Mass Gov Looks to Single-Payer

The Berkshire Eagle reports that regarding Massachusetts' mandated insurance scheme, Governor Deval Patrick says:

"the rate of increase in premiums is a serious problem for the state system and for private individuals, families and businesses as well. . . and there's a view out there that as long as private insurance is a part of health-care reform, we're never really going to break the back of the pattern." He called for serious consideration of a single-payer universal health care solution by the next administration in Washington.

The paper cited a series from the Boston Globe outlining the state's problems with their new system, which forces people to buy private insurance. In particular, the Berkshire paper noted,

Patrick inherited inaccurate assumptions about the cost of state-subsidized health insurance from the Romney administration, which created the program along with Beacon Hill lawmakers. (It's laughable whenever the presidential flunk-out blasts "Hillary Care" as socialized medicine, since it's based largely on "Romney Care.") Patrick's budget proposal for the upcoming fiscal year includes $400 million in extra health care spending — taxpayers would be responsible for nearly half of that, with the federal government counted on to supply the rest.

With the Bush administration now seeking massive cuts in health-care and other non-military spending, the immediate prospect of relief from Washington looks bleak. A McCain presidency would amount to a Bush third term when it comes to domestic spending. A Clinton or Obama administration would produce a sea-change, but it's unlikely the federal government will be in a position to bail out Massachusetts if health care insurance spending spirals out of control.

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The state program is run by the Commonwealth Connector, which hooks up uninsured residents with the appropriate coverage. Jon Kingsdale, head of the program, told The Globe in no uncertain terms: "This is not sustainable if we don't deal with affordability." Proposed solutions are vague or half-baked at this point, ranging from a $1-per-pack increase in the cigarette tax (a great idea anyway) to help fund the state's health program to plans by a pharmacy chain to put affordable clinics in its stores to deal with basic maladies (a highly-debatable idea). Down the road, tighter regulation of hospital fees and insurance rates may have to be considered.

To put it simply, unless and until the cost of health care — much of it administrative, tied to the bureaucratic jungle of dealing with private insurance carriers — is contained and reduced, the Massachusetts reform program is in jeopardy. And this would bode ill for any universal health care program, with or without mandates, nationwide.

Agreeing with the WSJ

This is a bit scary.

There is a part of me that is pretty sure that if the Wall Street Journal's certifiably malicious editorial page is against it, I'm for it.

On the other hand, I know for certain that it's wrong to garnish someone's wages or impose liens on their mortgage to force them to pay for private insurance.

The WSJ's article, misleadingly titled "Saying No to CoerciveCare" (that should be "Saying No to Coercive Private Insurance") noted that labor unions launched the last minute revolt against the mandates in California Gov. Schwarzenegger's plan and caused its downfall -- 7-1 in committee.

This defeat has national political implications. Hillary Clinton, for example, has denounced Barack Obama for refusing to include an individual mandate in his health-care plan. Yet many California unions argued that a mandate would force uninsured, middle-income working families to divert money from more pressing needs toward coverage whose price and quality they cannot control.

I'm no economist (but I'm married to one, something that leads to many, many conversations on true costs and the need for marketplace transparency, as well as mini-lectures on fixed vs. variable costs, and other truly boring matters) but the WSJ author seems to be making a leap to claim that health insurance costs have gone up in Massachusetts mandates because of heavy regulation and increased demand. Insurance costs are supposed to go down when you increase the risk pool, as supposedly happens with mandates. That's because suddenly all the healthy free riders who before had gambled that they weren't going to get sick are paying into the system. More money in the system, fewer claims per capita (because those folks are indeed healthy) and voila, costs per capita go down. Except they didn't.

The author instead seems to be suggesting that costs for health insurance would go up with increased demand in the same way that costs for a rare but suddenly popular dog breed would go up after everyone realized they wanted one.

No surprise to hear that regulations are also blamed. Those are the regulations that say that health insurers have to actually give some value for the money -- that they have to give a percentage of the value, for instance, that people in France get for their health dollars spent.

It's also no surprise that the private insurance industry cannot in fact give that kind of value for the dollars we pay them. Unless you're a shareholder or CEO. Good value received per share in that case.

The cost of health insurance went up 12 percent last year in Massachusetts -- twice the national average.

No one is escaping the financial sting. The state health-care bill for fiscal 2008-2009 is expected to touch $400 million -- 85% more than originally projected. Still the state won't be able to fully shield those it subsidizes from the premium increases. But uninsured folks who don't qualify for government help really get pounded. Before the hike, the cheapest plan for uninsured couples in their 50s cost $8,200 annually. Now, unless government bureaucrats hand them an exemption, they might well find it cheaper to pay the penalty -- up to half the price of a standard policy -- than purchase insurance. That is, pay to remain uninsured. This is legalized extortion: TonySopranoCare.

