Why Not Single Payer? Part 5: The Single Payer Health Care Movement and the Plans of the Democratic Presidential Nominee

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Following is the text of my speech at the Take Back America Conference panel on "The Single Payer Health Care Movement and the Plans of the Democratic Presidential Nominee." I was honored to be on the panel with Courtney Farr of the California Nurses Association and Congressman John Conyers, Chairman of the House Judiciary Committee and chief sponsor of H.R. 676, the single payer Medicare For All bill.

Most progressives agree that the government has an important role to play in guaranteeing health care for all Americans, in contrast to most Republicans who want to leave people at the mercy of the private market. But the Conference also revealed differences among progressives on strategies for achieving universal health care. For many years, most progressives have supported the principal of Medicare For All -- a system in which all Americans have guaranteed health care from cradle to grave, financed through taxes instead of insurance premiums, and in which medical decisions are made between patients and doctors and not by private insurance bureaucrats. The Campaign For America's Future, which sponsored the Conference, supports a compromise private/public hybrid, in which most people continue to get private insurance through their employers, but in which companies and uninsured individuals can also buy into a public alternative. Most versions of this plan, including that supported by Hillary Clinton, include an individual mandate in which the uninsured are required by the government to buy health insurance, although they are given the "choice" between private insurance and the public plan.

Such difference threaten to divide the progressive movement when it comes to health care reform. This was evident in California recently. A year ago, both houses of the California legislature passed a bill which would have established a single payer system for California's 37 million citizens, which was vetoed by Republican Gov. Schwarzenegger. This year some Democrats, led by California Assembly Speaker Nunez, tried to forge a compromise with Schwarzenegger for a health insurance mandate similar to that enacted in Massachusetts under Mitt Romney. The compromise was supported by some progressives, most notably Andy Stern of the SEIU. It was defeated 8-1 in committee in the State Senate after being opposed by the majority of the progressive health care movement, including the California Nurses Association and the California One Care Coalition.

Progressives will need to take great care not to let these differences undermine the movement for universal health care nationally.

Here's the speech:
Before introducing Chairman John Conyers and Courtney Farr of the California Nurses Association, let me outline a few principals for our discussion this afternoon about how progressives should respond to the health care proposals of the leading Democratic presidential contenders.

First, if we have a Democratic president and an increased Democratic Congressional majority after November, we will have the best opportunity to enact Universal Healthcare in America since the Truman administration. If we blow it, the opportunity could be lost for another generation.

Second, this kind of fundamental social change will never take place only from the top. It requires a mass movement pushing from below. If history proves anything, it's that Washington only enacts major social change if prodded by large scale social movements such as the union movement, the civil rights movement, the women's movement and the anti-war movement. There already is a strong mass movement of unions, doctors, nurses, churches and community organizations building support for Medicare for All as embodied In HR 676 sponsored by Chairman Conyers. It has, I believe, over 80 Congressional co-sponsors--that's nearly 1/3 of the Democrats in the house-- and has been endorsed by over 235 union organizations in 40 states, as well as many citizens, religious and medical organizations.

Third, any healthcare reform plan that's based on private insurance is fatally flawed. A. The incentive of private insurance is upside down. The less care a private insurance company provides for the same premiums, the higher their profits. Most of us saw the cases in "Sicko" of insurance companies paying bonuses to employees who rejected healthcare claims from the sick. B. With hundreds or thousands of different private health insurance plans, it's impossible to negotiate consistently lower costs with health care providers and drug companies. A single payer system has the market clout to reign in costs. C. Most important, private insurance is a colossal waste of money. Administrative costs for Medicare are 2-3%. Approximately 30% of private insurance premiums go to overhead, profits, and executive salaries. Doctors and hospitals have to employ huge staffs just to process insurance claims from a multiplicity of insurance companies. About 20% of the income of private doctors goes to pay for this staff. Overall, the administrative costs of private insurance exceed $400 billion a year. That.s enough to cover all of the uninsured without raising taxes.

Fourth, as Barack Obama has said, "Change is hard." You do not bring about fundamental social change by surrendering on basic principals without firing a shot. Let me say that again: You do not start by surrendering on basic principals without firing a shot. That's the problem with the approach of the leading Democratic presidential contenders and some progressives like those who spoke this morning on the Campaign for American's Future panel led by Jacob Hacker. Before the political battle even begins, they ask the mass movement for universal healthcare to abandon the principal of not-for-profit universal health care for a plan based on employer and individual mandates to buy private health insurance (albeit with a public alternative). George Lakoff's Rockridge Institute calls that approach "Surrender In Advance".

