Health Spectator

by Lindsay Beyerstein

Big news broke over the weekend: Evidently, the president lit a fire under Max Baucus (D-Mont) and the Senate Finance Committee by unexpectedly announcing last week that he’d be laying out his own vision for health care reform this Wednesday. Just weeks ago, committee member Kent Conrad (D-ND) predicted the Finance Committee wouldn’t have a bill until November. But Baucus circulated a legislative framework over the weekend.

Baucus’s bottom line: There will be no public option. Instead, the government will spend hundreds of billions of dollars to subsidize the same old expensive, inadequate private insurance system that health care reform was supposed to reform. The insurance companies get 46 million new customers, and in return, they will pay higher taxes to offset the cost of the subsidies—a kickback to Uncle Sam.

Last week Brian Beutler of Talking Points Memo and I sat down to discuss some burning questions in health care reform: What’s the president’s thinking on the public option? What leverage does he have over the progressives in the House who demand single payer and/or the Blue Dogs in the senate who reject it? Why is Sen. Olympia Snowe (R-Maine) the last best hope for bipartisanship? (The transcript of our discussion has been edited for brevity and clarity.)

You said the [week of September 1] really stood out from the last month in terms of the health care debate. How so?

Maybe the last two days just stood out from the previous month. … Obama’s approval [rating] slid and popular support for the idea of healthcare reform slid. And August came to an end and the President’s vacation is winding down, and suddenly the administration realizes that Congress is coming back and they are going to have to do something. And so, it seems they start leaking to a bunch of high profile reporters that they are going to perhaps ditch the public option as part of a grander move to regain control of the debate.

Are the anonymous leakers saying in so many words that they want to ditch the public option?

Well, it’s unclear what they are actually going to do. The Public Option would die with dignity. [If] that is accomplished, the President could maybe win over some Republicans, grab the debate and spell out in clearer terms what he wanted [beyond] the public option. He could do this all in a big speech for Congress which is scheduled to happen Wednesday.

Isn’t this just a repeat of what we saw during the week of August 20, when the White House seemed to be doing a good cop/bad cop routine where an anonymous aide would leak “to hell with the liberals and the public option” and then another adviser would say on the record how much the president loves the public option?

It could just be a replay. Once those stories came out, the picture sort of fogged up. [There were] secondary reports that the President was courting Olympia Snowe (R-Maine) again—as if maybe one Senate Republican would vote with him on health care reform. Snowe’s idea [includes a] public option, but you attach it to a trigger mechanism so that it is only enacted if the rest of healthcare reform is unsuccessful at bringing down prices and expanding coverage. And that’s sort of been unacceptable to reformers and progressives, but … that might be the pound of flesh that she yields from the bill. It fits in with the picture that the leakers painted … that the public option was no longer going to be one of the key features of the bill.

You wrote about how budget reconciliation could be used to get around the filibuster. How would that work?

The greater problem is the structure in the Senate, where legislation can pass with a majority vote—but only after Senators have debated the bill for as long as they want. As long as 60 Democrats aren’t there to shut the minority up, debate can go on and on and on. [ED note: AKA filibustering.] And for every major piece of legislation you see. this happens. …

There’s this de facto 60-vote rule on most legislation, at least in this Congress and the previous Congress since the Democrats took it over. It’s extremely difficult to pass a bill through just the regular procedure without either having to concede a bunch of substantive provisions … or just give up on the bill entirely. [There are] 59 members of the Democratic caucus right now, and maybe 10 of them are mushy on the more progressive part of the President’s agenda. Even if all of them are onboard, you’re still one vote short of what you need to end debate. And that is why Olympia Snowe matters right now.

So the House would pass the bill and the Senate would pass a bill with budget reconciliation?

