The Good, The Perfect and the Wisconsin Compromise
I attended an interesting conference on “Health Care for All,” sponsored by Citizen Action at Rutgers University today, with a lot of breathless anticipation about how the 2008 elections were going to provide a mandate to finally get a national health plan. That is, if our policy-thinkers and policy-makers don’t compromise it to death. Dr. Oliver Fein, of Physicians for a National Health Plan, provided a spirited advocacy for universal single payer health care – “Medicare for All” – with a direct challenge to the for-profit insurance lobby and the compromisers. Too bad he’s not running for President. Representatives for Obama’s and Clinton’s campaigns were in attendance and said a whole lot about nothing, which does not bode well for voters’ supposed mandate for meaningful reform.
In the face of federal inaction, many states are putting together piecemeal, stop-gap programs. New Jersey’s slow move in this direction was the ostensible purpose for the conference. The state of Wisconsin is apparently close to enacting (or at least voting on) a pretty good plan that, nevertheless, demonstrates the pitfalls of statewide solutions. What Wisconsin would do, according to Dr. Robert Kraig of Citizen Action, is what most states do to insure their own employees. They spell out the terms of coverage – what procedures would be fully reimbursed, how much hospitalization, whether there would be co-pays or deductibles, that no one be denied coverage because of age, location or pre-existing condition, that no more than 15% of the costs go towards advertising and administration, etc. – and then contract out with various companies to provide the coverage. The Wisconsin plan would replace private insurance with a payroll tax to fund a statewide system and throw everyone into the same statewide pool, but allow individuals to choose between different insurance companies – Blue Cross, GHI and the like – or a state-run, non-profit plan. This idea of creating a state plan to compete with the private companies is apparently coming up often in these compromise plans. The thinking is that it’s a backdoor to single-payer health insurance, since a non-profit state-run plan would be cheaper and more efficient and would inevitably drive the private companies out of the market. At the very least, it is reasoned, they will keep the private companies competitive and “honest.” Call me a cynical socialist, but I assume the public plans will be sabotaged in some way so that the “superiority” of private plans will be proved.
Nevertheless, from an operational standpoint, the Wisconsin plan would work. It would provide good, comprehensive health care for everyone. However, I’m afraid it wouldn’t retain enough public support to survive the gauntlet of opposition it will receive from business and the insurance lobby. The problem is the funding formula. The plan calls for a ten percent payroll tax on employers, which is a good, suitable level (California’s Super Hero Governor is proposing a meager 6% payroll tax for his less-than-universal plan). A ten percent tax is less than employers pay for good health insurance, but more than employers pay for lousy or no insurance, helping even the playing field for companies than have been competing over health care costs (like Wal-Mart and the unionized supermarkets).
However, the plan also calls for a four percent payroll tax on employees, which, simply put, represents a pay cut for many workers for something they already have. Workers who have formed unions and bargained to gain and maintain good health insurance have already forgone higher wages in lieu of that insurance. To propose that they take a cut now, essentially to bail out employers who have shirked their responsibilities, is not only unfair, it is politically untenable. No matter what proposals come out for universal health care, the insurance lobby is going to spend tons of money on television and radio advertising to scare voters out of supporting the plan. Why give them a good, scary issue? Perhaps I see this more clearly as a union organizer. During a union recognition vote, an employer campaigns to convince his employees to vote against forming a union. The employer never campaigns on his issues – his need to maintain “flexibility” and the ability to freeze or cut wages, increase hours and lay off employees as he sees fit – because these issues are obviously not in the interest of his workers. So, the employer instead campaigns on an issue that is in the interest of the workers: their paychecks. Every employer-run anti-union campaign makes union dues a main focus. The insurance lobby is not going to campaign on its need to maintain profits at the expense of people’s health, but they will campaign on issues of costs and taxes.
Wisconsin, like any other state, is limited in terms of its options for new revenue, so a payroll tax (the burden of which falls inordinately on working people) is one of its few options. The federal government, which ultimately should take up the responsibility of a universal plan, has many more equitable options. To fund a “Medicare for All” plan, Congress could and should implement a payroll tax on employers. But Congress could also repeal the Bush tax cut, which mostly went to the wealthy, or increase the capital gains tax, which is how the wealthy get obscenely wealthy. Congress could probably find enough money to fund the program in the billions that are currently being blown to smithereens in Iraq.
