Obama and the Health Care Movement

Obama & the Movement for Health Insurance Reform

The election of Obama opens up a space for progressive politics over the coming years in the US. It’s not going to be perfect, or socialism, but we can all heave a sigh of relief and say goodbye to 30 ugly years of Reganism. Obama has managed to become president as a result of a fortunate confluence of events and factors: (1) Most Americans are deeply ashamed of our behavior as a country over the last 8 years. (2) Partly because of #1, Americans wanted to use the ’08 election to become a fine people, to make a definitive break with anti-black racism. (3) Obama is a very talented and charismatic politician. (4) 1-3 might not have been enough to beat Clinton, and then McCaine, but oh lordy, the economic tsunami hits in September, and Regan Democrats split. Half vote for Obama. They’re not all such dummies, are they?

Our job as leftists is to find ways to mobilize grass roots working people around issues that really matter in a majority of American’s lives. I believe that Obama will side with us sometimes, but he needs us to organize a power base to help him stand up to the enormous forces of the American Right. If there is no mass movement to help Obama move to the left, he will probably just be another center-right president like Bill Clinton, hopefully without the sexual drama.

So, how can we do this? Let’s pick an issue like health care that can bring a large majority of Americans over to our side. With a powerful mass movement to back him, Obama might go for real health care reform. Without pressure from the grass roots, I fear we will be stuck with some form of private insurance solution, with all the co-pays, deductibles, and lack of health care access we’ve come to expect these days in the US.

Health care certainly is a hot issue in America today. Doctors, nurses, and all of our other caregivers are able to perform miracles of healing that previous generations could only dream of, but health care access and distribution are terribly broken. Our health insurance system is supposed to be a welcome mat that assures us care when we need it. Instead, it often acts as an insurmountable barrier, denying many of us help when we need it most.

The issue of health care is something that a vast majority of Americans can rally around. One would think that the incoming Obama administration would grasp this rising tide of concern and offer a simple and direct solution. Doing this could well set the country on a path similar to the one that Franklin Roosevelt took us on with his New Deal. Health care can lead the way. If there was a unified national movement around the issue of health care that involved more than a few committed socialists and a few thousand experts, maybe Obama would (could) begin a new New Deal with real health care reform at its cutting edge.

But, it looks to me like the movement for health insurance reform in the US is between a rock and a hard place.

On the one hand, we have thousands of committed advocates for Canada-style, single payer health insurance. What these folks are saying makes perfect sense: Eliminate for-profit health care insurance in the US, and use the huge (billions, according to the non-partisan Congressional Budget Office[1][1]) amount of money saved to replace it with a generous government health plan that covers everybody, with free choice of a private physician. What’s not to love?

Insurance companies don’t love the idea very much. Their business is very profitable, and they know that a single payer program would be the end of them. These companies are huge, powerful, and very well organized. Remember the highly successful “Harry and Louise” ad campaign that helped stop President Clinton’s timid stab at health insurance reform in the early 1990’s? One can imagine the subtle ferocity of the insurance companies’ response to a single payer bill in Congress that had a real chance. And why should we expect them to act differently? Their first duty, as private corporations, is to maintain profits as high as possible for shareholders.

The vast amount of suffering created by market forces in health care doesn’t matter a hoot to these private insurance guys. Almost 1/3 of the population is currently either uninsured or underinsured. Deaths from lack of insurance are conservatively estimated at 18,000/year by the National Institute of Medicine. That’s 6 World Trade Center 9/11 death tolls every year! Insurance company officials must look at the misery they cause and say something like, “That’s too bad, but our bottom line looks pretty good.”

The rock, then, is our highly profitable private insurance industry. It sits atop the modest number of single-payer advocates in the country, smothering us. The voices of all our bright and committed reformers are only heard as vague murmurs from under this huge, rich rock by the 99% of Americans who have yet to achieve the level of understanding of issues that is common among people in the health care movement. The necessary connection, between single payer and everyday folks, is just not happening. But the connection between insurance lobbyists and members of Congress is solid. Actually, there are a few less supporters of single payer in Congress today, about 90, than there were in 1990.