They could in theory. Budget reconciliation is sort of like a magic bullet. Every year, the Congress can pass what is known as a budget reconciliation bill. It sets new taxes, or moves money around within the federal budget to basically do what the Congress’s budget lays out. It … was made exempt from the filibuster because Congress [has to] set a budget. … They need to make sure that money is there and can’t have Senators filibustering it just because they’re in a fit of peak. So that bill can’t be filibustered, but at the same time, the legislation that can be passed in it has to be relevant to the budget, it has to move money around in some way.

So you can pass a lot of elements of healthcare reform in theory—you can pass subsidies to poor people and middle-income people. And you can pass Medicaid expansion, and you might even be able to pass the public option because the public option may need subsidies of its own and could drive down other costs and be a big moneysaver.

How might the president pressure progressives into accepting the bill?

My sense is that the President [will pressure] progressives to back off on the public option. But that could change. Trying to figure out what is going to happen is kind of like trying to move 23,000 moves ahead in a game of 17 dimensional chess. …

[Obama can] say is that what he’s planning will, while not perfect, help a lot of people make the healthcare system more progressive than it was. … But it would really harm the democratic party and his presidency if the whole project failed and nothing passed. Obama doesn’t have a tremendous amount of leverage. [Many] progressive members of Congress are progressive because they don’t have viable challenges. They come from progressive districts, with constituents like them, approval ratings in the 60s, 70s, and they aren’t going to lose to a member of the opposite party. So in that sense, they can do what they want.

How can Blue Dogs say that progressives should suck it up and vote for every bill when they are never prepared to do the same thing?

… It would at least be a good experiment, for the party and the country, for the [Blue Dogs] to be put on the spot. They believe that their jobs are on the line if they vote for controversial legislation. I don’t know how those conversations go when political members of the administration confront these guys and say ‘You got into politics to make the world a better place, not to just have a tenure job on Capital Hill. So you’re going to vote yes on this and if you lose your jobs as a result, then you did the right thing and we’ll make sure that the Democratic party infrastructure is there for you … .’ But that’s not the way the party thinks. [It's a] game of building an unstoppably large coalition, and that becomes the goal in the end. And at some point you lose sight of why you are amassing this giant congressional majority and you’re never willing to say, well we built this 70 whatever majority so that we could sacrifice some of these seats and do something really impressive and progressive for the good of the country.

[Editor's note: This piece by Lindsay Beyerstein was originally published on CARE2 make a difference with the stipulation that it was free to reprint. We thought it did such a good job of presenting the current status of things as of this morning, that we have posted it in its entirety. Thanks to Ms. Beyerstein for capturing the essentials.]

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Just yesterday we wrote that Max Baucus (D-Mont) had finally circulated details of a Senate Finance Committee health care framework that would not include the so-called public option.

Then, in his speech before a joint session of Congress last night, President Obama put the public option back on the table.

To do otherwise would seem to have been political suicide for Obama. There’s little doubt that his healthcare platform had a lot to do with his winning the election, and he will bitterly disappoint those followers who are expecting some public plan in health care if he does not at least go down fighting for that cause. So it would seem that the injection of the public option into the mix was the least he could do.

But he did it.

So now, liberals are somewhat encouraged that some form of national health care might yet happen in a reasonable time frame, though it has been about 35 years since the decidely non-liberal Richard Nixon proposed it and of course others have after him.

For those who missed Obama’s speech or would simply like to see it again, we’ve embedded the full version below.

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You’ve already heard what we have to say on this. If you missed it, check the list of related links, and you’ll surely get there. We’ve decided to put some other voices out there via video so you can watch or listen on your way to work or whenever.

We don’t always agree entirely with the conclusions drawn by these speakers. We’ve made no bones about favoring a single-payer system, because we believe it would be the cheapest way to cover everyone and cover them well. Nevertheless, there are arguments for other systems worth hearing.

This segment is entitled, “What is the best healthcare option?”

