Our Broken Healthcare System: Prospects for Change

growing concern

The good news: America is concerned about healthcare above all other domestic issues, supports a single-payer system, and is ready to cover everyone -- even if its means paying higher taxes. The bad news: the reason the country is so ready for change is that the current system is so horrifically flawed. As I wrote in the Globe last year.

Given that an estimated 18,000 Americans die each year from lack of health insurance, it is clear that reform is long overdue.

Even with the growing concern, and the fact that healthcare is gaining traction in the news cycle, there are reasons to be skeptical about the prospects for positive change. For example, the President's dead-on-arrival proposal didn't even pretend to provide universal coverage.

“Bush’s reform plan - fiddling with the tax system and peddling skimpy private health plans - will fail miserably,” said Dr. Oliver Fein, Professor of Medicine at Cornell University in a statement released in response to Bush’s State of The Union speech. He also noted that, like Massachusetts and California proposals that rely on private insurers, “it would leave millions without coverage.”

the 'individual mandate'

While we expect the president to offer nothing of substance on this issue, one would hope that state legislatures or Democrats may. That reform is overdue, however, does not mean it will come -- and it certainly doesn't assure that whatever plans are proposed will result in adequate care for all Americans. For example, the "individual mandate" is an idea that is gaining traction, and this is very troubling. The plan passed in Massachusetts last year, for example, is horribly flawed, and as Steffie Woolhandler told me, it is "pure fantasy" to claim it will result in universal coverage.

Still the bill was covered as if it were some kind of miracle solution. The New York Times ran a front page story that did not bother to find one source to counter the endless praise bestowed on the bill. The Globe also ran an editorial praising the "healthcare heroes" behind RomneyCare. (Thankfully a week later columnist Joan Vennochi countered with "Mitt's myth of healthcare." )

Perhaps the overly optimistic coverage of the Massachusetts plan could explain why other politicians have warmed to the idea. Governor Arnold Schwarzenegger has proposed his own plan which also works of the concept of an individual mandate, just a few months after he vetoed a bill that would have resulted in a single-payer plan saying he "cannot support a government-run health care system.”

While presidential candidate John Edward's was bold enough to suggest that we should roll back the Bush Tax Cuts to pay for universal coverage -- a step Clinton and Obama have not said they would be willing to make -- his plan is still at its core is, as Len Rodberg said, an "individual mandate with a pretty face." And indeed, Edwards is a skilled rhetorician which makes his plan sound much sweeter than it is.

a voice of reason

But fortunately there are some sharp experts on the issue of healthcare. One is Jonathan Cohn, the senior editor of the New Republic. He applauded some aspects of the Edwards proposal but rightly noted the big problem (emphasis provided by The Soapbox).

The new Edwards plan is not as far-reaching as some plans now circulating in Congress including plans that call for remaking the health care system top-to-bottom by creating a single-payer system modeled on Medicare. Precisely because the Edwards plan comes from the candidate positioning himself as the voice of working-class populism, that makes the final product just a tad disappointing.

Of course, Cohn has shown an embrace of radical change on healthcare, that most do not. In 2002, when Al Gore surprised the world by advocating for a single-payer system -- not exactly a risk-free move at the time -- Cohn came to his defense.

Is Gore nuts? Not on policy grounds. In a single-payer system, the government becomes the nation's health insurance company. Instead of paying premiums to an insurer (either directly or through an employer), each American would pay that money to the government; in turn, the government would pay the providers of medical care--i.e., mostly private doctors and hospitals--in the same way insurance companies now do.

Make no mistake: It's a radical overhaul. But single-payer also has clear virtues: As a general rule, the more people who belong to an insurance pool, the more thinly you spread the financial burden of illness, which can be devastating if you face it alone or within a small group. By definition, single-payer spreads the risk pool across the largest number of people possible--namely, everyone in the country. In addition, while people may associate government with excessive bureaucracy, single-payer systems devote far less money to administrative overhead than private insurance.


And, of course, single-payer systems by definition make coverage universal--i.e., they give insurance to every citizen as a birthright, regardless of employment status. This isn't just fair: It may also be more efficient, since it would allow people more freedom to change jobs and pursue better opportunities.

