Untitled Document
Like the Creature from
the Black Lagoon, the health-insurance monster has returned, creeping back
onto the public stage. After President Bill Clinton’s jury-rigged pen
to contain the monster collapsed in 1994, it never really went away.
Political leaders tried to ignore the beast or deal piecemeal with its
ravages, but it pushed more unsuspecting civilians into the uninsured pit,
devoured more family budgets, squeezed even giant corporations’
ability to compete globally, and raised fear and insecurity among the
populace. Now its depredations have become too loathsome to
ignore even for cautious politicians and business executives — who
still are inclined to see the monster as one of their own. After a rebuff
in the fall elections, when voters ranked health care as one of their top
concerns, President George W. Bush offered a plan that almost certainly
would not deliver his promise of “quality, affordable health care for
all Americans.”
Recently chief executives such as Lee Scott of
Wal-Mart, under attack for its skimpy health-insurance coverage of
employees, and Steve Burd of Safeway, which endured a long strike by
Southern California grocery workers to cut their health insurance, joined
such progressive leaders as Service Employees Industrial Union president
Andy Stern, head of the nation’s largest health-workers’ union,
to call for major changes in the health-care system. Under fire from both
other labor unions and many citizens’ health-care groups for joining
with strange bedfellows on behalf of very broad principles, Stern argues
that “the most essential change is to get everyone in a system where
they have health care,” then work to improve it. Although the war in Iraq is likely to dominate the
already energetic Democratic presidential-primary race, health care is
emerging as the leading domestic issue in both parties. Shortly after
announcing his candidacy, former U.S. Sen. John Edwards, D-N.C., laid out a
comprehensive health-care plan. U.S. Sen. Barack Obama, D-Ill., said that
the nation should provide universal insurance coverage by the end of the
next president’s term, though so far he has mostly advocated minor
and politically easy reforms, such as computerizing health records.
Republican candidate Mitt Romney signed a flawed plan for universal health
care when he was governor of Massachusetts; California Gov. Arnold
Schwarzenegger has proposed a health-insurance plan for his state; and
Illinois Gov. Rod Blagojevich just recently introduced his own
universal-coverage plan [see R.L. Nave, “A pound of cure,”
March 15]. There’s reason for hope when leaders across the
political spectrum recognize the problem, but there’s no guarantee
that such agreement will lead to a good solution. For more than a decade,
conventional wisdom has dictated that only incremental steps should be
taken. Now more politicians are willing to consider bolder steps —
but the right is still determined to push its agenda, and many progressive
reformers are cautious about pursuing their ideals as they nurse scars from
the fight business interests waged against the Clinton plan. “Overwhelmingly people are trying to find
incremental responses instead of a national response,” says Marilyn
Clement, national coordinator of Healthcare-NOW!, a coalition advocating a
public insurance program as the single payer of health-care bills. “They are still putting forward the same
proposals as last summer, such as ‘The first step is to get national
health care for children.’ Well, that’s good, but we won the
election. It’s time to escalate our hopes.”
The first crucial step
is to define the problem. For many people, it’s the increasing number
of Americans without health insurance, now nearly 47 million. But equally
problematic is the decline in quality and scope of coverage for those who
have insurance, and much of the public ranks the cost of health care as
their top medical and economic concern. Focusing primarily on insuring
everyone won’t necessarily solve those problems. Indeed, the
skyrocketing cost of health care is the main reason that the ranks of the
uninsured continue to grow. Faced with rising insurance premiums,
businesses have been trying to cut costs by evading responsibility for
providing health insurance, leading Stern to declare that “the
employer-based health-care system is dead.”
But the more fundamental problem is our reliance on
private for-profit corporations to provide health insurance — the
real monster in this saga. They’re the main reason for rising costs
(making health insurance in the United States about twice as expensive as
it is in most industrial countries), for the growing number of uninsured,
and for the inferior health results for the average American. In 2004, the
United States spent $6,100 per capita on health care, compared with $2,250
per capita on average by the countries in the Organisation for Economic
Co-operation and Development, which have national health-insurance
programs. Because public expenditures cover 60 percent of American
health-care costs, U.S. taxpayers are paying more than the cost of national
health insurance but not receiving it. “How much can a new system depend on private
insurance companies to provide affordable, good health care for
everyone?” asks Roger Hickey, co-director of Campaign for
America’s Future, a Washington, D.C.-based progressive advocacy
group. “That should be the debate.”
Now the country is faced with two radically different
proposals for reform. The first, pushed by conservatives and embraced by
Bush in his new plans, would make individuals more responsible for buying
their own health insurance. While giving them tax breaks to help pay the
premiums, it would push them in the direction of lower-cost, less
comprehensive plans (partly by taxing employer-provided insurance as
income). As part of this strategy, conservatives have also undermined
Medicare, first by subsidizing private insurance companies to provide
Medicare insurance and second by establishing a prescription program only
available through private insurers. The Bush strategy would be a boon for wealthy and
healthy individuals, as well as employers and insurance companies, but it
would ultimately leave most Americans paying more for less health security.
