With the final White House Forum on healthcare scheduled Monday, April 6 in downtown Los Angeles, advocates of single payer/guaranteed healthcare have one more opportunity to shake up what has become a dreary conventional wisdom about the presumed acceptable parameters of the debate.

Hundreds of nurses, doctors, healthcare and labor activists will rally at 9 a.m. outside the California Endowment, 1000 North Alameda St., Los Angeles.

It will mark the fifth time, at all five White House regional forums, that the single payer/Medicare for all message will come to the stage, outside and inside the forum.  You can extend that to the town hall meeting at the White House last week where the President was asked why we can't have a national healthcare system like they have in other industrialized nations.

But the scene is very different in the committee rooms where the top legislators, with their handpicked insiders, either from the healthcare industry or conventional players who won't upset the status quo, have determined the general framework of a legislative approach they deem acceptable — and dismissed as out of bounds the one reform most likely to work, a single payer approach.

While single payer is not on the table, accommodating the insurance industry and healthcare proposals by the party that was trounced in the polls in November apparently is.

That's why two of the biggest debates now are not over whether to adopt a national healthcare system, that has guaranteed access to care in every other industrialized nation, but whether to force people to buy private insurance and to tax their employer-funded health benefits.

Start with requiring everyone not covered to buy insurance, which amounts to a massive bailout for the insurance industry. The Democratic chairs of the key committees that are running the show on healthcare have all agreed that individual mandate, putting us all in hock to the insurance giants, will be part of the bill, the New York Times' Robert Pear reported this morning.

Their alleged premise, says Pear, “that if everyone had health insurance, it would be easier to control health costs.” 

Not to mention that it is the top priority for the insurance industry, which is salivating at the prospect of tens of millions of new customers marched into their offices under threat of federal penalties.

But it's not so popular with everyone else — a major reason why the individual mandate plan by Gov. Arnold Schwarzenegger, host of the LA forum, crashed and burned last year. And it hasn't worked so well in its prime model, Massachusetts, either.

Listen to the comments of Massachusetts State Sen. Jamie Eldridge, who voted for the law, but recently gave this assessment to a Congressional committee, as reported by healthcare writer extraordinaire, Trudy Lieberman at the Columbia Journalism Review:

The assumption was that, as more people—and, in particular, more young and relatively healthy people—joined the system, premiums would go down across the board. There was also the assumption that as more people became insured, the number of people going to the emergency room would drop dramatically, saving the Commonwealth money. Neither of those things have happened—at least not enough to produce the cost savings we were told we would see. In fact, health care reform has cost the Commonwealth much more than expected—-up to a record $1.3 billion this year. It is maddening that so many of our public health care dollars are diverted to HMOs and health insurance companies, under the current employer-based Massachusetts health care system.

As to taxing benefits, turn the page back to the fall campaign when that idea, the centerpiece of Sen. John McCain's healthcare plan, was widely denounced by soon-to-be President Obama and virtually every other Democrat running for office in stump speeches, election mail, and numerous TV ads.

It was considered so distasteful Sen. Joe Biden even found it to be a handy zinger to Gov. Palin in the vice-presidential debate, saying: “Taxing your healthcare benefit. I call that the ultimate Bridge to Nowhere.”

But, apparently that was then and this is now, as the Los Angeles Times affirmed this week:

Democrats and Republicans on Capitol Hill are expressing increasing openness to an idea that once seemed unthinkable: putting taxes on some healthcare benefits.

And Peter Orzag, the Obama administration's budget director, told the Washington Post that taxing benefits “should most definitely remain on the table.” Unlike real reform, apparently.

What changed? Lieberman has one idea:

What happened to Obama’s budget proposal of a $634 billion down payment (for health care reform) that was to be funded in part by making wealthier people pay higher income taxes? Or the $175 billion that was to be saved by cutting the excess payments to Medicare Advantage plans over ten years? … The Senate draft budget doesn’t contain any actual money for health care. Instead…there will be “space” for a health reform reserve fund. No taxing the rich—members of Congress beat up on that one. No trimming Medicare Advantage plans—insurers don’t like that.

