The Happy Dance of Richard Kirsch

From CorrentWire.com –

Every once in a while, Richard Kirsch, does a “happy dance” article celebrating his own Health Care for America Now campaign for health care reform, whose outcome of course was the wonderful bill legislated by the Congress last Spring. Kirsch, who is now a Senior Fellow at The Roosevelt Institute, posted his latest happy dance at The Nation, whose “liberal media bias” was nowhere in evidence near his article.

I have only a few comments to make on his description of the process of bringing this “progressive victory” to us all, since, no doubt, Kirsch is the leading expert on this process. However, I will say something about an aspect of the process which he’s neglected to describe and then go on to talk about the results of his noble efforts.

On process, Richard fails to talk about the successful efforts of HCAN to work with the Obama political team and other “progressive” organizations in Washington, to take Medicare for All “off the table” as an option that would receive serious consideration in Congress. HCAN persuaded most other progressive organizations based in Washington with significant funding to shut up about single-payer and get behind the public option proposal.

At first a comprehensive version of a public option bill outlined by Jacob Hacker was used to seduce the left organizations. It was claimed that it would be much more acceptable to the health insurance industry than single-payer, and had a much better chance to pass. Then as the public option alternative was de-fanged, a little more at each stage of the political process, HCAN held the coalition of progressive organizations together, in the “veal pen,” and prevented the resurrection of single-payer as a viable alternative.

In order to carry out its effort, HCAN and its predecessor organization, The Herndon Alliance conducted biased polling, manipulated the media, used its very substantial funding to flood the media with PO-based stories, did its best to label single-payer advocates as “unrealistic,” and, generally, to tell people that “the perfect is the enemy of the good,” while preparing to support legislation that was very far from being either perfect or good.

The story of the efforts and manipulations of HCAN, the “bait-and-switch tactics;” the lack of honesty with the public about the continued diminution of the public option as the legislative process moved forward; it’s unwillingness to say a loud “no” as the bill moved farther and farther away from either single payer, or the original public option compromise, and closer and closer to its final state as a pure bail-out for the insurance industry, delivering very little value to people, can be traced at the Physicians for a National Health Program (pnhp) web site. Please read Kip Sullivan’s many blogs to see a picture of real perfidy on the left, and to understand that the worst thing that could have happened to the left’s campaign for national health insurance was to have it led by HCAN and its objective of getting the Public Option “sparkle pony” passed into law.

A more general account, from the viewpoint of George Soros’s favorite notion of reflexivity, of the multi-stage de-generative political process engaged in by the left, under the leadership of HCAN is here. In short, the process engaged in by HCAN, under Richard’s leadership was, in my view, nothing short of a progressive disaster. It is one we must never duplicate, if we value the continued existence of the progressive movement and progressive values.

Moving on to the outcome of HCAN’s process, the Administration’s final health care reform bill, which Richard is pleased to call a “victory;” I doubt that there are very many progressives who would characterize it that way outside the land of Washington organization spin. Most people blogging or commenting at FireDogLake certainly thought it was a defeat and that it was worse than no bill at all. Of course, everyone in the Medicare for All movement thought it was a great betrayal, and there were many in the blogosphere generally, who thought the bill was a great failure, and that progressives should have been hanging their heads in shame over it, rather than doing happy dances.

I posted my own opinion of the bill in a piece called “J’Accuse” here and here, before the final compromise occurred, but none of my central criticisms were blunted in the final bill. The bill that Richard Kirsch calls a victory, is one that fails to stop hundreds of thousands of fatalities, and millions of bankruptcies, and home foreclosures, before it goes into effect in 2014, and even then dooms people to an additional 127,000 fatalities between 2014 and 2019, if there is no further reform.

The outcome of Richard’s process, which he celebrates, is not the victory he also celebrates, but a travesty of progressivism, a true failure and a catalog of sell-outs to corporate interests at every step of the way. Further, Richard’s “happy dance,” constituting a self-evaluation of the significance of his own efforts, holding it forth as a model for others to follow is itself a travesty, reminiscent of the efforts of Dick and Lynne Cheney to recast Dick’s own legacy of failure.

One of the most disturbing trends in Washington in past years has been the increasingly frequent efforts of politicians and those associated with them to give themselves credit for outcomes that only they and very few others recognize as worthy of praise. It would be in much better taste, and also much more conducive to learning the real lessons of the past, if they waited for others to praise them, and until then, kept a respectful silence, before they began “the happy dance.”

At the National Action Network Conference

Katie Robbins, National Organizer for Healthcare-NOW!, a leader in the fight for single-payer healthcare or Medicare for All, was invited to address the National Action Network in New York City.

It was clear after arriving that conference organizers believed she was representing a coalition with a similar name known as Health Care for America Now that launched in 2008 to support health reform and celebrates the passage of the bill that handed the insurance industry 447 billion dollars.

Healthcare-NOW! has been critical of the bill and the corporate control of the process that developed legislation without even considering truly universal, national health insurance. Here are her remarks.

No Insurance Company Left Behind

By Katie Robbins –

On Tuesday, the Health Care for America Now (HCAN) coalition performed a “citizen’s arrest” of the insurance industry at a meeting of Americas Health Insurance Plans, the private health insurance industry’s leading lobbying group, in Washington, DC.

Thousands came out to support this action, and rightfully so. There is no other place we need to be than in the streets in protest of the egregious crimes of the insurance companies. Advocates of Medicare for All agree that the private insurance industry must be held accountable for its crimes, and that it should be put out of business…permanently.

Behind the progressive facade, HCAN ultimately supports the Democrat’s bill, which would mandate that everyone purchase insurance from the very same companies they call evil.

Howard Dean stated at the HCAN event, “This is a vote about one thing: are you for the insurance companies or are you for the American people?” This is absolutely true, but Dean’s language is misleading. He implies that voting for the bill will help protect the American people.

In reality, both the House and Senate bills have at their core a regressive and harmful mandate that will force people to purchase insurance plans that will not guarantee they get health care when they need it or that the care will be affordable. It will keep the insurance company bureaucrats in control, handing them hundreds of billions of public dollars to subsidize these utterly inadequate insurance plans. These plans are more akin to an umbrella that melts in the rain. Moreover, the proposed legislation that HCAN is fighting for will continue to drive up health costs, raise premiums, and send people, even those with insurance, into bankruptcy.

The health care crisis will not end, and this bill will not bring us closer to a real solution.

Some at the rally said this bill will get our foot in the door; this is the best health reform we can get right now, but Healthcare-NOW!, the campaign for national single-payer health insurance, remains committed to implementing a real solution to the health care crisis. To get there, we cannot compromise on our principles. We must start the conversation by acknowledging the right to health care for all people, and when we do that, single-payer will be on the table.

As advocates, we must continue pushing for a system that guarantees high quality health care to everyone. We know we can do this at less cost than our current system and less cost to the American people. We will continue fighting alongside the doctors, nurses, and committed activists that support a real solution that puts the health of our people before the profits of insurance companies.

When this current reform fails to pass, or fails to solve our health care crisis, we will be ready with the solution.

The time to fight for what is right is always right now. Join us as we build an unstoppable movement for improved Medicare for all.

If Private Health Insurance Companies Are Evil, Why Are You Forcing Me to Be a Customer?

By Jon Walker for Fire Dog Lake –

A big part of the final push for this health care reform effort is focused on how terrible the private insurance companies are. On the White House blog, communications director Dan Pfeiffer is attacking the huge premium increases and monopoly power of some private insurers. HCAN is doing a “mass citizens’ arrest of the insurance companies.” On the stump, President Obama is hitting the terrible practices of the private insurance corporations hard. From Washington Post:

Obama and his health secretary staged a two-pronged attack Monday in a stern letter to health insurance chief executives and a speech in which the president castigated insurance companies 22 times. “How much higher do premiums have to rise,” he demanded, “before we do something about it?”

The messages are part of a strategy that Obama and those around him have begun to employ lately, to ratchet up the pace and the populist appeal of their rhetoric against the health insurance industry. The barbed tone moves far beyond that of the 2008 presidential campaign, when Obama began to say that medical coverage should be accessible and affordable for more Americans.

I agree with the message. I can’t decide if I dislike the industry more for its morally reprehensible practices or its bloated, inefficient, and completely unnecessary nature. Attacking the private insurers is smart politics and should have been done months ago.

