The ink was barely dry on the PPACA when the first of many lawsuits to block the mandated health insurance provisions of the law was filed in a Florida District Court.

The pleadings, in part, read -

The Constitution nowhere authorizes the United States to mandate, either directly or under threat of penalty, that all citizens and legal residents have qualifying health care coverage.

State of Florida, et al. vs. HHS

It turns out, the Founding Fathers would beg to disagree.

In July of 1798, Congress passed – and President John Adams signed - “An Act for the Relief of Sick and Disabled Seamen.” The law authorized the creation of a government operated marine hospital service and mandated that privately employed sailors be required to purchase health care insurance.

Keep in mind that the 5th Congress did not really need to struggle over the intentions of the drafters of the Constitutions in creating this Act as many of its members were the drafters of the Constitution.

And when the Bill came to the desk of President John Adams for signature, I think it’s safe to assume that the man in that chair had a pretty good grasp on what the framers had in mind.

Here’s how it happened.

During the early years of our union, the nation’s leaders realized that foreign trade would be essential to the young country’s ability to create a viable economy. To make it work, they relied on the nation’s private merchant ships – and the sailors that made them go – to be the instruments of this trade.

The problem was that a merchant mariner’s job was a difficult and dangerous undertaking in those days. Sailors were constantly hurting themselves, picking up weird tropical diseases, etc.

The troublesome reductions in manpower caused by back strains, twisted ankles and strange diseases often left a ship’s captain without enough sailors to get underway – a problem both bad for business and a strain on the nation’s economy.

But those were the days when members of Congress still used their collective heads to solve problems – not create them.

Realizing that a healthy maritime workforce was essential to the ability of our private merchant ships to engage in foreign trade, Congress and the President resolved to do something about it.

Enter “An Act for The Relief of Sick and Disabled Seamen”.

I encourage you to read the law as, in those days, legislation was short, to the point and fairly easy to understand.

The law did a number of fascinating things.

First, it created the Marine Hospital Service, a series of hospitals built and operated by the federal government to treat injured and ailing privately employed sailors. This government provided healthcare service was to be paid for by a mandatory tax on the maritime sailors (a little more than 1% of a sailor’s wages), the same to be withheld from a sailor’s pay and turned over to the government by the ship’s owner. The payment of this tax for health care was not optional. If a sailor wanted to work, he had to pay up.

This is pretty much how it works today in the European nations that conduct socialized medical programs for its citizens – although 1% of wages doesn’t quite cut it any longer.

The law was not only the first time the United States created a socialized medical program (The Marine Hospital Service) but was also the first to mandate that privately employed citizens be legally required to make payments to pay for health care services. Upon passage of the law, ships were no longer permitted to sail in and out of our ports if the health care tax had not been collected by the ship owners and paid over to the government – thus the creation of the first payroll tax in our nation’s history.

When a sick or injured sailor needed medical assistance, the government would confirm that his payments had been collected and turned over by his employer and would then give the sailor a voucher entitling him to admission to the hospital where he would be treated for whatever ailed him.

While a few of the healthcare facilities accepting the government voucher were privately operated, the majority of the treatment was given out at the federal maritime hospitals that were built and operated by the government in the nation’s largest ports.

As the nation grew and expanded, the system was also expanded to cover sailors working the private vessels sailing the Mississippi and Ohio rivers.

The program eventually became the Public Health Service, a government operated health service that exists to this day under the supervision of the Surgeon General.

So much for the claim that “The Constitution nowhere authorizes the United States to mandate, either directly or under threat of penalty….”

As for Congress’ understanding of the limits of the Constitution at the time the Act was passed, it is worth noting that Thomas Jefferson was the President of the Senate during the 5^th Congress while Jonathan Dayton, the youngest man to sign the United States Constitution, was the Speaker of the House.

While I’m sure a number of readers are scratching their heads in the effort to find the distinction between the circumstances of 1798 and today, I think you’ll find it difficult.

Yes, the law at that time required only merchant sailors to purchase health care coverage. Thus, one could argue that nobody was forcing anyone to become a merchant sailor and, therefore, they were not required to purchase health care coverage unless they chose to pursue a career at sea.

However, this is no different than what we are looking at today.

Each of us has the option to turn down employment that would require us to purchase private health insurance under the health care reform law.

Would that be practical? Of course not – just as it would have been impractical for a man seeking employment as a merchant sailor in 1798 to turn down a job on a ship because he would be required by law to purchase health care coverage.

What’s more, a constitutional challenge to the legality of mandated health care cannot exist based on the number of people who are required to purchase the coverage – it must necessarily be based on whether any American can be so required.

Clearly, the nation’s founders serving in the 5th Congress, and there were many of them, believed that mandated health insurance coverage was permitted within the limits established by our Constitution.

The moral to the story is that the political right-wing has to stop pretending they have the blessings of the Founding Fathers as their excuse to oppose whatever this president has to offer.

History makes it abundantly clear that they do not.

UPDATE: January 21- Given the conversation and controversy this piece has engendered, Greg Sargent over at The Washington Post put the piece to the test. You might be interested in what Greg discovered in his article, “Newsflash: Founders favored government run health care.”

