While President Obama has stated he will not urge cuts to Social Security in his speech tonight, a narrowly defeated proposal by the Deficit Commission to cut these programs means we have to continue to be vigilant.

Leaders in Congress are still seeking to privatize Social Security and turn Medicare into a voucher program, claiming it will save money.

Tell President Obama “No cuts, no privatization, and no raising the eligibility age of Social Security, Medicare, and Medicaid” on his watch.

Email President Obama here. Or call the White House at 202-456-1414.

The vast majority of Americans support increasing taxes on the rich to fund these programs rather than cut them.

Make your voice heard. Email President Obama here. Or call the White House at 202-456-1414.

Dr. William Hsiao made his presentation to the full Vermont House and Senate Wednesday, Jan. 19. His full 138-page report in PDF is here. His PowerPoint presentation is available in PDF here. For his 10-page summary statement in PDF click here .

The very day the U.S. House of Representatives declared last year’s health care bill excessive and voted to repeal it, Vermont’s Legislature heard – and seemed to welcome – a report declaring that the new law did not go far enough, and that Vermont should establish a unique “public-private single payer system” to “show the way forward for the rest of the United States.”

The concurrence was no doubt mere coincidence, but Vermont’s apparent determination to go its own way is not. If state lawmakers and Gov. Peter Shumlin, who campaigned on a single payer system, enact such a plan, Vermont would indeed be in the vanguard.

Though some in the Capitol were wary of the recommendations from Harvard economist William V. Hsiao, and no one endorsed every detail of his draft proposal (including an 11 percent payroll tax), Democratic and Republican lawmakers agreed that a major transformation of the state’s health insurance system was likely to pass the Legislature, and that it would go at least in the general direction of Hsiao’s report.

Hsiao says his single payer plan, designed to provide coverage to every Vermonter while reducing health care costs for most of them, would reduce eight to 12 percent of health care costs immediately (once implemented in 2015) and an additional 12 percent to 14 percent over time. In addition, he says it will help to create 5,000 new jobs because it will enable businesses that are burdened by health care costs to expand.

If Vermont adopted the hybrid single payer system he proposes, Hsiao said the state’s projected absolute savings over time would be $490 million in 2015; $1.35 billion in 2019; and $2.1 billion in 2024. (The margin of error for these estimates is 15 percent.) The savings would be used to provide coverage for uninsured and underinsured Vermonters, and would be invested in primary care services.

Whether the hybrid public-private plan would make Vermont the national model envisioned by Hsiao and Gov. Peter Shumlin, or saddle the state with an unworkable system out of synch with the rest of the country, remains unknown, and no doubt will be debated over the next few months.

But while some Republicans doubted Hsiao’s claim that switching to “a uniform rate and payment structure,” for health financing would make Vermont both healthier and richer, there was surprisingly little outright hostility and rejection of the hybrid single payer plan, radical though it may be from a national perspective.

The general sentiment seemed to be that something was likely to pass, and that an interest group has a better chance of influencing the final product if it did not trash the basic proposal from the get-go.

Even the private insurance companies, many of whose policy-holders would presumably be diverted to the new “single pipe” which would channel all payments to doctors and hospitals through set rates for procedures cautiously welcomed Hsiao’s proposal.

“It’s not keeping me up at night,” said Bill Little, the Vermont vice president for MVP Health Care, who said that under the plan his company might be able to offer supplemental coverage to Vermonters covered by the single-payer plan, including Medicare patients. The Hsiao plan would not affect Medicare coverage.

Blue Cross and Blue Shield, the state’s largest private insurer, issued a statement pledging to work with lawmakers “as they evaluate various approaches to health care reform.” The “Blues,” as a non-profit with a long history in the state, see the possibility of becoming an integral part of the proposed new system, which isn’t designed to be administered by state government. Under Hsiao’s plan, private companies could compete in a bidding process to provide health care and administrative services.

“If there’s a single payer system, we’d like to be the single payer,” said Leigh Tofferi, the Blue Cross-Blue Shield lobbyist in the Legislature.

Though anything can happen in the legislative session, the consensus that a health care bill would pass rested to some extent on the apparent support, in an overwhelmingly Democratic Legislature, from Shumlin, House Speaker Shap Smith, Senate President Pro Tem John Campbell, and the chairs of the health committees in both houses.

Smith said he was not bothered by the complication that though the new plan is scheduled to go into effect in 2014, right now federal law would not allow Vermont to make such extensive changes until 2017 and even then only with waivers from the Department of Health and Human Services. Hsiao points to 15 major barriers to reform, including waivers for Medicare, Medicaid, the employment self-insurance law known as ERISA and the Patient Protection and Affordable Care Act. (The law U.S. House Representatives voted to repeal today.)

It would not be unprecedented, the Speaker said, for the Legislature to enact “a plan to be implemented over a course of years,” based on some kind of “trigger mechanism” in which provisions would become active as federal law permitted.

Perhaps the most negative reaction came from The Associated Industries of Vermont, whose spokesperson, Bill Driscoll, said his organization was “fairly skeptical” that the plan would really reduce costs “on a sustainable basis.”

As several lawmakers pointed out, the report’s release was just the beginning of a long process, and despite the support from the Democratic majority for the general concept, many of the specifics face opposition from politically powerful interests.

As Hsiao acknowledged, much of the burden for financing the plan would be borne by specialist physicians, some small businesses, and affluent two-earner couples, all of whom are adept at public relations and political infighting.

Shumlin administration in wait-and-see mode

The Shumlin administration has already started writing a bill, which will be submitted to the Legislature in the coming weeks. Lawmakers will then vet the bill in the committees of jurisdiction in the House and Senate. In the meantime, Hsiao is taking public comment on his draft proposal, and he will present a final report on Feb. 17 after he has incorporated changes proposed by stakeholders and others.

