By Margaret Flowers, M.D.
For decades healthcare advocates in the state of Maryland worked with state senator Paul Pinsky who introduced a state health bill each year calling for a universal healthcare system that is publicly financed, a single payer system. Even when advocates educated lawmakers, gathered co-sponsors and testified in committees about the dire need for a health system that would solve the current healthcare crisis, one based on solid evidence, the bill fell flat. The closest we came was one vote short of getting it passed in one committee. We had all of the facts on our side, but no political muscle to move the bill.
The people in Vermont took a different approach starting in 2009, and we in Maryland have since followed their lead. The Vermont Workers’ Center and allies started by first building the grassroots movement necessary to provide that muscle. They focused on educating people throughout the state and used a human rights framework to do that.
After years of work to elect a favorable governor, pass legislation and implement it, the people of Vermont were recently spurned by Governor Peter Shumlin when he announced that the state would not go ahead with the health law as planned. This turn of events provides an important lens for examining what happened in the advocacy for health reform and what must be done now. The fight for universal healthcare has been going on for a century in the US and it is certainly not over because of Shumlin’s failure.
I want to say from the beginning that I applaud the people of Vermont. Hindsight is always clearer. The groups on the forefront of this struggle face many critical issues that need attention and lack adequate resources as it is for most groups that are working to change the system. So this article is not a criticism of them, but rather an analysis of the situation and what we can learn from it for current organizing efforts throughout the US as well as next steps in Vermont.
Human Rights Framework is Necessary
There has been hesitancy by some health reform advocates to embrace the human rights framework for single payer organizing. However, the human rights framework is necessary for organizing on all of the social, economic and environmental justice issues that are in crisis today. It helps us see that all of our issues are connected, know when our human rights are being violated and advocate for changes that respect all of our rights.
Many in the US don’t understand that they have human rights, let alone that their rights are being violated. The human rights framework is based on five core principles. Put simply, they are universality, that all people are included; equity, that all are able to participate; transparency, that all have access to information; accountability, that those who make decisions answer to the people; and participation, that all are able to participate in the process. It is the government’s responsibility to guarantee our human rights.
Once we have this understanding of our rights, we see the violation of our human rights across a broad sector of issues whether it is the right to housing, education, a job with a living wage, healthcare, clean water and air or other rights. Then we can look more deeply to understand why these rights are being denied and that there are systemic root causes that are the same for all of these issues. All of our struggles face the same obstacles of monstrous industries that are driven by profit through exploitation of people and the planet and that control not only the lawmakers but in most areas, the method by which they are elected.
Several studies were released last year documenting that public policy reflects the desires of the wealthy rather than the needs of the majority of people. We are facing a crisis of democracy. It will take all of us working together strategically to overcome these obstacles and shift the balance of political power to respect our rights.
The human rights framework teaches us that we cannot accept that rights are respected for some and not for others. A core principle is universality. For example, a health law that gains access to care for some but leaves others out does not fulfill the criteria. The human rights framework prevents the tried-and-true tactic of ‘divide and conquer’. It requires that our work is not done until we all have the same rights.
This human rights framework is especially relevant when it comes to health. The US spends the most per capita on health care in the world but our health outcomes are relatively poor. If our goal is a healthier population, then we must recognize that our fight is not only for access to health care, but is also for quality education, housing, a healthy environment, an end to systemic racism and all of the factors that constitute the social determinants of health.
And not only do we need to include all of these factors in our ultimate goal of health, but to succeed in changing the system we need to build a movement of movements that has the political muscle to overcome the for-profit health institutions that are heavily invested in maintaining the status quo. The healthcare movement needs to collaborate with those who are fighting for other rights.
Beyond the Human Rights Framework We Need Clarity
While the human rights framework is necessary for public education and connecting movements, it is not sufficient when it comes down to the details of policy and this is where clarity is key. This is one area that was problematic for the healthcare campaign in Vermont which resulted in the current failure of the health law and greater confusion about single payer health care.
The approach of the Vermont campaign was to first pass a law in 2010 requiring the state to hire a consultant to develop three health systems that meet the five human rights principles. The Health Care is a Human Right campaign organized across the state and built a strong grassroots base that not only led to passage of that law, but made single payer health care a major component of the gubernatorial race that year. Peter Shumlin, who won that election, spoke out strongly and publicly for single payer health care.
Once the law was passed and Shumlin was in office, the grassroots told lawmakers that it was up to them to design a system that met the human rights principles. The grassroots did not demand that it be a single payer system. And the ultimate choice for a health system in Vermont was not a single payer system but a multi-payer system with a tax-funded public option to be available to whomever did not qualify for Medicaid or Medicare and did not have private insurance.
This is where the lack of clarity caused significant problems. First, a single payer healthcare system is the only way to solve the healthcare crisis. The type of healthcare system that Physicians for a National Healthcare Program and other single payer advocacy groups have pushed for would create a unified system in which everyone is included that provides comprehensive benefits and is financed through a progressive tax. These are the essential ingredients that create a system which places health, not profit, as the priority and that has built-in cost savings that make such a system affordable. Because the Vermont plan lacked necessary cost-control features, it was unlikely to succeed.
