News & Opinion

Without Health Benefits, a Good Life Turns Fragile

New York Times, March 5, 2007
By ROBERT PEAR
SALISBURY, N.C. — Vicki H. Readling vividly remembers the start of 2006.
 
“Everybody was saying, ‘Happy new year,’ ” Ms. Readling recalled. “But I remember going straight to bed and lying down scared to death because I knew that at that very minute, after midnight, I was without insurance. I was kissing away a bad year of cancer. But I was getting ready to open up to a door of hell.”
 
Ms. Readling, a 50-year-old real estate agent, is one of nearly 47 million people in America with no health insurance.
 
Increasingly, the problem affects middle-class people like Ms. Readling, who said she made about $60,000 last year. As an independent contractor, like many real estate agents, Ms. Readling does not receive health benefits from an employer. She tried to buy a policy in the individual insurance market, but — having had cancer — could not obtain coverage, except at a price exceeding $27,000 a year, which was more than she could pay.
 
“I don’t know which was worse, being told that I had cancer or finding that I could not get insurance,” Ms. Readling (pronounced RED-ling) said in an interview in her office, near the tree-lined streets and stately old homes of this city in the Piedmont region of North Carolina.It is well known that the ranks of the uninsured have been swelling; federal figures show an increase of 6.8 million since 2000.
 
But the surprise is that the uninsured are not necessarily the poor, the unemployed and the undocumented. Solidly middle-class people like Ms. Readling are one of the fastest growing subgroups.
 
And that is one reason, according to a recent New York Times/CBS News poll, that the problems of the uninsured have jumped to the top of the domestic political agenda in Washington and on the campaign trail.
 
Today, more than one-third of the uninsured — 17 million of the nearly 47 million — have family incomes of $40,000 or more, according to the Employee Benefit Research Institute, a nonpartisan organization. More than two-thirds of the uninsured are in households with at least one full-time worker.
 
Ms. Readling’s experience is typical; people who have had serious illnesses often have difficulty obtaining insurance. If coverage is available, the premiums are often more than they can afford.While the government does not have an official definition of “middle class,” one commonly used point of reference is the median household income, which was $46,326 in 2005.
 
Katherine Swartz, a professor of health policy and economics at Harvard, said the soaring cost of health care was a major reason for the increase in the number of uninsured. She said it also reflected long-term changes in the economy, like the decline in manufacturing jobs and the growth in the share of workers in service industries and small businesses, which are less likely to provide health benefits.
 
Moreover, Ms. Swartz said, “Companies have become more aggressive in hiring people as temporary or contract workers with no fringe benefits.”
 
The National Association of Realtors says 28 percent of its 1.3 million members are without health insurance.
 
“Because real estate agents are independent contractors, they are forced into the individual insurance market, where there is no negotiating or leverage,” said Pat V. Combs, president of the association.
 
As an independent contractor with a Century 21 real estate brokerage, Ms. Readling had bought insurance on her own, a temporary extension of coverage from a prior job. But she was unable to renew it after she had surgery for breast cancer in 2005. Most insurers would not offer her coverage, she said, and one carrier quoted a price of $2,300 a month for coverage with a deductible of $5,000 a year.
 
Concerns about health insurance permeate her life.
 
To save money, Ms. Readling said, she defers visits to the doctor and stretches out her cancer medication, which costs her about $300 a month. She takes the tiny pills three or four times a week, rather than seven days a week as prescribed.
 
“I really try to stay away from the doctor because I am so scared of what everything will cost,” said Ms. Readling, who is divorced and has twin 18-year-old sons. Before every doctor’s visit and test, she asks, “How much are you going to charge me?” She says she tries to arrange “the best deals I can.” But in many cases, the price is still unaffordable, and “I have to do without.”
 
Even those with insurance have reason to be concerned, economists say, because they end up paying for the uninsured in various ways. Some of the costs are also passed on to taxpayers and employers. To help cover the cost of treating the uninsured, hospitals often increase charges to other patients. Insurers then increase premiums for companies that provide health benefits, and they in turn shift some costs to employees.
 
Ms. Readling is engaged to be married in June, to another real estate agent. But she said she may postpone the wedding because she would not want her husband to be legally responsible for her medical bills.
 
“I am scared to get married because I don’t have insurance,” Ms. Readling said. “If I have to go to the hospital and I can’t pay my hospital bills, what happens? Do they go after him? Can they take your home?”
 
To collect unpaid medical bills, health care providers often obtain judgments against a patient’s spouse, as well as the patient, and file liens against their homes. Ms. Readling says she does not own a house, but her fiancé does.
 
The idea of universal coverage, in the form proposed by President Bill Clinton, proved politically untenable. Since the Clinton plan collapsed in 1994, the politics of health care have changed because of the steady rise in health costs, the increase in the number of uninsured and the erosion of employer-sponsored insurance. Politicians are once again speaking about universal coverage as a goal, though opinion polls show that many voters still oppose the idea of a government-run health care system.
 
Ms. Readling said it was stressful enough visiting doctors every few months for her cancer follow-ups. Without coverage, she said, the experience is even more stressful.
 
“When you go to any medical person and they ask for your insurance card, you are so ashamed because you have to say, ‘I don’t have insurance,’ ” Ms. Readling said. “You just feel like you are dirt.”
 