Interviews with John McCain and Joe Lieberman about the public option in healthcare:

Keith Olbermann discusses health care reform, interviews Bill Maher:

And finally, you’ve heard lots about the French healthcare system in speeches, particularly speeches by Republicans, who love to dump on the French system, which costs less than half what ours does per person.

But do you (or they, for that matter) know anything about it? We thought not.

We were surprised too when we saw this video, which was produced for CBS. Whatever you thought the French system was like, we suspect the truth will surprise you. The numbers for U.S. healthcare here are a bit dated (figures for the U.S. currently exceed $7,000 per person annually in the U.S., which is more than twice the $3,400 quoted annually here for the French. However, the last figures we found for both countries at the same time had U.S. cost just shy of double the French cost, so the figures used in this video seem reasonable).

Don’t forget to use the Comments area below to share your ideas and reactions, whatever they may be.

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Wendell Potter, a former executive of the CIGNA health insurance company, spoke recently with Bill Moyers in an expose of the issues involved in national health insurance. Whether you are for or against universal healthcare, you should watch this video. It presents a rare opportunity to listen to a health-insurance insider tell the ins and outs of the current health-care system and the pros and cons of for-profit health insurance coverage.

Doctors, nurses, the fully insured and the unemployed—all will find something of interest here.

View the interview in its entirety below. Then view Michael Moore’s Sicko online.

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Hear how Big Pharma spent $40 million just in April, May and June of this year to influence Congress against single-payer plans and to ensure that pharmaceutical companies will come out on top in whatever healthcare plan results. This report will tell you why you don’t find discussion of certain issues during the healthcare debate.

Andrea Seabrook and Peter Overby explain that one of the most powerful players in health care is a group called the Pharmaceutical Research and Manufacturers of America, or PhRMA. It represents just 32 brand-name drug companies, but it has so much influence that when Congress passes a bill, PhRMA almost always gets its way. One big reason why: PhRMA and its members have spent millions of dollars lobbying Congress as lawmakers work to overhaul health care.

You can read their story here, or click here to listen to All Things Considered, July 23, 2009 while you browse our site.

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1974: Richard Nixon proposes healthcare reform

It is one of history’s greatest ironies that had Richard Nixon not run afoul of the Watergate scandal, Americans might long ago have obtained universal health care. But thanks to Watergate, Nixon found himself on the path to impeachment and resigned his office. His “sweeping new program” for “comprehsive health insurance” lay dead on the table.

It is another of history’s ironies that Nixon’s successor, President Jimmy Carter, did not have the clout to push through a similar program. We recall sitting with a friend in a bar in New Jersey the same night that John Lennon was shot. A German was expounding on an issue we had never considered before.

“The thing you have to understand about American presidents,” he intoned in his Teutonic accent, “is that they always do the opposite of what you expect them to do. It was Nixon who opened the door to China, and Kennedy and Johnson who got us into the Vietnam war.”

He was claiming, in effect, that a Democrat could get away with sponsoring a program or course of action that, were a Republican to attempt it, would arouse cries of “Nazism.” And a Republican—such as Nixon—is more likely to be successful pushing through a program that, were a Democrat to attempt it, would be called “socialized medicine.”

A tale of two presidents

We happen to think that he was right. And as a consequence, both Jimmy Carter and Hilary Clinton were doomed in their attempts to change our healthcare system. We personally were opposed to Hilary’s attempt and wonder if it is the times that have changed, or have we merely begun to see through the smokescreens that hid the truth from our eyes in former years?

Certainly we have become wiser by experience. We no longer view with suspicion government-sponsored health insurance. In fact, along with a growing majority of healthcare professionals, we have come to see it as the only realistic recourse for a system that is badly broken. Treating health care as a privilege available only to the few who can afford it is simply not a reasonable course of action, in our opinion. We would hope that a humane approach to health care would be an acceptable alternative to a majority of Americans.

We should mention too that we are entirely sympathetic to those who fear that government involvement might bring lowered health care standards. Indeed, we would heartily agree were it not for the fact that private industry has already set the bar so low that even the government can provide better bang for the buck.

