HR 676: "Still the One"
by Tim Foley
Change.org Blog
January 17, 2009
The top vote getter among health care ideas in Change.org’s Ideas for Change competition was “Free Single-Payer Health Care for All.” This no doubt is cause for joy for many of you who frequent this page. Weekends have become something of a “Policy Spotlight” for me, with an extensive look at the VA system and the Wyden-Bennett plan over the past couple of weekends. This weekend, I’m focusing on HR 676 — the “Expanded and Improved Medicare for All Act” or, more popularly, the “United States National Health Insurance Act.” It’s probably going to be reintroduced into the House of Representatives in March, when it will once again take its place as the most viable path to a single-payer system that covers every American with quality care—no premiums, no deductibles and no co-pays.
Many of you who are health care activists will recognize it by bill number alone You’ve been toiling in the vineyards for its passage for years now. So rather than give a standard write-up of the bill, I’m going to post on it three times this weekend: “The Good,” why both the policy and the bill supporting it make so much sense and inspire so much loyalty among health care advocates; “The Bad,” those areas of the bill that could figuratively use a fresh coat of paint to reflect the different circumstances of today compared to when the bill was first written 4 years ago; and “The Ugly” — the purely political calculations (regardless of sound policy) that do or do not make it a palatable option.
The Good
So these are my 5 reasons why HR 676 is, in the words of Shania Twain, “still the one.”
1.) 8 of the 10 best health care systems in the world have single-payer
If you look at the World Health Organization’s 2000 rankings of the top 10 countries in terms of health outcomes — you’re not going to see us. Ditto for the top 25 countries. You’ll find us at 37th — just above Slovenia and Cuba. But if you look at the top 10, 8 have public, single-payer systems where the government collects higher taxes and guarantees quality health care to all of its citizens. The remaining two have huge percentages of the population in a public program as well.
The way that each country implements it is quite different, from the British system where the providers of care are also run by the government, to the system in New Zealand which requires cost-sharing with individuals through income-based co-payments. Some of them, like Taiwan, have figured out how to put together an interoperable and unified Health IT system while we’re still trying to get a national beta program underway. Some of them have been more successful than others in emphasizing primary care and preventative medicine, and some of them have found a way to measure performance based on quality and reimburse accordingly.
There is no doubt that having a unified system for reimbursement — the single-payer solution — has made implementing these major structural changes that lead to better health outcomes significantly easier than it has been to even attempt the same with our patchwork system. It’s easier to change direction while driving one big 10-wheeler truck than it is to maneuver 25 cards, each with their own driver.
Yes, we know the United States is not like other countries. We’ve got a larger, more spread out and more diverse population. We also are fiercely independent and innovative. We’re not going to grab France’s system and say “Wham! We are all Parisians now!” But we can’t forget that medicine is firmly rooted in science and evidence. We know certain cures work better than others because we test, and we test, and we test, and we let the evidence tell us what worked best. Health care professionals do their job when they look at all the evidence and do what they can to make the patient better. In this case, the patient is our broken health care system.
We’re not going to agree with the way every country conducts its internal business. That’s fine. But if you’re willfully ignoring the evidence that a single-payer system can be implemented in a way that allows us to get a grip on the full range of health care issues we face, that’s just ignoring the evidence. Small wonder the patient’s condition worsens.
(And one quick note: you’re going to fear monger about “socialized medicine” when Taiwan — TAIWAN — uses it? Really? I’m pretty sure their “resistance to communism” street cred is equal to ours.)
2.) HR 676 is based on our own experience
Everything about the way lead author Rep. John Conyers (who, by the way, is a righteous dude) has set up his plan for Medicare for All is based on a particularly American experience. He’s content not to reinvent the wheel but pick and choose from what works about the best, most successful and least controversial social programs America has come up with.
Looking through the details of his plan is like a guided tour of American history. Reflecting Social Security, everyone gets a Unites States National Health Insurance card in the mail with a unique ID number. There’s something of the simplicity of voter registration in the no-more-than-2-page application form the law would require (and a far cry from the multi-page paperwork marathon that people expect to go through when applying for benefits for their new job). Of course the root of the program is Medicare, which is currently administered by the Department of Health and Human Services. There’s a slight shifting of accountability, but it’s still recognizably the bureaucratic structure of Medicare. Currently, the Secretary appoints a Director for the Centers for Medicare and Medicaid who run the system. In HR 676, the Secretary appoints a Director for the National Health Insurance. Done and done.
Why is it so important that HR 676 be based on Medicare? Because we already know it works. Patient satisfaction for Medicare trumps patient satisfaction for any other system except for the VA (also a single-payer system). As mentioned, the administrative costs are 14.1% for private insurance and 3.1% for Medicare. (Even Medicaid, which has to navigate a complex maze of 50 different sets of state-based regulations, is only 7%). As mentioned, when Medicare competed with private insurance through Medicare Advantage, it unquestionably kicked its butt in terms of costs and patient satisfaction.
Medicare’s not perfect — there needs to be a lot of reform to the system to reform what we pay for and how much. We need to overhaul payment to include not just fee-for-service but coordinated care and approaches that pay doctors for all the work they do on a patient’s case, not just the 15-minute procedure that’s explicitly billable. But the task of reforming Medicare arguably becomes easier the more clout it has.
