Just before the holiday break in December, the Courage Campaign hosted a conference call with several California bloggers and Sal Rosselli, head of United Healthcare Workers-West, and other members of the reform coalition to discuss the health care reform bill, ABX1 1, that is still pending in the legislature. The call spawned a follow-up discussion between some of the participants and Sal Rosselli over e-mail, which the participants (including Sal) wanted to post here.
Specific issues discussed include the relationship of UHW and other union leaders in the health care reform coalition to their rank-and-file, the financing of the ABX1 1 proposal, the political landscape against which this happens, and the relationship of ABX1 1 to single-payer care.
It’s my hope that the conversation Sal was gracious enough to help initiate can be continued here, with input from others on Calitics and in the netroots. Read what we’ve all said, and then weigh in with your own thoughts. These kinds of discussions between progressives are essential to the construction of a better California, even when – especially when – we have disagreements on policies. Thanks to Sal Rosselli for his continued engagement with us, and to the Courage Campaign for initiating this discussion.
Joel Wright, December 20, 2007:
Just wanted to note Sal’s response to my question about surveying UHW membership was quite troubling to me. Nothing personal to him or them, but I’ve seen that dodge by union leadership a lot. My experience on this issue has been consistent: when leadership is tops down, they almost always are not in tune with membership. Particularly on big issues. It’s akin to an elected saying “I know what my district thinks” because of the friends and donors they talk to.
Not to say UHW members don’t support the healthcare plan or the strategy. Maybe, maybe not. The point is leadership doesn’t actually know what membership thinks and they assume members will follow them. When the organization gets into a high profile, pitched battle like this, they sometimes find themselves distracted, having to put out backfires they didn’t expect because they didn’t get their internal ducks in a row first. So it says something politically very important to me that they haven’t gotten lock on with members on this. It’s a real vulnerability in the face of the high difficulty of getting the whole thing done, regardless how individuals in our team and the blogosphere view the plan itself.
Robert, December 20, 2007:
I had the same reaction to the response to that question as you, Joel. Similarly, I didn’t feel they directly addressed jsw’s points about the insurers. He’s right that the public is sour on health insurers and without clear means to “tame” them – means I don’t see in this specific proposal – it’s going to turn off voters from the idea they should be forced to pay into that system. There was an “action diary” at Daily Kos today about Cigna telling a 17-year old girl she can’t get a liver transplant, and it seems like that discussion and the discussion about giving health insurers a guaranteed place in the delivery of care in this state are happening on completely different planes.
There were any number of questions I felt like asking, but I was similarly left unconvinced by the response to my question about the funding sources. The employer contribution is going to decline as an overall number as CA continues to shed jobs. Already our unemployment rate is in the high 5% range, itself likely an understated number, and most economists now expect that number to rise throughout 2008. With a smaller payroll you get not only a smaller amount of money from employers, but you also have a lot more uninsured and jobless people wanting into the public system being proposed here. Massachusetts has already experienced this phenomenon – their public subsidies are currently running a $145 million shortfall. And they don’t have a $14 billion budget hole to worry about. And that doesn’t even begin to discuss the question of whether an ERISA waiver will be granted – the AB 1493 waiver hasn’t exactly turned out well for us has it?!
While I’m pleased that they are insisting that a minimum benefit package be defined in law, and not by a government board, it seems there’s too much acceptance of flawed principles to begin with. As far as I can tell this all comes down to a political assessment, that compromise with Arnold is necessary because we can never get the voters to accept something that is either more ambitious or that isn’t tied to an individual mandate. Single-payer is held out as the end of the Yellow Brick Road but it’s not clear how this actually takes us closer to it – and opponents on the left are portrayed, not surprisingly, as purists unwilling to accept a compromise.
Sal’s Response, dated December 27, 2007:
Thanks so much for initiating the dialogue on healthcare reform efforts in California between our union and so many important contributors to the progressive blogosphere, both in-state and nationally.
