The System is Baroque, We are Powerless, Single Payer Will Empower Us

(I have recently been engaging in an e-conversation about Single Payer with several psychologists and psychiatrists.   This has produced, I think,  some interesting points …)

Single Payer is a good idea.   But like all good ideas--  Independence from England, Civil Rights, Anti-War, the New Deal, the GI Bill,  Medicare/Medicaid…-- it requires involvement, action and stewarding in order to make it a bettering reality.   The development and structure of single payer calls for and will require our active participation.  We, all practitioners, must have significant seats around all the tables.     

COLLECTIVE BARGAINING

A major concern is that Single Payer will even further concentrate the power of the payer and leave practitioners even more  helpless in regards reimbursement and  administrative requirements than we are now against the power of the insurance corporations and government regulations.   CL stated it as being beholden to the  directives of Senate subcommittees.   Additionally, of course, the baroque multiple insurance systems and the confusing array of flying buttresses erected to support them is an administrative nightmare.   It represents 20-30% of healthcare costs that we should not have to direct away from clinical services. 

His recommendation  is “a legitimate socialized national health plan, i.e. one in which providers of care are employed by the state or federal government…”   This would allow for unionization and collective bargaining.   (Even here, of course, we would have to fight against the concentrated effort to disempower unions and public employees.)

I certainly could not agree more with the concerns about the external controls of our profession—and who the controllers are.  Managed care, at all, let alone in the hands of the insurance corporations or government structures is not our friend.   

 

But, I don’t think the only answer is a UK style NHS employment by government and unionized representation of clinician employees.   The key component is collective bargaining.    As it happens, Single Payer legislation—at least in NY and CA—call for just that.   (The two national bills—HR 676, Conyers/Ellis and S 1804 do not mention collective bargaining.  HR 676 does talk about fees being negotiated through state level “representatives of physicians”.)  

Assuring the legality of collective bargaining and developing the structures to represent various clinicians and assure sufficient leverage is, of course, a challenge. But, then, what isn’t?   The key is to move the clinician in to the middle of the process not the administrator. This is  true bargaining power—whether it is through unionization and/or professional trade groups.   Note that Clinicians United is a chapter of SEIU in Massachusetts and has already introduced legislation to allow for independent practices to collectively bargain with insurance corporations.   

COSTS

GH  asks—How much will Single Payer Cost in U.S. ?

Estimates of current costs and projected increase services and  savings vary.  I would be happy to present  a more thorough review at another time.  But the general ballpark is that the U.S. is spending around $3.3 Trillion annually (CMS 2016) or over $10,300 per capita.   The average OECD  country pays less than $4000 and Canada less than $5000 per capita--- with better quality.  The U.S. is spending around 17% of our GDP on health care ( soon to rise to 20% unless we enact single payer) while other countries typically spend no more than 10 or 11% and the OECD average is around 10%.

Estimates for a U.S. single payer system also vary but every study for U.S.  or state level Single Payer systems shows a significant decrease in overall costs.   Updating a 2015 estimate of Bernie Sanders’ proposal--The  current $3.3 T  would be reduced by 20% ( to about $2.65 T) .  Adding  back 5% of the original for current underutilization and expansion of services = $165B .  This comes to about $2.82T.   An overall savings of at least $500B annually.  (For the mathematically estimate inclined take any current cost and reduce by 15% for the cost under single payer.)    There are multiple explanations of the savings—decreased admin, better planning, earlier access to services, reduced pharmacy and institutional costs.  By the way—value-based/outcomes reimbursement is NOT one of the positive factors—and fee-for -service is.  (See Kemble articles)  But that is a matter for a more full exploration another time.  

In California,  the UM-Amherst study of the latest legislation for Single Payer (SB 562) shows a current total healthcare cost in CA at $370B.   The estimate for a Single Payer system, improving and expanding services to all residents,  is $320B.   (If you heard $400B--  that was a “back-of-the-envelope”  estimate produced by a legislative agency,  literally over-night and just included expanded service costs and not accounting for any systematic savings. )

Now, I have some problems with some of these estimate.   Many of them are based on Medicare rates—and we ( the SB 562 campaign) have directed UM to review with higher rates.   However the numbers crunch, we clearly get more services and more control under single payer.

WHO WILL PAY

But where will this money come from if we eliminate insurance corporations and premiums, deductibles, co-pays and other  payments?  Most likely a tax structure will be utilized. This could include a financial transaction tax. I prefer that along with a   simple straight forward use of a progressive income tax and a payroll tax that is also progressive. (As a candidate,  part of Sanders’ proposal was an across the board  6.2% payroll tax.  We ought to be able to add some progressivity and minimum pay exclusions.)   Again, much more to illuminate here, but overall estimates show 95% or more will pay less in taxes than they currently pay or lose to premiums and other costs. 

