With Coronavirus, ‘Health Care for Some’ Is a Recipe for Disaster
The Trump administration’s treatment of immigrants could make the epidemic worse.
by Editorial Board - NYT - May 6, 2020
In late January, as the new coronavirus was making its first incursion into the United States, the Supreme Court upheld
the Trump administration’s contested “public charge” rule, which
enables federal officials to deny green cards to immigrants who use
social safety net programs. The decision received scant media attention,
in part because it was overshadowed by the emerging epidemic. But
public health experts warn that the two stories are intimately, perhaps
disastrously, related: Infectious disease outbreaks have a long history
of preying on society’s most vulnerable, disenfranchised members.
Noncitizens who don’t have access to health insurance, nutritious food
or safe, affordable housing fall squarely into that category.
Doctors and immigration advocates have long worried that the public charge rule would present a grave public health danger. The rule could deter millions of noncitizens — even those who were not technically subject to its provisions — from using programs like Medicaid, WIC and SNAP or from seeking medical care of any kind, lest they imperil their immigration status. That kind of avoidance would make those groups less healthy and thus more susceptible to the vagaries of, say, an infectious disease outbreak.
The administration was not blind to those risks. When it first proposed the new rule, officials at the Department of Homeland Security noted that it could very well lead to worse health outcomes for immigrants, especially infants, children and women who were pregnant or nursing. Yes, they acknowledged, vaccination rates might fall as a direct result of what they were proposing. Yes, communicable diseases might become more prevalent. But, the agency said, the new regulations were essential to a goal more important than protecting public health: making immigrants “self-sufficient.”
Many changes to law and policy have been undertaken in the past several years under the banner of “self-sufficiency” and its close cousin “personal responsibility.” Social safety net programs like SNAP and TANF have been cut; work requirements have removed thousands of people from Medicaid; and immigrant communities have been subject to a roster of anti-immigrant policies — not just the public charge rule, but also family separations and abysmal treatment of detained migrants at the border, and ICE raids and mass deportations at home.
Doctors and immigration advocates have long worried that the public charge rule would present a grave public health danger. The rule could deter millions of noncitizens — even those who were not technically subject to its provisions — from using programs like Medicaid, WIC and SNAP or from seeking medical care of any kind, lest they imperil their immigration status. That kind of avoidance would make those groups less healthy and thus more susceptible to the vagaries of, say, an infectious disease outbreak.
The administration was not blind to those risks. When it first proposed the new rule, officials at the Department of Homeland Security noted that it could very well lead to worse health outcomes for immigrants, especially infants, children and women who were pregnant or nursing. Yes, they acknowledged, vaccination rates might fall as a direct result of what they were proposing. Yes, communicable diseases might become more prevalent. But, the agency said, the new regulations were essential to a goal more important than protecting public health: making immigrants “self-sufficient.”
Many changes to law and policy have been undertaken in the past several years under the banner of “self-sufficiency” and its close cousin “personal responsibility.” Social safety net programs like SNAP and TANF have been cut; work requirements have removed thousands of people from Medicaid; and immigrant communities have been subject to a roster of anti-immigrant policies — not just the public charge rule, but also family separations and abysmal treatment of detained migrants at the border, and ICE raids and mass deportations at home.
The wisdom of each of those measures will be sorely tested now, as the coronavirus threatens to morph into a full-blown pandemic.
More than 100,000 people across more than 80 countries have been
infected with the new virus — and more than 3,400 of them have died,
including at least 14 in the United States.
Proponents of closed borders and small social safety nets have a tendency to highlight the tension between citizen and noncitizen, to imply or explicitly state that the only way to help one group is to deprive the other. But the truth is, people on both sides are hanging by a thread.
Infectious diseases, especially those like Covid-19, have a knack for penetrating and exposing such false dichotomies. Already, citizens who are underinsured or uninsured are being slammed with medical bills that they can’t afford when they seek testing and treatment for the virus. Unsurprisingly, experts say that many of them are bound to avoid such care as the outbreak rages on. If quarantines become routine, tens of millions of low-wage workers, many of whom don’t have health insurance or paid sick leave, will not be able to stock up and stay home. One shudders to think what will happen if the courts dismantle the Affordable Care Act in the next year — a move that could ultimately leave 21 million or so more people without health insurance.
Among noncitizens, the effects of the public charge rule and other fear-based immigration policies have long been apparent. New mothers are turning away free baby formula. Hungry families are turning away food assistance. The chronically and even fatally ill are avoiding hospitals and rejecting medical care. In 2019, The Atlantic reported that at least 200 eligible families in a Virginia county had stopped accepting WIC and that many were also turning down reduced-price lunches. Both of those programs are exempted from the public charge rule — using them will not count against a person’s visa or green card application — but those families were too afraid to chance it.
It’s easy to see how all this fear might feed on itself in the months ahead and also where that might lead. If citizens struggling to cover their own health care nurture resentments against any group perceived to be getting help to which they themselves are not entitled — or worse, if they grow xenophobic and subscribe to the notion that immigrants carry diseases — they might be compelled to endorse policies even more draconian than those already in play. That would create more anxiety among noncitizen communities, which would lead to fewer people seeking medical care when they need it. From there, the epidemic would only get worse.
Proponents of closed borders and small social safety nets have a tendency to highlight the tension between citizen and noncitizen, to imply or explicitly state that the only way to help one group is to deprive the other. But the truth is, people on both sides are hanging by a thread.
Infectious diseases, especially those like Covid-19, have a knack for penetrating and exposing such false dichotomies. Already, citizens who are underinsured or uninsured are being slammed with medical bills that they can’t afford when they seek testing and treatment for the virus. Unsurprisingly, experts say that many of them are bound to avoid such care as the outbreak rages on. If quarantines become routine, tens of millions of low-wage workers, many of whom don’t have health insurance or paid sick leave, will not be able to stock up and stay home. One shudders to think what will happen if the courts dismantle the Affordable Care Act in the next year — a move that could ultimately leave 21 million or so more people without health insurance.
Among noncitizens, the effects of the public charge rule and other fear-based immigration policies have long been apparent. New mothers are turning away free baby formula. Hungry families are turning away food assistance. The chronically and even fatally ill are avoiding hospitals and rejecting medical care. In 2019, The Atlantic reported that at least 200 eligible families in a Virginia county had stopped accepting WIC and that many were also turning down reduced-price lunches. Both of those programs are exempted from the public charge rule — using them will not count against a person’s visa or green card application — but those families were too afraid to chance it.
It’s easy to see how all this fear might feed on itself in the months ahead and also where that might lead. If citizens struggling to cover their own health care nurture resentments against any group perceived to be getting help to which they themselves are not entitled — or worse, if they grow xenophobic and subscribe to the notion that immigrants carry diseases — they might be compelled to endorse policies even more draconian than those already in play. That would create more anxiety among noncitizen communities, which would lead to fewer people seeking medical care when they need it. From there, the epidemic would only get worse.
The best way to break this cycle of
fear and further contagion is to dispense with zero-sum thinking and
stitch together a safety net big enough, and strong enough, for
everyone.
On Monday, more than 700 public health experts laid out clear steps for doing exactly that. Among other things, they called on the federal government to ensure that the outbreak response doesn’t exclude — or worse, penalize — the poor. The doctors and scholars advised officials not to cut existing safety net programs to pay for the work of battling the current outbreaks. They also asked that “particular attention and funding” be directed to local health centers in under-resourced communities; that diagnostic tests, and any future vaccines or treatments, be made widely available regardless of a person’s ability to pay; and that health care facilities be clearly designated as ICE-free zones. “Neither immigration status nor concerns over medical bills should deter people from seeking care right now,” said Gregg Gonsalves, an epidemiologist and infectious-disease expert at the Yale School of Public Health.
That’s a moral position, but it’s also a practical one.
In 2018, before Covid-19 was known to humans, when the public charge rule was still just a proposal, Wendy Parmet, a professor of law and public health at Northeastern University, warned that the push for immigrant self-sufficiency would be both dangerous and quixotic. “None of us can be self-sufficient in the face of a widespread epidemic,” she wrote. “That is just as true for noncitizen immigrants as everyone.” In a pandemic, self-sufficiency can be self-deluding; our health is only as good as our most vulnerable neighbor’s.
https://www.nytimes.com/2020/03/06/opinion/coronavirus-immigrants-health.html?referringSource=articleShare
On Monday, more than 700 public health experts laid out clear steps for doing exactly that. Among other things, they called on the federal government to ensure that the outbreak response doesn’t exclude — or worse, penalize — the poor. The doctors and scholars advised officials not to cut existing safety net programs to pay for the work of battling the current outbreaks. They also asked that “particular attention and funding” be directed to local health centers in under-resourced communities; that diagnostic tests, and any future vaccines or treatments, be made widely available regardless of a person’s ability to pay; and that health care facilities be clearly designated as ICE-free zones. “Neither immigration status nor concerns over medical bills should deter people from seeking care right now,” said Gregg Gonsalves, an epidemiologist and infectious-disease expert at the Yale School of Public Health.
That’s a moral position, but it’s also a practical one.
In 2018, before Covid-19 was known to humans, when the public charge rule was still just a proposal, Wendy Parmet, a professor of law and public health at Northeastern University, warned that the push for immigrant self-sufficiency would be both dangerous and quixotic. “None of us can be self-sufficient in the face of a widespread epidemic,” she wrote. “That is just as true for noncitizen immigrants as everyone.” In a pandemic, self-sufficiency can be self-deluding; our health is only as good as our most vulnerable neighbor’s.
https://www.nytimes.com/2020/03/06/opinion/coronavirus-immigrants-health.html?referringSource=articleShare
Unions Fighting Single-Payer Are Fighting Against Their Workers’ Interests
by Michelle Chen - Truthout - March 3, 2020
In early February, as the momentum of the primaries gathered behind
Bernie Sanders, the senator’s universal health care plan took center
stage in Las Vegas, promising working-class Nevadans comprehensive
access to health care and relief from soaring medical costs.
Nonetheless, one of Medicare for All’s biggest critics in the lead-up to
the Nevada caucus seemed to come from one of Sanders’s key constituent
groups: organized labor. The Culinary Union, UNITE HERE Local 226, circulated a flier
that warned that Medicare for All would “end Culinary Healthcare.” The
flier argued that the plan to give everyone in the U.S. good health care
would mean an end to the “good health care” that powerful unions have
fought for over the years.
