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GRAY MATTERS: Health Care Reform

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Amid all the well-deserved celebrations and self-congratulations on the passage of the health insurance reform bill, I thought I heard a dog bark. I was wrong. From the very beginnings of the late great debate, this dog didn’t bark.

I speak of the one most popular alternatives to provide guaranteed comprehensive and universal health care coverage – not just private insurance - for all of us; Medicare for All was not even considered.

As a state legislator, senator and candidate, that was Barack Obama’s choice. But despite what he now says, he does not tell the truth when he says every idea was truly considered. In fact, he refused to allow others to consider any proposal for single-payer health coverage.

As a result, Obama, Nancy Pelosi, Harry Reid and most health research groups, and the mainstream press boycotted and wouldn’t permit discussions of the simplest, most straight forward possibility for health care reform, Medicare for All. It was shut out of White House meetings. Not even Kaiser or the Commonwealth Fund or AARP responded to my repeated appeals to at least give an airing to the single-payer alternative. Eventually, the process passed it by.

So it was ironic that John Dingell, a Michigan Democrat and the longest-serving member of the House was given the honor of calling for the decisive vote on the reform bill. But the universal health care legislation he and his late New Dealer father championed for years was ignored. Nevertheless, Dingell gallantly praised the passage of the Obama bill and was at the signing.

But the second longest-serving member of Congress, John Conyers, Jr., also from Michigan, was nowhere to be seen in the celebrations. His bill, HR 676, the U.S. National Health Care Act, Expanded and Improved Medicare for All, just 30 pages long, had nearly 100 congressional sponsors, including several blue-dog Democrats who voted against the Obama bill, plus more unions, doctors, nurses, advocacy groups and consumers than the White House was able to enlist for its proposal.

But Conyers was gracious, praising passage of “the first comprehensive set of reforms to our ailing health care system.” He noted that he “would have preferred a different approach,” but he didn’t repeat an earlier observation, that after a year of debate and compromises and deals with insurance companies and drug makers, the Obama bill passed the House by only three votes more than needed.

Conyers reiterated his support for a public health option which Obama gave away, “because I fundamentally believe in the value of public health insurance and remain an ardent supporter of universal single-payer health care,” like Medicare. And he called for a new campaign to achieve it.

Obama has said he would have favored Medicare For All “if we were starting from scratch.” So let’s review what might have been and may yet be.

The Conyers legislation would have established a “publicly financed, privately delivered health care system that uses the already existing Medicare program...”

It would cover, at no charge, all medically necessary services, dentistry, long term care with patients having the right to choose their providers. And because the free care would be paid for by taxes and premiums, private health insurers would be unnecessary and would be prohibited from selling coverage that duplicates the benefits.

And unlike the plan that has passed, HR 676 would eliminate the need for dozens of fragmented, wasteful programs by including the Children’s Health Insurance Program, Medicaid, and other government funded programs with the exception of the VA health program, which may eventually become part of the system. And it sets a goal of converting to a non-profit system in 15 years. Read for yourself here.

One problem with the bill that has passed is that it leaves in place all the federal, state and private insurance bureaucracies for the dozens of competing and duplicative agencies with their complex rules that differ from state to state. Premiums for Medicare Advantage and the Part D drug benefit, for example, may differ from one county to another. While subsidies for Medicare Advantage insurers are to be eliminated over time, the current system is to remain in place, although these plans will be required to spend at least 85 percent of their revenues on the care of patients.

Indeed, to give the Obama bill its due, while it is not a health care plan, it is a health insurance reform which can be strong measure to regulate and restrict the behavior of health insurance providers.

Insurance companies will be barred from dropping people from coverage when they get sick. They will be barred from excluding children for pre-existing conditions; later that will apply to adults as well. They must provide immediate access to insurance for Americans who are uninsured because of a pre-existing condition. Children will be able to remain on their parents’ health plan until age 26.

In addition, insurers cannot impose lifetime or yearly caps on benefits, and new plans are required to cover preventive services such as mammograms, colonoscopies and immunizations without cost-sharing. That’s to become a standard Medicare benefit for all beneficiaries, who have been required to pay for co-insurance.

As expected, the 40,000-member Physicians for a National Health Program, which supports HR 676, worried that the bill that has passed will take too long to implement, that it will further enrich the for-profit insurance industry by $447 billion, that costs will go higher and that the new regulations are riddled with loopholes.

All we can do is see how it works. Here is the best and clearest graphic to explain the bill. (pdf)

If things don’t really change for the better and Democrats remain in the majority in Congress, maybe we can come closer to the Conyers bill, and hear the dog bark.

