Are most presidential contenders proposing universal health care plans that can actually work? Absolutely not. But a lot has changed since I watched health care reform crash and burn from my perch as a Senate health staffer in 1994. State debates on reforms can continue re-shaping the landscape as we lead into the primaries next year.
Seven candidates spoke at the Forum on Universal Health Care sponsored by the Campaign for American Progress Action Fund and SEIU, webcast live last week from the University of Las Vegas, Nevada: Senator John Edwards, Governor Bill Richardson, Senator Barack Obama, Senator Hillary Clinton, Senator Chris Dodd, Rep. Dennis Kucinich and Senator Mike Gravel. (Details on the Forum at: http://www.centerforpolicyanalysis.org/id2.html),
One thing is still true: public-sector financing is the most efficient mechanism for collecting money fairly from everyone, and so the most effective way to assure universal health coverage. Then as now, such a single-payer system is a mighty threat to the private for-profit health insurance industry, which has allocated millions in rate payersÃ¯Â¿Â½ premiums in California alone to oppositional ballot and legislative campaigns. Their campaigns resonate with at least some Americans who find the government, well, disturbing.
Three things have changed since the 1990s: WeÃ¯Â¿Â½ve learned through painful experience that fragmented, market-based health care plans donÃ¯Â¿Â½t work. Our system costs more and more as we cover fewer and fewer. State by state, program by program, big reform announcements have been impaled by unstable funding, and by cumbersome enrollment and retention procedures. WeÃ¯Â¿Â½ve exhausted the inefficient ways that donÃ¯Â¿Â½t work to collect money from people if you want everyone in the system.
Second, for those businesses that still operate in the U.S., forking over a significant percent of profits to the insurance industry is a increasingly irritating pebble in the corporate shoe. Third, recent polls favor a government-financed solution, and in a landmark event the California legislature approved a single payer plan in 2006, though vetoed by the governor.
So, most of the candidates at the Forum addressed the idea of a single payer plan with respect Ã¯Â¿Â½ a far cry from the dismissive tone of the 1990s. All of them expressed the need to address universal coverage as part of their platform. Several acknowledged that effective cost control is impossible with 20% of the population lacking coverage, but still vulnerable to health catastrophes. They acknowledged that U.S. health care outcomes are deplorable, especially considering our $2 trillion annual health care bill. Clinton went after insurance companies for wasting 30% of every health care dollar on profits and administration, and discrimination against the sick.
Chris Dodd discussed how social and economic security affect heath, noting that, Ã¯Â¿Â½In the 20th century we extended life expectancy in this country by 30 years.Ã¯Â¿Â½ Only 5 of those years can be attributed to improved health care. We know empirically, he said, that better nutrition and housing, better wages and working conditions jobs, better incomes decent retirement, decent wages and working conditions have improved people's health, while income inequalty has not.
The big differences are still around single payer. Most candidates are dancing around proposals to expand the Federal Employees Health Benefits Plan, to throw a chunk more money here and there to the state childrenÃ¯Â¿Â½s health insurance programs (S-CHIP) and Medicaid, or, in EdwardsÃ¯Â¿Â½ case, as he describes it, to let a Ã¯Â¿Â½single-payerÃ¯Â¿Â½ Medicare type plan compete with market-based plans, in the hope that the public sector would eventually win out.
Kucinich, the lone single payer supporter Ã¯Â¿Â½ so far - raised important questions:
Ã¯Â¿Â½If you have competition between insurance companies, everyone knows what happens. That doesn't drive down costs, it drives up profits. That's a fact. If you say you're going to give people a choice, either be on a private plan or be with the government, the private companies start cherry picking the people in the best health, and you end up with adverse selection. The most medically compromised end up on programs that the government is paying for, and then the government program starts to go down. You end up in an insurance death spiral.
Ã¯Â¿Â½Even the insurance companies are for universal health care if the government is subsidizing them. What a deal that is for the insurance companies, but what a rotten deal for the American people. People are losing their homes because they can't pay the doctor bills. And so what it ultimately comes down to is who has the courage and the willingness to take a stand and can reach out to the American people and to say we're going to change this.Ã¯Â¿Â½
So there I think is the challenge leading up to next FebruaryÃ¯Â¿Â½s primary. For all of us who use and provide health care - generally for all of us who are eager for something important to start heading the right way in our country for people - this is the year to marshal what we really know about what works and what can work, to find out even more, to connect that with the political will that already exists, and see how much farther we can go.
Ellen R. Shaffer is Co-Director of the Center for Policy Analysis, which conducts research and advocacy on access to health care, and also on global trade and health. Former Senate trade staff. Author of a study modelling the implementation in California of Rep. Barbara Lee's HR 3000, the U.S Universal Health Service Act.