We can learn from LBJ in drafting health care reform

Albany Times-Union
Saturday, March 13, 2010

After seven years of academic medicine, 20 years of private practice and 10 years at the state Health Department in patient safety, I became convinced by my studies that uninsurance and underinsurance were our biggest public health problems, responsible for extensive unnecessary illness, deaths, bankruptcies and economic noncompetitiveness. I retired from state government in 2005 to help form an interfaith alliance to work on this issue.

Let me tell you what I think some of the main problems in this debate are:

Denial: Otherwise intelligent people have not really studied this issue. They are thus susceptible to extremist propaganda and hysteria. Some do not realize they are one pink slip away from health care insecurity. For irrational reasons, they are not willing to really work for an affordable health care system for all Americans. It is possible that some reasons are inspired by classism and racism, as was the case leading up to Medicare's passage in 1965.

The debate in Washington: The insurance companies have owned the debate table from the beginning, after we were promised during Barack Obama's presidential campaign that this would not be so. This has poisoned the debate and led to the exclusion, humiliation and alienation of the Medicare for All movement, which represents a very supportive, intelligent, loyal and progressive group of Democrats. We argued that the public option people were starting with was a poor compromise and would waste the energy of the progressives.

Valuable lessons have not been studied or learned: Jill Quadagno's classic 2005 history, "One nation uninsured," describes President Lyndon Johnson's brilliant maneuvering to pass Medicare. Johnson did not ask for directions from the insurance industry. He, House Ways and Means Committee Chairman Wilbur Mills and Wilbur Cohen, undersecretary of health, education and welfare, decided what they wanted and figured out how to get it. President Obama and his advisers have approached this backward.

The Massachusetts plan, on which the proposed reforms are based, is deeply in debt, with hospitals suing the state for millions of dollars of unreimbursed care. Costs are up. Emergency room visits are up and physicians are overwhelmed. Many people forced to pay high prices for high-deductible policies are very angry. Other states that have tried similar plans, like Maine, have failed.

What to do? The choices are forcing through some sort of public option, which will only add to provider overhead; forcing everyone to buy insurance, which will lock in insurance company profits and power, and fail to control costs; or going back to the drawing board and discussing this problem based on evidence.

What would Lyndon Johnson do?

Why Johnson? Because he brought in Medicare, the most successful public health initiative of the 20th century. I believe he would reject both the failed private insurance system and the failing Massachusetts plan as fatally flawed both conceptually and by history.

I believe Johnson would fight for an immediate total or partial expansion of Medicare as the best history- and evidence-based solution, with improved, careful funding, and financial and quality oversight.

Quadagno's book makes me think he would allow the insurance companies to be involved with the secondary insurance, approximating 20 percent of the pie. I would not want that, but I'm not a politician. But we would then have a plan with health security for all Americans, separate from employment. We would have much more control over spending, and we would have a publicly funded system run by private physicians and hospitals.

Health care is essential and the majority of the American public and physicians believe it should be a right. The current for-profit system with health care as a commodity is wasteful and covers too few well.

We need a one-tiered system for all Americans. Improved Medicare for All is the most cost-effective and proven system to enact.

Take action and tell President Obama what you want.

Richard Propp, M.D., of Albany chairs the Capital District Alliance for Universal Healthcare, Inc.