The government response to rising premiums is, unsurprisingly, price controls. The Commonwealth Health Insurance Connector Authority -- the bureaucracy created to oversee RomneyCare -- is considering prohibiting underwriters from raising premiums more than 5% for unsubsidized plans, meanwhile requiring them to cover 40-odd benefits from hair prostheses to chiropractic services. If companies can't scale back coverage, they'll have to compromise care; and the Connector is perfectly willing to assist.

As reported in the Boston Globe, the Connector is encouraging insurance companies to include only a limited network of cheaper physicians and facilities in some plans to hold down premiums. Patients who wish to see more expensive providers will have to dig into their own pockets. Dr. Steffie Wollhandler, a professor of medicine at Harvard University, worries that the Connector will revive Gov. Romney's original idea of enrolling poor people in plans that only offer access to neighborhood health centers ill-equipped to treat anything beyond routine ailments. Forcing people to buy substandard care they cannot afford is not universal care, she says. "It is a hoax." And so Massachusetts is marching toward a system of two-tiered medicine -- the alleged market inequity that universal care is supposed to cure.

Imagine that. Steffie Wollhandler approvingly quoted in the Wall Street Journal.

Gooz on mandates

From Merrill Goozner's Gooznews: on forcing people to buy private insurance:

... according to the Boston Globe's Health Blog, the intellectual architect of the Mass plan, Jon Gruber of the Massachusetts Institute of Technology, is admitting that a mandate can only work if there are sharp penalties attached to it since many low- and moderate-income households, even with subsidies, can't afford health insurance on their own. It's also likely that some young, healthy workers will skip buying insurance if they can get away with it. "The mandate has to be enforced," he told the paper. “We need to think beyond what looks mean and do what’s right.”

This is a prescription for dooming any national effort for universal coverage. We're going to impose heavy penalties on people who are already having a hard time paying their bills? Don't forget that the bare bones plans they will buy to meet the minimal insurance standards will probably have high co-pays and deductibles. From the perspective of a moderate-income person whose employer doesn't provide health insurance and who doesn't qualify for subsidies, this will cost them more money for the same care they now receive (emergency room care). The only difference is that they won't have the bill collector hounding them (or the hospital forgiving the bill) after they receive care. What kind of plan is that?

I've heard that before -- "This mandate has to be enforced. We need to think beyond what looks mean and do what's right."

Wasn't that Pol Pot's motto?

Slippery slope.

(Whoops. Did that look mean?)

Massachusetts' plan no gain

Take a look at "An Uninsured Kick in the Groin in today's Boston Globe. Alison Bass writes:

THE NEARLY 300,000 Massachusetts residents who signed up for health insurance under the state's new initiative are in for a rude awakening. They may now have some form of coverage, but many of them, even the very poor who used to get free care, are going to be socked with steep medical bills.

Welcome to the shadowy world of underinsurance, where high premiums, copays, deductibles, unexpected co-insurance charges, and skimpy coverage have put the lie to the dream of health coverage for millions of Americans. According to a 2005 Kaiser Foundation study, more than 58 million Americans already find themselves in this category: underinsured and at high risk of incurring punishing medical bills. My family is among them.

250 Mass docs call for single-payer

The California Nurses report that Doctors Give Massachusetts Health Reform a Failing Grade - Poor Early Outcomes Raise Red Flags, Only Private Insurers Profit.

You don't say.

Starting January 1, 2008 Massachusetts residents face fines if they cannot offer proof of insurance. Yet as of December 1, 2007 only 37% of the 657,000 uninsured had gained coverage under the new program. These individuals often feel well served by the reform in that they now have health insurance. However, 79% of these newly insured individuals are very poor people enrolled in Medicaid or similar free plans. Virtually all of them were previously eligible for completely free care funded by the state, but face co-payments under the new plan. In effect, public funds for care of the poor that previously flowed directly to hospitals and clinics now flow through insurers with their higher administrative costs.

Among the near poor uninsured (who are eligible for partial premium subsidies) only 16% had enrolled in the new coverage. And barely 7% of the uninsured individuals with incomes too high to qualify for subsidies had enrolled according to the official state figures. Few can afford premiums for even the skimpiest coverage; the lowest cost plan offered for a couple in their fifties costs $8,200 annually, and carries a $2,000 per person deductible.

