What is Universal Healthcare?

By Annie Brown
EDGE (Boston), March 18, 2011

Patients, doctors and health insurance companies are engaged in a historic debate surrounding the future of healthcare in America. Most of the discussions surrounding healthcare are led by politicians who either celebrate President Obama’s Patient Protection and Affordable Care Act (2010) as a necessary first step towards equal access or view it as a direct assault on constitutional rights.

However, there are millions of patients and physicians who aren’t pleased with either party’s response to the healthcare crisis.

Dr. Susan Miller, a family physician and Virginia’s representative for Physicians for a National Health Program, is one of these individuals.

Dr. Miller’s perspective on the healthcare issue is informed by extensive experience as a physician, a small business owner, and an individual who has witnessed first-hand the inequality and inefficiency of modern American healthcare. She, like many Americans, is frustrated with the rhetoric politicians are using to describe the current state of healthcare to their constituents.

Miller believes that politicians are manipulating this debate to support personal goals. In the process, they are also distracting Americans from the facts and making the road to universal healthcare longer and more complicated than it should be. Rhetorical speeches don’t effectively explain healthcare legislation and rarely present possible solutions. It is my hope that this article will fill in the blanks left by politicians.

Miller has practiced family medicine for over 25 years. In the process she has participated in many aspects of the medical profession from safety-net clinics, to running her own private practice in the Richmond suburbs and, for the past five years, working with people from the inner city of Richmond. "I understand what it means to be a small business...I also understand the needs of [insured] middle-class patients and I know the problems of people who don’t have insurance."

During our interview, I asked Miller to explain her perspective on American healthcare and why she supports a single-payer plan. I also spoke with her about resistance to The Patient Protection and Affordable Care Act (PPACA) in her home state of Virginia and the possibility of universal healthcare in states like Vermont. The intention of this article is to explore solutions beyond rhetoric and move towards a healthcare system that provides affordable and quality care to all Americans.

Improved Medicare for All

Miller supports the idea of "improved Medicare for all," also known as a single-payer plan because she entered the field of medicine to help people. She continues, "I was into medicine and politics from the very beginning. I have been a single-payer supporter since I was first involved in medicine because I believe that healthcare is a human right."

As the Virginia representative for Physicians for a National Health Program (PNHP), Miller educates others about a single-payer plan that could solve America’s healthcare crisis. PNHP is a single-issue organization that supports a universal, comprehensive single-payer national health program and has been advocating for healthcare reform since 1987.

The organization has over 18,000 members and chapters across the United States. Miller explains the concept of a single-payer plan as "taxpayers pool together money to fund a national health plan. With a single-payer system, insurance is nationalized, but healthcare is delivered by private practices."

This plan would essentially be an improved and expanded Medicare system. Medicare for all means that ideally everyone born in the U.S. would be given a health insurance card or number when they are born or, for immigrants, when they gain citizenship. A quote used often by PNHP is, "Everybody in. Nobody out."

Since the passage of PPACA, PNHP continues to lobby state and federal legislators to consider a single-payer national health program as a cost-effective and health beneficial program. However, PNHP lobbyists are going up against health insurance companies who, according to a 2010 article in the Huffington Post, supplied an average of eight healthcare lobbyists per every one member of Congress in 2009.

In 2010, Aetna spent $4,845,894 on lobbying expenditures, while Blue Cross/Blue Shield contributed $916,719 to political campaigns. The majority of Blue Cross/Blue Shield’s contributions supported Democratic candidates.

Health reform is a hot topic in Washington because it is an issue that affects all Americans and reform of the healthcare system is much needed.

In September of 2010, approximately 50.7 million people did not have health insurance. As a reformative bill, the 2010 PPACA aims to reduce this number and provide health coverage to over 30 million currently uninsured Americans "by expanding Medicaid and providing federal subsidies to help lower and middle-income Americans buy private coverage," according to a recent article in the New York Times.

