Wow. Great post. Rec’d.

If folks come across other informed reactions to the letter, lemme know and I’ll add them to the list. Thanks.

I heard Sen. Bennett today and he still doesn’t seem to understand that millions of people don’t have insurance and none of the reforms clearly shows ways to get them covered…except the public option. Further, he thinks a public option necessarily competes with private insurers, despite the fact the private insurers don’t want or can’t get those individuals. How can you have competition if the government would only be taking on individuals who aren’t already in the market?

I don’t especially like the mandate and as I recall Obama didn’t call for it during the campaign. But, we definitely need a better variety of plans which enable…ENABLE people to get coverage. The exchange idea is terrific!

I also like the idea of public option plans which utilize known low-cost high care systems like the Mayo or Cleveland or Kaiser Permanent approaches.

I can’t imagine using a calculated system for paying. I’d prefer to let the industry set their prices based on industry competition and let government devise the plan to keep it’s cost low.

Still, everyone is talking and I think this is the heart of the debate for this legislation.

Let the industry compete?

The industry has been setting the price through “competition,” but it’s not efficient competition as define in the text books. Several major studies show huge concentration in the industry, with a majority of the country served by only 2-3 major providers who don’t really compete; every econ text book tells you that leads to less care (or worse care) at higher prices — that’s exactly what we’re getting.

The private system is rationing coverage by price, leaving out 47 million, and rationing service by perverse incentives, resulting in millions more having their claims wrongly denied/delayed and provider payments fraudulently denied/delayed to increase profits. In such a system, calling on “competition” to restrain prices or improve quality, let alone expand coverage, is a waste of time.

In every truly “competitive” market, there tends to be a single commodity, or small set of defined commodities — uniform, definable, so that anyone can supply it. One supplier produces the same produce as another. That is overwhelmingly not true in health care, where you have millions of different services/treatments/opinions/professional competence/opinions, etc. Yes, different providers “compete,” but you can’t define that as the kind of efficient competition that produces some efficient outcome. Most of the talk about a competitive market for health care is gibberish.

I think you misunderstood my intent.

I agree with you that competition is missing in the health care industry (and some others like energy). That’s why I hope there are at least a few elements of the health care reform which ‘attack’ that issue. We need more med school slots, more family care physicians, more nurses, more clinics (instead of just 1 or 2 ERs in a community) and more national insurance providers (if not all) with federal regulation & oversight and the Exchange where insurers can “display” their products and compete for customers.

Perverse incentives (like insurance company doctors who say “No”) have to go. We’ve also seen that in the financial sector and it’s killing the world’s economy. How we survived these problems as long as we have is hard to understand.

As I sometimes say, Capitalism isn’t absolutely broken, but a lot of people keep hitting it over the head trying to get monopolies and special deals. We have to fix it.

I don’t especially like the mandate and as I recall Obama didn’t call for it during the campaign. But, we definitely need a better variety of plans which enable…ENABLE people to get coverage. The exchange idea is terrific!

No.

First of all, Obama did indeed campaign on the mandate. It was one of the key divisions between his and the Edwards/Clinton positions.

Second, healthcare is a human right; therefore, an “exchange” on which one can bargain for more or less of it based on ability to pay is no less odious than an exchange on which one can bargain for more or fewer human rights based on ability to pay.

Scarecrow, if you’re going to post links to the deceptive and industry-capitulatory HCAN, do please include links to…

Healthcare-Now!, which features this report from After Downing Street’s David Swanson, reporting on today’s meeting between single-payer advocates and Max Baucus;

The California Nurses Assocation, which carries a considerably more detailed, and in some respects, uplifting report from the same meeting;

The Physicians for a National Health Program (PNHP), which together with CNA, constitutes the most authoritative and influential bloc advocating for single-payer, NOT public option.

Anyone who doubts the deceptiveness of HCAN should scroll down from the post scarecrow links to, to another “blog” post by the organization’s communications elf, Jason Rosenbaum, who writes

Put simply, progressives are united behind the public option, and that if health reform does not include a public option, it won’t be real health reform.