The big problem is that the messaging is incompatible with pushing for Obama’s official health care proposal. That program will use the IRS to force Americans to buy insurance from the same, terrible, private insurance industry everyone is now rallying against.

If the private insurance industry is so evil, why would you ever possibly force me to be their customer?

The messaging would make sense of Obama were pushing for a Medicare-for-all system that would completely marginalize or eliminate the private insurers. It would make sense even if the bill only had a simple public alternative, like a public option or Medicare buy-in. I could understand the message even if the bill had a broad state waiver provision that would allow for states to possibly create single payer plans. I might even except the messaging if Obama was pushing for what Switzerland did by forcing all private health insurance companies to become highly regulated non-profits. It might even be accepting if there were only the new consumer protections but no individual mandate.

The issue is that Obama’s health care proposals don’t do any of those things. It places a few good, new regulations on the private insurance companies (which will probably see a very spotty record of enforcement because that function is left up to the states), but it will now force you to buy insurance from these same, terrible, private insurance companies Obama is now attacking, or you face a fine.

To me, this sounds like pushing for a bill that would force factory farmers and slaughter houses to treat livestock 15% more humanely, but in exchange, the laws would require every American to buy triple the amount of meat.

If everyone pushing for health care reform is pointing out how awful the private insurance companies are, why is Firedoglake the bad guy for saying it is therefore immoral to force people to be customers of these admittedly terrible companies (especially when health care reform could be done without an IRS-enforced individual mandate to buy private–and only private–insurance)?

Notes from “Medicare for All: Still the One”

If you missed last night’s national conference call, “Medicare for All: Still the One,” you can listen to it here. Also, please find a transcript of Kip Sullivan’s remarks below.

We had about 250 people on this call, and we’d like to thank all of you for participating, and donating. This call’s success means that we can keep organizing national conference calls in the future. Thank you for your support!

If you missed the call, listen to it here:

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Or download an MP3 file of the call here.

Kip Sullivan’s remarks from the call.

INTRODUCTION
It’s easy enough to explain why the “public option” was defeated. It’s a lot harder to explain why it rose to prominence in the first place. Even in the watered down form in which it was adopted by Democrats, the PO was probably no more politically feasible than single-payer was, but it was a lot harder to explain. And the watered down form wouldn’t work, and it probably wouldn’t even have survived.

The PO was so tiny when Democrats introduced it in June 2009 that it is fair to say it was moribund upon arrival if not dead on arrival. It was placed on life support when Sen. Reid struck it from the Senate bill in November, and it was finally put out of its misery by the election of Scott Brown in MA in January of this year.

The PO wasn’t politically feasible in 2009 for the obvious reason that it was opposed by the same people who would have opposed a single-payer system. Perhaps as importantly, the PO wasn’t politically feasible because the people who promoted it weren’t serious enough about it to make it a condition of their support for the Democrats’ bill.

So it’s pretty easy to explain why the PO fell. What’s not so easy to explain is why a lot of smart people thought the PO was such a good idea to begin with and why, if they thought it was such a good idea, they didn’t make it their bottom line. When the campaign for the PO began in 2005, it wasn’t at all clear that the leaders of the campaign intended to throw the PO overboard if that’s what it took to get Congress to pass an insurance industry bailout (by which I mean the individual mandate and the subsidies to make the mandate affordable). But by June 2009, it was clear the leaders of the PO campaign had NO intention of making a big, powerful PO a condition that Democrats had to meet. And by Xmas Eve 2009, it was clear the PO campaign had no intention of even making a TINY, ineffective PO a precondition for its support.

It appears, in short, that the leaders of the PO campaign saw an insurance industry bailout as more important than the PO. Many leaders of the PO campaign may even have seen the PO as merely a fig leaf to induce progressives (both inside and outside of Congress) to think it was ok to support a bailout.

The modern version of the PO was brought to us by Jacob Hacker. And it was promoted by Health Care for America Now and the Herndon Alliance. The Herndon Alliance has received much less publicity than HCAN, but it played a seminal role in the development of the PO campaign. So, to understand why the proponents of the PO supported it, but not enough to make it a non-negotiable demand, it helps to review the thinking of Hacker and of the founders of HCAN and the Herndon Alliance.

I doubt I’ll have enough time to describe both Hacker’s thinking and that of the Herndon Alliance and HCAN leaders. I think what I’ll do is describe Hacker’s original version of the PO, his rationale for it, what happened to the PO after it arrived in Congress in 2009, and how Hacker accommodated himself to the degradation of the PO. And then, if I have any time left over, I’ll talk briefly about the Herndon Alliance and HCAN. If I don’t have time to talk about HCAN and the Herndon Alliance, that’s ok. Their thinking pretty much mirrored Hacker’s. Like Hacker, they saw single-payer as politically infeasible; they started out supporting a big PO as a more politically feasible substitute for single-payer; and they didn’t object when congressional Democrats unveiled a microscopic form of the PO in June.

THE ORIGINAL HACKER PROPOSAL
Hacker first proposed what he called Medicare-Plus in a paper he wrote in 2001. He published another version of his idea in 2007. In that second paper, he called his idea Health Care for America. The label “public option” didn’t appear till early 2009.

Hacker’s idea, basically, was to have the federal government create a health insurance company that would sell health insurance to the nonelderly. Hacker assumed this company would enjoy all the efficiencies of Medicare and would therefore be able to undersell the insurance industry. Hacker never used the word “company” or “business” to describe the federal program he had in mind. Instead, he repeatedly described his proposed public entity as a program that would be “like Medicare.” Hacker’s refusal to use appropriate terminology contributed greatly to the confusion that became rampant among PO advocates by 2009.

There is, of course, a huge difference between what Hacker was proposing and Medicare. Medicare is a single-payer program – it’s the only insurer of basic medical services for Americans over 65 and the disabled. Because it is a single-payer insuring such a large population, and moreover a population with above-average medical needs, Medicare enjoys advantages that the insurance industry will never enjoy, including huge size, low overhead, and an ability to induce docs and hospitals to accept below-industry reimbursement rates.

The public company Hacker was proposing would have to compete with 1,500 other insurance companies within the multiple-payer jungle. The public company he was proposing would NOT be a single-payer – it would be just one insurance company among hundreds. It’s therefore far more accurate to refer to what Hacker was proposing as a company, a corporation, or a business that would be set up by the government. It was ALWAYs misleading for Hacker to refer to his proposed entity as a government program like Medicare, and it was EXTREMELY misleading for him and his acolytes to continue doing so after the Democrats adopted a microscopic version of the PO.

However, the early version of the PO that Hacker proposed DID have the potential to become a Medicare-for-all program for nonelderly Americans. In his 2001 and 2007 papers, Hacker said he wanted to give his public insurance company several very important advantages that would have allowed the company to start out with enormous size and to grow even larger early in its life. Hacker proposed five advantages or criteria for his original PO:

(1) It had to be prepopulated (he would have shifted Medicaid and SCHIP enrollees and all or some of the uninsured into the PO);
(2) Subsidies would go only to the PO;
(3) It would be open to all non-elderly Americans;
(4) It would have the authority to use Medicare rates (this was not as important as the first three criteria); and
(5) The insurance industry had to offer the same coverage.

According to an analysis of Hacker’s 2007 paper by the Lewin Group, Hacker’s original PO would have enjoyed premiums 23% below those of the insurance industry and would have enrolled 129 million people, or about half the non-elderly population. According to the Lewin Group, Hacker’s original version of the public company would grow rapidly, from insuring half the non-elderly in 2008 to two-thirds of the non-elderly within a decade. Conversely, the insurance industry’s share of the non-elderly market would shrink from half to 35% within ten years.

In my view, the Lewin Group grossly underestimated how much damage Hacker’s original version of the PO would do to the insurance industry. I think a public insurer with half the non-elderly population and premiums at 23 percent below the industry’s would have quickly destroyed the insurance industry. Twenty-three percent is an enormous differential. To put 23 percent in perspective, consider that HMOs in the 1980s had premiums only 5-10% lower than the traditional non-managed-care insurance companies they eventually displaced. Even though most Americans didn’t want to be in HMOs, employers all over the country pushed their employees into HMOs in order to take advantage of that 5-10 percent premium differential. And that was two decades ago when premiums took less of a bite out of everyone’s pocket. Can you imagine how fast employers would dump their existing insurance company today for a 23 percent cut in their premium, especially if the PO were as kind and gentle as PO advocates say it would be?

