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.

In a sign of the growing health care crisis in California, the number of health insurance policies offering maternity benefits – from pre-natal screenings to birth – has dropped dramatically in recent years. In the aftermath of the failure of Arnold Schwarzenegger’s “Year of Health Care Reform” in 2007 all sides agreed to pursue greater regulation of the insurance industry as a stopgap before a broader solution was reached. And yet Arnold Schwarzenegger vetoed a bill that would have mandated insurance plans cover maternity.

About 805,000 Californians have insurance policies that specifically exclude maternity coverage – a number that has more than quadrupled from 192,000 in 2004, according to the California Health Benefits Review Program, which provides independent analysis of proposed health insurance benefits mandates.

“You see this tremendous jump in just a few years. That’s where we’re going with this,” said Assemblyman Hector De La Torre, D-South Gate (Los Angeles County), whose bill to require maternity coverage is headed to the Assembly Health Committee today. Insurance companies are “pushing these policies clearly onto people, and people are making their decisions based solely on dollars and cents.”

De La Torre’s bill, AB 98, would solve this problem. But Arnold has repeatedly vetoed the bill, including one by then-State Senator Jackie Speier in 2004.

The failure of insurance companies to provide these basic benefits is especially acute here in Monterey County. The Chronicle article linked above profiled Wendy Root Askew, a good friend of mine, whose experience typifies the problem that results from insurers’ refusal to provide basic maternity benefits:

When Wendy Root Askew of Monterey started looking for a doctor she hoped would be her gynecologist as well as deliver her future children, she was shocked to discover her health insurance policy didn’t include a single OB/GYN in her county.

The 31-year-old considered changing health plans. But then she learned that while 85 percent of the plans available in Monterey County offered maternity coverage five years ago, just 15 percent offer it now.

She found only two individual policies that included maternity, but they were three to five times as much as the policy she already had and came with annual deductibles of up to $15,000.

What the insurers that oppose AB 98 claim is that if a woman gets pregnant, she can purchase maternity benefits for an “additional sum”. Insurers claim this amount is small, but as Wendy found it is anything but small – it can be as much as five times the monthly cost of existing health insurance. A $15,000 deductible is essentially punishing women for getting pregnant, a stunning example of gender bias and inequality in an insurance system where prostate exams are routinely covered by basic plans.

Some insurers, and Republican opponents of AB 98 like Audra Strickland, claim that it would cost all Californians more money to mandate maternity benefits be included in all health insurance policies. And while that might mean a whopping average increase of $7 per month per policy (oh noez!) for Californians, the savings are actually much larger. Numerous studies show that proper prenatal care is vital to the long-term health of a child. By spending a little more per month to ensure all insurance policies provide expectant mothers with maternity benefits, we will be saving a far larger sum when their children turn out to be healthier.

Strickland in particular argues that it’s a matter of choice – if women want to get pregnant, they should choose to pay the extra cost. This is absurd on its face. By segmenting high-cost risks out of the insurance “market” you’re also actually undermining the entire system of insurance. Insurance is supposed to work by pooling the cost of risk, making it cheaper for everyone to get health care. By dumping the costs of pregnancy onto a small handful of people, health care costs actually soar, public health is undermined, and insurance as a system will go from a state of near-collapse to total collapse.

In reality Strickland, and Arnold Schwarzenegger, are arguing that the only “choice” here is whether one accepts that unless you’re wealthy or lucky enough to still have a job with group coverage, you’re going to not be able to afford to have a child. It’s typical conservatism – the rich can afford the basics of life, and who cares about those who cannot?

There is no plausible reason to oppose AB 98, and certainly no reason for Arnold Schwarzenegger to again veto the bill, unless he believes that society has no obligation at all to ensure that mothers and their children are healthy. And while AB 98 won’t solve the health care crisis itself – and it’s surely no substitute for true universal health care – it is a sensible and necessary move to provide gender equity and basic health care to mothers and children.

Over the flip is Wendy Root Askew’s testimony given to an Assembly committee on AB 98 last week.

My name is Wendy Askew and I am here to testify on behalf of AB 98 – the maternity services bill from Assemblyman Hector D La Torre. I would like to thank my representatives Assemblyman Bill Monning and Assemblywoman Anna Caballero for co-sponsoring this bill. I’d also like to introduce my husband Dominick, my mom Gail, my good friends Shirley and Jessica who are here to support me today.  

Recently my two sisters and I traveled to Santa Barbara to celebrate my mother’s graduation from a Master’s degree program in Pre and Perinatal Psychology.  We were slightly amused, but very proud, to sit in the audience as she presented her thesis on “Grandmother Connection”.  You should know that despite having three daughters in their mid to late twenties, my mother is not yet a grandmother; thus our amusement with the topic.

As a result, I decided it was time to start building a relationship with an OB-GYN who would eventually help my mom become a grandmother.  I was surprised to find that my insurance plan did not have one single contracted OB-GYN in my County.  However, I figured it was a good thing I had plenty of time to get a new insurance plan that actually included these doctors.