Ms. Readling said she often woke up at night, terrified of the cost of getting sick without insurance.
 
“Anything that goes wrong with my health could destroy me financially,” Ms. Readling said. “I could be ruined.”
 
She said she had never voluntarily allowed her insurance to lapse and could not understand why she was being blackballed.
 
“What did I do wrong?” Ms. Read-ling asked. “Why am I being punished? I just don’t understand how I could have fallen through this horrible, horrible crack.”
 
Knowing her health benefits from her prior job would expire in January 2006, she began shopping for a new policy in May 2005. But in June 2005, she learned she had cancer.“At that point,” Ms. Readling said, “I called everybody I could think of, begging for help. But no insurer would touch me.
 
Barbara Morales Burke, the chief deputy insurance commissioner of North Carolina, said state law did not guarantee the availability of health insurance for individuals. “Most insurers decline to issue policies to those individuals whom they deem to be too risky because of their medical history,” Ms. Morales Burke said.
 
Blue Cross and Blue Shield of North Carolina will sell to anyone, regardless of the person’s medical condition, she added, but the premiums may be very high for people who have had serious illnesses.
 
Heidi Deja, a spokeswoman for Blue Cross and Blue Shield of North Carolina, said, “Rates are based on the anticipated cost of providing care.” For people who have had serious illnesses, she said, monthly premiums “can run into the thousands of dollars.”
 
A 1996 federal law limited the ability of insurers to discriminate against people because of pre-existing conditions. But consumer protections are much more extensive in the group health insurance market.
 
“In the individual market, the federal protections provide precious little help to people seeking coverage,” said Karen L. Pollitz, a research professor at the Georgetown University Health Policy Institute.
 
When Ms. Readling was shopping for insurance, she found two responses particularly galling. One insurer, she said, suggested she return to her prior job, at a furniture company, so she could participate in its group health plan, though she loved her work as a real estate agent. Another insurer suggested she remarry her former husband to get back on his insurance plan.
 
Working with her doctors, Ms. Readling raced to get as many tests as possible before her coverage expired. She recalled her anxiety in the final months: “It’s like a freight train coming at you, and it’s going to get you. And there was nothing I could do.”
 
Ms. Readling said she was mystified by the inability of real estate agents to band together and buy health insurance as a group.
 
“Why can’t Realtors in North Carolina, or a few counties, have coverage under one umbrella?” she asked. “You would think that some insurance company would want our business.”
 
Janet S. Trautwein, executive vice president of the National Association of Health Underwriters, which represents insurance agents and brokers, said employee groups were more attractive to insurers for several reasons.
 
“In a group health plan,” Ms. Trautwein said, “the employer typically pays a large share of the premium, so most employees sign up as soon as they are eligible, regardless of their health status.”
 
“The health plan covers a mix of sick and healthy workers,” she said. “By contrast, individuals and independent contractors are more likely to defer coverage until they need it, so the pool of people insured is, over all, less healthy. Sick people consume more health care. As a result, the cost to insure them is higher.”
 
Though satisfied with her care, Ms. Readling continually wonders if doctors and nurses treat her differently because she is uninsured.
 
“Are they going to turn their nose up at you because you don’t have insurance?” Ms. Readling asked. “Will they take care of other people first? They can make more money on patients with insurance. What am I? I am just a financial loss to them.”

The Health Care Monster Returns

Even Republicans acknowledge it's ravages, but what's the best way to slay the beast?

By David Moberg
IN THESE TIMES
March 7, 2007
 
Like the creature from the Black Lagoon, the health insurance monster has returned, creeping back onto the public stage. After President 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 for even 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 Bush offered a plan that almost certainly would not deliver his promise of "quality, affordable health care for all Americans."
 
Recently, chief executives like 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 progressive leaders like Service Employees Industrial Union (SEIU) 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 citizen 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, John Edwards laid out a comprehensive health care plan. Barack Obama 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 for minor and politically easy reforms, like computerizing health records. Republican candidate Mitt Romney signed a flawed plan for universal health care when he was governor of Massachusetts, and California Gov. Arnold Schwarzenegger, after vetoing statewide single-payer legislation passed last year, has his own health insurance plan.
 
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 continue to 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 rising 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 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 to $2,250 per capita on average by the countries in the Organization for Economic Cooperation 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 towards 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 citizens of almost every other industrialized country. Yet, while 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 to 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 Rep. John Conyers (D-Mich.) and supported by Ohio Rep. and Democratic presidential candidate Dennis Kucinich, 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 State 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 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 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 (aka, a "single payer" plan)? Proponents of compromises say Medicare for all is a political non-starter. 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 citizen 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 the United States is ripe for universal health care, but worries about both infighting over the best plan and the specter of corporate attacks. He wonders, "Can we figure out a way to talk about this so as not to get bogged down, sway, with "Harry and Louise" commercials [that the insurance industry used against President Clinton's plan]?"
 
But there's no guarantee that insurance companies won't launch a war against these compromises, especially any that curtail 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 non-emergency procedures.
 
Eventually, Medicare-for-all advocates might have to settle for a compromise. But the opportunity for major change in the health care system doesn't come around very often. Since any change will require a massive effort, why not fight for the best?
 
