Category Archives: Improved Medicare for All

Putting Patients Last: Corporate Capture of Doctors

Welcome to corporate healthcare, the new normal in doctors’ offices, where profits are king and patients are commodities. With government regulatory agencies essentially adopting a “hands-off” policy, the ever-inventive medical establishment has come up with a basketful of new procedures to delude the patient population into believing that more (traditional drug-and procedure-saturated medicine) is the way to go. This at a time when American health care is growing more expensive and less effective. Life expectancy in the U.S. has been dropping for two straight years, the US. has the highest maternal mortality rate among developed countries and, according to a report by the Commonwealth Fund — the U.S. fails to achieve better health outcomes than the other countries, and … is last or near last on dimensions of access, efficiency, and equity.”

The response of the medical community to the state of U.S. healthcare? General agreement that reasonably priced healthcare options are “junk science” (acupuncture, massage, chiropractic care). Even patient choice is no longer a given—

Arthur W. saw a neurologist in a big medical group affiliated with a major hospital. He decided to see another neurologist in the same practice. When he called to make the appointment, he was told that he would not be able to see the neurologist of his choice since he had already seen a neurologist in that practice. Arthur was outraged but decided against pursuing his complaint. He was afraid the medical practice would drop him. He ended up making a repeat visit to a provider he neither liked nor trusted.

What happened to Arthur happens more often these days as medical practices get bigger and scoop up more and more doctors in the same specialty. If you don’t like your doctor, the practice threatens, you can hit the road. For most Americans, particularly those millions forced into second or third jobs to pay their medical expenses or college loans, the effort required to go to another practice is not a realistic option.

The bottom line: U.S. healthcare has taken two critical components of a patient-centric system —access and choice — off the table. Like other corporations, medical practices these days slap an LLC (limited liability company) behind their names and suddenly are endowed with a lower level of liability for their actions (medical malpractice may still apply to individual doctors, but the owners of the practice have no personal legal liability). In Trump’s tax plan, LLC practices also shield their owners from some of the taxes assessed on non-LLC corporations. Another tax dodge for corporate America.

It was a nightmare scenario. Henry G. had been operated on for advanced bladder cancer and now used a catheter. Having come down with a bladder infection, he called to make an appointment with the urologist who had been taking care of him through his surgery and beyond. He was told that his doctor no longer worked at the practice and the practice would not divulge where his doctor had gone. Henry was blindsided ‘What do I do now?’”

Henry was stuck between a rock and a hard place. As it turned out, his doctor had been fired by his practice (not bringing in enough business is the usual cause for termination or violating the strict time caps —7-11 minutes —for each patient visit) and started a new urology practice with colleagues who had been similarly booted. But even if Henry had managed to find his doctor, he probably couldn’t have scheduled a visit. Under the terms of the contract his doctor signed with his former employer, he was bound by a restrictive covenant clause that barred him from treating former patients or even from practicing within thirty-five miles of his former employer.

How prevalent are these restrictive covenants? In a recent survey of two thousand PCPs (primary care physicians) in five states, 45% admitted to being bound by a non-compete clause. Wresting a doctor away from long-time patients, particularly those with chronic conditions, is devastating for patients. It happened to one long-term cancer survivor. She received a letter from her doctor’s medical practice announcing the doctor’s exit but omitting reference to his new practice. Her response— “Somehow they [the practice enforcing the non-compete clause] lost sight of patient care and were more concerned about the bottom line.

That goes for the entire healthcare industry which has steadily relegated patient care to the bottom of the priority list. On top —profits, the bigger, the better. “When doctors want to move from one practice to another, if they’ve got a good therapeutic relationship with their patients, you’d think that public policy would want them to continue to treat those patients that trust them”. (Judy Conti, National Employment Law Project).  Ah, that’s the rub, isn’t it? When “public policy” clashes with profit-driven capitalism, the pillage and plunder metrics of capitalism invariably win.

To defend the indefensible, big wigs at major healthcare practices pretend that non-compete clauses actually benefit patients — “…because they [non-compete clauses] provide stability with a practice and ensure continuity of care.” (director of a major Iowa clinic). Not convinced? Try this excuse on for size— “Patients get frustrated but what they may not understand is that this is a legal thing that we have to abide by.” (Spokesperson for the University of Wisconsin health care system). Without doubt, a major component of the success of non-compete clauses is the lack of moral courage on the part of those who feel bound to enforce them. How about the doctors’ “natural allies,” the AMA (American Medical Association)? As the official lobby for corporate medicine, not individual doctors, their allegiance is to the power brokers — in a carefully nuanced statement, Dr. Patrice Harris, President-elect dithered — “To the extent that these agreements disrupt continuity of care, this is of great concern to the AMA.”

What are the chances a group of doctors bringing a lawsuit challenging both terminations and restrictive covenant clauses in medical contracts will prevail? Very good, according to David Clark, an expert on the legality of healthcare non-compete clauses — “No court is going to deny a patient who wants to go see a doctor of her choice.”

As almost every American who has had the misfortune to be a patient knows, profit-driven healthcare is not the answer to a long, healthy life. Consider the checkered history of Electronic Health Records (EHRs), sold to the public as the one sure way for patients to receive the most effective treatments, reduce medical errors, and provide a fast and efficient way to share their medical histories with doctors and hospitals virtually anywhere in the world. These wildly exaggerated claims convinced Obama to make them part of Obamacare. So far the feds have poured $36 billion into the EHR industry and made a lot of fat cats fatter. What have patients gotten in return — an error-prone, cumbersome system whose requirements vitiate doctor-patient interactions, making them little more than a fill-in-the-blanks exercise. Here’s how one administrator at a large medical center described a typical office visit in the era of EHRs —In America, we have 11 minutes to see a patient and [our doctors have] to be empathetic, make eye contact, enter about 100 pieces of data, and never commit malpractice. It’s not possible”. (John Halamka)

But when it comes to outright larceny, “surprise billing” takes the cake. Let’s say you go to a hospital that’s part of your insurance company’s network, only to receive care without your knowledge or permission from a doctor who isn’t part of that network.