We were very pleased to take part in Thursday’s phone conference and thank you and Joel and Robert for sharing their response thread with us.
To keep the conversation going, I want to speak to a few of the issues that were raised and fill in a few of the details that may have been missing from the phone conversation.
Joel raises the question of whether we might be out of touch with our members on the direction of our healthcare reform work, prompted by hearing that we haven’t yet polled internally on the legislation in its most recent form.
No one takes more seriously than we do the need to stay close to our members on this and other issues of importance and polling is one of the many methods we employ to do so.
Over the course of 2006 and 2007, we have polled our members multiple times in the course of developing our approach to healthcare reform, sometimes conducting membership-only surveys and sometimes over-sampling our members in the course of conducting larger public surveys.
Compared to other Californians that are similar geographically and demographically, and by ideology and party identification, our members show greater concern for the crisis of our healthcare system and greater tolerance for the expanded government role and the taxes and spending necessary to address it, but the difference is not as dramatic or durable as we might wish and does not translate reliably into stronger support for specific reform plans.
In the end, our members are subject to the same key dynamics that make it so difficult to maintain a solid public majority for any healthcare reform plan: the many of them who have coverage and who are more likely to vote are afraid that change could make things worse, and as they learn more about any plan, significant numbers of them focus on things that trigger these fears and push them to reject it.
It is this fundamental fear of loss and the resistance to change it produces that make it politically impossible to move to a single-payer system in one leap and place such a premium on giving the supermajority of voters who have health insurance greater security that any reform proposal will allow them to keep what they have.
That’s the hard reality of why our current approach, like that of John Edwards, whom we support, and those of the other leading Democratic Presidential candidates, is focused on taking incremental steps to rationalize our healthcare system by expanding access, containing costs, and improving quality while still leaving many features of the current system in place.
All that said, I want to make clear that we don’t believe polling is the only way or the best way to keep in touch with our membership, and that we use polls less to determine our direction than to learn better how to lead in the direction we think we should, based on our principles and our policy analysis. We take responsibility to lead and keep ourselves accountable by engaging large numbers of our members not only in discussing, debating, and deciding the formal direction of the union, but in acting on it.
In the current instance, this means not only seeking the informed consent and engagement of our almost 100 rank-and-file Executive Board members and our more than 2,000 stewards who lead the union in workplaces and communities throughout the state – including my speaking personally with hundreds of them at numerous gatherings over recent weeks – but generating nearly 40,000 petitions in favor of our principles for healthcare reform, recruiting more than 7,000 new monthly political action donors since August based on our reform effort, and involving nearly 4,000 members directly in lobbying for healthcare reform at the Capitol and in the districts.
Union officials must be held accountable to serve workers’ interests, just as elected officials must be held accountable to serve the public interest, but I’m not sure either union democracy or U.S. democracy suffers primarily from leaders paying too little attention to polls, rather than leaders putting their fingers in the wind too frequently.
In the context of a coming recession, Robert raises the important question of whether the plan’s funding sources are sufficient to uphold its central promise: to make decent coverage affordable by expanding public programs to cover low-income children and their parents and providing tax credits that will allow middle-income families of four who earn up to $82,600 to purchase a basic HMO plan for no more than 5.5 percent of their income.
We, too, would like for the plan to be better funded and for its finances to be more secure under adverse circumstances and over a longer period of time. In addition to the minimum employer contributions, the hospital provider fee, and the tobacco tax, we would have liked another broad-based funding source, but voters’ showed no appetite for other methods of raising significant revenue.
Given what’s on the table, we are especially concerned that the minimum employer contributions not be of a level and a kind that encourage employers to dump large numbers of their employees onto publicly subsidized care, shortchanging the system and making it unsustainable.
While the currently proposed minimum employer contributions are a marked improvement over what the Governor would previously support, they would eliminate the separate assessment for low wage and high wage employees meant to deter “crowd out” and secure additional funds for the purchasing pool.