A few days of social media mayhem ensued, with pro-Sanders critics accusing Local 226 — which represents roughly 60,000 hospitality workers, mostly women and people of color — of sowing division with a reactionary stance on the left-most health care reform proposal in Washington. Then came another twist: On caucus day, many union members broke with their leaders and voted for the candidate who would supposedly end their union health plans.
The drama around Medicare for All in Nevada reflected an evolving debate on single-payer health care in the labor movement: Although a public, universal health care system would potentially prevent thousands of needless deaths as well as eliminate the hefty medical bills, premiums and copays that plague many workers and their families, leaders of unions — which collectively represent about 1 in 10 workers nationwide — are divided on Medicare for All. Many labor organizations have deep economic and political stakes in the health insurance industry, often because they help provide health care to members under multiemployer insurance plans. Local 226 is one of several unions that run their own health centers, financed through a so-called Taft-Hartley trust fund, a jointly managed benefits fund established through collective bargaining that supports workers in multiple firms. Overall, affordable health insurance is one of the keystone benefits that union contracts typically provide, for which unions have historically bargained as a form of compensation. Over time, labor advocates say, unions have been compelled to effectively prioritize long-term health care over other bargaining issues, as negotiations on insurance tend to crowd out discussions on take-home pay and other components of a compensation package.
But over the past several decades, collective-bargaining agreements have become so backloaded with costly health care programs that the benefits that union members guard so jealously are precisely what’s making their contracts unsustainable. As Truthout has reported, transitioning to a public universal health care system would liberate unions from having to haggle over insurance co-pays at the expense of demands on wages or pensions.
Mark Dudzic, national coordinator of the Labor Campaign for Single Payer, says that, as health care reform has become a central issue in Washington, the politics around it have changed. “People like Bernie [Sanders] have injected it into mass political consciousness, and more and more unions are convinced that there’s a political path to win this,” he told Truthout. Dudzic estimates that, based on public support for single-payer legislation in Congress, organized labor groups representing the majority of the union workforce support a universal, national health plan.
Dudzic sees universal health care as a path to dismantling the power imbalance intrinsic to a collective-bargaining dynamic, which holds workers hostage to employer-based insurance plans. “[W]hen we go into the bargaining process,” he said, “employers know that they can hold that as a sword over our heads, on every other issue that we’re bargaining over, and we can’t walk away from that table with huge concessions on health care, so when that sword disappears, we have more power. Just like an individual worker has more power if she knows that she can leave her job and not lose her health care.”
While hundreds of unions and labor federations have broadly endorsed Medicare for All legislation, not all unions are actively campaigning for single-payer. In 2017, the AFL-CIO conference unanimously passed a resolution aiming “to move expeditiously toward a single-payer system, like Medicare for All, that provides universal coverage using a social insurance model, while retaining a role for workers’ health plans.” The conservatively worded statement seemed to endorse some form of universal health care, but not as a replacement for existing union benefits. In recent months, AFL-CIO and American Federation of Teachers leaders have apparently waffled on earlier support for Medicare for All.
Last September, the Massachusetts AFL-CIO convention went further than the 2017 resolution by pledging to make their presidential endorsement conditional on support for Medicare for All. California’s single-payer legislation, which would implement a Medicare-for-All-type system statewide, has been endorsed by more than 30 unions and labor organizations, including the Los Angeles Federation of Labor, several municipal workers unions and UNITE HERE Local 11.
Health care workers, who are on the front line of the health care crisis as providers and patients, have been leading the charge for single-payer.
National Nurses United (NNU) points to recent nurses’ strikes as an illustration of the cruel intersection of health care and labor crises: nurses have recently gone on strike in Vermont and Minnesota both to protect their own health care and advocate for better working conditions — and thus better care — for their patients.
“If we didn’t have to fight so hard for that one aspect of our union contract, we would have more time to fight for other protections, like better wages, and for nurses — better patient care conditions,” said NNU President Deborah Burger via email. “As union workers in the healthcare industry, nurses see every day how our patients, working people in America, are suffering and dying unnecessarily in this profit-based system, where coverage is tied to employment. Guaranteed single-payer health care is a more permanent, humane solution, proven to work in every other industrialized nation on earth.”
Sal Rosselli, president of the National Union of Healthcare Workers (NUHW), recalled that in the 1980s, when he organized with SEIU Local 250 in California, the union bargained hard to secure quality health plans for health care workers and their families. But as health care became increasingly corporatized, union leaders got mired in “a defensive fight, every contract cycle” with tight-fisted employers. NUHW, representing 15,000 hospital and clinical personnel across California, champions Medicare for All not only as a basic public good, he says, but because it would help unions pursue stronger benefits and protections beyond just health insurance. “Single-payer will accomplish taking health care off the bargaining table so that economic gains — wages, pensions, childcare, elder care, training — can be prioritized, because employers will no longer have to put their profits or their budgets into health care,” Rosselli told Truthout.
NUHW acknowledges reasonable concerns among some Medicare for All critics about the potential loss of health care industry jobs under the transition to single-payer. While there will be economic disruption when replacing the health insurance bureaucracy with a leaner, state-run program, Rosselli noted that NUHW members would be able to gain new jobs from a health care system that provides more comprehensive coverage and includes more people.
“When we accomplish Medicare for all,” Rosselli said, “and have comparable access to care for all people that live in this country, there is going to be a demand for hundreds of thousands of jobs in the health care field — there’s already shortages…. So, there will be tremendous opportunity in all kinds of ways.”
Sanders’s Medicare for All legislation also has built-in safeguards for workers through the transition process. Union employers would be mandated to pass any health care savings from Medicare for All down to workers in their contracts — for example, by providing the equivalent value of their old health insurance plans in the form of wages and other benefits. His bill also pledges to support health care workers affected by the transition with up to five years of compensation and aid for displaced workers. (The Political Economy Research Institute at the University of Massachusetts, Amherst, estimates that within the five-year timeframe, the government could effectively implement a “just transition” to include retraining, relocation assistance and wage replacement for about 746,600 workers, for about $61.5 billion annually for two years — roughly 2 percent of total operational spending.)
The divisions around single-payer within the labor movement attest to a history of unions embedding themselves in the employer-based insurance industry, for reasons both practical and political. During the early 20th century, the American Federation of Labor joined with industry groups to oppose a proposal by social reformers for a universal health care plan, preferring instead to maintain labor’s status as a welfare provider to union members. From the 1950s through the Obamacare era, employer-based health plans solidified as part of the social contract that unions offered members, becoming entrenched as part of a standard collective-bargaining package.
According to Anand Singh, president of UNITE HERE Local 2, shifting health care responsibilities to the government could help expand unionization in the long term, because currently, fear of high insurance costs is one factor that ramps up employers’ union-busting campaigns and staunch opposition to workplace organizing. “Workers have a lot of reasons to join a union: a voice on the job, respect on the job. But [with respect to] employers, right now, health care is an impediment for workers really having that voice and exercising the right to join a union,” Singh said at a recent media conference.
Carl Rosen of United Electrical Workers, a left industrial union that has long championed a broad social welfare agenda including single-payer, said that he understands why some unions argue that they want to maintain the benefits that they fought hard for. Workers in his union have had the same fights, he said, but “you’d be hard-pressed to find any members in our union — the ones who’ve actually been involved in those fights, who’ve had to go on strike in order to preserve their health care, who have had to take lesser wage increases than they want, etc. — you won’t find any of them saying, ‘Therefore I want to keep exactly what we have right now, because I had to fight to get it.’”
If private health insurance were replaced by a state-run system, Rosen adds, unions would be challenged to shift the value of their contracts into other types of compensation, “and any union that doesn’t have the confidence that they can do that — that’s an issue that they’d better do some soul searching on: why they don’t think they’d be able to bargain to move that money into other parts of their package.”
In other words, making health care a state responsibility would expand the horizon of possibility in collective bargaining. Whether workers want better wages, training and education benefits, or childcare, both employers and unions would be pushed to become more creative in their demands and more responsive to workers’ aspirations.
For now, as Dudzic put it, “When we bargain for health care, we bargain against ourselves.”
Labor advocates increasingly see Medicare for All as an imperative for health care justice for working people, and unions must grapple with the prospect that the health care that they have bargained for as a union advantage could become a universal public entitlement. While single-payer would disrupt how they negotiate contracts, union workers might see it as a fair trade for enshrining health care as a right, not a bargaining chip.
A few days of social media mayhem ensued, with pro-Sanders critics accusing Local 226 — which represents roughly 60,000 hospitality workers, mostly women and people of color — of sowing division with a reactionary stance on the left-most health care reform proposal in Washington. Then came another twist: On caucus day, many union members broke with their leaders and voted for the candidate who would supposedly end their union health plans.
The drama around Medicare for All in Nevada reflected an evolving debate on single-payer health care in the labor movement: Although a public, universal health care system would potentially prevent thousands of needless deaths as well as eliminate the hefty medical bills, premiums and copays that plague many workers and their families, leaders of unions — which collectively represent about 1 in 10 workers nationwide — are divided on Medicare for All. Many labor organizations have deep economic and political stakes in the health insurance industry, often because they help provide health care to members under multiemployer insurance plans. Local 226 is one of several unions that run their own health centers, financed through a so-called Taft-Hartley trust fund, a jointly managed benefits fund established through collective bargaining that supports workers in multiple firms. Overall, affordable health insurance is one of the keystone benefits that union contracts typically provide, for which unions have historically bargained as a form of compensation. Over time, labor advocates say, unions have been compelled to effectively prioritize long-term health care over other bargaining issues, as negotiations on insurance tend to crowd out discussions on take-home pay and other components of a compensation package.
But over the past several decades, collective-bargaining agreements have become so backloaded with costly health care programs that the benefits that union members guard so jealously are precisely what’s making their contracts unsustainable. As Truthout has reported, transitioning to a public universal health care system would liberate unions from having to haggle over insurance co-pays at the expense of demands on wages or pensions.
Mark Dudzic, national coordinator of the Labor Campaign for Single Payer, says that, as health care reform has become a central issue in Washington, the politics around it have changed. “People like Bernie [Sanders] have injected it into mass political consciousness, and more and more unions are convinced that there’s a political path to win this,” he told Truthout. Dudzic estimates that, based on public support for single-payer legislation in Congress, organized labor groups representing the majority of the union workforce support a universal, national health plan.