The question is: Will the administration incorporate Hsiao’s report whole cloth into the bill it proposes to the Legislature? Probably not. Anya Rader Wallack, a health care policy expert who is spearheading Shumlin’s reform efforts in Vermont, said the Hsiao report will “heavily influence” the legislation. She said it’s “too early to tell,” for example, if Shumlin will propose a payroll tax.

“You’ll see some of our ideas in the bill,” Wallack said, which will be a roadmap for how the state gets from “here to there.”

Wallack said the report wasn’t finished until 3 a.m. on Tuesday, and she didn’t receive a final draft until today. At the “30,000 foot level,” she said conceptually some of the recommendations, such as a uniform payment system — across-the-board rates for medical treatments, procedures, visits and hospital stays — makes sense, but “what that means exactly” is anyone’s guess at this point. She agreed with Hsiao’s assessment that the current payment methods, in which health care providers are remunerated on a “fee-for-service” basis, makes the existing payment structure “chaotic.”

“You’d be hard-pressed to find someone who thought the best way to pay for medical care is through fee for service,” Wallack said.

Hsiao report redux

Last summer, the Vermont Health Care Reform Commission hired Hsiao to devise three different health care reform plans. He was charged with finding a way to contain costs, giving all Vermonters equal access to medical care and establishing a system in which medical providers can share information about their patients more efficiently.

Hsiao, an internationally renowned economist from the Harvard School of Public Health, designed three health care reform plans: a government run single-payer system (Option 1), a public option (Option 2), in which health insurers compete for patients through exchanges, and Option 3, a.k.a. the economist’s free choice.

Hsiao recommended Option 3, which he presented to lawmakers as a public-private hybrid single payer plan.

In the months leading up to the release of the report, Hsiao and his team of 20 specialists analyzed existing data from state agencies in order to get a snapshot of the cost effectiveness of the state’s system.

The findings were grim. They found waste, fraud and abuse; skyrocketing costs; and profound inequities between Vermonters who have good jobs with benefits and low-wage workers who pay a disproportionate share of their incomes toward health care costs.

Health care expenditures are likely to grow by $1 billion from 2010 through 2012, according to state data, and unless Vermont takes steps to reform its system, the number of state residents who are uninsured or underinsured would continue to remain high even after the federal Patient Protection and Affordable Care Act goes into effect. Fifteen percent of Vermonters would continue to lack adequate medical coverage and would spend a high percentage of their household budgets on insurance; 32,000 of the state’s residents would remain uninsured under the PPACA.

Against this backdrop, Hsiao and his team of 20 specialists ran the numbers on all three reform concepts. In his report, Hsiao rejects the public option for two reasons: It doesn’t save nearly as much money as the two single payer systems, and it doesn’t provide medical coverage for all Vermonters.

Hsiao’s Option 3, which is based on a public-private partnership, would provide the two crucial elements of a single payer system – a common benefits package for all Vermonters and a uniform payment program for all health care providers. The uniform payment program is a cost containment exercise in which a single rate is set for procedures, treatments and hospital stays. Under such a system, all payments would be administered through “one pipe.”

That single pipe concept sounds simple, but it’s one of the keys to the kingdom. Without it, the state will continue to see “chaotic conditions,” like the state has now, Hsiao said, in which providers all charge different rates for procedures, office visits, and the like. The result is cost shifting — or increases in rates to Vermonters who are paying for insurance.

The hybrid has another, not-to-be-underestimated saving grace: It doesn’t come with the political baggage of a government-run system, according to the report.

Does the hybrid plan meet the definition of single-payer system? It depends on where you’re sitting. “Single payer is like beauty, it’s in the eye of the beholder,” Hsiao said. “For our work we must define it precisely.”

Dr. Deb Richter, a longtime advocate for single payer (she’s been lobbying the Legislature for 22 years), said a government administered system “makes the most sense in terms of good policy,” but the system doesn’t have to be controlled by the government to be effective.

Richter describes Option 3 as a “hybrid of good policy and politics from Dr. Hsiao’s point of view.”

Under Hsiao’s version of single payer, all Vermonters would have insurance coverage and the system would be administered by private entity that would bid on the project every two years. The system would be paid for through an 11 percent payroll tax (split between the employer and employee, at one point estimated at a 30-70 split, but the number would be determined by the Legislature), federal Medicaid funding and savings achieved through a cost-containment system that would create a single pricing system for procedures, treatments and hospital stays. The payroll taxes would provide for less than half of the money needed to fund the system, according to Hsiao. Low-wage workers, their employers and Vermonters who receive non-wage income would be exempt from the payroll tax.

Medicare benefits would not change, though whoever wins the contract for administering payments to providers would also handle payments to providers for the federally subsidized program for Vermonters age 65 and older. Nursing home and home health care are not included in Hsiao’s hybrid plan.

The cost of health care for employers and employees would be 17.5 percent of payroll in 2015, under the Patient Protection and Affordable Care Act, according to an analysis by Hsiao’s team, and 18.5 percent by 2019.

If Vermont adopted the hybrid single payer system he proposes, Hsiao said the state’s projected absolute savings over time would be $490 million in 2015; $1.35 billion in 2019; and $2.1 billion in 2024. (The margin of error for these estimates is 15 percent.)

An independent commission would oversee the system to ensure that it is accountable to patients and taxpayers.

