How Libby, Montana, Got Medicare for All

By Kay Tillow
Firedoglake, June 15, 2011

In 2009 when the Washington Beltway was tied up with the health care reform tussle, Montana Democratic Senator Max Baucus, chairman of the all powerful Senate Finance Committee, said everything was on the table -- except for single payer. When doctors, nurses and others rose in his hearing to insist that single payer be included in the debate, Baucus had them arrested. As more stood up, Baucus could be heard on his open microphone saying, “We need more police.”

Yet when Senator Baucus needed a solution to a catastrophic health disaster in Libby, Montana, and surrounding Lincoln County, he turned to the nation’s single-payer health care system, Medicare, to solve the problem.

Baucus’ problem was caused by a vermiculite mine that had spread deadly airborne asbestos, killing hundreds and sickening thousands in Libby and northwest Montana. The W.R. Grace Company that owned the mine denied its connection to the massive levels of mesothelioma and asbestosis and dodged responsibility for this environmental and health disaster. When all lawsuits and legal avenues failed, Baucus turned to our country’s single-payer plan, Medicare.

The single-payer plan that Baucus kept off the table is now very much on the table in Libby. Unknown to most of the public, Baucus inserted a section into the health reform bill that covers the suffering people of Libby, not just the former miners but the whole community – all covered by Medicare.

They don’t have to be 65 years old or more. They don’t have to wait until 2014 for the state exchanges. No 10-year rollout – it’s immediate. They don’t have to purchase a plan – this is not a buy-in to Medicare – it’s free. They don’t have to be disabled for two years before they apply. They don’t have to go without care for three years until Medicaid expands. They don’t have to meet income tests. They don’t have to apply for a subsidy. They don’t have to pay a fine for failure to buy insurance. They don’t have to hope that the market will make a plan affordable. They don’t have to hide their pre-existing conditions. They don’t have to find a job that provides coverage.

Baucus inserted a clause in the Affordable Care Act to make special arrangements for them in Medicare, and he didn’t wait for any Congressional Budget Office scoring to do it.

Less than two months after the passage of the health reform bill on March 23, 2010, Nancy Berryhill of the Social Security Administration in Denver joined personally in setting up an office in Libby to sign up these newly eligible people.

“This is a new thing,” Berryhill told the Missoulian. “No other group like this has ever been selected to receive Medicare.” Berryhill issued a nationwide alert to inform anyone who had lived or stayed in Lincoln County of their eligibility. She opened a storefront in Libby at the old downtown city hall where she signed up 60 people on the first day. She plastered the towns of Whitefish and Eureka with pamphlets explaining the program and added three new staffers to the office in Kalispell.

Berryhill said she did not know how much the care would cost. That kind of analysis was beyond her directive to sign the people up. There have been no reports of competition from the private for-profit Medicare Advantage plans. The sick are not profitable.

No one should begrudge the people of Lincoln County. The mine wastes were used as soil additives, home insulation, and even spread on the running tracks at local schools. Miners brought the carcinogens home on their clothes. The W.R. Grace Company dumped much of the cleanup costs onto the federal government. A June 17, 2009, order by the Environmental Protection Agency, the first of its kind, declared Lincoln County a public health disaster. The Libby Medicare provision in the health reform law is based on the area covered by that EPA order.

Baucus gave his reasons to The New York Times for its only story on this unique benefit: “The people of Libby have been poisoned and have been dying for a decade. New residents continue to get sick all the time. Public health tragedies like this could happen in any town in America. We need this type of mechanism to help people when they need it most.”

Health tragedies are happening in every town. Over 51 million have no insurance. Over 45,000 uninsured people die needlessly each year. Employers are cutting coverage and dropping plans. States in economic crisis are slashing both Medicaid and their employees’ plans. Nothing in last year’s reform law will mitigate the skyrocketing costs. Most insurance is threadbare and doesn’t cover. More than 50 percent of us now go without necessary care. As Baucus said of Medicare, “We need this mechanism to help people when they need it most.” We all need it now.

Bill Clinton recently stated that the U.S. could give coverage to all for $1 trillion a year less than we now pay if we adopted the system of any other advanced nation. (Unfortunately, he did not say this when it would have mattered most during the 1993 and 2009 health care reform debates.)

Other industrialized countries have found that to cover everyone for less they must remove the profit-making insurance companies. Congressman John Conyers has reintroduced H.R. 676, the Expanded and Improved Medicare for All Act, which does exactly that. There are 60 cosponsors. It would cover all medically necessary care for everyone including dental and drugs by cutting out the 30 percent waste and profits caused by the private insurers.