No, Jason, that’s a lie. Tens of thousands of progressives (in fact, also liberals and moderates) are united in the clear understanding that a public option will not constitute “real health reform” but only a wasteful Rube Goldberg alternative (see, eg, this graphic of the Massachusetts system) to actual reform: ie, a system (single payer or otherwise) in which profit is expelled from the reimbursement apparatus.

Hundreds of thousands, perhaps millions by this point, of Americans think they support reform with a public option only because of a concerted blackout (with Bill Moyers constituting, as ever, the exception proving the rule) on explanations of the structural and economic inadequacies of such reform in contrast with a profit-purged reimbursement system.

For lovers of lines in the sand, here’s a crucial one: ensuring that any health care reform bill passed this year (short of a miraculous passage of national single payer) allows any state to opt out in favor of its own single-payer system. This is not science fiction; California passed a single payer bill twice, vetoed twice by Ahnold. And statewide resolutions supporting single payer, most recently this one voted by the New York State Senate, constitute a huge unsung wellspring of single-payer support flying below the Washington radar.

I would recommend that anyone inclined to harass the White House and legislators (as we ALL should do, whether we’re single-payer stalwarts or public option advocates) make a point to include in our calls, emails, and faxes the insistence that any federal bill not prohibit individual states from adopting single-payer systems as an alternative to federal reform, if they choose.

Ugh. My god the hoops we’ll jump through to try and shoehorn market dynamics into regulatory reform that is specifically a reaction to discovering that market dynamics don’t function in the institution of interest.

We do this with freaking everything. Environmental policy, healthcare policy, food safety policy, etc. It’s just a wee bit obsessive.

Clinton’s plan was the one with mandates. Obama’s plan during the campaign did not call for mandates. Here’s a discussion on mandates and why we have to be very careful about them. It’s not working in Mass. I don’t see how it can work if we have mandates to buy policies that people cannot afford and are inadequate in coverage so that sick people are still on the hook for hugh amounts of deductibles, copays, and uncovered procedures and medicines. Mandates mean penalties for non-compliance which would just be another added burden. It would be impossible to devise a fair system this way and it would not be in anyway universal health care.

http://volokh.com/posts/1204061613.shtml

” Dear Majority Leader Hoyer,

We appreciate the time you took to meet with Representatives Edwards, Cohen, Cleaver, and ourselves, along with Tim Carpenter from Progressive Democrats of America, Michael Lighty and Donna Smith from the California Nurses Association. We look forward to advancing, in your eloquent words, “robust, deep debate on single-payer,” in the House of Representatives during the 111th Congress.

We know health reform legislation is moving forward quickly, and we are concerned that the exclusion of single-payer from consideration by Congress would prohibit an informed policy discussion about true health reform. Given that more than 60% of Americans are in favor of national health insurance and that HR 676, the single payer non- profit universal health care bill, has the support of 78 House Members and, it is crucial that this perspective be part of this historic debate. HR 676 has also been endorsed by over 15,000 doctors, two former editors of the New England Journal of Medicine, 40 State AFL-CIO organizations, the U.S. Conference of Mayors, and the American Public Health Association. Clearly, there is much that can be learned from having an objective and substantive discussion on the merits of national health insurance.

Additionally, we would appreciate if you would inform us of whom you have designated to coordinate the bi-weekly meetings on single-payer, which you thought would be useful for Members and other health policy experts. Our staff would like to work with your office to help facilitate these meetings. Keeping these discussions structured and focused will be critical to their success in terms of addressing the lack of information available to Congressional members on the single-payer healthcare option.

Thank you for meeting with us on this important and timely issue and for agreeing that single-payer healthcare advocates should take part in the healthcare reform discussion.

Sincerely,

John Conyers, Jr., Raul Grijalva, Donna Edwards
Members of Congress “

http://www.afterdowningstreet.org/node/43210

Thanks to you and bluebutterfly for the links on the meetings with Baucus and the Conyers et al letter; I added them.