It’s hard to believe that someone as informed about health policy as Hacker didn’t know his original PO had the potential to become a single-payer for the non-elderly. Let me read to you a portion of a transcript of a phone conference call sponsored by EPI on January 11, 2007 in which two participants, Ezra Klein (a blogger for the Washington Post) and Bob Kuttner (co-editor of the American Prospect), asked Hacker why he thought his proposal would succeed any better than Clinton’s 1993 Health Security Act. Klein says, “What you’ve proposed here is much more fundamentally dangerous to the actors who killed it [ie, the Clinton bill] the last time around.” Kuttner, who must have seen an early draft of the Lewin report, says, “[Y]ou’re setting in train a gradual process whereby the whole system gradually shifts from 50/50 [meaning, 50 percent are in the public program and 50 percent are insured by the insurance industry] to 60/40 to 70/30. So after a couple of generations, almost everybody is in the quasi-Medicare program. Is that the intent?”

Hacker denied that was his intent. He agreed that the PO would start out at 50 percent, but then it would basically just get stuck there despite its enormous cost advantages over the private insurance industry. Here’s what Hacker said: “[Lewin] did not forecast a huge shift over just a 10-year period. I think it was a shift of two percentage points over that period. So, at that rate, we’d have everyone within Medicare in about 250 years.”

But Hacker was wrong. As I’ve already told you, when the Lewin Group released its analysis of Hacker’s proposed program a year after this conversation took place, they projected a 34% increase in the PO’s enrollment over a decade, not 2%. And as I said, I think Lewin was being way too conservative.

Hacker’s answer to Klein and Kuttner illustrates the strange state of denial Hacker and other PO advocates induced in themselves as they tried to sell the PO as a politically feasible alternative to single-payer even though it would, in its original form, do a lot of damage to the insurance industry and would probably have led to a single-payer for the non-elderly.

But Hacker’s confusion (and the confusion of other PO leaders) over whether the PO would be more feasible than a single-payer was MINOR compared to the confusion that set in when congressional Democrats adopted a microscopic version of Hacker’s original PO. When the Democrats released their draft legislation in June 2009, it was clear they had stripped out four of the five criteria for the public company that Hacker had specified in his original papers.

The only criterion the Democrats kept was the one requiring insurance companies to offer the same coverage as the PO. The other four criteria –
• the one calling for prepopulation of the PO,
• the one requiring that only the PO get subsidies,
• the one requiring that the PO be available to all non-elderly Americans, and
• the one authorizing Medicare’s reimbursement rates
– all four of those criteria were gone. Now it was crystal clear to anyone who understood what Hacker had originally proposed that the PO the Democrats had adopted was so small it wouldn’t affect the insurance industry. The Congressional Budget Office said the Senate version of the PO would insure no one; it said the House version would insure 10 million, and then later scaled that back to 6 million.
Now that the PO had been shriveled down from 129 million people to zero to 6 million, PO advocates faced not only the same old political feasibility problem (the insurance industry and the Republicans continued to scream about the tiny PO as if it were a big PO or a single-payer), but they also faced a huge logistical problem. A PO that represented no one on the day it opened for business wouldn’t be able to crack most insurance markets in the US, and might not even be able to survive.

This is where Hacker’s habit of always comparing the PO to Medicare became extremely misleading. When Medicare commenced operations on July 1, 1966, it represented nearly all seniors. With the exception of a few hospitals in the south that temporarily resisted integrating their facilities, all clinics and hospitals in America immediately began accepting Medicare enrollees even though there was no law requiring them to do so. The reason all clinics and hospitals did that is that Medicare represented an enormous constituency on day one and providers didn’t want to walk away from so many patients and so much money.

The tiny PO the Democrats incorporated into their bills was no Medicare. It would represent no one on the day it opened for business. It would have to do what NO insurance company has done in the last three or four decades, which is to create a new, successful insurance company in every state in the US. In fact, I’m pretty sure no insurance company has expanded into even ONE new market in the last three decades by building a new insurance company from scratch. For the last three decades, insurance companies that wanted to expand their empires have done so by BUYING their way into new markets. That is, they bought an existing insurance company.

But Hacker and other PO advocates blithely ignored this issue. They ignored it because they continued to talk about the Democrats’ PO as if it were the same huge PO Hacker had originally proposed. I might add that the CBO totally ignored this issue as well. The CBO never examined the issue of whether the PO would be able to crack even one US market, much less all of them. I think the CBO was being extremely generous to the House version of the PO when they said it would insure 6 million people.

Nevertheless, as inexplicably rosy as it was, the CBO’s reports on the PO sealed its fate. The poor PO was already hated by the right wing and the insurance industry. It was being promoted by people who cared more about an insurance industry bailout than the PO. And now the CBO was revealing the truth about the Democrats’ version of the PO – that it was laughably small and for that reason was going to save little or no money.

When Democrats throughout Congress, especially those in swing districts, asked themselves why they should vote for something as controversial as a PO when the darn thing wouldn’t save any money, PO advocates had no answers.

To sum up: The PO rose to prominence because powerful Democratic constituency groups thought single-payer was not feasible but the PO was. They were wrong. The PO failed politically, and it failed as a policy idea. Politically, it turned out to be no more feasible than single-payer. As a policy, it was a disaster. The tiny PO adopted by Democrats would have accomplished nothing other than to embarrass all of us who believe government must play a prominent role in insuring the uninsured.

Two-thirds of Americans support Medicare-for-all

Introduction to a Six-part Series By Kip Sullivan, JD for PNHP Blog -

“Americans are scared to death of single payer.”

These words were not uttered by some foaming-at-the mouth wingnut. They were written by Bernie Horn, a Senior Fellow at the Campaign for America’s Future, a member of Health Care for America Now, on June 8, 2009. Horn explained that he was moved to write this tripe because single-payer supporters were asking why Democrats had taken single-payer off the table to make room for the “public option”:

The question most frequently asked by progressive activists at last week’s America’s Future Now conference was this: We hear Obama and congressional Democrats talking about a public health insurance option, but why aren’t they talking about a single-payer system like HR 676 sponsored by Rep. John Conyers? Why is single-payer “off the table”?

Horn went on to assert that single-payer had been taken off the table because Americans want it off the table. He claimed polling data supported him, but he cited no particular poll. The truth is that the Campaign for America’s Future (CAF) and other groups in Health Care for America Now (HCAN) had decided years earlier they would push Democratic candidates and officeholders to substitute the “option” for single-payer, and they would tell both Democrats and progressive activists that Americans “like the insurance they have” and that Americans oppose single-payer.

The argument that single-payer is “politically infeasible” is not new. That argument is as old as the modern single-payer movement (which emerged in the late 1980s). It is an argument made exclusively by Democrats who don’t want to support single-payer legislation – a group Merton Bernstein and Ted Marmor have called “yes buts.”

The traditional version of the “yes but” excuse has been that the insurance industry is too powerful to beat or, more simply, that “there just aren’t 60 votes in the Senate for single-payer.” But the leaders of the “option” movement felt they needed a more persuasive version of the traditional “yes but” excuse. The version they invented was much more insidious. They decided to say that American “values,” not American insurance companies, are the major impediment to single-payer.

How did the “option” movement’s leaders know that Americans oppose single-payer? According to Jacob Hacker, the intellectual leader of the “option” movement, they knew it because existing polling data said so. According to people like Bernie Horn and Roger Hickey at CAF, they knew it because focus group “research” and a poll conducted by pollster Celinda Lake on behalf of the “option” movement said so.

About this series

This six-part series explores the research on American attitudes about a single-payer (or Medicare-for-all) system to evaluate the truth of the new version of the “yes but” argument. We will see that the research demonstrates that approximately two-thirds of Americans support a Medicare-for-all system despite constant attacks on Medicare and the systems of other countries by conservatives. The evidence supporting this statement is rock solid. The evidence against it – the focus group and polling “research” commissioned by the “option” movement’s founders – is defective, misinterpreted, or both.

In Part II of this series, I will describe two experiments with “citizen juries” which found that 60 to 80 percent of Americans support a Medicare-for-all or single-payer system. The citizen jury research is the most rigorous research available on the question of what Americans think about single-payer and other proposals to solve the health care crisis. It is the most rigorous because it exposes randomly selected Americans to a lengthy debate between proponents of single-payer and other proposals.

