Affordable Care?

Like a photograph slowly developing, recognizable features of the Democratic health care reform plan are finally taking shape. Insurers stand to receive $465 billion in subsidies via the Senate Finance Committee version of reform, while those citizens failing to pay for private insurance could face fines ($750 for failure to buy single coverage, $1,900 on family policies), all without an effective "public option" that would serve as a measuring stick to monitor and discipline private insurers. Moreover, many Americans—perhaps 25 million—will remain uninsured.

"Obviously, this plan won't work because middle-income people are right at the border line, caught between unaffordable premiums and unaffordable out of pocket expenses," said Dr. Don McCanne of Physicians for a National Health Program. This perverse outcome should be no surprise, given that former Wellpoint insurance lobbyist Liz Fowler played a central role in helping Senate Finance Chair Max Baucus (D-MT) write the committee's $829 billion bill, which is serving as the framework for reconciling the differences among the three main Democratic bills. (According to the Washington Post, Baucus raked in $3 million in campaign contributions from the health and insurance sectors between 2003 and 2008, amounting to 20 percent of his total contributions.)

The new mandate is a product that is "both defective and unreliable," in the words of Dr. Steffie Woolhandler of Harvard Medical School. The required payments in the least-expensive "silver" plan, for example, will be far out of reach for many middle-class families. Before receiving any coverage, families making $54,000 must shell out $5,000 in deductibles before their insurance kicks in, along with paying out another $5,300 in premiums.

If premiums exceed 12 percent of family income, the federal government will provide subsidies to make insurance more affordable. However, the subsidy does not apply to the sizable deductibles. Further, according to the New York Times (9/6/09), "To compare health plans, experts often focus on the percentage of medical expenses paid by insurance, on average, for a given population. This figure ranges from 70 percent to 95 percent under the House bill's options, but it would be less than 70 percent under Mr. Baucus's proposal."

The Baucus plan, which is scheduled to start in 2013, is being proposed at a time when 41 percent of Americans have already reported difficulty paying health care bills, according to the 2007 report Losing Ground, issued by the Commonwealth Fund. The impact of the Baucus/Wellpoint plan would be so draconian that Democrats have started scrambling to soften it through adding considerably more Medicaid funding (NYT, 9/30/09).

Thus, the most promising part of the sweeping "omnibus" reform bill is a provision for virtually immediate help for the low-income uninsured. While the exact scale of the new assistance to low-income people is uncertain, a number of Democrats see pumping up Medicaid as a means of helping both poor and middle-class families. Separate bills in the Senate and House also contain provisions inserted by Sen. Bernie Sanders (I-VT) and Rep. James Clyburn (D-SC) that would quadruple the level of spending for community health centers because: "Even if universal health care were enacted, there would still be some 60 million Americans located in areas without doctors, so the community health centers are vital for providing primary care, dental care, and mental health treatment," explained a Sanders spokesperson.

Lacking a public option, the plan has been scorned by Dr. Howard Dean, former Democratic national chair, as "a giveaway to the health insurance industry." What makes this giveaway so extraordinary is that the health insurance industry is one of America's most unpopular institutions. The favorability ratings of the health insurance industry are lower than the tobacco industry. A 2009 USA Today survey revealed that just 4 percent regard the insurers as "honest and trustworthy."

The industry's windfall is an appalling comment on the hollowness of American democracy in the face of overwhelming corporate power. While largely reviled by the public, the for-profit health insurance industry has been warmly welcomed by the Congress, the White House, and elite media as a legitimate and valuable ally in the cause of reform. This same gulf between elite and popular opinion was visible in the near-total exclusion by elites of the most popular model for reform, the "single-payer" or "Medicare for all" proposal.

Perhaps the most authoritative poll on single-payer was conducted by Business Week (5/16/05), because it explicitly referred to systems where the government has essentially replaced the private insurance industry: "67 percent of all Americans think it's a good idea to guarantee healthcare for all US citizens, as Canada and Britain do, with just 27 percent dissenting." But the single-payer plan was immediately ruled "off the table" in Baucus's words: "We are Americans. We're different from Canada; we're different from the United Kingdom" He was presumably not referring to the United States' distinctively poor health outcomes (e.g., higher infant mortality, shorter longevity) delivered at much higher per-capita cost ($7,290 for the U.S.) when he spoke of the American "difference."

President Obama has similarly excluded the single-payer plan from consideration. Obama, once an advocate of single-payer while an Illinois state senator, now argues, "The vast majority of people currently get health care from their employers and you've got this system that's already in place. We don't want a huge disruption as we go into health care reform where suddenly we're trying to completely reinvent one-sixth of the economy."