Dudzic sees universal health care as a path to dismantling the power imbalance intrinsic to a collective-bargaining dynamic, which holds workers hostage to employer-based insurance plans. “[W]hen we go into the bargaining process,” he said, “employers know that they can hold that as a sword over our heads, on every other issue that we’re bargaining over, and we can’t walk away from that table with huge concessions on health care, so when that sword disappears, we have more power. Just like an individual worker has more power if she knows that she can leave her job and not lose her health care.”
While hundreds of unions and labor federations have broadly endorsed Medicare for All legislation, not all unions are actively campaigning for single-payer. In 2017, the AFL-CIO conference unanimously passed a resolution aiming “to move expeditiously toward a single-payer system, like Medicare for All, that provides universal coverage using a social insurance model, while retaining a role for workers’ health plans.” The conservatively worded statement seemed to endorse some form of universal health care, but not as a replacement for existing union benefits. In recent months, AFL-CIO and American Federation of Teachers leaders have apparently waffled on earlier support for Medicare for All.
Last September, the Massachusetts AFL-CIO convention went further than the 2017 resolution by pledging to make their presidential endorsement conditional on support for Medicare for All. California’s single-payer legislation, which would implement a Medicare-for-All-type system statewide, has been endorsed by more than 30 unions and labor organizations, including the Los Angeles Federation of Labor, several municipal workers unions and UNITE HERE Local 11.
Health care workers, who are on the front line of the health care crisis as providers and patients, have been leading the charge for single-payer.
National Nurses United (NNU) points to recent nurses’ strikes as an illustration of the cruel intersection of health care and labor crises: nurses have recently gone on strike in Vermont and Minnesota both to protect their own health care and advocate for better working conditions — and thus better care — for their patients.
“If we didn’t have to fight so hard for that one aspect of our union contract, we would have more time to fight for other protections, like better wages, and for nurses — better patient care conditions,” said NNU President Deborah Burger via email. “As union workers in the healthcare industry, nurses see every day how our patients, working people in America, are suffering and dying unnecessarily in this profit-based system, where coverage is tied to employment. Guaranteed single-payer health care is a more permanent, humane solution, proven to work in every other industrialized nation on earth.”
Sal Rosselli, president of the National Union of Healthcare Workers (NUHW), recalled that in the 1980s, when he organized with SEIU Local 250 in California, the union bargained hard to secure quality health plans for health care workers and their families. But as health care became increasingly corporatized, union leaders got mired in “a defensive fight, every contract cycle” with tight-fisted employers. NUHW, representing 15,000 hospital and clinical personnel across California, champions Medicare for All not only as a basic public good, he says, but because it would help unions pursue stronger benefits and protections beyond just health insurance. “Single-payer will accomplish taking health care off the bargaining table so that economic gains — wages, pensions, childcare, elder care, training — can be prioritized, because employers will no longer have to put their profits or their budgets into health care,” Rosselli told Truthout.
NUHW acknowledges reasonable concerns among some Medicare for All critics about the potential loss of health care industry jobs under the transition to single-payer. While there will be economic disruption when replacing the health insurance bureaucracy with a leaner, state-run program, Rosselli noted that NUHW members would be able to gain new jobs from a health care system that provides more comprehensive coverage and includes more people.
“When we accomplish Medicare for all,” Rosselli said, “and have comparable access to care for all people that live in this country, there is going to be a demand for hundreds of thousands of jobs in the health care field — there’s already shortages…. So, there will be tremendous opportunity in all kinds of ways.”
Sanders’s Medicare for All legislation also has built-in safeguards for workers through the transition process. Union employers would be mandated to pass any health care savings from Medicare for All down to workers in their contracts — for example, by providing the equivalent value of their old health insurance plans in the form of wages and other benefits. His bill also pledges to support health care workers affected by the transition with up to five years of compensation and aid for displaced workers. (The Political Economy Research Institute at the University of Massachusetts, Amherst, estimates that within the five-year timeframe, the government could effectively implement a “just transition” to include retraining, relocation assistance and wage replacement for about 746,600 workers, for about $61.5 billion annually for two years — roughly 2 percent of total operational spending.)
The divisions around single-payer within the labor movement attest to a history of unions embedding themselves in the employer-based insurance industry, for reasons both practical and political. During the early 20th century, the American Federation of Labor joined with industry groups to oppose a proposal by social reformers for a universal health care plan, preferring instead to maintain labor’s status as a welfare provider to union members. From the 1950s through the Obamacare era, employer-based health plans solidified as part of the social contract that unions offered members, becoming entrenched as part of a standard collective-bargaining package.
According to Anand Singh, president of UNITE HERE Local 2, shifting health care responsibilities to the government could help expand unionization in the long term, because currently, fear of high insurance costs is one factor that ramps up employers’ union-busting campaigns and staunch opposition to workplace organizing. “Workers have a lot of reasons to join a union: a voice on the job, respect on the job. But [with respect to] employers, right now, health care is an impediment for workers really having that voice and exercising the right to join a union,” Singh said at a recent media conference.
Carl Rosen of United Electrical Workers, a left industrial union that has long championed a broad social welfare agenda including single-payer, said that he understands why some unions argue that they want to maintain the benefits that they fought hard for. Workers in his union have had the same fights, he said, but “you’d be hard-pressed to find any members in our union — the ones who’ve actually been involved in those fights, who’ve had to go on strike in order to preserve their health care, who have had to take lesser wage increases than they want, etc. — you won’t find any of them saying, ‘Therefore I want to keep exactly what we have right now, because I had to fight to get it.’”
If private health insurance were replaced by a state-run system, Rosen adds, unions would be challenged to shift the value of their contracts into other types of compensation, “and any union that doesn’t have the confidence that they can do that — that’s an issue that they’d better do some soul searching on: why they don’t think they’d be able to bargain to move that money into other parts of their package.”
In other words, making health care a state responsibility would expand the horizon of possibility in collective bargaining. Whether workers want better wages, training and education benefits, or childcare, both employers and unions would be pushed to become more creative in their demands and more responsive to workers’ aspirations.
For now, as Dudzic put it, “When we bargain for health care, we bargain against ourselves.”
Labor advocates increasingly see Medicare for All as an imperative for health care justice for working people, and unions must grapple with the prospect that the health care that they have bargained for as a union advantage could become a universal public entitlement. While single-payer would disrupt how they negotiate contracts, union workers might see it as a fair trade for enshrining health care as a right, not a bargaining chip.
'What More Do You Need to Know?' Health Insurance Stocks Drive Wall Street Rebound on Biden Super Tuesday Wins
"Biden is the preferred candidate for the financial markets."
by Eoin Higgins - Common Dream - March 4, 2020
Health insurance industry stocks surged Wednesday morning in the wake of former Vice President Joe Biden's strong showing in the Democratic presidential primary's Super Tuesday contests, opening up 600 points after traders appeared to bet the candidate's resurgence would box out any chance of single-payer universal healthcare.
"What more do you need to know," tweeted journalist Jack Mirkinson of the market's spike.
Sanders has made Medicare for All a centerpiece of his campaign. The healthcare industry has poured millions in ad buys against Sanders after the Vermont senator won primaries in Iowa, New Hampshire, and Nevada.
"The industry has long seen Biden as their white knight," said Dr. Adam Gaffney, the president of Physicians for a National Health Program and an outspoken Medicare for All advocate.
Biden on Tuesday won at least nine of the 14 states up for grabs to Sanders' four. At press time, Maine was yet to be called, with Sanders and Biden locked in a razor-thin contest.
The market surge came after a rough week for the stock market, which at the end of February saw its biggest decline since the 2008 financial crisis after fears of the economic cost of a worldwide coronvirus pandemic increased.
Business commentators also made the connection between Sanders' victories in the early primary states, particularly in Nevada, and the market's poor performance last week.
On Fox Business February 28, billionaire Steve Forbes remarked that the weeklong drop was not only about fears of the coronavirus.
"There's the political side," Forbes said of the reason for the poor performance. "In the last week, week-and-a-half, the possibility of Bernie Sanders becoming president of the United States has increased, exponentially."
According to the Washington Post:
"The market's sell-off last week on Sanders' primary victories and
rebound on Monday after Biden's big win in South Carolina and this
morning after Super Tuesday suggest that domestic U.S. politics may
matter as much as the global health crisis on investors," said Yardeni.
As Common Dreams reported, the results—which saw billionaire Michael Bloomberg and Sen. Elizabeth Warren (D-Mass.) coming in far behind the two frontrunners—transformed a once-crowded primary into a two-man race. Though Biden put up a good showing, exit polls from the contests showed a majority of Democratic voters backing the elimination of private insurance in favor of a single-payer system guaranteeing healthcare for all.
https://www.commondreams.org/news/2020/03/04/what-more-do-you-need-know-health-insurance-stocks-drive-wall-street-rebound-biden
by Eoin Higgins - Common Dream - March 4, 2020
Health insurance industry stocks surged Wednesday morning in the wake of former Vice President Joe Biden's strong showing in the Democratic presidential primary's Super Tuesday contests, opening up 600 points after traders appeared to bet the candidate's resurgence would box out any chance of single-payer universal healthcare.
"What more do you need to know," tweeted journalist Jack Mirkinson of the market's spike.
Sanders has made Medicare for All a centerpiece of his campaign. The healthcare industry has poured millions in ad buys against Sanders after the Vermont senator won primaries in Iowa, New Hampshire, and Nevada.
"The industry has long seen Biden as their white knight," said Dr. Adam Gaffney, the president of Physicians for a National Health Program and an outspoken Medicare for All advocate.
Biden on Tuesday won at least nine of the 14 states up for grabs to Sanders' four. At press time, Maine was yet to be called, with Sanders and Biden locked in a razor-thin contest.
The market surge came after a rough week for the stock market, which at the end of February saw its biggest decline since the 2008 financial crisis after fears of the economic cost of a worldwide coronvirus pandemic increased.
Business commentators also made the connection between Sanders' victories in the early primary states, particularly in Nevada, and the market's poor performance last week.
On Fox Business February 28, billionaire Steve Forbes remarked that the weeklong drop was not only about fears of the coronavirus.
"There's the political side," Forbes said of the reason for the poor performance. "In the last week, week-and-a-half, the possibility of Bernie Sanders becoming president of the United States has increased, exponentially."
