortunately, some doctors also proved to be slow learners even during an epidemic. In the early years of the AIDS epidemic, patients were often the people who had to educate our own doctors in the Standard of Care. And we also had to teach some doctors “the facts of life,” namely, the facts of our own lives. As for class politics, most doctors never learned any such subject in their classes, and yet medical training and practice carries all the background radiation of a corporate economy. PNHP is therefore in no position to teach health care activists the alphabet of class consciousness. A strictly empirical approach to science and medicine must be fused with resolute opposition to a class divided health care system. That is the true test of translating our common ethics into gaining the common ground of practical health care reform.

On that subject the good doctors in PNHP might listen more closely to their patients. Am I therefore “disenchanted” with PNHP? No, on the contrary, all political enchantment requires the cold shower of reality, and then we will find the work we can do in common. I regard PNHP as a crucial and honorable ally in the struggle for a civilized health care system in this country.

This conversation between one doctor and one writer, both of us active in the reform of our health care system, is not a detailed map of that terrain, and far less a scripture for those looking for a new religion. Any proposals for public policy must, of course, be discussed before the widest public. Within the secular horizon of the public realm, we must not lose our sense of balance and common sense, nor our sense of right and wrong. The right to health care is a human right, but the political will to win that right as a daily fact of life begins with a moral commitment to care for the poor, the sick and the dying, and for all of us without exception.Scott Tucker: President Obama said, on July 22, 2009, “I want to cover everybody. Now, the truth is unless you have what’s called a single –payer system in which everyone’s automatically covered, you’re probably not going to reach every single individual.”

Obama finessed the brutal reality that millions of people, not just “every single individual,” will still not receive comprehensive health care under the Affordable Care Act, also known as Obamacare, which became law in 2010. According to HealthCare.gov, three key dates are approaching in the translation of this complex legislation into the “Health Insurance Marketplace.” On October 1, 2013, “Market open enrollment starts.” On January 1, 2014, “Health coverage can start.” And on March 31, 2014, “Open enrollment ends.”

Don, what bumps in the road do you expect over the next two or three years, given the stated goals and limits of the ACA? And how many sick and injured people will go over the precipice, especially in working class communities, even if the ACA extends a medical safety net for the young and for people with “pre-existing conditions”?

Don McCanne: Implementation will proceed at a reasonable pace considering the complexity of the law, though the specifics of ACA make it clear that we cannot possibly achieve truly universal coverage that is affordable for everyone. The Congressional Budget Office has estimated that when the law is fully implemented, 31 million people will remain uninsured. Further, the relatively low actuarial value of the plans that most people will select — paying only 60 or 70 percent of the medical bills — will create financial hardships for people who actually need health care. Though lower-income individuals will receive subsidies for out-of-pocket expenses, the costs for which they will be responsible will still be very burdensome for far too many. Even those with employer-sponsored coverage — the majority of us — will have more difficulties in meeting medical expenses since employers are shifting more costs of care to their employees through higher deductibles and other forms of cost sharing.

The trend of the last couple of decades of shifting wealth from middle-income families to the very wealthy will also add to the burden of these families who are already having difficulties meeting other expenses such as funding their retirement accounts and paying for their children’s educations. Many low wage workers will continue to have problems with health care because it will either be paid for with forgone wages for employer-sponsored coverage, which they can’t afford, or their share of plans purchased through the exchanges plans will still be too expensive for them to afford. Worse, many will simply be excused from the mandate and the penalties for not being insured simply because the plans are deemed to be too expensive for them. Thus ACA has granted those with the greatest need for coverage the right to remain uninsured because they can’t afford it.

Theoretically, most of those living in poorer communities should be eligible for Medicaid, but many states have refused to accept federal funds to expand their Medicaid programs. ACA did not provide for exchange coverage for these very poor people because they were supposed to have been covered by Medicaid. These people also fall in the category of those who have the right to remain uninsured. ACA is a sick system that Congress has provided us.