Obama's argument was forcefully refuted by Dr. Marcia Angell of Harvard Medical School on "Bill Moyers Journal": "What he has essentially advocated is throwing more money into the current system.... Our problem is that we spend two-and-a-half times as much per person on health care as other advanced countries, the average of other advanced countries. And we don't get our money's worth. So, now he says, okay, this is a terribly inefficient, wasteful system. Let's throw some more money into it."

Moreover, the transition to a single-payer system need not be "disruptive," as it involves replacing the bureaucracy, rules, and paperwork imposed by 1,500 health insurers with one public entity and one comprehensive set of benefits. Recall that in a pre-computer era, tens of millions of senior citizens were enrolled in Medicare just 11 months after President Lyndon Johnson signed the bill in 1965.

For-profit insurers are eager for the version of "reform" now under consideration. Also standing to benefit are major non-profit insurers whose motives and mode of operation is virtually identical to the for-profits, such as Blue Cross/Blue Shield, Kaiser Permanente, HealthPartners, and Group Health of Puget Sound. "The only thing the insurers are willing to accept is a lot of new customers, at whatever premium, and they'll be happy with that," Angell reports.

In exchange for the universal mandate, America's Health Insurance Plans (the 1,300-member insurer trade association) has agreed to do away with pre-existing conditions after one year in considering applications or coverage of specific illnesses. However, the provision may prove difficult to enforce. As United Electrical workers political director Chris Townsend told me, "What's to stop them from denying you on the basis of a bad credit record with medical bills?" Further, "In exchange for issuing policies to sick people, insurers get to jack up premiums for older people...letting them charge four times more," writes long-time health advocate Trudy Lieberman (Columbia Journalism Review, 9/23/09).

The Baucus plan also lacks a strong "pay or play" employer mandate, with small fees for failing to provide insurance, so that corporations will continue to undercut their competition by withholding expensive health benefits. And it proposes that key regulations for the health insurance industry be unilaterally written, without Congressional review, by a private group of state insurance commissioners, long known for their servility to the industry and their lack of transparency (LA Times 9/28/09).

The pharmaceutical firms walked into the current health debate as the industry with the highest profit rate. According to Angell in her book The Truth About Drug Companies, in 2001, the drug industry enjoyed a profit rate of 18.5 percent measured as average return on sales. Moreover, in 2002, the 10 most profitable drug corporations earned $35.9 billion—more than the other 490 corporations on the Fortune 500 combined.

From the 2000 to 2007, the profits of major health insurers shot up 428 percent. CEO compensation at the 10 largest insurers averaged $11.9 million in 2008. During the 2000-2005 period, health insurers increased their staffing by 32 percent in order to more effectively scrutinize patient claims in order to withhold payments and authorization and thereby maximize profits. With this vast bureaucracy, highly-paid executives, and huge profits, it is no wonder that administrative costs consume 31 percent of America's private health care spending. (By comparison, administrative costs under Medicare are just 3 percent.) For-profit insurers' excess administrative costs amount to an unnecessary annual outlay of some $400 billion, according to a 2003 study by led by Woolhandler and other Harvard Medical School researchers.

Meanwhile, working families have suffered from sharply higher premiums, which have increased by 131 percent since 1999. Annual premiums for family health coverage climbed to $13,375 in 2009, with workers and their families contributing a $3,515 share on average, more than double what they paid nine years ago. A growing number of employers have simply dropped health coverage as unaffordable. Some 47 million were left uninsured even before the onset of the current economic downturn. According to a study by Harvard Medical School researchers, since the downturn, an estimated 14,000 people have been forced into the ranks every day and being uninsured results in an estimated 45,000 preventable deaths annually. A study by the California Nurses Association discovered that for-profit insurers routinely reject, on average, 21 percent of all health claims in California, with Cigna rejecting a remarkable 40 percent. Millions of Americans have thus faced endless delays and direct interference in the doctor-patient relationship in terms of what treatments for-profit insurers will authorize and pay for. They have also frequently encountered duplicate and deceptive billing practices.

"It will take at least a decade for real change," McCanne ruefully predicts. "It will take about four years for the national insurance exchange to be set up for the uninsured and then at least another six years before people conclude that it simply doesn't work. What's going to wake people up is that middle Americans are going to find out that they still can't pay for health insurance or health care. Even if they can afford insurance premiums, they'll be unable to afford the out of pocket deductibles."

