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Despite Obamacare rollout, Progressives see single-payer health care as goal
December 10, 2013
Among the people who express dissatisfaction with Obamacare (the Affordable
Care Act), the bigger number are actually progressives who were upset by the
contortions Obama went through to preserve profit-making private insurance
companies as the gatekeepers to the health care system.
Progressives wanted a single-payer system which every other advanced
industrialized country has. Because in essence, health care - life and death
- is not a commodity subject to free market forces - consumers are in no
position to shop around or make rational choices when faced with a health
emergency, and in fact, there is no transparency or competition that would
even allow a "free market" to exist.
What is more, Obamacare is focused principally on the problem of access to
care - presently denied to 49 million uninsured people and millions more
underinsured people for whom a single medical emergency can result in
bankruptcy, but amazingly, a proportion that has remained consistent at 16%
- rather than the cost crisis of health care. Ultimately, this is
unsustainable.
The charge that Obamacare addresses access and not cost, is an essential
aspect of the argument that Leonard Rodberg. Professor and Chair of the
Urban Studies Department at Queens College of the City University of New
York and Research Director of the New York Metro Chapter of Physicians for a
National Health Program, presented recently to Reach Out America, a local
activist group.
There is great bitterness in his tone - and the botched rollout of the
exchanges because of glitches in healthcare.gov site only serves to be an "I
told you so" because of a program that is unbelievably - and in
progressives' minds unnecessarily - complicated.
Indeed, his indictment of Obamacare as doing little to contain the
inexorable rise in health care costs seems overstated, considering that
health care spending is growing at the slowest rate on record and health
care price inflation is at its lowest rate in 50 years, according to a
recently released report from the Council of Economic Advisers on “The
Recent Slowdown in Health Care Cost Growth and the Role of the Affordable
Care Act."
The report also found that health care spending is growing at the slowest
rate on record: "According to the most recent projections, real per capita
health care spending has grown at an estimated average annual rate of just 1
.3 percent over the three years since 2010. This is the lowest rate on
record for any three-year period and less than one-third the long-term
historical average stretching back to 1965. This slower growth in spending
is reflected in Medicare, Medicaid, and private insurance."
Keep in mind, the health care exchanges, which for the first time will
inject transparency and competition as well as value into individual
insurance, have yet to be implemented. But just the early phases of
Obamacare - the requirement that insurance companies spend 80% of the
premium of actual health care rather than profits, salaries and marketing as
well as for preventive and wellness care without co-pays, and the ability
of young people to stay on their parents' policy until age 26 - has already
bent the cost curve, which had been inexorably rising at triple the CPI for
decades. The result has been that more and more companies stopped offering
health insurance to employees or raised the employee share so that it was
unaffordable (the average cost for a family of 4 was $16,000 last year in an
employer-sponsored program), let alone making insurance unaffordable for
those forced to buy privately. that was the reason so many people were
underinsured, so that a health care emergency could plunge them into
bankruptcy.
What no one has said, but Rodberg is acutely aware of, is that the private
insurance companies still control allocation of health care.
Rodberg knows first-hand. He didn't relay this anecdote to Reach Out America
, but it is in the testimony he gave in 2007 to the "Hearing on the
Partnership for Coverage before the Department of Health and Department of
Insurance" (Nov. 2, 2007).
He told the story of his wife, Joanne Lukomnik, who served as medical
director for several community health centers in the New York area and was a
consultant on primary care to a number of State and Federal agencies. In
1994 she was diagnosed with multiple myeloma, a cancer of the bone marrow.
Doctors recommended she have an autologous stem cell transplant.
"Our insurance company turned it down, claiming it was 'experimental.' "
even though Joanne showed that this was a well-established procedure that
had been used extensively and successfully at centers throughout the United
States and France.
"She sent this to the insurance company, whose medical director called her a
few days later. He said that, actually, he didn’t know anything about
myeloma and just routinely signed the denial letters. He would reverse the
denial.
"But it was too late. The transplant had been delayed by the denials and
appeals, and she died before it could take place, leaving two teenage
children and an angry husband. I had witnessed at a personal level what I
had previously understood only theoretically.
"For-profit health insurance is a corrupt and conflicted enterprise. Their
ads say they really care about our health but, as Milton Friedman told them
and us, their job is to make money for their shareholders; they are not to
be led astray by the claims of social responsibility. Somehow, in the last
several decades, we have turned medical decisions over to these profit-
making companies, whose interest is in saving money by denying care, not in
preserving life."