If Hsiao’s recommendations are implemented in 2015; the savings would be immediate and substantial, according to the report. Vermonters would save $1.35 billion in 2019. Some of that money — $50 million — would be used to support incentives for primary care nurses, doctors and community health care communities. The system would also provide coverage for 32,000 uninsured Vermonters and better access to care for underinsured residents.

Hsiao identified 15 “major fiscal, legal, institutional, political and operational barriers” to meeting the goals set under Act 128, including ERISA, the federal law governing corporate self-insurance, in addition to four other federal waivers.

One of the slides Hsiao invited his audience to think of an analogous image – a painting of a hiker viewing a miles-away mountain in the distance. Achieving single-payer is every bit as ambitious, he said.

Lawmakers react

In a committee hearing, Sen. Kevin Mullin, R-Rutland, asked whether Hsiao had considered an in-migration of sick patients to Vermont as a result of the new system, and questioned there should be a “lockbox” on Vermont residency.

Hsiao said his team looked at the historic record and determined that in the past there has not been an influx of new residents to the state when new benefits – such as the Vermont Health Access Program and Dr. Dynasaur – were introduced. Hsiao said Vermont’s existing benefit rules for residency are sufficient.

Rep. Mary Morrisey, D-Bennington, asked Hsiao how the payroll and provider patient systems would work when Vermonters seek care out of state. (About 20 percent of Vermonters use medical providers in New Hampshire, Massachusetts and New York, Hsiao said – though the bulk of those patients seek treatment at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.)

Hsiao said the single-payer administrative organization would still pay Dartmouth-Hitchcock. “We expect the single-payer organization will negotiate more effective rates with Dartmouth-Hitchcock because it will represent all of Vermont,” Hsiao said.

What would the system look like for big companies, say IBM?

Hsiao said the payroll tax would cost substantially less for large employers than the insurance premiums companies offer. Corporations could continue offering wrap around plans or supplemental insurance, to workers if they choose, to match the plans already in place, or they could ask employees to pick up the single-payer insurance. Under the latter scenario, the difference would free up capital to expand businesses, hire more workers and pay existing employees higher salaries, Hsiao said.

For many small companies that don’t already pay health insurance, the payroll tax will be a new burden, Hsiao said.

Winners and losers

Who benefits? Hsiao says the winners are the 47,000 uninsured Vermonters, as well as the state’s many underinsured residents who pay a disproportionate percentage of their income toward health care costs, large businesses and their employees, and most primary physicians.

Under his hybrid plan, all Vermonters would have access to an “essential benefits package” that would cover 87 percent of medical care and 77 percent of drug expenses. There would be small co-pays for doctors’ visits, but no deductibles. Hsiao said deductibles discourage patients from getting the routine care they need to catch untreated diseases early on.

Hsiao said the payroll tax will be less expensive than the current insurance system for most employees and businesses. Here’s an exception: In cases where both spouses in a household have insurance, and can choose one plan over another, both would pay the payroll tax.

Who bears the burden of the new system? Private health insurance companies. Under Hsiao’s plan there would be room for only one administrative entity for the hybrid single payer system.

Hsiao said that MVP and Cigna, two major out-of-state insurers who do business in Vermont, could have provide supplemental care to Vermonters who want enhanced plans that provide more services than the “essential” benefit. BlueCross BlueShield could carve out a niche if it wins a bid for the administrative contract.

Sales, marketing and underwriting personnel would no longer be needed to promote insurance products in the new system. Administrative staff at hospitals and clinics who provide billing and insurance reimbursement services would also be likely eliminated in the brave new world of single payer.

The uniform payment rate for physicians could also put a squeeze on medical specialists.

Employers who do not now offer health insurance for workers would be required to contribute through a payroll tax. About 30 percent of small businesses provide insurance benefits to employees, according to the report.

How teachers union and state workers’ unions will be affected by the change remains to be seen. Joel Cook, of the Vermont-NEA, said he supports the idea of separating insurance from employment. “We’re not afraid of it,” he said.

Sen. Randy Brock, R-Grand Isle, Franklin County, said that he doesn’t see how supplemental insurance policies reduce costs. “Does this imply single payer includes a level of benefit that doesn’t match what people have now?” Brock asked.

The senator also questioned the idea of creating a single pipeline for payments. “That further removes consumers” from the cost of treatments, Brock said.

In addition, Brock said the hybrid single payer approach would further accelerate the monopolization of the system by giving one insurer the contract to administer the program.

Stakeholders, including the unions, providers, business leaders and insurers will be meeting with Hsiao and Shumlin administration officials in a series of private meetings at the Department of Banking, Insurance, Securities and Health Care Administration offices today.

A plurality of the physician respondents, 34 percent, picked single-payer health reform as their preferred model of reform, followed by 32 percent who favored a private-public insurance mix with a public option buy-in. Seventeen percent voted for the pre-reform status quo, including the permissibility of insurers offering low-premium, high-deductible health plans.

Remarkably, only 14 percent of Massachusetts doctors would recommend their own state’s model as a model for the nation. A small number of respondents, 3 percent, chose an unspecified “other.”

In other words, the doctors with the most on-the-ground experience with the Massachusetts plan, after which the Obama administration’s new health law is patterned, regard it as one of the least desirable alternatives for financing care.

The findings contrast with an earlier survey of Massachusetts physicians’ opinions on health reform funded by the Blue Cross Blue Shield of Massachusetts Foundation and the Robert Wood Johnson Foundation. That survey, published in the New England Journal of Medicine in October 2009, found that three-fourths of doctors in the state support the Massachusetts reform law. However, the survey did not allow respondents to express their preference for alternative models of health reform.

