"It would be nice if something made sense for a change." – Alice, from Alice in Wonderland.

Perhaps we live in an alternative universe.

One in which two thirds of Americans want the government to guarantee healthcare for everyone, while the policy makers in Washington labor to craft a reform plan that caters first to the threats and demands of the insurance industry and the minority voices on Capitol Hill.

One in which the Senate Finance Committee plays congenial host to the insurance industry, the drug companies, and right wing think tanks and it's chairman Max Baucus can proclaim all options are on the table while slamming the door on the nurses and doctors — and arresting them when they speak out.   Why? For advocating the most comprehensive, cost effective reform of all, a single-payer/Medicare for all approach.

One in which single payer is considered off the table inside the rarified airs of Congress, but when President Obama ventures into a town hall meeting with regular folks, the first question he is asked is:

"Why have they taken single-payer off the plate?" asked one woman in the audience to great applause. "And why is Senator Baucus on the Finance Committee discussing health care when he has received so much money from the pharmaceutical companies? Isn't it a conflict of interest?"

Watch here:

http://www.youtube.com/watch?v=Q6d45duX_WU

And one in which Drew Altman, CEO of the Kaiser Family Foundation can ponder today about how baffling it is that the "experts" — presumably people like him who was given a seat at the table by Baucus — sees the world so differently than the vast majority of Americans struggling to survive a cruel, inefficient, and inhumane healthcare system:

"Experts believe the health care system is full of unnecessary care and troubling variations in care, … The public has a very different world view: People think that underservice is a bigger problem than overservice. They want relief from the problems they are having now paying for health care and health insurance in very tough economic times. … And many are worried that they will not be able to afford their health insurance in the future or may lose it altogether."

The "experts" say the problem is too much "unnecessary" care. The public thinks too many people are being denied care they need.

The experts think costs are so high because consumers don't have enough "skin in the game" (i.e., we like to go to the doctor, get invasive tests, and endure long waits for care and high out of pocket costs). The public thinks the reason is "because drug and insurance companies make too much money."

The experts think health care information technology is a panacea to improve quality and cut costs. The public thinks it will probably increase costs (the Congressional Budget Office happens to agree) and are concerned about the privacy of their medical records.

The experts think we must have comparative research to limit future costs. The public thinks "insurers should pay even if their doctor recommends a treatment that has not been proven to be more effective than a cheaper one." (Imagine, getting the care you actually paid your insurance company to provide, what a concept)

Either we need to get more in tune with the self-appointed experts, or they ought to listen to what the people actually think. Or perhaps, as Marcia Angell, former editor of the New England Journal of Medicine told the Great Falls Tribune in Baucus' home state of Montana, "Single-payer is simply considered not realistic for a politician. The medical industrial complex just won't permit it."

But at a price, to our health, to the well being and financial security of American families, and to the cause of health care reform.

Or as Michael Lighty, national policy director for the California Nurses Association/National Nurses Organizing Committee put it:

"Hillary Clinton and President Clinton took single payer off the table much more dramatically than Baucus has, yet everyone draws the lesson that because of 1994 we can't do single-payer. They should draw a different lesson from the Clinton-era struggle. The lesson is we didn't fix the problem. We didn't offer a solution that works and so no one wanted it. That's the risk they run this time going down the road they're currently going. They won't solve the problem, it'll ruin their credibility even if it's enacted, and that's much greater risk."

With Max Baucus’ Senate Finance Committee continuing to shut out the voices of single payer advocates while rolling out the red carpet for the insurance giants and other health care corporations, five more were arrested today and dozens of other nurses stood before the committee in a dramatic silent protest.

Today’s action — the second in a week that led to 8 arrests — coincided with the anniversary of the birth of Nightingale. It also marked the kickoff of two days of actions by nurses from around the country who are pressing for a legislative agenda for quality nursing care and a single standard of quality care for all.

Here’s AP.  Here’s a link to a photo of the nurses being arrested.  The Wash Times covers it here and here’s Patricia Murphy.

Action!  Fax Mad Max and tell him single-payer deserves a voice in the debate!

All told, this is the most media coverage single-payer healthcare has received since SiCKO was released in 2007-ironic given that it comes from an attempt by Washington insiders to keep America’s caregivers out and stifle discussion of their healthcare plan.

“What a disgrace that RNs and physicians are shut out and arrested while the insurance industry is given a seat at the table. We would expect that from the Bush administration, not in the time the Obama administration,” said NNOC/CNA Executive Director Rose Ann DeMoro. “The Baucus Committee can arrest nurses, but they can not silence the voices of RNs who will continue to speak from their hearts on behalf of their patients who want and deserve real reform.”

