By Dr. Marcia Angell
PBS Bill Moyers Journal
March 5, 2010
[The following is an excerpt from an interview with Dr. Marcia Angell, editor emeritus of the New England Journal of Medicine, on the second half of Bill Moyers Journal on March 5. The full interview can be watched here.]
BILL MOYERS: Dr. Marcia Angell has been one of the foremost champions of a “single payer” nationalized health system, a kind of Medicare for everyone that was a plan favored by Barack Obama before he was president. But he backed off in the health care debate, saying it’s just not viable in the current climate.
You’ve seen Marcia Angell at this table before. A physician trained in both internal medicine and pathology, she was the first woman editor-in-chief of “The New England Journal of Medicine.” She’s now senior lecturer in the Department of Social Medicine at Harvard University Medical School and writes extensively and often about health care. On her previous visit to the Journal last July, she had this to say:
MARCIA ANGELL: I would rather see Obama go down fighting for something coherent and practical that the public could mobilize behind, than go down fighting for this amorphous plan that tries to keep the private insurance industry in place.
BILL MOYERS: Since then, health care reform has gone through more twists and turns than a mountain road. And Dr. Marcia Angell is back to tell us what she thinks now. Welcome to the Journal.
MARCIA ANGELL: Thank you very much. Good to be here.
BILL MOYERS: So, has President Obama been fighting as hard as you wished?
MARCIA ANGELL: Fighting for the wrong things and too little, too late. He gave away the store at the very beginning by compromising. Not just compromising, but caving in to the commercial insurance industry and the pharmaceutical industry. And then he stood back for months while the thing just fell apart. Now he’s fighting, but he’s fighting for something that shouldn’t pass. Won’t pass and shouldn’t pass.
What this bill does is not only permit the commercial insurance industry to remain in place, but it actually expands and cements their position as the lynchpin of health care reform. And these companies they profit by denying health care, not providing health care. And they will be able to charge whatever they like. So if they’re regulated in some way and it cuts into their profits, all they have to do is just raise their premiums. And they’ll do that.
Not only does it keep them in place, but it pours about $500 billion of public money into these companies over 10 years. And it mandates that people buy these companies’ products for whatever they charge. Now that’s a recipe for the growth in health care costs, not only to continue, but to skyrocket, to grow even faster.
BILL MOYERS: But given that, why have the insurance companies, health insurance companies been fighting reform so hard?
MARCIA ANGELL: Oh, they haven’t fought it very hard, Bill. They really haven’t fought it very hard. What they’re fighting for is the individual mandate. And if they get that mandate, if everyone does have to buy their commercial products, then they’re going to be extremely happy with it.
BILL MOYERS: But this is all about politics now. It’s not about pure health care reform. So given that reality, what would you have the President do?
MARCIA ANGELL: Well, I think you really do have to separate the policy analysis from the political analysis and I’m looking at it as policy. And it fails as policy. Moreover, a lot of people say, “Let’s hold our nose and pass it, because it’s a step in the right direction.” And I say it’s a step in the wrong direction.
You’re right. Politics is different and there are a lot of people who say, “Look, it’s a terrible bill. Even a step in the wrong direction as policy goes. But we need to get Obama elected again and we need to continue with the Democratic majority in Congress. And so we need to give Obama and the Democrats a win. If we don’t, the Republicans will come in and take over Congress in the fall, and then the White House in 2012.” But the problem with a political analysis is sometimes you’re right and sometimes you’re wrong. And Democrats and particularly liberals have a history of outsmarting themselves.
And I’m not so sure that if this bill goes down, it’s going to make it any harder for them politically. So I think it’s difficult times for the President and for the Democrats. But if you look at it as a matter of policy, the President’s absolutely right that the status quo is awful. If we do nothing, costs will continue to go up. People will continue to lose their coverage. Employers are dropping health benefits. Things will get very bad. The issue is will this bill make them better or worse? And I believe it will make it worse.
BILL MOYERS: The President, with all due respect, would disagree with you. Let me show you something he said--
MARCIA ANGELL: Yes.