Dr. Rachel Nardin, chair of neurology at Cambridge Hospital and president of the Massachusetts chapter of Physicians for a National Health Program, said: “Massachusetts physicians realize that the state’s health reform has failed to make health care affordable and accessible, and won’t work for the nation. These findings show the high support for single-payer Medicare for all by physicians on the front lines of reform.”

While many in the country look to Massachusetts as a role model for the country, Dr. Patricia Downs Berger, co-chair of Mass-Care, the single-payer advocacy coalition in Massachusetts, and a member of the Massachusetts Medical Society, notes, “Physicians in Massachusetts, particularly after health reform, know from experience that the current health care system is not sustainable and is not addressing the deep inequalities and high costs faced by patients, and they are calling for a more fundamental change.”

A survey published in the Annals of Internal Medicine in April 2008 showed that 59 percent of U.S. physicians support government action to establish national health insurance, an increase of 10 percentage points over similar findings five years before.

Link to the 2010 Physician Workforce Survey (relevant pages: 86-90):
http://www.massmed.org/AM/Template.cfm?Section=Research_Reports_and_Studies2&TEMPLATE=/CM/HTMLDisplay.cfm&ContentID=36167

Sounds a little bit like Healthcare-NOW!’s campaign to implement a national universal healthcare system as the only sane answer to our healthcare crisis.

Yet, corporate interests pour millions into propaganda and lies about rationing and death panels to stop universal health care from coming to the US.

If you are going to DC, or one of the hundreds of local rallies to restore sanity around the country, don’t forget to talk about the sanest of healthcare systems – single-payer healthcare: a system that will cover everyone, use our healthcare dollar wisely, and save money for our country, our states, our cities, our schools, and our families.

In Washington, DC, single-payer advocates will be at the Rally to Restore Sanity this Saturday (12 noon) and will meet at 4th Street on the National Mall (Capitol side of the street). Join us and help us get Healthcare-NOW! postcards filled out. Please bring your single-payer signs!

Download some postcards (.pdf) to get signed by other sane people who don’t want to cut Social Security and Medicare, and instead want improved Medicare for All.

Or copy some of our sign ideas pictured here.

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.”

Groups across the country are organizing events this Friday to celebrate the 45th anniversary of Medicare – and to continue to push for a single payer, improved and expanded Medicare for All program. Join a party near you!

Why? Didn’t we just past health care reform you say? Despite the new health law, many injustices continue to exist as patients fall the cracks of this profit-driven system. In addition, our most successful social insurance programs are under attack.

Congress created a Deficit Commission that will report back to Congress after the November election but before the new Congress takes office, to recommend how to close the huge federal budget deficit. Of course, it won’t address the biggest problem – the massive military budget. Instead it will go after entitlement programs for seniors such as Medicare and Social Security.

That’s why we are celebrating the birth of these critical programs – to tell Congress to keep their hands off Medicare and Social Security!

If you don’t see an event in your community, organize your own! Or call or email your Representatives today and urge them to protect Medicare, improve it, and expand it to all!

Whatever you can do to spread the word and support these efforts is critical. Now is not the time to be silent.

A close reading of the new health care legislation, which will conveniently take effect in 2014 after the next presidential election, is deeply depressing. The legislation not only mocks the lofty promises made by President Barack Obama, exposing most as lies, but sadly reconfirms that our nation is hostage to unchecked corporate greed and abuse. The simple truth, that single-payer nonprofit health care for all Americans would dramatically reduce costs and save lives, that the for-profit health care system is the problem and must be destroyed, is censored out of the public debate by a media that relies on these corporations as major advertisers and sponsors, as well as a morally bankrupt Democratic Party that is as bought off by corporations as the Republicans.

The 2,000-page piece of legislation, according to figures compiled by Physicians for a National Health Plan (PNHP), will leave at least 23 million people without insurance, a figure that translates into an estimated 23,000 unnecessary deaths a year among people who cannot afford care. It will permit prices to climb so that many of us will soon be paying close to 10 percent of our annual income to buy commercial health insurance, although this coverage will only pay for about 70 percent of our medical expenses. Those who become seriously ill, lose their incomes and cannot pay skyrocketing premiums will be denied coverage. And at least $447 billion in taxpayer subsidies will now be handed to insurance firms. We will be forced by law to buy their defective products. There is no check in the new legislation to halt rising health care costs. The elderly can be charged three times the rates provided to the young. Companies with predominantly female work forces can be charged higher gender-based rates. The dizzying array of technical loopholes in the bill—written in by armies of insurance and pharmaceutical lobbyists—means that these companies, which profit off human sickness, suffering and death, can continue their grim game of trading away human life for money.

“They named this legislation the Patient Protection and Affordable Care Act, and as the tradition of this nation goes, any words they put into the name of a piece of legislation means the opposite,” said single-payer activist Dr. Margaret Flowers when I heard her and Helen Redmond dissect the legislation in Chicago at the Socialism 2010 Conference last month. “It neither protects patients nor leads to affordable care.”

“This legislation moves us further in the direction of the commodification of health care,” Flowers went on. “It requires people to purchase health insurance. It takes public dollars to subsidize the purchase of that private insurance. It not only forces people to purchase this private product, but uses public dollars and gives them directly to these corporations. In return, there are no caps on premiums. Insurance companies can continue to raise premiums. We estimate that because they are required to cover people with pre-existing conditions, although we will see if this happens, they will argue that they will have to raise premiums.”

The legislation included a few tiny improvements that have been used as bait to sell it to the public. The bill promises, for example, to expand community health centers and increase access to primary-care doctors. It allows children to stay on their parent’s plan until they turn 26. It will include those with pre-existing conditions in insurance plans, although Flowers warns that many technicalities and loopholes make it easy for insurance companies to drop patients. Most of the more than 30 million people currently without insurance, and the 45,000 who die each year because they lack medical care, essentially remain left out in the cold, and things will not get better for the rest of us.