The hard place, on the other hand, would be the barriers raised by those who call for “affordable” health care, and never spell out exactly what “affordable” means, or what they mean by “health care”, for that matter. Is 5, 6, or $700 per month affordable? Who can afford it? Does anybody’s definition of decent, accessible health care include $50 co-pays or deductibles in the many thousands? I don’t think so.

“Affordable” reform is certainly the big kid on the block, though. A good example of possible affordable reform is the public/private insurance partnership proposal put forward by the recently introduced group, Health Care for America Now (HCAN). The Service Employees International Union (SEIU) and moveon.org have teamed up to found HCAN. They planned to spend $40 million last summer and fall, through the November election, on a campaign to promote their version of “affordable” health care. The HCAN proposal looks enough like the Obama campaign plan to consider them the same, or close to the same, plan. We can assume that many of the leaders of the Democratic Party are for HCAN. The enormous sum of $40 million will go a long way toward making HCAN look like a strong alterative for health insurance reform. HCAN, or something much like it, appeared to be a very influential item on the health care agenda for the election campaign this fall, and probably will be the same for next year’s action in Congress. Since simply repeating, over and over, our support for single payer will just keep us out on the margins, how should we deal with this situation?

Health insurance reform is a very complicated topic, particularly when a public/private partnership is being considered. I thought it would be a good idea to try to explain a few concepts, to help people understand enough to participate in this debate, along with the health care experts.

Single payer means that only the government pays medical bills, like in Canada. Many countries that have generous, successful, and universal coverage of health care do not have single payer (some do.) Germany, Switzerland, France, and Japan allow private insurance companies to operate; not freely, but they do play a role. In Japan, according to author T.R. Reid[2], the public loves their health insurance system.

The Japanese go to the doctor 3 times as often as we do in the United States. Visits to the doctor are very cheap, as are hospital stays and hi tech tests, like MRI’s. We don’t have to win single payer to have a generous, universal system. It does appear, however, that it’s necessary to outlaw profit on health insurance, and have the government set prices for needed medical care, like they do in Japan. One question to ask the HCAN folks might be, “does your plan take profit out of health insurance?” Also, we should find out if HCAN calls for setting prices on medical procedures, drugs, and equipment.

The “public” part of the HCAN public/ private partnership is interesting. Many believe that the public plan in Obama’s proposal will determine everything. The claim, made by supporters, is that it is there to compete with private insurance, and make everybody’s premiums go down. Is there anything to this? Can it be that Congress will pass on a public plan that truly competes with private insurance? Probably not. The HCAN public plan, to offer government insurance to those who can’t afford private plans, looks like little more than a gussied up version of charity care. How come?

Community rating is the key concept here. Good community rating means that all insurance companies are required to offer the same comprehensive plan to everybody, at the same government set price. No age or pre-existing condition exclusions allowed. This is how it’s done in Japan, Germany, and Switzerland. If there is no community rating, then an epidemic of Cherry Picking is sure to break out. The term “cherry picking” calls attention to the effort made by private, for-profit insurance companies to select only the youngest and healthiest people to be on the company rolls. If your customers never need to go to the doctor, the health insurance business is, of course, very profitable. How does this work? Easy. Sell stripped down, high deductible plans, really cheap. These plans will be of no use to older, less healthy people, who tend to need more health care. Those who can’t use the cheap plans, or even get on them if they try, will be forced onto the public one. All those older and less healthy people will drive the cost of the public plan through the roof. Without real community rating, the public plan will be bled dry. Community rating would stop this by preventing different rates and different health plans within a given locality. That way, the public plan could truly compete with private insurance. So, another question for the HCAN guys is, “Does your proposal have vigorous community rating in it?”