Charlotte C. was forced to have an emergency C section. Although the hospital was in her insurer’s network, an in-network anesthesiologist wasn’t available, so she was billed $15,000 for the out-of-network doctor who replaced her.

There’s an even darker side to U.S. healthcare.  “Predictive medicine” (not unlike predictive policing) helps insurers predict how likely you are to develop specific illnesses and more important, from the doctor’s point of view, how likely you are to pay what your insurer doesn’t cover. As high deductibles and co-pays force patients (both those insured by their employers and those buying insurance on the federal marketplaces) into paying a greater share of the larcenous fees doctors and hospitals charge, health providers want to know how likely they are to be paid before they treat you. A couple of companies are getting rich investigating your credit worthiness for doctors and hospitals.

There was a time when healthcare was exactly that. Fifty-eight years ago, this dedication celebrating the commitment of the U.S. medical system to the welfare of patients appeared at the end of the movie The Young Doctors “This film is dedicated to the medical profession for its constant devoted service to mankind.”

Little more than a half century later, it’s hard to imagine that U.S. medicine ever operated that way.

What will it take to unseat the power brokers who control healthcare in America? Lots of us united around one goal — single payer universal healthcare. “Small acts, when multiplied by millions of people, can quietly become a power no government can suppress, a power that can transform the world.” (Howard Zinn)

Putting Patients Last: Corporate Capture of Doctors

Welcome to corporate healthcare, the new normal in doctors’ offices, where profits are king and patients are commodities. With government regulatory agencies essentially adopting a “hands-off” policy, the ever-inventive medical establishment has come up with a basketful of new procedures to delude the patient population into believing that more (traditional drug-and procedure-saturated medicine) is the way to go. This at a time when American health care is growing more expensive and less effective. Life expectancy in the U.S. has been dropping for two straight years, the US. has the highest maternal mortality rate among developed countries and, according to a report by the Commonwealth Fund — the U.S. fails to achieve better health outcomes than the other countries, and … is last or near last on dimensions of access, efficiency, and equity.”

The response of the medical community to the state of U.S. healthcare? General agreement that reasonably priced healthcare options are “junk science” (acupuncture, massage, chiropractic care). Even patient choice is no longer a given—

Arthur W. saw a neurologist in a big medical group affiliated with a major hospital. He decided to see another neurologist in the same practice. When he called to make the appointment, he was told that he would not be able to see the neurologist of his choice since he had already seen a neurologist in that practice. Arthur was outraged but decided against pursuing his complaint. He was afraid the medical practice would drop him. He ended up making a repeat visit to a provider he neither liked nor trusted.

What happened to Arthur happens more often these days as medical practices get bigger and scoop up more and more doctors in the same specialty. If you don’t like your doctor, the practice threatens, you can hit the road. For most Americans, particularly those millions forced into second or third jobs to pay their medical expenses or college loans, the effort required to go to another practice is not a realistic option.

The bottom line: U.S. healthcare has taken two critical components of a patient-centric system —access and choice — off the table. Like other corporations, medical practices these days slap an LLC (limited liability company) behind their names and suddenly are endowed with a lower level of liability for their actions (medical malpractice may still apply to individual doctors, but the owners of the practice have no personal legal liability). In Trump’s tax plan, LLC practices also shield their owners from some of the taxes assessed on non-LLC corporations. Another tax dodge for corporate America.

It was a nightmare scenario. Henry G. had been operated on for advanced bladder cancer and now used a catheter. Having come down with a bladder infection, he called to make an appointment with the urologist who had been taking care of him through his surgery and beyond. He was told that his doctor no longer worked at the practice and the practice would not divulge where his doctor had gone. Henry was blindsided ‘What do I do now?’”

Henry was stuck between a rock and a hard place. As it turned out, his doctor had been fired by his practice (not bringing in enough business is the usual cause for termination or violating the strict time caps —7-11 minutes —for each patient visit) and started a new urology practice with colleagues who had been similarly booted. But even if Henry had managed to find his doctor, he probably couldn’t have scheduled a visit. Under the terms of the contract his doctor signed with his former employer, he was bound by a restrictive covenant clause that barred him from treating former patients or even from practicing within thirty-five miles of his former employer.

How prevalent are these restrictive covenants? In a recent survey of two thousand PCPs (primary care physicians) in five states, 45% admitted to being bound by a non-compete clause. Wresting a doctor away from long-time patients, particularly those with chronic conditions, is devastating for patients. It happened to one long-term cancer survivor. She received a letter from her doctor’s medical practice announcing the doctor’s exit but omitting reference to his new practice. Her response— “Somehow they [the practice enforcing the non-compete clause] lost sight of patient care and were more concerned about the bottom line.

That goes for the entire healthcare industry which has steadily relegated patient care to the bottom of the priority list. On top —profits, the bigger, the better. “When doctors want to move from one practice to another, if they’ve got a good therapeutic relationship with their patients, you’d think that public policy would want them to continue to treat those patients that trust them”. (Judy Conti, National Employment Law Project).  Ah, that’s the rub, isn’t it? When “public policy” clashes with profit-driven capitalism, the pillage and plunder metrics of capitalism invariably win.