I had seen other reports on Baucus but not these. Sam Stein and Ryan Grim at HuffPo had picked up on the reception Baucus aides got in Montana, which I linked to in a previous post. I would have expect Baucus to keep saying ”no.” But for Max to tell the meeting with single-payer advocates on Wednesday that “gosh, that was a mistake to exclude (and arrest) you guys, but looks like it’s too late to fix that error” is pretty insulting.

Thanks, and instant apologies to MarkH; I clearly got the who-promoted-mandates part of my post entirely ass backwards.

For lovers of lines in the sand, here’s a crucial one: ensuring that any health care reform bill passed this year (short of a miraculous passage of national single payer) allows any state to opt out in favor of its own single-payer system.

that makes very good sense. thanks.

p.s. thanks for continuing to document the dishonesty from hcan.

No, Jason, that’s a lie. Tens of thousands of progressives (in fact, also liberals and moderates) are united in the clear understanding that a public option will not constitute “real health reform” but only a wasteful Rube Goldberg alternative (see, eg, this graphic of the Massachusetts system) to actual reform: ie, a system (single payer or otherwise) in which profit is expelled from the reimbursement apparatus.

Yes, it would continue as a two-tier system where ‘the best’ health care is delivered to only part of the population and still some people are left out altogether.

I don’t see any real difference between the approach recommended by the current administration and the previous. The models are basically the same insofar as people are obligated to pay out-of-pocket for their health care or do without. It’s a deep philosophical difference that underlies the motivation for single-payer.

I think insuring that anything passed in Congress and signed by Obama that dismisses the single-payer philosophy does not bar states from pursuing a single-payer alternative is an admirable goal to pursue.

I think insuring that anything passed in Congress and signed by Obama that dismisses the single-payer philosophy does not bar states from pursuing a single-payer alternative is an admirable goal to pursue.

Bernie Sanders has introduced S. 2031, a bill creating a waiver from federal health reform legislation for up to 5 states that wish to create model single-payer systems. You can read about it on his web site.

All sorts of legislators and others supporting “public option” proposals claim to support single payer in principle (even Chuck Schumer!). Democratic Senators who take this rhetorical tack should be hounded into supporting S. 2031; they really have no excuse.

Another very important update (and then I have to scoot and take miniralphbon to the aquarium for the morning):

Check out this diary from DrSteveB (member of PNHP) on today’s release of a peer-reviewed article on medical bankruptcies in the United States. Co-authors, BTW, include two of PNHP’s founders, Drs David Himmelstein and Steffie Woolhandler, as well as Elizabeth Warren, JD. (Warren, you’ll recall, is currently serving as the Congressional watchdog on the financial bailout, and her name is continually mentioned as the candidate to spearhead modern-day Pecora hearings.)

Core nuggets (from the press release):

– Medical problems contributed to nearly two-thirds (62.1 percent) of all bankruptcies in 2007;

– More than three-quarters (77.9 percent) were insured at the start of the bankrupting illness, including 60.3 percent who had private coverage.

Click the above link, and drill through to download the full journal article, for more.

That’s right. Two-thirds of all bankruptcies are medical, and two-thirds of those are in people with private insurance. Private insurance from the companies the public-option proponents are bending over backwards to keep in business.

The difficulty of having mutliple systems is sorting out the funding, the tax and exemption/credit provisions, federal start-up funds for a public plan vs private plans vs some single payer that is different from that. I haven’t seen any good explanations for how this works even if the choices are between public and private. McCain tried to address this with taxing benefits, but giving tax credits back, and people came up with examples of how that was a cost/tax shift, depending on the costs and income brackets.

For Medicare, it’s a fairly simple age cut off; once you reach 65, you switch to Medicare. But suppose people before that age of 65 can choose private, then switch to public, then back to private? How does that work without confusing cross subsidies? Add if there’s a waiver for 1-5 states to try single payer (without other options), and how does that work?

The private industry fears that there will be preferential funding for a public plan; hence the competition with this option is not “fair.”

