At the beginning of the recent presidential campaign season, health care reform was generally regarded as a high priority. That was until early in 2008, when the magnitude of the economic crisis began to overshadow the need for restructuring America’s health care system. Many people continue to experience the ongoing problems of higher premiums, persistently large numbers of uninsured people (about 46 million) and the epidemic effects of "underinsurance"—a term that describes higher premiums, high shares of cost of job-based coverage, higher deductibles, co-pays and denial of claims—the results of a privatized health care system. Under current conditions, it is not clear whether the Obama Administration can find the time, focus, maneuvering space, and political capital to generate a big push on the health care front. Even if it succeeds, many critics fear that the approach will be a re-run of misguided half measures, similar to what occurred in the Clinton debacle of 1993-1994. The single payer solution In the two decades that health care reform has been on the table, one effective solution has been available to us all along: a "single payer" system, similar to Canada’s. This system would eliminate the private insurance industry from the provision of basic health insurance and replace it with one agency - the single payer - that assists everybody. Other single payer advocates, especially backers of Congressman John Conyers's (D-Mich) H.R. 676 (a bill in congress, that if passed will create single-payer national health insurance for all--with, 93 co-sponsors, including Marylanders Donna Edwards and Elijah Cummings), call for an expanded and improved "Medicare for All." The savings from eliminating the profit motive from a health insurance industry that now includes 1,500 companies would come from industry profits and stockholder payouts, CEOs' and other executives' salaries, campaign finance contributions and lobbying, public relations and advertising, paying off fines and lawsuits, and, most importantly, the mountains of paperwork necessitated by the current fragmented system. Savings estimated to run in the range of $350 billion could be re-directed to the provision of care. In addition, most people would save money over current premium payments. Any health care system, bill, or proposal must be evaluated in these four areas: the pool, the package, funding, and the providers. The Pool All single payer proposals insist that the pool (the group of people covered) include all residents. In the United States, the wealthiest nation in the world, every person should receive excellent medical care. The larger the pool the better, risk is reduced by including everybody, the healthiest and the sickest, in the same pool. The single payer system would benefit all poor and working class people, and includes everyone, regardless of class, race, gender, and age. The Package H.R. 676 calls for coverage of "all medically necessary services." These include prescription drugs and long-term care (the big ticket items that do the most damage to elderly people's pocketbooks), services sometimes regarded as "extras," such as dental and chiropractic, and new drugs, technologies, and treatments (which will inevitably come under closer scrutiny). However, the status of alternative/complementary services, like acupuncture, are not specified. Funding This system will mainly be paid for by eliminating the enormous injustices in the current system. The majority of ongoing funding will come from the current government outlay for Medicare and Medicaid-related programs in every state (already 50% of total health care costs!). There will also be a tax on payroll for both employers and workers. H.R. 676 proposes a 4.75% tax on both employers and workers. Simple arithmetic shows that a person making $50,000 a year would pay $2,375 a year (add in taxes), which is just under $200 a month. Providers We live in a "service society" in which we are all invited to sit back, relax, and experience a vast menu of options. Of course, missing from this hoax scenario is the fact that, in order for services to be consumed, some people, the workers, must be there to provide the services. Nowhere is this relationship more obvious than in the provision of health care. Wise consumers will insist on the best possible conditions of work for providers, and a single payer system could open the way to enormous improvements in this regard. With a single payer funding mechanism we could establish the basis for the health care system that we want. We could choose our doctors and other providers, eliminate insurance company interference in medical decisions, and have continuing coverage regardless of whether or where we are working. Most wealthy countries in the world have adopted universal healthcare in some form or another. In their systems everyone is covered and gets better overall health indicators all while controlling costs. What's missing in the United States, is the political clarity and initiative to take on the corporate powers that now control our system. Health care reform prospects in Maryland This year the "Maryland Health Security Act," a single payer bill, will be introduced in Annapolis in the Senate and the House. The bill has not been finalized, but a draft version can be found on the website of Health Care Now- MD. Principal sponsors in the Senate will be Paul Pinsky (Prince Georges County) and Jamin Raskin (Montgomery). Principal sponsors in the House will be Karen Montgomery (Montgomery County) and Roger Manno (Montgomery). Dozens of other bills on health care issues will also be considered, but only one other bill will be thought of as a proposal for comprehensive reform of the system, the "Health Care for All" plan proposal of the Maryland Citizens' Health Initiative (MCHI). MCHI was founded in 1998, with the intention of working for comprehensive reform of the system to achieve universal coverage for all