The $634 billion figure was always too small to provide all the subsidies people will need if they are required to buy health insurance, which seems to be the direction the pols are going. But if Obama’s revenue source doesn’t survive the budget process, then where does the money come from? …  Bingo! The money might just come from taxing the health insurance benefits of …  everyone else who gets insurance from their boss.

Ironically, the main reason President Obama says single payer reform is not under consideration is because it would “scrap (the employer based system) everybody is accustomed to,” as he said in the town hall meeting last week in response to the question of why we can't have the system that works for everyone else:

But demolishing what we have now is almost exactly what would happen when you tax health care benefits.

Many if not most of the youngest and healthiest employees, especially in a recession, would drop their employer coverage to shop for cheaper, barebones plans in the private individual market.

Employers, left with the more expensive employees to cover and an unsustainable risk pool, would see their premium costs skyrocket even more, prompting many to sharply reduce coverage or eliminate benefits entirely.

As Texas employers and healthcare analysis succinctly told the Dallas Morning News' Jason Roberson during the campaign, “this could eventually lead to the death of company-provided health plans.”

Some seem to have forgotten that consequence. On April 6, come help us remind them.

Haven't we heard this song before? It sure looks like the people who already control our healthcare system are framing the biggest issues of the present healthcare reform debate.

From the back rooms to the committee hearings to the White House summits to the front pages of the newspapers, the demands of the insurance industry are given enormous deference and accommodation.

Is it fear of Harry and Louise, the insurance campaign that some believe torpedoed the muddled Clinton health proposal? Is it the considerable influence of insurance industry contributions in the pockets of many legislators?

Or perhaps it's the caution or lack of will of some liberal groups to press for more fundamental reform–such as a single payer/expanded Medicare for all approach–that permits the industry and its conservative champions in Congress to dominate the terrain.

There's two major indications of this trend.

First, who is in the room where the key decisions are being made. As Consumer Watchdog put it:

First we heard that consumer advocates had been left out of closed-door negotiations orchestrated by senate staffers to formulate health care reform legislation. Then, consumer advocates were left off the invite list to the White House summit on health care reform.  The third strike came when no consumer voices were heard at a U.S. Senate Heath, Education, Labor and Pensions committee round table discussion about insurance reforms in the forthcoming national health care reform effort.  Three of the seven panel members were from the insurance industry.  A forth panelist represents an insurer-friendly think tank.

The second key sign is what the chattering class defines as the contours of the debate.

In a telling piece earlier this week, the Washington Post's Ruth Marcus called the present moment “crunch time” in which only five major pieces remain to be resolved.

Piece One: Should there be a public insurance option?
Piece Two: How to pay for the program? Specifically, should employer-provided health insurance, no matter how generous, continue to be treated as tax-free income?
Piece Three: Should individuals be required to purchase insurance?
Piece Four: What mechanism should there be to control costs?
Piece Five: How much muscle should Democrats use to get health-care reform done? The temptation is to use special budget procedures known as reconciliation that would allow Senate Democrats to approve health reform with just 51 votes. House leaders, fed up with being held hostage by Senate gridlock, are pushing this approach.

On each of the policy points here, the insurance industry and its defenders are on the offensive. And on every point, major concessions that will appease the insurers, but do little to rein in skyrocketing costs or protect families, lurk.  

Imagine a scenario in which the bill that finally emerges includes a mandate that all individuals must buy private insurance, but there are no uniform standards, widely varying prices for coverage depending on where you live or your age, no real controls on what the insurance companies can charge in premiums, co-pays, deductibles and other out of pocket costs. If that sounds a lot like the badly flawed Massachusetts model, it should.

If you get health coverage at work, your benefits are now taxed, a clear incentive for your employer to reduce or drop coverage, pushing more people into the still poorly regulated cutthroat private market.

And even if proponents win on the much debated public plan option, don't expect it to solve the problem, as Physicians for a National Health Program leaders David Himmelstein and Steffi Woolhandler point out :

1. It forgoes at least 84 percent of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes, which would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even if 95 percent of Americans who are currently privately insured were to join the public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16 percent of the roughly $400 billion annually achievable through single payer — not enough to make reform affordable.