Questions? Write


So why wasn't HR 676 considered? Did the players predict that it was too big a change to pass? That it would be labeled "socialism"? That the money of the insurance companies would defeat it? Was Congress largely bought off by the insurance companies before this even began?

I don't see how this is helpful. What do you want? Repeal? Talking about how Obama and the Democrats suck helps...who, exactly?

The Dittohead Mob is out for blood - real blood, the sticky red kind, not the metaphorical, parlor-party kind. That the Democrats in both houses of Congress did as much as they did, given the dominant cultural rhetoric and the threats to their lives and those of their staffers, is to be celebrated.

To Mary and Saul: What's hard to deal with is not the partial reform -- it is good our Democratic members did something. We all needed this. And it did take all they had; Nancy Pelosi has risen enormously in respect in my eyes.

But what is hard is the lack of honesty at the center of the Democratic leadership's campaign for this. The people in their own base who were already focused on health care issues (single payer and Medicare for all activists) had to be excluded from the debate because the Administration had to buy off the industry: hospitals, doctors, drug companies and insurers. The Administration made the calculation they couldn't beat them, so they had to pacify them. But they couldn't level with their own base who would have cheerfully hung the medical profiteers out to dry. So, from the perspective of the most engaged health activists, the whole thing was a kind of depressing shadow boxing with an unreal adversary.

I actually think the Obama administration and Congressional leadership may have made a right, prudential choice in excluding their own base from the debate, but there will be costs. For our politics to be democratic (small "d"), pols need to find the courage and imagination to level with their own people. Otherwise it's a kind of phony theater in which most of us are bit players and we gradually withdraw.

Looking back, it is clear that a single-payer plan was not a possibility. With the Republicans united in opposing anything at all, the Democrats had to look to their own caucus. Which meant that the moderates had the whip hand, and they weren't about to support single payer. Also, progressive activists never showed a unified or even especially active front, other than carping.

The bill we have is a step in the right direction. It's the first time in the history of the country that we actually have a national policy in place regarding health care. Its benefits outweigh the risks of doing nothing. Let's appreciate it for what it is, and go on to the next steps.

If both the Republicans and the democrats are upset about this bill, it must be just right. As a middle of the road type of guy, I like it a lot. I hope the one dog doesn't bark and the other dog doesn't bite.

Early on I advocated for something along the lines of "Medicare for All". Such a plan would have utilized a system that is already in place and thus avoided some of the costs associated with starting up a new program. I think President Obama realized that the Republicans and especially their fellow-traveler tea-party types would have even more of a field day spewing hate against universal Medicare than they did with the plan that became law this week. He accepted reality and decided that we had to start somewhere. I agree.

It would have made sense to me to expand Medicare and perhaps Medicaid for very low income citizens. However, if the Democrats had been completely inflexible (as the Republicans were), we might have ended up with nothing at all. The Republicans are indeed the "Party of "No, Zip, Zero, Nil" when it comes to actually getting something done. President Obama succeeded in accomplishing something that presidents for the last 60+ years had tried, and failed to do. Kudos, I say!

I tried to present a balanced view of what might have been and what was accmplished. I have my doubts that the insurance companies won't take advantage of loopholes. I will continue to report and watch. I do plan another piece giving Obama's explanation of why he chose this middle ground.

I can understand why they couldn't get single-payer thru, but why couldn't they fight for the public option?

Janinsanfran said it all for me. I fought long and hard for the single payer plan; the only one that made fiscal sense.

As I said before, I am grateful for crumbs. It is so far from perfect that it makes me sick, but it's a stepping stone, albeit a small one. I have to swallow my tongue and be grateful that a small start has occurred in reforming the system.

Saul, perhaps you could tackle an issue that I suspect lies behind the many progressive failures of the last 30 years: what happened to the "fairness" laws regarding our public airwaves? I believe that the rise of Rush Limbaugh, right-wing talk radio, and, later, FOX news has pushed Democrats, liberals, and progressives off the stage of the national media. Without access, the so-called "left wing"--the movements that brought us everything from civil rights to Medicare to equal credit for women--has been increasingly on the ropes. The very idea of government is on the ropes, portrayed as a great evil destroying the private sector.

What happened?

Medicare currently has nearly a $40 trillion unfunded liability and is a very costly way to provide health insurance. It pays set fees for each service and encourages health providers to do more tests/services on patient than may be needed or appropriate.

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