Contact Rick at This e-mail address is being protected from spambots. You need JavaScript enabled to view it

By Sarah Kliff, Washington Post

Published: November 23

President Obama’s top Medicare official has resigned in the face of Republican pledges to block his confirmation in the Senate.

Center for Medicare and Medicaid Services Administrator Donald M. Berwick notified colleagues Wednesday that he will step down Dec. 2, nearly a month before the expiration of his recess appointment.

The White House will nominate Marilyn Tavenner, Medicare’s deputy administrator, as his replacement.

“Don Berwick did outstanding work at CMS,” White House deputy press secretary Jamie Smith said Wednesday. “It’s unfortunate that a small group of senators obstructed his nomination, putting political interests above the best interests of the American people.”

Obama nominated Berwick to run Medicare in April 2010. In July 2010, with no confirmation hearing scheduled, the president appointed him to the job while Congress was in recess. As a recess appointment, Berwick’s term was to expire Dec. 31. Earlier this year, 42 Republican senators signed a letter pledging to block his confirmation, effectively ending any chance of him serving beyond 2011.

“It was a mistake to recess-appoint him,” said Sen. John Barrasso (R-Wyo.), who has been a vocal Berwick critic. “He was the wrong person for the job, and I think it was wrong of the president to make an end run around Congress.”

A Harvard-educated pediatrician, Berwick won accolades and the endorsements of major health-care groups for his academic work, which focused on reducing the cost of care while improving quality and patient experience.

Republicans, however, seized on remarks he made praising Britain’s National Health Service as an “example” for the United States to follow. Many accused him of supporting the “rationing” of services, a claim Berwick has rejected.

“Every bone in my body, as a physician, even as a person, is to get everything [patients] want and need and to help them at every step,” he told The Washington Post in an interview this summer. “I have gone to the mat to get a last-ditch bone marrow transplant for a child with leukemia .?.?. and they are telling me I'm rationing? They haven’t met me.”

In his 18-month tenure, Berwick oversaw the rollout of crucial health reform regulations that stand to reshape both the private insurance market and the Medicare program. His agency drafted rules for the new health insurance marketplaces, called exchanges, where Americans will be able to compare and buy health insurance plans in 2014.

Berwick also weathered an aggressive backlash to his draft rules for Accountable Care Organizations, a pilot program that is meant to move Medicare away from paying doctors for the volume of services they provide and toward reimbursements based on quality of care. Medical groups reacted much more positively to the final regulations for that program.

Republicans have responded cautiously to the White House’s nomination of Tavenner, a former nurse and hospital administrator who has served in the Obama administration since February 2010. She was Virginia’s secretary of health and human resources under then-Gov. Tim Kaine (D).

In announcing her nomination, the White House highlighted Tavenner’s nearly 35-year health-care career, “including almost 20 years in nursing, 3 years as a hospital CEO and 10 years in various senior executive level positions for Hospital Corporation of America.”

Sen. Orrin Hatch (R-Utah), ranking member of the Senate Finance Committee, said, “Republicans on the Finance Committee look forward to examining her record and gaining an understanding of her views of Medicare, Medicaid and the presi­dent’s health law.”

Rep. Hayes, I write you this open letter in response to your Circleville Herald column of 10 August “Health Care Close to Home”. I sincerely invite you to spend a shift or two with me in the emergency department to see and feel face to face the desperation of the tens of thousands of down-home Ohioans without access to healthcare. These are not slackers or persons who just wish to freeload on your tax dollars, they are our neighbors and friends, the barber who cuts your hair, the server who waits on you, the clerk in the that large store. Often they are working two jobs trying to make ends meet, while cutting back on their own medicines to save for kid’s school supplies. Come and feel the pain of real persons suffering and dying in your district having been abandoned by profitable insurance companies, whose profit margins are at record levels (“Health Insurers Make Record Profits as Many Postpone Care” New York Times 14 May 2011).

Like you, I too have problems with the Patient Protection and Affordable Care Act (PPACA), called “Obamacare” by detractors when “Romneycare” is in fact more accurate, as the PPACA is modeled after Massachusetts healthcare reform signed by Republican governor  Mitt Romney in 2006. I have problems with the PPACA not because of your concern that it is a government program controlled by  inaccessible far-away elected  representatives, but because it keeps  in place  private health insurance companies controlled by  even more inaccessible, often dishonest, and even  farther away corporate boardrooms that I can’t even un-elect.

Dishonest a strong word?  The Associated Press article of 27 July “Insurers Allegedly Provided Inaccurate Medical-Loss Ratios” notes several Florida insurance companies took advantage of lax oversight under Governor Rick Scott, falsely claiming they spent funds on children’s Medicaid when in fact they pocketed the cash. Florida Governor Rick Scott, a tea party favorite, presided as CEO of the Hospital Corporation of America/Columbia Healthcare when his company was fined one of the largest penalties ever levied by the federal government for insurance fraud. Rep. Hayes, your column implies that the PPACA removes local choices that “are best handled by the people closest to home who know the situation best.” Ask your constituents how much honest close-to-home help they received from their health insurance company.