BILL MOYERS: --in his speech on Wednesday.
MARCIA ANGELL: Yes.
PRESIDENT BARACK OBAMA: My proposal would bring down the cost of health care for millions, families, businesses, and the federal government. Our cost-cutting measures mirror most of the proposals in the current Senate bill, which reduces most people’s premiums and brings down our deficit by up to one trillion dollars over the next two decades. Brings down our deficit. Those aren’t my numbers. Those are the savings determined by the Congressional Budget Office, which is the Washington acronym for the nonpartisan, independent referee of Congress.
BILL MOYERS: Not good enough for you?
MARCIA ANGELL: Well, first of all, you have to look at what the CBO is looking at.
BILL MOYERS: Congressional Budget Office.
MARCIA ANGELL: Yes. They’re not looking at the cost to the system as a whole, to the larger system. They’re not looking at the private system. They’re simply looking at the federal budget as a budgetary item.
BILL MOYERS: Right. They look at the government--
MARCIA ANGELL: The government part of that. So if they can save money in Medicare, then they come out ahead, no matter what happens out in the private sector. And so that’s what he’s talking about. It will take money out of Medicare and put it into the private sector. Medicare is the source for a lot of the funds that are going to go to subsidize the private health insurance industry. So that’s the first thing. The second thing is the CBO has to build in assumptions. And those assumptions are arguable, to put it mildly.
And as far as cost-cutting, there are sort of promissory notes. ‘We’ll get a committee to look at the cost of effectiveness, of various medical procedures.’
BILL MOYERS: Well, you remind me 45,000 people, as Wendell Potter said earlier, die every year for lack of health insurance. That should be-- they’re--
MARCIA ANGELL: It’s not lack of health insurance. It’s lack of health care. There is a difference between health insurance and health care. You can have insurance offered that is too expensive to buy or too expensive to use. What good does it do? And what happens when this occurs, is that what you see is instead of improvements, look at my state of Massachusetts.
Instead of seeing improvements, you see it shredded even further. You see more people denied access anyway. Now they’re about, I think over 60,000 people in my state who are exempted from the plan for financial hardship and this is also in the Obama plan. If you’re really poor, you don’t have to participate, and these are the very people who should be in a plan to cover them.
BILL MOYERS: But, the very poor do get Medicaid.
MARCIA ANGELL: Yes, yes. And one of the things about the Obama plan that I do like is that it expands Medicaid up to 133 percent of the federal poverty level and that’s fine. The problem is that could have been a stand alone measure. You didn’t need to have it incorporated in this massive Rube Goldberg apparatus.
BILL MOYERS: Is there anything else in there you like, in the Obama plan?
MARCIA ANGELL: Oh yeah. I mean--
BILL MOYERS: What?
MARCIA ANGELL: First of all, the intention is very good. The expansion of Medicaid is very good. Raising the age of dependents to 26, and saying that they have to be covered under parents’ plans. I think that’s very good. Looking at the cost-effectiveness of various procedures is a good thing to do in its own right.
So yes, there are things in it. But the bill as a whole, the more I look at it, the worse it gets. It’s going to increase costs, not decrease them. And it’s going to increase the rate of growth. It’s not going to bend the curve, except in Medicare.
I think in order to look at a reform and to measure a reform, you have to look at the problem it’s designed to answer. You have to look at what’s wrong with our system, in order to evaluate a reform. You have to ask yourself, “Why is it that we spent over twice as much per person on health care and yet don’t manage to cover everyone?”
BILL MOYERS: Why is that?
MARCIA ANGELL: And the reason is that we have chosen, alone among all advanced countries, to leave health care to for-profit industries, to leave health care to businesses that then distribute health care as a market commodity according to the ability to pay and not according to medical need.
So if you look at what’s causing the problem, the causes are not being targeted in this plan. They’re not being addressed. Maybe some of the symptoms of the causes are being addressed like let’s stop excluding people from pre-existing conditions. But it doesn’t stop the insurance industry from raising its premiums.