Of the two “juries” I report on, the one sponsored by the Jefferson Center in Washington DC in 1993 remains the most rigorous test of public support for single-payer legislation ever conducted. After taking testimony from 30 experts over the course of five days, a “jury” of 24 Americans, selected to be representative of the entire population, soundly rejected all proposals that relied on competition between insurance companies (including President Bill Clinton’s “managed competition” bill) and endorsed Sen. Paul Wellstone’s single-payer bill. These votes were by landslide majorities. Washington Post columnist William Raspberry accurately noted, “Perhaps most interesting about last week’s verdict is its defiance of inside-the-Beltway wisdom that says a single-payer … plan can’t be passed” (“Citizens jury won over by merits of Wellstone’s single-payer plan,” Washington Post October 21, 1993, 23A).

In Part III, I’ll review polling data and explore the question, Why do some polls confirm the citizen jury research while other polls do not? We will discover an interesting pattern: The more poll respondents know about single-payer, the more they like it. We will see that polls that claim to find low support for single-payer provide little information about what a single-payer is (they fail to refer to Medicare or to another example of a single-payer system), they provide misleading information, or both. For example, when Americans are asked if they would support “a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers,” two-thirds say they would, but when they are asked, “Do you think the government would do a better or worse job than private insurance companies in providing medical coverage?” fewer than half say “government” would do a “better job.” Although neither question provided anywhere near as much information as the citizen jury experiments did, it is obvious the former question was more informative than the latter.

In Parts IV and V, I’ll discuss the evidence that “option” advocates cite for their claim that single-payer is opposed by most Americans. Part IV will examine polling data that Jacob Hacker uses to justify his refusal to support single-payer and his decision to promote the notion of “public-private-plan choice.” Part V will examine the survey and focus group “research” done by Celinda Lake for the Herndon Alliance and subsequently cited by leaders of HCAN, the two groups most responsible for bringing the “public option” into the current health care reform debate.

We will see that Hacker’s research relies on polls that pose such vague questions that the results resemble a Rorschach blot more than a guide to health care reform strategy. Would you make a decision about whether to abandon single-payer based on a poll that asked respondents to choose between these two statements: (1) “[I]t is the responsibility of the government in Washington to see to it that people have help in paying for doctors and hospital bills… ;” and (2) “these matters are not the responsibility of the federal government and … people should take care of these things themselves”? I wouldn’t, but Hacker did. If it turned out that about 50 percent of the respondents said it was the federal government’s responsibility, 20 percent said it was the individual’s responsibility, and the other 30 percent split their vote between government and individual responsibility, would you read those results to mean Americans “are stubbornly attached to employment-based health insurance”? I certainly wouldn’t, but Hacker did. Would you use this poll as evidence that “American values [are] barriers to universal health insurance”? I wouldn’t, but Hacker did.

The “research” that Celinda Lake did for the Herndon Alliance used strange methods. For example, she selected her focus groups based on their answers to questions about “values” that had nothing to do with health care reform. The values included “brand apathy,” “upscale consumerism,” “meaningful moments,” “mysterious forces,” and “sexual permissiveness.” “Meaningful moments,” for example, was described as, “The sense of impermanence that accompanies momentary connections with others does not diminish the value of the moment.” Do you think it’s important to ask Americans about their “sense of impermanence” before deciding whether you will support single-payer legislation? I don’t, but Celinda Lake and the Herndon Alliance did.

The “option” movement’s “research” turns out to be no match for the more rigorous research which demonstrates two-thirds of Americans support Medicare-for-all.

In Part VI I discuss the wisdom of allowing polls and focus group research to dictate policy and strategy, something the “option” movement’s founders talked themselves into doing. Hacker has been especially vocal about this. He repeatedly urges his followers to think “politics, politics, politics,” a squishy mantra that, in practice, translates into an exaltation of opportunism. The failure of Hacker and HCAN to object to the shrinkage of the “public option” by congressional Democrats, from a program covering half the population to one that might insure 1 or 2 percent of the population, documents that statement.

The fact that two-thirds of the American public supports single-payer does not mean the enactment of a single-payer system will be easy. It won’t be. But it does mean the new “yes but” justification for opposing single-payer, or indefinitely postponing active support for single-payer, is false and should be rejected.

Stay tuned.

Report from Healthcare-NOW! 2009 National Strategy Conference

On November 14 and 15, 2009, 125 single-payer activists met in St. Louis, MO to hash out the strategy for building the Healthcare-NOW! (HCN) network. Despite the passing of the House bill with the Stupak amendment, and the bait and switch of the first vote in the House on single-payer, the energy for going forward was high.

For those of you who were there, and for those who couldn’t make it, we have a comprehensive report back from the panels, workshops, and resources for all to use in their single-payer advocacy.

Video from the conference is at the bottom of this page.

This annual conference is meant to bring together activists from across the country to build the movement. Highlights included:

1. Firm commitment to oppose the legislation in it’s current form HCN would oppose the House Bill in its current form but do so in a manner that was respectful of the diversity of views within HCN, clearly distinguishes our position from that of right-wing teabaggers and is mindful of our strategic imperative to reach out to potential allies who realize that the public option movement has reached a dead end. A committee is working on a statement to circulate to HCN activists. If you would like to contribute to this effort, please contact Jeff Muckensturm at jeff@healthcare-now.org.

2. Firm commitment to support the Sanders efforts. Along with the Mobilization for Health Care for All Campaign, we are putting together a call to action to deliver letters to Senators offices, and organizing a day of action around Human Rights Day on Dec 10th. We will be announcing more details soon.

3. 6 new Healthcare-NOW! board members! We welcome Rita Valenti, Lindy Hern, Mikuak Rai, Edith Kenna, Vashti Winterberg, and Mona Shaw to the board! Part of the new structure of HCN which was voted on at the meeting in new bylaws is to allow membership to vote on board members. We welcome these experienced activists and organizers. Board elections will happen every two years, so keep this in mind for the 2011 HCN membership meeting, so that you can run and help in the collective decision making process of HCN.

4. Michael Lighty’s presentation on the current legislation and it’s inadequacy helped shape the membership decision to oppose the bill. Download his comparison of the bills and more resources here.

5. Terry O’Neill, President of the National Organization for Women, announced her plans to roll out a national action plan for single-payer! Also, she announced plans to challenge the Stupak amendment.

6. Ethel Long Scott’s remarks on Going Forward received a standing ovation – Read more here.

7. Sandy Fox made a call to action to save our community hospitals. Reporting on the closing of Braddock Community hospital in Pittsburgh, she said their local coalition has been able to garner significant local media attention and reach a new community to support single-payer national health care. Read about their work here. To get involved with the campaign to Save our Community Hospitals, contact Dr. Anne Scheetz at annescheetz [at] gmail.com.

8. The wonderful hospitality of the Missourians for Single Payer, and having the input from so many committed activists from the area. Special thanks to them for their support.

9. Mikuak Rai closing out with his song “The System is Sick.”
The System is Sick

Strategy Ideas for Healthcare-NOW! in 2010

1. Add and build new coalitions while strengthening existing ones (all methods to build local coalitions got priority status, especially working on local hospital and primary care facility closing and cut-backs)
-Go back to all of our local organizations with the info from the conference
-Draw in LGBT community
-Draw in campuses – use their energy – hold meetings on campuses
-Local vigils
-Support local hospital/primary care facility campaigns
-Add a “best practices’ page to our website
-Draw self-help health groups into our movement
-Double our membership over the next year
-Use national and regional conference calls

2. Expand the diversity of our movement
-Add artists from music, poetry, etc. Concert for our issue
-Use You Tube channel, commercials to build our movement
-Reach youth – national book sale, health care stories from youth and minority communities (note Families USA story book from Tennessee)
-Create HCN Youth Advisory Board

3. Grow understanding and support for federal level single-payer
-Don’t be afraid to talk to folks from Chambers of Commerce and AARP that may be disillusioned at this point
-Collect new stories behind HR 3962 or whatever comes out of Congress
-Force insurance industry to be transparent and report their denials
-National demonstration
-One on one house parties
-Consolidate national messaging; coordinated analysis of issue and guidelines for response – have one place for folks to get this information
-New messages that brands our values, gives human dimension to issue, avoids “socialist” problem. “Single payer” works to some degree – may not be our best label.
Perhaps something like “America’s Healthy Families Plan” (Priority—committee set up to work on this; D. Breitzman is taking the lead)
-Healthcare is a human right must be part of the messaging; tie health reform to eliminating poverty
-Tie in activists from various mobilization civil disobedience campaigns – they will help us all understand the importance of these tactics and that they aren’t that scary
Continue to target insurance companies
-Bring HCAN and Obamacare folks into the fold

4. Increase Healthcare-NOW’s national visibility
-Huffington Post, etc. work on fairer media exposure
-More visual media
-Endorse Fair Elections bills
-VOTE DOWN 3962 – support “civilized” medicine; be clear about our message in taking a position (Those present voted to take a position against HR 3269, and a large committee formed to craft the position so that our position is clear and thoughtful; Jeff M. from Healthcare-NOW staff will convene the group on-line)

5. Shift energy from national coalition building effort to grassroots coalitions
-Build groups at the Congressional district level – regional, too.
-Work on electing democrats who might support single payer; make single payer key criteria for election

6. Implement the Marilyn Clement Healthcare Justice Intern Program

Download all the minutes from the conference here.
Download all the strategy ideas from the conference here.
Download the report back from the workshops.