2. A quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan — which started as the single payer for seniors and has now become a funding mechanism for HMOs — and a place to dump the unprofitably ill. A public plan option does not lead toward single payer, but toward the segregation of patients, with profitable ones in private plans and unprofitable ones in the public plan.

Yet only on the final piece identified by the Post's Marcus, process, does it look like the insurers and the right are being aggressively challenged. Perhaps what may be most telling is the gushing this week over the non-concession by the insurance industry that it will be willing to end its immoral practice of denying coverage to people with pre-existing conditions if it gets everything else it wants. 

In his town meeting yesterday in which the public got to ask the questions, President Obama was asked about single payer, and while demurring that we have “a legacy, a set of institutions that aren't that easily transformed” showed that he understands a central tenet of what is clearly right about single payer.

“A lot of people think that in order to get universal health care, it means that you have to have what's called a single-payer system of some sort. And so Canada is the classic example: Basically, everybody pays a lot of taxes into the health care system, but if you're a Canadian, you're automatically covered. And so you go in — England has a similar — a variation on this same type of system. You go in and you just say, “I'm sick,” and somebody treats you, and that's it.”

The challenge to the rest of us is to show that legacy has collapsed and no longer works for the uninsured or the insured, and move the debate beyond what the insurers want to what the rest of us need.

Lots of people are showing up at the White House forums on healthcare and delivering a very different message from Beltway insiders about what the final bill should look like.

In Des Moines Monday, registered nurses, doctors, and other healthcare activists, led by the California Nurses Association National Nurses Organizing Committee, Minnesota Nurses Association, Physicians for a National Health Program, and Healthcare Now, showed up outside the hall pressing the case for single-payer reform, and then took the theme inside the meeting.

Dr. Jess Fiedorowicz, a psychiatrist at the University of Iowa Hospitals who was with the protest group, told the meeting a majority of Americans support a “single payer” or government-run national health insurance program.

“Can we put it on the table for discussion?” Fiedorowicz asked Nancy-Ann De Parle, director of the White House Office on Health Reform.

“Can we study costing? Can we study feasibility of this truly universal, socially just and fiscally responsible alternate to our currently unjust and woefully inefficient system?” Fiedorowicz asked. Many in the crowd applauded.

Vashti Winterburg, 61, co-chair of Kansas Health Care for All, said she opposes any plan that keeps health insurance companies in business.

Rally in Des Moines, Iowa

Presumably that was not what the planners of this process were expecting when they started holding these forums away from Washington. And, somehow, the White House blog on the event neglected to mention Fiedorowicz's speech.

But though the White House and some in the media continue to close their eyes, the regional events are providing a reminder of what type of reform does have the support of doctors, nurses, and so many grassroots activists.

In Des Moines, Iowa, Dearborn, Mi., and Burlington, Vt., all three forums have seen big turnouts by single payer activists outside and inside the meetings outlining vocal opposition to any reforms that leave the insurance industry with a chokehold on our health.

Rally in Burlington, Vermont 

In Dearborn, for example, Adrian Campbell Montgomery, one of the real life stars of “SiCKO” recounted her chilling experiences with the insurance industry that have continued since the release of the film.

Adrian Campbell Montgomery is waiting to hear if she'll qualify for Medicaid, which could pay for the surgery she needs to have her cancerous ovary removed. It was the second brush with cancer for the 26-year-old from Howell, who four years ago had to pay an $8,000 surgery bill for surgery to treat her cervical cancer because her parents' insurance company said surgery wasn't recommended until patients were 26 years old.

“When you're sick, you need help. Other countries do that,” she told reporters after getting a standing ovation from the hundreds of people who attended the first White House Regional Health Reform Forum at the Ford Conference and Convention Center. “The debt, the worry, the stress — I don't want it anymore.”

What is it that those other countries do?  They have single payer or national health systems and don't let the insurance companies decide who will receive care and who won't. That's a message those holed up in the insular committee rooms in Washington seem anxious to avoid.

Two more summits and two more opportunities remain, for all of us to send a reminder about what real reform would look like: March 31 in Greensboro, NC, and April 6 in Los Angeles. Join us.

It's time to lay to rest the myth that spending billions on more high tech is the salvation for rising healthcare costs. Some people will peddle any notion to avoid addressing the best way to rein in costs, pushing the insurance companies out of the way with a single payer system.