ST: The Los Angeles Times published a September 14 article by Chad Terhune titled, “Insurers limiting doctors, hospitals in health insurance market,” and the reporter wrote, “To hold down premiums, major insurers in California have sharply limited the number of doctors and hospitals available to patients in the state’s new health insurance market opening October 1.”

The article quoted Donald Crane, chief executive of the Association of Physician Groups: “We are nervous about these narrow networks. It was all about price. But at what cost in terms of quality and access? Is this contrary to the purpose of the Affordable Care Act?” How would you compare some of the provider networks, and are we witnessing another conflict between comprehensive public health and the profit motive of private insurers? How do we muddle through this terrain, and is there a better path?

DM: When we speak of provider networks, it is important to distinguish between integrated health systems that are designed to improve efficiency and quality in the delivery of care, and networks contracted by insurers designed to reduce health care spending. Physicians and hospitals joining together to improve patient care is great, but insurers using contracts to limit access to low-cost providers is not in the patients’ best interests. Patients who have free choice of their health care providers would be wise to choose high-quality, integrated systems that can actually save on health care costs by reducing inappropriate care. Patients who will have limited choices in the narrower insurer networks to be offered in the exchanges may not be able to continue to see their current physicians, and may find that the physicians in the narrow networks are not as accessible because they are overbooked or because the approved office locations and hospitals are too far away to be convenient.

As you imply, I think that this can be characterized as a conflict between providing health care as a public service and providing health care as a means to advance the business models of private insurers. Leave policy decisions to private insurers and they will always select policies that will advance their business models as opposed to policies that would provide optimal access, quality and affordability for patients. Having cheaper premiums through narrow network plans is no solution when you can’t get a doctor when you need one, and, when you finally do, you’re left broke because the subsidies for the exchange plans are inadequate to avoid financial hardship for those in need. Single payer would have avoided all of this, and it still can.ST: When the ACA was pushed through Congress, even the limited “public option” was deliberately removed from health policy debates in congressional hearings. Dr. Margaret Flowers of PNHP and seven other health activists were arrested when they demanded an open debate. The message of career Democrats was that the ACA was the best they would give us, so we’d better be grateful. That remains puzzling to many people who know that other industrialized democracies spend less per capita on health care, do better in health outcomes, and extend health coverage for all citizens. Instead, the private insurance companies are still big winners from this reform, and millions of Americans are still losing adequate health care.

Could you summarize our national health care situation before and after ACA? Of course any statistical survey will have a margin of error, but some basic trends have been closely studied up to this date. What are some of the likely numbers of the uninsured and underinsured in the future?

DM: Regarding the national health care situation before and after ACA, there will not be much fundamental change. We will still be using the same fragmented, dysfunctional financing system, but we will be bringing more people under the umbrella. Although 48 million are uninsured now, when ACA is fully implemented, 31 million will still be left without coverage, and those with coverage are more likely to face excessive out-of-pocket costs should they need health care because of the gradual transition from traditional coverage to underinsurance, which is rapidly becoming the new norm. Not only do patients face much higher deductibles, they also are beginning to have fewer choices of health care providers because of greater use of more limited narrow networks of providers, and some employers are switching to private (non-ACA) health insurance exchanges which use defined contributions to transfer future cost increases from the employers to the employees. If we had a single payer, improved-Medicare-for-all program, underinsurance would be eliminated, and the number of uninsured would not be 48 million, it would not be 31 million, it would be zero!

ST: Health care spending is always a minefield in public policy debates. I’ll place some quotes from recent front-page articles in The New York Times side by side, and then raise a few questions. On September 18, Sheryl Gay Stolberg wrote, “Washington’s health care revolving door is spinning as fast as the new online health insurance marketplaces, a central provision of President Obama’s health law, are set to open on Oct. 1.” Stolberg went on to note, “The health care industry now spends more money on lobbying in Washington than any sector of the economy — more than $243 million last year alone, higher than the $242 million spent by financial, insurance and real estate companies, according to the Center for Responsive Politics here.”

Among the lobbyists is Dr. Dora Hughes, a former Obama administration official who spent “nearly four years as counselor to Health and Human Services Secretary Kathleen Sebelius,” and left government to work for Sidley Austin, “which represents insurers, pharmaceutical companies, device makers and others affected by the law.” Stolberg added, “She is not a registered lobbyist, but rather a ‘strategic adviser,’ although some call that a distinction without a difference.”