There will be no premiums, or other expenses.  There will be no point of service payments.  It will all be paid for by a progressive taxing structure.    Our system already taxes those that have more to provide for those that do not.  Unfortunately the long term Reagan revolution has been efforting  to make this a bad thing and reduce our caring for others and, in the process, demonize government. This has  led to a Gilded Era like inequality  and to forgetting that we are better as a we society than a me society. 

WHO WILL BE IN CHARGE

The  reality is that the insurance corporations and government administrators are now in charge and, in general, have no clue about the delivery of clinical services.   What they know is outcomes and value based number crunching.   And what they know is wrong.   Such approaches  make logical and administrative sense but not only make no clinical sense--  they are destructive clinically and socio-economically.

Single Payer will empower us.  Practitioners  and practitioner organizations  will be members of governing boards—not just advisory boards.  We will have the power to collectively bargain.

The question arises is how  would the insurance corporations be persuaded to cede authority.   They would not and could not be persuaded.  Single Payer will basically eliminate them.  Yes, it is a power/political struggle.  In fact, that is all it really is.  The debate on all other levels-- financial, intellectual, service delivery, consumer access, etc.  is really over.  Single Payer wins.  Underneath all the counter arguments is just the powers that be not wanting to give up their huge salaries,  stock market positions and outrageous profits.

We will not persuade--  we will progressively win.   We will not, as has been done in the past, allow a program like Medicare to be incomplete and need subsidization, or takeover, by private corporations.

Some  call for more heavily regulated insurance corporations, as in Germany or Switzerland--the so-called Bismark plans.   That ignores the very same question about the power of the insurance corporations.  As long as the corporations continue they will increase in power and resist true regulation.  Experience has  consistently shown us that no matter what public policy/regulation we try to create, somehow the insurance corporations in their Byzantine ways end up making more money, health care quality decreases and inequality of services increases. 

CHOICE

There has also been expressed a concern about “choice” and the power of the market place.  

I think many of us have  seen enough of public health to see how the so-called consumer choice is really  more a leverage for private corporations to cut out substantial public dollars away from services and towards  their profits.

The choice most people in the private market have is what insurance plan they will buy/can afford/best balances needs and costs.   And even those choices are limited by employers or whoever is providing the choice.   And then the choice of practitioners is further limited by the policy’s network.

In Single Payer, yes we do not have the choice of what insurance plan we can put between us and our healthcare needs.  But we then have the choice of any practitioner for any health service that is covered. What is covered will be substantially more than the typical plan that is available now.

IF HEALTHCARE IS A RIGHT THEN WE SHOULD MAKE SURE EVERYONE HAS IT

Being in  social welfare and public health delivery we see more than our share of those who aren’t and/or can’t contribute as much as we would like.   A few, probably,  by their nature, most by having been beaten down may not seem to “cut it.”  Leaving aside who decides what is an adequate contribution we certainly should not build a health care payment system around the limits of those less able--  but around the appropriate level of care that everyone needs.   

I can’t speak for New York—but it is clear that California is a much more prosperous state since it has returned to the management  of even   moderate Democrats and their expansion of health care, education and  social services. As inadequate as they are, they demonstrate that the we society is so much richer, in oh so many ways, than the me society.

Incrementalism is a Road Block Not a Road Map

In words that might sound familiar—whether or not Gandhi actually said similar ones--

During the 1914 biennial convention of the Amalgamated Clothing Workers of America  Nicholas Klein of Cincinnati, talking about that union, said, "First they ignore you. Then they ridicule you. And then they attack you and want to burn you. And then they build monuments to you. And this is what is going to happen to the Amalgamated Clothing Workers of America."

Well they haven’t built monuments to Quentin Young yet.  But they are not ignoring or ridiculing us.   They are fighting us.            And we will win.

It is said that imitation is the sincerest form of flattery.  In politics, imitation is a sincere form of cooptation.  Part of the attack/fight, conscious or not, well-meaning or not,  is to divert and or coopt our energy our  work our language.

You do and will hear about “Universal Coverage”, “Universal Healthcare” , “Universal Access”,    Oregon’s Senator Jeff Merkley has introduced a “MediCare Option for All”   and, in the language of California’s AB 2517— a “Unified Publicly Funded Healthcare System”.    Is that Politician for Single Payer ?  Who knows--  the purpose of the Politician language is to confound and confuse. 

They talk of incremental steps towards SP.   Really what They are proposing are  incremental steps towards improving health care.  Steps that may be  good in their own right.   But they are not steps towards SP and the elimination of Insurance Corporations’ controlling our health care.   Perhaps some incremental steps in THAT direction would involve legally forbidding for-profit insurance companies and capping “surpluses” of so-called non-profit systems.  Then, doing the same thing for for-profit and Non-profit hospitals.