Nothing in that basic paradigm of health care provided under profit-making
structure changes under Obamacare, with the exception that the level of
profit in the insurance premium (not cost) is now capped. If true "free-
market" supply-demand system would operate, a hospital could say, "What is
it worth for you to save the life of your child? One million dollars? Two
million?" (The insurance company negotiates what it will pay for the
operation; you sign a document with the doctor that says you will be liable
for the rest.)
Health insurance companies still have the power to refuse coverage for what
they deem "experimental" (a best practices panel, which right-wingers have
dubbed "death panels" would have helped, not hindered, especially if health
consumers could have a place to apply to overturn a rejection); also, they
still get to negotiate repayments schedules which can cause doctors to
refuse to drop accepting insurance companies or leave their practice
altogether. The newest development is that insurance companies are "
consolidating" the number of doctors and networks they work with, which may
force people to have to change doctors.
"No other country allowed the so-called free market to control health care
costs," Rodberg says. "They understand in a way that we are taught not to
understand, that patients are in no position to bargain over prices or
comparison shop. When they need care, they need care, and you want a doctor
that cares about you."
New York Times this week was the latest to examine the outrageous and
unequal prices charged by hospitals:
"California Pacific Medical Center’s 400-page chargemaster for this year
contains some eye-popping figures: from $32,901 for an x-ray study of the
heart’s arteries to $25,646.88 for gall bladder removal (doctor’s fees not
included) to $5,510 for a simple vaginal delivery (not including $731 for
each hour of labor, or $137 for each bag of IV fluid). Even basic supplies
or services carry huge markups: $20 for a codeine pill (50 cents at Rite-Aid
or Walgreens), $543 for a breast-pump kit ($25 online), $4,495 for a CT
scan of the abdomen (about $400 at an outpatient facility nearby). Plenty of
other hospitals set similar prices," Elizabeth Rosenthal wrote in "As
Hospital Prices Soar, a Stitch Tops $500," (Dec. 2) (See also: New York
State Hospital Data Exposes Big Markups, and Odd Bargains)
This prompted a response from Rich Umbdenstock, President and Chief
Executive, American Hospital Association, Washington DC (an organization
that spends $20 million a year on lobbying):
"Paying the wages and benefits of the highly qualified nurses, physicians,
caregivers and other staff required to be on hand around the clock consumes
about two-thirds of hospital budgets. This standby capacity is not
explicitly funded and must be built into the charges for covered items, but
patients and communities depend on this capacity and expect it when needed.
"No other institution operates under a system in which it receives less than
the cost of providing services to the majority of its customers — Medicare
and Medicaid patients — and routinely provides emergency and other
services to patients who cannot pay. And few operate under a regulatory
burden that comes close to that of hospitals — a burden that is increasing
and adds greatly to the cost of providing services. To keep their doors open
, hospitals must account for these factors and many more in their billing
practices," Umbdenstock wrote.
That seems a fair argument - doctors and nurses should be well compensated -
but the story also prompted another letter writer to relate her experience,
drawing the distinction between US health care (which contrary to the
Rightwing Anti-Obamacarists is not the best in the world) and a universal
coverage system: "While on a recent visit to Berlin, I sustained a large
gash on my leg while getting into a small bus. Bleeding profusely, I went to
the nearest hospital’s emergency room, where after a few minutes I was led
into a large, well-equipped treatment room. There, a doctor, assisted by
two nurses, gave me a physical, I received a tetanus shot and the wound was
thoroughly treated.
"About an hour later I was discharged after receiving nonnarcotic
painkillers and extra bandages to take with me. Not carrying German
insurance, I was handed a bill, which listed in great detail all procedures.
I was charged the equivalent of about $68. What would the same treatment in
a New York hospital have cost?"
Rodberg says, "You commonly hear 'American’s don’t have enough skin the
game' – people think others are getting free ride. But we’re spending more
than any other country, 41% spend $1000 or more out of pocket, almost twice
the rate of next highest, Australia."
"We are unique in two ways. Not only do we not have universal coverage but
we spend 60% more than the next most expensive system (Switzerland), twice
as much as the average advanced industrial country. We spend too much and
get too little."
Theoretically - and contrary to the bleak picture Rodberg painted for Reach
Out America - some of this price issue will be moderated because there will
be less "uncompensated care" - if people all have access to health insurance
, fewer will be using emergency rooms as their primary care and fewer
procedures will be "uncompensated" and therefore heaped onto the cost of
everyone else ($1000 in every premium, and clearly, in the rest of the
prices we are charged for services).