To defend the indefensible, big wigs at major healthcare practices pretend that non-compete clauses actually benefit patients — “…because they [non-compete clauses] provide stability with a practice and ensure continuity of care.” (director of a major Iowa clinic). Not convinced? Try this excuse on for size— “Patients get frustrated but what they may not understand is that this is a legal thing that we have to abide by.” (Spokesperson for the University of Wisconsin health care system). Without doubt, a major component of the success of non-compete clauses is the lack of moral courage on the part of those who feel bound to enforce them. How about the doctors’ “natural allies,” the AMA (American Medical Association)? As the official lobby for corporate medicine, not individual doctors, their allegiance is to the power brokers — in a carefully nuanced statement, Dr. Patrice Harris, President-elect dithered — “To the extent that these agreements disrupt continuity of care, this is of great concern to the AMA.”

What are the chances a group of doctors bringing a lawsuit challenging both terminations and restrictive covenant clauses in medical contracts will prevail? Very good, according to David Clark, an expert on the legality of healthcare non-compete clauses — “No court is going to deny a patient who wants to go see a doctor of her choice.”

As almost every American who has had the misfortune to be a patient knows, profit-driven healthcare is not the answer to a long, healthy life. Consider the checkered history of Electronic Health Records (EHRs), sold to the public as the one sure way for patients to receive the most effective treatments, reduce medical errors, and provide a fast and efficient way to share their medical histories with doctors and hospitals virtually anywhere in the world. These wildly exaggerated claims convinced Obama to make them part of Obamacare. So far the feds have poured $36 billion into the EHR industry and made a lot of fat cats fatter. What have patients gotten in return — an error-prone, cumbersome system whose requirements vitiate doctor-patient interactions, making them little more than a fill-in-the-blanks exercise. Here’s how one administrator at a large medical center described a typical office visit in the era of EHRs —In America, we have 11 minutes to see a patient and [our doctors have] to be empathetic, make eye contact, enter about 100 pieces of data, and never commit malpractice. It’s not possible”. (John Halamka)

But when it comes to outright larceny, “surprise billing” takes the cake. Let’s say you go to a hospital that’s part of your insurance company’s network, only to receive care without your knowledge or permission from a doctor who isn’t part of that network.

Charlotte C. was forced to have an emergency C section. Although the hospital was in her insurer’s network, an in-network anesthesiologist wasn’t available, so she was billed $15,000 for the out-of-network doctor who replaced her.

There’s an even darker side to U.S. healthcare.  “Predictive medicine” (not unlike predictive policing) helps insurers predict how likely you are to develop specific illnesses and more important, from the doctor’s point of view, how likely you are to pay what your insurer doesn’t cover. As high deductibles and co-pays force patients (both those insured by their employers and those buying insurance on the federal marketplaces) into paying a greater share of the larcenous fees doctors and hospitals charge, health providers want to know how likely they are to be paid before they treat you. A couple of companies are getting rich investigating your credit worthiness for doctors and hospitals.

There was a time when healthcare was exactly that. Fifty-eight years ago, this dedication celebrating the commitment of the U.S. medical system to the welfare of patients appeared at the end of the movie The Young Doctors “This film is dedicated to the medical profession for its constant devoted service to mankind.”

Little more than a half century later, it’s hard to imagine that U.S. medicine ever operated that way.

What will it take to unseat the power brokers who control healthcare in America? Lots of us united around one goal — single payer universal healthcare. “Small acts, when multiplied by millions of people, can quietly become a power no government can suppress, a power that can transform the world.” (Howard Zinn)

Corporate and “Progressive” Democrats Threaten Medicare Itself

The Democratic Party won a majority in the House of Representatives in the November 2018 elections by making health care one of its top “messages.” Yet events from Bernie Sanders’ bill of 2017 to legislation that “progressive” Representative Pramila Jayapal introduced on February 27, 2019 show that the Party is on its way to destroy Medicare.

For decades activists identified the prize as “single payer health care.” The program would issue a Medicare card to everyone, like the one senior citizens get now. The card would be good at any doctor’s office, clinic, hospital, laboratory, and prescription pharmacy. These largely private businesses would be reimbursed from a public single-payer fund. The fund would receive broadly collected tax revenues; the patient would pay little or nothing at the reception desk, and no monthly premium. This is guaranteed, comprehensive health care.

In other words, single payer is Medicare for all, carried to completion by eliminating Part B premiums and by more comprehensive coverage including prescribed drugs.

Health care activists always agonized over the colorless name “single payer.” A few years ago many of them began to speak of Improved Medicare for All. Actually, it had been in the title of the benchmark bill, H.R. 676, when congressperson John Conyers introduced it in 2003. A few years later he shortened the title to The Expanded and Improved Medicare for All Act. The text remained stable, and although the bill went nowhere in Congressional committees, H.R. 676 became the centerpiece of organizing. It is readable, only thirty pages of double-spaced large type. Hundreds of trade union locals and councils endorsed this model legislation in a steady stream year after year.

The health care industry has enjoyed a long-term phase of expansion, like railroads in the latter half of the nineteenth century. Back then, the new way of moving heavy goods and people was amazing and useful; today, new biological and biochemical understanding makes possible longer life, survival from a heart attack, restored clarity of vision, and so on. In both situations, capital has had strong pricing power and taken fat profits. And just as anger at railroads swelled into a populist revolt against The Octopus (Frank Norris’ novel about the Southern Pacific railroad corporation), people today are angry at insurance corporations, pharmaceutical monopolies, and hospitals, whether or not they call themselves “non-profit.”1

Opinion polls measure growing support for single payer health care for all. Employers continue to raise the employee cost of coverage, or simply not provide a health benefit. Health insurance purchased individually on the so-called exchanges of the Affordable Care Act (“Obamacare”) turns out to be full of exceptions like a slice of Swiss cheese.