It's become an article of faith that a national system of electronic medical records would produce huge savings.  President Obama made it a centerpiece of his healthcare plan during the campaign (as did Sen. John McCain), and has emphasized it repeatedly in legislation and speeches.

As a first step, the stimulus bill allotted $17 billion in incentives to prod doctors and hospitals to get on board during a five year period beginning in 2011, along with financial penalties if they don't.

The administration has relied in large part on a RAND study claiming savings of $80 billion a year through the nirvana of what Wall Street Journal reporter Anna Wilde Mathews caustically referred to as “whizbang computer systems.” The President cited the $80 billion figure again during the White House health-care summit last week. Or, as White House press secretary Robert Gibbs asserted, “The health IT in the economic recovery plan will make health care more affordable, will save patients' lives, and increase the quality and the outcome of the health care that millions of people are provided.” He might want to take a mulligan. As a series of reports this week make clear, the bloom is coming off the rose. Writing in the Wall Street Journal, Harvard Medical School faculty Jerome Groopman and Pamela Hartzband debunk the received wisdom, noting:

Following his announcement, we spoke with fellow physicians at the Harvard teaching hospitals, where electronic medical records have been in use for years. All of us were dumbfounded, wondering how such dramatic claims of cost-saving and quality improvement could be true.

It's not, they conclude. And they are not alone. The RAND study has been sliced and diced fairly regularly now by, among others, one Peter Orszag, now the White House budget director.

Last May, when Orzag was director of the Congressional Budget Office, CBO examined the Rand report and a parallel study concluding they “appear to significantly overstate the savings for the health care system as a whole — and, by extension, for the federal budget.” Summing it the CBO findings, Orzag concluded that while the technology, in combination with other moves, may help reduce expenses, “by itself it typically does not produce a reduction in costs.”

Another report from Avalere Health, quoted by the Associated Press this week, concludes it will cost providers far more to implement the golden goose systems than they will get back in return.

Using government cost estimates, Avalere researchers found that it would cost about $124,000 for a single doctor or small practice to upgrade to electronic health records over the five year period from 2011-2015 when the stimulus bill offers incentives to do so.

But the total incentive payments a doctor could get over that time period only add up to $44,000. In 2015, penalties start to kick in for doctors who haven't switched to electronic record-keeping. But in one scenario mapped by Avalere, the starting penalty would be $5,100 a year — far less than how much it would cost to install and maintain an electronic health system.

In other words, a pig in a poke. And, that's just the supposed financial benefits. Registered nurses have long raised alarms that some of the technology may be intended to displace staff or an RN's professional judgment, which is especially critical with the complex medical conditions seen in the patients who get through the hospital doors these days, and said those billions could be better spent on actual care delivery. Many doctors, like those in the Journal report, are speaking out now as well. Groopman and Hartzband note “there is no evidence that electronic medical records lower the chances of diagnostic error.” And they point to studies that raise further doubts. For example:

A 2008 study published in Circulation, a premier cardiology journal, assessed the influence of electronic medical records on the quality of care of more than 15,000 patients with heart failure. It concluded that “current use of electronic health records results in little improvement in the quality of heart failure care compared with paper-based systems.”

Another such warning came from MD Scott Haig this week in Time who describes the frustrations of doctors who are forced to use such systems “or risk losing our hospital privileges” if they don't. Yet some big hospital chains are spending billions of dollars for the high tech hype with despite the lack of evidence it will produce either cost savings or improved healthcare. Haig wonders who is really behind it and concludes:

Not surprisingly, nationwide adoption of Electronic Medical Records is being pushed hardest by those who would profit financially from it. The slightly embarrassing financial reality of EMR is that large, mechanized medical operations like hospitals, clinics and big multi-doctor practices stand to make quite a bit of money by adopting them — given our current convoluted system of paying for health care. Two clear factors make EMR a money-winner: improved billing and internal cost control.

And, there's another hook for the insurers here, Haig notes:

Computerized medicine means both more information — and less medicine. Less therapy, less surgery and less testing too. That's how it saves money. A variety of promising terms describe it — terms like targeted treatment, algorithmic patient-care, fiscally responsible medicine and evidence-based practice — but for doctors treating patients, one word describes how computerized records save money. Denial. EMR has the potential to greatly increase insurance company denials of the tests and treatments that doctors order.