According to the Washington Post:
Stocks of healthcare companies roared in response to Biden's performance. Cigna was up more than 10 percent in morning trading, while UnitedHealth Group rose nearly 12 percent. Humana jumped 1.25 percent and Anthem soared nearly 14 percent.Investor Ed Yardeni told the Post that Wednesday's spike was a correction to earlier fears of what he called "Bernie Sanders' socialist program."
As Common Dreams reported, the results—which saw billionaire Michael Bloomberg and Sen. Elizabeth Warren (D-Mass.) coming in far behind the two frontrunners—transformed a once-crowded primary into a two-man race. Though Biden put up a good showing, exit polls from the contests showed a majority of Democratic voters backing the elimination of private insurance in favor of a single-payer system guaranteeing healthcare for all.
https://www.commondreams.org/news/2020/03/04/what-more-do-you-need-know-health-insurance-stocks-drive-wall-street-rebound-biden
Single-Payer Health Care Did Not Fail in Vermont
Rather, the plan was killed by conservatives and the health care industry for political reasons before it was ever implemented
by Lee Russ - The Progressive - May 4, 2020
The people intent on killing “Medicare for All” have found a
convenient weapon—the fact that Vermont, Bernie Sanders’s own state,
passed a law creating a single-payer system in 2011, then killed the
idea in 2014 before it was ever implemented.
The supposed failure of single payer in Vermont was even used to attack the proposed single-payer plan in Colorado that was voted down in 2016.
In 2019, The Washington Post’s national health care policy writer, Amy Goldstein, wrote the article “Why Vermont’s single-payer effort failed and what Democrats can learn from it,” in which she quotes an anonymous “analyst” who says many advocates shared “a belief that borders on the theological” that the system would save money.
Since every reasonably objective analysis has found that an American single-payer system would cost less than the current system, that is hardly a “theological belief.” In fact, way back in 1991, the Government Accounting Office reported to Congress that if the United States adopted a Canadian-style system, “the savings in administrative costs alone would be more than enough to finance insurance coverage for the millions of Americans who are currently uninsured. There would be enough left over to permit a reduction, or possibly even the elimination, of copayments and deductibles.”
The Goldstein article and others like it are quickly added to the collection of scare pieces that the health care industry’s designated single-payer attack group, the Partnership for America’s Health Care Future, uses to terrify anyone who even thinks about single-payer health care.
Vermont’s single-payer plan did not fail in operation. Then-Governor Peter Shumlin, a Democrat, killed it unilaterally in December 2014 before it was ever implemented. So how can Vermont serve as an example of what to expect if Medicare for All is implemented?
Shumlin’s ambiguous and contradictory announcement that he was pulling the plug on GMC set the stage for this phenomenon. In it he said the “risk of economic shock is too high;” a “more equitable system” must wait until “the time is right;” and that “GMC would yield savings of $378 million over the first five years of the program relative to current predicted trends.”
Between GMC’s enactment and its untimely death, opponents hammered the public with fear and misinformation. A nonprofit called “Vermonters for Health Care Freedom” devoted all of its energies to that effort. Vermont’s significant Libertarian community did the same.
I lived through the incessant barrage of op-eds, letters to the editor, online ads, and free video showings across the state, all designed to terrify Vermonters that implementation of GMC was the apocalypse.
Vermonters were told over and over that GMC would require “the biggest tax increase in history.” That was absolutely true, but it would also have produced the biggest reduction in premiums and copays and deductibles in history. In fact, almost everybody would have paid less under GMC than they were paying under the current system.
Most scares were based on sheer speculation. Doctors and businesses would flee the state. Poor people would flood in for free care. Medicare recipients would lose benefits (even though the law required benefits at least equal to Medicare). And so on.
Shumlin and the state made no effort to counteract the misinformation or explain how GMC benefited everybody, not even after a 2014 poll showed many Vermonters understood little about it. Rumors that Shumlin’s commitment to GMC was wavering began circulating near the time of that poll. But at a public forum a month or so later, Shumlin publicly reassured me that his commitment to GMC was as strong as it had ever been.
Another major factor in GMC’s demise was Vermont’s introduction of “Vermont Health Connect,” its own online insurance exchange to implement Obamacare. That was an unmitigated disaster, causing major problems for a large number of Vermonters, including me. It was such a disaster that it gave the whole idea of government involvement in health care a bad name.
Given all this, it’s not surprising that Shumlin was barely reelected in November 2014. He failed to get a majority of the popular vote, requiring that he be elected by the legislature. By the time he pulled the plug on GMC the next month, he was in a very weak political position.
Whether to implement GMC was a comparative choice: are we better off with GMC or with the current commercial insurance system? Looking only at the potential consequences of GMC, as its opponents did, totally ignored the very real flaws of the current system.
What has the actual “Vermont experience” with our commercial insurance system been in the four-plus years since the demise of GMC? Things have gotten progressively worse and far more expensive. Some examples:
While the people of Vermont are paying a heavy health care price for being left to the vagaries of commercial health insurance, two of the most prominent and vocal opponents of GMC have fared quite well.
Wendy Wilton, former treasurer for the City of Rutland made claim after claim that her financial analysis predicted disaster from single payer. She now works for the Trump Administration as the Vermont state director of the Agriculture Department’s Farm Service Agency.
Darcie Johnston headed “Vermonters for Health Care Freedom” during that group’s extensive efforts to scare Vermonters away from GMC. She now works in the Department of Health and Human Services.
Peter Shumlin is also doing pretty well. This past fall, he was made a senior leadership fellow at Harvard’s T.H. Chan School of Public Health. The course he taught was called “Health Policy and Leadership: Reforming America’s Broken Health Care System from Within.”
https://progressive.org/dispatches/single-payer-health-care-did-not-fail-in-vermont-russ-200304/
A clear-eyed assessment of institutional realities that will face the next presidential administration, Billy Wynn recently argued in the Health Affairs blog, should temper Democrats’ demands. He cautioned that Democratic victories in federal elections are far from secure; that Medicare for All may not be passable via budget reconciliation even if Democrats take the Senate with only a simple majority; and that Democratic legislators are, in any event, hardly unified in support of Medicare for All. Similarly, John E. McDonough recently warned that comprehensive healthcare reform has, in the past, required an elusive “super-majority Trifecta” — Democratic control of the House, Senate (with 60-seats), and Presidency. Even under such favorable conditions, he contends, our political capital might be better invested elsewhere.
While the hurdles are certainly formidable, steep political odds hardly compel us to abandon Medicare for All. Indeed, advice to drop the push for such reform rests on a misunderstanding of the dynamics of political change. History suggests that movements organized around ambitious demands can, over time, create the conditions for their passage — and that demands for radical change often advance, rather than undermine, the prospects for more incremental progress in the interim. As important, the life-and-death urgency of single-payer healthcare reform – too often underemphasized by its critics – has the potential to bring together a coalition of supporters across cultural, geographic and even class lines. It may, in other words, trigger a movement that could accomplish the unexpected.
Consider, for instance, the passage of Medicare and Medicaid in 1965. Democrats had been stymied since the Truman administration in their efforts to pass a public national health insurance plan, obstructed in part by members of Congress intent on accommodating the insurance industry. John McDonough is right to emphasize that, from a narrow perspective, a super-majority Trifecta made Medicare achievable. 1964 saw a historic electoral shift, that, as Ted Marmor has noted, all but “guaranteed the passage of legislation on medical care for the aged.” But the achievement was only possible because people had been laying the groundwork for Medicare for years prior to the pivotal election. Senior citizen groups, progressive activists, organized labor, and allies in the civil rights movement forced it onto the national political agenda, holding politicians feet to the fire year after year — a point made by Natalie Shure in the Nation. Moreover, it required years of legislative efforts and coalition building to ready the ground for the final push. Had supporters not done so — had everyone waited to design and advocate for Medicare until the political chess pieces were in perfect position — the window would have opened, the window would have closed, and Medicare might very well not have come to be.
The same can be said for almost every sweeping political change in US history. The abolition of slavery, the reforms of the New Deal era, the civil rights legislation of the 1960s, and the legalization of gay marriage — none would have happened if reformers had patiently waited for the proper political alignment in the halls of Congress before envisioning, designing, and demanding change. The 2020 elections may or may not cause a political earthquake on par with 1964, but it hardly follows from this that we ought to lower our sights. After all, nobody can accurately predict when the pivotal shift will come. We do know, however, that if we wait for it happen, we will already be too late.
That uninsurance is deadly is no longer up for debate. Quasi-experimental studies of multiple coverage expansions have demonstrated that insurance reduces mortality (confirming earlier observational work), including: the Massachusetts health reform (number needed to insure [NNI] to prevent one death a year: 830); pre-ACA state Medicaid expansions (NNI: 239-316); and now the ACA Medicaid expansions (NNI: ~714 for adults 19-64). Two of these estimates are remarkably close to that of the randomized Oregon Medicaid Experiment (NNI: 769), although that effect estimate was not statistically significant. Most recently, however, another randomized study — of an intervention by the Internal Revenue Service — provided powerful experimental evidence that health insurance is life-saving. Regardless of which NNI estimate one uses, basic arithmetic makes clear that — with 30 million uninsured — tens of thousands of people are dying annually for lack of coverage. Notably, such deaths from lack of medical care are occurring everywhere, not only in states that have not expanded Medicaid. While non-expansion states have higher uninsurance rates, the number of uninsured in expansion states — for instance, 2.8 million in California and 1.0 million in New York — mean that hundreds or thousands are dying from lack of medical care a year in most states.
Critics might respond, however, by noting that Medicare for All is not the only way to address this challenge — that there might be other, and easier, ways to realize universal coverage. That being said, most other alternative health reform proposals would fail to achieve this end. Democratic presidential candidate Joseph Biden’s public option proposal, for instance, would leave some 3% of Americans (or approximately 10 million individuals) uninsured according to his campaign’s own estimates. A recent analysis by RAND researchers of a Medicare “buy-in” for those age 50-64 found that it would have “little to no effect on total health insurance enrollment.” An estimate from the Congressional Budget Office similarly found that a public option made available on the ACA exchanges would have “minimal effects on … the number of people who would be uninsured.” And a recent analysis from the Urban Institute found that a package of reforms that included a public option could leave as many as 21.3 million uninsured. In fairness, other more expansive proposals might cover everyone. Nonetheless, in addition to achieving universal coverage, Medicare for All is uniquely designed to do something else: achieve a universal improvement of coverage.