Moreover, the state's cost for subsidies is running $147 million over the $472 million budgeted for fiscal year 2007. Meanwhile, collections from fines on employers who fail to provide coverage are 80% below the original projections. The funding gap will widen in future years as health care costs escalate and insurers raise premiums. Already, state officials speak of making up the shortfall by forcing patients to pay sharply higher co-pays and deductibles, and by slashing funds promised to safety net hospitals.

While patients, the state and safety net providers struggle, private insurers have prospered under the new law, and the costs of bureaucracy have risen. Blue Cross, the state's largest insurer, is reaping a surplus of more than $1 million each day, and awarded its chairman a $16.4 million retirement bonus even as he continues to draw a $3 million salary. All of the major insurers in our state continue to charge overhead costs five times higher than Medicare and eleven-fold higher than Canada's single payer system.

Republican candidates talk health care

Republican talking points on health care as displayed at the New Hampshire debate last night:
(List points and discuss which elements are correct, which need rebuttal. Test Monday!)
DR. TIM JOHNSON, ABC MEDICAL EDITOR: In general, Republicans have criticized Democratic proposals for health care reform as radical expansions of the federal government's role. But many health care experts say that it is actually the Republicans' emphasis on individuals buying their own policies versus getting their insurance through employers that is a more radical change. And it raises concerns. Individual policies can be more expensive for the same coverage because of administrative overhead and sales costs.

Group policies like those provided by employers can bargain with providers for lower costs and do a better job of monitoring quality. Medical professionals caution that individual insurance may sound good on paper but it usually turns out to be very difficult for people, on their own, to find quality policies at the right cost.

GIBSON: ... We're the only industrialized nation in the world that doesn't insure all of our citizens. If we can afford a trillion-dollar war in Iraq, why can't we afford medical insurance for everybody?

GIULIANI: The reality is that, with all of its infirmities and difficulties, we have the best health care system in the world. And it may be because we have a system that still is, if not wholly, at least in large part still private.

To go in the direction that the Democrats want to go, much more government care, much more government medicine, socialized medicine, is going to mean a deteriorated state of medicine in this country. I mean, I said, jokingly, in one debate, if we go in the direction of socialized medicine, where will Canadians come for health care?

GIBSON: But do you all agree that we have the best health care system in the world?

MCCAIN: Now, tell me when people get sick where they come to to get health care...

GIULIANI: Charlie, that doesn't mean it shouldn't be improved. And I think that the notion of people buying their own private health insurance is a very good one, so long as a lot of them do it. Only 17 million Americans right now buy their own health insurance. If 50 million Americans were buying their own health insurance, because it would be just as tax advantageous to do it that way, and we had a health savings account, people -- economists believe there'd be a 30 percent to 50 percent reduction in the cost of health insurance, and quality would come up. The only thing that reduces cost and increases quality is a significant, dramatic, large consumer market, not government control.

GIBSON: You all have proposed free market, consumer-purchased insurance. And you all talk about giving tax deductions for buying insurance. Let me do a little math. The average family employer-provided insurance, when the company's buying, it's $13,000 a family. Now, you talked about a $15,000 to $20,000 deduction -- right? -- for people buying their own insurance. If you take a median-income family of $62,000 in this country, you've just saved them $3,000 on their taxes. That doesn't come close to buying an insurance policy.

MCCAIN: Sure. And next year, if you continue 10 percent inflation associated with it, it'll be even further away. And the next year after that. Because the problem with health care in America, it's not the quality. It is the inflation. And in all due respect to your expert that we just saw, he's talking about the wrong aspect of this issue. The right aspect of this issue is inflation, if we could get it under control and get it reduced so that health care costs are reasonable in America, then those people will be able to afford it... But we have to make the recipient of the health care more responsible. We have to have outcome-based results for health care. We have to emphasize wellness and fitness. One of the most disturbing things in America is the increase in diabetes, obesity and high blood pressure amongst younger Americans. So we have to award wellness and fitness...

But, again, you made a statement about European nations, they all get health care. Well, some people here in New Hampshire have been to Canada. I don't think they want that system.

ROMNEY: ... [after boasting about the Mass. plan] And where the doctor -- good doctor was wrong is that it's true the insurance companies don't want to sell policies to one person at a time. It's expensive. We established what we called a connector, a place where individuals could go to buy policies from any company, and that connector would in turn send their premiums on to those companies. So the economics of scale existed. And as a result of what we did, the premiums for health insurance for an individual buying insurance went from $350 a month to $180 a month, with lower deductibles and now with prescription drugs.

