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.    

Trickle Down....

What’s trickled down is the hate and the solipsism of the conservative elite who have  pushed what they knew to be  the bogus trickle down economic theory.  It is a trickle down of morality not  of the economy.  They have connected with the baser elements of our morality, that, yes, exists in all levels of society.   Notwithstanding the virulence of these baser emotions extant in all sections of the non-elite, it has been the conservative elite that have prayed upon and stimulated these emotional and (im)moral proclivities.  No matter how disguised ( with  perhaps some self-delusion)  the fear and greed of our society is trickling down from , supported by,  the elite who will best be served by such divisive tactics. 

As for the economic trickle down malarkey, I am with David Cay Johnston who refutes that and more accurately calls it "Niagra Falls,  Up"

More PK and Single Payer

Paul K has another item on the unfeasibility of Single Payer.  This one utilizes the not uncommon mislabeling of  Vermont's attempts as "Single Payer."

A better account of Vermont's almost , but-not-really, single payer plan is at PNHP--.
Covers most of the same territory as the Kliff article-- but is more informed on single payer , e.g. --" It’s a misnomer to label Vermont’s Green Mountain Care plan 'single payer.' It was hemmed in by federal restrictions that precluded including 100 percent of Vermonters in one plan, and its designers further compromised on features needed to maximize administrative savings and bargaining clout with drug firms, and improve health planning."

I would add that Vermont's small population, and therefore, risk pool would hamper even a true single payer process. But, Single Payer would still be best. This was, indeed, a political/organizational failure, not an economic one.

Further-- it is also inaccurate to include doctors (and other practitioners) in the list of those who will be negatively financially impacted. Institutional costs-- pharma, hospitals and the like will be reduced. But practitioners will actually be more empowered, and less burdened, so as to be able to be appropriately compensated. Canadian institutional costs are far less than ours, Canadian practitioners-- particularly primary care physicians-- are compensated similarly to U.S.'s--- especially once you take the weight of insurance required work off of their backs. 

And BTW, Colorado Care's universal care initiative  to be voted on in November is not Single Payer either.  From funding tab of summary : ColoradoCare will serve as a supplemental plan to Medicare and will apply to become a Medicare Advantage Plan. For any other health insurance plans that are in effect, ColoradoCare will be a secondary payer, up to the payment level of ColoradoCare coverage.

An Appeal to Paul Krugman

Paul, Paul

You have recently expressed rejection of the idea that we can adopt single payer, expand coverage and services and still save lots o' money. 

Please, Please, if you haven't already, read Lewin report 2005 on California Single Payer and any of several of Gerald Friedman's  economic review of several SP plans, including for New York. (And just about every, if not every, SP study done.) They all consistently point out the savings and expansion in coverage and services that you decry as impossible.   Perhaps you have strong economic disagreement with them.  If so, I am sure we would be happy for your insight.

Why Economists Took So Long to Focus on Inequality

Over at Bloomberg Views Justin Fox has an excellent article of the same name.  In fact it inspired my thoughts.  He does  a very good job of explaining the what--  needing data--  but not so much the why.   As always, "The Grail Question,"  -- Who does it Serve? helps us focus on understanding the underlying dynamics. 

The push for "data" to prove what we already know is a time honored delaying tactic.  It is endemic and, in  general, serves those who, we already know, will be disadvantaged once what we already know has been sufficiently "proven."

E.g. ,  We knew not only that there was growing inequality but that it is harmful to society ("children and other living things." ) Yet, for 30 years "no one had the data"  for what we all could see if we only looked. No one had the data for "welfare queens" either but that seemed more readily believed and influential in our economic and political discourse.  

End of the day--  there are plenty enough resources for education, mental health, health care, the 99%... It is just that it all resides in the pockets of those who are benefiting from a rigged system  (euphemism for--"they stole it !") and are "awaiting the date."

Fee for Service and the Consolidationistas

 This post  will be need more background to be completely comprehensible. But I will pay that background foward by excising some of the referenced material and posting it later... Meanwhile I do not want to lose the thrust energy of the below thoughts--

 

First of all -- I am talking  about how I see the proposed reimbursement structure for single payer.  Yes,  HR686 and other discussions allow for FFS.  But what I see is a continuing thrust not only to lower the already inadequate reimbursements but to marginalize, if not eventually eliminate, the utilization of that process. 

 Pay for Performance, Global Budgeting, Accountable Care Organizations, etc are already being pushed as the main administrative structures.  And MediCare, et al, are setting targets for enhancing this process.

As I see it these structures are being pushed as if they are already proven approaches.  This is far from true.  In vivo they are only retreads of Managed Care, Capitation , Case Rates, etc that proved such failures in the 90’s.   In research and logic they seem to primarily promote more administrative game playing in the service of  capturing income/profit at the expense of actual appropriate service delivery.

Further, it seems to me,  one of the largely unspoken drivers away from FFS is distrust of the professional—as if some big administrative agency can be held more accountable.  Do we need to appropriately monitor services for fraud and incompetency—of course we do.  But incentivizing ever larger corporate entities only makes it more difficult to hold them accountable.

All this would be moot, or, at least,  of less concern,  if  there were  actual co-committed efforts towards  sustainability and enhancement of FFS .  However, I certainly do not read the current environment (and tea leaves) that way. 

Two recent commentaries illuminate my concerns from opposing ends of the spectrum.   The first is Lessons from an Early Adopter  ACO  (free subscription may be required. ) This is from Open Minds—a Mental Health data advocate par extraordinaire,   that promotes- despite its own internal evidence to the contrary--  subservience to ACO’s as the only way to accrete the mountain of data that is seen as a good in its own right.   The second is from a  Don McCanne discussion of concerns about consolidators missing the point of interference with, not enhancement of, service delivery.

Anyway, I suspect much of this is falling on sympathetic ears.  But the main point I want to address is finding some way to enlarge this discussion.  I do not pretend to be in the know about all that is going on.  But, from twenty five years of public health, non-profit and political service and private practice it seems pretty clear to me that the corporatizing consolidationists continue to control the discussion and the actual people who deliver and receive the service are marginalized.   

Strong advocacy  for the efficacy and preference for FFS does not seem to be very visible.  I want to help change that. 

BTW--- I WON!

Probably not many have read the two previous blogs.  However, it occurs to me, belatedly?, that I should at least note that -----    I WON the election for membership to the Board of AAMFT-CA. ( 3 years beginning in January.)  As time permits, I will add to this post-- or add new ones for further thoughts/actions in re: ....

For now, suffice to express  my gratitude and  my excitement for the opportunity to  further  engage/educate/impact the process of a more people-sized mental health, medical and social reality.  NUF-SAID (stanlee)