Rep.  Hayes, Ohioans health is at risk not because of too much government, but too little. We the people have failed to demand that our elected representatives appropriately oversee and regulate Wall Street traded health insurance giants that increase their bottom line by not keeping their word on the promise they offer:  financial security in the face of illness. Wendell Potter, former Cigna public relations officer turned whistleblower and author of “Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans” warns “One of the secrets to achieving these [record profits] is what the insurers euphemistically call ‘medical management’. That often translates into denied claims and denied coverage for doctor-ordered care. The fewer claims they pay and the more procedures they refuse to pay for, the more money is left over for investors to put in their pockets… … It’s to the insurer’s advantage for it to be complicated and confusing and hard to deal with insurance companies. They profit as a result of the confusion.” Private for-profit health insurance companies, these are the real death panels.

Rep. Hayes, for the sake of all Ohioans I urge you to support HB 287 the “Ohio Health Security Act” introduced by Reps. Bob Hagan and Mike Foley. HB 287 would move Ohio closer to a single payer model, shown throughout the industrialized world to be the most cost-effective and compassionate. Vermont has just passed single payer—no one in Vermont will die for lack of health insurance. The prestigious New England Journal of Medicine, September 2009,  published  “Health Insurance and Mortality in U.S. Adults” estimating that  45,000 Americans die yearly from  lack of health insurance; this does not include those who die as a result of denied claims. Some of these deaths are your constituents.

Rep. Hayes, until we reach single payer you can save the lives of many Ohioans by reining in the worst of health insurance company abuses by supporting the PPACA. Under these reforms no Ohioan can be denied insurance for pre-existing conditions, no neighbor of ours will find their insurance taken away when their care threatens company profits.  Arbitrary denials of claims by insurers will, for the first time, be subject to appeal, as will premium increases. Insurers will be forced to spend at least 80-85% of all premiums collected on direct patient care. Under the Patient Protection and Affordable Care Act more Ohioans will live, certainly the best “down home” neighborly gift we can give.

 Brad Cotton, member Physicians for a National Health Program

By the St. Louis Dispatch Editorial Board | Posted: Wednesday, August 10, 2011 12:00 am

If America truly is serious about dealing with its deficit problems, there's a fairly simple solution. But you're probably not going to like it: Enact a single-payer health care plan.

See, we told you weren't going to like it.

But the fact is that everyone who has studied the deficit problem has agreed that it's actually a health care problem — more specifically, the cost of providing Medicare benefits to an aging and longer-living population. The bipartisan National Commission on Fiscal Responsibility and Reform reported last December: "The Congressional Budget Office (CBO) projects if we continue on our current course, deficits will remain high throughout the rest of this decade and beyond, and debt will spiral ever higher, reaching 90 percent of GDP in 2020.

"Over the long run, as the baby boomers retire and health care costs continue to grow, the situation will become far worse. By 2025 revenue will be able to finance only interest payments, Medicare, Medicaid, and Social Security. Every other federal government activity — from national defense and homeland security to transportation and energy — will have to be paid for with borrowed money."

That being the case — and nobody argues that it isn't — there are two broad ways for the government to address its spiraling health care costs. One, shift more of those costs to recipients, by trimming benefits and/or extending eligibility ages and indexing eligibility to personal income. This is politically unpalatable, particularly to most Democrats, President Barack Obama being a conspicuous exception.

The second way for government to address its health costs is not to shift them, but to reduce them. This is what a single-payer health care system would do, largely by taking the for-profit players (insurance companies for the most part) out of the loop.

The advocacy group Physicians for a National Health Program estimates that "private insurance bureaucracy and paperwork consume one-third (31 percent) of every health care dollar. Streamlining payment through a single nonprofit payer would save more than $400 billion per year, enough to provide comprehensive, high-quality coverage for all Americans."

Once everyone is covered, the government would have the clout to bring discipline into the wild west of health care spending. It could insist that providers be paid for quality of service, not quantity. Health facilities and equipment could be managed by regional boards. Medical services could be "bundled" — rather than paying hospitals and doctors and laboratories separately, there would be fixed prices for treatments. And so on.

The Patient Protection and Affordable Care Act passed in 2009 contains many pilot programs designed to test cost-reduction strategies. Most of them won't kick in for another six to eight years, by which time health care costs will be approaching 20 percent of U.S. gross domestic product. The combined state and federal share of that will be 49 percent, up from 45 percent today.

Indeed, a study published this month in the journal Health Affairs estimates that while the Affordable Care Act will pay for itself by 2020, it won't actually "bend the cost curve," as the Obama administration had hoped. But the study, done by the Actuary Centers for Medicare and Medicaid Services, says the ACA will significantly slow the rise of health care costs to state and local governments.

But consider those two findings: In effect, they say that if reducing overall health care costs is the goal, then the ACA didn't go far enough. Thirty million more people will be insured and government costs will grow more slowly. But overall health care costs will continue to explode.

Sooner or later, a nation serious about controlling spending must take broad control of the health care system.

It surely won't be sooner. Compared to the political fight that would erupt over a single-payer plan, the congressional battle over the Affordable Care Act would seem as tame as resolution praising mom, the flag and apple pie.