Consumer Driven Health Care (CDHC) is another important concept to keep in mind when evaluating a public/private partnership. It includes various incentives for NOT going to the doctor, or doing what the doctor suggests. A more accurate name for CDHC might be Financial Penalties for Going to the Doctor. Co-pays, deductibles, co-insurance; all of them amount to the same thing; out-of-pocket expenses for health care. These are the main mechanisms used by private insurance companies to make public/private plans “affordable.” How do out-of-pockets make the plans (monthly premiums) affordable --and profitable --for the insurance companies?

Simple: they raise the cost of going to the doctor until we hesitate. Maybe that breast lump will go away by itself. Maybe my son will quit wheezing if I just send him to school. That’s how they work. I believe that a person with a hand out asking for money cannot also be a good health care giver. Most people already avoid going to the doctor enough as it is. It’s only natural to want to think of ourselves as healthy. If we’re going to admit we’re sick and go to the doctor, we want to believe that she/he cares about our health more than our money.

Out-of-pockets are getting to the point where many must decide between buying a needed pair of shoes for Johnny or going to the clinic when he wheezes. $50 co-pays and $5000 annual deductibles take a pretty big bite out of many budgets!

This brings up the idea of First Dollar Coverage. (FDC). FDC means coverage starting at the first dollar; no co-pays, no deductibles, no co-insurance (where the patient must pay a % of the cost every time she/he accesses the health care system.) Canada has FDC for what they call their “core health services,” which include doctor visits, and whatever you need while you’re in the hospital. With FDC, Canada manages to cover everybody for about half the money we spend per person—with better health outcomes, according to the World Health Organization.

Do Canadians overuse their health care because of FDC? Many observers believe that the increased access that the Canadian system affords its citizens leads to increased confidence in family doctors and the medical system. This confidence probably leads to fewer fretful visits by patients one wag refers to as the “worried well.” Remember: Canada covers everybody for half of what we spend!

Japan has co-pays (not first dollar coverage), but they are limited to only a small fraction of a person’s monthly income. They must look pretty small to the Japanese, considering how often they go to the doctor. So, we should ask the people who back the HCAN health insurance proposal, “What’s your limit on the co-pays and other financial barriers that private insurance companies love so much?” Let’s make health care accessible in America! People have enough to worry about (their health) when deciding to go to the doctor.

Consumer Driven Health Care appears to have lead to a growing phenomenon called Underinsurance (UI). A study[3], recently published by the Commonwealth Fund, finds that 75 million Americans are underinsured because of CDHC. The commonwealth study defines underinsurance as having spent 10% or more of one’s income (5% if low income) on health care out-of pockets. The study’s authors show that needed health care is often avoided at these levels, and for this reason conclude; “The goal is high-quality care and improved outcomes—not just coverage. There is growing recognition of the need for coherent strategies that combine coverage with payment and other policies to change directions and move toward a more inclusive and higher-performing, high-value health system."

There, we have another question for HCAN: “When you up the co-pays and deductibles to keep the monthly premiums affordable, how much underinsurance do you create?” But, you say, there is still that rock, and that hard place. What are we going to do about them? If we are ever to overcome, we will need to build a movement powerful enough to push the private insurance companies aside, and, at the same time, stand up to the ‘affordable’ guys.

Single-Payer is far too technical a concept to ever organize a mass movement around in America. By mass movement, I mean people in the streets or citizens voting. Not just a few members of Congress, or union staffers without visible support from their members. Single-Payer advocates have great difficulty drawing large crowds to support the movement. There have been a couple of public demonstrations here and there, most notably backed by the California Nurse’s Association (CNA), but these moderate size gatherings tend to prove my point. They don’t draw everyday folks, not really.

It will take street demonstrations approaching the levels achieved by the movements against the Vietnam and Iraq wars—Hundreds of thousands, at least--before fence sitters in Congress will consider moving toward us. As for voting, single payer has not been able to overcome the mega-dollars the insurance industry can throw into a political campaign. California had a single payer measure on the ballot in the early 90’s, with the vigorous backing of the CNA, and it received less than 30% ‘yes’ votes. Single payer is far too complex a concept for voters to take into the voting booth and vote ‘yes’ in defiance of the confusing, money-backed claims of private insurance.