Another strong point by Cohn, whose TNR article on Gore was a strong enough defense of single-payer to be be republished by Physicians for a National Health Program, was that no matter how business-friendly a politician tries to make a universal healthcare plan --(see HillaryCare) --they will inevitably be attacked as radical socialists anyway. So why bother trying?

The lesson is that even if you don't actually propose a radical overhaul of the health care system, critics from the right will still have an easy time denouncing it as medical socialism. Indeed, critics from the right have been known to level that charge at even piecemeal health reform measures--from the State Children's Health Insurance Program (S-CHIP), which merely allows states to subsidize coverage for kids living at or near the poverty line, to HMO reform, which doesn't expand coverage at all but simply regulates the way insurance companies make treatment decisions.

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

I noted Cohn's vision six weeks ago when I said:

Cohn’s suggestions for implementing universal health care, which are laid out in the book’s conclusion, are unambiguously and impressively bold. He has high praise for Medicare calling it “remarkably efficient.” Moreover, he speaks glowingly about many foreign governments’ health care systems. He has high praise for France’s system (where all legal residents have insurance and the government subsidizes around 75 percent of all heath care costs), which he says may be “the best showcase for what universal health care can achieve.” He also defends Canada’s single-payer system and says stories of long lines in Canadian hospitals are “wildly exaggerated.”

Given Cohn's perceptiveness and principle on the issue, it is good to see that he is featured in the Times twice this week. As this debate moves forward, having a senior editor of TNR, who is a respected, non-divisive figure handling the issue of healthcare, is a huge improvement to the early 90s when then editor of TNR, Andrew Sullivan, helped to kill the Clinton plan with an assault from the right. Of course he has a lot of help from then Republican operative, William Kristol, but TNR's role was substantial in the pre-Internet days, when they really did drive debate in Washington.

the role of business

Today, the Times has book review on Jonathan Cohn's new book Sick: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price. In February I reviewed the same book for Campus Progress.

That the reviewer, Sally Satel, is from the American Enterprise Institute made some the critiques predictable.

Cohn is himself being unfair when he sweepingly denounces “the principles of modern conservatism” for being “conspicuously short on ... comfort or hope.” In truth, there is nothing inherently pessimistic in choice, self-reliance or limited bureaucracy — the values that underlie a market-based proposal like the one introduced by Senator Ron Wyden, an Oregon Democrat. In this plan, employers would no longer provide insurance and would instead convert those costs into a bigger paycheck, enabling workers to buy private insurance from providers who would then be forced to compete for business by offering better plans.

But still it is telling that even someone from the ultra conservative think tank (the AEI's fellows include Mary Cheney, Fred Kagan, John Yoo and Newt Gingrich) also seemed obligated to acknowledge the tragedy of our current system as highlight by the book.

The timing of this book is perfect. An epidemic of anxiety over the cost of health care has catapulted reform back onto the national agenda, and states from California to Massachusetts are now experimenting with universal coverage. It also promises to be a key issue in the 2008 election.

In “Sick,” Jonathan Cohn, a senior editor at The New Republic, lucidly shows how America’s system for financing medical care helps determine who gets proper medical attention — and who doesn’t. He tells this story through the experiences of ordinary people ...

By the end of Cohn’s narrative we’ve run the gamut of woes: the hopeless fragmentation of the mental heath system; staggering medical debt; the dependence on job-based insurance; frayed social safety nets; lousy (or no) guarantees of preventive care; selective access to medications.

In his article in last weeks New York Times Magazine, Cohn also illustrates a growing consensus on healthcare amongst strange bedfellows, big-business and the left, who for different reasons are being squeezed by the rising costs of care.

Is all of this indicative of a broader shift in the politics of health care? Perhaps. As health care has become more expensive and even middle-class Americans have become anxious that their hold on employer-sponsored coverage is precarious, politicians have been talking seriously again about making health insurance a birthright, just as it is in every other developed nation.