Sanders Promotes Health Care for All Then Undercuts Conyers

Popular support erupted into a political force when Bernie Sanders launched his presidential campaign at the end of April 2015. Record-breaking crowds filled his rallies around the country. The top three issues in a Sanders speech rotated – sometimes including inequality of wealth and income, sometimes climate change – but he always revved up on health care for all. It had been the cause of a few thousand health care activists. Now Improved Medicare for All became a challenge to the neoliberal establishment. For the first time in forty years, people were on the verge of a mass campaign for a major gain in their quality of life and their security.

It did not happen. Sanders did not win the Democratic presidential  nomination. He returned to the Senate, making an implicit or private deal with the party: he would speak as a independent progressive, but he will act on all serious matters as an unannounced Democrat.

Doing something about health care for people largely fell out of public view. Health care activists carried on. Policy aficionados spun proposals. Sanders had used the issue in his campaign, but sustained mass organizing for it did not happen.

Then in September 2017, senator Sanders introduced his “Medicare for All Act.” S. 1804 is three times as long as H.R. 676, and the reader must unravel cross-references within the text. Sanders made no mention of Conyers’ H.R. 676 at his press conference. Since then, no one has asked him the obvious question: Why didn’t Sanders simply introduce the text of H.R. 676 in the Senate?

The “Buy-In” Trap

Sanders’ bill would actually undermine Medicare. It would set up a “Transitional Medicare Buy-in Option and Transitional Public Option.” Sanders portrayed it as a four-year period (longer if necessary) to bring people of age 55 or over into Medicare, then down to age 45, then down to age 35, then everyone. This scheme is the very opposite of guaranteed single-payer health care for all.

How is Medicare financed today? Most of the money comes from payroll and income tax revenues, not enrollees’ Part B premiums, by a ratio of 3½ to one.2 We all pay into Medicare. At the moment when someone needs care, she gets it, period – without financial worry. That is the single-payer principle, and Medicare implements it, although not entirely, since enrollees must keep up-to-date on their Part B monthly premiums, and there are some co-payments for services.

Expanded and Improved Medicare for All would eliminate premiums and co-pays. That is what H.R. 676 declared, but in Sanders’ S. 1804 people younger than 65 could “join” Medicare by paying fat monthly premiums (a “buy-in”). People who want to sign up this way would use the notorious Obamacare exchanges.

Trade union campaigners for genuine Medicare for all, H.R. 676, wrote in a December 11, 2018 letter:

Unlike HR 676, S 1804 inserts supposedly incremental steps of public options and Medicare buy-ins for four years prior to arriving at a real single payer plan. Because S 1804 expands care while maintaining the private insurance companies, costs will skyrocket before the savings of single payer kick in. The incremental steps will become a roadblock rather than a path to single payer. Perhaps the worst part of this inclusion of the public option and the Medicare buy-in is the reinforcement of the false notion that there should or must be transitional steps to single payer. Neither the public option nor the Medicare by-in are based on sound policy. To place them in the bill for even a short period of time endangers the single payer goal.

All Unions Committee for Single Payer Health Care, HR 676, Kay Tillow, coordinator

It is a neat trick: under the guise of expanding Medicare, you make it more dependent on premiums. You change it from a public good, like the neighborhood fire station, into a commodity insurance product that individuals buy. You make health care dependent on the patient’s finances.

This perversion of Medicare is not only a fraud upon people of age 55, 45, or 35. It is a threat to Medicare itself. Whenever Medicare seems headed for a financial crunch, real or conjured, the pressure in Congress will be to shift more and more toward a premium- and co-pay-financed program rather than one supported by general and progressive tax revenues – and to take chunks of medicine out of Medicare.

An independent in name but a Democrat, in fact, senator Sanders at his press conference happily introduced several corporate Democrat co-sponsors of his bill. Behind closed doors he had let them write sections of S. 1804! The public option section was written by senator Kirsten Gillibrand of New York. “One part of the bill that I worked with my colleagues to put in was the ability for every American to buy into a nonprofit public option as part of a four-year transition…,” she said during the news conference introducing the bill.

A public option is a competition with insurance corporations rigged in their favor. They know how to repel potential enrollees who are likely to need expensive care. A government health plan cannot and, of course, should not play that game. It can either raise premiums, or it can turn the program into something like its poor cousin Medicaid. Either way, it cannot become improved Medicare for all.

Democratic Party: “Death to H.R. 676!”

Two important bills stood in contradiction to each other: one for Expanded and Improved Medicare for All (H.R. 676), the other a threat to Medicare itself (S. 1804). Conyers’ bill has been the acknowledged model legislation since 2003; Sanders introduced his in 2017.

But words do not move on their own. The corporate Democratic Party soon put H.R. 676 on the chopping block. Representative John Conyers was pushed out of Congress in a #MeToo incident, resigning from a hospital bed, denying the charges but not up to the rigor of a fair hearing if he could get one.

Somehow, sponsorship of H.R. 676 went to new congressperson Pramila Jayapal. 3 She immediately announced that she was in consultations to rewrite it. In the meantime, she surrendered the number 676 that had been reserved for Conyers’ bill since 2003. It was issued to military legislation on January 17, 2019.

After the Democrats won control of the House of Representatives in the November 2018 elections, it became more urgent for them to gut single payer health care for all. Otherwise, they might have to deliver. Representative Nancy Pelosi, during a post-election whirlwind of bargaining to make sure she became Speaker of the House, agreed to help advance the same scheme that senators Sanders and Gillibrand had put into S. 1804: a buy-in to a premium-based option for people age 50 to 64. Jayapal, who also praised Pelosi during her run for Speaker, spoke out of both sides of her mouth. “I would prefer to have a reduction of the age of Medicare so that more people could qualify but not a buy-in, because that continues the problems that we have right now.” She said lowering the eligibility age “would be an appropriate way to go where we’re taking a step forward towards a system that will ultimately cover everybody.”

