After the Reform: Aiming High for Health Justice

By Margaret Flowers, M.D. for Tikkun Magazine

As we sit here on the other side of the recent health reform process, we have an opportunity for reflection. There were many times during the past year and a half when passage of a health bill seemed unlikely. However, in the end, the White House and Democratic leadership joined forces and converted the last holdouts with scare tactics of electoral turnovers and even a trip on Air Force One in order to muscle a bill over the final hurdles. The mere fact that any bill was passed at all was hailed as the great accomplishment, because no honest proponent of health reform could call the final product a solution to our nation’s serious health care crisis.

This entire health reform process occurred under the shadow of the previous attempt to pass significant health legislation. President Obama made this his signature issue, and so for his administration failure was not an option. He surrounded himself with many of those who were traumatized by their participation in the last go-round. Thus, the resulting strategy was based more on fear of the opposition than on sound health policy. An opportunity for an honest debate about the needs of our people was squandered for backroom deals with industry giants and the photo ops so reminiscent of the previous administration. And for the most part, the resulting legislation benefits the very industries that profit most from our current situation more than it benefits the people of America.

Pros and Cons of the Legislation

There are some provisions within the bill that are positive steps: comparative effectiveness research; funding for demonstration projects to improve care; a new emphasis on prevention, wellness, and public health; increased funding for community health centers; and incentives for primary care providers. These are all necessary provisions, but they do not offset the harm done by other provisions in the bill, such as the individual mandate to purchase private insurance with penalties for noncompliance and the $447 billion in public dollars being used to subsidize such purchases. The bill will omit at least 23 million people from having any coverage. And the requirement to accept people with pre-existing conditions will most certainly increase premiums such that they become unaffordable, or people will purchase policies with skimpier coverage. This will likely result in a larger population of underinsured people—those who risk bankruptcy from medical debt should they develop health problems.

And none of the positive steps turn us in the direction of creating a national health system such as there is in every other advanced nation. Rather, on the whole, this legislation, which was written with heavy input from private health insurance and pharmaceutical lobbyists, further privatizes the financing of our health care and further enriches and empowers the very industries that are the problem. We know from experience both in the United States and abroad that market-based financing of health care is both the most expensive model and the most unjust, providing only as much health care as the patient can afford.

The Public Option Was Ruled Out at the Start

From the beginning of this process, it was clear that the administration and leadership had developed a strategy based on an outcome they believed they could achieve. The path was predetermined. All of the steps along the way, from the house parties that started during the winter of 2008 to the hearings, to the media spin, were planned so that the resulting “debate” was a drawn out performance of political theater. In order to disarm the corporate interests, the health industries that had opposed previous reforms were included on the inside. In order to disarm the Right, bipartisanship was at the forefront. In order to disarm the supporters of a single-payer plan, who are the majority, a campaign was developed around a promised “compromise,” the public option, and given tens of millions of dollars for organizing and advertising. The public option succeeded in splitting the single payer movement and confusing and distracting it with endless discussion about what type of public option would be effective.

Despite all of the attention, the public option was never meant to be part of the final legislation. As early as March 2009, Senator Baucus admitted that the public option existed as a bargaining chip to convince private insurers to accept increased regulation. And a year later, Glenn Greenwald and others confirmed that the public option had been privately negotiated away, although members of Congress continued the charade and “fought” for it.

Toward the final vote, supporters of the public option were hearing the same excuses that single-payer advocates have heard for decades. We are always told that single-payer is not politically feasible. However, we know that political feasibility can change. We are told to be pragmatic, yet we know that the reform being passed was not practical, in that it failed to guarantee health care to everyone and to be financially sustainable. We are told we are asking for too much and should accept incremental change. However, we know that the smallest effective step we can take in health reform is the creation of a publicly funded health system. Beyond that, there is much more to do in order to create a health system that raises us into the top ten in the world.

Profit-Driven Insurers Cannot Prioritize Care

While politicians claim that we have finally achieved comprehensive health reform and that now all Americans will have guaranteed affordable health care, we in the single-payer movement experience a sense of déjà vu. We have seen the same scenario occur at the state level from Oregon to Maine to Tennessee, and most recently in Massachusetts. Every state that has passed a health reform package has made these claims, only to find that within a few years they were unable to cover the number of people they had hoped to cover and that their health care costs exceeded their budget. The reason for this is that every state, and now our federal government, ignored the data showing that we cannot achieve universal and affordable health care as long as we retain private insurers as an integral part of health care financing. This truth has been documented both in practice and in numerous economic studies.

We cannot control health care costs, without severe rationing, as long as we retain multiple private insurers, because this model wastes at least a third of our health care dollars on areas that have nothing to do with direct health care: marketing, high CEO salaries, profits, and administration. We cannot guarantee that patients will be able to afford needed care using private insurers because the private insurance model is profit driven. These corporations profit by avoiding the sick and denying and restricting payment for care. Their bottom line is profit, not improved health. And no amount of industry regulation to date has been successful in changing that bottom line. Likewise, the new federal legislation is full of loopholes that will allow private insurers to continue to skirt the regulations.