Another problem has arisen because although the Vermont plan is not a single payer system, some health advocates, the Governor and other lawmakers and the media have been calling it a single payer system. Now that it has failed, the message that the public is hearing is that “single payer is too expensive.” This is the opposite of the truth. Numerous studies and practical experience in the US and abroad have shown that the US’ current market-based system is the most expensive and single payer systems are the most cost effective.
Clarity on the details of what does and does not work is critical because it is common for health laws to be called universal, affordable and guaranteed when the reality is that they are none of those things. We saw this when the Affordable Care Act was signed into law. That is why it is imperative that the grassroots not only understand the human rights principles, but is also clear about what policies will and will not accomplish the end goal.
Human Rights Principles Also Apply to the Political Process
Another obstacle for the health reform process in Vermont is that the process itself did not meet the human rights principles, particularly of transparency, accountability and participation. Early on, as the legislation was being formed in the state house, members of the grassroots were heavily involved and watchful of each change to the bill. When they noticed changes that were negative, they applied pressure on lawmakers to have them changed or dropped. This vigilance and pressure were critical to shaping the law in favor of the people.
Once the law was passed and signed, the next steps were the implementation of the various pieces of it such as the public insurance, called Green Mountain Care, and the financing mechanism, which was to be determined by the governor. It was the process of determining the financing that was problematic. Governor Shumlin ignored requests from the grassroots to include health finance experts that were proponents of a single payer system.
Business leaders and pro-market-based healthcare reform advocates were close advisers. A chief consultant to the health reform process was Anya Rader Wallack, who came directly from the Blue Cross Foundation. Blue Cross is the largest private insurer in Vermont. Rader Wallack is now leaving Vermont to go to Rhode Island to work on the health insurance exchange (essentially the government selling health insurance).
The governor also used a flawed economic model which is known to overestimate health care spending developed by Jonathan Gruber, a former White House adviser during the 2009 national health reform process. Not only does Gruber support the health insurance dominated Affordable Care Act, but he supports privatization of Medicare by pushing the elderly and chronically ill into the insurance exchanges.
The governor delayed his announcement of the financing for the system, ignoring the deadline set by the law that it be completed in 2013, until after the election in 2014. In mid-December, he held a press conference where he said that the cost of the system was too expensive and therefore, it would be impossible. The grassroots movement, led by the Vermont Workers’ Center, immediately responded with a protest of the Governor calling his career “toast” for his failure to meet his obligation established by the health law.
Holding Politicians Accountable
In my experience, lawmakers have an endless supply of excuses to explain why they fail to meet the needs of the people and most of them are manufactured. It is unlikely that Governor Shumlin would have reached the same conclusion about the financing of the health system if he had used an open and transparent process that allowed participation of the grassroots base and health finance experts that are proponents of single payer systems rather than of market-based systems. Even if he did reach the same conclusion, a more open and participatory process would have allowed the public a deeper understanding of the reasons for it.
This is why the grassroots must insist on transparency and participation. And if these demands are not met, then politicians must be held accountable. Secrecy only exists in public policy when the needs and desires of the people are being disregarded.
Political muscle is critical for a progressive legislature which defies the interest of the big industries that are in control of the system. Take the recent fracking ban in New York. That only came about because a strong grassroots demanded studies of the effects of fracking and hounded Governor Cuomo literally everywhere he went for six years.
Randy Shaw, author of “The Activist’s Handbook,” said that the proper relationship between the grassroots and lawmakers is fear and loathing. Too often when activists become close with lawmakers, they are pulled into compromising for a political agenda rather than holding true to their mission. In New York, because protesters showed up with anti-fracking signs everywhere he went, Governor Cuomo reportedly told his staff that he hated them.
Recommendations for Single Payer Healthcare Activists
If we are to succeed in gaining single payer healthcare systems at the state or national level, we need more than the facts on our side. We must have political muscle that we are willing to flex.
After the 2009-10 national health reform process, I wrote an article that outlined three key elements for the single payer movement, calling it “I.C.U.” The “I” stands for independence because the movement must remain independent of political parties and their agendas; “C” for clarity, knowing what policies are real solutions and what are false solutions so that you can evaluate proposed policies; and “U” for uncompromising because as Gandhi said, “You cannot compromise on fundamentals for it is all give and no take.” We will keep getting crumbs if we are willing to take them.
Here is a summary of a few more recommendations:
The healthcare crisis and many crises continue in the United States. Our struggles will continue despite temporary setbacks. We must not give up. Let’s continue the conversation about next steps in our work for healthcare justice.
Dr. Margaret Flowers is co-director of It’s Our Economy, co-host of Clearing the FOG Radio and an organizer of the occupation of Freedom Plaza in Washington, DC. She is also with the Health Care is a Human Right campaign in Maryland.