The Buy-in Trick Again

Representative Jayapal introduced H.R. 1384, her replacement for the Conyers’ model, on February 27, 2019. The 119-page bill is a masterful card trick. On one hand, it maintains the ban on premiums and co-payments, and it specifies a broad list of covered medical services, including some never proposed before in such legislation.

On the other hand, Jayapal copied Sanders’ big step backward – an optional “buy-in” transition period with premiums, only shortened from his four years to two. (After the first year, minors up to age 18 and people 55 and older would move automatically into the new system.) H.R. 1384 states:

The Administrator shall determine the premium amount for enrolling in the Medicare Transition buy-in, which may vary according to family or individual coverage, age, and tobacco status,… (H.R. 1384, Title X, Subtitle A, Sec. 1002 (e)(A))

Since Conyers introduced H.R. 676 in 2003, his bill never had a premium-based buy-in. Why does Rep. Jayapal think a buy-in period is necessary?

With a buy-in transition, the first experience people would have with the new system would be yet another commodity insurance plan with monthly premiums. This is a recipe for political failure. During those two years the tentative new system would soon be under attack as financially unworkable and just not popular enough.

People could buy in if they wished as individuals through the notorious Affordable Care Act exchanges (“Obamacare”). Because of the extensive benefits, the plan would be one of the most costly choices. Unaffordable for most as an individual premium plan, trying to compete in an unreformed health care system with its bloated costs, the buy-in would attract few enrollees. Enemies of genuine universal health care will pounce on the result, demanding that genuine Medicare for All be postponed and turned into a supplement of one kind or another to corporate health insurance.

Only H.R. 676 delivers guaranteed healthcare for all, the equal care for all of which our advanced society is capable. Bernie Sanders and Pramila Jayapal, just like openly corporate yet arguably less devious Democrats, cower before insurance capital, pharmaceutical capital, hospital capital, etc. These parasites demand that healthcare be a set of commodities that some can afford and others cannot. The people or the dollar – that is the inescapable choice.

  1. A nominally “non-profit” hospital today is not the church-run charity that it might have been a hundred years ago. Non-profit simply means that the corporation is tax-exempt. It does not pay dividends to stockholders, but it still makes a profit. Banks share in the loot, and layers of executives are paid millions of dollars. Affiliated for-profit clinics and labs may suck profits out under cover. Examine the Sutter Health and Kaiser hospital chains in California, for example.
  2. Medicare trust fund trustees’ report, 2018, pp. 45 and 78.
  3. Jayapal went to elite Georgetown University, got an MBA after that, worked on Wall Street on leveraged buyouts, switched to executive positions in several nonprofits, sat a mere two years in the Washington state senate, and won election to the House in 2016.

To Sen. Sanders: We cannot begin from a position of compromise

At the start of the August congressional recess, Senator Bernie Sanders announced that he will introduce a senate bill this September “to expand Medicare to cover all Americans.” Since the election, the movement for improved Medicare for all, has been urging Sanders to introduce a companion to John Conyers’ HR 676: The Expanded and Improved Medicare for All Act, which currently has a record 117 co-sponsors in the House and is considered the gold standard by the movement.

Recent reports are that Sanders’ bill falls far short of HR 676 in fundamental ways. In fact, Sanders’ bill is a multi-payer system not a single payer system. His bill reportedly would allow private insurers to compete with the public system, allow the wealthy to buy their way out of the public system and allow investor-owned health facilities to continue to profit while providing more expensive and lower quality health care.

As a leader in the Democratic Party in the Senate, Sanders is trying to walk the line between listening to the concerns of his constituency, which overwhelmingly favors single payer health care, and protecting his fellow Democrats, whose campaigns are financed by the medical industrial complex. Sanders needs to side with the movement not those who profit from overly expensive US health care.

Today, August 30, Health Over Profit for Everyone steering committee members and supporters sent the letter at the end of this article to Senator Sanders raising specific concerns and urging Senator Sanders to amend his bill before it is introduced.

CLICK HERE TO SEND AN EMAIL TO SENATOR SANDERS.

There are two realities

It has become the practice in Washington, DC to offer weak bills, which fail to address the roots of the crises we face, to make them ‘politically feasible’. The Affordable Care Act (ACA) is an example of this. It was a compromise with the health insurance, pharmaceutical and private hospital industries from the start – an attempt to appease them with public dollars in exchange for greater access to care. The ACA was built on a foundation of private industry even though the priorities of those industries are profit for a few, not health for everyone. That faulty foundation has perpetuated the healthcare crisis – tens of millions without health insurance, tens of millions more who have health insurance but can’t afford health care and poor health outcomes including tens of thousands of deaths each year.

There are two realities that must be considered. The healthcare crisis will not end until a system is put in place that guarantees universal comprehensive and affordable healthcare coverage through National Improved Medicare for All or another form of single payer system such as a national health service. That is what we call the ‘real reality’, and it simply won’t change until there are real changes in policy that solve it. The political reality of what is ‘politically feasible’ is the other reality. This reality will change as people organize and mobilize to demand what they need. Politicians change their positions when they believe it is necessary to maintain their position of power. It is the task of movements to change what is politically feasible.

The movement for National Improved Medicare for All has been working for decades to educate, organize and mobilize the public to change the political reality. And it is working. There is broad public support for Improved Medicare for All and legislation in the House that articulates the demands of the movement. What is needed now is a companion bill in the Senate that is as strong as HR 676. Once that is introduced, activists will work to secure support for it.