The law also forces health insurance companies to stop practices that prevent people from purchasing insurance. However, this most recent attempt at healthcare reform disappointed single-payer supporters. The PPACA "was health insurance reformed."

"Single-payer supporters never even got to the table ... Obama made a pragmatic political decision. Obama was a single-payer supporter before he ran for office ... he abandoned that because he would have been labeled a socialist," Miller explains.

As Miller sees it, Obama’s plan "cut back on some of the excesses, where these companies were denying people care and refusing to cover people if they had a preexisting illness. However, it is not healthcare reform."

Although the final version of the bill did expand Medicare and provides more Americans with coverage, it bolsters the problematic private insurance industry and leaves 23 million Americans still uninsured by 2019, according to a recent Congressional Budget Office estimate

Deconstructing Healthcare Rhetoric

Despite the amount of conservative compromise that shaped the bill as it passed through both houses of congress, politicians are still debating the role of government in medicine. Many prominent political leaders have publically stated that one of their primary goals this year is to repeal Obama’s healthcare legislation on the basis that government should be separate from medicine.

Since the PPACA was passed, the Republican Party has turned to misleading rhetoric as they work to have the bill repealed. Although Republicans do support national healthcare plans, such as veteran’s insurance and Medicare, much of the party’s rhetoric attacks the PPACA as well as a single-payer system for being socialist and anti-business.

Miller explains that Obama’s bill is far from socialist. She says the act is "merely insurance reform, built on the privately owned profit making health insurance industry." Although the solution of a single-payer plan, or Medicare for all, eliminates the need for private health insurance providers, it does not deserve the term socialist.

The single-payer system would not be socialized medicine, it would be social insurance, says Miller, "this means that society pools the risk, so that the people who are really ill get treatment...In this system healthcare is still delivered privately by your local doctor."

Miller clarified that the only socialized healthcare we have in this country is insurance provided by the VA [the U.S. Department of Veterans Affairs], because it is supported by taxpayers as well as delivered by the government. Unlike in the single-payer system, healthcare provided though the VA is funded and delivered by the government.

Miller defends nationalized insurance against anti-business rhetoric by emphasizing the burden that providing insurance places on employers. "You would think people who support businesses should support a single-payer healthcare system. ... Why is Toyota the best car company in the world? Because our companies in Detroit have to take $15,000 from the sale of each vehicle to pay for employee health benefits." In a single-payer system, citizens would no longer have to rely on their employer to provide healthcare.

Today the United States remains the only industrialized country without a national health insurance plan. Medicare and Medicaid are the closest the country has ever come to a national health insurance program, but neither of these government programs were ever expanded to cover all Americans.

Understanding Cuccinelli’s Arguments

Some of the most intense arguments over government’s role in healthcare have occurred in Miller’s home state of Virginia.

On March 2, Attorney General Ken Cuccinelli stood before the House Judiciary Committee and explained his concerns about the PPACA. "The litigation is not so much about healthcare as it is about liberty," Cuccinelli says. He took this same argument to Virginia Courts.

In the lawsuit, The Commonwealth of Virginia vs. Kathleen Sebelius, the Attorney General argues the federal law is unconstitutional due to the bill’s individual mandates provision, which requires that all Americans must purchase healthcare by 2014, or face a federal penalty. Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, is defending her motion to dismiss Cuccinelli’s claim against individual mandates. Cuccinelli is acting as Plaintiff and representative of the Eastern District of Virginia.

"In this case, I agree with Cuccinelli. When else have we required Americans to buy a defective product?" Miller explains, "Individual mandates where the only way that the health insurance companies would agree to certain regulations, such as not eliminating people who had preexisting conditions." With individual mandates, health insurance companies can maintain profits and also (using the money paid by insured customers) pay for more American’s healthcare.

In December, Virginia federal district judge Henry E. Hudson agreed with Cuccinelli’s argument stating, "The law’s central requirement that most Americans obtain health insurance exceeds the regulatory authority granted to Congress under the Commerce Clause of the Constitution."

