The Single Payer Movement and the Path Forward

June 18, 2017

By Amanda Buddenbaum

The United States is the only wealthy country that does not have a universal health care system. The US spends about $10,000 per capita annually on health care, more than double the average spent by the OECD (Organization for Economic Cooperation and Development) countries. Despite this massive expense that is approaching 20% of GDP, people in the US are not getting their money's worth. We are paying more yet suffering worse outcomes.

The United States is 29th in life expectancy, below Costa Rica, Chile, and Slovenia. The Italians live four years longer than we do. We're not taking good care of our newborns either—the US is 33rd in infant mortality. US mothers die in childbirth more frequently than in Iran, Turkey, Croatia, and many other countries. In fact, a woman in the US is more likely to die in childbirth than a woman in any other industrialized country.

It is now clear that the Affordable Care Act (ACA), passed in 2010 by the Obama Administration, did not, and cannot, solve the fundamental problems of a health care system based on profit. The ACA reduced the level of uninsured from about 48 million people to 28 million. Yet 28 million uninsured will result in 28,000 unnecessary deaths annually. Those who have coverage are now subjected to higher premiums, deductibles, co-pays, co-insurance, and narrow networks that still deprive millions of the care they need. At least one third of people who have coverage go without necessary care or medicine because of the cost.

Costs are rising with no end in sight as insurers pull out of the exchanges in counties and states where they deem profits too low. The cooperatives that were supposed to have provided competition in the exchanges have collapsed. None of the measures placed in the ACA to control costs are working—not bundled payments, not pay for performance, not medical homes, not chronic disease management, not Accountable Care Organizations, not pay for value or quality, none of the pilot programs that Ivy league wonks, working in conjunction with insurance company experts, placed in the ACA to lower costs while improving care is working. None. Period.

Perhaps most telling are studies that show the US comes in last on death rates for conditions amenable to treatment. A wealthy nation with high death rates for curable conditions should be due an uprising for change, and that is beginning to happen. There is a massive outpouring of sentiment for an improved Medicare for All, a single payer, publicly financed health care system that removes the for-profit insurance companies and the for-profit hospitals while improving care and extending it to all.

The American Health Care Act passed by the House GOP is so malevolent that it has been called "mean" even by Donald Trump. Millions have become avid supporters of single payer Medicare for All as they learned of it from Bernie Sanders in his presidential campaign. The anger against the health system is rising, and national single payer legislation, HR 676, Congressman John Conyers' Expanded and Improved Medicare for All, is the focus of an energized movement.

Can it grow and move forward to actually pass the legislation?

Some sidetracks threaten to derail this momentum. They are first,  an incremental approach through a public option and, second, a  state-by-state single payer plan.

An Incremental Approach through a Public Option

The leadership of the Democratic Party, Nancy Pelosi, Hillary Clinton, et al., propose a public option plus an infusion of more money to subsidize insurers. They assure us that creating competition in the exchanges through a publicly financed alternative and a few tweaks will make the ACA work. It isn't true. The public option will add only one more plan to a system that cannot work because it is based on the market and private insurance. The system will still maintain all the administrative waste that makes it so expensive while yet denying care. [1]

Making a profit requires administrative waste. Insurance companies must have watchdogs to assure that physicians will be questioned repeatedly before approval for the treatments they propose. Many doctors and hospitals are placed outside of the narrow networks. Expensive drugs are placed on upper tiers making co-pays unaffordable. This interference with patients' choice of physician and with physicians' professional judgement makes private insurance cost 15% to 20% to administer while traditional Medicare costs less than 2% to administer.

The drive for profit places insurance company interests in opposition to the interests of patients. What increases care cuts profits. What increases profits cuts care. The public option leaves the profits in place. Illusions about this public option are widespread. The Congressional Progressive Caucus includes the public option in their proposed peoples' budget. Peter DeFazio of Oregon introduced the public option into the current congress in February. There are 15 cosponsors on the bill. The single payer movement has major work ahead to keep the Democratic Party from taking us down a doomed public option path.

Single Payer State by State

There is another unworkable proposal diverting the focus of the single payer movement. It is a plan to win single payer state by state, eventually reaching a national system by showing how effectively it works in the states. The proponents assert that the political situation blocks any national approach. The problem is, single payer cannot work in one state.

Don McCanne MD, policy expert of the Physicians for a National Health Program, tells why:

"We cannot use the example of Saskatchewan and pretend that a state can set up a single payer system that could serve as an example for the nation – a model that could be expanded to all states. No. Saskatchewan began with a tabula rasa. They were able to create a de novo single payer system. The Public Citizen report shows us that our existing federal laws create complexities that would prevent states from enacting a financing model that could be held up to the rest of the nation as an example of the benefits of single payer, even though that is a noble intent of the report.

"In fact, there is a risk that such an effort would allow opponents to claim, 'See, single payer doesn't work.'"[2]

The Vermont, New York, and California "single payer" bills include a plan to ask the federal government for a waiver to give Medicare funds to the states to establish their state health care systems. There is no current law that allows that. The Vermont, New York, and California "single payer" bills include a plan to ask the federal government for a waiver to give Medicare funds to the states to establish their state health care systems.

There is no current law that allows that. It will take an Act of Congress. Newt Gingrich, Grover Norquist, and all those who want to destroy Medicare, will line up to help block grant Medicare to the states. Perhaps one or two states would be able to use that to implement state single payer. In the rest of the states, the money would go to backward plans that promote profit while we lose Medicare for the nation. It's a price too big to pay to promote state single payer innovation.

Some have proposed that we pass a federal law that will turn over Medicare monies only to the states that are implementing single payer plans.  How are we going to pass that?  When we have the ability to pass such a law, we would also have the ability to pass single payer for the entire nation—so why not cut to the chase?  

Don McCanne, MD, puts it:   

“Although states could improve billing functions, that captures only a very small portion of the profound administrative waste in our system. Any savings on a state level would be very modest and would not be enough to pay for the elimination of uninsurance and underinsurance. Total health care costs would increase even more, when costs are already intolerable.” [3]

Health Care is Now Squarely on the National Agenda.  

The model bill, HR 676, national single payer, Expanded and Improved Medicare for All, is rapidly gaining support.  There are now 112 cosponsors, more than ever before, and Congressman Conyers has been introducing HR 676 into every Congress since 2003.

Congressman Mark Pocan of Wisconsin recently reported the rising enthusiasm:

“What happens in the Town Halls across my district from Dodgeville to Darlington from Monroe to Madison, all in Wisconsin, every single town hall when we get talking about health care inevitably we get to what about Medicare for All.  And when we get to that it gets the largest response of any in that Town Hall.”  Pocan said the same response to Medicare for All happened even at a town hall in Speaker Paul Ryan’s district.

If the single payer movement can avoid the distraction of the public option and keep its national focus, then a powerful movement is a-borning, one that can shake the foundations of the profits in health care—and perhaps do even more.

_____________________________________________

1. http://www.pnhp.org/change/Public_Option_Myths_and_Facts.pdf

2. http://pnhp.org/blog/2013/07/10/how-states- can-get- close-to- a-single- payer-system

3. Ibid.

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