We don't have to have government take over health care to get everybody insured. That's what the Democrats keep on hanging out there. The truth is, we can get everybody insured in a free market way. We don't need Hillary-care or socialized medicine.

PAUL: Charlie, you really answered the question -- you answered it in your question, because you said, "How can we afford a trillion- dollar war and we can't afford health care?" Well, that's the reason. The resources are going overseas. We're fighting a trillion- dollar war and we shouldn't be doing it. Those resources should be spent back here at home. There is an inflationary factor. We can't afford it. We do have good medical care, but the costs are so high now that our people in this country are actually going to India and getting their heart surgery done. They pay the plane ticket, the hospital and the hotel and they get it for half-price.

So it's inflation, but if you don't understand how inflation comes, we can't solve this problem. It comes from deficit financing with this war-mongering foreign policy we have. We run up the deficits. We tax. We borrow. We borrow from the Chinese. We can't borrow enough. Then what do we do? We print the money, and then you wonder where the inflation comes. The value of the dollar is down and the prices go up, where the government gets involved in certain things like housing or medical care or education, prices are skyrocketing. So you have to deal with the monetary issue to solve the problem of the medical issue.

THOMPSON: Ahem. ... So if we would stop printing so much money, we could get out of the war and provide health care to everybody.

We've got the best health care in the world. It costs more than it should. We can either go one of two ways. We can let the government take it over, and that'll lower costs, like they do in other countries. We will also sacrifice care, which nobody wants to do -- we're not going to do, in this country.

Or we can make the markets work more efficiently. There are a lot of components to that. Part of that is not just giving a tax break to the individual. That's part of it. But it's also putting them in a position to get the best prices for the care they're getting. We do that in every other aspect of our life. That's what keeps prices as low as they are. I mean, if the consumer had no concept of what the product was costing and did no shopping for it, when you could get an MRI here for one price or over here for half the price, you don't even know that to make the choice. It wouldn't work at all. So you can do that. You can open up these markets so a person can buy their insurance from all over the country. We've got various state regulations now, that, as a practical matter, prohibit that. Make the markets work.

But we're never -- let's be honest with the people. We're probably never -- if you lower costs, more people who want insurance will be able to afford it. We're probably never going to achieve total coverage. A good number of the people who are uninsured can afford it and choose not to do so. A good number of people who are eligible for government assistance, and choose -- can manage and choose not to.

GIBSON: But Government Romney's system has mandates in Massachusetts, although you backed away from mandates on a national basis.

ROMNEY: No, no, I like mandates. The mandates work.

THOMPSON: I beg your pardon? I didn't know you were going to admit that. You like mandates.

ROMNEY: Let me -- let me -- oh, absolutely. Let me tell you what kind of mandates I like, Fred, which is this. If it weren't...

THOMPSON: The ones you come up with.

ROMNEY: Here's my view: If somebody -- if somebody can afford insurance and decides not to buy it, and then they get sick, they ought to pay their own way, as opposed to expect the government to pay their way. And that's an American principle. That's a principle of personal responsibility. So, I said this: If you can afford to buy insurance, then buy it. You don't have to, if you don't want to buy it, but then you got to put enough money aside that you can pay your own way, because what we're not going to do is say, as we saw more and more people...

THOMPSON: The government is going to make you buy insurance...

ROMNEY: No, the government is going to stop...

THOMPSON: ,.. and make you pay -- I mean, the state -- your state plan, which is, of course, different from your national plan, did require people to make that choice, though. The state required them to do that. What was the penalty if they refused?...

ROMNEY: ... It actually applies to people at three-times federal poverty. They pay for their own policy. At less than three-times federal poverty, we help them buy a policy, so everybody is insured, and everybody is able to buy a policy that is affordable for them. The question is this, again, if someone could afford a policy and they choose not to buy it, should they be responsible for paying for their own care? Or should they be able to go to the hospital and say, "You know what? I'm not insured. You ought to pay for it."

What we found was, one-quarter of the uninsured in my state were making $75,000 a year or more. And my view is they should either buy insurance or they should pay their own way with a health savings account or some other savings account.

... I think my plan is a good plan that should be adopted by other states.... I would not mandate at the federal level that every state do what we do. But what I would say at the federal level is, "We'll keep giving you these special payments we make if you adopt plans that get everybody insured." I want to get everybody insured....