Video

Dr. Quentin Young from PNHP speaks on the panel “How To Grow the Movement to Win Single-Payer National Health Care.”

Jerry Tucker from Labor for Single Payer speaks on the panel “How To Grow the Movement to Win Single-Payer National Health Care.”

Terry O’Neill, president of National Organization for Women, speaks on the panel “How To Grow the Movement to Win Single-Payer National Health Care.”

Ethel Long Scott, Executive Director of the Women’s Economic Agenda Project, speaks on the panel “How To Grow the Movement to Win Single-Payer National Health Care.”

Tim Carpenter, Executive Director of Progressive Democrats of America, speaks on the panel “How To Grow the Movement to Win Single-Payer National Health Care.”

Michael Lighty, director of public policy for the California Nurses Association, speaks on the panel “How To Grow the Movement to Win Single-Payer National Health Care.”

More videos
Michael Lighty – “How National Reform Fails” part 1, part 2, part 3, part 4.

Panel – “Grassroots Strategy and Recommendations” part 1, part 2, part 3, part 4, part 5, part 6.

See the rest here.

“I Prefer Single-Payer, But …. “

The Selling of Single-Payer Features

By HELEN REDMOND for Counterpunch –

“Start off on high ground but end up somehow crawling…”
–Bruce Springsteen, The Big Muddy

The farce in Washington DC called health care reform makes the blood of single-payer supporters boil. That the Obama administration has crafted and is trying to push through an unfathomable, over one-thousand page piece of shit legislation that in no way ends the health care crisis, and in fact, strengthens the power and position of the private insurance industry, should not be surprising. Obama sold out on the single-payer solution the moment he decided to run for the presidency and accepted campaign contributions from both the insurance and pharmaceutical industry.

That the voice of single-payer (SP) has been blacked out nationally (documented by Fairness and Accuracy in Reporting) also makes our blood boil. It’s as if our movement doesn’t exist. But it does. There are hundreds of grassroots SP organizations all across the country engaging in public activism and protest, we just don’t get press.

Only John Conyers single-payer legislation, HR 676, The United States National Health Care Act, fundamentally restructures health care, guarantees it to the entire population (the undocumented, too) and is fully funded. No other piece of legislation is as comprehensive. How many Americans know about this amazing, life-transforming bill that delinks employment from insurance and abolishes the despised health insurance industry? Has there been a front page story or major magazine interview with Congressman Conyers? There’s been virtually no stories about labor’s support for HR 676, despite the fact it’s been endorsed by 554 union organizations in 49 states and by 130 Central Labor Councils. But we heard plenty when Andy Stern, the president of the SEIU sat down with Lee Scott, the CEO of Wal-mart to discuss solutions to the nation’s health care crisis. Those two are experts on providing health care to workers? What about the nurses and doctors who support single-payer and got dragged out of, and arrested in Max Baucus’s senate hearings in Washington, DC? If doctors and nurses had been arrested for any other political issue it would have been the lead story in every newspaper and online edition. Doctors and nurses never deliberately get arrested — that’s news!

The sea change in the public’s attitude toward government financed health care, however, has gotten press. A New York Times poll in June found that 72 percent supported a government-administered insurance plan – like Medicare for everyone under the age of 65. That poll also reported 64 percent believed the federal government should guarantee coverage to the entire population, i.e. health care should be a human right. Another interesting number: 85 percent of respondents said the health care system needed to be fundamentally changed or completely rebuilt. This is in stark contrast to President Obama’s position of tepid, incremental reform. Obama asserts if he was starting from scratch he might favor SP, but we aren’t so he can’t. He wants to build on the existing system and not “disrupt” the employment-based provision of health care. As if employment-based health coverage isn’t being massively “disrupted” by the economic depression that has laid off millions of workers and forced them down into the ranks of the 50 million uninsured.

But what is truly disgusting is how the “progressive” left has caved so quickly and cravenly, given up the fight for single-payer and support for HR 676. They have become the indignant foot soldiers, apologists and spinmeisters for Obama’s piece of shit legislation. They are betraying what they absolutely know to be true: the private insurance industry must be evicted in order to provide health care to everyone and end the fiscal crisis the multiple-payer system creates. Even the insurance companies know that according to revelations by Cigna whistleblower Wendell Potter. He reports the implementation of a single-payer health care system is what keeps the billionaire CEO’s of insurance companies and Karen Ignagni, the high priestess of America’s Health Insurance Plans (AHIP), awake at night cowering in fear and forced to spend 1.4 million dollars a day to make sure it doesn’t happen. They don’t fear a public option despite their protestations; they accept that due to the depth of the crisis, a few token compromises are in order to stay in business. It’s chump change and in exchange for perhaps losing a little market share, they’re going to get a mandate that legally obligates every person to buy their priced-to-make-profits “insurance products” or be financially penalized. If the Obama bill subsidizes the uninsured going into private plans, that’s millions of new customers to extract profits from and a transfer of taxpayer dollars into insurance industry coffers. The Massachusetts mandate madness gone nationwide.

First the “progressive” Democratic Caucus jumped the single-payer ship arguing without even launching a fight that HR 676 was not “politically viable.” A senior research associate with Physicians for a National Health Program (PNHP) told the following story. He gave testimony to the caucus on why the public option was flawed and to continue robust support for HR 676. He was appalled to learn staffers for caucus members were claiming the public option was the same as single-payer or would lead to single-payer. The staffers banned him from handing out information comparing the public option to single-payer. They tried to censor his speech but he gave it anyway. When members of the caucus asked questions staffers continually interrupted him.

Health Care for American (HCAN), Katrina Vanden Heuvel of The Nation, Robert Reich, Joshua Holland of Alternet, and a raft of other progressive political pundits are pumping out article after article attempting to explain away or marginalize the myriad problems with the public option: the gaps in coverage, the millions that will be left uninsured, and how to fund it so that it’s “deficit neutral.”

They often begin by declaring, “I’d prefer a single-payer system but…” But what?

Joshua Holland’s article titled, “We Need Clear Thinking: There Should Be No Clash Between Public Option and Single-Payer,” is the most recent and best example of giving up and selling out single-payer. He too confesses in the piece (three times!) he really is an advocate of single-payer, but … But what? Holland argues, “The public insurance/single-payer rift is a false dichotomy and is distracting us from the real fight.” Dead wrong. The so-called public option and SP as embodied in HR 676 stand in direct opposition to one another. The “real fight” is to pass HR 676. The “distraction” is the public option. Holland then goes on to undercut his argument even further by maintaining, “The proposal before us today, if done right – and the devil is most certainly in the details – achieve a hybrid public-private system with “some single-payer features…” Huh? We already have that system, it’s not working. Holland thinks eventually the public option will “achieve something approaching a single-payer system – through the back door.” I’m gobsmacked by Joshua’s naiveté or is it stupidity? Single-payer health care systems always come in through the front door. They don’t evolve into existence over time.

Secretary of Health and Human Services Kathleen Sebelius was asked about the public option, “Can you say flat out that it’s just never going to be single-payer health insurance?” She replied, “Oh, I think that’s very much the case.” She then went on to make the case which I won’t repeat here. When President Obama addressed the American Medical Association (AMA) he asserted, “What are not legitimate concerns are those being put forward that claim a public option is somehow a Trojan horse for a single-payer system…So when you hear the naysayers claim that I’m trying to bring about government-run health care, know this – they’re not telling the truth.”
We would do well to believe Obama and his fellow Democrats when they straight up tell us they are opposed to single-payer.