On Sept. 23, Robert Pear wrote, “When insurance marketplaces open on Oct. 1, most of those shopping for coverage will be low- and moderate-income people for whom price is paramount. To hold down costs, insurers say, they have created smaller networks of doctors and hospitals than are typically found in commercial insurance. And those health care providers will, in many cases, be paid less than what they have been receiving from commercial insurers.”

The present system offers perverse incentives for Washington political insiders to become lobbyists, and to profit from the very pieces of legislation they moved through Congress. Insurance companies can easily mutate to profit from the new set of rules and regulations. As Pear notes, “Even though insurers will be forbidden to discriminate against people with pre-existing conditions, they could subtly discourage the enrollment of sicker patients by limiting the size of their provider networks.”

Pear quotes President Obama: “Competition and consumer choice are actually making insurance affordable.” Do we have any reason to believe that is generally true now, or will be nearer to the truth when the insurance marketplaces roll out in October?

DM: Your comments about the cozy relationship between lobbyists and the administration and Congress demonstrate why we ended up with legislation that took such good care of the insurance and pharmaceutical industries while falling so short in meeting the goals of covering everyone and providing plans that should ensure both health security and financial security for all of us.

President Obama and members of his administration have been claiming that health insurance is now more affordable because of the provisions of Obamacare. The problem with that claim is that it is health care, not health insurance, that we need to be affordable. Unfortunately, under Obamacare there are very few provisions that will reduce health care costs much whereas there are some provisions that will increase out-of-pocket spending by patients.

In claiming that competition and consumer choice are making insurance affordable, they are referring only to the price of the health insurance plan. Insurers aren’t dumb. They are going to do everything they can to keep premiums competitive. When the law was written they were there to see that the plans that most people will buy in the state exchanges will have low actuarial values — 60 or 70 percent. That means that patients will have to pay 30 to 40 percent of their health care costs out-of-pocket. Typical employer group plans have actuarial values of 80 to 95 percent, so the exchange plans that most will buy are inadequate in comparison. Even for those individuals who qualify for government subsidies, the financial exposure will still be too great for too many.

One of the ways that insurers can keep the premiums competitive is to require large deductibles that must be paid before the insurance kicks in. Many will find difficulty paying these deductibles. Another method that insurers are using is to sharply limit the lists of physicians and hospitals that you can use — so-called narrow networks. Insurers save money if you have trouble finding physicians who will see you, or if they are too far away to get there.The competition and consumer choice that Obama touts merely keeps the premiums from skyrocketing, but such market forces are undesirable when it does that by creating crummy insurance products that do not provide adequate financial security. Instead of relying on the dysfunctional marketplace, we should have the government administering the program. Medicare has been far more effective in controlling health care prices than have the private insurers, but, furthermore, Medicare does it at an administrative cost of less than 2 percent, whereas private insurers will be using 15 to 20 percent of premium dollars for their own administrative costs and profits. If Obama really wants us to have greater value in health care he should have supported Medicare for All instead of accommodating the private insurance industry.

The Office of the Actuary of the Centers for Medicare and Medicaid Services recently released a report that shows in the next decade administrative costs for government health programs such as Medicare, Medicaid, VA, Children’s Health Program, Indian Health Service and others will be about $79 billion. Contrast that with the administrative costs of private insurers. They will be spending $313 billion on administration and profits — far more than the government spends on administration of its extensive public programs. The government gives us a far better deal than the private insurers. Yet Obama insisted that we should keep this lousy system in place.

ST: Health care for all is a basic social democratic reform that was won by class conscious movements in every industrial Western democracy other than the United States. Once the reform was gained, even the conservative parties of those countries soon adjusted to the new reality and made it part of the practical consensus in government. In some of those countries, that consensus is once again being eroded by parties and groups committed to a greater “free market” in health care.