Sanders has it backwards. Rather than starting from a position of strong legislation and building support for it, he is starting from a position of weak legislation that he considers to be more politically feasible. By doing so, he is losing the support of the movement that he needs to pass expanded and improved Medicare for all.

Activists versus legislators

This is where it is important to recognize the difference between activists and legislators. Activists and legislators have different priorities. Activists work to solve crises. Their dedication is to an issue. Legislators work to maintain their position, whether it is re-election, seats on committees, good standing with other legislators or continued funding from Wall Street or other wealthy interests. Legislators compromise when they believe it is in their personal best interest. Activists can only compromise when it is in the interest of solving the crisis they face.

To win National Improved Medicare for All, activists need to follow the principles outlined in I.C.U.:

The “I” stands for independence. Activists must keep their allegiance to their issue independent of the agenda of legislators and political parties. The goal is to solve the healthcare crisis, and politicians from both major parties will need to be pressured to support Improved Medicare for All. Remember, the movement is going against the interests of the big money industries that finance members of Congress.

The “C” stands for clarity. Legislators will attempt to throw the movement off track by claiming that there are ‘back doors’ to our goal or smaller incremental steps that are more ‘politically feasible’. They will use language that sounds like it is in alignment with the goals of the movement even though the policies they promote are insufficient or opposed to the goals of the movement. This is happening right now in the movement for Improved Medicare for All. Numerous people, who consider themselves to be progressive but who are connected to the Democratic Party, are writing articles to convince single payer supporters to ask for less.

And the “U” stands for uncompromising. Gandhi is quoted as saying that one cannot compromise on fundamentals because it is all give and no take. When it comes to the healthcare crisis, the smallest incremental step is National Improved Medicare for All. That will create the system and the cost savings needed to provide universal comprehensive coverage. Throughout history, every movement for social transformation has been told that it is asking for too much. When the single payer movement is told that it must compromise, that is no different. The movement is demanding a proven solution to the healthcare crisis, and anything less will not work.

The momentum is on the side of the movement for National Improved Medicare for All. Act now to push Sanders to amend his bill so that it matches HR 676. Sign and share the petition tool, and read the letter below to understand the concerns about Sanders’ bill.

CLICK HERE TO SEND AN EMAIL TO SENATOR SANDERS.

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Dear Senator Sanders,

For almost fifteen years the movement for National Improved Medicare for All has organized around HR 676: The Expanded and Improved Medicare for All Act, introduced each session since 2003 by Congressman John Conyers. As you know, HR 676 has 117 co-sponsors so far this year. This legislation is considered by the movement to be the gold standard framework for a universal healthcare system in the United States.

We appreciate your support for Improved Medicare for All and the work that you have done to elevate the national dialogue on Improved Medicare for All. We hope to continue to work with you to make this a reality in the near future.

To that end, we are writing to share our concerns about the legislation that you are planning to introduce. These concerns are based on what we have learned about your legislation without having the benefit of reading a draft of it.

In order to maintain the cohesion and strength of the movement for Improved Medicare for All, the legislation in the senate must be in alignment with HR 676. This is important so that the movement is unified and so that the process begins from a position of asking for what we want and need, rather than starting from a position of compromise. It is the task of the movement to build political support for the legislation in Congress.

Here is a list of our concerns:

  1. We oppose the inclusion of copayments and deductibles in an Improved Medicare for All bill.

As outlined in the recent letter to you from Physicians for a National Health Program, including copayments adds administrative complexity and creates a barrier to care, which leads to delay or avoidance of necessary care. Economic analyses indicate that the administrative and other savings inherent in a well-planned single payer system offset the added expense of eliminating copayments and deductibles. HR 676 does not include copayments. The movement for Improved Medicare for All has coalesced around the elimination of these financial barriers to care.

  1. We support a rapid transition to National Improved Medicare for All. The Medicare system was implemented within a year of passage without using computers. Unlike when Medicare became law, the United States now has basic infrastructure in place for a national health insurance based on Medicare. We urge you to utilize the timeline in HR 676, which would start the universal system in less than two years, rather than delaying or phasing it in by age group over time. Beginning with a universal system allows savings and cost controls that can be used to provide comprehensive benefits without cost sharing.
  2. We support a single payer healthcare system. We understand that your legislation will allow employers to continue to provide employee health insurance that duplicates what the national health insurance covers to avoid conflict with the Employee Retirement and Income Security Act (ERISA). We urge you to include a carve out of ERISA for national health insurance so that the new system is a single payer system. Without doing so, your bill will be a multi-payer system. This is required to achieve administrative simplicity and significant cost savings. HR 676 allows private insurance that does not duplicate the benefits of the system. Employers and unions would be able to provide extra benefits beyond what the system covers.
  3. We support a universal system. We understand that your legislation will allow health providers to opt out of the national health insurance system. This would create a parallel health system for the wealthy and undermine the quality of the public system. Universal systems are of higher quality than tiered systems because they create a social solidarity in which everyone has an interest in making the system the best it can be. We urge you to reject a tiered healthcare system as healthcare is a human right and should not be based on wealth.
  4. We oppose inclusion of investor-owned health facilities. Investor-owned health facilities treat health care, which is a necessary public service, as a commodity for profit. These facilities have an incentive to cut corners, under and over treat and charge higher prices. The result is higher cost and lower quality. We urge you to reject profiteering in the healthcare system so that the bottom line is improving the health of our population, not profits for Wall Street.

The above concerns are based on what we know about your legislation at present. We do not know if they are warranted because we have not read the text. Upon reading it, there may be additional concerns.