Fifth, Congressman Conyers has kept the issue of universal healthcare alive in Congress for many years when others have given up. John Edwards, Hillary Clinton and Barack Obama deserve credit for placing health care reform at the top of the domestic political agenda for the next president. But their actual plans are deeply flawed. There is no reason that the mass movement for Universal Healthcare has to fall in line behind their specific proposals. We can use the opportunity of a Democraric president and Congress to push beyond the proposals put forth by the presidential candidates.

The argument that some progressives make for surrendering in advance is that a plan based on employer and individual mandates, albeit with a public alternative that the uninsured may buy into with their own money, is more politically practical than Medicare-For-All. I think they're wrong. Their proposals are bad social policy and even worse politics.

Here's what I want to know. Why is it more politically pragmatic to tell middle class voters that if they don't have health insurance, or lose their health insurance, the government will force them to buy it?

The average cost of an individual policy is nearly $5,000 a year and its $12,000 for a family of 4. Hillary and Obama don't specify how poor you have to be to get a government subsidy, but Massachusetts gives full subsidies to those earning up to 150% of the poverty level of about $10,000 for individuals and $14,000 for couples. Premiums are reduced for those earning up to 3 times the poverty level. Individual making more than $30,630 and couples making more than $41,880 have to pay full freight. To quote a column from the Boston Globe by 2 Doctors, "244,000 of Massachusetts uninsured get zero assistance--Just a stiff fine if they don't buy coverage. A couple in their late 50s faces a minimum premium of $8,638 annually, for a policy with no drug coverage at all and a $2,000 deductible per person before insurance even kicks in. Such skimpy yet costly coverage is, in many cases worse than no coverage at all. Illness will still bring crippling medical bills - but the $8,638 annual premium will empty their bank accounts even before the bills start arriving. Little wonder that barely 2% of those required to buy such coverage have thus far signed up."

A government mandate requiring people to pay these kinds of premiums, even if a national plan had somewhat higher subsidies, is effectively a huge hidden tax increase for the middle class and a huge boondogle for the private insurance companies to whom the government delivers large numbers of new customers. Maybe that's why such a plan is more politically "pragmatic". It's a plan private insurance companies could learn to love.

So here's what John McCain will say to a candidate running on a mandate plan: "The Democrats want to punish the middle class with a backdoor tax. If you're an uninsured family and make over $40,000 a year so you aren't poor enough for subsidies but can't afford insurance, the Democrats will fine you or garnishee thousands of dollars of your wages since the average policy for a family of 4 is $12,000." That should be enough to scare off millions of middles class families from voting for a Democrat. Pragmatic politics? I don't think so.

I ask again. Why are these kind of plans more politically pragmatic than Medicare-For-All?

These plans are intricate Rube Goldberg contraptions that are hard to explain to voters. They are complicated mix and match systems which include mandates on employers to provide insurance or pay into a pool, exemptions for small business, tax credits, health market pools for buying insurance, mandates that uninsured individuals purchase insurance, government penalties for people who fail to buy insurance.

To quote Jonathan Cohn, author of "Sick", "If you're going to propose a large-scale change to the health care system and invite the 'socialized medicine' charge anyway, you might be better off endorsing a single payer system, which at least has the virtue of being easy to explain. Unlike, say, a hybrid public-private system, which involves all sorts of convoluted regulations, which then require all sorts of tortured explanations, the essence of single payer can be reduced to three simple words: 'Medicare For All'".

There are progressives who argue that Medicare For All is just too controversial to sell to the American public. A number of polls show that fear is misplaced. A CBS News poll last September asked "Which do you think would be better for the country: having one health insurance program covering all Americans that would be administered by the government and paid for by the taxpayers, or keeping the current system where many people get their insurance from private employers and some have no insurance?" 55% chose "One Program for All" and only 29% chose "The Current system". A January 2007 NBC News/Wall Street Journal Poll found that 53% would be willing to pay higher taxes so that everyone can have health insurance.

And that's while the movement for Medicare for All is still in its relative infancy. With the combination of leadership in Washington by people like Congressman Conyers and a mass movement of citizens groups, unions and churches, we can get the majority of people behind us.

In fact, for those who say that Medicare for All is not practical, I remind you that both houses of the California legislature already passed a single payer health care bill in 2006. Unfortunately, it was vetoed by Governor Schwarzennegger. But we'll be back in 2 years when we will hopefully have a Democratic Governor. Remember, single payer healthcare in Canada started in 1 province, Saskatchewan, and was so successful that it spread to the whole country. That may end up being the path in the US too, whether it's in California, Wisconsin, or Washington state.