The ACA was a compromise. Mr. Obama brought everyone to the table — doctors, insurance companies, drug companies, hospitals — and came away with a "best we can get" kind of bill. Many of those at the table turned around and lobbied against it or sought special favors once the bill came before Congress.

It passed by narrow margins, and Congress is decidedly more conservative now. Indeed, the new House majority has voted to repeal the ACA and challenges to its constitutionality continue to work their way toward the Supreme Court.

But now, like a baby discovering its toes, Congress has discovered the deficit. And the plain fact is that unless you want to commit political suicide and cut Medicare to the bone — as Rep. Paul Ryan's, R-Wis., budget plan would do — the best way to seriously address long-term deficits is to get control of health care costs through a single-payer plan.

In 2008, when health care costs amounted to "only" 16 percent of U.S. gross domestic product, Great Britain was spending 8.7 percent of its GDP on health care, and Canada was spending 10.4 percent. Both nations have single-payer plans. Quality of care scores in both nations are at least comparable, and in most cases, better.

Eventually, the United States will have a single-payer plan. But we'll waste a lot of money and time getting there.

New York Times, July 24, 2011

By PAUL KRUGMAN

At the time of writing, President Obama’s hoped-for “Grand Bargain” with Republicans is apparently dead. And I say good riddance. I’m no more eager than other rational people (a category that fails to include many Congressional Republicans) to see what happens if the debt limit isn’t raised. But what the president was offering to the G.O.P., especially on Medicare, was a very bad deal for America.

Specifically, according to many reports, the president offered both means-testing of Medicare benefits and a rise in the age of Medicare eligibility. The first would be bad policy; the second would be terrible policy. And it would almost surely be terrible politics, too.

The crucial thing to remember, when we talk about Medicare, is that our goal isn’t, or at least shouldn’t be, defined in terms of some arbitrary number. Our goal should be, instead, to give Americans the health care they need at a price the country can afford. And throwing Americans in their mid-60s off Medicare moves us away from that goal, not toward it.

For Medicare, with all its flaws, works better than private insurance. It has less bureaucracy and, hence, lower administrative costs than private insurers. It has been more successful in controlling costs. While Medicare expenses per beneficiary have soared over the past 40 years, they’ve risen significantly less than private insurance premiums. And since Medicare-type systems in other advanced countries have much lower costs than the uniquely privatized U.S. system, there’s good reason to believe that Medicare reform can do a lot to control costs in the future.

In that case, you may ask, why didn’t the 2010 health care reform simply extend Medicare to cover everyone? The answer, of course, is political realism. Most health reformers I know would have supported Medicare for all if they had considered it politically feasible. But given the power of the insurance lobby and the knee-jerk opposition of many politicians to any expansion of government, they settled for what they thought they could actually get: near-universal coverage through a system of regulation and subsidies.

It is, however, one thing to accept a second-best system insuring those who currently lack coverage. Throwing millions of Americans off Medicare and pushing them into the arms of private insurers is another story.

Also, did I mention that Republicans are doing all they can to undermine health care reform — they even tried to undermine it as part of the debt negotiations — and may eventually succeed? If they do, many of those losing Medicare coverage would find themselves unable to replace it.

So raising the Medicare age is a terrible idea. Means-testing — reducing benefits for wealthier Americans — isn’t equally bad, but it’s still poor policy.

It’s true that Medicare expenses could be reduced by requiring high-income Americans to pay higher premiums, higher co-payments, etc. But why not simply raise taxes on high incomes instead? This would have the great virtue of not adding another layer of bureaucracy by requiring that Medicare establish financial status before paying medical bills.

But, you may say, raising taxes would reduce incentives to work and create wealth. Well, so would means-testing: As conservative economists love to point out in other contexts — for example, when criticizing programs like food stamps — benefits that fall as your income rises in effect raise your marginal tax rate. It doesn’t matter whether the government raises your taxes by $1,000 when your income rises or cuts your benefits by the same amount; either way, it reduces the fraction of your additional earnings that you get to keep.

So what’s the difference between means-testing Medicare and raising taxes? Well, the truly rich would prefer means-testing, since they would end up sacrificing no more than the merely well-off. But everyone else should prefer a tax-based solution.

So why is the president embracing these bad policy ideas? In a forthcoming article in The New York Review of Books, the veteran journalist Elizabeth Drew suggests that members of the White House political team saw the 2010 election as a referendum on government spending and that they believe that cutting spending is the way to win next year.

If so, I would respectfully suggest that they are out of their minds. Remember death panels? The G.O.P.’s most potent political weapon last year — the weapon that caused a large swing in the votes of older Americans — was the claim that Mr. Obama was cutting Medicare. Why give Republicans a chance to do it all over again?

Of course, it’s possible that the reason the president is offering to undermine Medicare is that he genuinely believes that this would be a good idea. And that possibility, I have to say, is what really scares me.

New York Times - June 12, 2011

By PAUL KRUGMAN

Every once in a while a politician comes up with an idea that’s so bad, so wrongheaded, that you’re almost grateful. For really bad ideas can help illustrate the extent to which policy discourse has gone off the rails.

And so it was with Senator Joseph Lieberman’s proposal, released last week, to raise the age for Medicare eligibility from 65 to 67.