Standing up in the audience and speaking before she was arrested, Sue Cannon RN, said, “don’t guarantee drug profits, guarantee health care. We’re entrusted to care for our patients, and we can’t do that without single payer, guaranteed healthcare. We need no more Blue Crosses and double crosses.”

“In honor of Florence Nightingale, patients need access to healthcare. We need to protect our patients, we need single payer now,” said NNOC/CNA Board member DeAnn McEwen, RN.

Also raising their voices and accepting arrest were Steve Fenichel and Judy Dasovich, two physician members of the Physicians for a National Health Program, and  Jerry Call of PNHP and Health Care Now.

Some 40 other RNs staged a silent protest — standing before the committee in red nursing scrubs and turning their backs to show signs reading “Nurses and Patients First. Stop AHIP. Pass Single Payer.” AHIP, America’s Health Insurance Plans, is the private insurance industry lobby arm that is given a regular voice by the Baucus Committee, which is in the forefront of discussion on a health plan.

The protests, before a sea of reporters and cameras marked a continuing escalation of voices of protest —  last week eight were arrested — in an ongoing spectacle in which the committee has bent over backwards to accommodate the insurers, the drug companies, the coalitions representing America’s largest corporate interests, even the rightwing Heritage Foundation and conservative think tanks. All while excluding the doctors and nurses who favor single payer and have the most direct, hands on experience with our failed insurance based healthcare system.

Noting the shut out, Call said to the committee, “60 percent of the chairs at the table should be for single payer advocates because 60 percent of the people want single payer” reform.

That’s a system in which choice of doctor and other providers is guaranteed, with comprehensive benefits, real cost controls, and an end to insurance industry denials of care.

And more pix here.

1. Karen Ignani, the president of the insurance industry trade lobby, America's Health Insurance Plans, offers to end the outrageous industry practice of charging women more than men for health coverage, and is widely praised for the concession.

Even though the reprehensible practice of institutionalized gender bias should have been considered out of bounds long ago. The industry was not even shamed by the report last fall by the National Women's Law Center that insurers charged 40-year-old women up to 48 percent more than men of the same age for the same coverage.

And even though the “offer” remains conditional. AHIP continues to demand conditions in health reform proposals now before Congress, including a requirement that all Americans currently without coverage be forced to buy private insurance, and that Congress block any inclusion of a public alternative to private insurance. Now they've increased the ante and want federal pre-emption of state-based public protection regulations on insurers, such as requirements in a number of states that private insurers must cover such critical basics as maternity care or preventive cancer screenings.

Instead of gushing over AHIP for being conciliatory, it's time to demand the insurance industry stop holding our health hostage and end all discriminatory practices, including all higher charges based on age, health status, where you live, or other factors that serve as a financial barrier to access to care.

There can be no more excuses, no more exceptions, no more impediments to care. If anything, the widespread disparities and offensive pricing practices that characterize the private system  are a major reason why so many Americans are fed up with the insurance based system and want real reform, such as a single payer/Medicare for all approach.

Which brings us to Ignani's other remarkable comment yesterday.

2. “We are not asking people to trust us, we are asking people to trust government.”

Yes, Ignani apparently actually said that. And it was presumably not just a Freudian slip. In other words, a tacit admission that the insurance industry has no credibility with the public — and given their legacy of practices such as charging women more because they are of childbearing age they don't deserve it — and have to rely on the government to give them any trust with the public.

Yes, that government. The same government the insurance industry regularly excoriates “government-run” healthcare and is doing its best to provoke fear and loathing of even a public option alternative to private insurance.

3. The very Republicans who the Democratic leadership is bending over backwards to accommodate on the final form of a health plan are making it increasingly clear that they will work to defeat the legislation no matter what it is.

As now reported, GOP strategist Frank Lutz has put together a 26-page memo for the

Republican leadership on how to revive the Harry and Louise ads from 1994 to campaign against the new bill, using almost identical language from that campaign.

So a bill is being crafted to please the Republicans who will oppose it anyway on the assumption that they can use the specter of “government-run” health care, the same government Karen Ignani admits the public trusts more than her insurance industry, to regain political power at the polls.

Which, finally brings us to:

4. The Senate Finance Committee and its chair Sen. Max Baucus held a hearing Tuesday shutting out doctors and nurses and community supporters of single payer while providing a red carpet to AHIP, the Chamber of Commerce, Blue Cross Blue Shield, America's Health Insurance Plans, Business Roundtable, and the rightwing Heritage Foundation.

No wonder that some finally turned to peaceful protest and subjecting themselves to arrest.

The irony or tragedy, if you prefer, is that by trying to silence the voices of doctors, nurses and advocates of broader reform the Democratic leaders have, as the Washington Times put it, “forfeit a crucial bargaining chip with Republicans, meaning that any compromise with Republicans would swing too far toward the center or right” and leave themselves in a position of crafting even more unworkable reform.