We hope that you will share the draft text of your legislation with us and address the above concerns before it is introduced. Our support for your Improved Medicare for All legislation will depend upon whether or not it will serve as a companion to HR 676. If it is, we are ready to work in our states to build political support for it. If the above concerns are not addressed, then your bill will not be a single payer Improved Medicare for All bill and we believe it will undermine the movement for HR 676.

We recognize that legislators tend to compromise from the start to build political support for legislation. This has served as a failed strategy because the final legislation is too weak to accomplish its goals. We suggest a different approach of beginning from a position of what is required to solve the healthcare crisis. We have organized for too long to concede from the start on these fundamental principles.

Signed,

Vanessa Beck, Health Over Profit for Everyone Steering Committee
Claudia Chaufan, MD, California Physicians for a National Health Program*
Andy Coates, MD, past president, Physicians for a National Health Program*
Dena Draskovich, Leader of Indivisible Omaha and disabled citizen*
Margaret Flowers, MD, director of Health Over Profit for Everyone
Leslie Hartley Gise MD, Clinical Professor Psychiatry, University of Hawai’i*
Leigh Haynes, People’s Health Movement-USA*
Joseph Q Jarvis MD MSPH, Utah*
Stephen B. Kemble, MD, Physicians for a National Health Program advisory board, past president of Hawaii Medical Association*
Edgar A Lopez MD, FACS, member, Physicians for a National Health Program, Kentuckians for Single Payer*
Ethel Long-Scott, Women’s Economic Agenda Project (WEAP)*
Eric Naumburg, MD, co-chair Maryland chapter of Physicians for a National Health Program*
Carol Paris, MD, president, Physicians for a National Health Program*
George Pauk, MD
Julie Keller Pease, MD, Topsham, Maine
Julia Robinson, MD, People’s Health Movement-USA*
Anne Scheetz, MD, Illinois Single-Payer Coalition, Physicians for a National Health Program and steering committee of Health Over Profit for Everyone*
Mariel Scheinberg, OMS 4, Rowan University School of Osteopathic Medicine*
Lee Stanfield, Health Over Profit for Everyone Steering Committee and Single Payer Tucson NOW*
Bruce Trigg, MD, Public Health and Addiction Consultant
John V. Walsh, MD, California Physicians for a National Health Program*
Robert Zarr, MD, past president, Physicians for a National Health Program*
Kevin Zeese, co-director of Popular Resistance

*For identification purposes only.

• First published at Health over Profit

Response to Nation Article on Single Payer: Improved Medicare for All is the Solution

On August 2, 2017, The Nation published an article by Joshua Holland, “Medicare for All isn’t the Solution for Universal Health Care,” chastising Improved Medicare for All supporters because, in his view, the single payer movement has “failed to grapple with the difficulties of transitioning to a single-payer system.” The article, which doesn’t quote anyone involved in the movement for Improved Medicare for All, begs a response because it shows what liberals opposed to single payer believe. Holland dredges up the same arguments used to keep single payer off the table during the creation of the Affordable Care Act (ACA). He even dusted off a few that were used to try to stop Medicare from coming into existence in the 1960s. And then he attempts to distract single payer supporters away from supporting Improved Medicare for All and settling for something less, as was done successfully in 2009.

The first error that Holland makes is confusing the term “Medicare for All” as meaning that advocates would simply take the current Medicare system, with both traditional and ‘Advantage’ plans, and expand that. This is why it is important to use the phrase “Improved Medicare for All.” As outlined in HR 676: The Expanded and Improved Medicare for All Act, the new system would be based on the current Medicare system, which is already national, but it would be a single public plan that is comprehensive in coverage and does not have out-of-pocket costs or caps. It would ban investor-owned facilities and ban private insurers from selling policies that duplicate what the system covers. A single system is the simplest for patients and health professionals because there is one transparent set of rules.

Most people who purchase health insurance have no idea which plan is best for them because nobody can anticipate what their healthcare needs will be in the future. A study of the Massachusetts health exchange plans done by the Center for American Progress showed that some plans were best for patients with cancer and other plans were best for people with heart disease or diabetes, but that isn’t something that can be advertised up front. Even if it were, people can’t predict if they will be diagnosed with cancer, heart disease or diabetes in the future. HR 676: The Expanded and Improved Medicare for All Act solves this problem by creating a single public plan designed to cover whatever our healthcare needs will be.

A second error that Holland makes is saying that HR 676 calls for the new system to start within a single year. The bill will take effect “on the first day of the first year that begins more than [emphasis added] 1 year after the date of the enactment of this Act.” This means that if HR 676 were to be signed by the President in July of 2018, then it would take effect in January of 2020. Holland raises the concern that we can’t move the whole country into the new Improved Medicare for All system that quickly. In fact, HR 676 has transition periods for the Veteran’s Administration, the Indian Health Service, displaced workers and buying out for-profit health providers.

When Medicare was enacted in 1965, more than 50% of seniors were uninsured and the rest had some form of health insurance. Without computers and without a national health system in place, all 19 million seniors were enrolled in the first year (almost twice as many as were enrolled in the ACA in the first four years). At present, the United States has Medicare infrastructure in place and all practicing health professionals have a National Provider Identifier issued to them by the Centers for Medicare and Medicaid Services (CMS). When the new Improved Medicare for All system takes effect, enrollment will be very simple because there is only one plan that is universal and paid for up front though taxes. All health professionals will be in it. Every person could be sent a card, much as CMS does now for people who are turning 65. For those who do not receive a card, HR 676 has a solution – when they present for care at a health facility, they are assumed to be in the system, are treated first and then are enrolled in the system afterwards.