Like Republicans who want to end Medicare as we know it and replace it with (grossly inadequate) insurance vouchers, Mr. Lieberman describes his proposal as a way to save Medicare. It wouldn’t actually do that. But more to the point, our goal shouldn’t be to “save Medicare,” whatever that means. It should be to ensure that Americans get the health care they need, at a cost the nation can afford.

And here’s what you need to know: Medicare actually saves money — a lot of money — compared with relying on private insurance companies. And this in turn means that pushing people out of Medicare, in addition to depriving many Americans of needed care, would almost surely end up increasing total health care costs.

The idea of Medicare as a money-saving program may seem hard to grasp. After all, hasn’t Medicare spending risen dramatically over time? Yes, it has: adjusting for overall inflation, Medicare spending per beneficiary rose more than 400 percent from 1969 to 2009.

But inflation-adjusted premiums on private health insurance rose more than 700 percent over the same period. So while it’s true that Medicare has done an inadequate job of controlling costs, the private sector has done much worse. And if we deny Medicare to 65- and 66-year-olds, we’ll be forcing them to get private insurance — if they can — that will cost much more than it would have cost to provide the same coverage through Medicare.

By the way, we have direct evidence about the higher costs of private insurance via the Medicare Advantage program, which allows Medicare beneficiaries to get their coverage through the private sector. This was supposed to save money; in fact, the program costs taxpayers substantially more per beneficiary than traditional Medicare.

And then there’s the international evidence. The United States has the most privatized health care system in the advanced world; it also has, by far, the most expensive care, without gaining any clear advantage in quality for all that spending. Health is one area in which the public sector consistently does a better job than the private sector at controlling costs.

Indeed, as the economist (and former Reagan adviser) Bruce Bartlett points out, high U.S. private spending on health care, compared with spending in other advanced countries, just about wipes out any benefit we might receive from our relatively low tax burden. So where’s the gain from pushing seniors out of an admittedly expensive system, Medicare, into even more expensive private health insurance?

Wait, it gets worse. Not every 65- or 66-year-old denied Medicare would be able to get private coverage — in fact, many would find themselves uninsured. So what would these seniors do?

Well, as the health economists Austin Frakt and Aaron Carroll document, right now Americans in their early 60s without health insurance routinely delay needed care, only to become very expensive Medicare recipients once they reach 65. This pattern would be even stronger and more destructive if Medicare eligibility were delayed. As a result, Mr. Frakt and Mr. Carroll suggest, Medicare spending might actually go up, not down, under Mr. Lieberman’s proposal.

O.K., the obvious question: If Medicare is so much better than private insurance, why didn’t the Affordable Care Act simply extend Medicare to cover everyone? The answer, of course, was interest-group politics: realistically, given the insurance industry’s power, Medicare for all wasn’t going to pass, so advocates of universal coverage, myself included, were willing to settle for half a loaf. But the fact that it seemed politically necessary to accept a second-best solution for younger Americans is no reason to start dismantling the superior system we already have for those 65 and over.

Now, none of what I have said should be taken as a reason to be complacent about rising health care costs. Both Medicare and private insurance will be unsustainable unless there are major cost-control efforts — the kinds of efforts that are actually in the Affordable Care Act, and which Republicans demagogued with cries of “death panels.”

The point, however, is that privatizing health insurance for seniors, which is what Mr. Lieberman is in effect proposing — and which is the essence of the G.O.P. plan — hurts rather than helps the cause of cost control. If we really want to hold down costs, we should be seeking to offer Medicare-type programs to as many Americans as possible.

Kaiser Health News

Jun 07, 2011

As Republicans battle with Democrats and President Barack Obama over the future of the health care law, Donald Berwick, the administrator of the Centers for Medicare and Medicaid Services, is focused on something else.

New York Times, May 21, 2011

By ABBY GOODNOUGH

MONTPELIER, Vt. — Many people move to Vermont in search of a slower pace; Dr. Deb Richter came in 1999 to work obsessively toward a far-fetched goal.

She wanted Vermont to become the first state to adopt a single-payer health care system, run and paid for by the government, with every resident eligible for a uniform benefit package. So Dr. Richter, a buoyant primary care doctor from Buffalo who had given up on New York’s embracing such a system, started lining up speaking engagements and meeting with lawmakers, whom she found more accessible than their New York counterparts.

“I wrote a letter to the editor, and the speaker of the House called me up to talk about it,” Dr. Richter, 56, recalled recently. “It was astounding. In New York, I couldn’t even get an appointment with my legislator.”

Twelve years later, Dr. Richter will watch Gov. Peter Shumlin, a Democrat, sign a bill on Thursday that sets Vermont on a path toward a single-payer system — the nation’s first such experiment — thanks in no small part to her persistence. Though scores of people pushed for the bill, she was the most actively involved doctor — “the backbone,” Mr. Shumlin has said, of a grass-roots effort that helped sway the Democratic Legislature to pass it this spring even as other states were suing to block the less ambitious federal health care law.

“We wouldn’t be where we are without Deb,” Mr. Shumlin said in an interview. “She’s made this her passion. And like anyone that’s making significant social change, she has qualities of persuasiveness and leadership and good judgment that are hard to find.”