Rising copays and deductibles are causing more and more patients to go without needed care, or to face harsh financial consequences when they do. Underinsurance is, today, as much a problem as uninsurance — and, according to estimates from the Commonwealth Fund, is growing most rapidly among those with employer-sponsored coverage. Exhibit 1 provides rates of uninsurance (including those with lapses of coverage) and underinsurance in 2018. Overall, about 1 in 3 Americans — or more than 100 million individuals — fall into one of these categories, and can be classified as having deficient health coverage.
Source: 2018 National Health Interview Survey; 2018 Commonwealth Fund Biennial Health Insurance Survey; Commonwealth Fund analysis of 2012 Medicare Current Beneficiary Survey extrapolated to 2018 (see notes).
Source: Author’s analysis of reports of randomized trials and quasi-experimental studies
The policy advantages of Medicare for All, in other words, aren’t mere minutiae: they are part of the force for political change.
All of which is to say that at the end of the day, the vast majority of the nation could benefit from single-payer reform — and that fact makes it winnable. Above all, however, we can be sure of one thing: not bothering to push for Medicare for All today will guarantee that it doesn’t happen tomorrow.
https://www.healthaffairs.org/do/10.1377/hblog20200309.156440/full/
“Canada can provide universal health care to all their people at half the cost,” he said at a recent Democratic debate. “The U.K. can do it. France can do it. Germany can do it. All of Europe can do it.”
Mr. Sanders is right: All these countries provide universal coverage. But what he doesn’t talk about is the excruciating battle they went through to get there.
It took Canada more than a decade to move from a patchwork of insurance plans to a single-payer system. At one point, doctors were so incensed that they went on strike for 23 days. Doctors from the United States and Britain flew in to help keep the health system going.
Today, most Britons revere their National Health Service: One lawmaker has called it the closest thing the English have to religion, and the 2012 Olympic opening ceremony honored it with a four-minute song-and-dance routine.
But when it began in the mid-1940s, 89 percent of doctors were opposed. They raised £1.6 million (or £58 million today, equivalent to $76 million) for a “fighting fund” to protest the plan. Some patients showed interest in contributing, too.
Look around the world and you start to see a common theme: Creating universal coverage is hard. The countries with the systems that Mr. Sanders admires went through years of failed legislation, doctor protests and uncertain futures.
“No country did this without a huge political conflict,” said Jacob Hacker, a professor of political science at Yale who studies the formation of international health systems. “But once they put in the strong, basic foundations, there was no going back.”
Most countries, like the United States, build their health systems incrementally. They start with smaller programs that cover a certain group of people (such as the poor) or a certain type of medical care (like hospital visits).
In other countries, it was the leap that the United States hasn’t made yet — from a system that covers some people to one that covers everybody — that in many cases was the hardest part. Abroad, the arguments made against universal coverage were similar to those we hear today: that it's just too expensive, or gives government too much control over the practice of medicine.
“Universal coverage may be considered a laudable goal,” one Canadian trade group said in 1967, before arguing that “it is not yet within the economic reach of our province or country.”
One British doctor told The New York Times in 1948 that, in fighting against the National Health Service, he and his colleagues were “engaged in a life or death struggle for our freedom and independence.”
Mr. Hacker said: “People look at the current levels of support that other systems have, and extrapolate backwards to think that universal coverage was always popular. But that isn’t the case. Everywhere this happened, it was a very fierce fight.”
Tommy Douglas, widely credited for establishing single-payer health care in Canada, campaigning in front of a crowd of about 12,000.Getty Images
In 1944, Saskatchewan elected a premier named Tommy Douglas, the first
Democratic socialist to hold that position in North America. He got to
work building the province’s health system, starting with hospital
benefits in 1947.
Mr. Douglas ran his 1959 re-election campaign on a health care agenda, promising “a high standard of medical care to every citizen of Saskatchewan.” He also offered a prediction: If his province stepped forward and created single-payer health care, “before 1970, almost every other province in Canada will have followed the lead of Saskatchewan.”
He won re-election in 1960 and passed legislation to create the single-payer system he’d promised voters. It did not get the positive reception that he might have hoped for: Doctors went on strike for more than three weeks when it began in July 1962. They took out newspaper ads warning that “compulsory state medicine would be a tragic mistake for this province and it would undermine the high quality of medical care which you now enjoy.”
“All the issues you’re hearing about in the Democratic debate, those were voiced in Canada in the 1950s and ’60s,” said David Wright, a history professor at McGill University in Montreal with a coming book on the history of Canada’s health system. “You had an industry concerned about becoming redundant, and individuals who had insurance worried about their doctors.”
Eventually, the doctors began to lose support, as Saskacthewan residents became frustrated with their lack of access to medical care. An independent mediator from London then brokered a deal. The compromise, known as the Saskatoon Agreement for where it was settled, guaranteed doctors they would not become employees of the state but remain independent contractors within the public insurance plan.
Despite the early hurdles, Mr. Douglas’s prediction was ultimately proved right. Saskatchewan’s system became quite popular, and other provinces began putting in their own. The federal government later began providing funding for these systems, and, by 1971, the entire country had transitioned to single-payer health care.
Even so, the nation wasn’t fully sold on the idea of overhauling its health system. One 1944 poll recently unearthed by the historian Nick Hayes found that just 44 percent favored a nationalized health system. A full third wanted to leave things as they were, a mix of public and private programs. Doctors made their views quite clear in a poll conducted by the British Medical Association: 89 percent opposed the new system.
Facing ambivalence from the public and staunch opposition from physicians, the National Health Service didn’t move forward until the Labour Party won control of Parliament with a landslide victory in 1945. From there, things moved quickly. As Mr. Hacker writes in his history of the system, it moved “from a Cabinet proposal in December 1945 to a White Paper in March to a law in November.”
Doctors considered going on strike but ultimately decided against it after the government offered financial concessions. Doctors would be allowed to earn additional money seeing patients in private practice outside of the National Health Service (this is still done in Britain but is outlawed in Canada).
Two years after the start of the National Health Service, the health minister Aneurin Bevan remarked that he had “stuffed their mouths with gold” to broker his deal with British doctors.
Australian workers protested outside Parliament in 1975. Australia adopted a single-payer system, repealed it and then re-adopted it years later.Kenneth Stevens/Fairfax Media, via Getty Images
When Australia started working toward universal coverage in the 1960s,
the landscape looked similar to that of the United States: 80 percent of
residents had some form of private or government-subsidized coverage
for hospital visits.
The country’s Labor Party argued this wasn’t good enough, and won the 1972 country’s national election campaigning on a health care platform.
Things did not proceed smoothly from there.
“The journey has been quite tortuous,” said Anne-Marie Boxall, an associate professor at the University of Sydney, who has written a book on Australia’s health system. “No other developed country has managed to introduce universal health care and get rid of it.”
Legislation to create universal health care failed in 1973. It failed again in 1974. It passed in 1975 by a mere three-vote margin. The new system would leave private insurance markets intact but create a parallel public program to cover all Australians.
“It was an epic legislative battle to get universal health care up and running,” Ms. Boxall said. “It was nothing short of extreme brinkmanship.” She said the leader at the time, Prime Minister Gough Whitlam, had a motto: “crash or crash through.”
The Labor Party did manage to create a universal coverage system called Medibank, but voters’ support for the idea had fallen during the bruising legislative battle. One poll showed that, by 1975, only 38 percent of Australians supported the idea of mandatory coverage for all. Voters made this point especially clear in the 1976 election, when they booted the Labor Party out of power. A more conservative coalition government took control and, within years, rolled back the Medibank plan.
This gives Australia the perhaps unenviable distinction of being the only developed country to repeal universal coverage.
But the battle wasn’t over. When Labor returned to power in 1983, the party immediately went back to health care. It changed the name of its health coverage plan to Medicare and passed it again in 1984. This one has survived, so far.
Could something similar happen in the United States?
Those who study the history of other health systems say it is certainly possible — but will probably be more difficult.
The United States is different in that its medical industry is bigger and more powerful. Health care spending accounts for one-sixth of the American economy, and no industry spends more on lobbying Congress.
Another obstacle comes from the structure of the U.S. government, in which dueling political parties often wield partial control over different branches of government.
“The American political system makes this harder,” said Mr. Hacker, the Yale professor. “The kind of determined, take-no-prisoners approach that happened in some provinces like Saskatchewan doesn’t work as well here.”
That said, there is nothing so structurally different about the United States that leads historians to think of universal coverage as impossible.
“Of course the United States could do this,” said Mr. Wright, the history professor at McGill. “There’s no reason except for political will that it couldn’t happen.”
Ms. Boxall, who studies the system in Australia, notes that 80 percent of people there had private health insurance when the Labor government began to pursue universal public coverage. That suggests to her that change can still happen, even in the face of an entrenched insurance industry.
“The private market hadn’t achieved universal coverage here, and it became clear government was the only way to get from 80 percent up to 100 percent,” she said.
Still, widespread private insurance did mean party leaders had to compromise: To this day, Australia has a private health insurance system that runs in parallel to its universal coverage. Enrollment in the private plans typically rises when conservative parties are in power, and falls when liberals come into government.
“People had been paying into their private coverage for 25 years, and were nervous about what a government-run scheme would mean,” Ms. Boxall said. “After fighting the political battle left to get to universal coverage, they just didn’t have the political capital left to do something sensible with the private insurance arrangements that sat alongside it.”
https://www.nytimes.com/interactive/2020/03/10/upshot/the-hard-road-other-countries-single-payer-health-care.html?action=click&module=News&pgtype=Homepage
Vermont’s single-payer plan did not fail in operation. Then-Governor Peter Shumlin, a Democrat, killed it unilaterally in December 2014 before it was ever implemented. So how can Vermont serve as an example of what to expect if Medicare for All is implemented?Conservatives and the for-profit health care industry portray this as a “failure” and a clear sign that a single-payer system like Medicare for All is simply foolish. They push the idea that Vermont’s plan, Green Mountain Care (GMC), failed because single-payer health care is unworkable, expensive, even dangerous.
The supposed failure of single payer in Vermont was even used to attack the proposed single-payer plan in Colorado that was voted down in 2016.