The harsh edges of the plan could be softened — by regulating the
insurance companies’ attempts to charge more or deny coverage to
people seeking insurance or by offering tax credits or direct subsidies to
the poor instead of tax deductions. But these changes still embody what
economist Jared Bernstein, of the progressive think tank the Economic
Policy Institute, calls YOYO (“you’re on your own”)
economics. The diametrically opposite alternative is to
recognize that “we’re in this together” (WITT, in
Bernstein’s schema) and move toward social insurance, or a plan like
Medicare. In this case, the federal government — through a public
agency — would provide comprehensive insurance. It would be financed
directly by progressive taxes on individuals and business, unlike the
current system, which provides $200 billion a year in economically
regressive and largely unrecognized tax deductions to subsidize
employer-based health insurance. The public insurance agency would then
bargain with health-care providers, drug companies, and others to control
prices and improve quality of care. The Bush YOYO strategy assumes that when health-care
consumers — otherwise known as patients — confront costs of
medical care, they’ll consume less, and overall medical costs will go
down. But Americans already spend more out of pocket on health care and use
doctors and hospitals less than do citizens of almost every other
industrialized country. Yet even though the overall health cost in the
United States is much higher, the outcomes — by virtually every
measure of health — are worse. U.S. health care costs more mainly
because of private insurance: Overhead at insurance companies runs close to
20 percent of total revenues, compared with less than 4 percent for
Medicare. When the extra administrative costs imposed on providers are
counted, the overall overhead that private insurance imposes on the system
eats up about one-third of what Americans spend on health care. Eliminating
those costs, as proposed by U.S. Rep. John Conyers, D-Mich., could finance
most of a Medicare expansion to cover all Americans much more
comprehensively than the program does now.
Most progressive
reformers acknowledge that Medicare for everyone would best slay the
health-crisis monster, but many strategists worry that trying to eliminate
the private insurers will provoke a withering counterattack. Consequently,
many current proposals try, as Hillary Clinton did in 1993, to preserve a
more regulated role for the insurance companies and at the same time expand
public programs, on the model of Medicare, to provide a competitive
alternative to private insurers. Edwards’ plan would require employers to cover
employees or help pay for their insurance (what’s widely known as
“pay or play”). Everyone would have to buy insurance, taking
advantage of tax credits, expanded programs such as Medicaid and the
Children’s Health Insurance Program, or new regional “health
markets” that would provide a choice of competitive private plans and
a public plan. Along the same lines, but with a simpler design and more
robust public component, Yale University political scientist Jacob Hacker
proposes that everyone not in Medicare be covered either by insurance at
work or a public insurance pool, including both regulated private plans and
a Medicare-like plan. Both of these proposals move in the direction of
Medicare for all but strike a compromise with the existing system, losing
the potential for better efficiency and more equity in the bargain. Why not
push for universal Medicare (also known as a “single-payer”
plan)? Proponents of compromises say Medicare for all is a political
nonstarter. Americans, they argue, are suspicious of government, like
choices, and often like the private insurance they already have. And
besides, they say, the insurance industry — along with most business
interests and political conservatives — would launch a scorched-earth
campaign against such a proposal. “There are a lot of dedicated, smart people who
have made the judgment that taking some steps toward a comprehensive system
with a public health-care plan is better than waiting for the perfect
system,” says Hickey, whose organization supports Hacker’s
proposal. The labor movement, which was divided over support of a
single-payer system in the ’90s, seems even more cautious now.
“The political will isn’t there now, but it could get there for
single-payer,” says AFL-CIO health-care lobbyist JoAnn Volk. A close
union ally adds, “Most of the labor movement has already accommodated
to the reality that we’re not going to get a pure single-payer
system. They have made the judgment that it’s just not within the
range of possibility.”
SEIU’s Stern — who has argued that the
United States needs an “American” plan and not a foreign model
like Canada’s single-payer system — says, “First we
should create [a health-care system] in which everyone is covered; then we
can figure out how to rationalize it. It will cost more money than if we
did it the other way [i.e, pursing the best alternative], but I think we
have more chance of getting it done. The perfect cannot be the enemy of the
good.”
Although a small but
rebounding movement for some form of Medicare-for-all exists, some
progressive groups that would be its natural partisans are reluctant to
commit themselves to a specific plan. William McNary, president of
USAction, a national group of statewide citizens’ organizations,
notes that many of their allies are splintering over proposals. “Things are fracturing,” he says.
“It would be best for us to line up behind principles” and not
a plan. Jim Dean, chairman of Democracy for America, a liberal movement
within the Democratic Party, thinks that the United States is ripe for
universal health care but worries about infighting over the best plan and
the specter of corporate attacks. “Can we figure out a way to talk
about this so as not to get bogged down?” he asks. But there’s no guarantee that insurance
companies won’t launch a war against these compromises, especially
any that curtails
insurance-industry profits. And corporations that support universal health
insurance will almost certainly oppose any plan that doesn’t
seriously reduce their financial responsibility, which would threaten to
shift costs to individuals. “Everyone says they’re for universal
health care,” says Don Bechler, chair of the California Universal
Health Care Organizing Project, “but the fundamental question is
‘Who pays?’ Is [universal health care going to be] a
sliding-scale health-care plan where everyone is entitled to first-class
health care, or a flat tax to sell junk insurance?”
When Clinton tried to finesse such political
opposition by making insurance companies central to his plan, he suffered
merciless attacks. No plan worth having will win without a massive
grassroots organizing-and-education campaign — and Medicare for all
is the one most likely to do so, while simultaneously strengthening
progressives politically. The American people are at least open to the
argument. In a 2003 Washington Post poll, one of the few to pose alternatives fairly, 62
percent of respondents said they would prefer a universal health-insurance
program like Medicare, run by the government, to the current
health-insurance program. And support for the Medicare program remained
nearly as high even if it limited the choice of doctors or led to waiting
lists for nonemergency procedures. Eventually Medicare-for-all advocates may have to
settle for a compromise, but the opportunity for major change in the
health-care system doesn’t come around very often. Because any change
will require a massive effort, why not fight for the best?
David Moberg is a
senior editor at Chicago-based In
These Times.
This article appears in Mar 22-28, 2007.