But Holland’s noxious line of reasoning goes even further. He posits the false notion that single-payer systems don’t really exist in other countries, but instead are “multiple-payers but with some single-payer features.” He cites Germany, Holland, Belgium and France as examples. This is simply not true. Elimination of U.S.-style private insurance, if it existed in the first place, has been a prerequisite to implementing a universal health care system in every country that has socialized health care. In each country the government guarantees coverage and pays for the majority of it, even though it might be privately delivered. Moreover, in none of these countries does the private insurance industry have the power, profits or influence they do in the United States. In some, they are allowed to feed around the edges of the system which can lead to problems. Ireland is an example. The private health insurer BUPA recently left the Irish market after a judge determined the company had unfairly skimmed healthier patients from the public system and ordered the company to make adjustment payments. Can you imagine that ever happening in the United States?

Holland thinks progressives need to “refocus the debate toward how much private sector involvement we want, what structure we might adopt for health care financed through the private sector in order to keep the insurance industry’s predations in check.” He acts as if all sides in the health care debate were sitting down as equals and had equal input. Progressive don’t even have a seat at the damn table. Holland sounds like Obama who tells us we have to keep the insurance companies “honest.”

This is a debate over fundamentals and ideology, not tactics on how to get to a single-payer system, despite Holland’s insistence it’s the other way round. Single-payer supporters aren’t fighting for a health care system designed to keep corporate killers predations in check, ensuring their honesty or “fair competition.” Why would anyone want to do that? Our movement is fighting to get rid of an industry that puts profits over patients once and for all and we have the audacity to believe we can do it.

We haven’t given up and we haven’t sold out.

It’s both better and honest to stand up and get arrested fighting for a piece of legislation you know will end unnecessary death and human suffering than to crawl and “advocate fiercely” as Holland is for a piece of shit legislation he knows will not.

Helen Redmond is a member of Chicago Single-Payer Action Network (CSPAN) and a licensed clinical social worker at Cook County Hospital and Clinics. She can be reached at: redmondmadrid@yahoo.com

Bait and switch: How the “public option” was sold

By Kip Sullivan for PNHP -

The people who brought us the “public option” began their campaign promising one thing but now promote something entirely different. To make matters worse, they have not told the public they have backpedalled. The campaign for the “public option” resembles the classic bait-and-switch scam: tell your customers you’ve got one thing for sale when in fact you’re selling something very different.

When the “public option” campaign began, its leaders promoted a huge “Medicare-like” program that would enroll about 130 million people. Such a program would dwarf even Medicare, which, with its 45 million enrollees, is the nation’s largest health insurer, public or private. But today “public option” advocates sing the praises of tiny “public options” contained in congressional legislation sponsored by leading Democrats that bear no resemblance to the original model.

According to the Congressional Budget Office, the “public options” described in the Democrats’ legislation might enroll 10 million people and will have virtually no effect on health care costs, which means the “public options” cannot, by themselves, have any effect on the number of uninsured. But the leaders of the “public option” movement haven’t told the public they have abandoned their original vision. It’s high time they did.

The bait

“Public option” refers to a proposal, as Timothy Noah put it, “dreamed up” by Jacob Hacker when Hacker was still a graduate student working on a degree in political science. In two papers, one published in 2001 and the second in 2007, Hacker, now a professor of political science at Berkeley, proposed that Congress create an enormous “Medicare-like” program that would sell health insurance to the non-elderly in competition with the 1,000 to 1,500 health insurance companies that sell insurance today.

Hacker claimed the program, which he called “Medicare Plus” in 2001 and “Health Care for America Plan” in 2007, would enjoy the advantages that make Medicare so efficient – large size, low provider payment rates and low overhead. (Medicare is the nation’s largest health insurance program, public or private. It pays doctors and hospitals about 20 percent less than the insurance industry does, and its administrative costs account for only 2 percent of its expenditures compared with 20 percent for the insurance industry.)

Hacker predicted that his proposed public program would so closely resemble Medicare that it would be able to set its premiums far below those of other insurance companies and enroll at least half the non-elderly population. These predictions were confirmed by the Lewin Group, a very mainstream consulting firm. In its report on Hacker’s 2001 paper, Lewin concluded Hacker’s “Medicare Plus” program would enroll 113 million people (46 percent of the non-elderly) and cut the number of uninsured to 5 million. In its report on Hacker’s 2007 paper, Lewin concluded Hacker’s “Health Care for America Plan” would enroll 129 million people (50 percent of the nonelderly population) and cut the uninsured to 2 million.

Until last year, Hacker and his allies were not the least bit shy about highlighting the enormous size of Hacker’s proposed public program. For example, in his 2001 paper Hacker stated:

[A]pproximately 50 to 70 percent of the non-elderly population would be enrolled in Medicare Plus…. Put more simply, the plan would be very large…. [C]ritics will resurface whatever the size of the public plan. But this is an area where an intuitive and widely held notion – that displacement of employment-based coverage should be avoided at all costs – is fundamentally at odds with good public policy. A large public plan should be embraced, not avoided. It is, in fact, key to fulfilling the goals of this proposal. (page 17)

In his 2007 paper, Hacker stated:

For millions of Americans who are now uninsured or lack … affordable work place coverage, the Health Care for America Plan would be an extremely attractive option. Through it, roughly half of non-elderly Americans would have access to a good public insurance plan…. A single national insurance pool covering nearly half the population would create huge administrative efficiencies. (page 5)

Hacker’s papers and the Lewin Group’s analyses of them have been cited by numerous “public option” advocates. For example, when Hacker released his 2007 paper, Campaign for America’s Future (CAF) published a press release praising it and drawing attention to the large size of Hacker’s proposed public program. The release, entitled “Activists and experts hail Health Care for America plan,” stated:

Detailed micro-simulation estimates suggest that roughly half of non-elderly Americans would remain in workplace health insurance, with the other half enrolled in Health Care for America…. A single national insurance pool covering nearly half the population would create huge administrative efficiencies…. Because Medicare and Health Care for America would bargain jointly for lower prices …, they would have enormous combined leverage to hold down costs.

When the Lewin Group released its 2008 analysis of Hacker’s 2007 paper, CAF’s Roger Hickey wrote in the Huffington Post, “efficiencies achievable … through Hacker’s public health insurance program” would save so much money that the US could “cover everyone” for no more than we spend now.

The switch

Now let’s compare the “single national health insurance pool covering nearly half the population” that Hacker and other “public option” advocates enthusiastically championed with the “public option” proposed by Democrats in Congress, and then let’s inquire what Hacker and company said about it.

As readers of this blog no doubt know, the Senate Health, Education, Labor, and Pensions (HELP) Committee, and three House committee chairman working jointly, published draft health care “reform” bills in June. (The third committee with bill-writing authority, the Senate Finance Committee, has yet to produce a bill.) According to the Congressional Budget Office, the “public option” proposed in the House “tri-committee” bill might insure 10 million people and would leave 16 to 17 million people uninsured. The “public option” proposed by the Senate HELP committee, again according to the Congressional Budget Office, is unlikely to insure anyone and would hence leave 33 to 34 million uninsured. The CBO said its estimate of 10 million for the House bill was highly uncertain, which is not surprising given how vaguely the House legislation describes the “public option.”

Here is what the CBO had to say about the HELP committee bill:

The new draft also includes provisions regarding a “public plan,” but those provisions did not have a substantial effect on the cost or enrollment projections, largely because the public plan would pay providers of health care at rates comparable to privately negotiated rates – and thus was not projected to have premiums lower than those charged by private insurance plans. (page 3)

Obviously the “public option” in the Senate HELP committee bill (zero enrollees; 34 million people left uninsured) and the “public option” in the House bill (10 million enrollees (maybe!); 17 million people left uninsured) are a far cry from the “public option” originally proposed by Professor Hacker (129 million enrollees; 2 million people left uninsured). Have we heard the Democrats in Congress who drafted these provisions utter a word about how different their “public options” are from the large Medicare-like program that Hacker proposed and his allies publicized? What have Professor Hacker and his allies had to say?

In public comments about the Democrats’ “public option” provisions, the leading lights of the “public option” movement imply that Hacker’s model is what Congress is debating. Sometimes they come right out and praise the Democrats’ version as “robust” and “strong.” But I cannot find a single example of a a statement by a “public option” advocate warning the public of the vast difference between Hacker’s original elephantine, “Medicare-like” program and the Democrats’ mouse version.