The real shocker came when my insurance broker explained that almost all of the plans offered in my County excluded maternity coverage.  I had a hard time swallowing the details of the only two plans that actually included maternity coverage.  It became clear that the risk pool for these plans was limited to women who intended to become pregnant and thus the plans were significantly more expensive than my current high deductible plan.

I felt I was an expensive liability that was going to drain our hard earned savings and saddle our family with medical debt.  I felt guilty for indulging in my dream of being a self-employed small business owner.  I felt like a second-class citizen at the mercy of decision makers who didn’t care about my health, dreams or goals.  The more I learned, the more disheartened I felt with the whole system.

Dominick and I take pride in being financially responsible.  Dominick is a self-employed licensed architect.  I started a fruit brokerage business.  We built a solid emergency fund. We set up and made regular contributions to our retirement accounts.  We each carried a high-deductible individual health insurance policy.  We live frugally, but very comfortably.  We made conscious decisions to build flexibility into our careers that would allow us to support our future family.  

For us, the issue of maternity coverage will be resolved when I accept a new job with a large employer who offers an excellent group insurance plan.  Ironically the new job will provide me with the maternity coverage I need to start a family, while ultimately preventing me from maintaining the work-life balance that will allow me to actually raise my family.  It will be difficult to leave behind a small company that I built, but my mother will be thrilled to know that at least one of her daughters has the relevant insurance coverage to make her a grandma!

I am here testifying before you today because the rules governing the Individual Health Insurance market, specifically as they relate to the exclusion of maternity coverage, preventing young couples like me and Dominick, from being able to start a family without the threat of financial ruin or dependence on state subsidized programs.  I’ve learned that the issues surrounding health reform are exceedingly complicated, and the solutions are riddled with trade-offs.  Without this legislation and without access to comprehensive individual health insurance that includes maternity, women face exceptional challenges as entrepreneurs or as stay at home mothers.

Thank you for allowing me to share my story today.  

Again I strongly urge you to vote for AB 98.

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.

Like everyone, I’ve been watching the bloodbath on Wall Street unfold, but I had figured that so far, I’m relatively unaffected by it all, since I haven’t involved myself in any of the investments (and losses) that such outfits as Bear Stearns, Countrywide, or AIG made.  I have been pretty prudent with my money, and I thought I would stay clear of the damage.  Now I’m not so sure.

On Saturday, I got a new policy declaration from my auto insurer, 21st Century.  I’ve been pretty happy with thim, and it was nice to be going with a California company.  But now, even though the declaration does list 21st Century at the bottom, up on the top, prominently displayed is the “AIG” logo.

I admit I knew this was coming, and up until recently, I wasn’t particularly concerned since AIG is (was) a really big, solid insurance company with a good conservative reputation (and I like that in an insurance company).  But in light of the news about the company, this change is no longer comforting.

Things have been further complicated by Governor Paterson’s statement today that AIG would be able to “tap its subsidiaries” for up to $20 billion in “liquidity” to help it through a rough patch.  Just which “subsidiaries” does the Governor mean?

If it’s 21st Century, I am not pleased.  It doesn’t happen that often, but insurance companies do default on their obligations from time to time.  It happened to me about 20 years ago with another car insurance company, and I ended up in the “assigned risk” pool while I undertook the always pleasant task of shopping for car insurance.  That’s how and when I ended up with 21st Century (back when it was only 20th Century).

I don’t want to go auto insurance shopping, and I don’t want to have to do it more than once either.  I am left with the uneasy feeling that if AIG sucks the reserves out of Century 21, I’ll be in the assigned risk pool again.

Also, if I do find another company, I am really not all that assured that it won’t be at risk as well.  This whole financial mess is much more complex than just the parts we know about, and probably all the insurers are hooked into crazy investments like Credit Default Swaps and Collateralized Dept Obligations.  SO, while I shop, I have to wonder if I’m simply trading one problem for another.

I called the Department of Insurance today to find out it anyone there knew what was going on and what might happen if AIG does drag 21st Century down.  I should have spent my time on something else, because they either don’t know anything or aren’t going to tell anyone anything until there really is a problem.

Tomorrow, I think I will be calling 21st Century just to see if they can give me any assurances.  If they can’t, I guess I will be spending my free time in the next couple of weeks evaluating auto policies and insurance company balance sheets.  WooHoo!

A few months ago, there was great hope that the Department of Managed Health Care was going after the big insurance companies on the rescission of individual policies.  The DMHC is an executive department, and thus reports to Arnold, not to the Insurance Commissioner (Poizner). So, a few weeks ago we got the news that the DMHC called off the dogs against Blue Cross because they knew Blue Cross would just litigate them to death. Or something like that.

I know, it’s shocking that Arnold’s administration wouldn’t pursue a corporation, but they thought it better just to let BC get off on that charge and settle with them elsewhere.  Ther problem with that? The settlement that the DMHC agreed to with the biggest five insurers in the state is barely a slap on the wrist.  The new procedure requires patients to go through a vague arbitration procedure where they have to prove their case.