 Our language is seeping into Legisation—Federal and State…  With the exceptions, of course,  of Bernie Sanders’  and Ellison/Conyers M/C for All bills --  this is to be regarded more with concern than celebration.
 

Merkley’s “Chose Medicare”- Medicare Option ,S 2708  (co-sponsored by Kamala Harris and Dianne Feinstein) proposes a Medicare option for the ACA exchanges.  Similarly, the  Medicare X-Choice (S 1970/HR 4094--Bennet/Higgins) requires   a Medicare option on some exchanges by 2020, all by 2023.   This is also co-sponsored by Feinstein and Harris

These are  supported by the likes of the  Progressive Change Campaign Committee/Bold Progressive, Democracy for America   and Daily Kos   I think  they actually believe they are doing some good… much like Obamacare was doing some  good…  but now we need to  be  clear about  the diversion and back tracking it is…  it furthers empowers  and entrenches the corporation

This is a BAD idea.   It would 1.  Further confuse/complicate Medicare structures and 2. Having done so will undermine the general support for  an Improved Medicare for All approach.  

It is being pitched as a step towards single payer--  but, if it is,  it is because, like the Affordable Care Act, it ultimately proves unsuccessful and subject to undermining.    The corporate effort to confuse  this Medicare Option with Medicare for All  will  make things more difficult for us.    This is adding another layer of payment/administrative structures-- not making it a single structure.  It will  make Medicare (gov't and private) more confusing, complicated and frustrating .  Corporate MediCare Advantage plans, as they do now, will surely find ways to scoop money into their coffers.

Bills  have  also been introduced in the California Legislature that are being touted as a “Road Map to Single Payer”   Actually, since there appears to be no words in Politician for “Single Payer”,--  It is being called the “Road Map to Universal Health Coverage”.

  AB3087,

Would establish a state agency "California Health Care Cost, Quality, and Equity Commission" which would have the power to set reimbursement rates for all heath care providers in California.

from the bill :

- The chief cause of high health care spending in the United States is high prices.

- to regulate the cost of health care by regulating health care prices for health plans, hospitals, physicians, physician groups, and other health care cost drivers

- Set the amounts accepted as payment by health plans, hospitals, physicians, physician groups, and other health care providers
 
What this would mean--

- High payments  generally go towards hospitals and other institutions not  to clinicians. The primary problem is the existence of health care insurance companies. Their existence creates a loss of 20-30% of expenditures towards profit,  administration, advertising, and costs to health care  offices for filing claims and getting authorizations for care.

- It will include limits on "non-contracting health professionals", further inhibiting private practice.

- The savings will not go to individuals, but the insurance companies will pay less to their providers. If you think that they will pass on their savings to their customers, as  a friend of mine says—"You are unclear on the concept.”

- We already face a shortage of clinicians in all fields of primary and mental health care- This will only further exacerbate the situation …

This bill is “in suspense”  and likely will not pass—at least this year.

Of more immediate concern is AB  2517

 

It would establish an Advisory Panel on Health Care Delivery Systems and Universal Coverage as an independent body, to develop a plan to achieve universal coverage and a "unified publicly financed health care system." Some of the proposed timelines are---

--On or before March 20, 2020, the advisory panel shall submit to the Legislature for approval a proposal to control health care costs.

--On or before March 1, 2021, the advisory panel shall submit to the legislature for review, a proposal for the state to seek necessary  federal waivers and federal statutory changes

--On or before December 1, 2022, and contingent upon the fulfillment of the requirements of the above subdivisions, the advisory panel shall submit to the Legislature, a proposal of the state constitutional and statutory amendments necessary to create a publicly financed health care system along with a proposal to submit to the voter at the next statewide primary or general election.

4 more years!!??  We don't need no 4 years.  We already know what we need to do, we just need to do it-- TO continue on the Road of Single Payer.  We need not to be diverted by detours created by this Road Block to Single Payer.  ...  Created by politicians and officials who are unduly influenced by their corporate donors and conflict of interests...4 more years is 4 more years of declining health care, 4 more years of furthering unequal distribution of healthcare, 4 more years of enriching and empowering the insurance corporations, Big Pharma and their political cronies!
 
This bill is working its way through the California  Senate at this moment.  If passed it will continue to provide cover for the corporate democrats to not stand up for an Improved Medicare NOW!

Churchill said you can always count on the Americans to do the  Right  Thing,  once they’ve tried everything else…    There are far too many other things we have tried and there are far too many more things that could be tried, that they will try to divert us by---   We just need to step straight forward to SP

The stronger and more powerful we are the more will be the efforts to undermine, obfuscate and adopt our language towards deferring our ultimate success.