As Dr. Fein, of PNHP, remarked at the conference, a long-held saying in the movement for national health, has been “don’t let the perfect be the enemy of the good.” Meaning, don’t let our pipe dream of single payer health insurance stand in the way of a compromise that we can get now. Now, with health care reform definitely on the agenda, it’s all the more important to hold firm to our convictions that single payer health care is not a pipe dream. It is not merely a wonky distinction between a bunch of “equally good” compromise plans put forth by the candidates. It is the only plan that can coalesce and maintain a coalition of unions, community and advocacy groups, healthcare professionals and taxpayers that can survive the barrage of attacks that any plan – good, perfect or terrible – will inevitably face from the merchants of death in the insurance lobby.
Do You Know What It Means To Miss New Orleans?
I saw a street car crawl down Canal Street today. It was the first operational street car I’ve seen in the streets of New Orleans since I’ve been here. I also saw a garbage truck collecting trash in the French Quarter late last night. These are the signs of progress in post-K NOLA. Only a Bourbon Street tourist, or someone (like me) who has been away for nine months, could appreciate the little bit of progress that has been made in New Orleans’ recovery from the storms and floods of 2005.
The Lake Shore neighborhood, for example, has seen relatively little change since Katrina. Before the storm, this was a prosperous middle class neighborhood of lakefront property. Then the lake flooded. These are people with money and insurance, so even if the FEMA money hasn’t arrived, they have the means to rebuild. Entire blocks in Lake Shore are renovated and back to normal. But these are generally on the high ground. Most blocks look like they did when the waters receded. Some houses were torn down, some gutted and some remain abandoned. Packs of wild dogs – formerly beloved pets – still roam the streets and menace passersby. The streets have no names. The storm blew away traffic and street signs, which have yet to be replaced. It is all too easy to turn the wrong way down a one-way street. Take it from me, don’t try this at night.
In Broadmoor, a teacher who is still living in a trailer on her front lawn for another week or two gave me a tour of her work-in-progress house. Her house was partially gutted. The drywall was stripped off only about a foot above the high-water mark – basically half-way to the ceiling. Her day labor repair men (the joke in New Orleans is that FEMA stands for “Find Every Mexican Available”) did a fantastic job of seamlessly matching the new drywall to the old. With a fresh paintjob, you can hardly tell what happened. In some rooms, the wood floor didn’t even buckle, so it was sanded down and varnished and looks good as new. A marble-top kitchen counter here, and a light switch plate there and she’ll be ready to move back in to her home. One or two other trailers dot the street, which is otherwise back to normal, save for the house directly across the street, which is decrepit, abandoned and still bears the dated neon orange “X” put there by the relief workers who searched for survivors or bodies.
Across town, in Metarie, I caught a brief set by the Brooklyn band Matt and Kim at a house party. This house, too, was practically gutted, except the walls remained stripped to the high water mark, exposing the building’s wood frame and allowing the punk rock sounds to waft through the neighborhood. Someone called in a noise complaint to the cops and the National Guard responded! It’s some real Wild West shit out here. At least Matt and Kim got to play “Yea Yeah” before they shut down the party.
There has long been a sign in restaurants and bars here that said “Be Nice Or Leave.” This time around, there seems to be a recognition that it’s time to “Rebuild Or Leave.” Gone are the heady days when the local mantra was “Rebuild It Better.” This is a city that desperately needs to be elevated a good ten to fifteen feet, to create proper sewers and storm drainage, the smooth out the roads and provide a little breathing room for global warming’s ocean elevation changes; a city that desperately needs taller, stronger levees. And this is a city that seems resigned to the fact that it ain’t gonna get those things so it better get on with the task of rebuilding.
The impetus to rebuild is obvious to anyone who has spent enough time in this city to fall in love (basically, a week). This is the most unique city in America. That is, this city is the least like the rest of America than any other great city in the U.S.A. Something about the weird confluence of French, Spanish, Mexican and Southern influences. Delicious foods, beautiful architecture and exhilerating music.
It almost feels like the haphazard rebuilding process (aided and abetted by the Bush administration and the banks and insurance companies) was designed to preserve the prickliness of this city. Expand these narrow streets, raze these balconies and porches, replace these restaurants with corporate chains and mute this raw racial discourse and you’ll make this great city a lot more like everywhere else. No thanks. It takes a special kind of lunatic to live in this city. Be nice, or leave.