In 2019, The Washington Post’s national health care policy writer, Amy Goldstein, wrote the article “Why Vermont’s single-payer effort failed and what Democrats can learn from it,” in which she quotes an anonymous “analyst” who says many advocates shared “a belief that borders on the theological” that the system would save money.
Since every reasonably objective analysis has found that an American single-payer system would cost less than the current system, that is hardly a “theological belief.” In fact, way back in 1991, the Government Accounting Office reported to Congress that if the United States adopted a Canadian-style system, “the savings in administrative costs alone would be more than enough to finance insurance coverage for the millions of Americans who are currently uninsured. There would be enough left over to permit a reduction, or possibly even the elimination, of copayments and deductibles.”
The Goldstein article and others like it are quickly added to the collection of scare pieces that the health care industry’s designated single-payer attack group, the Partnership for America’s Health Care Future, uses to terrify anyone who even thinks about single-payer health care.
Vermont’s single-payer plan did not fail in operation. Then-Governor Peter Shumlin, a Democrat, killed it unilaterally in December 2014 before it was ever implemented. So how can Vermont serve as an example of what to expect if Medicare for All is implemented?
Enter the Magic Mirror: single-payer opponents hold the “Vermont experience” up to it and see only the aspects that can be spun to support the conclusions they wish to reach.Enter the Magic Mirror: single-payer opponents hold the “Vermont experience” up to it and see only the aspects that can be spun to support the conclusions they wish to reach.
Shumlin’s ambiguous and contradictory announcement that he was pulling the plug on GMC set the stage for this phenomenon. In it he said the “risk of economic shock is too high;” a “more equitable system” must wait until “the time is right;” and that “GMC would yield savings of $378 million over the first five years of the program relative to current predicted trends.”
Between GMC’s enactment and its untimely death, opponents hammered the public with fear and misinformation. A nonprofit called “Vermonters for Health Care Freedom” devoted all of its energies to that effort. Vermont’s significant Libertarian community did the same.
I lived through the incessant barrage of op-eds, letters to the editor, online ads, and free video showings across the state, all designed to terrify Vermonters that implementation of GMC was the apocalypse.
Vermonters were told over and over that GMC would require “the biggest tax increase in history.” That was absolutely true, but it would also have produced the biggest reduction in premiums and copays and deductibles in history. In fact, almost everybody would have paid less under GMC than they were paying under the current system.
Most scares were based on sheer speculation. Doctors and businesses would flee the state. Poor people would flood in for free care. Medicare recipients would lose benefits (even though the law required benefits at least equal to Medicare). And so on.
Shumlin and the state made no effort to counteract the misinformation or explain how GMC benefited everybody, not even after a 2014 poll showed many Vermonters understood little about it. Rumors that Shumlin’s commitment to GMC was wavering began circulating near the time of that poll. But at a public forum a month or so later, Shumlin publicly reassured me that his commitment to GMC was as strong as it had ever been.
Another major factor in GMC’s demise was Vermont’s introduction of “Vermont Health Connect,” its own online insurance exchange to implement Obamacare. That was an unmitigated disaster, causing major problems for a large number of Vermonters, including me. It was such a disaster that it gave the whole idea of government involvement in health care a bad name.
Given all this, it’s not surprising that Shumlin was barely reelected in November 2014. He failed to get a majority of the popular vote, requiring that he be elected by the legislature. By the time he pulled the plug on GMC the next month, he was in a very weak political position.
Whether to implement GMC was a comparative choice: are we better off with GMC or with the current commercial insurance system? Looking only at the potential consequences of GMC, as its opponents did, totally ignored the very real flaws of the current system.
What has the actual “Vermont experience” with our commercial insurance system been in the four-plus years since the demise of GMC? Things have gotten progressively worse and far more expensive. Some examples:
- Commercial insurance rates have risen so much that the regulatory agency’s chairman publicly said, “We acknowledge they are not affordable. But at the same time we can’t put a company out of business.”
- Average employee contributions to the premiums on their employer-provided health insurance rose from $3,451 in 2014 to $4,311 in 2018; average deductibles on those policies rose from $2,679 to $3,292.
- Total health care spending in Vermont topped $6 billion in 2017, up from $5.54 billion in 2014, the year that GMC died.
- The most recent annual state survey found 3 percent of Vermonters under age sixty-five were uninsured, with another 36 percent underinsured (unable to afford their deductibles and copays).
While the people of Vermont are paying a heavy health care price for being left to the vagaries of commercial health insurance, two of the most prominent and vocal opponents of GMC have fared quite well.
Wendy Wilton, former treasurer for the City of Rutland made claim after claim that her financial analysis predicted disaster from single payer. She now works for the Trump Administration as the Vermont state director of the Agriculture Department’s Farm Service Agency.
Darcie Johnston headed “Vermonters for Health Care Freedom” during that group’s extensive efforts to scare Vermonters away from GMC. She now works in the Department of Health and Human Services.
Peter Shumlin is also doing pretty well. This past fall, he was made a senior leadership fellow at Harvard’s T.H. Chan School of Public Health. The course he taught was called “Health Policy and Leadership: Reforming America’s Broken Health Care System from Within.”
Lee Russ
Lee Russ is a retired legal editor who was, and remains, a member of the Health Care is a Human Right campaign in Vermont.https://progressive.org/dispatches/single-payer-health-care-did-not-fail-in-vermont-russ-200304/
Medicare For All: If Not Now, When?
by Adam Gaffney - Health Affairs Blog - March 9, 2020
The rise of Medicare for All has triggered mixed reactions. Supporters see it as a cause for hope — the culmination of decades of research, education, and advocacy. President Donald Trump, on the other hand, is dyspeptic, fuming in his recent State of the Union that single-payer would “bankrupt our nation,” and vowing not to “let socialism destroy American healthcare.” A third group expresses sympathy for the goals of Medicare for All, and even acknowledges its policy merits, but sees the political obstacles as insurmountable — and advises that advocacy for such reform should be abandoned because it risks undermining beneficial, and more realistic approaches.A clear-eyed assessment of institutional realities that will face the next presidential administration, Billy Wynn recently argued in the Health Affairs blog, should temper Democrats’ demands. He cautioned that Democratic victories in federal elections are far from secure; that Medicare for All may not be passable via budget reconciliation even if Democrats take the Senate with only a simple majority; and that Democratic legislators are, in any event, hardly unified in support of Medicare for All. Similarly, John E. McDonough recently warned that comprehensive healthcare reform has, in the past, required an elusive “super-majority Trifecta” — Democratic control of the House, Senate (with 60-seats), and Presidency. Even under such favorable conditions, he contends, our political capital might be better invested elsewhere.
While the hurdles are certainly formidable, steep political odds hardly compel us to abandon Medicare for All. Indeed, advice to drop the push for such reform rests on a misunderstanding of the dynamics of political change. History suggests that movements organized around ambitious demands can, over time, create the conditions for their passage — and that demands for radical change often advance, rather than undermine, the prospects for more incremental progress in the interim. As important, the life-and-death urgency of single-payer healthcare reform – too often underemphasized by its critics – has the potential to bring together a coalition of supporters across cultural, geographic and even class lines. It may, in other words, trigger a movement that could accomplish the unexpected.
- The Dynamics of Political Change: Lessons from History
Consider, for instance, the passage of Medicare and Medicaid in 1965. Democrats had been stymied since the Truman administration in their efforts to pass a public national health insurance plan, obstructed in part by members of Congress intent on accommodating the insurance industry. John McDonough is right to emphasize that, from a narrow perspective, a super-majority Trifecta made Medicare achievable. 1964 saw a historic electoral shift, that, as Ted Marmor has noted, all but “guaranteed the passage of legislation on medical care for the aged.” But the achievement was only possible because people had been laying the groundwork for Medicare for years prior to the pivotal election. Senior citizen groups, progressive activists, organized labor, and allies in the civil rights movement forced it onto the national political agenda, holding politicians feet to the fire year after year — a point made by Natalie Shure in the Nation. Moreover, it required years of legislative efforts and coalition building to ready the ground for the final push. Had supporters not done so — had everyone waited to design and advocate for Medicare until the political chess pieces were in perfect position — the window would have opened, the window would have closed, and Medicare might very well not have come to be.
The same can be said for almost every sweeping political change in US history. The abolition of slavery, the reforms of the New Deal era, the civil rights legislation of the 1960s, and the legalization of gay marriage — none would have happened if reformers had patiently waited for the proper political alignment in the halls of Congress before envisioning, designing, and demanding change. The 2020 elections may or may not cause a political earthquake on par with 1964, but it hardly follows from this that we ought to lower our sights. After all, nobody can accurately predict when the pivotal shift will come. We do know, however, that if we wait for it happen, we will already be too late.
- The Urgency of National Health Insurance
That uninsurance is deadly is no longer up for debate. Quasi-experimental studies of multiple coverage expansions have demonstrated that insurance reduces mortality (confirming earlier observational work), including: the Massachusetts health reform (number needed to insure [NNI] to prevent one death a year: 830); pre-ACA state Medicaid expansions (NNI: 239-316); and now the ACA Medicaid expansions (NNI: ~714 for adults 19-64). Two of these estimates are remarkably close to that of the randomized Oregon Medicaid Experiment (NNI: 769), although that effect estimate was not statistically significant. Most recently, however, another randomized study — of an intervention by the Internal Revenue Service — provided powerful experimental evidence that health insurance is life-saving. Regardless of which NNI estimate one uses, basic arithmetic makes clear that — with 30 million uninsured — tens of thousands of people are dying annually for lack of coverage. Notably, such deaths from lack of medical care are occurring everywhere, not only in states that have not expanded Medicaid. While non-expansion states have higher uninsurance rates, the number of uninsured in expansion states — for instance, 2.8 million in California and 1.0 million in New York — mean that hundreds or thousands are dying from lack of medical care a year in most states.
Critics might respond, however, by noting that Medicare for All is not the only way to address this challenge — that there might be other, and easier, ways to realize universal coverage. That being said, most other alternative health reform proposals would fail to achieve this end. Democratic presidential candidate Joseph Biden’s public option proposal, for instance, would leave some 3% of Americans (or approximately 10 million individuals) uninsured according to his campaign’s own estimates. A recent analysis by RAND researchers of a Medicare “buy-in” for those age 50-64 found that it would have “little to no effect on total health insurance enrollment.” An estimate from the Congressional Budget Office similarly found that a public option made available on the ACA exchanges would have “minimal effects on … the number of people who would be uninsured.” And a recent analysis from the Urban Institute found that a package of reforms that included a public option could leave as many as 21.3 million uninsured. In fairness, other more expansive proposals might cover everyone. Nonetheless, in addition to achieving universal coverage, Medicare for All is uniquely designed to do something else: achieve a universal improvement of coverage.