This article is permanently archived at: http://www.inthesetimes.com/main/article/3059/
 
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David Moberg, a senior editor of In These Times, has been on the staff of the magazine since it began publishing. Before joining In These Times, he completed his work for a Ph.D. in anthropology at the University of Chicago and worked for Newsweek. Recently he has received fellowships from the John D. and Catherine T. MacArthur Foundation and the Nation Institute for research on the new global economy.

What we need: single payer, a single plan

When it comes to genuine reform of the health care system, a band-aid solution won't do.
 
StarTribune / Minneapolis-St.Paul, Minnesota
March 14, 2007
Lisa Nilles
 
The universal health insurance plan introduced last week by Healthy Minnesota (a coalition of providers, legislators and insurers) is nothing more than a band-aid on a system in need of a much bigger fix.
It promises universal access to health care by requiring all Minnesotans to "own" health insurance (called individual mandate).
 
On the surface, it may look good, momentarily, to claim that Minnesota has a universal health care plan, but without underlying repair of our overly complex and outrageously expensive health care system, the satisfaction won't last long.
 
Healthy Minnesota's proposal is similar to the universal-health-care-by-individual-mandate plan passed in Massachusetts last year. This is somewhat surprising, since the Massachusetts plan is already failing in its promise to make "affordable" health insurance available to all.

We need repair of the broken system to achieve universal health care. It's that simple, and it's that hard. Band-aid solutions are "politically possible." Genuine reform, which replaces our fragmented, failed system of multiple private insurers with a single payer and one single plan for all, is considered "politically impossible." But it is what we need to do.

It is not un-American to suggest that we work together to solve the health care crisis. It is a huge social and economic problem that affects each and every one of us. Eighty-six percent of Minnesota physicians believe "it is the responsibility of society, through the government, to ensure that everyone has access to good medical care."
 
We can't expect the private market to solve this problem: Entrusting it to manage health care just fractures the system and drives up cost. We need to work together on this one, and the only institution that represents all of us is government.

We don't want to waste any more time or money on band-aid solutions. We are ready for real reform: single-payer with universal coverage.
 
Lisa Nilles, M.D., of Minneapolis, is a graduate student in theology and a member of Physicians for a National Health Program.
 
©2007 Star Tribune. All rights reserved.

The Corporate Crime of Selling Private Health Insurance

Counter Punch

March 27, 2007

Political Players and Single Payer

By CORPORATE CRIME REPORTER

In most of the world, it is a corporate crime to sell private health insurance.

 

That's because most countries insure their citizens as a matter of right.

Private insurers dilute the public pool.

One nation, one payer.

Medicare for all.

Everybody in, nobody out.

No bills from the doctor.

No bills from the hospital.

No deductibles.

No co-pays.

No in network.

No out of network.

No corporate profits.

No threat of bankruptcy from health bills.

Health insurance will be the number one domestic political issue in the USA in 2008.

Polls indicate that the majority of the American people want single payer.

But who will deliver?

On Saturday, the Center for American Progress Action Fund and Service Employees International Union (SEIU) sponsored a forum in Las Vegas for presidential candidates to discuss health care.

No Republicans accepted.

Seven Democrats accepted.

All the candidates at the forum agreed that universal health care was the goal. (Even the Business Roundtable and the insurance industry now say they want "universal health care.")

But only one--Congressman Dennis Kucinich (D-Ohio)--accepts the only answer that will work--single payer.

Medicare for all.

The rest--including Barack Obama, Hillary Clinton, Chris Dodd, Bill Richardson, Mike Gravel, and John Edwards--want some mixture of public and private health insurance.

They know this public/private mix won't work--the healthy wealthy will buy private insurance, the sick poor will sign on with the government--and the government program will be crippled.

But they don't have the guts to stand up to the private insurance industry and say--get out.

Kucinich has introduced single payer legislation (HR 676) in Congress that would make it unlawful to sell private health insurance for benefits that are medically necessary.

Last week, we entered the belly of the beast--the American Health Insurance Plans (AHIP) 2007 National Policy Forum at the Capital Hilton in Washington, D.C.

AHIP is the trade association for the companies that will be sacked if single payer becomes law.

We walked into a session titled--Coverage for All Americans: Putting Access at the Top of the National Agenda.

The session was moderated by AHIP President Karen Ignagni.

Not once during the 90-minute session was single payer mentioned.

Universal coverage, yes.

Single payer, no.

But during the discussion, the geography of nowhere was laid out.

On one side, Ron Pollack, executive director of Families USA had teamed up with AHIP's Ignagni.

On the other, Bill Novelli, CEO of AARP and John Catsellani, president of the Business Roundtable.

AARP and the Business Roundtable have joined with SEIU to form something called Divided We Fail.

Divided We Fail is a corporate liberal answer to single payer.

All Americans should have access to affordable quality health care.

All Americans should have peace of mind about their future long-term financial security.

Families USA and AHIP do a separate dance but mouth similar platitudes.

But both Divided We Fail and Families USA/AHIP dismiss single payer as unworkable.

On the single payer side is Kucinich, about 60 members of the House of Representatives, the California Nurses Association, Physicians for a National Health Program, and Health Care Now.

Kucinich is now the single payer champion.

The problem with Kucinich, of course, is that if he doesn't get the nomination, he will take the stage at the Democratic Convention in 2008 in Denver--as he did in 2004 in Boston--raise the hand of the corporate nominee and endorse the corporate platform.