BILL MOYERS: So how can you be sure, just as you say politics often goes off-track. We don’t get the politics or the policy we want. How can you be sure that these terrible things are going to happen?
MARCIA ANGELL: Well, if you get-- I think it was Senator Rockefeller who said, I mean, that was a wonderful comment he made in the summit last week. Senator Rockefeller referred to the private insurance companies as rapacious, rapacious, and said, “Like sharks, they swim under the water, and you don’t know they’re there until you feel their teeth.” Now there are not many people in America who would disagree with that description and so what this plan does is says, “This is a terrible industry, so let’s force people to buy their commercial products. And let’s subsidize it and put a lot of money into it.”
And what do you think they’re going to do? If you were an insurance company, you would say, “Well, thank you, Santa Claus. I’ve got all of these captive customers. Young ones are healthy. They probably won’t even use the insurance. There’s nothing to stop me from raising my premiums. I have all of these subsidies coming in.” Don’t you think that the prices would go up? I think it would be remarkable if they didn’t.
When I look at the Senate bill and the President’s suggestions, almost every paragraph, there is a poison pill for someone. I think sometimes they’re unintended. Let me give you one example. They allow for insurance companies to charge three times as much for older people as for younger people.
So from the point of view of the insurance industry, this is a god-send because either way, they win. Either the 55-year-olds cough up three times the premiums, and that’s good. Or else they can’t, and that’s probably the more likely situation. They can’t, and then they’re fined. And the insurance companies don’t have to take care of people who might actually get sick. They’re left with all of the thirty-year-olds, who are less likely to get sick, but who are required to buy their products.
So this sets up a situation which probably all plans, for 55-year-olds, are high priced. So they can’t afford to buy it, or if they do buy it, they have to pay an excise tax on it. This is a real poison pill for these older people. It’s a gift for the insurance industry.
BILL MOYERS: But the President is pushing ahead; he wants Congress to act in the next month. What would you have us do?
MARCIA ANGELL: I think the problem is this, Bill. If this plan is passed, and I think there’s real doubt as to whether it will be, and there’s even more doubt as to whether it would ever be fully implemented, but let’s say that it’s passed. It will begin to unravel almost immediately. And then what will people do? Well, they’ll say, “We tried health reform, and it didn’t work. Better not try that anymore.”
It’ll be like what happened after the Clinton plan failed. There’ll be another 16 years before anybody comes up with the courage to try that again. People say, “Too expensive. Just can’t have universal care. Tried that, did that, didn’t work, good-bye.” Whereas if the bill dies now, people can say, “This bill died because it was a bad bill.” And the problem is still on the front burner. And then one can hope that we get some version of Medicare for all. And that we don’t have to wait 16 years.
BILL MOYERS: What makes you think it would come back in 16 years or more? What makes you think it will ever be back on the table?
MARCIA ANGELL: Oh, I think it has to be. I mean, I think that this system is unraveling so fast, doing nothing or doing the Obama plan, so fast, that something will have to be done. Unless we want to, you know, explicitly be a third world country. So I don’t think it’s going to wait. But if we pass this plan, it’s going to delay.
BILL MOYERS: Are there any, you know, three or four things that could be changed in the next month that would make you change your mind and vote for this if you were in the Senate?
MARCIA ANGELL: No, I don’t think so.
BILL MOYERS: Not one?
MARCIA ANGELL: That could be--
BILL MOYERS: If they took out the mandate--
MARCIA ANGELL: --that realistically--
BILL MOYERS: Yeah, realistic.
MARCIA ANGELL: No, no. If you take out the mandate, then the private insurance industry says, “No, we’re out of here.” This Congress will do what the private insurance industry wants it to do. If you look at the money that has flowed into Congress over the last year, and particular to people who were crafting this bill, you can see that the pay masters get what they want.
BILL MOYERS: Marcia Angell, thank you very much for returning to the Journal.
MARCIA ANGELL: Well thank you.