Like many conservatives, we wax queasy when others speak of “Medicare for all” as if Medicare were some sort of laudable standard for heath care. Indeed, it is not. There is much to be improved in Medicare, and most of the incursions by Congress into that realm in recent years have been disastrous. (Investigate Medicare Part D if you doubt us.)

Everybody in, nobody out

But getting back to the stated theme of this piece, the essence of a single-payer system is the motto, “everybody in, nobody out.” This is the crux of the matter. When everyone—congressman, senator, doctor, lawyer, president, tax-payer, homeless war veteran—becomes entitled to the same health care, we think government health care standards will markedly improve. Certainly the care meted out by Veterans Administration hospitals is no standard to emulate for the rest of us. But who more deserves the kind of coverage and care afforded to Federal employees and elected officials than those who gave their bodies to defend those same exalted healthcare standards while defending our freedoms? Should we deny any veteran—whether or not she can now afford a home—the very best health care?

We think not. But our system does, daily. And this is unfair.

Health care for patients, not profits

Unfortunately, those who stand to profit from the status quo—mainly health insurance and pharmaceutical companies—have sought to address the discussion of this issue by kicking up dust. They have filled town meetings with loud lackeys who seek to block meaningful discussion.

But this does not mean that the rest of us cannot both study and discuss the issues. The billions of dollars of industry profits are not fiction and they are not funny. If that money were going towards health care in a single-payer system, we would all be receiving better care without higher taxes.

Keep in mind that those industry profits are paid for by those of us who pay out for health care, whether through health insurance premiums for policies we don’t use or through emergency-room visits that we pay for out of our own pockets. If you pay any money at all towards health care, whether you use the healthcare system or not, you are supporting it. Your taxes go towards Medicare and Medicaid, systems for people that private insurers do not cover because it is not in their best economic interest to do so.

Insurance coverage for the rest of us

A government system that cares for everyone, on the other hand, would operate the way insurance companies should in theory, but don’t in practice. That is, the premiums paid by the healthy would go to pay for the needs of those who are sick. Most of us are lucky enough to start out our lives healthy, though most of us gradually develop more need for health care later in life.

Real insurance systems are designed to deal with these disparities among individuals and could do so quite well, we think, were not billions of dollars annually drained from the coffers to pad the pockets of health-insurance CEOs.

A Harris poll taken last fall showed that only 1 in 14 Americans trusts health insurance companies. Yet, Obama and the Democrats in Congress seem to be trying to put together a system that everyone—including Republicans and the insurance companies—will feel good about. We think that goal is as impossible as it is unwarranted. So long as some of those billions in excess profits floating around the health care industry are donated to politicians to get them to support the existing system, there will be those who are not aligned with our common interests. We can’t expect them to be happy about eliminating all that waste when they are the beneficiaries. Obama himself has received massive amounts of money from the healthcare industry, which might explain his recent restraint in pushing for a single-payer program.

Eliminating unnecessary costs

costs
We need a system that provides everyone good and equitable health care. That should be our first priority. Dr. Sidney Wolfe, a physician and acting president of the non-partisan group Public Citizen, has stated repeatedly that eliminating the current healthcare industry would save $4 trillion over the next 10 years. That’s in contrast to offers from the health insurance industry—now faced with possible extinction—to save up to $2 trillion in costs over the same period.

Why would we want to pay an additional $2 trillion to sustain current inequities? What is intrinsically desirable about paying high premiums and high deductibles for health care, much less having a significant portion of our population under- or un-insured? Are we really afraid that going to the doctor will surpass going to the mall as a form of family entertainment in our society?

It is time to set aside emotion in dealing with this issue. Shouting and name-calling are simply not constructive. Now more than ever, Americans need to focus on what is truly desirable in a healthcare system and to stop thinking in terms of what we have done in the past. We have the opportunity to create something new, a system that is designed to serve all our people. We should not waver from that goal just because it will require some politicians to roll up their sleeves and do some work.