Mind you the arbitrator will see far more of the insurance companies than the patients. Where do you think this is going? Yup, just like other arbirtration settings this is going to end up favoring the big company. By the by, that link above states that 99.8% of the cases filed by consumers against credit card companies decided on the merits end up with the company winning. 99.8%! That’s a track record minor deities wouldn’t mind. And even when they get to the arbitrators, cases under $15,000 will typically be decided on the paperwork only. Furthermore, the settlement doesn’t define any legal standards for these decisions, but it appears the legal burden of proof is on the patient to prove he didn’t lie rather than the insurer to prove they did.

This is no victory at all.  And that’s part of why LA City Attorney Rocky Delgadillo filed suit against Blue Shield in mid-July.

“For decades, health insurers have gamed the system and reaped billions,” Delgadillo said. “The time has come to . . . set things right.”

The suit also accuses Blue Shield of falsely advertising its coverage, alleging that the company often reneges when its members need substantial medical care.

Dr. Richard Frankenstein, president of the California Medical Assn., and Dr. Robert Bitonte, president-elect of the Los Angeles County Medical Assn., praised Delgadillo’s efforts to stop the practice known as rescission. (LAT 7.17.08)

Single-payer (likely at the national level) is the ultimate solution, but meanwhile, back in reality land, the insurers are getting off scott free. If the DMHC is going to claim to do its job, it can’t leaving gaping loopholes like this. Delgadillo and other attorneys will have to press the insurance companies for every last concession, because they’re not giving anything away for free.

I will be discussing this and other state political issues on KRXA 540 AM at 8 this morning

Today I will be in San Francisco for the National Day of Protest against health insurance corporations and for truly universal health care – which only a single-payer system can provide. I wanted to take a moment and explain why I will be out there demonstrating against these criminals.

I currently do not have health insurance. My part-time job does not offer it and when I last looked into individual coverage I could not afford what was being offered to me. But more importantly, it’s not health insurance that I need – but health care. They are not the same thing. Health insurance companies have a long and ugly record of denying care and claims even to those they insure. We have discussed here the horrifying stories of Nataline Sarkisyan and Nick Colombo, young people whose insurers denied them life-saving treatment until protests forced them to back down. In Nataline’s case, as we will never forget, it came too late, and she died.

Courage Campaign (where I do some work) has partnered with the California Nurses Association and LA City Attorney Rocky Delgadillo to put out an ad lambasting insurance company practices. It’s based on the true story of Patsy Bates whose health insurance was canceled by HealthNet in the midst of her chemo treatments for breast cancer.

Speaking for myself, I see this ad and the protest at Moscone Center as fundamentally linked. Health insurance is a toxin, not a cure – the profit motive means that there will always be a desire to cut benefits, even in spite of government regulations (the recission practices Delgadillo is investigating are currently illegal under CA state law but they happen anyway).

Last year I was one of the leading voices on this blog against the mandated insurance plan proposed by Arnold and nearly passed by the legislature. It was not going to succeed in making health care more affordable and it was not going to succeed in making it more available. Mandated insurance plans haven’t worked anywhere they’ve been tried in the US, including in Massachusetts – whereas single-payer systems have a long record of success around the world.

We protest, we fund ads, we get outraged, and we fight because we believe health care to be a fundamental human right. Every one of us deserves to have it when they need it, without regard to cost. When someone gets sick their first thought should not be “how will I pay for this?”

As we debate specific health care reforms, that focus on human rights needs to remain at the center of our work. Health insurance companies inherently disagree with it – to them health care is something only those who can afford it deserve to have. It is that mentality that we fight against and protest against today. I’m not naive; single-payer health care will not be an easy political victory. But as polls continue to show growing support for it, and growing revulsion at insurance company practices, it can’t hurt to give Californians a reminder of why their health care is so screwed up – insurance companies are at the core of the problem. Today, we fight back.

I’ll let folks draw their own conclusions and pick their own fights for the most part, but I thought this poll (link changed to pdf of Field Poll) was pretty interesting (favorable/unfavorable/net):

California Nurses Association/Nurses: 53/15/+35

California Hospital Assn./Hospitals: 33/30/+3

Gov. Arnold Schwarzenegger: 40/40/0

Assembly Speaker Fabian Nunez: 20/29/-8

Chamber of Commerce/Business Groups: 25/36/-11

News Media: 28/46/-18%

Republican State Legislative Leaders: 22/48/-26

Health Insurance Companies: 16/55/-39

I will throw a few rather obvious ones out along with one that may be less so. One- people don’t care much for politicians. Two- they care even less for the media, which is interesting as the media keeps cutting back on news coverage. Three- they HATE insurance companies, which makes me wonder why anyone keeps trying to keep them in the equation.

Also, CNA’s numbers are pretty darn impressive. Some of that is that people just like nurses I would imagine. But average Californian on the street, if they have an actual opinion of CNA proper, it’s likely to be an opinion on single-payer. Which makes me think that, given the opportunity, people might be pretty supportive of single-payer.

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.

-Robert

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!

In unity,

Sal Rosselli

Robert’s response to Sal, dated January 8, 2008

Sal,

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.

-Robert