“We are still a nation full of health care hostages,” Redmond said. “We live in fear of losing our health care. Millions of people have lost their health care. We fear bankruptcy. The inability to pay medical bills is the No. 1 cause of bankruptcy. We fear not being able to afford medications. Millions of people skip medications. They skip these medications to the detriment of their health. We are not free. And we won’t be free until health care is a human right, until health care is not tied to a job, because we still have an employment-based system, and until health care has nothing to do with immigration status. We don’t care if you are documented or undocumented. It should not matter what your health care status is, if you have a disease or you don’t. It should not matter how much money you have or don’t, because many of our programs are based on income eligibility rules. Until we abolish the private, for-profit health insurance industry in this county we are not free. Until we take the profit motive out of health care we cannot live in the way we want to live. This legislation doesn’t do any of that. It doesn’t change those basic facts of our health care system.”

Redmond held up a syringe.

“I take a medication that costs $1,700 every single month,” she said. “I inject this medication. It costs $425 a week for 50 milligrams of medication. I would do almost anything to get this medication because without it I don’t have much of a life. The pharmaceutical industry knows this. They price these drugs accordingly to the level of desperation that people feel. Billy Tauzin, the former CEO of [the trade organization of] Big Pharma, negotiated a secret deal with President Obama to extend the patents of biologics, this new revolutionary class of drugs, for 12 years. And Obama also promised in this deal that he would not negotiate drug prices for Medicare.”

Obama’s numerous betrayals—from his failure to implement serious environmental reform at Copenhagen, to his expansion of the current wars, to his refusal to create jobs for our desperate class of unemployed and underemployed, to his gutting of public education, to his callous disregard for the rights of workers and funneling of trillions in taxpayer money to banks—is a shameful list. Passing universal, single-payer nonprofit health care for all Americans might have delivered to Obama, who may well be a one-term president, at least one worthwhile achievement. Single-payer nonprofit health care has widespread popular support, with nearly two-thirds of the public behind it. It is backed by 59 percent of doctors. And it would have helped roll back, at least a bit, the corporate assault on the citizenry.

Medical bills lead to 62 percent of personal bankruptcies, and nearly 80 percent of these people had insurance. The U.S. spends twice as much as other industrialized nations on health care, $8,160 per capita. Private insurance bureaucracy and paperwork consume 31 percent of every health care dollar. Streamlining payment through a single nonprofit payer would save more than $400 billion per year—enough, PNHP estimates, to provide comprehensive, high-quality coverage for all Americans.

Candidate Obama promised to protect women’s rights under Roe. v. Wade, something this legislation does not do. He told voters he would create a public option and then refused to consider it. The health care reform bill, to quote a statement released by PNHP, has instead “saddled Americans with an expensive package of onerous individual mandates, new taxes on workers’ health plans, countless sweetheart deals with the insurers and Big Pharma, and a perpetuation of the fragmented, dysfunctional, and unsustainable system that is taking such a heavy toll on our health and economy today.”

“Obama said he was going to have everybody at the table,” Redmond said, “but that was a lie. Our voice was not allowed to be there. There was a blackout on our movement. We did not get media attention. We did actions all over the country but we could not get coverage. We had the ‘Mad as Hell Doctors’ go across the country in a caravan, and they had rallies and meetings. If that had been a bunch of AMA Republican doctors, Cooper Anderson would have been on the caravan reporting live. NPR would have done a series. Instead, they did not get much coverage. And neither did the sit-ins and arrests at insurance companies, although we have never seen that level of activity. They turned us into a fringe movement, although poll after poll shows that the majority of people want some kind of single-payer system.”

Our for-profit health system is driven by insurance companies whose goal is to avoid covering the elderly and the sick. These groups, most in need of medical care, diminish profits. Medicare, paid for by the government, removes responsibility for many of the old. Medicaid, also paid for by the government, removes the poor people, who have a greater tendency to have chronic health problems. Hefty premiums, which those who are seriously ill and lose their jobs often cannot pay, remove the very sick. If you are healthy and employed, which means you are less likely to need expensive or complex treatment, the insurance companies swoop down like birds of prey. These corporations need to control our perceptions of health care. Patients must be viewed as consumers. Doctors, identified as “health care providers,” must be seen as salespeople.

Insurance companies, which will soon be able to use billions in taxpayer dollars to bolster their lobbying efforts and campaign contributions, know that single-payer nonprofit insurance means their extinction. And they will employ considerable resources to make sure single-payer nonprofit coverage is denied to the public. They correctly see this as a battle for their lives. And if human beings have to die so they can survive, they are willing to make us pay this price.

The for-profit health care industry, along with the Democratic Party, consciously set out to confuse the public debate. It created Health Care for America NOW! in 2008 and provided it with tens of millions of dollars to supposedly build a public campaign for a public option. But the organization had no intention of permitting a public option. The organization was, as Dr. Flowers said, “a very clever way to distract members of the single-payer movement and co-op some of them. They told them that the public option would become single payer, that it was a back door to single payer, although there was no evidence that was true.”

Physicians for a National Health Plan attempted to fight back. It worked with a number of organizations under a coalition called the Leadership Conference for Guaranteed Health Care. The group, which included the National Nurse’s Union and Health Care Now, sought meetings with members of Congress. Flowers and other advocates asked Congress members to include them in committee debates about the health care bill. But when the first debate on the health care reform took place in the Senate Finance Committee, chaired by Sen. Max Baucus, a politician who gets over 80 percent of his campaign contributions from outside his home state of Montana, they were locked out. Baucus invited 41 people to testify. None backed single payer.