In his final ruling, Hudson ruled in favor of Cuccinelli, rejecting the federal government’s motion to dismiss the Commonwealth’s lawsuit and thereby allowing Cuccinelli to continue his efforts to have the PPACA repealed. A Circuit Court of Appeals in Richmond is scheduled to hear the government’s appeal this spring, unless the U.S. Supreme Court decides to take on the case first. If the Supreme Court rules that individual mandates are unconstitutional, the entire PPACA would be repealed since the mandates are a requirement of the law.

While the individual mandate clause may be the central focus of the healthcare debate in Virginia, Miller suspects that Cuccinelli’s argument against this one provision is representative of a broader conservative stance.

"The argument in this country is whether healthcare is a human right or if healthcare is a profit center," says Miller, "Republicans want to make people cost sensitive so people won’t go to the doctors all the making costs transparent and asking patients to be responsible when they choose providers. But the problem with this is that when someone needs their appendix out, they can’t shop around."

In many ways, the competitive nature of capitalism doesn’t benefit patients. Miller elaborated on this point by citing several studies, including a Harvard study that showed for-profit dialysis centers to have higher death rates than nonprofit centers, as well her own experience as a doctor.

"Just before speaking with you," Miller said after a brief pause in our interview, "I had a patient on the phone. I could tell that she was wheezing. I told her she should go to the emergency room, but she says she couldn’t afford the co-pay...We need to remove barriers to care."

The Future of Universal Healthcare

While PPACA is being resisted in some states, such as Virginia and Florida, other states are taking this as an opportunity to discover sustainable solutions to America’s healthcare problem. For states to implement their own version of "Obamacare" the law requires they obtain federal waivers that relieve them of particular requirements specified by the plan.

The waiver provision was included in the original bill to allow states to test alternative ways of making health care accessible to the millions of Americans who need it. Waivers were not supposed to be available to states until 2017, but recently Obama stated he would support an amendment that would grant early waivers so that new healthcare models could be implemented as soon as possible.

Vermont is one of the states requesting an early waiver. After Obama announced his support of the early waivers amendment, Vermont Democratic Senator, Patrick Leahy stated, "Vermont has already been working hard to improve the state’s system of health care, and passage of the delegation’s waiver bill will move our state one step closer to that goal."

Miller is hopeful about the future of healthcare in America. "They are moving forward with single-payer program legislation in states like Vermont, Oregon and California," she says with excitement, "once states begin using a single-payer system, we will have a national experiment. We will see which states have better healthcare."

There is already a federal bill written that lays out the steps needed to implement a single-payer program. The Expanded and Improved Medicare for All Act (HR676) established "a unique American universal health insurance program with single payer financing." The summary written by Representative John Conyers Jr. (D-MI) continues,

"The bill would create a publicly financed, privately delivered health care system that improves and expands the already existing Medicare program to all U.S. residents...The goal of the legislation is to ensure that all Americans will have access, guaranteed by law, to the highest quality and most cost effective health care services regardless of their employment, income or health care status."

The bill failed to make it past committee, but was reintroduced on February 11 of this year as "The United States National Healthcare Act," with 28 co-sponsors. "The bill gradually transitions the whole healthcare system from profit to not for profit," says Miller.

According to the Healthcare-NOW website, the program established in HR676 "will cover all medically necessary services. ... Patients have their choice of physicians, providers, hospitals, clinics, and practices. No co-pays or deductibles are permissible under this act."

With so much resistance towards the idea of a single-payer program coming from both the moderate left and the right, there is little chance that this bill will pass through either house any time soon, even if it is a potential solution to America’s healthcare crisis. "Americans need improved Medicare for all."

"Of course Medicare is not perfect," she adds, "but it’s a great platform to start from." Miller speaks openly about the single-payer option with her colleagues because she wants to separate the facts from the rhetoric politics have built up around them.

Justifiably, she worries when politicians complicate the issue of healthcare reform. Circular rhetorical arguments cause Americans to tune out, even though this debate and its outcome is critical to national prosperity and personal health.






6. Section 1311, b(1)