For example, on June 23, Hacker testified before the House Education and Labor Committee that “the draft legislation prepared by [the] special tri-committee promises enormous progress.” He went on to enumerate all the benefits of a “public option.” Yet the House tri-committee proposal bore no resemblance to the public plan he described in his papers and that the Lewin Group analyzed. Later, when Kaiser Health News asked Hacker in a July 6 interview why “your signature idea – a public plan – has become central to the health care reform debate,” Hacker again praised his “public plan” proposal and offered no hint that the “public option” so “central to the debate” was very different from the one he originally proposed.

Ditto for Hacker’s allies. Representatives of Health Care for America Now (HCAN), the organization most responsible for popularizing the “public option,” repeatedly describe the House and Senate HELP committee bills as “strong” or “robust,” always without any justification for this claim, and have repeatedly failed to warn the public that the “public options” they promote today are mere shadows of the “public options” they endorsed in the past. On July 15, the day the HELP committee passed its bill, Jason Rosenbaum blogged for HCAN:

The Senate HELP Committee has just referred a bill to the floor of the Senate with a strong public option.

Searching the websites of the organizations that serve on HCAN’s steering committee – AFSCME, Democracy for America, Moveon.org and SEIU, for example – one will find not a shred of information that would help the reader comprehend how small and ineffective the “public options” proposed in the Democrats’ bills are, nor how different these are from the one Hacker originally proposed. Yet these groups continue to urge their members and the public to “tell Congress to support a public option.”

Hacker’s original model compared with the Democrats’ mouse model

It has become fashionable among advocates of a “public option” to trash the expertise and the motives of the Congressional Budget Office. But the CBO’s characterization of the “public option” proposed in the Democrats’ legislation is entirely reasonable. This becomes apparent the moment we compare Hacker’s blueprint for his original “Medicare Plus” and “Health Care for America” programs with the “blueprints” (if tabula rasas can be called “blueprints”) contained in the Senate HELP Committee and House bills.

Hacker’s papers laid out these five criteria that he and the Lewin Group said were critical to the success of the “public option”:

• The PO had to be pre-populated with tens of millions of people, that is, it had to begin like Medicare did representing a large pool of people the day it commenced operations (Hacker proposed shifting all or most uninsured people as well as Medicaid and SCHIP enrollees into his public program);
• Subsidies to individuals to buy insurance would be substantial, and only PO enrollees could get subsidies (people who chose to buy insurance from insurance companies could not get subsidies);
• The PO and its subsidies had to be available to all nonelderly Americans (not just the uninsured and employees of small employers);
• The PO had to be given authority to use Medicare’s provider reimbursement rates; and
• The insurance industry had to be required to offer the same minimum level of benefits the PO had to offer.

Hacker predicted, and both of the Lewin Group reports concluded, that if these specifications were met Hacker’s plan would enjoy all three of Medicare’s advantages – it would be huge, it would have low overhead costs, and it would pay providers less than the insurance industry did. As a result, the “public option” would be able to set its premiums below those of the insurance industry and seize nearly half the non-elderly market from the insurance industry. According to the Lewin Group’s 2008 report, Hacker’s version of the “public option” would, as of 2007:

• Enroll 129 million enrollees (or 50 percent of the non-elderly);
• Have overhead costs equal to 3 percent of expenditures;
• Pay hospitals 26 percent less and doctors 17 percent less than the insurance industry (but these discounts would be offset to some degree by increases in payments to providers treating former Medicaid enrollees); and,
• Set its premiums 23 below those of the average insurance company.

I question some of Hacker’s and the Lewin Group’s assumptions, including their assumption that any public program that has to sell health insurance in competition with insurance companies could keep its overhead costs anywhere near those of Medicare (Medicare is a single-payer program that has no competition), especially during the early years when the public program will be scrambling to sign up enrollees. A public program will have to hire a sales force and advertise. It will have to open offices. It will have to negotiate rates, and perhaps contracts, with thousands of hospitals and hundreds of thousands of clinics, chemical treatment facilities, rehab units, home health agencies, etc. Or it will have to contract with someone to do all that. But I have little doubt that if a public program were to open with a large enough customer base, and it had the advantage of a law requiring that only its customers receive substantial subsidies, it could do what the Lewin Group said it could do.

Now let us compare Hacker’s original model with the mousey “public options” proposed by the Senate HELP Committee and the House. Of Hacker’s five criteria, only one is met by these bills! Both proposals require the insurance industry to cover the same benefits the “public option” must cover. None of the other four criteria are met. The “public option” is not pre-populated, the subsidies to employers and to individuals go to the “public option” and the insurance industry, employees of large employers cannot buy insurance from the “public option” in the first few years after the plan opens for business and maybe never (that decision will be made by whoever is President around 2015), and the “public option” is not authorized to use Medicare’s provider payment rates. (The House bill comes the closest to authorizing use of Medicare’s rates; it authorizes Medicare’s rates plus 5 percent).

Is it any wonder the CBO concluded the Democrats’ “public option” will be a tiny little creature incapable of doing much of anything? More curious is that CBO gave the House “public option” any credit at all (you will recall CBO said it would enroll maybe 10 million people). The CBO should have asked, Can the “public option” – as presented in either bill – survive?

Put yourself in the “public option” director’s shoes

To see why the “public option” proposed by congressional Democrats remains at great risk of stillbirth, let’s engage in a frustrating thought experiment. Let’s imagine Congress has enacted the House version (it is not quite as weak as the HELP Committee model and thus gives us the greatest opportunity in our thought experiment to imagine a scenario in which the “public option” actually survives its start-up phase). Let us imagine furthermore that you have been foolish enough to apply for the job of executive director of the new “public option,” and the Secretary of the Department of Health and Human Services (the federal agency within which the program will be housed) decided to hire you. It’s your first day on the job.

You know the House bill did not create a ready-made pool of enrollees for you to work with the way the 1965 Medicare law created a ready-made pool of seniors prior to the day Medicare commenced operations. You realize, in other words, that you represent not a single soul, much less tens of millions of enrollees. You will have to build a pool of enrollees from scratch. You also know the House bill authorized some start-up money for you, so you’ll be able to hire some staff, including sales people if you choose. You can also open offices around the country, and advertise if you think it necessary. But you know you can’t pay out too much money getting the “public option” started because the House bill requires that you pay back whatever start-up costs you incur within ten years. In other words, you may hire enough people and open enough offices and buy enough advertising to create a critical mass of enrollees nationwide, but you must do it quickly so that your start-up costs don’t sink the “public option” during its first decade.

The only other feature in the House bill that appears to give you any advantage over the insurance industry is the provision requiring you to use Medicare’s rates plus 5 percent, which essentially means you are authorized to pay providers 15 percent less than the insurance industry pays on average. But the House bill also says providers are free to refuse to participate in the plan you run.

So what do you do? Let’s say you open offices in dozens or hundreds of cities, you hire a sales force to fan out across the country to sign up customers, you advertise on radio and TV to get potential customers (employers and individuals) to call your new sales force to inquire about the new “public option” insurance policy. What happens when potential customers ask your salespeople two obvious questions: what will the premium be and which doctors they can see? What do your employees say? They can’t say anything. They haven’t talked to any clinics or hospitals about participating at the 15-percent-below-industry-average payment rate, so they have no idea which providers if any will agree to participate. They also have no idea what the “public option” premium will be because they don’t know whether providers will accept the low rates the plan is authorized to pay. And they have no idea about several other factors that will affect the premiums, including how much overhead the “public option” will rack up before it reaches a state of viability, or who the “public option” will be insuring – healthy people, sick people, or people of average health status.

So, let’s say you redeploy your sales force. Now instead of talking to potential customers, you direct them to focus on providers first. But when your salespeople call on doctors and hospital administrators and ask them if they’ll agree to take enrollees at below-average payment rates, providers ask how many people the “public option” will enroll in their area. Providers explain to your salespeople that they are already giving huge discounts, some as high as 30 to 40 percent off their customary charge, to the largest insurers in their area and they are not eager to do that for the “public option” unless the plan will have such a large share of the market in their area that it will deliver many patients to them. If the “public option” cannot do that, providers tell your salespeople, they will not agree to accept below-average payment rates.

In other words, you find that the “public option” is at the mercy of the private insurance market, not the other way around.