Some progressives argue that a plan based around private insurance would also have a Medicare like public alternative that people can buy into. They claim that eventually this program might, by some form of alchemy, evolve into a single payer system. Their logic is flawed. If this plan is modeled on Medicare, it would be a fairly generous plan in which you can choose your own doctor, in which most treatments your doctor recommends are covered, and in which deductibles and co-pays are low. Even with reduced administrative costs, this would be expensive insurance. Private insurance companies would offer lower cost policies with high deductibles and co-pays. This would lead to what's called "adverse selection". The young and healthy would opt for the cheaper plans. Mostly older and sicker people would opt for the public plan. Far from slowly evolving into a single payer system, the Medicare-like plan is likely to become increasingly expensive, making it even less affordable and forcing more and more people back to bare bones private insurance.

So, to sum up, here's what the progressive movement should be saying to our Democratic frontrunners: Run on your Universal Mandate plans if you must. At least you'll keep the issue of health care reform on the political front burner. We'll contribute money and work hard on your campaign. The country cannot afford another 4 years of a Republican in the White House.

But if you're elected president, we're not going to lend the force of our mass movement to supporting your compromised plans. We'll be organizing millions of people behind Medicare For All, the only type of plan than can actually guarantee quality Universal Health Care to all Americans.

ADDITIONAL NOTE: One comment asked for links for activists who want to become involved in the single payer movement. Here are a few good ones:
http://www.pnhp.org/
http://www.healthcare-now.org/
http://www.everybodyinnobodyout.org/AllStates.htm

To read prior installments of this multi-part Huffington Post series, "Why Not Single Payer?", see:
Part 1: http://www.huffingtonpost.com/miles-mogulescu/why-not-single-payer-a_b_67836.html
Part 2: http://www.huffingtonpost.com/miles-mogulescu/why-not-single-payer-par_b_70848.html
Part 3: http://www.huffingtonpost.com/miles-mogulescu/why-not-single-payer-par_b_75070.html
Part 4: http://www.huffingtonpost.com/miles-mogulescu/why-not-single-payer-par_b_84862.html

Comments

[WorkingClass]

The reason the politicians wont advocate single payer is no secret. The insurance and pharma companies own their ass.

[ThomH]

Bravo. Great post. Especially important for showing how the "universal healthcare plans" offered by Barack and Hillary will never see the light of day because they are wide open to attack from both the left and the right. Both plans propose a virtual crazy quilt of complexity, new regulations, government intrusion, increased insurance costs, increased government costs, taxes, subsidies, and mandates. All this, and they still leave many uncovered, and the insurance companies deciding what gets paid for. They will simply be torn to shreds, and deservedly so.

For more, see "The HillBar Healthcare Plan Revealed" at

http://whatsnotso.blogs.com/whatsnotso/2008/03/the-hillbar-hea.html

[tbone99]

HuffPost's Pick

You do not start by surrendering on basic principals without firing a shot. THANK YOU.You can't sit down at the table with insurance companies and expect to come away a winner.

Although the insurance and pharmaceutical companies are going to squeal bloody murder, other businesses thoroughly back governtental health care , as it drastically reduces their operating costs.If we want businesses to remain here we are going to have take the plunge,it's not just NAFTA tthat has compromised our workers.

[Spoons]

The health insurance industry is to America's Health Care as the KKK is to our Civil Rights, or Al Qaeda to our National Security. All three entities' goals are perverse and contrary to our goals of achieving successful protection for people in America, and do not deserve a seat at the negotiating table.

[KenTerry]

I agree that no reform plan based on delivering more business to the wasteful, greedy insurance companies can possible succeed. Also, it's clear that if a Democratic candidate proposes an individual mandate (even one that will cost "only" 10 percent of your income), he or she will be easy prey for the Republicans. But I'm a bit puzzled by the claim that Medicare For All is going to save tons of money. Of course, it will reduce the administrative costs of private insurance (although only about a third as much as Mr. Mogelescu claims, because private insurance covers only about a third of total health costs.). But, as this article points out, Medicare is a very expensive, open-ended insurance program. So putting everyone in the Medicare program is not going to cut costs enough to provide everyone with sustainable access to good health care.
In fact, no reform plan that is only about expanding access can succeed; we need to control costs by restructuring the health-care delivery system and by slowing the introduction of new medical technologies until we're sure that they offer more benefit than harm to patients.

[ProudLiberalDan]

Since Obama is the likely nominee, is there any way to get him and the Democratic Party Platform to move from his current weak, non-universal proposal to actually calling for single-payer health care?

That way, when he wins, he has a mandate for it, as opposed to George W. Bush's non-mandate to privatize Social Security.