Then where will we be?

Nowhere.

Again.

Corporate Crime Reporter is located in Washington, DC. They can be reached through their
website.

Hope and Sense

 

By Robin Podolsky | bio

Again, thanks to Jon for bringing us together into this conversation and for laying out the contours of the problem so succinctly. It’s sobering, isn’t it, to realize how well his description of early 20th Century conditions corresponds to our own situation?

 
As a staff member for a state senator who is both the author of SB 840, California’s pending single payer legislation, and the Chair of the State Senate Health Committee and, therefore, obligated to work with all due speed for whatever useful reforms can be crafted, I appreciate Jon’s call for healthcare advocates to work in several time frames at once. But I would invert his concerns. While we don’t want to make the perfect the enemy of the good, neither do we want the incremental to be the strangling death of the remedial.

It’s almost once a week that I hear some variation of the ‘single payer won’t pass so why bother’ argument—and the assumptions behind it are more than a little disquieting.

From all sides of the debate, I hear the following question: “What makes you think we can achieve single payer when Big Insurance opposes it?” After all these years, I’m hardly naïve about the role of money and lobbying in the legislative process. Law, sausages, yada. But are we actually willing to concede the boundaries of healthcare policy to a business interest that currently guards its profit margin by seeking to strip health coverage from sick people? (Lisa Girion; Los Angeles Times: Sep 17, 2006; February 16, 2007; March 22, 2007)


First of all, Jon’s right—-single payer makes sense. If we look at a study by the Lewin Group, an independent medical cost/benefit analysis firm (numbers available at www.sen.ca.gov/kuehl), we see that, if we remove the artificial middle-man (private insurance) and marshal California’s purchasing power to negotiate bulk rates for prescription drugs and durable medical equipment, we really can insure every Californian with comprehensive coverage, save some money in the short run and control costs in the long run.

So the question becomes, “Just because this is supposed to be a representative democracy, what makes you think we can achieve a common sense solution if a powerful interest opposes it?” If the answer is, ‘we can’t,’ then why are we even torturing ourselves with this dialogue?

In fact, in large part because of the grass roots support it continues to gain (as well as Senator Kuehl’s acumen in moving it through), SB 840 has emerged as the bill that wouldn’t die. This is the third two-year version that the Senator has introduced, and each year, as the bill stays in front of the llegislature and its varied constituencies, it garners more legislative co-authors and a diverse range of endorsers who run from labor to business to nurses and doctors, along with local governments. As other options are raised and defeated (a pay-or-play employer mandate, for instance, was rejected at the polls), and the discussion of concrete solutions continues, single payer is beginning to stand out, in the Capitol building and among advocates, as the Gold Standard to which we are advancing.

Also, as Joe Paduda argues, this isn’t exactly a case of Big Business vs. the Little Guy. This is Big Insurance vs. everybody else. Single payer would save money for almost all businesses that now pay for health coverage benefits, and it would level the playing field for everybody else. As one of our main advocates, John Hughes, President of Rhythm and Hues, points out, California’s entertainment industry is having a hard time competing with those of other industrialized nations (that offer universal coverage)for many reasons, not the least of which is the cost of insuring top level employees. Small business owners, for their part, are healthcare consumers too, with families and health problems of their own. They don’t appreciate being forced to go without insurance or pay whatever a monopolized industry can extract for substandard plans.

To make a more general point: automatic cynicism is as idealistic as reflexive optimism. Batting away any hope for positive change is like refusing to hear bad news—-both reflexes demand a rejection of factual evidence. In truth, change is protracted, difficult and imperfect; and it is possible. Or we wouldn’t have Social Security at all, or, for that matter, universal suffrage.

Last year, California history was made when both houses of the legislature passed this bill. The Governor vetoed it, but he too has acknowledged the need to make healthcare reform a key priority. While, as of this writing, the Governor has not found a sponsor for his own ideas for reform, which combine old ideas, such as individual mandate and pay-or-play for businesses, his own stated goals only make SB 840 look more attractive: affordability, shared responsibility and preventive care/wellness. Single payer answers those needs and realizes two more principles: a mandate for quality care and genuine consumer choice.

Which brings me to my final point of the day. I don’t agree, Jon, that single payer would wipe out “American-style competition” or freedom of choice. If we were all insured, all healthcare providers would be competing for our business. And we would have more personal freedom to make decisions about whether to start businesses, go to school, get pregnant or change neighborhoods, because our insurance would follow us.

Which brings me to my final point of the day. I don’t agree, Jon, that single payer would wipe out “American-style competition” or freedom of choice. If we were all insured, all healthcare providers would be competing for our business. And we would have more personal freedom to make decisions about whether to start businesses, go to school, get pregnant or change neighborhoods, because our insurance would follow us.

Canada's Health Care Lauded by One Who Knows

by Sol Littman

Ever since my wife and I chose to leave Canada and settle in Tucson, we have been amazed and angered by the distortions and misrepresentations in the American media of Canada's government-funded, one-payer medical system. Among them is the recent op-ed article in the Arizona Daily Star by Dr. Jane M. Orient.
For most of my adult life, I worked as a journalist in Canada and took full advantage of Canada's health-care system. My wife, daughter and grandchildren were free to choose their own primary doctors and specialists. Service was consistently kindly, prompt and concerned. If something serious was suspected, we were tested, X-rayed and examined in a matter of days. Our physicians were highly trained and the hospital facilities modem and pleasant.
 
