Jun 22, 2009
I'm sure I'm not the only reader who noticed the juxtaposition of two front page stories in Sunday's New York Times
dealing with health care. The first article cited a new Times-CBS poll
showing that 72 percent of Americans favored a government run health
plan comparable to Medicare, which would be available to everyone.
The second reported on a rogue radiologist at a Philadelphia VA hospital who botched 92 prostate procedures.
The right will doubtless go to town on that one, as what we can
expect of government-sponsored medicine. I'll have more to say about
the VA in a moment, but first let's consider the poll findings.
The poll is relevant because Congress will soon decide whether to
include the so-called "public option" in the Obama health reform bill.
As drafted by three House leaders and unveiled last Wednesday, the 852-page bill would include a government-sponsored, Medicare-like public plan.
Republicans and the health industry have been kicking and screaming
that this is socialistic. But the poll suggests that defenders of the
public plan have nothing to fear politically, and that Republicans are
in danger of getting on the wrong side of a popular issue.
However, that's only the beginning of the story. The reform package,
as drafted by the Obama administration and the House leadership, is
dubious legislation even with the inclusion of a public option.
Basically, it leaves the two worst aspects of the system intact. First,
private insurers will continue to dominate. Second, most people will
continue to get their insurance through their employers. Given these
two bedrock realities, there is no way that the bill can make serious
inroads on cost without cutting back on care. The high cost of the
approach is already causing key legislators to back off. The current
system wastes huge sums, but because it is so fragmented the money
flows to profit opportunities and not to the most cost-effective forms
of health care.
Also, as my American Prospect colleague Paul Starr warns, a
mixed system with a public option effectively invites the most
expensive and hard-to-treat people to opt for the public plan, while
private insurers will seek to insure the young and the healthy. This is
a familiar problem known as adverse selection. The private insurers
will then smugly point out that the public plan is less "efficient,"
when in fact it simply will have a more costly population. The only way
to avoid this problem is to have everyone in the same universal
plan--what's otherwise known as a single-payer plan.
The public option is a not-very-good second best--because our
leading liberal politicians lack the nerve to embrace the one reform
that simultaneously solves the problem of cost, quality, and universal
inclusion. The policy that dare not speak its name is of course
comprehensive national health insurance, or Medicare-for-All. I try to
avoid using the term "single payer," because a technical, policy-wonk
phrase not understood by most civilians has become insider shorthand
for national health insurance. Let's call the thing by its rightful
name. Medicare-for-All is something regular people understand.
The Times-CBS poll is
evidence that this is what more than two Americans in three really
want. Most voters have not followed the nuances of how the public
option in the Obama plan would compete with private insurance. The poll
simply indicates that voters want access to a straight-up,
Medicare-style plan to be available to one and all. In past polls, when
Times-CBS pollsters ask whether people favor national health insurance,
responses generally favor Medicare-for-All by margins of about
In the current debate, liberals find themselves fighting to keep the
public option alive, so that some form of efficient, publicly-run
health insurance will stay in the mix--but knowing that it is embedded
in a reform package that is far more costly and inefficient than it
should have been. Instead of validating the common sense and reformist
demands of ordinary Americans and identifying the insurance, drug, and
corporate elites as the obstacles to real reform, too many of our
liberal leaders from President Obama on down hope to co-opt business
elites with a convoluted scheme that undermines the efficiencies of a
comprehensive and universal system. And just wait until it gets watered
down further in order to retain the support of these same elites. A
plan that all of these groups would endorse would not be worth having.
So what's the matter with our politicians? Why are the people so far
ahead of their elected leaders on this one? One reason, as usual, is
money. The combination of the insurance industry, the drug industry,
the American Medical Association, the hospital lobby--all of whom
oppose Medicare-for-All--represents a huge amount of political
spending. It takes a brave politician to face down all of these
industries, even though the people are on the side of real reform. The
AMA's position is especially shameful, since the professional societies
that represent most actual physicians favor national health insurance.
The second reason that liberal politicians wimp out on single payer
is that the self-styled realists in this debate have decided that
Medicare-for-All, even if it's the first-best system, is too hard
politically. But think about it. Has the administration picked up one
Republican vote by supporting the present system plus a public option?
Hardly. The current House leadership bill, offering a mixed system,
with a robust public option, a requirement that employers provide good
insurance or pay a tax, and that insurers not discriminate against
pre-existing conditions, is just as heavy a political lift as national
health insurance--and far inferior policy. So why not just go for the
The advocates of Medicare-for-All have become something of an embarrassment to the liberals. The White House forum on health reform on
March 5th, which boasted a diverse range of viewpoints, including
representatives of the Business Roundtable, the health insurance
industry, the drug lobby, as well as a broad spectrum of business,
labor and Congressional leaders, left advocates of Medicare-for-All
banging on the door. None were included, despite requests for
When Sen. Bernie Sanders recently arranged for five prominent
advocates of national health insurance to have a courtesy meeting with
Senate Finance Committee Chair Max Baucus, the story was newsworthy
because the political elite usually pretends that this viewpoint
doesn't exist, much less that it represents the desires of two
Americans in three. The mainstream media have also colluded in the
general effort to keep the single-payer option out of the limelight.
The organization FAIR recently published an important study in its
heroic magazine, "Extra", titled "Media Blackout on Single-Payer Healthcare."
Indeed, the Sunday New York Times-CBS poll didn't even offer
Medicare-for-All as a free-standing option. It took the Obama position
as the left edge of the debate.
As for that rogue doctor at the Philadelphia veterans' hospital,
quality control is not what it should be throughout our fragmented
system. And the oases of public medicine are particularly starved for
resources. Yet studies consistently find that on average, the VA does
more with less than its private sector competitors. Phil Longman has
written the definitive book on the subject, "Best Care Anywhere." Here
is a summary.
In this case, the offending radiologist, Dr. Gary D. Kao, was actually a contract employee and not a VA physician.
Only by having a comprehensive system can we marry quality,
cost-effective care, and universal access. One of these days, a
national leader will have the nerve to embrace national health
insurance and fight for it. Until then, we will keep paying more money
for less care, and liberals will defend reforms they themselves
scarcely believe in.
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