Big profits, for the tech corporations that manufacture them, and the software companies that design them. Better bill collection for the hospitals. Improved billing, and fewer nettlesome claims for the insurers whose first priority is always receiving payment, not actually paying for care. Who would have guessed? A boondoggle for some, it looks like, and misplaced priorities for the rest of us.

While thousands of activists step up efforts to make single payer a part of the national debate on healthcare reform, similar efforts are underway in many state capitals as well.

With a dual purpose. Single payer might end up enacted in a few states first, then spread like a prairie fire across the nation — the approach that worked for Canada. And the grassroots campaigns in states should reinforce the national push.  

California is a case in point. Twice in the last few years, a single payer, Medicare for all style bill has passed the state legislature, only to be vetoed by the insurance companies’ ever loyal Gov. Arnold Schwarzenegger.  

But the campaign to pass the bills has brought together dozens of healthcare, labor, and community organizations across California who have subsequently become a central component of national coalitions for single payer, and an impressive army of activists who have made their voices heard on healthcare.

Just ask the insurance trade lobby association which hosted a national convention in San Francisco last June, only to be greeted by 3,000 people surrounding the conference center and resonating it with chants that were heard throughout the conference hall.

Fast forward to today, and the re-introduction of a single payer bill in Sacramento in a press conference jammed with dozens of nurses, health care activists, doctors, medical students, union members, seniors, and many others.

As bill author State Sen. Mark Leno of San Francisco, put it, the new bill, SB 810, “is not just legislation. It’s one of the fastest growing social movements in California.”

California State Sen. Mark Leno with California Nurses Association/NNOC Executive Director Rose Ann DeMoro to his right and community activists at Sacramento press conference.

Despite the political pragmatists or cynical policy wonks or legislators who have tried to shut single payer out of the healthcare reform debate, the movement itself has taken on a life of its own.

“We’re not going away — and our ranks are building,” said Rose Ann DeMoro, executive director of the California Nurses Association/National Nurses Organizing Committee, principal sponsor of the bill, said at the press conference.  

Among the many others represented were the California School Employees Association, One Care Now (a coalition of many other community and senior groups), Los Angeles Unified School District, California Physicians Alliance, medical students, and about a dozen other legislators.

“What we are doing here will influence and impact the debate nationally,” Leno pointed out, adding that it just might be passed in California — or any number of other states — first.

And he used a national example, the banking meltdown, to emphasize part of the argument for the single payer. “In health care, it is the industry who decides who they will insure and who takes the profit, and we the public who take all the risk. Just as in the banking system, the private banks took the profits, and now we the public are taking the risk.

Anticipating the expected opposition of Schwarzenegger again, Leno noted, “we intend to keep the debate alive through the facts” of the bill, place it on the governor’s desk again, said Leno, and, if needed, “work hard to elect a governor in 2010 who will sign our bill.”

SB 810 is an successor to SB 840, the single payer valiantly carried for years by now retired State Sen. Sheila Kuehl.  From both a health care policy and economic perspective the bill is more critical than ever.

As if any more reminders were needed, one came with a Gallup-Healthways Well-Being Index survey reported today in USA Today which found that 21 percent of Americans have difficulty paying for needed medical care or medications, with great disparities based on race and class. And the numbers facing that financial stress grew rapidly in 2008. http://www.usatoday.com/news/h…

Single payer remains the most cost-effective, comprehensive way to fix the broken system.

Cost effective by removing the bloated private insurers with their high administrative costs and financial incentives to continually raise premiums, co-pays, deductibles, and other fees that are the primary cause of rising costs.

Comprehensive in guaranteeing choice of provider, all you lose is your claims adjustor and utilization review team blocking care recommended by your doctor.

And, as a CNA/NNOC study has demonstrated, DeMoro added,  single payer “not only saves lives and people’s health, it is also an economic stimulus.”