Thirty years ago, I had my gall bladder removed and had to spend three or four days in hospital. When I was discharged, I was presented with the bill — a total of $5.50 for the use of the television set in my semi-private room. The Ontario Hospital Insurance Plan paid the rest.
 
It is important for Americans to know that people in Canada tend to live a couple of years longer than their U.S. counterparts and that Canada's infant mortality rate is lower. This is attributed to the fact that everyone — young, old, working or unemployed — is covered for basic hospital and medical care in Canada without co-insurance or deductibles. This is in contrast to the United States, where there are more uninsured people (over 40 million) than Canadian inhabitants.
 
American critics of Canada's health care are quick to cite the fact that there are lengthy waiting lists for non-emergency medical procedures. It is also true that there is considerable overcrowding in some hospitals, but this is due to the fact that emergencies are treated immediately even if it means a lineup of gurneys in the hospital corridor — a situation I have found exists in American emergency wards as well.
 
The Canadian system does not rely on private insurance companies. The system is run by 10 provinces and two territories. They pay the bills and set the rules.
Medicare, which services the American elderly, is the closest approximation to the Canadian one-payer system, but there are important differences.
 
In the United States, the government pays the bills but private insurance companies that are more wasteful than the government run the system. In addition, some of our American health-care dollars go to make the insurance companies rich and play no role in actual health care.
 
The waiting times for some procedures are longer in Canada than in the United States, but this problem is being actively tackled by the government in the wake of a Canada Supreme Court decision that "access to a waiting list is not access to health care." However, the decision did not abolish the one-payer system — in fact, it reinforced it by giving the Quebec government, which was the chief object of the lawsuit, 12 months to remedy the situation.
 
As a result, Quebec is working hard to catch up with the rest of Canada. The average wait for a hip replacement has been reduced to four to five weeks, and knee replacements usually take six to seven weeks. This may still be too long, but if you happen to be one of the 40 million uninsured Americans, you might have to wait forever.
 
Why have my wife and I chosen to spend our retirement years in Tucson? We did, in fact, worry about leaving behind our Canadian health care, but climate, the availability of year-round golf and relatively good health persuaded us to take the chance.
 
We have found medical services in Tucson excellent, but expensive and complicated. We don't like being at the mercy of an HMO and have yet to decipher the ins and outs of the new drug plan. We continue to long for the simplicity and efficiency of Canada's single-payer system.
 
Sol Littman is a former Canadian journalist living in Tucson with his wife, Mildred.
Copyright © 1999-2006 AzStarNet, Arizona Daily Star and its wire services and suppliers

Sicko? The truth about the US healthcare system

Michael Moore's new film is a damning indictment of the way the world's richest country looks after those who fall ill. Andrew Gumbel finds out whether his accusations are justified
 
The Independent
June 4th, 2007
 
Cynthia Kline knew exactly what was happening to her when she suffered a heart attack at her home in Cambridge, Massachusetts. She took the time to call an ambulance, popped some nitroglycerin tablets she had been prescribed in anticipation of just such an emergency, and waited for help to arrive.
 
On paper, everything should have gone fine. Unlike tens of millions of Americans, she had health insurance coverage. The ambulance team arrived promptly. The hospital where she had been receiving treatment for her cardiac problems, a private teaching facility affiliated with the Harvard Medical School, was just a few minutes away.
 
The problem was, the casualty department at the hospital, Mount Auburn, was full to overflowing. And it turned her away. The ambulance took her to another nearby hospital but the treatment she needed, an emergency catheterization, was not available there. A flurry of phone calls to other medical facilities in the Boston area came up empty. With a few hours, Cynthia Kline was dead.
 
She died in an American city with one of the highest concentration of top-flight medical specialists in the world. And it happened largely because of America's broken health care system - one where 50 million people are entirely without insurance coverage and tens of millions more struggle to have the treatment they need approved. As a result, medical problems go unattended until they reach crisis point. Patients then rush to hospital casualty departments, where by law they cannot be turned away, overwhelming the system entirely. Everyone - doctors and patients, politicians on both the left and the right - agrees this is an insane way to run a health system.
 
When Elizabeth Hilsabeck gave birth to premature twins in Austin, Texas, she encountered another kind of insanity. Again, she was insured -- through her husband, who had a good job in banking. But the twins were born when she was barely six months pregnant, and the boy, Parker, developed cerebral palsy. The doctors recommended physical therapy to build up muscle strength and give the boy a fighting chance of learning to walk, but her managed health provider refused to cover it.
 
The crazy bureaucratic logic was that the policy covered only "rehabilitative" therapy - in other words, teaching a patient a physical skill that has been lost. Since Parker had never walked, the therapy was in essence teaching him a new skill and therefore did not qualify. The Hilsabecks railed, protested, won some small reprieves, but ended up selling their home and moving into a trailer to cover their costs. Elizabeth's husband, Steven, considered taking a new, better-paying job, but chose not to after making careful inquiries about the health insurance coverage. "When is he getting over the cerebral palsy?" a prospective new insurance company representative breezily asked the Hilsabecks. When Elizabeth explained he would never get over it, she was told she was on her own.
 