“That's why it looks like (Democrats) are moving so far to the Republican position because they're not even considering the advantages” of a single-payer system, said Michael Lighty, national policy director of the California Nurses Association/National Nurses Organizing Committee.

After years of shredding our public health infrastructure and ill advised minimal preparations for the next great global pandemic, the spreading swine flu threat is at last making clear the very real calamity that could be just around the corner. If not today, surely from the next epidemic.

The Obama administration’s call on Congress Tuesday to allocate $1.5 billion for combating the virus is a start, but only a start. The RNs of the National Nurses Organizing Committee and California Nurses Association (NNOC/CNA) believe that far more is needed in federal action, in regulatory crackdown on insurance practices that potentially inhibit those who are infected from seeking help, and in global coordination.

From SARS to avian flu to the swine influenza, the only question has not been if, but when.

Three years ago, during the advent of an avian flu outbreak, in an article by Conn Hallinan and Carl Bloice in the national magazine of the National Nurses Organizing Committee, we warned that the “firewalls for stopping the next great pandemic are getting thinner.”

If the swine flu or the next pandemic has only the fatality of the 1918-1919 global influenza pandemic — 2.7 percent — it would have a catastrophic effect. That pandemic killed 675,000 Americans and anywhere from 50 to 100 million people at a time when the world’s population was less than a third what it is today, and when populations were far more isolated.

Obviously, there have been medical advances in the past 90 years. But on many other levels, conditions remain as precarious as ever.

In the U.S., public health services are often first on the chopping block when budgets are tight — such as the now evidently foolhardy decision of politicians to slash $870 million from the President’s economic stimulus bill that was allotted to fight pandemics.

And many politicians compete to see who can transfer more resources from the public setting into the pockets of private healthcare corporations — often while harvesting hefty campaign contributions from those same companies.

The result is a virtual decimation of many community clinics, especially in rural and medically underserved communities, and a starving of badly needed funds for public hospitals and services.

Over the past eight years especially, we’ve also seen a rash of hospital and emergency room closures, reductions in available hospital beds, and the type of equipment needed to fight pandemics. For example, in 2005, we noted, there were only 105,000 mechanical ventilators, between 75,000 and 80,000 of which are in constant use. Ventilators are particularly important if a pandemic takes on the characteristics of the 1918-1919 flu in which a major killer was acute respiratory distress syndrome.

Hospital and bed closures are all too often driven by the insatiable lust of healthcare industry corporations for greater profit that can be secured by relocating in wealthier communities or re-allocating resources to more profitable services, such as boutique clinics and surgery centers. Such is curse of our absurd reliance on the privatization of healthcare.

An immediate shift in priorities and thinking is needed, if not for swine flu, for the coming plague. Here’s the first call to action by the national nurses movement (link is a .pdf):

• Recruit and mobilize teams of scientists to create the appropriate effective vaccine for the virus.  

• Cease and desist any reductions in public health programs at federal, state and local levels. Lift any freezes on public health funding currently in place.

• Implement a moratorium on any closures of emergency rooms, layoffs of direct healthcare personnel, and reductions of hospital beds.

• Allocate funding for recruitment and retention of school nurses, public health nurses.

• Expand the network of community clinics, especially in medically underserved areas.

• Add thousands of additional ventilators/respirators, which are critically needed in the event of epidemics.

• Assure the availability of protective equipment for all healthcare personnel.

• Require all insurance companies to suspend or waive all out-of-pocket expenses, including co-pays, deductibles, or co-insurance that discourage individuals from seeking preventive care for early signs of infection.

On the international level, it’s apparent that the World Health Organization is overwhelmed. A global infrastructure similar to what is being discussed for the economic crisis should be formed and sanctioned, at least by the G20.  International cooperation and most importantly, transparency of data from all sources, health care facilities, governments, and individuals, is essential to identify the virus and track its patterns.  The global health community must have the authority to require systematic, uniformly collected information to be reported on influenza cases in order to start formulating an effective vaccine.

Within the U.S., we should learn the lessons of the 1918-1919 flu pandemic, one of which was the enormous mitigating effect on mortality of adequate nursing care. We need to rededicate our nation to expanding the supply of nurses and safe patient care in our hospitals and clinics, which is a central component of the healthcare safety net that is especially vital at times of public health crises.

Finally, in order to promote containment and convention, we must eliminate the greed-driven barriers to care based on ability to pay.

Recent reports have emphasized the growing number of Americans who are skipping routine medical screenings, exams, and general preventive care due to the skyrocketing co-pays, deductibles, and other use charges imposed by insurance companies.

Price gouging by the healthcare industry has already put tens of millions of families in healthcare jeopardy, especially in an economic crisis. At a time when untold numbers are already exposed to a dangerous virus, we need to be removing any barriers to medical care that would exacerbate the spread of contagion. We can not afford to wait.

