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:
[audio:http://recordings.freeconferencecalling.com/mp3/441086/441086/MN2124_02152010170451871_1050338.mp3]
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.
Thanks for inviting me to last night’s conference call. I enjoyed it and learned a lot! I sent the link for this page to all my friends and relatives so they will understand why Single-Payer is the best solution.
I’ve listened to this call and I’m very discouraged from what I’ve heard. We’re failing to heed the words of Voltaire… “Don’t let the perfect be the enemy of the good.” We can not wait another 16 years for a decent shot at providing a “Good” healthcare reform package that will result in coverage being provided to those who can’t get or afford coverage today. We need to learn from countries like Switzerland who learned it in 1994 that you can work within the culture to get the “Good” for your people. It’s hard to argue that they’ve been unsucessful when they have accomplished universal coverage at almost half of our costs. Oh and by the way… I’m a lifelong Republican who has come to the decision that this is a moral decision. Let’s make some real strides in this battle and quit making the perfect the enemy of the good.
Don’t let the “Perfect” be the enemy of the “Good”. Let me first say that I’d take Single payer in a heart beat but I’d rather offer 50 million American’s coverage based on a system that’s more likely to be accepted here in America vs trying to convince the far right and blue dog Dems for the next two decades that Medicare for all is the “Perfect” solution. Too many people will have died by then due to no coverage to ever declare a meaningful victory.
Here’s an NPR story and a segment on PBS by TR Reid regarding the Swiss model which uses a private non profit model for basic health insurance with tight regulatory control by the federal and state governments. It has a individual mandate for the basic non profit coverage but gives the insurance companies the ability to still make profit on supplemental coverages.
http://www.npr.org/templates/story/story.php?storyId=92106731
Chapter 5 is where the Swiss system is discussed.
http://video.pbs.org/video/1050712790/#
As a small business owner I have seen the discrimination and downright immoral (but amazingly legal) behavior that our uniquely American profit-before-people health unsurance industry (that simply has NO mercy) uses (and will always use because that’s what it does) against honest decent human beings. It denies and delays desperately needed medical care without remorse to the point where millions of innocent Americans have literally DIED (or been disabled, bankrupted, terrorized) as a result.
I say we must understand that pure evil IS the enemy of the good, and pure evil by any other name still stinks to high heaven. I cannot think of pure evil as “the good” by any stretch of the imagination. We must not be left to its mercy because (as I said previously) it has NONE. Leaving the health unsurance industry in control of anyone’s health care security is as wrong as wrong can be, and we have more than ample empirical evidence of this fact. It has been allowed to run so far amok for so long that it has become incapable of anything but anti-social behavior of absolutely no redeeming value. Anyone who believes otherwise has been fooled.
Becky, I think we have to face the reallity that we’re not going to get our single payer system any time soon. The politics we’ve seen the past year prove this sad fact. I’ve come to the conclusion I’m very alone on this one. Unfortunately, most of my fellow Republicans just aren’t within me regarding single payer, mandates or Washington involvement. Most of them are a lost cause because they’re too lazy to think for themselves or check their bruised egos at the door of doing what’s right. With that said, if the Dems can’t get a simple public option passed with control of the House, Senate and White House I have no faith they’ll ever get single payer passed. There’s too many Blue Dogs who are really purple Republicans. I think we’ve got to face the fact that if we truly care about getting people the care they need anytime soon we have to work within crap system we’ve created for ourselves. So let’s make it illegal to deny care, discriminate and recind.Let’s make it illegal to make profits on peoples lives and regulate the heck out of these companies so they can’t make money on the healthcare people need. Make them compete for us if they want our business and award them for quality care and paying claims faster then their competitors. Harness the greed that’s gotten them to where they are today. Let’s tranform them into good members of society most of their founders intended. Let’s pass laws that make the system work for us instead of against us. Many countries like Germany and Switzerland have a history of private insurance companies and have made this transformation. Let’s give them a bone and let them make their money selling supplemental plans for botox and boob jobs and private rooms. I know it’s alot more complicated then this but there are smart people who can figure this out. Let’s make our leaders transform these guys into good citizens. There are thousands of good honest people working at these companies who never dreamed they would be part of a system that let people die. I’d gurantee most of them never knew the day they started how the system really impacted people. Like most of us, they were simply looking for a decent paying job with health insurance. Let’s show the greeding Exec’s the door and keep the lower ranks on the job doing jobs that ensure claims are paid fully and timely and get rewarded for doing just that. As they discover that it doesn’t take as many people to do just what I’ve said let’s provide incentives to transition them into providing frontline healthcare for the millions of people who will need them when they can actually afford to see a doctor. Please don’t get me wrong. If I could get single payer tomorrow I’d be the first to sign up. I just don’t want to get so close minded on this that I’m not willing to trade the “perfect” for a very good system that’s proven you can force private insurance into becoming good citizens of society. I continue to learn that it’s lonely being in the middle. Until the left and the right meet in the middle we’ll continue to see people die or go bankrupt for the sake of chasing or fighting against the “perfect”.