Rising copays and deductibles are causing more and more patients to go without needed care, or to face harsh financial consequences when they do. Underinsurance is, today, as much a problem as uninsurance — and, according to estimates from the Commonwealth Fund, is growing most rapidly among those with employer-sponsored coverage. Exhibit 1 provides rates of uninsurance (including those with lapses of coverage) and underinsurance in 2018. Overall, about 1 in 3 Americans — or more than 100 million individuals — fall into one of these categories, and can be classified as having deficient health coverage.
Exhibit 1: Deficient health coverage in the United States, 2018
Source: 2018 National Health Interview Survey; 2018 Commonwealth Fund Biennial Health Insurance Survey; Commonwealth Fund analysis of 2012 Medicare Current Beneficiary Survey extrapolated to 2018 (see notes).
1. These are individuals who were insured at the time of survey but uninsured within the last year; the category does not overlap with those who are currently uninsured or underinsured in the Commonwealth Fund report I draw it from. Of note, that analysis reported only 24 million uninsured, but this excludes children and seniors. Adding the estimated 4.1 million uninsured children in 2018 to the Commonwealth figure produces a similar number of total currently uninsured as the National Health Interview Survey estimate I use here.Similar to uninsurance, underinsurance has staggering adverse effects on health. Exhibit 2 presents evidence, drawn exclusively from randomized or quasi-experimental studies, on the health consequences of copays or deductibles for patients with six conditions: high blood pressure, heart attacks, diabetes, breast cancer, multiple sclerosis, and rheumatoid arthritis. For those with each of these diseases, cost-sharing deters the use of needed medications and care and, in many instances, causes demonstrable clinical harm.
2. Defined by the Commonwealth Fund investigators as having deductibles >= 5% of income or annual out-of-pocket spending in last year >= 10% of income (or >5% of income for those with low incomes).
3. In 2016, according to Commonwealth Fund estimates, 24% of Medicare beneficiaries were underinsured (defined as annual out-of-pocket spending >= 10% of income year, a narrower definition than used for the age 19-64 group). Applied to the 2018 elderly population of 52 million, this translates to 12.6 million individuals.
4. The Commonwealth Fund investigators report a lower total of the “inadequately insured” of 87 million. However, this estimate excludes both children and seniors who are uninsured and underinsured. My estimate also excludes underinsured children, as I am unaware of recent estimates of underinsurance for this group.
Exhibit 2: Health consequences of copays and deductibles for those with select diseases
Source: Author’s analysis of reports of randomized trials and quasi-experimental studies
Medicare for All — unlike other reforms — would alleviate such widespread and unnecessary suffering not merely by covering the uninsured, but by eliminating financial barriers to care. Rising costs from higher care utilization will be offset by large savings from simplifying administration. Indeed, a recent systematic review found that some 19 out of 22 economic analyses of Medicare for All predicted overall savings in the first year as a result of such efficiencies. Transforming healthcare financing is what makes such an unprecedented coverage expansion economically— and hence politically — feasible.
- https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2752366
- https://www.ncbi.nlm.nih.gov/pubmed/28564682
- https://www.ncbi.nlm.nih.gov/pubmed/29847485
- https://jamanetwork.com/journals/jama/article-abstract/400929
- https://www.nejm.org/doi/full/10.1056/NEJM198312083092305
- https://www.nejm.org/doi/full/10.1056/NEJMsa1107913
- https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.0654
- https://annals.org/aim/article-abstract/2716078/high-deductible-insurance-delay-care-macrovascular-complications-diabetes
- https://www.ncbi.nlm.nih.gov/pubmed/29382660
- https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05026?journalCode=hlthaff
- https://www.ncbi.nlm.nih.gov/pubmed/28736929
- https://www.ncbi.nlm.nih.gov/pubmed/28736929
The policy advantages of Medicare for All, in other words, aren’t mere minutiae: they are part of the force for political change.
Medicare for All: The Link Between Policy and Politics
Yet policy and politics are linked in another, more fundamental way. The experience of illness and of medical care is almost universal. This means that in the United States, encounters with our dysfunctional healthcare financing system are also near universal. How many have never had a spell of being uninsured, dealt with an onerous copay or deductible, contended with a medical bill or collections agency, gone without needed care because of cost, or faced a denial of care from their insurer? It is not merely uninsured Americans who have much to gain from single-payer reform, in in other words, but also those with chronic conditions who pay a tax for their illness in the form of cost-sharing; those with Medicare coverage who lack dental and long-term care benefits; those with Medicaid who must hurdle administrative barriers to remain covered and face frequent “churn” out of the program, and who sometimes have inferior access to care. Indeed, even those satisfied with their employer-sponsored coverage know that they are but one sickness — and consequent job loss — away from losing it.All of which is to say that at the end of the day, the vast majority of the nation could benefit from single-payer reform — and that fact makes it winnable. Above all, however, we can be sure of one thing: not bothering to push for Medicare for All today will guarantee that it doesn’t happen tomorrow.
https://www.healthaffairs.org/do/10.1377/hblog20200309.156440/full/
Strikes and Attack Ads: The Hard Roads to Universal Health Care
By Quoctrung Bui and
It is a common refrain from Bernie Sanders on the campaign trail: The United States is the only developed country that does not provide health coverage to all residents.“Canada can provide universal health care to all their people at half the cost,” he said at a recent Democratic debate. “The U.K. can do it. France can do it. Germany can do it. All of Europe can do it.”
Mr. Sanders is right: All these countries provide universal coverage. But what he doesn’t talk about is the excruciating battle they went through to get there.
It took Canada more than a decade to move from a patchwork of insurance plans to a single-payer system. At one point, doctors were so incensed that they went on strike for 23 days. Doctors from the United States and Britain flew in to help keep the health system going.
Single-payer systems take a long time to establish
Note: The start dates are based on interviews with historians and a review of historical records.
But when it began in the mid-1940s, 89 percent of doctors were opposed. They raised £1.6 million (or £58 million today, equivalent to $76 million) for a “fighting fund” to protest the plan. Some patients showed interest in contributing, too.
Look around the world and you start to see a common theme: Creating universal coverage is hard. The countries with the systems that Mr. Sanders admires went through years of failed legislation, doctor protests and uncertain futures.
“No country did this without a huge political conflict,” said Jacob Hacker, a professor of political science at Yale who studies the formation of international health systems. “But once they put in the strong, basic foundations, there was no going back.”
Most countries, like the United States, build their health systems incrementally. They start with smaller programs that cover a certain group of people (such as the poor) or a certain type of medical care (like hospital visits).
In other countries, it was the leap that the United States hasn’t made yet — from a system that covers some people to one that covers everybody — that in many cases was the hardest part. Abroad, the arguments made against universal coverage were similar to those we hear today: that it's just too expensive, or gives government too much control over the practice of medicine.
“Universal coverage may be considered a laudable goal,” one Canadian trade group said in 1967, before arguing that “it is not yet within the economic reach of our province or country.”
One British doctor told The New York Times in 1948 that, in fighting against the National Health Service, he and his colleagues were “engaged in a life or death struggle for our freedom and independence.”
Mr. Hacker said: “People look at the current levels of support that other systems have, and extrapolate backwards to think that universal coverage was always popular. But that isn’t the case. Everywhere this happened, it was a very fierce fight.”
It took Canada 11 years to bring health care to everybody
Tommy Douglas, widely credited for establishing single-payer health care in Canada, campaigning in front of a crowd of about 12,000.Getty Images
Mr. Douglas ran his 1959 re-election campaign on a health care agenda, promising “a high standard of medical care to every citizen of Saskatchewan.” He also offered a prediction: If his province stepped forward and created single-payer health care, “before 1970, almost every other province in Canada will have followed the lead of Saskatchewan.”
He won re-election in 1960 and passed legislation to create the single-payer system he’d promised voters. It did not get the positive reception that he might have hoped for: Doctors went on strike for more than three weeks when it began in July 1962. They took out newspaper ads warning that “compulsory state medicine would be a tragic mistake for this province and it would undermine the high quality of medical care which you now enjoy.”
“All the issues you’re hearing about in the Democratic debate, those were voiced in Canada in the 1950s and ’60s,” said David Wright, a history professor at McGill University in Montreal with a coming book on the history of Canada’s health system. “You had an industry concerned about becoming redundant, and individuals who had insurance worried about their doctors.”
Eventually, the doctors began to lose support, as Saskacthewan residents became frustrated with their lack of access to medical care. An independent mediator from London then brokered a deal. The compromise, known as the Saskatoon Agreement for where it was settled, guaranteed doctors they would not become employees of the state but remain independent contractors within the public insurance plan.
Despite the early hurdles, Mr. Douglas’s prediction was ultimately proved right. Saskatchewan’s system became quite popular, and other provinces began putting in their own. The federal government later began providing funding for these systems, and, by 1971, the entire country had transitioned to single-payer health care.
Jan 1960Jan 1962Jan 1964Jan 1966Jan 1968Jan 1970
Dec. 1959:
Saskatchewan's premier, Tommy Douglas, a Democratic socialist,
campaigns on expanding public health insurance to doctor visits if
re-elected.
Jun. 1960: Douglas wins re-election.
Oct. 1961: Douglas's political party makes good on his promise, and introduces legislation to create North America's first universal coverage plan. It passes, and is set to take effect the following year.
Jul. 1962: Saskatchewan's system starts up, and the province's doctors go on strike. Doctors fly in from the United States and England to keep emergency rooms running. The strike lasts 23 days, ending after a British negotiator flies in to broker a deal between the government and physicians.
Jan. 1968: Saskatchewan's once-controversial health plan starts spreading across the country as the federal government agrees to help fund the system. British Columbia launches a similar program, followed by an additional four provinces the next year.
Jan. 1971: Canada's single-payer system is finally complete, with the province of New Brunswick introducing a program to cover all residents.
0.4 years
1.8 years
2.5 years
8 years
11 years
Jun. 1960: Douglas wins re-election.
Oct. 1961: Douglas's political party makes good on his promise, and introduces legislation to create North America's first universal coverage plan. It passes, and is set to take effect the following year.