The right wing in this country has tried to demonize Obama and the Democratic Party by calling them “socialists,” which turns reality upside down. Sen. Ted Cruz, a Texas Republican, launched a 21 hour speech against Obamacare in the Senate, and he compared anyone who fails to join his crusade to those who appeased the Nazis. Cruz was promptly upbraided by a Republican colleague, Sen. McCain of Arizona, who has always opposed the ACA and who reminded Cruz that “elections have consequences.”

The ACA was not designed to be truly comprehensive, and it turns out to be a bargain for private insurance companies. The right wing treats any kind of health care reform as though it is a foreign import from scarlet Scandinavia, but we have a closer example of social democratic health care in Canada.

Don, in your Quote of the Day for September 25, you refer to a column by Matt Miller, “Canadians don’t understand Ted Cruz’s health care battle,” published in The Washington Post on the same day. Miller, who defines himself as a political centrist, wrote, “The moral of the story? Don’t let the rants of cynical demagogues like Cruz confuse you — it is entirely possible to be a freedom loving capitalist and also believe in a strong government role in health care.”

You commented on Miller’s column by writing, “That single payer is appropriately a centrist concept is demonstrated by the fact that it fulfills the fundamental business principles of being efficient (lower costs per person), effective (everyone is included), and of high quality (better health outcomes.)”

Matt Miller, however, failed to mention Tommy Douglas, who was named “The Greatest Canadian” in 2004 by a CBC Television program, after counting the votes on a viewer-supported survey. Douglas was a Baptist minister, a Scottish-born social democratic politician and a founder of Canada’s universal health care program. He was by no means a political “centrist,” and when he was premier of Saskatchewan from 1944 to 1961, he led the first democratic socialist government in North America.

The pioneering Saskatchewan Medical Care Insurance Act of 1961 became the prototype for other provinces, and by 1971 a single payer, universal health care plan was established throughout Canada. Tommy Douglas was a freedom loving socialist who fought for a health care program that lowered costs per person, that included everyone, and that maintained high quality and health outcomes. Most of the doctors in Saskatchewan had other ideas of fundamental business principles when they went on strike on July 1, 1961, the first day that Saskatchewan’s new health care program came into effect. Doctors from other provinces gave their own aid and services to the new program, and the public turned against the striking doctors. The social democratic reform of health care gained ground and momentum.

Obama did not even make the business oriented “centrist” argument for universal health care that Matt Miller has made. Indeed, Obama and the Democrats in Congress shut down an open debate on health care, and treated health care reform as though it was one more backroom deal between career politicians. The doctors who are members of PNHP no doubt include some Republicans, but I’d venture to guess most of them are Democrats. Some of them would even be partisan social democrats, if only this country had greater democracy in big elections. Since a corporate “centrist” such as Obama is red-baited by the right wing, anyone who proposes real social democracy in health care can expect the same treatment, though with more political justice.

So my questions concern the present political culture within Physicians for a National Health Program (PNHP), against the wider background of partisan corporate politics in this country. The social democratic reform of health care in other countries was won only with the support of strong labor movements and indeed of strong social democratic parties. Less than 12 percent of this country’s labor force is now unionized, and no one would mistake the party of Obama for a party of social democratic hope and change. Our situation seems dire, yet we have a world to win. Do the doctors of PNHP have the political will to form a strategic alliance with labor unions and with democratic socialists? Have such strategic political issues already been raised within PNHP? And how would PNHP envision a historical breakthrough for universal health care in this country, of the kind that occurred in Saskatchewan in 1961?DM: Physicians for a National Health Program is a nonpartisan, single issue advocacy organization, advocating for a single payer national health program. We have not inquired about political affiliations of our members, but through casual conversations, I know that many members are not pleased with the Democratic Party and its neo-liberal leadership that specifically excluded single payer from consideration during the initial stages of the reform process. Some of our more avid members happen to be Republicans, some nonpartisan, and, of course, several are Green Party members, since single payer is part of their platform.

Even though single payer legislation has been introduced in Congress, it is not realistic to expect any action when one party — the Republicans — currently has an agenda of obstructing government. With gerrymandered districts, it is unlikely that that will change in the near future.