Marylanders. Initially, MCHI considered the single payer approach. The MCHI- commission/Lewin Report (2000) clearly spelled out many of the advantages of single payer. Although MCHI saw the benefits of a single payer system, in December, 2000, MCHI leaders announced that they would abandon single payer in favor of an approach that keeps the private health insurance industry in place. Since 2000 MCHI has worked for a number of limited reforms, and this is their first shot at a comprehensive proposal. The proposal has not yet been drafted into a bill, but its contents can be found at the MCHI website. The principal sponsor will be Delegate James Hubbard (Prince Georges), and as of now, there is no firm plan for a Senate bill. In many ways this proposal differs dramatically from single payer. Since the Clinton debacle of '93-'94, there has been a steady stream of proposals that attempt to square the policy circle. These proposals try to offer affordable, comprehensive, and universal care without eliminating the role and profit motive of private health insurance companies. Possibly the most important of these proposals since the Clinton plan was the passage of the 2006 Massachusetts reform bill. MCHI's proposal follows the Massachusetts model, and President Obama's pronouncements have been in the same vein. We often hear people complain that health care reform is complicated. We're most likely to hear this when someone is trying to understand the inner workings of the insurance industry or when policy makers are trying to persuade us that the complexity of their proposal is necessary and helpful. MCHI's proposal is indeed complicated, unnecessarily so, and destined to the failure of so many similarly structured plans in other states. Under the MCHI proposal there would be several pools, rather than just one. Hundreds of private insurance companies would continue to operate in Maryland, Medicare and Medicaid would continue, and a "Catastrophic Reinsurance" benefit would be put in place. Most ambitiously, a "Maryland Health Insurance Pool" would be set up to bring individuals and small group plans together in the same pool, an attempt to give the consumer the greater leverage that comes with being part of a larger pool. The proposal is hard to understand because, again, there will be many different insurers with many different packages. Even the Maryland Health Insurance Pool would offer three packages; basic, typical, and generous. These packages would include a 2% tax on employers. There would also be an increase on tobacco and alcohol tax, a "dime a drink". Also, individuals who do not qualify for exemption would be mandated to buy insurance. There is nothing in the proposal that would enable any substantial change in working conditions in the industry. There is no reason to believe that the insurance companies would not continue to interfere in the treatment process. MCHI identifies additional areas of concern, including a "value-based" assessment of treatments to help control costs, more efficient use of electronic records, and measures to promote prevention. However, as has been shown in other states' programs, without re-directing the money that now goes to the profit of the insurance industry, something will have to give: the pool, the package, the funding, or working conditions, or possibly all four will suffer. The proposal's frequent promises to regulate the insurance industry will not eliminate the core problem, which is that the pursuit of profit and the pursuit of quality care are in fundamental conflict. It is not shocking that the word "profit" is nowhere to be found in MCHI's literature. In sum, MCHI's proposal would actually make things worse. It's an invitation to deal with the insurance companies on their grounds, and give these industry executives an even firmer grip on our well being. The current trend toward various forms of underinsurance would be intensified. It adds up to mandatory unaffordable underinsurance - this in the name of "reform." In this time of dire economic crisis both of these bills face uphill battles in Annapolis. Though we have a proposal that would bring real relief and benefits, the single payer movement has to turn to grass-roots organizing to build a network of support capable of pushing forward. Over the next year, single payer will, at best, be stalled. At worst, especially if Obama finds momentum for his version of reform, we could be in for a re-run of the years that followed the Clinton administration’s failed attempts to reform our healthcare system. The question, then, is the following: how will the single payer movement weather the storm? Bill Harvey holds a one-time study session on single payer health insurance on the first Monday of every month at St. John's United Methodist Church, St. Paul St. at 27th St. Next session will be on Monday, February 2, 2009. bharvey@smart.net 1.Lisa Wangsness, "Health care reform a joint mission," BOSTON GLOBE December 26, 2008 www.truthout.org/122608HA For many resources critical of Obama on health care reform, see www.pnhp.org/change/ 2. www.healthcare-now.org 3. Steffie Woolhandler, et. al., "Costs of health care administration in the United States and Canada," NEW ENGLAND JOURNAL OF MEDICINE 349 (2003), 768-75 www.pnhp.org/publications/nejmadmin.pdf 4. www.mdsinglepayer.org/hsa2009.pdf 5. www.mdsinglepayer.org/links.htm for the LEWIN REPORT. See especially the 8 page "Executive Summary." 6. Bill Harvey, "Single payer health insurance endangered," BALTIMORE CHRONICLE (April, 2001) www.baltimorechronicle.com/health_apr01.html 7. www.healthcareforall.com/HTML18.phtml 8.www.masscare.org/ma-health-reform-law/ 9. Marcia, Angell, "Health reform you shouldn't believe in," AMERICAN PROSPECT (May, 2008) www.prospect.org/cs/articles?article=health_reform_you_shouldn't_believe_in and Steffie Woolhandler, et al., "State health care reform flatlines," INTERNATIONAL JOURNAL OF HEALTH SERVICES 38,3 (2008), 585-592.