Most importantly, we know how to do this. We know how to administer quality care nationwide. We know how to deal with complex and chronic diseases. We know how to work private and public hospitals, primary care and specialist doctors, long-term care and mental health into the system. Government programs already account for 46% of health care spending in the US, and that’s focusing on the sickest and poorest members of society. A national health insurance system modeled on Medicare is adding capacity to a system that has proven over 43 years that it can handle it.
We don’t even need to look to what the Swiss are doing. We just need to focus on our own best practices.
3.) What would we be missing, exactly?
One of the arguments for keeping the private insurance industry is that, as with all things in the free market, it encourages innovation. It’s Business Evolution 101: Change or Die. Make a better product, or convince others that you have the better product and you will prosper and thrive. This “build a better mousetrap” instinct is embedded deep in our national DNA.
So you would think I would have an easier time answering the question, “What benefit does private insurance give over public insurance for patients?”
There are a few anecdotes about private HMOs improving care through better coordination. Maggie Mahar details the innovations at Group Health Cooperative in Seattle. Rather than paying fee for service, doctors are on a salary, since the insurance company is also the management for the care center. “In this case, the key is paying doctors for the time they spend e-mailing patients, returning phone calls, and doing research on their behalf. Because doctors are on salary, they are paid for everything they do—not just for the number of patients they manage to “see” in a given day.” She’s right, that’s a great innovation.
So great that it’s preserved in HR 676. HMOs that employ clinics and physicians and deliver care are the HMOs that are preserved in section 103© of HR 676 — provided they’re not for profit.
Look, a private insurance company’s job is to spread around risk — collect money from all to pay for the care of those who need it. The more money you take in that you don’t need to spend on care, the better you do, the higher your profits, the better your stock price. It should be no wonder, then, that all of the most remarkable innovations of the insurance industry have been towards the aggregation of profit. Using “experience rating” to offer better deals for young, healthy customers and making health care more expensive for those who need it; high deductible plans that adapt to the rising cost of health care by offering a plan with less monthly costs, but which provide less care; the HMO model of a network of providers, with its rigid system of paperwork and fees for going outside of network; limiting the amount of care that can be consumed in a year; and the practice of cherry-picking young, healthy patients through rejection based on “pre-existing conditions.” All of these are great profit improvements on the old non-profit Blue Cross Blue Shield models of the mid 20th Century — and all of them are pretty crappy for patient care.
The simple fact is that if private insurance companies were interested in innovating and improving the quality of health care instead of just profit, it would have happened already. But HR 676 is actually interested in innovation based on prevention, changing the structure of provider reimbursement, community based care, negotiating prices on prescription drugs, and health disparities — so much so that it’s written into the law.
4.) Choicus Maximus
Much like the crowd in the Coliseum cheering on Russell Crowe, we tend to instinctively rally around uncompromising notions of individualism. The line that constantly comes up when people argue against any government intervention in health care is, “Do you want a government bureaucrat choosing your doctor?” No we don’t! Freedom! Maximus! Maximus!
Honestly, it’s a non sequitur. There is next-to-no choice in the system we have now. You take what your employer gives you in terms of coverage or you buy your own. In either case, you choose your doctor based on who takes your plan. Sometimes that’s a lot, sometimes that’s a little. I have a pretty good plan myself, but I know I haven’t always been able to go to the specialist referred to by my primary care physician because he didn’t take my insurance. Even keeping my primary care doctor was potentially a little awkward when I switched jobs.
Medicare is better — you choose your primary care doctor, or specialist, or long-term care provider or what have you fairly easily, since the overwhelming number of doctors still take Medicare. A friend of mine recently got her Medicare card and now, as she says, “I have almost too many choices!”
Granted, more doctors stop taking Medicare patients each year because of low reimbursement rates (although I haven’t been able to find hard numbers to back up the anecdotes.) Providers are enabled to do that because they can get a better deal from another plan. But if everyone is covered under the National Health Insurance plan, there are no better deals — most doctors will return to the system. If we’re really serious about wanting a choice, do we want a solution that truly maximizes choice, or just empty rhetoric?
5.) “We’ve got the tools, we’ve got the talent.”
A single-payer system solves coverage, but what about quality and cost — the other two legs of our universal health care stool? After all, none of those well-performing countries have quality, affordable health care through universal coverage alone?
Some cost savings comes from cutting administrative costs, putting the National Health Insurance program into a better negotiating position when it comes to prescription drugs and the economy of bulk purchasing of medical supplies. Conyers estimates these would save $387 billion per year. It would drop the per capita spending in the U.S. from about $7,400 to about $6,100 — a good start, if still much higher than any other country.
Far more intriguing is the National Board of Universal Quality and Access. The major impediment to cutting costs is that there’s no uniform standard for what things should cost. Medicare has a strong influence in setting prices, but the National Board would take it even farther. Comprised of health care professionals, hospitals and long-term care institutions, advocacy groups, labor and patient advocates, the board members would have 6 year terms to insulate them from the demands of the political calendar. They would have two jobs — definite the best practices in care, and define the costs for that care.
Right now, Medicare reimbursement rates are set by the administration, from a combination of political appointments and career bureaucrats. The Secretary of HHS sets rules for reimbursement which can be overruled by Congress. They get advice from a number of groups (the AMA most prominently), but there’s no guarantee this is an evidence-based process so much as a politics-driven process.
Doctors, nurses, hospitals, patient advocacy, health care advocates and labor may or may not be the right combination, but they take the politics out of the system. Maybe… just maybe… they’ll also be immune from the fear of political calculation as well.