Jul. 1962: Saskatchewan's system starts up, and the province's doctors go on strike. Doctors fly in from the United States and England to keep emergency rooms running. The strike lasts 23 days, ending after a British negotiator flies in to broker a deal between the government and physicians.
Jan. 1968: Saskatchewan's once-controversial health plan starts spreading across the country as the federal government agrees to help fund the system. British Columbia launches a similar program, followed by an additional four provinces the next year.
Jan. 1971: Canada's single-payer system is finally complete, with the province of New Brunswick introducing a program to cover all residents.
0.4 years
1.8 years
2.5 years
8 years
11 years
British doctors raised millions to protest the National Health Service
A dentist working in a health center that was part of the newly established National Health Service.Popperfoto/Getty Images
In 1942, a dense government tome known as the Beveridge Report
recommended that Britain vastly expand its welfare state. The 300-page
policy paper by the economist William Beveridge became a surprise hit,
selling more than half a million copies.
Even so, the nation wasn’t fully sold on the idea of overhauling its health system. One 1944 poll recently unearthed by the historian Nick Hayes found that just 44 percent favored a nationalized health system. A full third wanted to leave things as they were, a mix of public and private programs. Doctors made their views quite clear in a poll conducted by the British Medical Association: 89 percent opposed the new system.
Facing ambivalence from the public and staunch opposition from physicians, the National Health Service didn’t move forward until the Labour Party won control of Parliament with a landslide victory in 1945. From there, things moved quickly. As Mr. Hacker writes in his history of the system, it moved “from a Cabinet proposal in December 1945 to a White Paper in March to a law in November.”
Doctors considered going on strike but ultimately decided against it after the government offered financial concessions. Doctors would be allowed to earn additional money seeing patients in private practice outside of the National Health Service (this is still done in Britain but is outlawed in Canada).
Two years after the start of the National Health Service, the health minister Aneurin Bevan remarked that he had “stuffed their mouths with gold” to broker his deal with British doctors.
Jan 1943Jan 1944Jan 1945Jan 1946Jan 1947Jan 1948
Dec. 1942:
A coalition government releases the Beveridge Report, a 300-page
document calling for a vastly expanded social welfare state and
universal health coverage.
Jul. 1944: A public poll finds that only a little over half of British citizens favor a nationalized health system.
Mar. 1946: The National Health Service Act is introduced in Parliament.
May. 1946: The National Health Service Act is enacted by Parliament, with services set to start July 5, 1948.
Mar. 1948: Months before launch, the British Medical Association finds 86 percent of its members oppose it.
Apr. 1948: The British government responds to the doctors with amendents that would guarantee a certain level of autonomy in the practice of medicine.
Jul. 1948: The National Health Service begins as planned.
1.6 years
3.3 years
3.4 years
5.3 years
5.3 years
5.6 years
Jul. 1944: A public poll finds that only a little over half of British citizens favor a nationalized health system.
Mar. 1946: The National Health Service Act is introduced in Parliament.
May. 1946: The National Health Service Act is enacted by Parliament, with services set to start July 5, 1948.
Mar. 1948: Months before launch, the British Medical Association finds 86 percent of its members oppose it.
Apr. 1948: The British government responds to the doctors with amendents that would guarantee a certain level of autonomy in the practice of medicine.
Jul. 1948: The National Health Service begins as planned.
1.6 years
3.3 years
3.4 years
5.3 years
5.3 years
5.6 years
Australia created universal coverage. Then repealed it. Then created it again.
Australian workers protested outside Parliament in 1975. Australia adopted a single-payer system, repealed it and then re-adopted it years later.Kenneth Stevens/Fairfax Media, via Getty Images
The country’s Labor Party argued this wasn’t good enough, and won the 1972 country’s national election campaigning on a health care platform.
Things did not proceed smoothly from there.
“The journey has been quite tortuous,” said Anne-Marie Boxall, an associate professor at the University of Sydney, who has written a book on Australia’s health system. “No other developed country has managed to introduce universal health care and get rid of it.”
Legislation to create universal health care failed in 1973. It failed again in 1974. It passed in 1975 by a mere three-vote margin. The new system would leave private insurance markets intact but create a parallel public program to cover all Australians.
“It was an epic legislative battle to get universal health care up and running,” Ms. Boxall said. “It was nothing short of extreme brinkmanship.” She said the leader at the time, Prime Minister Gough Whitlam, had a motto: “crash or crash through.”
The Labor Party did manage to create a universal coverage system called Medibank, but voters’ support for the idea had fallen during the bruising legislative battle. One poll showed that, by 1975, only 38 percent of Australians supported the idea of mandatory coverage for all. Voters made this point especially clear in the 1976 election, when they booted the Labor Party out of power. A more conservative coalition government took control and, within years, rolled back the Medibank plan.
This gives Australia the perhaps unenviable distinction of being the only developed country to repeal universal coverage.
But the battle wasn’t over. When Labor returned to power in 1983, the party immediately went back to health care. It changed the name of its health coverage plan to Medicare and passed it again in 1984. This one has survived, so far.
Jan 1974Jan 1976Jan 1978Jan 1980Jan 1982Jan 1984
Dec. 1972: Gough Whitlam is elected prime minister
Dec. 1973: A universal coverage plan, Medibank, is introduced and fails to pass through Parliament.
Aug. 1974: Parliament passes Medibank after being rejected by the Senate three times.
Jul. 1975: Australian states resist signing up to participate in the program, which pushes back Medibank's introduction from July to October.
Dec. 1975: Months after Medibank takes effect, voters push Labor out of power, electing a more conservative party to the majority.
Jul. 1976: As the conservative government looks to make cuts to Medibank, unions organize a 24-hour strike of millions of Australians to show their opposition. The New York Times reported that this strike was "bringing to a halt almost all public transport, closing most industrial plants, and severly disrupting commerical life in the cities for 24 hours."
Apr. 1981: A conservative coalition repeals the Medibank program despite public outcry, ending Australia's national health plan.
Jan. 1984: Radiologists and surgeons balk at the new universal coverage plan, refusing to sign contracts with the government-run health system. On Feb. 22, they begin a strike, refusing to perform any surgery that is not an emergency.
May. 1984: More strikes crop up among other specialties. In Canberra, the entire hospital closes for any scheduled care, seeing only emergency patients.
Dec. 1984: The doctor strikes drag on, but the re-election of the Labor government reduces enthusiasm as doctors now see Medicare as here to stay.
Apr. 1985: Sixteen months after the strikes began — and with public frustration with the strike growing — the government and doctors reach a deal to return the doctors to work.
0.9 years
1.6 years
2.5 years
2.9 years
3.5 years
8.3 years
11 years
11.3 years
11.9 years
12.3 years
Dec. 1973: A universal coverage plan, Medibank, is introduced and fails to pass through Parliament.
Aug. 1974: Parliament passes Medibank after being rejected by the Senate three times.
Jul. 1975: Australian states resist signing up to participate in the program, which pushes back Medibank's introduction from July to October.
Dec. 1975: Months after Medibank takes effect, voters push Labor out of power, electing a more conservative party to the majority.
Jul. 1976: As the conservative government looks to make cuts to Medibank, unions organize a 24-hour strike of millions of Australians to show their opposition. The New York Times reported that this strike was "bringing to a halt almost all public transport, closing most industrial plants, and severly disrupting commerical life in the cities for 24 hours."
Apr. 1981: A conservative coalition repeals the Medibank program despite public outcry, ending Australia's national health plan.
Jan. 1984: Radiologists and surgeons balk at the new universal coverage plan, refusing to sign contracts with the government-run health system. On Feb. 22, they begin a strike, refusing to perform any surgery that is not an emergency.
May. 1984: More strikes crop up among other specialties. In Canberra, the entire hospital closes for any scheduled care, seeing only emergency patients.
Dec. 1984: The doctor strikes drag on, but the re-election of the Labor government reduces enthusiasm as doctors now see Medicare as here to stay.
Apr. 1985: Sixteen months after the strikes began — and with public frustration with the strike growing — the government and doctors reach a deal to return the doctors to work.
0.9 years
1.6 years
2.5 years
2.9 years
3.5 years
8.3 years
11 years
11.3 years
11.9 years
12.3 years
Could it happen here?
Demonstrators carried signs supporting the Medicare for All Act
of 2019 at a news conference about the bill outside the House of
Representatives in Washington.T.J. Kirkpatrick for The New York Times
Australia, Canada and Britain all overcame enormous opposition to build
health systems that their citizens now support. In each case,
politicians stood firm, and eventually the outcry subsided.
Could something similar happen in the United States?
Those who study the history of other health systems say it is certainly possible — but will probably be more difficult.
The United States is different in that its medical industry is bigger and more powerful. Health care spending accounts for one-sixth of the American economy, and no industry spends more on lobbying Congress.
Another obstacle comes from the structure of the U.S. government, in which dueling political parties often wield partial control over different branches of government.
“The American political system makes this harder,” said Mr. Hacker, the Yale professor. “The kind of determined, take-no-prisoners approach that happened in some provinces like Saskatchewan doesn’t work as well here.”
That said, there is nothing so structurally different about the United States that leads historians to think of universal coverage as impossible.
“Of course the United States could do this,” said Mr. Wright, the history professor at McGill. “There’s no reason except for political will that it couldn’t happen.”
Ms. Boxall, who studies the system in Australia, notes that 80 percent of people there had private health insurance when the Labor government began to pursue universal public coverage. That suggests to her that change can still happen, even in the face of an entrenched insurance industry.
“The private market hadn’t achieved universal coverage here, and it became clear government was the only way to get from 80 percent up to 100 percent,” she said.
Still, widespread private insurance did mean party leaders had to compromise: To this day, Australia has a private health insurance system that runs in parallel to its universal coverage. Enrollment in the private plans typically rises when conservative parties are in power, and falls when liberals come into government.
“People had been paying into their private coverage for 25 years, and were nervous about what a government-run scheme would mean,” Ms. Boxall said. “After fighting the political battle left to get to universal coverage, they just didn’t have the political capital left to do something sensible with the private insurance arrangements that sat alongside it.”
https://www.nytimes.com/interactive/2020/03/10/upshot/the-hard-road-other-countries-single-payer-health-care.html?action=click&module=News&pgtype=Homepage
No comments:
Post a Comment