Everyone in America has a health-care horror story or knows someone who does. Mostly they are stories of grinding bureaucratic frustration, of phone calls and officials letters and problems with their credit rating, or of people ignoring a slowly deteriorating medical condition because they are afraid that an expensive battery of tests will lead to a course of treatment that could quickly become unaffordable.
 
Even when things don't go horribly wrong, it is a matter of surviving by the skin of one's teeth.
 
In Montana, Melissa Anderson can't find affordable insurance because she is self-employed - an increasingly common affliction. When her son Kasey came down with epilepsy two years ago, she was saved only by a recently introduced child health insurance programme specifically tailored to people who aren't poor but can't afford to pay monster medical bills. She herself remains uninsured for anything short of major care needs.
 
Over the past 15 years, the stories have become less about poor people without the economic means to access the system - although that remains a vast, unsolved problem - and more about the kind of people who have every expectation they will be taken care of. Middle-class people, people with jobs that carry health benefits or - as the problem worsens - people with the sorts of jobs that used to carry robust health benefits which are now more rudimentary and risk their being cut off for a variety of reasons.
 
This is the morass that Michael Moore has chosen to explore in his latest documentary, Sicko, which goes on release later this month. Moore spends much of the film demonstrating that there is nothing inevitable or necessary about a system that enriches insurance companies and drug manufacturers but shortchanges absolutely everyone else. His searching documentary looks at health care in France, Britain, Canada, and even Cuba - still regarded as a model system for the Third World.
 
Moore has his share of ghoulishly awful stories. The film kicks off with an uninsured carpenter who has to decide whether to spend $12,000 (£6,000) reattaching his severed ring finger or $60,000 to reattach his severed middle finger. Later on, Moore focuses on a hospital worker whose husband needed a bone marrow transplant to save him from a rare disease. The couple's insurance company refused to cover the transplant because it regarded the treatment as "experimental". The husband died.
 
Many more stories are collected in a newly published book called Sick: The Untold Story of America's Health Care Crisis, by Jonathan Cohn. A woman in California called Nelene Fox died of breast cancer after she, too, was turned down for a bone marrow transplant by her insurance company. In Georgia, a family whose infant son went into cardiac arrest were forced to take him to a hospital 45 miles away on their insurance carrier's orders. He survived, but suffered permanent disabilities that more prompt treatment might have averted. In New York, an infant called Bryan Jones - whose case was trumpeted all over the local media at the time - died of a heart defect that went undetected because his insurance company kicked him and his mother out of hospital 24 hours after his birth, too soon to carry out the tests that might have spotted the problem.
 
America's health system offers a tremendous paradox. In medical technology and in the scientific understanding of disease, it is second-to-none. Since doctors are better paid than anywhere else in the world, the country attracts the best of the best. And yet many, if not most, Americans are unable to reap the advantages of this. In fact, as The New York Times columnist Paul Krugman has argued, the very proliferation of research and high-tech equipment is part of the reason for the imbalance in coverage between the privileged few and the increasingly underserved masses. "[The system] compensates for higher spending on insiders, in part, by consigning more people to outsider status --robbing Peter of basic care in order to pay for Paul's state-of-the-art treatment," Krugman wrote recently. "Thus we have the cruel paradox that medical progress is bad for many Americans' health."
 
Having the system run by for-profit insurance companies turns out to be inefficient and expensive as well as dehumanizing. America spends more than twice as much per capita on health care as France, and almost two and a half times as much as Britain. And yet it falls down in almost every key indicator of public health, starting, perhaps, most shockingly, with infant mortality, which is 36 per cent higher than in Britain.
 
A recent survey by the management consulting company McKinsey estimated the excess bureaucratic costs of managing private insurance policies - scouting for business, processing claims, and hiring "denial management specialists" to tell people why their ailment is not covered by their policy - at about $98bn a year. That, on its own, is significantly more than the $77bn McKinsey calculates it would cost to cover every uninsured American. If the government negotiated bulk purchasing rates for drugs, rather than allowing the pharmaceutical companies to set their own extortionate rates, that would save another $66bn.
 
Astonishingly, there hasn't been a serious debate about health care in the United States since Bill Clinton, with considerable input from his wife Hillary, tried and failed to overhaul the system in 1994. That, though, may be about to change as the 2008 presidential race heats up. Everyone acknowledges the system is broken. Everyone recognizes that 50 million uninsured - including almost 10 million children - is unacceptable in a civilized society.
 
Even the old, classically American free-market argument - that "socialized" medicine is somehow the first step on a slippery slope towards godless communism - doesn't hold water, because in the absence of a functioning private insurance regime the government ends up picking up about 50 per cent of the overall costs for treatment anyway. The indigent rely on a government program called Medicaid. The elderly have a government program called Medicare. And perhaps the most efficient part of the whole system is the Veterans' Administration, a sort of NHS for former servicemen.
 
Rather like London and Paris in the 19th century, where the authorities belatedly paid attention to outbreaks of cholera once the disease started affecting the rich and middle classes, so the American health crisis may be coming to a head because of the kinds of people who are suffering from its injustices.
 
Corporate chief executives, for a start, are gagging under the ever-increasing costs of providing coverage to their employees. Starbucks now spends more on health care than it does on coffee beans. Company health costs, as a whole, are at about the same level as corporate profits. In a globalized world where US businesses are competing with low-wage countries such as India and China, that is rapidly becoming unacceptable.
 