Nationally, the study found, implementation of a single payer system would create 2.6 million new jobs, infuse $317 billion in new business and public revenues, and inject another $100 billion in wages into the U.S. economy. The jobs, through increased spending on health care delivery, ripple through the economy, creating employment in retail, manufacturing, and other sectors in addition to healthcare. But in healthcare alone, DeMoro noted, the impact would be especially great in California where an estimated 15 percent of the new jobs would be generated. http://www.calnurses.org/resea…

A large part of the task of the coalition, several emphasized, is public education. The campaign has begun.  

“In this effort, every voice must be heard. Every idea must be considered. Every option must be on the table.” — President Obama, opening the White House health care summit.

Except one idea, apparently. The one reform that will actually contain health care costs, cited by the President as his main goal, and, as a bonus, solve the healthcare crisis —  single payer, or expanding and upgrading Medicare to cover everyone.

In the weeks leading up to the summit, the White House made sure all the people it wanted in the room were there. The insurers, drug companies, corporate lobbyists, and those consumer and advocacy groups willing to play by the script.

One group, however, was conspicuously absent, advocates of single payer reform. Who happen to include, nurses and doctors, the people who have the most daily experience with the collapsing health care system and who by large margins support single payer.

Why were they excluded? When the dean of the press core, Helen Thomas, asked White House Press Secretary Robert Gibbs that question yesterday, he came up with this charmer:

MR. GIBBS:  I will certainly check on — I told Chip we rented a big room, but we didn’t get the Nationals’ baseball stadium.

http://www.whitehouse.gov/the_…

 

So despite their years of experience in fighting for real reform, the single payer proponents had to take to the streets (again), to pound their way in. Just a few hours before the meeting, and apparently hoping to head off the announced protest at the gates of the White House, invitations were hurriedly and belatedly extended to Rep. John Conyers, author of HR 676, the Medicare for all bill in Congress, and Oliver Fein, MD, president of the Physicians for a National Health Program.

Two seats out of some 120, not exactly a message of inclusion. And there was no space for their voices in the tightly scripted sessions.

As John Nichols wrote on the Nation website afterwards:

while the doctor was not included on any of the lists of breakout session speakers, the CEOs were, along with representatives of the U.S. Chamber of Commerce, America’s Health Insurance Plans, the Blue Cross Blue Shield Association and the Business Roundtable.

In other words, the overwhelming weight of opinion at what was supposed to be a wide-ranging discussion of health reform was — at best — on the side of tinkering with the existing for-profit system. Change we can believe in was not on the agenda.

http://www.thenation.com/blogs…

Maybe the redoubtable Mr. Gibbs can explain:

Helen Thomas:    Why is the President against single-payer?

MR. GIBBS:  The President doesn’t believe that’s the best way to achieve the goal of cutting costs and increasing access.

Or perhaps there’s the reason suggested by Harper’s Magazine editor Luke Mitchell on Democracy Now this morning:

it’s a threat to a great deal of people who are making a lot of money right now, which is to say the insurance companies. A single-payer system would take a lot of money out of the insurance system, the private insurance system. And it’s also something that a lot of people in Washington understand as ideologically threatening,

http://www.democracynow.org/20…

And, as Democracy Now host Amy Goodman noted, the silence in the summit is largely echoed in the exclusion of single payer voices in the major media:

A new study being released today by FAIR, Fairness and Accuracy in Reporting, found the views of advocates of single payer have only been aired five times in the hundreds of major newspaper, broadcasts and cable stories about healthcare reform over the past week. No single-payer advocate has appeared on a major TV broadcast or cable network to talk about the policy during that period.

It’s not single payer advocates who are harmed by this wall of exclusion, it’s all the American families and patients who yearn for real reform and will almost surely be disillusioned by proposals that fail to achieve it.

Because you can’t genuinely rein in costs without tackling them at the source — the insurance companies and their built in incentive to perennially jack up premiums, co-pays, deductibles and all the other ATM-type fees that are bankrupting families and crushing businesses. Nor can you begin to address the callous and routine denial of care for those already insured by the claims adjustors and bean counters who don’t want to pay for it.

There’s another potential casualty here as well, President Obama who himself famously said in 2003 that he was a proponent of single payer and must surely know it is best approach. A lot of political capital will be expended to pass reform this year, it ought to be devoted to a reform that will actually work.