This thought experiment illustrates for you the mind-numbing chicken-and-egg problem created by any “public option” project that does not meet Hacker’s criteria, most notably, the criterion requiring pre-population of the “public option.” If the pre-population criterion isn’t met, the poor chump who has to create the “public option” is essentially being asked to solve a problem that is as difficult as describing the sound of one hand clapping. You need both hands to clap.

How did the mouse replace the elephant?

How did the “Medicare Plus” proposal of 2001 (when Hacker first proposed it) get transformed into the tiny “public options” contained in the Democrats’ 2009 legislation? The answer is that somewhere along the line it became obvious that the Hacker model was too difficult to enact and had to be stripped down to something more mouse-like in order to pass. Did the leading “public option” advocates realize this early in the campaign? Or midway through the campaign when the insurance industry began to attack the “public option”? Or late in the campaign when they found it difficult to persuade members of Congress to support Hacker’s original model? Whatever the answer, will they find it in their hearts to tell their followers their original strategy was wrong?

I suspect the answer is different for different actors within the “public option” movement. Hacker surely knew what was in his original proposal and surely knows now that the Democrats’ bills don’t reflect his original proposal. Hacker and others familiar with his original proposal were probably betrayed by the process. As the “public option” concept became famous and edged its way toward the centers of power, they couldn’t find the courage to resist the transformation of the original proposal into the mouse model.

For other actors within the “public option” movement, ignorance of Hacker’s original proposal and of health policy in general may have led them to rely on more knowledgeable leaders in the movement. Their error, in other words, was to trust the wrong people and, as the “public option” came under attack, to cave in to group think. This error was facilitated by the “public option” movement’s decision to avoid mentioning any details of the “public option” whenever possible.

What next?

Those of us in the American single-payer movement must continue to educate Congress and the public on the need for a single-payer system. We must also convince advocates of the “public option” that they have made two serious mistakes and, if they learn quickly from these mistakes, that real reform is still possible.

The first mistake was to think that a “public option” that merely took over a large chunk of the non-elderly market (as opposed to one that took over the entire market) could substantially reduce health care costs and thereby make universal coverage politically feasible. Any proposal that leaves in place a multiple-payer system — even a multiple-payer system with a large government-run program in the middle of it — is going to save very little money. Even if Hacker’s original Health Care for America Plan had taken over half the non-elderly market and then reached homeostasis (something Hacker swore up and down it would do), the savings would have been relatively small. The reason for that is twofold. First, any insurance program, public or private, that has to compete with other insurers is going to have overhead costs substantially higher than Medicare’s. (It is precisely because Medicare is a single-payer program that its overhead costs are low.) Second, the multiple-payer system Hacker would leave in place would continue to impose unnecessarily large overhead costs on providers.

The second mistake the “public option” movement made was to think the insurance industry and the right wing would treat a “public option” more gently than a single-payer. Conservatives have a long history of treating small incremental proposals such as “comparative effectiveness research” as the equivalent of “a government takeover of the health care system.” It should have been no surprise to anyone that conservatives would shriek “socialism!” at the sight of the “public option,” even the mouse model proposed by the Democrats.

The bait-and-switch strategy adopted by the “public option” movement has put the Democrats in a terrible quandary. Seduced by the false advertising about the potency of the “public option” to lower costs, Democrats have raised public expectations for reform to unprecedented levels. Failing to meet those expectations during the 2009 session of Congress, which is inevitable if the Democrats continue to promote legislation like the bills released in June, is going to have unpleasant consequences. Is there no way out of this quandary?

Conventional wisdom holds that if the Democrats don’t pass a health care reform bill by December, they will have to wait till 2013 to try again. But if the “public option” movement were to join forces with the single-payer movement, the two movements could prove the conventional wisdom wrong. This won’t happen, obviously, if the “public option” movement fails to perceive the reasons it failed.

It is conceivable the “public option” movement could decide the bait-and-switch strategy was wrong and that their only error was not to stick with Hacker’s original model. It should be obvious now that that would also be a tactical blunder. We have plenty of evidence now that conservatives will react to the mousey version of the “public option” as if it were “a stalking horse for single-payer.” We can predict with complete certainty they will treat Hacker’s original version as something even closer to single-payer. If a proposal is going to be abused as if it were single-payer, why not actually propose a single-payer? At least then, when a particular session of Congress comes and goes and we haven’t enacted a single-payer system, we will have educated the public about the benefits of a single-payer and have further strengthened the single-payer movement.

To sum up, “public option” advocates must choose between continuing to promote the “public option” and seeing their hopes for cost containment and universal coverage go up in smoke for another four years, and throwing their considerable influence behind single-payer legislation. At this late date in the 2009 session, it is unlikely that a single-payer bill could be passed even if unity within the universal coverage movement could be achieved. But if the “public option” wing and the single-payer wing join together to demand that Congress enact a single-payer system, December 2009 need not constitute a deadline.

Kip Sullivan belongs to the steering committee of the Minnesota chapter of Physicians for a National Health Program.

Healthcare-NOW! is Not Mobilizing for June 25th Rally in DC

This statement has been prepared in response to the many inquiries as to why organizations supporting single-payer national health care are not mobilizing to support the June 25th rally in Washington DC organized by Health Care for America Now.

Friends:

As you know, the single-payer movement is driven by a diverse coalition of doctors, nurses, labor, civic and faith groups, and concerned Americans advocating for single-payer national health care, improved Medicare for all. This year, key organizations, including Healthcare-NOW!, the California Nurses Association, Physicians for a National Health Program, Progressive Democrats of America, and 80 other member organizations have come together under the umbrella of the Leadership Conference for Guaranteed Health Care (LCGHC), the National Single Payer Alliance.

This alliance operates with a decision making body of member organizations that support single-payer legislation HR 676 and S703. We all agree that single-payer is the only answer to our health care crisis. All other reform options fall short of the single-payer standards of universality and cost-effectiveness.

With our commitment to single-payer, we are widening the debate to include advocacy for a guaranteed health care system for all people in the United States. We have seen a powerful response from the public of this nation as we stand firmly behind single-payer as the best way to achieve health care as a human right. Especially in recent weeks, this strategy has proved fruitful in raising consciousness for the demand for a single-payer system that removes profit and waste from the system to guarantee health care to everyone. We have 82 cosponsors on HR 676 and continue to pull in resolutions from unions, faith groups, and other organizations regularly. We are having the first official congressional hearing on single-payer in the House on June 10th.

In the face of other reform proposals that maintain the private insurance industry, single-payer is still the preferred reform for the American people and physicians. Many in the Health Care for All movement agree that single-payer is the gold standard for reform, but some coalitions and individuals are now supporting the choice of private insurance or a public option. While the LCGHC has formally decided not to support a public option that maintains wasteful private insurance companies, we know that there are many people who feel that advocating for the public option may lead to meaningful reform.

The LCGHC will not be supporting any rallies, events, lobby days, or other activities for the public option reform for the following reasons:

1) Many member organizations feel that disrupting an event organized to support the public option will be counterproductive to our work in building the movement for single-payer. Many public option supporters are also single-payer supporters. We don’t want to alienate those who still support single-payer despite other reform strategies that they hope will lead to meaningful reform.

2) Previous events that were attended by both Health Care for America Now and Single-Payer groups caused confusion. Healthcare-NOW!, with a similar name, received many emails concerned that Healthcare-NOW! was no longer supporting single-payer. We don’t want to contribute to the confusion between two very different policies, single-payer and the public option.

3) We want to focus on building the movement for single-payer and the best way we can do that is by focusing on single-payer actions in DC and locally. The events committee of the Leadership Conference is working to coordinate actions that will support single-payer. We hope you will join us as we move forward. It is very heartening to see the energy and support nationwide as we build the grassroots energy to insert this much needed solution into the health reform discussion. We do not want to bury single-payer support within principles, no matter how politically practical, that will not solve our health care crisis.

There will be a rally for Human Rights in Washington DC sponsored by the National Health Care for the Homeless Council on Friday, June 26th at 6 p.m. You are invited to join advocates, service providers and consumers to speak out for the right to health care, housing, and livable incomes.

We hope that everyone will mark their calendars for a National Call-In Day for single-payer on June 22nd, and again on July 30th celebrating Medicare’s Birthday in DC and around the country. Stay tuned for details.

Thank you for helping to build the single-payer movement!

In common cause,

Leadership Conference for Guaranteed Health Care, Steering Committee
Healthcare-NOW!, National Staff

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