One could also make the argument that Obamacare will help reduce overall
spending for health care because of the focus on prevention and wellness (
free annual checkups and major diagnostic tests) - which will help prevent
illness as well as catch ailments early when they can be treated more
effectively and cheaply.
Still, Rodberg argues that Obamacare will not stop the increase in health
care as a percentage of GDP. He points out that the national health
expenditure as percent of GDP is projected to rise from 17.8% of the economy
in 2009 to 21% in 2019.
Other countries that actually have universal health care have seen their
percentage of health expenditure consistently stay below 10% of their
economy, in the 8-9% range for the past 15 years.
"If we keep going this way, health care costs keep rising, taking larger and
larger share of money we would like to spend on living rather than doctors.
At some point, we have to do this in a rational way – like the rest of
world has done it."
(I would suggest that one reason health care will continue to rise as
percentage of GDP reflects the lack of economic progress in other sectors,
like clean energy, but also, health care will continue to grow as a share of
GDP because of the demographics toward an older population living longer
and the improvements in medical treatments available to keep them living
longer. At some point, this society will have to start thinking about
allowing euthanasia - people shouldn't be forced to stay alive.)
But Rodberg goes further, puncturing the claim that Republicans make that
Obamacare shifts the "burden" of health care for "others" onto taxpayers,
makes the argument that taxpayers are already shouldering the biggest burden
of health care expense. In essence, the argument is the same as for
corporations like Walmart and McDonald's who pay their workers so little
money, they qualify for billions in federal services - food stamps and such
(corporate welfare).
Today, half of Americans get insurance from employer-based private insurance
, 169.7 million but represents only 34% of the dollars spent on health care
(the government takes the lion's share) because they only [or rather mostly]
cover the healthy ones, and government has to pay for sicker. The federal
government also subsidizes private insurance by making it a business expense
(tax breaks). The government already is spending more than half of all the
health care costs."
This makes sense because employers don't tend to hire sick people and if an
employee gets too sick to work, they also lose employer-based insurance and
the ability to pay for insurance if they can acquire it at all because of
their pre-existing condition.
With Obamacare, he says, even more money will come from the public sector:
29% will come from private insurance (subsidized by federal taxes); 40% will
be paid by the federal government; 12% by the state; 12% out of pocket and
7% from other private sources like charity.
So Rodberg makes the argument that we are already more than half way to
universal health care, in the sense of government payments, but we do not
have universal health care in terms of access or cost controls.
It didn’t have to be this way, Rodberg says.
in Obama's words, he found a way to increase access to health care for the
greatest number with the least disruption to the existing health care system
. At the time, more and more employers were abandoning subsidized health
benefits or requiring employees to pay so much, it was unaffordable,
especially as the cost of health care continued to rise, averaging $16,000/
year for a family; while 20,000 people a day were losing access to coverage
because they lost their jobs altogether. That was the immediate crisis that
Obama faced in 2009, while at the same time, seeing the growing share of
health care to the GDP as draining the life out of economic recovery. But in
trying to placate Republicans and the insurance industry's Senator Joe
Lieberman, they made a "kludge."
"ACA is a political Kludge - a clumsy, jury-rigged solution forming a
distressing whole," Rodberg says "The simple solution which would have been
to put everybody on Medicare wasn’t politically possible, so Obama and
Democrats went for a more complicated solution, invented by Republicans 20
years ago and passed in Massachusetts on a bipartisan basis.
"But why did this thing have to be so complicated in the first place?"
Rodberg asks.
The Affordable Care Act is 2700 pages. The Canadian Health Care act
establishing a single payer system is eight pages, he said.
"Imagine, now, a much simpler system in which the government just pays your
major medical expenses… Such a system actually exists and is wildly popular
and efficient: It’s called Medicare."
And yet, it is Medicare that is under attack by Republicans looking to
unravel every aspect of a social safety net. they want to voucherize it,
basically capping the amount of service seniors can obtain without going
into their own pocket.
The problems that greeted the federal website rollout - largely because the
system had to accommodate the 36 states that refused to set up their own
exchanges, compounded by the absurdity of the federal procurement system
that virtually guarantees poor results - only served to confirm the worst
predictions of those who do not want universal health care at all.
But the bigger problems were caused by every act of sabotage and obstruction
from the Republicans who are absolutely determined to kill health care
reform.
Millions are being spent by the likes of Koch Brothers-funded campaigns to
propagandize young people not to sign up - because unless 45% of the
enrollees are the "young, health" people, the premiums will go up and the
cost benefit of Obamacare will be defeated. But what happens to that young
buck who is hit by a car, runs into a tree while skiing, or has the poor
luck of contracting cancer or heart disease? The preventive procedures - a
wellness exam and tests which can disclose problems while they can be easily
treated - more than pay for the premium, anyway, not to mention the fact
that about half of them will get subsidized.