HUCKABEE: I think it's important to realize that the issue is not just insurance. The issue is that the whole model of our health-care system is upside down. We really don't have a health-care system. We have a disease- care system. And the insurance model that we use, we act like that if we insured everybody, we've fixed it. We haven't. Because the real problem is that our model, both in the insurance model and the health-care model, waits until people are catastrophically ill before it intervenes. And we really have to change the concept to a preventive focus rather than an intervention focus. And that means the entire system starts working on health and wellness, because 80 percent of the $2 trillion that we spend on health care goes to chronic disease. We could prevent it or we could cure it, but we don't. So it's not an issue of there's not enough money to cover people. But if a real health care system exists, it has three components: It has affordability, it has quality, and it has accessibility.

And if it doesn't have those elements, it's not a system; it's a maze. And what we have in America is a health care maze. It's built on the idea that we wait until people are so desperately ill that the cost to try to fix them is catastrophic and out of control. And no wonder we have a system that needs major, major attention. And by the way, just out of due respect, you said $1,000 for a repair. It's about $1,000 for a Kleenex at a hospital anymore. And that's why we need to have a totally different system that keeps you from going to the hospital in the first place.

GIULIANI: Charlie, a health savings account actually helps to accomplish what the governor is talking about. If somebody can put aside -- and the plans that we've been talking about include a health savings account. You'd have an exemption up to $15,000. If you could find a policy for $11,000, you can have a $4,000 health savings account. You would be able to buy some of your health care and your prevention yourself. It gives you an incentive over a lifetime to deal with wellness.

GIBSON: ... Look, if you're going to control costs, you got to do three things. You're going to limit access to technology, you're going to limit, in some way, change the reimbursement system for doctors and hospitals, or you're going to have to limit the amount of treatments. That's the only way we can bring costs down. And that's the third rail of health care. Which of you is going to touch any of that?

HUCKABEE: Charlie, that's not at all the way it is...

MCCAIN: I think that there's additional choice here: a choice of having outcome-based treatment. There are five major diseases that consume 75 percent of health care costs in America. If someone has diabetes, we should give the health care provider a certain amount of money and say, "Care for that patient. And if, at the end of that period of time, and that patient is well, we'll give you a reward." Rather than every test, every procedure, every MRI. And we need walk-in clinics, and we need community health care, and we need incentives for home health care as opposed to long-term care. In my state of Arizona, we adopted a proposal which incentivizes health care providers to keep people in home health care settings -- dramatically less expensive than long-term care. In Arizona, we have one-half the number, per capita, of people in long-term care facilities as the state of Pennsylvania.

Incentives to keep costs down, Charlie. There are no incentives in the system today.

Could I just mention one other thing? Both the attorney general of South Carolina -- I don't know why I mention South Carolina... and the attorney general of Iowa ... have sued the pharmaceutical companies because of overcharging of millions of dollars of Medicaid costs to their patients. How could that happen? How could pharmaceutical companies be able to cover up the cost to the point where nobody knows? Why shouldn't we be able to reimport drugs from Canada? It's because of the power of the pharmaceutical companies. We should have pharmaceutical companies competing to take care of our Medicare and Medicaid patients.

ROMNEY: OK, don't leave me. Don't send the pharmaceutical companies into the big bad guys.

MCCAIN: Well, they are.

ROMNEY: No, actually they're trying to create products to make us well and make us better, and they're doing the work of the free market. And are there excesses? I'm sure there are, and we should go after excesses. But they're an important industry to this country. But let me note something else, and that is the market will work. And the reason health care isn't working like a market right now is you have 47 million people that are saying, "I'm not going to play. I'm just going to get free care paid for by everybody else." That doesn't work.

Number two, the buyer doesn't have information about what the cost or quality is, or different choices they could have. If you take the government out of it to a much greater extent, you'd get it to work like a market and it will rein in cost.

Cape Care moves forward

Cape Care has hired its first employee, and hopes to bring single-payer to the 11 communities on Cape Cod that passed a non-binding resolution in support of single-payer — called Cape Care. What they haven't done is passed a tax levy to support the system.

Under a single-payer system, every resident of Barnstable County would be entitled to comprehensive health care coverage, in the same way that all residents are entitled to municipal police protection or public school education.

The county would have its own insurance product and pay for coverage by assessing residents a certain amount, the mechanics of which have yet to be worked out.

Barnstable County commissioners haven't bought into the plan yet, nor do they know much about it. "We haven't heard any details on how much it would cost or how it would work," Commissioner Bill Doherty said.

The Cape Cod folks are pointing out that while taxes would go up, overall costs would go down. This could be a silver lining for mandates like those in Massachusetts. If you're forced to buy a bad product, you might be more open to paying more taxes (but less overall) for a better product.