That explains, perhaps, why the chief executive of Wal-Mart, Lee Scott, has made common cause with America's leading service sector union - more commonly a bitter critic of Wal-Mart's labor practices - in calling for a government-run universal health care system by 2012. It's going to be a tough battle. The insurance and pharmaceutical industries bankroll the campaigns of dozens of congressmen and have so far been brutally efficient in protecting their own interests. The Clintons were defeated in 1994 in part because of the power of the industry lobbies. Doing better this time will take singular political courage.
 
In the meantime, we will hear ever more crazy stories like the one told by Marijon Binder, a former nun in Chicago who ended up being sued by a Catholic hospital for $11,000 because her two-night stay for a heart scare was not considered a worthy charity case. Binder, who works as a live-in companion to a disabled old woman, wrote on all her admission forms that she had no insurance and, in her telling at least, was reassured the hospital would take care of her anyway.
 
After a year and a monstrous bureaucratic fight that went nowhere, a civil judge promptly absolved her of responsibility for her bill - a lucky outcome, for sure. Binder said: "The whole experience was very demeaning. It made me feel very guilty; it made me feel like a criminal." She is, though, alive and solvent. Not everyone in this system catches the same break.

I Am Not a Health Reform

December 15, 2007
Op-Ed Contributors
New York Times

By DAVID U. HIMMELSTEIN and STEFFIE WOOLHANDLER

IN 1971, President Nixon sought to forestall single-payer national health insurance by proposing an alternative. He wanted to combine a mandate, which would require that employers cover their workers, with a Medicaid-like program for poor families, which all Americans would be able to join by paying sliding-scale premiums based on their income.Nixon’s plan, though never passed, refuses to stay dead. Now Hillary Clinton, John Edwards and Barack Obama all propose Nixon-like reforms. Their plans resemble measures that were passed and then failed in several states over the past two decades.
 
In 1988, Massachusetts became the first state to pass a version of Nixon’s employer mandate — and it added an individual mandate for students and the self-employed, much as Mrs. Clinton and Mr. Edwards (but not Mr. Obama) would do today. Michael Dukakis, then the state’s governor, announced that “Massachusetts will be the first state in the country to enact universal health insurance.” But the mandate was never fully put into effect. In 1988, 494,000 people were uninsured in Massachusetts. The number had increased to 657,000 by 2006.
 
Oregon, in 1989, combined an employer mandate with an expansion of Medicaid and the rationing of expensive care. When the federal government granted the waivers needed to carry out the program, Gov. Barbara Roberts said, “Today our dreams of providing effective and affordable health care to all Oregonians have come true.” The number of uninsured Oregonians did not budge.
 
In 1992 and ’93, similar bills passed in Minnesota, Tennessee and Vermont. Minnesota’s plan called for universal coverage by July 1, 1997. Instead, by then the number of uninsured people in the state had increased by 88,000.
 
Tennessee’s Democratic governor, Ned McWherter, declared that “Tennessee will cover at least 95 percent of its citizens.” Yet the number of uninsured Tennesseans dipped for only two years before rising higher than ever.
 
Vermont’s plan, passed under Gov. Howard Dean, called for universal health care by 1995. But the number of uninsured people in the state has grown modestly since then.
 
The State of Washington’s 1993 law included the major planks of recent Nixon-like plans: an employer mandate, an individual mandate for the self-employed and expanded public coverage for the poor. Over the next six years, the number of uninsured people in the state rose about 35 percent, from 661,000 to 898,000.
 
As governor, Mitt Romney tweaked the Nixon formula in 2006 when he helped devise a second round of Massachusetts health care reform: employers in the state that do not offer health coverage face only paltry fines, but fines on uninsured individuals will escalate to about $2,000 in 2008. On signing the bill, Mr. Romney declared, “Every uninsured citizen in Massachusetts will soon have affordable health insurance.” Yet even under threat of fines, only 7 percent of the 244,000 uninsured people in the state who are required to buy unsubsidized coverage had signed up by Dec. 1. Few can afford the sky-high premiums.
 
Each of these reform efforts promised cost savings, but none included real cost controls. As the cost of health care soared, legislators backed off from enforcing the mandates or from financing new coverage for the poor. Just last month, Massachusetts projected that its costs for subsidized coverage may run $147 million over budget.
 
The “mandate model” for reform rests on impeccable political logic: avoid challenging insurance firms’ stranglehold on health care. But it is economic nonsense. The reliance on private insurers makes universal coverage unaffordable.
 
With the exception of Dennis Kucinich, the Democratic presidential hopefuls sidestep an inconvenient truth: only a single-payer system of national health care can save what we estimate is the $350 billion wasted annually on medical bureaucracy and redirect those funds to expanded coverage. Mrs. Clinton, Mr. Edwards and Mr. Obama tout cost savings through computerization and improved care management, but Congressional Budget Office studies have found no evidence for these claims.
 
In 1971, New Brunswick became the last Canadian province to institute that nation’s single-payer plan. Back then, the relative merits of single-payer versus Nixon’s mandate were debatable. Almost four decades later, the debate should be over. How sad that the leading Democrats are still kicking around Nixon’s discredited ideas for health reform.
 