Next, Holland brings up the same arguments used to prevent universal health care attempts in the past. He states that people don’t want to give up what they have. This is called ‘loss aversion.’ It is a task of the single payer movement to build the public support for Improved Medicare for All necessary to overcome any potential loss aversion. Public figures and elected officials can play a role in building support as well.

Holland raises concerns that employers and seniors won’t want to give up their private plans, but that is based on his mistaken belief that Improved Medicare for All will be the same as current Medicare. The reality is that people will be less worried about giving up what they have if they know that it will be replaced with something better and that they will no longer fear losing their doctor as they will all be in the new system. Improved Medicare for All will provide more comprehensive benefits, no out-of-pocket costs and an unrestricted network of health professionals from which to choose. Employers will no longer be burdened with the high costs of health insurance. People with pre-existing health conditions will no longer worry about losing coverage or having to pay more. Unions and employers can offer supplemental plans for extras not covered by the new system, as is done in countries like France, if they choose to do so.

Holland also raises the concern that people will lose their doctor because they will opt out of the system due to low reimbursements. We are already losing doctors because of the current system. Physician burnout was listed as the second biggest concern by the Surgeon General last year. Under Improved Medicare for All, all health professionals will be in the system. There won’t be any place to opt out to. And why would they want to? Health professionals will save tens of thousands of dollars each year on billing and won’t have to worry about whether a patient has insurance or not. They can see anyone who calls for an appointment. And they will have a system with which to negotiate fair reimbursement. Private health insurance doesn’t negotiate with physicians and hospitals. Each year they make an offer and providers can either basically take it or leave it. Doctors in single payer systems that spend much less per capita than the United States are paid well, so the US can certainly afford to reimburse doctors adequately.

Every transformative change has suffered from loss aversion, but that hasn’t stopped them. When Medicare was enacted, it was called socialized medicine, a government intrusion that would take away people’s choices and freedom and become an opening to government control over our lives. The scare tactics didn’t work and Medicare is one of the most popular parts of our current healthcare system. Desegregation, women’s rights, workers’ rights and more were great changes that were successful and we are a better society for them. Why is the right to health care any different?

Finally, Holland dives into the myth that we can’t afford Improved Medicare for All because it will be too expensive. My first response when I hear this is that the same excuse wasn’t made when we spent $16 trillion to bail out the banks in 2008 and is never made when we invade another country, so why is it raised when it comes to one of the most basic necessities a society can have? The United States has the highest wealth and the highest wealth inequality of industrialized nations. The new “Commitment to Reducing Inequality Index” recommends social spending on education, health and other basic social protections as its top priority. Congress can appropriate the funds to do this. This should be a top priority in the United States as well.

The reality is that the United States is already spending the most on health care per person each year because the market has failed to control costs. That is exactly why we need a single payer system like National Improved Medicare for All. It is the only way to simplify the bloated bureaucracy of the current healthcare system, which would save around $500 billion each year, and to control the costs of medical procedures, medical devices and pharmaceuticals by having a single system that can negotiate fair prices. In addition to the bureaucracy created by a multi-payer system, the US subsidized the insurance industry with more than $300 billion last year. A system based on health, rather than profits for investors, can identify and prioritize our greatest health needs and work to address them.

For example, the US is failing when it comes to care for people with chronic diseases. There are numerous reasons why this is occurring – lack of access to consistent care, inability to afford medications, insufficient time for health education when patients see a health professional, cheap and highly processed food, environmental pollutants and more. An actual health system could take meaningful action to address these issues, and keep people healthier. Think about it: people with high blood pressure or diabetes in the US may not be able to see the doctor regularly or stay on their medicines due to cost, but when they suffer a stroke or kidney failure, and need long term care or dialysis, then they can receive disability benefits and Medicare. How much better and less expensive would it be for everyone to prevent strokes and kidney failure in the first place?

Just as many ‘progressive’ groups did during the health reform process that resulted in the ACA, Holland works to convince us that we don’t need a single payer system, and that we can work with the current system. Once again, Jacob Hacker, a leading advocate for the ACA and single payer opponent, is invoked and we are told that we can add a Medicare buy-in or another form of a public option. We are told that other countries use private insurance, so why can’t we? The Democrats, beholden to the medical industrial complex, want us to believe these false non-solutions that protect the insurance industry. It feels like 2009 all over again.

Rather than go through all of the reasons why these approaches will fail, I urge you to read articles on that topic posted on HealthOverProfit.org (Click here for a list of them). Instead, I refer to a saying used by my now-deceased mentor Dr. Quentin Young: “You can’t cross an abyss in two jumps.” The only way we can get to a universal single payer healthcare system in the United States is by creating a universal single payer healthcare system in the United States. Anything less than that will fail because it will not achieve the savings on administration and prices needed to cover everyone and it will not compete with the powerful private insurance industry.

Throughout time, every great social movement has been told that it was asking for too much. Advocates for worker’s rights, women’s rights, civil rights, etc., were labelled as unreasonable radicals wishing for some pie-in-the-sky change that can’t be achieved. Holland is doing the same to the single payer movement. Don’t fall for it. We have the resources in the US to have one of the top healthcare systems in the world. We have health policy experts who have helped to design excellent systems for other countries. Single payer is a proven solution, unlike the plans being proposed by the Democratic leadership.

One thing that Holland and I do agree on is that there is more than one way to skin a cat, so to speak. We could have an excellent national debate about which type of single payer healthcare system we support – a fully socialized system like the Veteran’s Health Administration, a national health service, or a socialized payer with multiple types of providers as in the Expanded and Improved Medicare for all Act. At the basis of our discussion must be the principles that every person in the US deserves high quality health care without financial barriers.

•  First published in Health Over Profit