"America has the best health care system in the world, pure and simple." - President George W. Bush, May 1, 2006
"The U.S. health care system is a scandal and a disgrace." - New York Times columnist Paul Krugman, Jan. 1, 2007
Will 2007 be the year when the U.S. renews the battle over health care reform, as Paul Krugman suggests in yesterday's column? And if it does, will Congress even consider his call for a government-run, single-payer health insurance plan?
A dozen years ago, First Lady (now Senator) Hillary Clinton led an ill-conceived health care reform initiative that would have kept the insurance industry in the game. They rewarded her efforts with the deliberating confusing "Harry and Louise" advertising campaign that convinced most Americans that they didn't want "the government in their medicine chests." The insurance industry sidetracked reform for half a generation (and, in part, helped create the anti-government political climate that put the Republicans in charge of Congress).
Is the public now ready to listen to single-payer proponents? The arguments for single-payer (sometimes called Medicare for all) are straightforward and well-covered in this article from the Sunday Times. A single-payer plan could cover the nation's 46 million uninsured without raising taxes by eliminating administrative waste. Centralized administration would have the marketplace clout to hold down the skyrocketing cost of drugs, needless diagnostic tests and duplicative hospital beds. Single-payer plans exist in virtually every other advanced industrial nation, and they achieve better health care outcomes at far lower costs.
However, despite the Democrats return to controlling Congress, the political alignment is less hospitable for single-payer proponents than it was a half generation ago. In 1993, nearly a hundred Congressmen signed onto a bill calling for single-payer.
Today, some of the leading single-payer advocates from that era (Rep. Pete Stark and Sen. Ron Wyden) are pushing incremental reform bills that would essentially leave the insurance industry untouched. Legislation calling for single-payer has so far attracted just a handful of supporters.
Meanwhile, the Center for American Progress, led by John Podesta, President Clinton's former chief-of-staff, and some other progressive groups have called for a value-added tax to provide funds for covering the uninsured. Their plans would also leave the insurance industry in the game.
You don't need Karl Rove to write Republican talking points attacking such proposals. Do you think average Americans faced with skyrocketing co-payments and deductibles in their own insurance plans, not to mention stagnant real wages in their working lives, will support increased taxes to subsidize employers who refuse to provide their workers with health insurance?
And do you think the average American wants to give hospitals, physicians, and the drug and insurance industries even more money? The health care system already pays for the uninsured in the most expensive way possible - at the emergency room where they go for critical care. Those costs are shifted onto the insured through higher premiums and higher taxes. Why should the public pay even more money to get the uninsured into the regular system where costs should be lower?
It's going to take more than a few articles in the New York Times to build a movement for single-payer health insurance - the only reform that can end the relatively meaningless debate over insurance and begin the more important debate that we need to have in this country. Why does America, despite spending twice as much as most other countries on health, have significantly worse outcomes?
We need to move beyond the debate over insurance reform so we can begin talking about the quality of care that we receive in this country. Why don't we have preventive care? Why do we have low vaccination rates? Why are we light years behind every other country in electronic medical recordkeeping? Why do we have so many specialty hospitals? Why do we have so many specialists and so few primary care physicians? Why do so few physicians practice evidence-based medicine? Why do we buy so many expensive me-too drugs instead of equally effective generics?
To ask such questions is to list the special interests groups lined up ready to attack any serious movement for single-payer health insurance reform.
And then there's the issue of tax reform, which is central to the issue of health care reform. The U.S. currently spends about $1.9 trillion a year or 16 percent of gross domestic product on health care. Between Medicare, Medicaid, the Veterans Administration, the Defense Department, federal, state and local governments and the tax subsidy for employer-provided health insurance, the public sector picks up about 65 percent of that tab.
So a single-payer plan would "only" need to cover the other third or about $665 billion (in 2002, according to the Center for Medicare and Medicaid Services, private insurers covered about 36 percent of the nation's $1.34 trillion bill for health care services). What would it take to raise that much money another way? The Medicare payroll tax, 1.45 percent on workers wages with a comparable match from employers, raised $171 billion in 2005, according to the Medicare trustees report.
Should we quintuple the tax to 7 percent? That would raise enough to replace the employer contribution, but half would now come from workers in addition to the 15 percent of all health care costs they're already paying out of pocket, according to the same CMS report.
The movement for single-payer health care reform is badly in need of a think tank to think through all of these questions and issue white papers that would answer the legitimate questions that will be raised by legislators, medical consumers, taxpayers and medical providers. Until such a think tank exists, the movement for this much-needed reform will go no farther than the op-ed page of the New York Times.