The Leadership Conference, which represents more than 20 million people, again requested that one of their members testify. Baucus again refused. When the second committee meeting took place, Flowers and seven other activists stood one by one in the room and asked why the voices of the patients and the health care providers were not being heard. The eight were arrested and removed from the committee hearing.

Single-payer advocates were eventually heard on a few of the House and Senate committees. But the hearings were a charade, part of Washington’s cynical political theater. It was the insurance and pharmaceutical lobbyists who were in charge. They dominated the public debate. They wrote the legislation. They determined who received lavish campaign contributions and who did not. And they won.

“We are talking about life and death, about the difference between living your life and dying,” Redmond said. “And once again it came down to the Democratic Party trumping the needs of the people.”

For Democrats, passing the new health care law may have been the easy part. Now that it’s the law, everything that happens in health care, whether due to the Patient Protection and Affordable Care Act or not, is their responsibility.

“The Democrats have guaranteed that the American health care system is going to be affordable. They put it in the title of their bill,” health policy analyst Bob Laszewski said. “So everything that happens after March 23, 2010 [the day President Obama signed the measure] is theirs. They own it.”

Democrats came under fire from Republicans on Monday for the latest set of regulations they issued. The new rules lay out which insurance plans can remain as is when new consumer protections and other requirements take effect.

“This rule reflects the president’s policy that Americans should be able to keep their health plan and doctor if they want,” Health and Human Services Secretary Kathleen Sebelius said.

But plans won’t be able to remain “grandfathered” if they raise premiums too much, or cut too many benefits. Sebelius said the idea was to create a balance, “to make sure the grandfathered plans still have the flexibility they need to make reasonable changes, but also making sure that insurance companies don’t use this additional flexibility to take advantage of their customers.”

Republicans, however, were quick to point out that by the department’s own estimates, many insurance plans would not qualify to remain unchanged.

Despite repeated promises by President Obama to the contrary, said Senate Minority Leader Mitch McConnell (R-KY), “the government is about to change the plans most Americans have. Here’s one more promise the administration has broken on health care and one more warning Republicans issued on this bill that’s been vindicated.”

What Republicans don’t say is that plans that do have to change will have to offer more, rather than fewer, benefits and consumer protections. That includes things such as free preventive services and guaranteed direct access to obstetrician/gynecologists for women.

But most of those new benefits won’t take effect for another three years. What makes Democrats more immediately vulnerable is what’s going to happen to people’s health insurance costs next year. They’re going up.

At least that’s the finding of a new report from the consulting group PricewaterhouseCoopers.

“I think you can expect to continue to see significant increases in what you pay for your health care,” says Mike Thompson, a principal with the firm and the study’s lead author.

In order to cope with a projected medical inflation rate of 9 percent next year, Thompson says, he expects that employers will load more costs onto workers, both through higher deductibles and by replacing flat co-payments with percentage coinsurance. In other words, rather than paying a flat $20 fee to see a doctor, more workers will be expected to contribute 20 percent of that doctor’s bill.

Both Thompson and Laszewski say next year’s rising costs aren’t due to the new health law. And none of the new law’s provisions intended to restrain health spending have yet to take effect. But those are subtleties likely to be lost on most of the public. They’re simply going to wonder why their costs keep going up.

“I myself would not have called it the ‘affordable’ health care act,” Laszewski says. “I think that’s making a promise you’re not likely to be able to keep.”

As we sit here on the other side of the recent health reform process, we have an opportunity for reflection. There were many times during the past year and a half when passage of a health bill seemed unlikely. However, in the end, the White House and Democratic leadership joined forces and converted the last holdouts with scare tactics of electoral turnovers and even a trip on Air Force One in order to muscle a bill over the final hurdles. The mere fact that any bill was passed at all was hailed as the great accomplishment, because no honest proponent of health reform could call the final product a solution to our nation’s serious health care crisis.

This entire health reform process occurred under the shadow of the previous attempt to pass significant health legislation. President Obama made this his signature issue, and so for his administration failure was not an option. He surrounded himself with many of those who were traumatized by their participation in the last go-round. Thus, the resulting strategy was based more on fear of the opposition than on sound health policy. An opportunity for an honest debate about the needs of our people was squandered for backroom deals with industry giants and the photo ops so reminiscent of the previous administration. And for the most part, the resulting legislation benefits the very industries that profit most from our current situation more than it benefits the people of America.

Pros and Cons of the Legislation

There are some provisions within the bill that are positive steps: comparative effectiveness research; funding for demonstration projects to improve care; a new emphasis on prevention, wellness, and public health; increased funding for community health centers; and incentives for primary care providers. These are all necessary provisions, but they do not offset the harm done by other provisions in the bill, such as the individual mandate to purchase private insurance with penalties for noncompliance and the $447 billion in public dollars being used to subsidize such purchases. The bill will omit at least 23 million people from having any coverage. And the requirement to accept people with pre-existing conditions will most certainly increase premiums such that they become unaffordable, or people will purchase policies with skimpier coverage. This will likely result in a larger population of underinsured people—those who risk bankruptcy from medical debt should they develop health problems.

And none of the positive steps turn us in the direction of creating a national health system such as there is in every other advanced nation. Rather, on the whole, this legislation, which was written with heavy input from private health insurance and pharmaceutical lobbyists, further privatizes the financing of our health care and further enriches and empowers the very industries that are the problem. We know from experience both in the United States and abroad that market-based financing of health care is both the most expensive model and the most unjust, providing only as much health care as the patient can afford.