Stop the interference

“There’s no way we are ever going to have good health insurance for everyone so long as there’s a health insurance industry in the way, obstructing care,” says Dr. Wolfe.

“In Canada, you can go to any doctor, any hospital you like,” explains Dr. David Himmelstein of Harvard University, founder of Physicians for a National Health Program. “Canadians have better choice than we do,” he adds, while “[they] spend half as much per person as we do on health care.” Himmelstein admits that if we wanted to cut our healthcare expenditures in half to match the Canadians, we would have to put up with longer waits than we do now. But, he says, if we are willing to maintain our current per capita level of spending on health care, “we could cover everybody with terrific access to care” and still not have to pay copays, deductibles, or insurance premiums. (In other words, our health care would be covered by our current level of taxes and would be better care than most of us receive now.)

His statements have been confirmed by the Congressional Budget Office (CBO) and the Government Accountability Office (GAO). These are solid figures, not empty promises.

Keep your doctor, keep your hospital

And note that there is nothing here about having to give up your favorite doctor or be refused procedures your doctor legitimately thinks you need. That is one of the primary reasons distinguished physicians such as Drs. Wolfe and Himmelstein are behind single-payer. It simply promises us a better system of healthcare for a given amount of money.

Perhaps the best part is that we can eliminate thereby interference in healthcare decisions by non-doctors who are simply trying to amass profits. Insurance companies currently hire hundreds of individuals whose job it is to say “no” to legitimate healthcare decisions made by doctors simply because the insurance company would have to pay to cover those benefits. In a healthcare system in which doctors have the final say on medical decisions, patients are better served. In such a system, doctors are not trying to set aside money to be paid out as profits to CEOs and shareholders, they are simply trying to provide healthcare to their patients.

And isn’t that the point, after all?

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Four speakers present their views on a single-payer plan

View/listen—then comment below.

True healthcare reform will have to involve some form of government-sponsored health insurance. The current system, as those of us who have watched the Wendell Potter interview already know, simply allows insurance companies to cherry pick their subscribers, allowing them to collect $30 billion in profits annually.

Yet Americans have been told for decades that so-called “nationalized medicine” is wrong and will lead to healthcare rationing and long lines at doctors’s offices and clinics. You simply won’t be able to get health care anymore, we are told.

Well, for almost 50 million people, that is the reality already. Prices for pharmaceuticals are far higher here than they are for the same drugs in other countries. Many Americans would love to be able to purchase their drugs from Canadian pharmacies, for example. (Many do, but not legally.)

Doctors may be ready

One of the surprises for us in watching the videos below was the statement that most doctors are ready for universal health care, even perhaps eager for it. Yet, when we think about it, that makes sense. Doctors have to deal with the health insurance mess on a daily basis. For them, having to deal with a single set of standards would probably be a blessed relief.

The truth is that while we are constantly told of the horrors of having a government bureaucracy standing between us and our doctors, the current system gives us an arbitrary set of rules established for the benefit of only one group—insurance company stockholders and executives. Insurance-industry executive salaries are what they are (around $14 million annually, on average—some astoundingly higher) because of the tremendous profits in health insurance.

Whether we realize it or not, we currently have a huge insurance-industry bureaucracy standing between us and our healthcare. And the motivation of that industry is purely profit, not our welfare.

We are constantly told that Americans have the best healthcare system (and health care) in the world. In fact, Americans rank 30th in life expectancy¹ and the latest figures we can find from the CDC rank us 27th in infant mortality. (The CIA Factbook, on the other hand, ranks the U.S. 180th for infant mortality—apparently the CIA has a lower opinion of U.S. healthcare than the UN.) What’s worse, the U.S. infant mortality figures have gotten steadily worse for at least two decades, placing us steadily further behind those countries with the best ranking.