We need to convince the Governor of the dumping risk associated with the current plan and win his agreement to adjust the minimum employer contributions accordingly.
It’s important to note that while the economic downturn and the state budget crisis create significant obstacles to healthcare reform, they also produce a greater urgency to pass the best possible reform now, reaping billions in new federal funds and sparing Californians the severe damage that market forces will cause their healthcare in a recession without reform.
Moreover, no social insurance program of such large scope – and certainly not one with economics, technology, professional practices, and consumer preferences that change as rapidly as those in healthcare – can be funded securely in perpetuity, with a sufficient margin to accommodate every circumstance. Medicare is a case in point, as planners badly underestimated the increased utilization of services by newly insured people with greater longevity, but the social entitlement that the program established built a political base strong enough to secure its funding and make good on its commitment.
This brings us to another of Robert’s concerns, that it is unclear how this plan takes us any closer to single-payer.
The brief answer is that by creating the largest purchasing pool outside the federal government, a pool that would make healthcare more affordable for both low and middle-income Californians, it would unite their interests and build common cause for sustaining and improving our healthcare system through collective action.
By giving a significant cross-section of the public a direct investment in and a positive experience with a social insurance program that helps solve their healthcare problems, and by giving them the choice and the example of a public insurer alongside private insurance options financed through the purchasing pool, we will create the context and the security necessary for people to deal with healthcare reform systemically and to see the advantages of a single-payer approach, rather than react out of vulnerability and fear that make them resistant to change.
Finally, regarding the comments from Joel, Robert and Jeremy about the need to be clearer and more forceful in articulating how the plan “tames” health insurers, we agree completely. Throughout the development and execution of the reform battle to date, we’ve carefully tracked the public’s anger at insurers and drug companies and kept in mind the value of naming our enemies and the danger of appearing to benefit them at consumers’ expense.
That’s the impetus for our campaign to expose Blue Cross’ fight against reform and for our achievement of good policy measures that include placing a cap on insurance company profits and overhead; ending denials of coverage and higher rates based upon pre-existing conditions; banning “rescission” of health insurance to avoid paying for needed care; and providing for bulk purchasing of prescription drugs.
We need to make these points more strongly, especially to our base and we thank you all for the reminder and your ongoing help in doing so. However, making this all about the negatives of the insurance companies won’t cut it either, since these hits aren’t strong enough across a broad enough segment of the electorate to carry the day for us.
As negotiations move forward toward a final package, we’ll be doing more opinion research among our members and the general public, as well as trying to fix the things we know are both political and policy problems in the bill as it stands, namely: the lack of a “safety valve” to exempt people over 400% of the federal poverty level from the individual mandate if coverage becomes unaffordable to them; defining an appropriate minimum benefit package in statute; and protecting the purchasing pool and the state budget against the potential for more dumping of employer-sponsored coverage than the bill anticipates.
We’re trying to thread the needle and it won’t be easy, but having worked through the alternatives, we’re confident this is our best chance to make real change that would provide affordable, quality healthcare to nearly 4 million people in the largest expansion of coverage since the enactment of Medicare. That’s an opportunity we can’t afford to miss, because the human cost in needless suffering is too great, and Californians and the caregivers who serve them can’t afford to wait.
Let’s keep the discussion going over the holidays and into the new year!
Robert’s response to Sal, dated January 8, 2008
Thanks so much for not just your extended and detailed response, but for your openness with us and your commitment to an open dialogue about health care in California. In a broad sense, I think progressives in California have an opportunity to make some long overdue changes in this state and through conversations such as this we help build the coalitions that will make those changes real.
I should lay all my cards out on the table – as a Californian without access to affordable health care (i.e. “uninsured” but I don’t believe that term is the best one to use any longer), I am very much interested in efforts to provide people like myself with the access to health care that we need. At the same time, I am also concerned that whatever reforms we do undertake will actually work for us, and not leave Californians facing costs they cannot pay or a quality of care that is substandard or not sufficient to meet our needs.
