A prescription that makes the patient sicker

WHAT DO you think of the proposals for health care reform as they stand now in Washington?

PHYSICIANS FOR a National Health Program have had an analysis of the problem in the health care system for some years. Every new development seems to confirm the accuracy of our analysis. To be explicit, the problem is the private insurance company, which is a giant enterprise and has grown each year as the health care costs explode.

Everyone is familiar with the figure that one-sixth of the gross domestic product now goes to health care, and that's a spectacular figure. It turned out to be $2.5 trillion last year. I know a trillion doesn't sound as surprising as it once did, but that's a lot of money--it amounts to just under $8,000 per person in the country.

As you know, this country now has about 50 million people who are uninsured, and the number is rising. The tragic reality is that many, many millions more will almost certainly lose their insurance coverage in the immediate period ahead because of the economic downturn.

So all of the indicators are negative, and the health system is dragging down the whole national economy. We're told that American products can't compete with countries that have a national insurance scheme because U.S. companies are burdened with such huge health care costs.

We at PNHP remain firmly convinced of the experience of all similarly placed countries in the world--by that, I mean countries that have a democratic political system and an industrial base, the more developed nations in the world--that have all moved to a single-payer national health insurance scheme. All of them are doing much better than we are.

We spend twice as much as the closest countries to us, which include France, Switzerland and Germany--they spending around $4,000 per person. Their systems are much more efficient and much more popular, and they have much better health outcomes, judged by such basic criteria as life expectancy, infant mortality and prevention of certain diseases.

All the evidence is in that we should move in a way that all the other countries have. But that isn't what's happening--because of the awesome political power of the insurance companies and Big Pharma.

WHAT'S YOUR assessment of the Obama administration's "public option" proposal?

THE PUBLIC option is being opposed by conservatives who say that it's a slippery slope to socialized medicine. I don't think it's anything of the sort, and I don't think it will solve any problems.

The history of American health insurance demonstrates the spectacular skill of private businesses in selecting the healthy and excluding the sick. They call it cherry-picking. There are numerous costly examples of that in the Medicare system and Medicare Part Four, which is the prescription drug benefit. It always works to the maximum return of the private sector.

To put it simply, no plan will succeed--meaning take care of everybody at the best cost--as long as the private insurers are in the mix.

Nations across the world--we're talking about Western Europe, Scandinavia, the United Kingdom, Canada and now Asian countries--have all adopted a modification of single-payer government health insurance, with several important results: They spend half as much as we do on health care. Everyone is covered. Public satisfaction and support for the health system is very high and positive, in comparison to the way Americans feel about their health care system. And we're the odd guy out.

What's being enacted in Congress--such as the administration's favored bill, with a public option and a mandate to have insurance and a variety of strategies to control costs and extend coverage--is not going to work.

What they're proposing is pretty much what's happening in Massachusetts right now, and the bad news is that the costs there are out of control, and they're having to cut out beneficiaries. Most recently, the state was preparing to cut 30,000 legal immigrants from the program. And it's running out of money.

So we don't need to wait until the national program fails. It's already failing in its state incarnation.

IN A recent article, Kip Sullivan, a single-payer supporter, described what the Democrats did on the public option as "bait and switch." Do you agree with that?

HE'S RIGHT. Bait and switch is a good way to put it.

The administrative proposal, broadly speaking, has a mandate. The way it works is that if you don't have insurance, you must purchase it. You can purchase it from the private insurance industry, which already dominates the market. This would give them tens of millions more customers.

Or, as Obama would have it, there's a public option. He touts this as a way of creating competition with private insurance, therefore driving down their price. People would have a choice of getting a publicly administered program--presumably something close to Medicare.

In reality, the description is fallacious. Medicare works because everybody in a given group is in the program. Everyone over 65 has Medicare--it doesn't matter whether you're rich or poor, work or don't work. It's a total service to a given population.

Also, it's worth noting that when Medicare was enacted in 1965, it very quickly added all disabled people--a smaller group, but a very costly group. You'll notice what the private sector gave over to the government--people over 65 and disabled people. Common sense will tell you that these are the costliest groups medically in this society.

That's a good example of what the private sector does when it has to--it gets rid of the high-cost clients and sticks with the healthy. Well, that ain't a way to build a health system. A health system has to benefit people when they get sick and need coverage.

So we at the PNHP are, with Kip Sullivan, deeply skeptical of the public option. We think it will do very little to adjust the questions of cost, access or quality.

WHAT DO you think of the behavior of the Democrats in all this? They seem to be bargaining themselves away from any substantial proposal.

I THINK you're right. In their effort to get a bill passed, the concessions are all being made to the conservative elements. The kind of concessions that we read about daily can all be interpreted as maintaining market kinds of solutions--and indeed making sure that the private industry dominates the health system. That's a formula for disaster.