The Public Option Was Ruled Out at the Start

From the beginning of this process, it was clear that the administration and leadership had developed a strategy based on an outcome they believed they could achieve. The path was predetermined. All of the steps along the way, from the house parties that started during the winter of 2008 to the hearings, to the media spin, were planned so that the resulting “debate” was a drawn out performance of political theater. In order to disarm the corporate interests, the health industries that had opposed previous reforms were included on the inside. In order to disarm the Right, bipartisanship was at the forefront. In order to disarm the supporters of a single-payer plan, who are the majority, a campaign was developed around a promised “compromise,” the public option, and given tens of millions of dollars for organizing and advertising. The public option succeeded in splitting the single payer movement and confusing and distracting it with endless discussion about what type of public option would be effective.

Despite all of the attention, the public option was never meant to be part of the final legislation. As early as March 2009, Senator Baucus admitted that the public option existed as a bargaining chip to convince private insurers to accept increased regulation. And a year later, Glenn Greenwald and others confirmed that the public option had been privately negotiated away, although members of Congress continued the charade and “fought” for it.

Toward the final vote, supporters of the public option were hearing the same excuses that single-payer advocates have heard for decades. We are always told that single-payer is not politically feasible. However, we know that political feasibility can change. We are told to be pragmatic, yet we know that the reform being passed was not practical, in that it failed to guarantee health care to everyone and to be financially sustainable. We are told we are asking for too much and should accept incremental change. However, we know that the smallest effective step we can take in health reform is the creation of a publicly funded health system. Beyond that, there is much more to do in order to create a health system that raises us into the top ten in the world.

Profit-Driven Insurers Cannot Prioritize Care

While politicians claim that we have finally achieved comprehensive health reform and that now all Americans will have guaranteed affordable health care, we in the single-payer movement experience a sense of déjà vu. We have seen the same scenario occur at the state level from Oregon to Maine to Tennessee, and most recently in Massachusetts. Every state that has passed a health reform package has made these claims, only to find that within a few years they were unable to cover the number of people they had hoped to cover and that their health care costs exceeded their budget. The reason for this is that every state, and now our federal government, ignored the data showing that we cannot achieve universal and affordable health care as long as we retain private insurers as an integral part of health care financing. This truth has been documented both in practice and in numerous economic studies.

We cannot control health care costs, without severe rationing, as long as we retain multiple private insurers, because this model wastes at least a third of our health care dollars on areas that have nothing to do with direct health care: marketing, high CEO salaries, profits, and administration. We cannot guarantee that patients will be able to afford needed care using private insurers because the private insurance model is profit driven. These corporations profit by avoiding the sick and denying and restricting payment for care. Their bottom line is profit, not improved health. And no amount of industry regulation to date has been successful in changing that bottom line. Likewise, the new federal legislation is full of loopholes that will allow private insurers to continue to skirt the regulations.

The White House and Congress claimed throughout the process that we must retain private insurance because Americans desire choice, and this has been framed as choice of insurance. However, this is a false concept. No person can anticipate what their health care needs will be or which insurance will be best. Health care needs change the day a patient has a serious accident or is diagnosed with a serious illness. We all need the same health insurance: one that covers all medically necessary care when and where we need it. Those of us who travel and listen find that people in America desire choice of health care provider and choice of treatment: the two choices that private health insurers restrict.

So what are the White House and Congress really saying when they claim that we must retain a private insurance model? That they are unwilling to take on these powerful industries, and so we, the people, must be willing to compromise and work within their framework. Mohandas Gandhi said:

All compromise is based on give and take, but there can be no give and take on fundamentals. Any compromise on mere fundamentals is a surrender. For it is all give and no take.

When it comes to health reform, compromise on the fundamentals is unacceptable because the human costs are continued preventable deaths, continued suffering as patients fight for needed care, and continued bankruptcy from medical debt as families struggle to pay for deductibles and uncovered services. In a study published in Health Affairs in January 2008 that looked at the top nineteen industrialized nations, the United States ranked the worst—we have the highest number of preventable deaths (101,000 each year) because we lack a health system. All of the other industrialized nations have health systems based on the principles of health care as a human right: universality, equity, and accountability.

Why We Failed

Why have the American people been denied this same right? As I look back at the health reform process, I see three serious errors: a willingness to compromise, a lack of clarity about what we require, and a fear that failure to pass reform will have electoral consequences. These are the areas we must address as a people if we want to see real change in this nation, not just in health care but also in many areas that affect our ability to survive on this planet.

The willingness to compromise has occurred repeatedly at the state level. As a result, fewer people have access to care, and health care costs continue to rise; the fundamental problems are not corrected. This willingness to compromise is based on a real sense of desperation. We see real suffering. We want to do something. We are told that this reform, whatever it is, is the best we can get this time. We accept that and tell ourselves that it is something, it is a step.

As the congressional fellow of Physicians for a National Health Program, I saw this desperate attempt to pass something, anything, rise to the surface in the final weeks of the reform process. Patients and their families were brought into Congress to tell their stories of abuse at the hands of private insurers. Well-meaning legislators looked them in the eye and told them that this reform would change that. When I challenged the truth of that response, I was told, often in heated tones, that they (the legislators) had to do something and that at least this reform would help some people. I could only think of those who would not be helped. What about them?

The lack of clarity was grounded in the belief that if we simply advocated based on principles such as access and affordability, then the legislation would meet those principles. Legislators and pro-reform groups were content to speak based on principles as long as they were not challenged about whether those principles were being met. We must go beneath the surface of simple principles, educate ourselves, and define what is acceptable and what isn’t. If we don’t know exactly what we are asking for, we won’t get it. And we mustn’t be afraid to ask for what we require. As a people, we have become willing to accept crumbs when we require so much more than crumbs.