HR676 is the only way to go. Why can’t this country take care of their own?
Other countries take care of their own. We shouldn’t be 37th in healthcare. That is shameful for a nation as great as ours.
Compared with the present American system, does the Swiss model – the Bismarck model – operate on the principle of social solidarity and provide basic access to healthcare for all? Of course it does.
Did anyone among the elected officials in Washington propose such a system? No.
Is there anyone who seriously demands, in the U.S. in 2010, a conversion of profit-seeking insurance to a non-profit system with heavy regulation and books open to the public – every aspect of the “business” dictated by the government? Of course not – because politically that is beyond “not feasible” – it amounts to utopian fantasy!
What the elected officials in Washington proposed instead was the bipartisan Romney reform from Massachusetts – criminalize the uninsured and force people to buy insurance. This proposal, written by the insurers themselves, is not “good,” Mr. Greene! (Indeed with such friends, who would strengthen the hand of the private insurance industry, does the “perfect” really need an “enemy”?)
Hey – thought experiment. Imagine a social force with the ideas, the people, and the supporting data capable of transforming the American insurance system of oligopoly market control by profit-seeking corporations, into a model based upon the Swiss system, the famous Bismarck model. Sure, propose to convert every corporation to non-profit, dictate what they will cover and what margin they will make, including executive compensation. TR Reid has pointed out that in Germany, the company that makes too much money has to give it to the company that has lost money.
So how do you propose to convert the United States into Switzerland, Mr. Greene? For the mass and momentum of the social force needed would be far greater than that required to simply abolish private health insurance and begin anew with Medicare for all – expanding Medicare is practical and immediately possible. Oops – perhaps that is why Healthcare-Now! has hundreds of people on the calls you find so discouraging!
One more thing. Single-payer Medicare-for-all is in fact an incremental proposal. Public financing, private delivery – this is but a small but essential step in reforming our many hideous problems with quality of care, disparities, the erosion of the privacy and the privacy and choice in the provider-patient relationship. Single payer is an increment – but the crucial building block.
Single payer now!
Dr. Coates,
Thanks for taking the time to respond to my post. I was personally sold on single payer early on in my quest to understand this problem. Primarily from watching T.R. Reid’s documentary and reading his book along with reading Dr. Howard Dean’s book and watching Sicko. I’m also reading Critical Condition by Bartlett and Steele. Please remember that I did call single payer the “Perfect” solution. I’m a Republican who’s only chosen to support Healthcare reform after I made a choice to do my homework. I’ve determined first that it’s the right thing to do and should be a human right and secondly that we can’t afford to keep the status quo. I don’t have years invested in the single payer fight so I fully understand your vigorous defense in response to my Swiss model suggestion. I guess what I’m proposing is that it might be easier to attract more conservatives to fight with us if multiple models reaching the same goal are offered. While you and I both would prefer a single payer solution the goal isn’t us being right, it’s getting people quality healthcare at an affordable price and in the shortest amount of time so people don’t have to keep dying while we argue what the “Perfect” solution is. There are countries who have done this without using the single payer model ie Germany, Switzerland, Japan etc. Let’s get the “Good” done now and work toward the Perfect. Is that not reasonable?
Why can’t we just get along and dance together and all win together?
We live in a Capitalist society and one of the evils of our society is self-interest and corporate profit maximization at all cost.
*I am for single payer and public option and integrated health insurance/taxes/jobs bill reform.
Personally and currently,I have sick friends and relatives who end up in bankruptcy because health insurance companies denied their claims. I have physician friends who are squeezed by high malpractice insurance year in and year out. I have friends who work for health and malpractice insurance & pharmaceutical companies who are overworked and underpaid. I have unemployed and underemployed friends who cannot afford Cobra and exhausted their unemployment benefits. Our organization for the past 2 years, have been denied over 800 times and never got grant funding from the government and public/private foundations for our nonprofit organization to further our public causes we established since 1993. Hence, our volunteers don’t have health insurance.