Those clever health insurance companies. I couldn't understand why they'd be against the Massachusetts' plan — which, after all, forced people to buy their crappy product. It turns out they were thinking ahead. I'm afraid they're smarter than the rest of us put together.

Obama plays it safe

Obama came out with his healthcare plan yesterday — and it wasn't single-payer.

Counterpunch's Corporate Crime Reporter explained why back in February:

The majority of the American people want a single-payer health care system ­ Medicare for all.

The majority of doctors want it. A good chunk of hospital CEOs want it. But what they want doesn't appear to matter.

Why?

Because a single-payer health care plan would mean the death of the private health insurance industry and reduced profits for the pharmaceutical industry.

Presidential candidates John Edwards, Barack Obama, Hillary Clinton, and Mitt Romney and California Governor Arnold Schwarzenegger talk a lot about universal health care.

But not one of them advocates for single-payer ­ because single-payer too directly confronts the big corporate interests profiting off the miserable health care system we are currently saddled with.

Take a look at that entire Counterpunch article, which interviews Dr. Steffie Woolhandler of PNHP.

Back to the present, Edwards estimates his plan would cost $90 billion to $120 billion; Obama figures $50-$65 billion for his. (A nice chunk of protection cash either way for the various powerful insurance families. The Gambinos themselves couldn't have done better.) Obama's plan, like Edwards, includes unspecified employer contributions, cost-saving measures, and specifically coverage for all children. Edwards' plan mandates that individuals have insurance; Obama's doesn't.

Speaking of the families, in particular the bosses, this wouldn't be a complete win. Both Edwards and Obama would pay the insurance families in part by getting rid of some of Bush's tax cuts for the wealthy.

As for the other candidates, Senator Christopher Dodd, who sold out to the insurance industry back in the 1990s, and Governor Bill Richardson also like mandates. Alaska Mike Gravel likes vouchers — which could be single-payer. Sen. Joseph Biden is the most timid. He'd insure children — an increasing number of them orphans and paupers as parents have a harder and harder time covering themselves. Sen. Hillary Clinton also talks a lot about children. She hasn't shown us her cards yet, but she has promised to reduce the power of insurance companies and to computerize medical records — a good start.

Rep. Dennis Kucinich is of course unabashedly for single-payer. He'd pay for it with income and payroll taxes, and a tax on stock and bond transactions.

Kevin Drum doesn't think much of Obama's plan. "Obama's voting record shows him to be, possibly, the most liberal of the three main Democratic candidates. But his record also shows him to be a very cautious liberal. This is not necessarily a bad thing: the time he's spent in the trenches doing community organizing and then as a state legislator seems to have taught him that there are no easy answers; that political coalitions are hard to build; and that real progress often requires a slow but steady approach. He may even be right about that. Certainly I'm no revolutionary myself. Still, sometimes audacity requires audacity. Hope isn't always enough."

Ezra Klein explains the plan, which includes a new regulatory agency called the National health Insurance Exchange — which would both regulate the insurance industry and administer a new public insurance program:

...That's a big deal — one of the real tests of seriousness for the new plans is whether they create a public insurance program, and Obama's does. Unlike Edwards' and Jacob Hacker's plans, he doesn't use Medicare as the basis for the program, but instead creates an entirely new public insurer.

Here's the catch: The Obama plan does not set the public and private plans in competition with each other, as the Edwards plan does. Rather, the best way to think of it is as a two-track plan. The first track extends the new public program to the self-employed, small businesses, and the uninsured. In other words, the public plan is open to those who are currently disadvantaged in the insurance market — it is not a new insurance market unto itself. That said, if it proves popular and effective, it would be trivial to expand it in the future, letting all businesses, or all individuals, buy in.

The second track is a restructured insurance market. Participating insurers ... will have to offer minimum benefits, spend a certain portion of their budget on patient care (rather than profits and advertising), be barred from discriminating on health history, and be forced to justify large premium increases. Employers will have to either pay into this market, or pay into the national plan.

...The Obama campaign's decision to omit a mandate is a puzzling one, both from a policy perspective -- you want the largest possible risk pool -- and a political one. His plan, unlike others, is not truly universal, it's simply possibly universal.

RJ Eskow predictably puts down criticism of incremental plans that funnel tax money to the private insurance market:

Rose Ann De Moro, for example, has done terrific work as leader of the California Nurses Association. But she drips with contempt for anything less than immediate single-payer reform. Barack Obama is "rearranging deck chairs on the Titanic," she writes. Really? Someone who receives coverage for the first time under the Obama plan, or who gets better care, might feel more like they'd been rescued from a shipwreck. The John Edwards plan, which forces private insurers to compete with a public program, would lead inevitably to single payer unless private insurers could offer something else that some part of the public might want. Nevertheless, to Ms. De Moro the Edwards plan is a "soggy mix and match."