As in all states, the cost of health care has increased sharply in Vermont in recent years. It has doubled here over the last decade to roughly $5 billion a year, taking a particular toll on small businesses and the middle class. All 620,000 of the state’s residents would be eligible for coverage under the new system, which proponents say would be cheaper over all than the current patchwork of insurers. A five-member board appointed by the governor is to determine payment rates for doctors, what benefits to cover and other details.

But much remains to be worked out — so much that even under the most optimistic projections the plan might not take effect until 2017. Most significantly, Mr. Shumlin still has to figure out how much it will cost and how to pay for it, possibly through a new payroll tax. Whether he will still be in charge by 2017 is among the complicating factors.

“If we had the exact same Legislature and the same governor we could get it done,” Dr. Richter said. “It’s a big if, because the opposition has a ton more money to convince people that the governor is evil and this is socialized medicine and all kinds of other scary stuff.”

The opposition will probably include insurance companies, drug makers and some employers who say there are too many unknowns. Many doctors, too, are wary of the change and what it might mean for their income. Dr. Richter said she believed a “slim majority” of the state’s 1,700 licensed physicians were supportive.

“One of the bigger worries I have is we’ve had all this hoopla and nothing’s going to happen,” she said at a coffee shop here recently on a rare quiet afternoon. “But it might also be helpful to us, because it’s going to be hard for any opposition to be steadily pushing for seven years.”

The federal health care law has complicated Vermont’s plans, requiring the state to first create a health insurance exchange to help residents shop for coverage by 2014. The state would then need a federal waiver to trade its exchange for a government-run system.

Dr. Richter said she embraced the idea of a single-payer system as a young doctor in Buffalo, where many of her patients put off crucial treatments because they were uninsured. As a medical student, she saw a patient with a life-threatening heart infection caused by an infected tooth that had gone untreated because he lacked dental insurance.

“He was in the hospital for six weeks, and I was like, ‘This makes no sense,’ ” she said.

She went to a meeting of Physicians for a National Health Program, a group that advocates for a national single-payer system, and started researching the concept. Before long she became a vocal advocate, even becoming president of the physicians’ group, and moved to Vermont.

John McClaughry, a former Republican state senator who is against the new law, said Dr. Richter meant well but did not understand the “long-term damage” it would wreak. In particular, he said the law would drive away businesses that did not want to help pay for it. “She’ll tell you that putting in single-payer will attract businesses from all over the place,” said Mr. McClaughry, vice president of the Ethan Allen Institute, a conservative research group. “I don’t think she has any appreciation of business decisions at all.”

Since moving with her husband and two sons to a rambling old house within view of the State House, Dr. Richter has given about 400 talks on the single-payer concept, tutored lawmakers in the State House cafeteria and testified before the Legislature more times than she can remember. Once, she presented a printout of all the insurance companies her small practice in Cambridge had billed over five years.

“It was like 190 pages long,” she said. “Here we were, this tiny rural clinic having to bill all these different addresses. And all of them have different rules and reimbursements; I mean, it’s ridiculous.”

Some supporters of single-payer health care say Vermont’s law does not go far enough, mostly because it would allow at least a handful of private insurers to stay in the market indefinitely. Self-insured businesses like IBM, the state’s largest employer, could continue providing health coverage to workers under the law, though they would have to help finance the new system, possibly through a payroll tax.

Physicians for a National Health Program is among the critics, saying the law “falls well short of the single-payer reform needed.” Allowing private insurers to remain in the state will prevent meaningful savings, the group says.

Dr. Richter acknowledges that the law will not allow for “strict single-payer,” but said it still promised “health care for everybody, for less cost.”

“This is not the top of the mountain, but it’s the first time anyone has headed up the mountain,” she said. “No other place in the country has gotten this far.”

April 21st, 2011 9:51 PM

By Wendell Potter

Rep. Paul Ryan's plan to privatize Medicare would accelerate a trend started several years ago by corporate CEOs and their political allies to shift ever-increasing amounts of risk from Big Business and the government to workers and retirees.

If enacted, the Ryan plan would represent a windfall of unprecedented proportions for insurance corporations and other businesses.

For millions of average Americans, many of whom already are finding it impossible to save for retirement, it would represent financial calamity. The nation's middle class would pay dearly for Ryan's proposed shredding of the social safety net that Medicare currently provides.

Ryan, chairman of the House Budget Committee, wants to dismantle the Medicare program and replace it with a system of vouchers. Starting in 2022, the government would give the average 65-year-old Medicare beneficiary $8,000 a year to buy coverage from a private insurer. That's the amount health care analysts estimate will be what the Medicare program will spend on every 65-year-old in 2022 if the government doesn't turn it over to private insurance companies.

While that might sound fair on the surface, it would actually be a very bad deal for people who turn 65 that year, compared to those who turn 65 in 2021. That's because commercial insurance plans are much more expensive, and operate far less efficiently, than the current Medicare program.

The amount of money commercial plans actually spend to pay medical claims has been declining rapidly over the past several years while the amount they spend on administrative activities such as marketing and underwriting -- and to pay executives and reward shareholders -- has been increasing. That's why Congress included a provision in last year's health care reform law to require insurance firms to spend no more than 20 percent of their policyholders' premiums on overhead. By contrast, the current Medicare program spends just 3 percent of its budget on administration.