Specifically, the ABX1 1 plan includes individual mandates to purchase health insurance. When mandates are involved, the plan adds a new kind of risk – that Californians will wind up having to buy something they cannot afford. And that in turn means that the subsidies that are going to be used to ease this burden on we who are uninsured and who aren’t able to afford insurance on the open market have to be reliable and sound – that we won’t find that, when it comes time to get the subsidies or public insurance care, that there’s not enough to go around.
That’s a problem Massachusetts is already facing. As reported in a New York Times op-ed last month by two Harvard doctors affiliated with Physicians for a National Health Program, Massachusetts is currently running a $145 million shortfall in its public subsidies. This impacts the ability of those who need subsidy to actually get them, and is one reason why over 200,000 Massachusetts residents remain uninsured even after the implementation of their mandated insurance plan.
My questions about funding stemmed from this basis. As California is entering a recessionary period, one that many economists believe will be characterized by higher unemployment than we saw in the 2001-02 recession, it seems reasonable to assume that the employer contribution will decline as an overall amount (due to shrinking payrolls) and more Californians will seek public assistance – either for subsidies to meet the mandate requirements or public health care itself, whether at hospitals or through an expanded Medi-Cal program. Given the higher cost of health care in CA and the much larger number of Californians without health care or insurance than in MA, it seems like a recipe for a big financial hole.
I agree with you that it’s the rare public program that is properly funded, and even nations with single-payer, like Canada and Britain, struggle with this problem, largely because of neoliberal economic beliefs that public programs should be starved to maintain low taxes on business. (Though Social Security is an example of a social insurance program that is properly funded, at least before Congressional raids on its capital.) But if there isn’t enough funding to subsidize people in a mandated insurance environment, it’s going to cause serious harm to the budgets of working Californians. Especially as under the revised ABX1 1, the process to be excused from the mandate requires petitioning a state board – MRMIB, I believe – whereas in earlier versions it was much simpler to be excused from the mandate, and in AB 8, there was no mandate at all.
Even in the absence of a mandate, a funding shortfall in a public health care program brings other risks – political risks. This is where the budget deficit is so key. Arnold is already demanding health care cuts. That will not inspire confidence in voters that the public subsidies and care will actually materialize to meet their needs. Further, if the system does run deficits – as MA’s public subsidies are – then it could sour voters on the use of government to provide and guarantee health care, and erode public support for it right when we need them to increase their support.
I think your comments on “dumping” and about the elimination of the separate assessments are on target, though I would go further. In an op-ed I had published in the LA Times last month (“Why Won’t the Times Talk Tax Hikes,” Dec. 9), I cited an LA Times/Bloomberg poll that showed 60% of voters would support higher taxes for universal health care. While those numbers might fluctuate when you talk specific taxes, it seems that we should work to ensure that the program is fiscally sound. The risk of a public backlash to a program that produces more deficits seems bigger than the risk of public rejection of taxes, especially when the public is demanding some kind of health care reform and willing to pay taxes for it.
Sal also speaks of the underlying politics of reform, that we have to address the “fear of loss and resistance to change it produces” when discussing health care. While I believe that there is more support out there for single-payer than is usually assumed, I see the value of an incremental approach. However, is this the best – or the only – form of incremental change that we can offer? At the federal level, SCHIP was a politically popular expansion of public health care options for children. A similar effort here in CA, such as the expansion of public care options, of eligibility for Medi-Cal – in short, everything in ABX1 1 except the mandate – would seem to be a much more useful and popular method of dealing with this crisis. Obviously we have Arnold to contend with, but that should not force us to accept a flawed plan as the price of getting something done this year.
Ultimately this may be a case where you and I will agree to disagree, though I also hope this is but the beginning of a longer conversation about how to provide universal, affordable, and comprehensive health care for Californians. Thanks again for your response to my questions.