We're in the situation we're in now because that's precisely what has been sanctioned by government action since Medicare was passed--which was very good, but everything else that has been done hasn't been very good, and we have a bunch of costly, ineffective systems.

Number one in my book would be the Medicaid system, for which states and the federal government share costs. But Medicaid is for the poor. It's means tested, and the quality of care in that sector is bad. Not all doctors will participate, and the payment schemes are low. It's a good example of selective oppression of poor people. As long as you have these kinds of systems, you're going to have a relatively poor health program.

THE CONVENTIONAL wisdom the media keep pushing about health care reform is that something is better than nothing, and that compromising is the responsible thing to do. How do you respond to this?

WE DON'T buy it. We're strong, uncategorical advocates for a single-payer national health insurance.

We have many friends who agree that single payer is best. But they say, "Can't we take less than the best as a stepping stone to something better?" If that were really true, it would be a reasonable argument, and I for one would be willing to move in the direction of a better system by incremental measures.

But the really important message--and we try hard to make our critics understand this--is not that we're purists or that we don't like to compromise. That's not the case. The problem is these proposals will not work.

There have been variations of the kind of proposals being discussed now at the national level in as many as a half a dozen states over the last 10 years, and they don't work. Each of these states have more uninsured now than they did when they enacted their programs, and they've had to abandon the programs, or at least parts of them.

So we're resisting getting into a fool's gold arrangement, in which several bad things will happen. First of all, these halfway proposals won't succeed in the goal of spreading coverage to everybody. It won't happen. Second, they'll be very costly fiscally.

And perhaps most important, they fix the idea in the popular mind that the government can't do anything right. I remind you that this is a touchstone of conservative politics, and proposals like these are how they make it happen. We don't need that kind of pessimism in facing this huge social problem.

THE PNHP Web site had a speech from Barack Obama from a few years ago in which he supported single-payer.

WE PUT up one of the speeches, but there are at least a half-dozen recorded statements by Obama where he supports single-payer as the best answer. You know the rest.

WHAT WOULD you say happened to him between then and now?

I CAN'T get inside his head, but the facts are that no more than four or five years ago, maybe fewer, he went on record publicly saying that he was for single-payer health--that this was the best way to go.

But as his fortunes rose, and he went from being an obscure state senator in Illinois to the leading political figure in the world, his characterization of health reform changed more and more in the direction of centrist ideas--which is a polite term for big business control of the system.

The Obama I know--he's my neighbor, and we've supported his political career because it is supportable--is very smart; everybody recognizes that. It's not Bush-like stupidity that explains support for mistaken alternatives. I think they're calculations of what he thinks is possible to achieve--a notion of compromise that will include people.

But sometimes there are compromises that don't work. I give you human slavery in our country's 19th century experience. It was clear by the mid-19th century that slavery was incompatible with the survival of the country. And we had a ghastly Civil War to pay for it. The fact is that all the compromises of the first half of the century didn't work. The contradictions got worse.

You could cite other measures--women's suffrage, all of the New Deal reforms, unemployment insurance, Social Security. Those things came to be because not doing them would have been destabilizing.

I think we're in that position with health care. Because of its enormous economic impact, we're going to have to face up to the contradiction and have a reasonable system, so that our country can go forward.

ALONG THOSE lines, there were social movements--the abolitionists, the women's movement--that helped make those achievements possible. Can you talk about that a little? What do you think will get single payer on the table?

THERE'S NO question that there will need to be a movement. This isn't going to happen because it's a great idea or there'll be a sudden conversion of congressional leaders. It's going to take a push from below--a big one, just as with civil rights and the women's movement and the anti-slavery movement, to name a few. And when that movement actually takes off, this will come faster than we could ever hope. That's what it's going to take.

And I'm happy to report that we as a single-payer movement are stronger now than we've ever been. But we're not, I have to add, nearly strong enough to make it happen.

People who know me think I'm dangerously optimistic, and I plead guilty to that. But what I'm about to say is not in that spirit.

We have a much harder fight. There's been a 20-year period of right-wing domination of the debate and political power, not to mention literally hundreds of millions of dollars spent for lobbying by various interest groups. We've been in wars that made no sense, and we're still in them. Our economy, which was so robust and seemed so prosperous, no longer is. So we have a much more complicated political challenge.

The trade union movement gives a lot of lip service to single-payer, but hasn't shown nearly the kind of strength that, for example, the British labor movement did after the Second World War. The first act after the war ended was the enactment of the national health system, which has been a tremendous success in the last half-century.

We have to have those kind of events. Labor has to be much more militant and effective than it is now. Happily, there's more support for single payer in labor than there ever has been. But it's not sufficient by itself.