The nonpartisan Congressional Budget Office says the $8,000 voucher won't be nearly enough for seniors to buy comparable coverage from private insurers and pay the additional out-of-pocket costs that those insurers would require them to pay. The amount the average 65-year-old would have to shell out to buy private insurance in 2022, according to the CBO, will actually be $20,510. Seniors would have to pay the difference -- $12,510. If Medicare is not privatized, the difference would be $6,150.

Here's why this would be a dream-come-true for the insurance industry: The more health plan enrollees have to pay out of their own pockets, the less insurers have to pay for medical care. The money that insurers avoid paying out in claims goes straight to their bottom line -- and into shareholders' pockets.

Insurers have been shifting more and more of the cost of care to their policyholders over the past several years by enticing -- or pushing -- them into plans with ever increasing deductibles. This trend is part of what Yale professor Jacob S. Hacker called "the personal responsibility crusade" -- making people more responsible for the management and financing of the major economic risks they face -- in his 2006 book, The Great Risk Shift.

This crusade has been led by Republicans and insurance company executives who have been saying for years that the best way to control medical costs is for Americans to have more "skin in the game." That's an expression that former Aetna CEO Jack Rowe used often before he retired in 2005, the year he made $22.2 million. It was also a sound bite favored by the CEO I used to work for, CIGNA's Ed Hanway, before he retired in 2009. Hanway's total compensation that year was almost $111 million.

The problem is, most Americans have far less skin to put in the game than CEOs like Rowe and Hanway or even Rep. Ryan, who makes $174,000 as a member of Congress. The median household income in the United States was just $49,777 in 2009, which was down $335 from 2008.

That decline, by the way, was the continuation of another trend that began as the Clinton era was ending and the George W. Bush era was beginning. Median household income in the United States peaked in 1999 at $52,388 (adjusted for inflation). It fell more than $2,000 during the eight years of the Bush administration.

During that time, health costs rose dramatically. According to the Kaiser Family Foundation, the average annual health insurance premium for family coverage increased from $5,791 in 1999 to $13,770 in 2010. The average amount that workers contributed out of their own pockets for family coverage increased from $1,543 to $3,997.

With household incomes declining, Americans have had far less money to put into retirement. According to a recent survey conducted by Opinion Research Corp. for America Saves and the American Savings Education Council, less than half of current workers are saving enough to have a "desirable standard of living in retirement."

If workers are having this much difficulty saving for retirement, where in the world will they find the money to pay what Rep. Ryan would make them pay for Medicare coverage when they turn 65?

Ryan's "blueprint" is one that will take America back to the pre-1965 days when senior citizens were losing their homes and their farms to pay for medical care. They were becoming destitute -- and dying much earlier than they are today -- because insurers would not sell them coverage because they were too much of a risk to insure, and there was no safety net for them.

That's exactly the same place future senior citizens would find themselves if Ryan's plan to privatize Medicare ever becomes public policy. #

About that advisory board: We have to do something about health care costs, which means that we have to find a way to start saying no. In particular, given continuing medical innovation, we can’t maintain a system in which Medicare essentially pays for anything a doctor recommends. And that’s especially true when that blank-check approach is combined with a system that gives doctors and hospitals — who aren’t saints — a strong financial incentive to engage in excessive care.

Hence the advisory board, whose creation was mandated by last year’s health reform. The board, composed of health-care experts, would be given a target rate of growth in Medicare spending. To keep spending at or below this target, the board would submit “fast-track” recommendations for cost control that would go into effect automatically unless overruled by Congress.

Before you start yelling about “rationing” and “death panels,” bear in mind that we’re not talking about limits on what health care you’re allowed to buy with your own (or your insurance company’s) money. We’re talking only about what will be paid for with taxpayers’ money. And the last time I looked at it, the Declaration of Independence didn’t declare that we had the right to life, liberty, and the all-expenses-paid pursuit of happiness.

And the point is that choices must be made; one way or another, government spending on health care must be limited.

Now, what House Republicans propose is that the government simply push the problem of rising health care costs on to seniors; that is, that we replace Medicare with vouchers that can be applied to private insurance, and that we count on seniors and insurance companies to work it out somehow. This, they claim, would be superior to expert review because it would open health care to the wonders of “consumer choice.”

What’s wrong with this idea (aside from the grossly inadequate value of the proposed vouchers)? One answer is that it wouldn’t work. “Consumer-based” medicine has been a bust everywhere it has been tried. To take the most directly relevant example, Medicare Advantage, which was originally called Medicare + Choice, was supposed to save money; it ended up costing substantially more than traditional Medicare. America has the most “consumer-driven” health care system in the advanced world. It also has by far the highest costs yet provides a quality of care no better than far cheaper systems in other countries.

But the fact that Republicans are demanding that we literally stake our health, even our lives, on an already failed approach is only part of what’s wrong here. As I said earlier, there’s something terribly wrong with the whole notion of patients as “consumers” and health care as simply a financial transaction.

Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional. There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers.