The White House and Congress claimed throughout the process that we must retain private insurance because Americans desire choice, and this has been framed as choice of insurance. However, this is a false concept. No person can anticipate what their health care needs will be or which insurance will be best. Health care needs change the day a patient has a serious accident or is diagnosed with a serious illness. We all need the same health insurance: one that covers all medically necessary care when and where we need it. Those of us who travel and listen find that people in America desire choice of health care provider and choice of treatment: the two choices that private health insurers restrict.

So what are the White House and Congress really saying when they claim that we must retain a private insurance model? That they are unwilling to take on these powerful industries, and so we, the people, must be willing to compromise and work within their framework. Mohandas Gandhi said:

All compromise is based on give and take, but there can be no give and take on fundamentals. Any compromise on mere fundamentals is a surrender. For it is all give and no take.

When it comes to health reform, compromise on the fundamentals is unacceptable because the human costs are continued preventable deaths, continued suffering as patients fight for needed care, and continued bankruptcy from medical debt as families struggle to pay for deductibles and uncovered services. In a study published in Health Affairs in January 2008 that looked at the top nineteen industrialized nations, the United States ranked the worst—we have the highest number of preventable deaths (101,000 each year) because we lack a health system. All of the other industrialized nations have health systems based on the principles of health care as a human right: universality, equity, and accountability.

Why We Failed

Why have the American people been denied this same right? As I look back at the health reform process, I see three serious errors: a willingness to compromise, a lack of clarity about what we require, and a fear that failure to pass reform will have electoral consequences. These are the areas we must address as a people if we want to see real change in this nation, not just in health care but also in many areas that affect our ability to survive on this planet.

The willingness to compromise has occurred repeatedly at the state level. As a result, fewer people have access to care, and health care costs continue to rise; the fundamental problems are not corrected. This willingness to compromise is based on a real sense of desperation. We see real suffering. We want to do something. We are told that this reform, whatever it is, is the best we can get this time. We accept that and tell ourselves that it is something, it is a step.

As the congressional fellow of Physicians for a National Health Program, I saw this desperate attempt to pass something, anything, rise to the surface in the final weeks of the reform process. Patients and their families were brought into Congress to tell their stories of abuse at the hands of private insurers. Well-meaning legislators looked them in the eye and told them that this reform would change that. When I challenged the truth of that response, I was told, often in heated tones, that they (the legislators) had to do something and that at least this reform would help some people. I could only think of those who would not be helped. What about them?

The lack of clarity was grounded in the belief that if we simply advocated based on principles such as access and affordability, then the legislation would meet those principles. Legislators and pro-reform groups were content to speak based on principles as long as they were not challenged about whether those principles were being met. We must go beneath the surface of simple principles, educate ourselves, and define what is acceptable and what isn’t. If we don’t know exactly what we are asking for, we won’t get it. And we mustn’t be afraid to ask for what we require. As a people, we have become willing to accept crumbs when we require so much more than crumbs.

The final mistake was to pin the results of the upcoming elections to the success or failure of passing reform. Those who were reluctant to support the legislation were forced to support it in the end or risk being blamed for possible electoral consequences. As has often happened in past campaigns, people were forced to vote for the lesser of two evils instead of for what they truly wanted.

We Can Still Create a National Health Program!

So what do we do now that a health bill has been signed? Now that the clamor has quieted, it is time for a civilized discussion of what our health needs are and how best to meet them. This discussion is unlikely to occur in a mainstream media dominated by advertising dollars from health insurance and pharmaceutical corporations. We will need to have this discussion at a more personal level and through independent sources of media. We must educate ourselves and those around us about what is possible to achieve in this nation.

It is possible to create a national health program in which every person living in this country is able to receive the same high standard of medical care whenever and wherever they need it, without fear of financial consequences. We call this health security. Other advanced nations have achieved this goal. The United States has not, and is currently ranked thirty-seventh in the world for health outcomes. We spend more per capita on health care than every advanced nation, yet leave a third of our population either completely on the outside or vulnerable to financial ruin should they have a serious health problem.

Physicians for a National Health Program, founded in 1987, educates and advocates for a health system that will improve our health outcomes and provide health security based on the evidence of what has worked in our nation and what is effective in other advanced nations. We envision a lifelong universal health system—much like traditional Medicare—that is nationwide. We envision a system that allows patients to choose where they receive their care, permits caregivers and patients to determine the best course of treatment with assistance from evidence-based data, controls costs in a rational way through simplified administration and negotiation of fair prices, and is progressively financed. Its publicly funded nature would make it transparent and accountable. Because it would be privately delivered, it would allow caregivers to compete based on quality of care provided. Private health insurers would be relegated to a position of offering supplemental plans and possibly providing administrative support.

The Rev. Dr. Martin Luther King Jr. taught us that to witness an injustice and not work to correct it is in itself an act of violence. As a physician and an advocate for nonviolence, I cannot ignore the injustice of the great health inequality that exists in our nation or ignore those in need who cannot afford medical treatment. We have delayed this struggle for too long. Alice Walker said, “We are the ones we have been waiting for.” So, let’s do it. We have the resources. Now we must create the political will. Together, we can create a health justice movement, educate ourselves, speak with clarity, and organize independently of any political party. Please join us. You can learn more at www.pnhp.org or join the grassroots movement at www.healthcare-now.org.

Dr.Margaret Flowers is a pediatrician who serves as the congressional fellow for Physicians for a National Health Program and is on the board of Healthcare-NOW! She is one of the “Baucus 8.”