The updated CNA/NNOC swine flu page is here.

In Canada, it took the dogged determination of one province, Saskatchewan, and a visionary leader Tommy Douglas, to pave the path to a national health care system, which they call Medicare.

For all the detractors of the Canadian system in the studios of Fox News and the board rooms of rightwing think tanks, consider this one note: In 2004, the Canadian Broadcasting Corporation conducted a national poll to select the greatest Canadian of all time. The winner in a landslide — Tommy Douglas. 

While the federal window remains open for reform, with two national single payer bills, John Conyers' HR 676 in the House and now Bernie Sanders'  S 703 in the Senate, many nurses, doctors, and health activists are turning to the states to lead as well.

It's worth recalling that Supreme Court Justice Louis Brandeis famously called states “the laboratories of democracy.” As columnist Froma Harrop has suggested, “being closer to the people and more attuned to the local culture, states are better equipped than the federal government to introduce new social policies. Innovations are usually first tried in the places most receptive to them.”

More than a half dozen U.S. states now are considering legislation to establish single payer systems, essentially an expanded and updated form of the U.S. Medicare system to cover everyone in their states.  Here's a roundup of some of the state bills:

California

The latest bill SB 810 passed its first legislative test Wednesday in the Senate Health Committee on a party line 7-4 vote before a room packed with nurses, doctors, medical students, California School Employees Association members, and healthcare activists.

In her lead testimony, Malinda Markowitz, RN, co-president of the California Nurses Association/National Nurses Organizing Committee noted that “nurses know insurance companies don't provide any value whatsoever in the delivery of medicine. Under SB 810, we would be free of their interference, their denial of care, their massive bureaucracy, and their waste of healthcare dollars.”

UC Irvine medical student Parker Duncan said that he did not want to “be in a world not doing what I was trained to do,” referring to the paperwork that is one of the expensive burdens that undermine the ability of the current system to deliver health care.

Twice this decade California's legislature passed earlier versions of SB 810 (SB 840 carried by now retired Sen. Sheila Kuehl), but the bills were vetoed by Gov. Arnold Schwarzenegger. State activists say they will continue to push single payer in California, even if they need to wait until the next governor, who won't be Schwarzenegger, is elected in 2010.

Colorado

House Bill 1273 by Fort Collins Democrat John Kefalas, passed its first vote in the state House April 6. The bill sets up a 23-member commission to design a universal health-insurance system.

“Our current health-care system is not well,” Kefalas said. “Our current health-care system is unsustainable, with the cost of health care and the numbers of the uninsured rising dramatically.”

Press reports note a state Blue Ribbon Commission on Health Care Reform two years ago studied single payer and found it was the only approach that saved money compared to what Coloradans now spent on healthcare.

Illinois

HB 311, the Healthcare for All Illinois Act, sponsored by Rep. Mary Flowers, had its first hearing in March. Though no votes have been taken yet, the new Gov. Pat Quinn is a long time supporter of single payer reform.

At an introductory press conference, Brenda Langford, Cook County RN, said that “Illinois can once again be a symbol of hope and progress for our nation. Nurses are tired of watching our patients suffer from denial of care and lack of access to coverage.  We see far too much of this at Cook County hospitals—and that’s why we support guaranteed healthcare through a single-payer system.”

Maine

LD 1365, sponsored by Brunswick Rep. Charles Priest, and co-sponsored from legislators from all over the state, had its first hearing April 13.

The hearing came just days after both houses of the Maine legislature passed resolutions calling on President Obama and Congress to enact federal single payer legislation. A poll this winter showed 52 percent of Maine physicians also favor single payer.

As Cathy Herlihy of the Maine State Nurses Association put it in a state forum featuring U.S. Senator Olympia Snowe, a single-payer system is the “the only solution,” she said. “We do not have time to wait. Our health should not be sacrificed for limited reforms.”

Pennsylvania

Two single payer bills are alive in the state, House Bill 1660, the “Family and Business Healthcare Security Act of 2009,” and Senate Bill 300.

Gov. Ed Rendell has said that if a single payer bill were to make it to his desk, he will sign it, reports Chuck Pennachio of Health Care for All Pennsylvania.

The state Democratic House Caucus is holding a public forum on the bill Friday, April 17 at 10 a.m. at the University of Pennsylvania campus in Philadelphia, featuring speakers from Physicians for a National Health Program, the Pennsylvania Association of Staff Nurses and Allied Professionals, and other single payer supporters..

The hearing comes on the heels of a resolution passed by the Philadelphia City Council calling for both state and federal lawmakers to establish a single-payer health system. 

Other states

Single payer bills are also on the docket in Minnesota, Missouri, and Washington.

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.

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.