The idea of single payer, by itself, is just not going to be able to move that insurance rock far enough, is it? Should we just give up and allow the affordable guys to play around and let the health care system degenerate for the next 50 years??

Heck no!

What’s missing is the demonstrable, public support of Americans from all walks of life for real health insurance reform. We have to get millions of people to the voting booth, and later, into the streets. We need to quit thinking of health care reform as the province of a few hundred elite intellectuals. Without the power of an organized grass roots movement, the right will always be able to trump our arguments with their money and media campaigns

In Seattle, Washington, in 2005, we organized a petition campaign to have a ‘Right to Health Care’ placed on our city ballot. It became an advisory measure, and it gave everybody in town the chance to say, “yes, I believe health care is a right!!” 70% (105,000) voted yes. In 2006, Seattle’s nearby sister city of Tacoma, Washington did the same, and got 73% yes. In 2000, a campaign for what was called the Bernadin Amendment, named after the recently deceased and much beloved Catholic Cardinal of Chicago, took place in Illinois. A Right to Health Care, the main message of the amendment campaign, went on the Chicago ballot and received 80% yes. Activists decided to take the amendment campaign (for a right to health care amendment to the Illinois constitution) downstate. According to Quentin Young, leader of the campaign, the amendment received at least 70% yes everywhere it ran. After the attack on the World Trade Center caused the political climate in Illinois to shift far to the right, organizers decided, for the time being, to halt the campaign for the Bernadin amendment.

The election of Obama has changed things in America. The apocryphal story about Franklin Delano Roosevelt’s advice to A. Phillip Randolph applies here. Matter of fact Obama has cited the comment FDR made to Randolph after listening to a speech by the union leader: “Sounds great! Now make me do it,” FDR said. Obama needs us to make him do real health care reform.

Policy wonks in the health care reform movement are often dissatisfied with the idea of a national movement for a right to health care. They complain that it is a vague slogan that won’t result in any concrete changes to the way health insurance is structured in America. Better, they often tell me, to stick with single payer until we’ve said it enough times for people to finally understand it. When we get enough members of Congress and the president on our side, we’ll pass it and everything will be great!

I think they are forgetting that big, private insurance rock. We need to bring the American people together in a movement well beyond policy wonks. Then, we’ll be able to push that rock away. People understand intuitively what a right to health care means. I like to say it means that money can no longer interfere with anybody’s decision to go to the doctor, or interfere with the doctor’s decisions about what we need. When we say, “health care is a right,” we strongly imply that health care should be distributed fairly among all Americans. Whether you’re rich or poor, everybody gets the same high quality care. A right to health care is something everybody can get behind, especially now, as a way for grass roots people to let Obama know how we think health care should be reformed. The more cities that declare it, the more states that place it in their constitutions, the more pressure there will be for genuine health insurance reform, not just ‘affordable’ smokescreens. With millions of Americans saying “health care is a right,” like House Speaker Nancy Pelosi in her opening speech at the Democratic Convention in Denver, good members of Congress will finally be able to get something done that helps everyday Americans, not the insurance companies.

It would not surprise me if that something turned out to be an American version of single-payer, by the way, maybe by making the public plan in the HCAN proposal good enough for us to drop private, and go public. Or, we might wind up with an American version of what they have in France, or Japan, or Germany. If we can convince the good activists working on single-payer that we need a genuine mass movement, I think we can do it.

Then, we’ll have to start looking for the other things we need to get a new New Deal started!

Brian King. January ‘09

9518 32 Ave NESeattle, WA. 98115206-526-8169

[1][1] Canadian Health Insurance: Lessons for the United States GAO/HRD-91-90 June 1991
Watch the illuminating Frontline documentary “Sick Around the World” with T.R. Reid at http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/
Cathy Schoen, M.S., Sara Collins, Ph.D., Jennifer Kriss, Michelle Doly, Ph.D. How Many are Underinsured? Trends Among US Adults 2003 and 2007, The Commonwealth Fund, June 2008