[jdm58]

Yes. This is what is done at the local, state, and then national conventions. Only a small part of the convention time is dedicated to voting on delegates for candidates. After that process, issues are submitted, considered, and then, according to Roberts Rules, a motion can be made to accept or reject a proposal, if seconded, it goes to a vote of the assembly present. It is amazing how many people leave the convention before the issues get underway. Truly, only a handful of people articulate what is important and what happens in this party. If only more people would get involved, we could accomplish so much more!

[swift_goat_pet_for_truth]

Good ideas.
I would suggest, however, that another important participant would be the large corporations who are constantly whining about how their legacy systems leave them in an uncompetative situation. Automakers and legacy airlines come to mind.

However, until such a plan seems to move towards reality, I will continue to plan to take my retirement bankroll with its falling US dollar to some civilized country in the near future.

BTW, I believe the article meant to say that private med insurance is $12K / year for a HEALTHY family of four. For my family of three during my unfortunate time between jobs, it was about $11K.

[geobushono]

I've been hearing about the corporate benefits burden for about 10 years....if the corps wanted to move forward with this idea it would have already been done.

[emhaas]

Miles, you are right on. The progressive message gets all mixed up when you include mandates. Progressives can't argue that government can and should be a force for good in society and then have it penalize people with a mandate because they can't afford to buy the insurance they want and need to have. It's a huge contradiction. And, as you point out, the Republicans will kill the Democrats with it in the Fall. It's plain bad framing and policy.

Great job.

Eric Haas
Senior Fellow
Rockridge Institute

[EspritDeVoltaire]

Anything other than a single payer system is simply prolonging the problem. Mandated insurance will not work and itself will have to be revised. We need reform, not band-aid solutions to a problem which requires surgery.

[jdm58]

Am hoping, Miles, that you will post a link for activists and those who wish to volunteer their time and energy in this grass roots movement.

[emhaas]

HuffPost's Pick

Miles,

You are right on. You can't argue for a health care plan based on progressive principles, including that government can and should be a force for good in society, then have a government mandate that fines people for not getting the health insurance they want but can't afford. It's a non sequitor and a non starter.
You are so right--the Republicans will kill the Democrats with this in the Fall.

Eric Haas
Senior Fellow
Rockridge Institute

[Spoons]

I agree 1000% with Single Protective Pool Health Coverage for Americans (AKA Single Payer). The only thing I disagree with in this article is that needed change will come from the bottom, up. Too many Americans are too poor, sick and weak to be able to fight the battle that needs to be fought for them, and their enemy (health insurance industry robbing us all blind) is far too wealthy and powerful. The people know they need protection, and know they are unable to protect themselves. The only thing we lack is the right leadership, and that (unfortunately) includes McCain, Obama and Clinton.

I even heard Karl Rove explaining on C-SPAN yesterday that the bigger the health insurance coverage pool we can form, the better off we are. The irony is that he didn't realize where that statement leads if taken it to its logical conclusion...that we would ALL be better off by uniting into the largest protective pool possible.

[JacobSinger]

"We'll be organizing millions of people behind Medicare For All, the only type of plan than can actually guarantee quality Universal Health Care to all Americans."

This cannot be stressed enough; such an approach is our only real chance at seeing the goal of Universal Healthcare come to fruition in the US. There are many issues that progressives need to take to task, provided that a democratic president combined with a democratic majority in congress becomes a reality.

But it is our depth of our sincerity and resolve that our prospects hinge upon; should a conducive political environment actually materialize, it will be up to the US populace to rise to the occasion and make a show of populist will in the face of entrenched resistance to change by the DC establishment. Despite the possibility of optimum political conditions arising through the aforementioned electorial processes, the falling off of pressure or a resignation and retreat into typical patterns of apathy upon resistance will leave us with the same convoluted healthcare "system" that we've suffered through for far too long.

Neither Obama nor Clinton--even with the support of a democratic majority in congress--can deliver to us a solution that they both seem to feel is to politically risky to even "run up the flag pole." The Responsibility will be ours, in that we must stay politically engaged and push our elected democrats in DC to behave like true progressives.

[RumiSouth]

As someone who works with insurance and prescription refills all day, I can safely say the country would save loads of money and years of hassle if we just went to single-payer on drugs alone.

[GOP4MoreTears]

An excellent argument Mr. Mogulescu, it seems that I find it quite convincing, and the correct stance on the issue. The private insurers better find another line of work because they will never be a part of the solution. Single payer makes sense, and will workout fine after the growing pains.

[Spoons]

The insurance industry will be just fine after Single Payer. It will need to devise ways to make money that do not kill, disable, bankrupt and terrorize innocent Americans....but it is well positioned to diversify any direction it may choose....unlike the millions of other businesses and families from whom it pulls the rug out from ubder without warning.