And if that is not enough, there are actually fraudulent campaigns being run
- outright lies along the same lines as the likes of Michelle Bachmann and
Sarah Palin ("death panels") have been spewing from the beginning.
California Republicans created a fake health care website to discourage
people from getting health insurance, and they are using official mailers to
send constituents to the site, (Daily Kos, 12/2/13).
"Instead of sending constituents to CoveredCA.com, the official California
health insurance exchange site, Republicans created CoveringHealthCareCA.com
. The Republican website poses as a hub for health care information but just
contains negative information about Obamacare that could discourage people
from obtaining health insurance."
Meanwhile, 30 governors - way more than the White House anticipated- have
refused to join the program - basically screwing millions of their residents
from access to Medicaid which means they also will not be able to qualify
for subsidies for private insurance. These are the poorest states - Texas
and Mississippi and Louisiana - which have the highest rates of uninsured.
Now President Obama owned up and took responsibility for the problems with
the website launch (overdoing it in my opinion). For weeks, the media was
obsessed reporting the problems with the website (even though Obamacare is
not just a website) and the "broken promise" of millions of people whose
junk policies were cancelled - so much so, "pundits' are talking about
Democrats losing the Senate and more of the House because of it (no matter
than Republicans shut down government and nearly crashed the economy,
somehow that doesn't stick. I just don't get it). But now that the problems
have been largely fixed and people are signing up by the tens of thousands,
you hardly hear a peep.
The reality is that "More people signed up on the government's new health
insurance website on the first two days of December [after the self-declared
Nov. 30 deadline to fix the website] than in the entire first month of the
launch - 29,000 people enrolled on Sunday and Monday, surpassing nearly 27,
000 for all of October. (See also: Health Care Exchange Is Vastly Improved,
Users Say)
"I have acknowledged more than once that we didn’t roll out parts of this
law as well as we should have," Obama said in his speech last week to the
Center for American Progress, vowing to keep fighting to uphold its
implementation.. "But the law is already working in major ways that benefit
millions of Americans right now, even as we’ve begun to slow the rise in
health care costs, which is good for family budgets, good for federal and
state budgets, and good for the budgets of businesses small and large. So
this law is going to work. And for the sake of our economic security, it
needs to work."
Now some Republicans are charging - absurdly - that the roll-out was an
intentional disaster in order to push people out of their private insurance
and force them into a situation where everyone will have government run,
single-payer (that's right up there with "death panels.")
"Democrats are not that clever to have the Machiavellian scheme to have this
kludge as a way of really getting single payer – I wish they were that
smart," Rodberg says.
And yet, Obamacare may well be to health care what "natural gas" is to
climate change - a transition. Like natural gas, it benefits controlling
interests in the economy. And like natural gas, it was the best that could
be accomplished in this political environment. Even a public option - the
opportunity for individuals to purchase into a Medicare-like system, which
candidate Obama had once championed - was thrown under the bus in order to
win the crucial vote from the insurance industry's senator, Joe Lieberman.
There are those in Congress that are still pushing to for single payer-
Congressman John Conyers has a bill, HR 676, to do just that: extend
Medicare to cover everyone; offer comprehensive benefits; free choice of
doctor and hospital; public agency processes and pays bills; pay for it
through progressive taxes; spend no more than we are spending now.
Similarly, some states are working toward universal coverage - Vermont, for
one. And there is health care reform legislation in NYS- Gottfried-Perkins
New York Health bill which would provide for: universal comprehensive
coverage – everybody in, nobody out; coordination of care by care manager;
no copays or deductibles; paid for by graduated payroll tax and existing
federal funds; covering everyone while spending less than we pay now).
In 2016, states will be able to get waiver under ACA in 2016 to do their own
plan. That would be the Republicans' chance to put up or shut up, since so
far, they only have offered "repeal" based on their abhorrence of a federal
"takeover" of health care without offering any alternatives.
In fact, if the private insurance industry knew what was good for it, it
would support, not obstruct ACA (as it has with fraudulent letters that
blame Obamacare for cancellation of junk policies).
Because now that the American people have had a taste of true health care
reform, they are going to question the whole for-profit system.
And that's the Republicans' worst nightmare about Obamacare - not just that
people will like it and it will demonstrate that government can actually
deliver vital services, but that people will in fact press for Medicare for
All.
Karen Rubin, Long Island Populist Examiner |
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