The final mistake was to pin the results of the upcoming elections to the success or failure of passing reform. Those who were reluctant to support the legislation were forced to support it in the end or risk being blamed for possible electoral consequences. As has often happened in past campaigns, people were forced to vote for the lesser of two evils instead of for what they truly wanted.

We Can Still Create a National Health Program!

So what do we do now that a health bill has been signed? Now that the clamor has quieted, it is time for a civilized discussion of what our health needs are and how best to meet them. This discussion is unlikely to occur in a mainstream media dominated by advertising dollars from health insurance and pharmaceutical corporations. We will need to have this discussion at a more personal level and through independent sources of media. We must educate ourselves and those around us about what is possible to achieve in this nation.

It is possible to create a national health program in which every person living in this country is able to receive the same high standard of medical care whenever and wherever they need it, without fear of financial consequences. We call this health security. Other advanced nations have achieved this goal. The United States has not, and is currently ranked thirty-seventh in the world for health outcomes. We spend more per capita on health care than every advanced nation, yet leave a third of our population either completely on the outside or vulnerable to financial ruin should they have a serious health problem.

Physicians for a National Health Program, founded in 1987, educates and advocates for a health system that will improve our health outcomes and provide health security based on the evidence of what has worked in our nation and what is effective in other advanced nations. We envision a lifelong universal health system—much like traditional Medicare—that is nationwide. We envision a system that allows patients to choose where they receive their care, permits caregivers and patients to determine the best course of treatment with assistance from evidence-based data, controls costs in a rational way through simplified administration and negotiation of fair prices, and is progressively financed. Its publicly funded nature would make it transparent and accountable. Because it would be privately delivered, it would allow caregivers to compete based on quality of care provided. Private health insurers would be relegated to a position of offering supplemental plans and possibly providing administrative support.

The Rev. Dr. Martin Luther King Jr. taught us that to witness an injustice and not work to correct it is in itself an act of violence. As a physician and an advocate for nonviolence, I cannot ignore the injustice of the great health inequality that exists in our nation or ignore those in need who cannot afford medical treatment. We have delayed this struggle for too long. Alice Walker said, “We are the ones we have been waiting for.” So, let’s do it. We have the resources. Now we must create the political will. Together, we can create a health justice movement, educate ourselves, speak with clarity, and organize independently of any political party. Please join us. You can learn more at www.pnhp.org or join the grassroots movement at www.healthcare-now.org.

Dr.Margaret Flowers is a pediatrician who serves as the congressional fellow for Physicians for a National Health Program and is on the board of Healthcare-NOW! She is one of the “Baucus 8.”

The PBS program Frontline on April 13 offered a look at the White House drive for healthcare reform titled Obama’s Deal. Like a previous Frontline special about the U.S. healthcare system, the program failed to adequately include single-payer. But the way the show did it this time was remarkable.

Margaret Flowers of Physicians for a National Health Program was interviewed by Frontline–leading one to suspect that the show might include some discussion of truly universal healthcare systems like single-payer (aka Medicare for All).

But the program was a major disappointment. As she wrote (Consortium News, 4/15/10) after it aired, “Curiously, just as it was in the health ‘debate,’ single-payer, improved Medicare for All, was also excluded from the film.”

The strange thing is that Flowers actually appears on the show (albeit briefly), in a scene recounting how single-payer activists disrupted a Senate Finance Committee hearing last May. But the protesters’ views are muddled by Frontline.

As the program explained it, insurance industry lobbyists were working to kill the public option from the Senate bill. At this point single-payer activists appear. As Flowers explained:

The producers at Frontline carefully cut single-payer out of the film. When the host, Mr. [Michael] Kirk, interviewed me for “Obama’s Deal,” we spoke extensively of the single-payer movement and my arrest with other single-payer advocates in the Senate Finance Committee last May. However, our action in Senate Finance was then misidentified as “those on the left” who led a “counterattack” because of “liberal outrage” at being excluded.

The framing of the Frontline segment would lead viewers to believe these activists were public-option proponents, which they are not. Groups like PNHP were critical of the public option–a government-run insurance plan that would be offered to some as an alternative to mandatory private health insurance–arguing that it would leave the insurance industry intact as dominant players in the healthcare business.

After Frontline aired footage of the arrests of single-payer activists, a voice says: “So what Chairman Baucus has decided this option cannot be part of the discussion at a Senate hearing? Now, I think that’s wrong. I don’t think it’s fair.” The implication was that “option” here refers to the public option– since no other option had been mentioned.

That voice was actually MSNBC host Ed Schultz–a supporter of single-payer. His full quote (5/7/09) would have made that clear:

Now, let me explain single-payer for just a minute.

The money comes from one source, the government. Now, you and I pay taxes, OK. The government pays the bill. It’s that simple.

Patients are not caught in the middle between doctors and insurance companies, no game-playing here. There’s no middleman. You know? There’s no decision-makers between you and your doctor. It’s a clean deal.

So what Chairman Baucus has decided, this option cannot be part of the discussion at a Senate hearing? Now, I think that’s wrong. I don’t think it’s fair.

Thus single-payer activists were transformed into advocates for the public option.

This is not the first time that Frontline has decided that a conversation about healthcare reform should exclude single-payer from the discussion. The March 31, 2009 Frontline special Sick Around America avoided discussions of national healthcare plans. This omission led Frontline correspondent T.R. Reid–who had hosted a previous Frontline special (4/15/08) that examined various public healthcare models– to withdraw from the project.

PBS ombud Michael Getler agreed with those who thought the show missed a chance to discuss single-payer. It looks like the program has done so again.