But I understand that Canada strongly discourages private insurance (is this correct), because it fears the mechanism for opting out of the Canadian public plan will subsidize the priate choices. That fear may be legitimate. In other words, it’s not clear in these various proposals how you get the funding sorted out when you have a mix of public and private choices and people are free to do what they want.

Thanks for the advisory.

I like the language used there for those who are supporting the “public option”. In Yes Minister: Equal Opportunities, Sir Humphrey and Sir Arnold support the minister’s scheme to introduce quotas for women in government, in principle.

At a meeting of all the Permanent Secretaries, the quota is discussed. As it turns out everyone fully agrees in principle, but does not see how it could be instigated within their own departments. And this is the same what happens at the Cabinet meeting of all the Ministers; each Minister applauds the principle but then says it would not work in their department.

To frame this problem as an economic crisis is to challenge the principle that health care is a human right and not a privilege or commodity for sale.

Right out of the gate, the Obama administration errs in the first premise of health care reform. The subsequent premises can all be subverted based upon claims for economic expediency.

We are entitled to control medical costs because everyone is entitled to care and therefore services are not to be rationed to yield profits or allowed to rise in price so as to become inaccessible.

We are entitled to include everyone and cover everyone’s health care because it is their right to receive health care.

We are entitled to ask everyone to contribute to the cost of the program because they are automatically included in it, not because we want to squeeze bucks from their wallets to go to insurance companies. We have to adjust expected contributions to the limited incomes of many of the currently uninsured.

The best plan to achieve the goal of real reform is HR 676 Single Payer health care.

Obama’s gonna let the voters have part of what they want and need. Big of him.

Related posts:

Ezra Klein expands on how the various features are complementary.

Bernie Sanders talks about single payer.

It seems to me that Obama is not leading on this issue, and he places entirely too much faith in “The Market”. He is behaving like a Reagan Democrat. And I think John Edwards point during the campaign is the telling one: “Why is anybody talking about ‘universal access’ to health insurance?”

Precisely. If we talk about access, it should be universal access to healthcare proper, not to the insurance.

If folks come across other informed reactions to the letter, lemme know and I’ll add them to the list. Thanks.

Well, I guess we all know what political party followers that leaves out.

Then we are fucked.

” also like the idea of public option plans which utilize known low-cost high care systems like the Mayo or Cleveland or Kaiser Permanent approaches.”

I dropped Kaiser this year. $800/month for a family of 3 with a co pay of $50 and deductable of $7,000 was too expensive. I now have wellpoint.

[Update: Single-payer advocates finally got a meeting with Sen. Baucus.

That, IMHO is very good news.

Not just for obvious reasons, but I believe once ‘in the room’ single payer becomes the 800 pound gorilla.

They’ll try to ignore it, but it will just make more and more sense to move in that direction, and it will then become painfully apparent to the masses that only reason to not to have it is the insurance companies.

Scarecrow, I concur completely that “But he leaves the details of what that option entails, and how open it is to everyone, to Congress. I predict the toughest battles for real reform will be fought there.”

And with that thought in mind let me refer others to selise’s diary here for more perspective on this issue.

It seems to me that Obama is not leading on this issue

You may not like the direction he’s going, but I can’t see how on earth you can say that.

Please don’t tell me the insurance companies are, they had to beat on the door last week to be let in as they saw the train leaving the station.

Argh… …what part of single payer don’t they understand?

The polls show the people want it, regardless of the demonization of the concept. When will our representatives hear? When we can afford to buy their ear like the insurance companies?

Man, that state single payer thing is brilliant!

I’m surprised that some state hasn’t enacted it yet; like gambling, the first ones to do it will benefit most.

Can you imagine how many businesses would flock to a state with single payer?

Which would jump start employment, which would fill up the empty houses, which would increase state tax revenue from a whole host of sources, etc. etc.

SEIU, “Let’s be clear — this is big news for health care reform”

Bad link (404 error).

Hey, this is great. Obama’s throwing his weight behind insurance for all…

Hang on! WTF. Since when was it the goal of a “progressive” to increase the size of insurance business? It’s crazy that there is any suggestion that anyone “liberal” or anything like on the “left” would accept this.