But it is corporate America’s interest that is most striking. For many years, the only business leaders openly calling for universal coverage were mavericks like Howard Schultz, the chairman of Starbucks, who has long preached the need for business to show greater social responsibility. The C.E.O.’s rallying to universal coverage now — particularly in the last few months — are acting not so much out of social solidarity as out of financial necessity, as the burden of financing workers’ premiums has become ever more onerous.“The refrain from business was, ‘We can’t afford to do universal health care,’ ” says Wyden, whose plan calls for shifting responsibility for buying insurance from employers to individuals. “Now the refrain is, ‘We can’t afford not to do it.’ ”

Now, that the business community has a reason to support healthcare reform does not mean that change is inevitable. They have been woefully short on specifics but would seem to be motivated to support some kind of individual mandate plan, and not what would a far better plan: HR 676 -- Medicare for All.

In the early phases of the last great debate about health-care reform, during the early 1990s, prominent business leaders sent out strikingly similar signals — suggesting they were ready to embrace universal health care, for the same essential reasons they cite now. At one point, a coalition of business leaders put out a “play or pay” proposal that would have required corporations either to insure their workers or to pay into a common fund for the uninsured. But as President Clinton’s health-care plan lost political momentum, the business community’s support for universal health care faltered and, eventually, collapsed. Is its support any more reliable now? “This is precisely the political equation the Clintons bet on,” says Jonathan Oberlander, a health-policy scholar at the University of North Carolina. “Sorry to say this may turn out to be another mirage.”

And as the Massachusetts plan is likely to show, the mandate plans -- which make health insurance, like car insurance, something one must buy -- the reason why triangulating on healthcare only perpetuates the main problem: the fact that health insurance is controlled by the pharmaceutical companies, who are paying wasteful administrative costs, turning in a profit and giving money to politicians in both major parties.

And this has some within the single-payer movement conflicted. I attended a forum for PNHP METRO in late February and there was some dissension on how to approach the Edward's plan. While virtually no one there thought the Edwards plan would pass, or for that matter would be an efficient plan even if it did, there were still questions? Do you attack the plan for its obvious flaws, and its inability to address the root of the problem (private insurance companies and a lack of a single-payer system)? Or, do you hold off on harsh criticism, knowing the plan will never be implemented anyway (even if Edwards won the presidency, the sausage making fest that is the legislative process would either kill, or alter the plan greatly,) and try to use the momentum to help build the single-payer movement?

medicare for all

It seems, the majority of members preferred the former. There is simply no question that (HR676) The United States National Health Insurance Act which calls for "Medicare for All" is the best proposal in Washington -- and the only one that aims to take down private insurers and give the US with what every other developed country in the world has: a national universal healthcare plan.

But still, there are good signs. Aforementioned polls show that 56 percent of the public has said that they prefer a plan "like Medicare" to our current system and that healthcare is the countries top domestic priority. HR 676 now has 78 cosponsors and labor is on board as well; the AFL-CIO Executive Committee has endorsed Medicare for All.

Sure the Democratic Candidates, sans Kucinich, are predictably and sadly failing to represent the will of the country. But let us not choose the candidates, let them choose us. As an editorial in The Nation said.

Voters have to demand more if they want more. Obama at least recognizes the frustration of Americans for whom meaningful healthcare reform has been a dream deferred at least since the collapse of the Clinton Administration’s bureaucratic proposals of the mid-1990s. The Clinton plan rejected single-payer and embraced a complicated hybrid that relied too heavily on the same insurance companies that had failed to make healthcare affordable and accessible. “We can’t afford another disappointing charade in 2008, 2009 and 2010,” says Obama. He’s right. But he and his fellow front-runners should recognize that as long as they avoid talking about single-payer and continue to tinker around the edges of the current system, they are players in the charade.

Something is brewing out there. Recall two years ago when virtually every Democrat currently running for President, sans Kucinich, was opposed to a timetable in Iraq. What seems a more likely cause of the latest shift? Was it that they all has some moral epiphany, or did they begin to realize that the public will not allow them to keep walking, willfully, down the road that is destroying us. Politicians don't make change unless it becomes a political liability for them not to. Right now, the winds are at our back.