*I fully support “Medicare to All” and in all my posts in Facebook, Linkedin, and Twitter for the past week, my wife Frances Strain and I called this “MEDISHARE”.
Everyone must concede, share, forgive, forget, and help each other!
– If we implement “Medicare for Everyone” or “MediShare”, what will be our plans for my friends who work for health insurance, malpractice insurance, and pharmaceutical companies who will lose their jobs? Any ideas? What jobs will the government create for them?
– What are we going to do with the Board of Directors & Officers of these health/malpractice insurance and pharmaceutical companies who are excessive, sociopaths, and financial sociopaths? Any ideas?
– Any ideas on how can my sick friends, who are now mostly bankrupt, recover from the evils done by health/malpractice insurance companies? They cannot even borrow money and losing their homes due to foreclosure!
– Any response President Obama, Congressmen, Senate, IRS, lobbyists, health/malpractice pharmaceutical companies, and us the majority financially poor?
EVERYONE HELP! WE NEED BALANCE! DON’T BE A FINANCIAL SOCIOPATH! PLEASE HELP EACH OTHER OUT!
The perfect should not be the enemy of the good but it should be the enemy of the bad. The current proposals don’t address premium costs and benefits. The insurance companies will pretty much be able to charge what they want and to tailor policies with minimal coverage. If the legislation passes under either of these proposals they will collapse under their own weight and will probably be repealed by Repubs before they even go into effect.
Newsflash! Humana (a health insurance company) cutting approximately 2500 jobs! Their reason: Low enrollment.
The “majority” who are financially strapped just cannot afford the premiums anymore! Or the “majority” does not have trust and faith with the health insurance companies anymore.
I am one of the majority who does not trust the health insurance companies anymore because they technically killed my friends financially and physically by not paying on valid claims. What can you do if you lose your faith and trust? You cannot just give your hard earned dollars to these health insurance companies knowing that they will find a way to deny you and give your money to their financial sociopath Board of Directors and Officers (the powerful and rich “minority” who happens to be strong lobbyists)!
One of my friend working for Humana will probably lose her job. ***Solution: Health Insurance Analysts and Clerks who will lose their jobs must be helped to work for the hospitals as medical testing technicians or accounts receivable & payable clerks or community aid specialists ( those who will help the “majority”, who live in their hospital community to obtain healthcare protection based on sliding scale of income — like the Cook County Hospital model except it should be mandated to all private hospitals too).
If we have to eliminate the middlemen (health insurance companies), I am all for it as long as the “majority” will be served and as long the eliminated middlemen “majority” will be helped.
They are not even talking about health care coverage for the chronically unemployed, chronically underemployed, and chronically temporary workers who cannot really afford anything because they are very careful of giving out to health insurance companies whatever money they have left. How can the health reform cover them?
They are not even talking about those healthy people who give up and don’t trust health insurance companies anymore. Those who are healthy want value – first dollars & medical testing/preventative coverage before any deductibles.
Still unacceptable to vote yes as of March 19, 2010…Mandating everyone to pay for health insurance (including small businesses) or else pay penalties? That sounds extortion to me! What if your one of the 40 million who are uninsured and unemployed and also no money left after paying just the rent, food, basic clothing and transportation? double whammy! Where else these people get the money upfront to purchase health insurance? High interest loans? Your bailing out the banks and health insurance companies again!!!
AMEND THIS CLAUSE BEFORE VOTING YES AND CREATE SOME EXCEPTIONS!!!
Keep in mind that State governments also pay for the jails LOL! Jail overcrowding is a rampant problem LOL! People who are healthcare uninsured will be jailed because they cannot pay the penalty? Give us a break!!!
SOLUTION: A NEW PROGRESSIVE HEALTH CARE TAX
This is how it works: For people (young and old 16 years and over) and families earning under 20K, 1% of their paycheck is automatically deducted for heath care tax. 30K and under but over 20k 1.5%, 40K and under but over 30K 2%. 70K and under but over 40K 2.5%. 100K and under but over 70K 3%. 150K and under but over 100k 3.5%. 250K and under but over 150k 4%. 300K and under but over 250K 4.5%, 400K and under but over 300k 5%….and so on and so forth…
Of course the rich has to share the wealth unless they are inconsiderate financial sociopaths!