American health care the most expensive

So, what Americans really have is the most expensive health care in the world ($7,421 per person in 2007, according to Kaiser Health²). A lot of that excess expense goes to insurance premiums, excessive drug and medical device prices, and yes, even for unnecessary tests and procedures.

We also don’t buy the notion, as some of the more enthusiastic Democrats will tell you, that Medicare as it stands is a wonderful system. In fact, Congress weakened that system considerably several years ago when it began requiring retirees to use a significant portion of their already too-limited social security to pay for prescriptions. Medicare needs a lot of cleaning up, in our opinion.

But one of the clear advantages of a single-payer system is that everyone is covered by the same insurance plan. That puts considerable pressure on the insurer (in this case, the government) to provide satisfactory service and coverage. If members of Congress were required to use the same healthcare system as the rest of us, you can rest assured that the healthcare system would be in good shape. Then we really would have the best in the world.

Watch the videos below and form your own opinion. Be sure to share that opinion with us in the newly revised Comments area below.

After you’re done viewing the videos, listen to the NPR report on how the pharmaceutical companies have spent over $40 million in just three months to fight health care reform by clicking here.

And to see how the California Nurses Association views these same issues, go here.

Dr. David Himmelstein is associate professor of medicine at Harvard Medical School and serves as the chief of the Division of Social and Community Medicine at Cambridge Hospital where he practices primary care internal medicine. He received his M.D. from Columbia University and completed internal medicine training at Highland Hospital/University of California San Francisco, and a fellowship in general internal medicine at Harvard.

Dr. Himmelstein was a founder of Physicians for a National Health Program and serves as co-director of the Center for National Health Program Studies at the Cambridge Hospital/Harvard Medical School. He co-edits PNHP’s newsletter and is a principal author of PNHP articles published in the JAMA and the New England Journal of Medicine in conjunction with Dr. Steffie Woolhandler.

Howard Dean — May 8, 2009

Dennis Kucinich on single-payer care, June 30, 2009

Eric Massa and others (pro and con) on single-payer care, around June 16, 2009

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Remote Area Medical (RAM), founded by Stan Brock, is a foundation that provides free medical care to remote parts of the world—including the United States. For 20 years now, RAM has provided free medical service to people in Wise County, VA via an annual “health fair” set up at the Wise County Fairgrounds. RAM also operates a similar program in Los Angeles.

This is the very same fair that converted insurance industry executive Wendell Potter—at the time, an employee of CIGNA—to a believer in healthcare reform.

Watch this video to find out what United States health care has in common with the Third World.

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Your doctor may or may not be in it for the money, but you know down deep in your heart that your nurse is in your corner if anyone is.

When a friend was in the hospital to assess whether or not he had had a heart attack, and a doctor too busy worrying about his golf game had him on a medication that could soon have killed him, the night nurse came on duty and challenged the doctor’s judgment. She probably saved his life.

These nurses just might save yours. Hear what they have to say about financing healthcare. It may give you a whole new outlook on the subject.

This is another brilliant Bill Moyers segment from May 2008 about the California Nurses Assciation and its members’s views on healthcare insurance and similar issues healthcare-related. Here you will find out about CheneyCare. Have you had any of that lately?

Aside from the fact that the administration in power has since changed, you’ll find it’s just as timely and informative as if it had been filmed today.

If you would prefer to download the video to Winamp or another flash video player rather than using the embedded player, click here.

Otherwise, click the image below to watch the video.

For more on the subject, including a Harvard doctor’s viewpoint, click here.

And if you’re in the mood for a good read on the subject of healthcare, this August 29, 2005 New Yorker piece by Malcolm Gladwell (The Moral-Hazard Myth) seems uncannily timely. It explains why there’s so much resistance to concepts such as single-payer healthcare in this country, how insurance theory influences our thinking and why healthcare isn’t just another commodity. Read it here.

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