So as the Ryan Republicans try to destroy Medicare and far too many Democrats use the deficit excuse to suggest cuts in its benefits, let us counter with the Libby prescription to clean up the whole mess. Only a single payer, improved Medicare for All, can save and protect Medicare, rein in the costs, and give us universal coverage.

Medicare will celebrate its 46th birthday on July 30, 2011, and all are invited to join in the festivities. Medicare was passed in 1965 and implemented within less than a year. When we pass H.R. 676, this single-payer bill, we can all be enrolled in the twinkling of an eye.

Kay Tillow lives in Louisville, Ky., and is a leader of All Unions Committee for Single Payer Health Care – H.R. 676.

PNHP note: The following is a reply that Kay Tillow made to a reader in Libby, Mont., who questioned some of the assertions in her article. We reproduce her reply here (the reader's name has been removed) because it sheds additional light on the situation there. Tillow also provides a number of useful citations.

Dear reader,

Your response to my article about Libby and Medicare was forwarded to me by the Physicians for a National Health Program.

The Medicare provision for Libby in the Affordable Care Act applies to the whole community not just the miners. Those who are eligible for Medicare immediately are defined by complex provisions in Amendment 1881 A made to the Social Security Act by the Affordable Care Act. That section lays out criteria for eligibility including the specifics diseases and conditions and the pilot programs that will provide additional benefits. Then this new law broadens that by stating that a person is eligible for Medicare who “is diagnosed with a medical condition caused by the exposure of the individual to a public health hazard to which an emergency declaration applies, based on such medical conditions, diagnostic standards, and other criteria as the Secretary specifies.”[1]

The law is complex. I wrote that the new provision “covers the suffering people of Libby” and linked that statement to the Social Security Administration’s (SSA) website for Libby[2] so that those who are interested can read the further detail.

Those in the Libby area who are diagnosed with an asbestos-related disease are immediately eligible, not just for asbestos-related symptoms, but for the full range of benefits that cover any Medicare recipient. The law includes a waiver of budget neutrality. This Medicare for Libby is an astounding provision, an amazing departure from any past practice of Medicare. There is no other instance of Medicare picking up coverage under any condition in a specific geographic region, and I do not understand any effort to minimize this benefit.

You assert that only 700 people so far have signed up for the benefit, but unfortunately the massive asbestos exposure of people in the region assures that many more will be diagnosed and become eligible. In the Washington Post of June 17, 2011, Tanis Hernandez of the Center for Asbestos Related Diseases asserted that more will sign up when the state-federal grant program ends this summer. Hernandez also stated that new cases are being diagnosed at the rate of four a week.

People in Libby and Troy do not have to be 65 to be eligible for Medicare. They don’t have to wait until 2014 for the state exchanges. They do not have to buy in to Medicare--Medicare Part A is free. To quote the SSA, “The Affordable Care Act provides certain individuals who were exposed to asbestos in Lincoln County, Montana: Free Medicare Hospital insurance (Part A).”[3] The SSA states further, “To qualify, you do not need to be age 65 or receive disability benefits. In addition, there is no waiting period, and you do not need to have worked and paid into Social Security or Medicare.”[4]

Unlike for the rest of the country, people in Libby and Troy do not have to have paid into Social Security and Medicare for a minimum number of quarters nor to have qualified for disability benefits. So the provision that Senator Baucus inserted into the Affordable Care Act breaks down the barriers so that people can get the care they need. Yes, Libby residents are to pay, like every other Medicare recipient in the country, for Medicare parts B and D, but there are also more special grants and pilot programs to assist the people of Libby. And, yes, the people of Libby deserve all of the care and compassion that our nation can give them. Nothing can restore to them the health that was stolen from them as the mine owners exploited their labor and polluted their beautiful region for profit.

I did not assert that “New residents continue to get sick all the time.” I was simply stating that Senator Max Baucus was quoted in New York Times as saying that. But, all too sadly, I believe that he is correct in this. The asbestos remains in many houses and gardens of the region—so much so that even after the clean up, the Environmental Protection Agency recommends that people do not disturb either the walls of homes or the soil. Region 8 of the Environmental Protection Agency states on its website that, “While EPA’s cleanup efforts have greatly reduced exposure, past and future exposures of amphibole asbestos may remain a public health concern in the area.”[5] That website was last updated in May of 2011.