Unfortunately, for-profit insurers and pharmaceutical corporations have massive resources which have proven effective in influencing Congress, The health-care industry as a whole employs more than four lobbyists per member of Congress. More than 350 former members of Congress or congressional aides have been hired to lobby for industry-shaped reform. Big Pharma alone is spending vast amounts. According to the Washington Post: "The hirings are part of a record-breaking influence campaign by the health-care industry, which is spending more than $1.4 million a day on lobbying in the current fight, according to disclosure records. And even in a city where lobbying is a part of life, the scale of the effort has drawn attention. For example, the Pharmaceutical Research and Manufacturers of America (PhRMA) doubled its spending to nearly $7 million in the first quarter of 2009, followed by Pfizer, with more than $6 million."

Health-care interests have been both generous and strategic in their campaign contributions. "[The health insurance industry] has donated more than $19 million to federal candidates since 2007, 56 percent of which has gone to Democrats," reported Business Week. In particular, conservative "Blue Dog" Democrats who have generally been highly sympathetic to the industry have received about 25 percent more than their fellow Democrats, according to the Center for Responsive Politics.

One of the most misunderstood components of the health-care debate is the "public option." Many Americans assume that it is a voluntary version of the single-payer model, which would somehow exist alongside the for-profit insurers, a view reinforced by hysterical Republican attacks that it would lead to a single-payer system or "socialized medicine." Others have understood it as an extension of Medicare which anyone could choose to join—a far cry from the three major Democratic bills. Finally, a large number of supporters—including many progressives in Congress—see it as a critical element necessary as a measuring stick for the performance and premium levels of the for-profit industry and, thus, the only effective cost-control mechanism (if the option was broadly inclusive).

A NY Times/CBS poll released September 24 shows a stunning 65 percent majority (with just 26 percent opposed) for "the government offering everyone coverage in a government-administered health insurance plan—something like coverage that people 65 and over get—that would compete with private health insurance plan." A 47 percent plurality of Republicans favored such a plan. Unfortunately, the public option will not be able to live up to that vision. No public plan put forth thus far would offer it to all Americans.

As written now, the Baucus plan offers a weak network of cooperatives hatched by Sen. Kent Conrad (D-ND) as its version of the public option. "These non-profit insurance cooperatives would be pitted against already-existing for-profit insurers who have well-established provider networks and quasi-monopolistic market share," notes Kip Sullivan, a Minnesota health activist and author of The Health Care Mess.

Further, the final version of the public option will almost certainly force any public health-insurance entity to conduct itself exactly like private for-profit insurers. Even advocates of the public option like Sen. Charles Schumer (D-NY) have spoken of forcing the new public option plan to operate "on a level playing field" with private insurers who have long monopolized markets in many states. Under these rules, the public option will neither serve as a vibrant alternative nor be in a position to force down premium costs. "The public option would face the same administrative and marketing costs of insurers and trying to gain entry to the same delivery system," points out McCanne. "The public option won't be able to do anything to cut costs. If the public option has to function on a 'level playing field,' it will be forced to function like any private insurance company."

Moreover, the public option will be open initially only to newly-insured people who select the option through Health Insurance Exchanges. Enrollment will be limited to 25 to 30 million until 2019—giving the public option only a tiny sliver of the market, along with other handicaps.

The public option received a setback September 29 in a Senate Finance Committee vote. Following two 15-8 votes against different variants of the public option—neither close to the model favored by 65 percent in the recent NY Times/CBS poll—Baucus smirked, "No one shows me how to get to 60 votes with a public option." However, public option advocates are considering a procedure under which they would assemble 60 votes to defeat a Republic filibuster and then use a "reconciliation" procedure that would require only 51 votes for the public option.

In the House, more than 60 members of the Progressive Caucus, backed up by new AFL-CIO President Richard Trumka, are insisting that no health-care plan will pass without a strong public option. Unfortunately, a strong option has yet to be crafted. At this moment, progressives are placing far too much weight on just two lines of House bill HR 3200, according to the analysis of Kip Sullivan, and given the extreme complexity of the legislation, it will be relatively easy for even progressive, well-intentioned congresspeople to be sold on a toothless public option.

Woolhandler worries that the final Democratic plan will be a national version of the highly unpopular Massachusetts "reform" plan enacted by Republican Mitt Romney: an individual mandate, high premiums, fines for those who don't buy insurance, and a lack of cost controls on insurers and providers. "It will be Massachusetts writ large," predicts Woolhandler.

As of this moment, the only bright spot remains proposals for significantly expanded Medicaid enrollment and more community health centers for low-income people. A guarantee of health coverage for all? Freedom from constant bureaucratic interference by insurers? Health care that is affordable? For now, these rights—basic in all other advanced nations—will remain a dream deferred in the U.S.

Roger Bybee is a freelance writer and progressive publicity consultant whose work has appeared in Dollars & Sense, The Progressive, Multinational Monitor, American Prospect, and Foreign Policy in Focus.

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