Jeff Kaye upstairs at the Mothership!
Two Generals Who Enabled Torture Skirt Accountability

You’re right; I’ll try to fix that.

This sounds like another con. A mandate would be a bureaucratic nightmare. What the “public” option would be is left up in the air. I see nothing about using market share to negotiate drug prices with Big Pharma. Effective low cost systems sound good but I have doubts about national implementation. Perhaps MedPac does something more but glancing through one of its reports there doesn’t seem to be anything there about real healthcare decisions. It pretty much looked like administrative stuff to me. As for financing, closing tax loopholes has been a time honored dodge for what is usually non-viable legislation. Maybe Obama is serious about eliminating them but it sounds like pixie dust.

No, Edwards and Clinton’s plans had mandates, Obama’s specifically did not have a mandate. Otherwise, largely agree.

I was willing to entertain a public option co-existing with private insurance, but only tentatively. I have this thing about permitting for-profit enterprises to compete with public (essential) services (this goes for schools, etc.) – it seems to me that the well-to-do will always work to cripple the public option, IMO.

As I said, I was willing to entertain it, but this is looking so convoluted… I’m sorry, but anything short of single-payer is still going to look like more of the same-old…

Thanks; someone else caught my goof well upthread.

What tripped me up on this, FWIW, is the fact that all sorts of people, like Paul Krugman, asserted during the primary that the Edwards/Clinton proposal was more progressive than Obama’s.

I note that Krugman in today’s Times gives sort of the standard line in favor of the public option. In the process, BTW, he sneakily pretends single payer advocates don’t exist:

Now nobody is proposing that Americans be forced to get their insurance from the government. The “public option,” if it materializes, will be just that — an option Americans can choose. And the reason for providing this option was clearly laid out in Mr. Obama’s letter: It will give Americans “a better range of choices, make the health care market more competitive, and keep the insurance companies honest.” [emphasis mine]

When he says “nobody,” he’s really referring to single-payer (or at least HR 676) advocates, and I’ve got to say, per the old Lone Ranger joke, “Speak for yourself, Paleface.” The loaded word “forced” is really a slippery characterization: An overwhelming majority of Americans, in poll after poll, choose single payer; we want to “force” it on our leaders, not ourselves.

I think Krugman is correct; he’s describing the advocates of an option of using the public plan, not advocates of single payer. In the Obama letter, it’s an option to purchase public plan insurance, not a mandate.

The mandate is to purchase something (unless you’re exempt). But of course, we already have “mandates,” in a sense. We have to pay taxes; we have taxes withheld for medicare/medicaid and for other health programs, such as SCHIP. Our employers convert part of our salary/wages/compensation to insurance premiums, and we don’t really have much choice about that. When we use our insurance plans, we have to pay premiums and/or co-payments and/or the deductibles.

There are mandates everywhere. The question is not whether to have a mandate; it’s how to structure a mandate that’s fair and efficient and has decent incentives.

I understand your points and your reading of Krugman. You may be right, but after re-reading, I still think Krugman was drawing a distinction between a public option and a public plan mandatory for all (ie, single payer). Otherwise the notion of “forcing” anyone to take the public option would be just a strange non sequitur.

Agree re “there are mandates everywhere.”

I still think that the President and the Congress are missing the point. They act as if universal health insurance is the objective. It is not.

We know that the percentage of people with insurance is about the same as the percentage of people that go bankrupt from medical costs. The problem is not so much lack of insuranceas it is lack of coverage. Private insurance plans simply do not cover the costs of the illnesses that really ruin us.

What we need is universal healthcare. The only way to get it is the only way that anyone else in the world has gotten it–through a single-payer, government-run system.

If health insurance is to be mandatory, then a self-insured option should be added. Force doctors, hospitals, and pharmacies to post their prices so that consumers can make informed choices, and legislate an option for people to form “health cooperatives” as an alternative to the health insurance industry. And let’s end the travel ban to Cuba so that Americans can have access to low cost care in that island nation.