"Edwards does deserve some credit for proposing that at least one plan in each health market be a public program based on Medicare," she writes. "But, if a public program, as he implies, is more likely to assure affordable alternatives to the private insurance model, why get off in Chicago when your plane is going to New York?" Here's why: If the plane doesn't have enough fuel to get to New York, you stop off in Chicago. If some passengers want to get off there, that's fine too. But Ms. De Moro, like other single-payer absolutists, gives this aspect of the Edwards plan only a passing glance before dismissing him by saying he "should go back to being a populist."

Eskow claims he'd switch our system in a heartbeat for Britain's — but, since that won't work, he's for the incremental steps. Which is a bit of a self-fulfilling prophesy...

MSNBC rounds up of mainstream coverage of Obama's announcement. Here is the quote there from the LAT: "Like the other top Democratic presidential contenders, he rejects the left's growing support for a government-run, single-payer healthcare system. Instead, he proposes to reinforce the existing system, under which the vast majority of Americans receive coverage either through their employers or through government programs such as Medicare and Medicaid."

208 Commission in the Post

Jim Spencer, news columnist for the Denver Post, wrote a great column today about Colorado's (208) Blue Ribbon Commission for Health Care Reform's task of finding the best three to five of 28 proposals for comprehensive reform that they've received.

None of the proposals assumes people are not entitled to treatment if they cannot pay retail. The hardest question the commission must answer is the private/public mix in the provision of health care. Still, no one argues for the status quo.

Spencer interviewed Service Employees International Union's Colorado point man for health care and Dr. Rocky White, an Alamosa physician, conservative rancher, and Health Care for All Colorado board member. Both SEIU and Health Care for All Colorado submitted proposals to the commission. Rocky was lead author for HCAC's proposal. Spencer described Rocky's proposal as being, "the simplest, most progressive and most controversial of the commission's proposals."

Spencer got right to the heart of the problem when he quoted an advisor to SEIU, who said that what is easiest to administrate — single-payer — may be hardest to approve politically.

This advisor helped Mitt Romney come up with the Massachusetts scheme, which is ticking away — before it even begins — with costs overruns and inadequate plans that people will be forced to buy. "Republicans support the subsidized purchase of private health insurance," he told Spencer.

That is such a mystery to me — but it must be related to what our friend Jack Long says: People are either scared of the wealthy or of the government.

So they'd rather go with inefficiencies that is on course to bankrupt individual families and the government as well, all in the name of free markets. Except if the government is subsidizing private insurance, they're not free markets. Bush's Health and Human Services secretary, Mike Leavitt, recently said that government's role in healthcare should be to "manage markets." If that's the case, why not manage them right, and take private insurance out of the game?

State single-payer news

California State Sen. Sheila Kuehl's single-payer measure, SB 840, is supported by the California Nurses Association, California Federation of Teachers, SEIU, California Association of Retired Americans, League of Women Voters, Friends Committee on Legislation and many more labor, community and faith-based organizations.

At BeyondChron Peter Lauterborn writes in favor of S.B.840, the California single-payer plan. He calls out John R. Graham, director of Health Care Studies at the Pacific Research Institute, who has been busy penning anti-single-payer editorials for papers around the country.

Graham sounds like he doesn’t even see the need to cover the uninsured. “Eighty percent of the uninsured report good, very good, or excellent health,” he proudly boasts....

He writes that the fiscal burden of supporting these individuals is “caused by uninsured patients who apparently have nothing better to do than sit around emergency rooms consuming treatment for which the rest of us pay.”

Yikes.

Illinois State Senator David Koehler told Chicago Public Radio that adopting the Illinois' governor's proposal to "significantly increase affordable health insurance" is a last ditch effort. "Let's face it folks. This is kind of the last hurrah in terms of a public and private partnership for healthcare. If we don't do it at this point in time, then the next step is for us to look at a national single-payer system." And that would be a bad thing?

Pennsylvania Democratic Gov. Ed Rendell stopped by a public health forum to tout his multi-payer plan for the state.

Rendell defended his multipayer plan, even while conceding a single-payer model might be better. He listed Pennsylvania's powerful health-insurance lobbies and lack of support on the national level for universal health care as hurdles preventing him from proposing a single-payer plan....