David U. Himmelstein and Steffie Woolhandler are professors of medicine at Harvard and the co-founders of Physicians for a National Health Program

How Can a $124.8 Million a Year CEO Make Health Care More Affordable?

An op-ed piece in the Providence Journal about huge pay packages for corporate CEOs mentioned the breath-taking $124.8 million total compensation of United Health Group (parent of United Healthcare) CEO William McGuire. This figure can also be found in the Forbes Special Report on CEO compensation. Here one can find that other managed care CEOs got less fabulous, but still formidable compensation, e.g., Howard Phanstiel, PacifiCare, 3.38 million; Edward Hanway, Cigna, $13.3 million; John Rowe, Aetna, $22.2 million; and Larry Glassrock, Wellpoint, $25.0 million.
 
McGuire's compensation was so large as to take a measurable part of this large company's net income (5%). Or to look at it from a stock-holder's (and hence, an company owner's) viewpoint, had McGuire, who is an employee, been only paid a cool million, and this money had been distributed as a dividend, it would amount to about a $0.20 per share dividend. (The current dividend is $0.03 per share.) (See company data available from Forbes as well.)

To look at it from a United employee's viewpoint, had McGuire, who is an employee, been only paid a cool million, and this money had been distributed to employees, each of the 40,000 employees could have received a bonus larger than $3000.

To look at it from the viewpoint of the health care system, the $124.8 million total compensation of a single United employee could pay the salaries of 833 general internists at current typical salaries. Or the $124.8 million could run one reasonable size community hospital for a year.

United Health Group's mission statement is "the company directs its resources into designing products, providing services and applying technologies that improve access to health and well-being services; simply the health care experience; promote quality; and make health care more affordable." (See this fact sheet.) Rather, it seems to be directing a good chunk of its resources into salaries of top management employees. How a $124.8 million CEO salary can be reconciled with a mission to "make health care more affordable" is completely beyond me.

United Health Group's mission statement is "the company directs its resources into designing products, providing services and applying technologies that improve access to health and well-being services; simply the health care experience; promote quality; and make health care more affordable." (See this fact sheet.) Rather, it seems to be directing a good chunk of its resources into salaries of top management employees. How a $124.8 million CEO salary can be reconciled with a mission to "make health care more affordable" is completely beyond me.

Single-payer healthcare is the one way

By Michael Kaplan
Boston Globe
December 3, 2007

Along with most residents of Massachusetts, I assumed that the Massachusetts Health Reform Law was going to allow my daughter to keep her health insurance coverage after she graduated from college. The Connector Authority specified that for two years of post- dependency status, a young adult could remain on a family policy. What a relief that was. She graduated this May and is in those early stages of becoming self-supporting.
 
When my wife's employer, Berkshire Health Systems, informed us that my daughter's coverage would end on Dec. 31 of this year, I was shocked. It turns out that the law requires only companies that pay health insurance premiums to give the extra two years of coverage. Those companies that self-insure are governed by federal law under ERISA and are not bound by this requirement. Self-insured companies pay the health insurance companies to administer the benefit, not to insure them. So our Blue Cross Blue Shield policy seems like an insurance policy, but it is not. Berkshire Health Systems insures itself, as do national companies that employ across state lines. Many large local employers are self-insured as well. These large companies do not have to pay the extra cost to cover dependents for those two more years.
 
Small businesses are generally not able to take on the financial risk required to self-insure, so those companies that provide insurance to employees do have to pay the extra premiums. Whatever happened to the relief that small business was supposed to get from this reform law? Ask any small business owner and you will learn that health insurance costs for employees may have risen by as much as 50 percent since this law was passed!
 
My daughter has been able to get two part-time jobs, but of course she has not been offered health insurance. I am told that she may qualify for Commonwealth Care that the Connector offers under the new law.
 
Although the Commonwealth Care subsidized insurance is not tied to employment, coverage would be lost if she either started earning above a threshold amount or moved from Massachusetts, both likely events for a young graduate. And as a consequence of the loophole exempting many big employers from covering their employees' children for two post-college years, Commonwealth Care is likely to include more young people than expected.
 
This will create higher expenses for the state than originally projected, worsening the cost problem that that casts a shadow over the entire program.
 
Jon Kingsdale, executive director of the Connector Authority, recently said, "If we continue with double-digit inflation [in health insurance premiums] I don't think health reform is sustainable." However, there is nothing in the new law that works to control these sky-rocketing costs.
 
As a physician and healthcare activist for many years, I was aware that this reform law was not a panacea and did nothing to control the rapidly rising costs of private insurance that force both employers and their employees to pay more in premiums, with the insured also paying more in higher copayments and deductibles. While the reform widened the safety net for some poor families, this safety net will shred if there is not a massive infusion of new money from the state or federal governments.
 
Two important lessons can be learned. First, we need to sever the connection between healthcare and employment. People need continuous, portable coverage that is affordable, comprehensive, and equitable. Second, we cannot depend on the private insurance industry to provide this for us.
 
Piece-meal reform such as the new law will not work. Both employers and the public support the concept of single-payer healthcare. Big business is starting to realize that a single payer system will be the only affordable way to cover everyone. When will our politicians understand that their political futures will depend on supporting this kind of comprehensive reform?
 
Michael Kaplan is a family physician and a member of Physicians for a National Health Plan and the board of directors of the Universal Health Care Education Fund.

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