According to a scholarly article[6] published in the Journal of Environmental and Public Health in 2009 written by Julie F. Hart et al., the danger remains in the forests of the region. “This research demonstrates the potential for airborne exposure and transport of AA (Amphibole Asbestos) in the Kootenai National Forest. These findings are especially relevant to those that work in the area and to the general public who may conduct recreational activities,” the authors state.

My statement that “other industrialized countries have found that to cover everyone for less they must remove the profit-making insurance companies,” is indeed true. Nobel Laureate economist Joseph Stiglitz said it well:

“The U.S. model of private health insurers has been proven inefficient and expensive. Rather than provide better healthcare at lower costs, insurance companies innovate at finding better ways of discrimination. They are inefficient because they are trying to figure out how to insure people who don’t need the cover and keep out people who need it. With many companies, they also need to spend on marketing and advertising. The incentives are all wrong and the transaction costs are very high and you have to give them a high profit. In health, social and private incentives are totally disparate. Competition does not work in healthcare especially in the health insurance market. Several countries like the U.K., France and Sweden have a single payer system, differing only in the organisation of healthcare delivery.”[7]

England, or the United Kingdom, covers all its people with a national health service. Private health insurance covers only 1 percent of health expenditures and is limited to supplementary areas. You assert that England has unsustainable costs, but in relation to health care costs in the U.S. that country is doing remarkably well. In 2007, the U.K. spent $2,990 per capita for health care while the U.S. spent $7,290. That means the U.K., with a national health service and only a tiny very limited private health insurance, spent 41 percent of what the U.S. spent per person.[8] Yet the U.K. outpaced the U.S. in life expectancy in 2009 by a full year.

The 30 percent in administrative waste and profits in the U.S. health system is caused by the private health insurers. According to the Physicians for a National Health Program, “Private insurers necessarily waste health dollars on things that have nothing to do with care: overhead, underwriting, billing, sales and marketing departments as well as huge profits and exorbitant executive pay. Doctors and hospitals must maintain costly administrative staffs to deal with the bureaucracy. Combined, this needless administration consumes one-third (31 percent) of Americans’ health dollars.”[9]

The costs of administering the Medicare program have remained low over the years – less than 2 percent of program expenditures [10], according to research by the Kaiser Family Foundation. The private for-profit health insurers are fighting against the rules of the new Affordable Care Act that would limit them to 20 percent for some insurance, 15 percent for others, in administrative costs. In my state of Kentucky, the insurance commissioner asserts that the rate allowed for administrative costs is currently 35 percent and that any sudden shift to the 15 percent or 20 percent limit would cause undue hardship and force companies to leave the state. Clearly the private insurers are more costly, less efficient.

Contrary to your assertion that Medicare is unsustainable, it is the gigantic overhead of the private health insurers that is unsustainable. Research by the Physicians for a National Health Program shows that by moving to a single payer system, our country could save $400 billion annually that could then be applied to expanding coverage for all of us and extending coverage to those who are uninsured. Such a program will be instituted when we pass Congressman John Conyers H.R. 676, Expanded and Improved Medicare for All Act.

At your suggestion I looked up information about Rulon Stacey and saw that in a news release about his new book “Over Our Heads,” he states, “Our current healthcare crisis was fueled by government intervention.”[11] The above data on Medicare versus private insurance show just the opposite—that the crisis is propelled by the domination of our system by private for profit insurance.

I agree that you live in a very beautiful area, and I do not seek in any way to deter the people of that region from finding the ways to reclaim a clean, healthful, environment in a new future. The courageous people who brought the problems to light are responsible for pointing a way forward. Clean up and health care are crucial to that.  

It is informative for people in the country to know that Senator Max Baucus made certain that the people of Libby suffering from asbestos exposure did not have to buy into exchanges they could not afford nor wait endlessly. He chose the more efficient and effective single payer program, Medicare, to assure that they got care. He did that while ordering the arrest of single payer advocates for seeking to place improved Medicare for all on the table in the national health care debate, thereby denying the nation as a whole a chance to choose a vastly superior health plan that would cover us all while controlling the costs.  

1. Sec. 1881A. [42 U.S.C. 1395rr-1] Medicare Coverage for Individuals Exposed to Environmental Health Hazards, (a) Deeming of Individuals as eligible for Medicare benefits.







8. Organisation for Economic Co-operation and Development, 2007