That plan would guarantee 85 percent of every dollar invested in health care would be spent on treatment, not administrative costs. His plan also allows the state's insurance commissioner to set rates, as the commissioner does for car insurance.

Insurance breaks the bank

Marcia Angell, former editor of the New England Journal of Medicine, says in a guest edit in the Boston Globe that we can't fix the system with band-aides. She says the states' reforms haven't come close to fixing the problem.

Though well-intentioned, plans like [Massachusetts'] all have the same fatal flaw: They offer no workable mechanism to control costs, mainly because they leave the private insurance industry in place. Yet, soaring costs are the fundamental problem ; lack of coverage follows from that. Already the Massachusetts Connector is having difficulty holding premiums down to the levels forecast when the plan was enacted. Even if they are held down at the start, there is little to stop insurers from raising them afterward , shrinking benefits, or both. It will take a large and costly bureaucracy to ride herd on all the ways to game this system. Perhaps the biggest risk is that failure will give universal care a bad name, just as the failure of the Clinton plan did 13 years ago. (That plan, too, made the mistake of giving the private insurance industry a central role.)

The problem, not the solution

This is the first specific I’ve heard about the Massachusetts’ plan working out exactly as predicted. Members of a panel charged with implementing Massachusetts’ healthcare plan this week told some insurers to offer more affordable premiums.
Then-Gov. Mitt Romney had promised that the plans Massachusetts’ citizens are mandated to buy would be affordable, the least expensive being about $200 a month.
Try $340 to $380 a month.
Just as single-payer realists warned, “universal health care achieved through the requirement to buy private insurance will lead to bloated premiums and bare-bones coverage for middle-income residents who can only afford the minimum plans.”
Steffie Woolhandler, co-founder of Physicians for a National Health Program and a physician, said, "We should not let these board members get away with telling us that they’re surprised [about the costs for the minimum plans].”
The executive director of Mass-Care, a single-payer advocacy group, says making a low-cost but effective private-insurance plan is impossible.
"’I call it a ‘Marie Antoinette’ policy,’ Woolhandler said. ‘Private insurance is the problem, not the solution.’”

Cape Care Moves Forward

Cape Care is a non-profit, single-payer plan that would be funded by a tax to residents of Cape Cod, Mass., municipalities that have voted it in. It was supported by town meetings in 11 towns and voted down in three others.

The Harwich Oracle reports that it “would eliminate the role of insurance companies and take a form much like schools and public safety...

"Based on the population Cape Care would work with and the potential savings of buying medicine in bulk and eliminating insurance company profits, the coalition said it’s feasible that health care could be provided for everyone. The state estimates there are 14,000 uninsured Barnstable County residents.

Cape Care member Doug Marshall of Sandwich says that Sandwich is now spending 16 percent of the town budget, and that in five or six years they'll spend 20 to 22 percent of their entire budget on health care.

This is an exciting plan. Can the insurance industry stop reform even at the town hall level? There’s more information at the Cape Care website.

Kevin Drum's How To

Kevin Drum and Ezra Klein are as far as I know the two progressive, generalist bloggers best educated about health care issues, how our system performs, and how health care systems work in other developed countries.

Drum today links to a LA Times article describing Gov. Arnold Schwarzenegger's soon-to-be-announced plan to insure all California children, whether they're legal immigrants or not.

A key element: "Administration officials have privately told people outside government that they intend to guarantee medical coverage for children of families earning up to 300% of the poverty level, or $60,000 a year for a family of four. Those families have 90% of the children without insurance. But the cutoff is not yet set in stone.

"Schwarzenegger's proposal goes further than one put forward last month by Senate President Pro Tem Don Perata (D-Oakland). His plan excluded illegal immigrants. Assembly Speaker Fabian Nuñez (D-Los Angeles) incorporated children of undocumented residents into his plan, which also was announced in December."

..."'It's the low-hanging fruit of the healthcare reform debate,' said Dr. Bob Ross, president of the California Endowment, a private foundation in Los Angeles that was created to push for expanded access to healthcare.

"'Kids are relatively cheaper to cover' than adults, he said. 'From a public health standpoint, it's smarter to cover all children regardless of immigration. You just don't want unimmunized kids surfing around in the population.'"

Drum makes the point that with two Republican stars, Mitt Romney in Massachusetts AND Schwarzenegger in California, pushing to insure ALL children, that Democrats have little excuse in continued timidity on this issue. He posits that "(a) universal healthcare is no longer some lefty fringe notion, and (b) the plans from Schwarzenegger and Massachusetts' Mitt Romney are now the starting point for any serious healthcare proposal."