Politicians do not lead, they follow (including following lobbyists’ money). We would have to have a critical mass of grass-roots support before the politicians would pay attention. Although polls indicate that a majority of the public would prefer a national health program, that support does not translate into activism. Single payer ballot measures in California and Oregon had considerable support until close to election time. It took only a few sound bites from insurance industry ads to destroy that support, and both measures lost by staggering margins. The stated support for single payer is very fragile.

Creating movements requires education, coalitions, and intensive grass-roots organizing. PNHP’s mission is to educate the public on single payer, and that is the role that we fill in coalition efforts in grass-roots organizing. Our expertise is in policy, but not in politics, so we are dependent on other coalition members to move the process. We have held numerous strategy sessions and do recognize the need for greater activism, but our organization is not the vehicle for that. For that reason we supported the founding of Healthcare-NOW! (not to be confused with the Obamacare supporters — Health Care for American Now), a single pager advocacy organization dedicated to activism. They are quite active, but their efforts have not yet approached the threshold that we need.

The Washington Post article by Matt Miller that you cited mentioned the very strong support by Canada’s business community for their single payer system (their Medicare). I personally know several Republican businessmen here who are privately supportive of the single payer concept, but are not ready to lead the advocacy parade, though who are likely to join in once there is a groundswell of support.

I think that it would be a mistake to allow U.S. socialists and other leftists to capture the single payer concept and jealously guard it as their own. It is a far better business model of health care than our current, fragmented, dysfunctional system that has only been expanded by Obamacare without correcting the intolerable flaws in the financing infrastructure. Although it is trite to say this, we really should lay politics aside and join together in an effort to start receiving much greater value for our nation’s health care investment. You have to question the intellect of anyone who would continue to support our current system if they were adequately informed on the health policy issues.

Could we have a Saskatchewan moment? When they began their single payer program they did not have to go to Ottawa to try to extract funds from a multitude of federal programs, but rather their federal government had already authorized funds to be transferred to provincial health programs for their own use. In the United States, although we have various waiver programs, we do not have a mechanism of releasing most federal program funds to the states (Medicare, Medicaid, CHIP, VA, FEHBP, IHS, etc., plus ERISA waivers). For a state to establish a single payer system, enabling legislation would be required which would be as politically difficult as would be enacting a national single payer program. Can you imagine our current highly polarized, cutthroat Congress coming to agreement on such legislation?

ST: The new health insurance exchanges (sometimes called health insurance marketplaces) will be different in each of the 50 states. Not everyone will be shopping around for coverage, especially if they are satisfied with their existing Medicare coverage. Many others, however, will need to be guided through the terrain of new regulations. What advice would you give to people looking for such immediate guidance? And what kind of state coalitions now exist to promote a truly comprehensive health care system for all?

DM: For those who want to know their options under Obamacare, HealthCare.gov is an interactive site that can answer most of your questions and lead you to your options. There will also be publicity campaigns in most states that may provide you with other resources, especially if you do not have access to an online computer — though most libraries have them.

As you interact with Obamacare, keep in mind that if we had a single payer system, you would not need to make any choices, but rather just register with the system once only, and you would have much better health care coverage for the rest of your life.

There are many organizations and coalitions throughout the nation that continue to advocate for single payer. PNHP has an interactive map that can provide you with some of the resources in your state.

Keep a watch out for single payer activities and join in them when you can, and take friends and associates with you. Networking will help to grow the movement.

ST: Last question, Don, and I thank you for your time and work. There will be political differences in the spectrum of any democratic movement, including the movement for comprehensive health care, and some of those differences are plain enough in this conversation. But there is significant moral ground in common, and a temporary tent on that ground is still better than any sectarian bunker. We must orient ourselves in the terrain of human pain, aging, illness and death, not just in the terrain of party programs and election campaigns. Don, how would you define your ethical and professional creed in your daily work for health care reform?

DM: For my home office that I use for my health reform advocacy work, I had put away all of my credentials and hung on the wall only one item: the Oath of Hippocrates. The credentials are only about me. Health care is about the patient. We need a health care system that respects the primacy of the patient.