The idea that all this can be reduced to money — that doctors are just “providers” selling services to health care “consumers” — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

Tuesday, December 14, 2010

By Josh Goodman, Stateline Staff Writer

Circleville Herald
Thursday, September 30, 2010 9:54 AM EDT

What are we afraid of?

"You can always tell if you're succeeding by the viciousness of the opposition." — Dr. Quentin Young, PNHP National Coordinator

By Nicholas Skala. Updated by Chris Gray, July, 2010

As the movement for single payer expands, attacks on single payer in the media by the far right have increased. In addition to misleading articles and op-eds, several books attacking single payer by conservative pundits were published in recent years, including one endorsed by former GOP Speaker of the House Newt Gingrich.

The PNHP National Office has identified 20 right-wing think tanks that employ full-time health policy "scholars" to oppose national health insurance and advocate for health care privatization, deregulation and market-based reforms. These groups are funded with millions of dollars from wealthy far-right foundations such as the Lynde & Harry Bradley Foundation, the Charles Koch Foundation, the John Olin Foundation, the Adolph Coors family’s Castle Rock Foundation and the Scaife Family Foundations, which share an ultra-conservative social agenda.

The Right-Wing "Echo Chamber": Although they masquerade as legitimate research institutions, most of these policy think tanks are little more than PR firms for those who want to obscure the facts about health care in America. Many, such as the Fraser Institute, produce bogus research and purposely avoid peer review. Instead, they provide "experts" with fancy titles to write editorials and appear on TV news programs to spread misinformation. Each of these institutions is funded by the same small group of ideological foundations, and it is extremely common for these "experts" to cite each other's bogus research in their commentaries, giving the impression of wide scientific credibility for their views. Twenty of the top "think" tanks are detailed below. Members are encouraged to take the lead on behalf of PNHP in responding to misinformation spread by these and other groups.

September 1, 2010

By Don McCanne

Speaker John Perez of the California State Assembly, on the very last day of the legislative session, pulled SB 810, the single payer bill, from the Assembly floor.

This highly unusual move of pulling a bill that had cleared all legislative hurdles except for the final Assembly floor vote was to protect Democrats from having to cast a health care reform vote in a difficult political environment three months before the next election.

Democrats feared a backlash from those who are opposed to the recently enacted federal health care legislation should they vote for the bill, and they feared offending their progressive base should they vote against the bill. Since a veto by Gov. Schwarzenegger was a given, it was decided that it would be safer to avoid the political risks by simply pulling the bill.

But did they really avoid that risk? Are the single payer advocates expendable? Don't think so.

Fortunately, Senator Mark Leno is not to be deterred. He has vowed to reintroduce the bill in the next legislative session which begins in January.

The Democrats are worried about their political base, but maybe that's not the framing we should be looking at. Perhaps the single payer advocates should be reassessing their own base instead.

Not all Democrats have been supportive of single payer, and several Republicans who are not part of the prevailing lock-step bloc do understand the benefits of the single payer model. The Patient Protection and Affordable Care Act is proof that we can't rely on the Democrats to do the right thing. Most importantly, everyone understands the benefits of Medicare as a social insurance program (even if there is a fringe reactionary element that would emasculate it).

The Tea Party is proving that passionate voices can be heard. Maybe we can learn from them, though our message should contain more than simple platitudes. Our message needs to convey the principled substance of health care justice, and it needs to be loud, clear and highly infectious.

Honeywell locks out USW Local in Illinois over health care — sister Local in Canada wins contract with no problem; everyone there Is covered under Canada’s single-payer plan

On June 28, 2010, Honeywell locked out the 230 union workers at its uranium hexafluoride plant in Metropolis, an Ohio River town of 6,500 at the tip of southern Illinois 400 miles south of Chicago. A working class town nestled amidst the corn, soybean and wheat fields, Metropolis is known for its Superman statue on the court house square where most Illinois candidates, including Barack Obama, have stopped by for a photo op.

Honeywell didn’t care if the workers liked their health care plan. This corporation said it was not going to let them keep it. The members of United Steelworkers (USW) Local 7-669 refused to accept the company proposal to increase workers’ out of pocket health care maximum to $8,500 a year and to end retiree health coverage. The union proposed to continue working as they bargained. Honeywell said no and locked the doors.

USW 7-669’s sister local in Canada signed their current contract in July 2010, and health care coverage did not present a problem. “Bargaining was not particularly difficult this time around,” said Chris Leavitt, President of USW Local 13173 in Port Hope, Ontario, Canada, home of the Cameco plant, the only other one in North America to make the uranium hexafluoride used to produce nuclear energy. Canadian USW Local 13173 is about the same size as the Metropolis local and was a part of District 50 of the United Mine Workers which affiliated with the USW.

Everyone is covered under the Ontario Health Insurance Plan—automatically–as a part of Canada’s Medicare, a single payer plan, explains Leavitt. Members of Local 13173 and their families pay nothing—no premium, no co-pay, no co-insurance, no deductible–for hospital care plus medication, out patient services, doctor’s visits, and other doctors’ services such as surgery. Health care is publicly funded for everyone so unions can use their bargaining power to negotiate for wages and other benefits. Read full article.