Health Care’s “Death Spiral”
In “Uninsured in America,” Susan Starr Sered and Rushika Fernandopulle attempt to find out “where the bodies are buried” in our health care system where over 45 million people have no insurance. The book is a patchwork of profiles of people who got sick at times when they lacked insurance and the often devastating effects this had on their lives. The authors, who describe this phenomenon as the “death spiral,” don’t find so many bodies buried (although they do find many in jails or on the street) but they do find health problems that are allowed to become critical before state assistance will kick in and doctors actually pay attention, and emergency rooms used as primary care resulting in crippling debts.
Without getting bogged down in dry facts and figures, the authors provide a pretty good understanding of how the number of uninsured Americans hides how many Americans are functionally uninsured, covered by plans that have expensive premiums, deductibles and co-pays, that refuse to pay for the very “pre-existing conditions” that people most need health care for and slipping in and out of the patchwork system of Medicaid, charity, clinics and emergency rooms.
The book reminds me of an experience working for the health care workers union, doing community organizing among poor souls on Long Island whose medical debts were referred to collection agencies. Although the non-profit hospital where they went to the emergency room was required by law to provide a certain amount of charity care, these patients were never informed of the option to apply for the charity. Instead they were treated, charged tens of thousands of dollars that they could not possibly afford and had their lives turned into nightmares of bill collectors, bankruptcy and foreclosure. One family actually had good health insurance won through a union contract, but a bureaucratic error at the hospital resulted in the patient – not the insurance company – being billed. The insurance company and the hospital fought, refusing to admit error, and the hospital simply referred the matter to a collection agency. The rest of the people had no insurance. A surprising number of them had children with asthma who had bad attacks that required a visit to the emergency room. Just like that, the family became poor.
This patchwork system results in poor health care for all of us, I think. I hate going to the doctor with any kind of health complaint. I never get any kind of satisfying diagnosis. Usually, the doctor just guesses at a diagnosis and prescribes some kind of medication, without running any tests, and there’s no follow-up. I think the paperwork and bureaucracy is too much of a hassle. Fortunately for me, if my doctors miss something big, the care will be paid for by insurance so I won’t have to wait until I get so poor and so near-death that the state will finally pick up the bill, like the people profiled in “Uninsured in America.” Of course, why would I really want to push for tests that would confirm a medical condition, if that will only be used against me in seeking insurance in the future?
Why No National Health Care?
The United States has the best health care that money can buy, provided one has the money to buy it. Jill Quadagno’s “One Nation Uninsured” answers the question “Why the U.S. has no national health insurance.” It’s a brisk, engaging read that neatly summarizes how 90 years of failed reform efforts have entrenched the powerful interests that profit from the system.
The most prominent early opponents of a national health service were the doctors themselves. Their lobby, the American Medical Association, fought against “socialized medicine” out of fear that it would lead doctors to lose their sovereignty to bureaucrats basing decisions on budgetary needs rather than medical needs. Allied with southern politicians who feared that a federal health system would force racial integration of hospitals, these forces successfully kept national health care out of Roosevelt’s original Social Security legislation. They favored market solutions like Blue Cross and commercial insurance. A new business was created, resulting in a more powerful lobby.
The trade union leaders of the time, many of whom were social democratic in their outlook, reluctantly shifted their efforts at creating a social safety net to the bargaining table, winning employer-sponsored health care plans. Some unions – notably Sidney Hillman’s Amalgamated Clothing Workers – created their own networks of health care clinics, socialized medicine in miniature. Wartime government policies that encouraged fringe benefits over wage increases greatly expanded the private welfare state so that by the 1950’s, most large employers (including non-union firms that aimed to remain non-union) provided health care benefits.
Trade unions continued to push for a government solution to health care, but by the 1960’s they narrowed their focus to the proverbial “camel’s nose under the tent,” health insurance for the nation’s elderly. The Medicare program that the coalition of labor and seniors won had several unintended consequences. One was that with senior citizens covered through the program, and most working families fully covered by an employer’s plan, few voters clamored for a universal national health care system for the next few decades. Another consequence, happily, was the racial integration of most hospitals, under threat of being denied Medicare funding.
A regrettable consequence of Medicare was rampant inflation of cost of health care. Doctors and hospitals provided comprehensive care for senior citizens, ordering tests, procedures and drugs that they might not have before there was guaranteed funding, which was a boon not only to the health of senior citizens but to the corporate bottom line of the for-profit hospitals and insurance companies that joined the market for health care services. The cost of Medicare skyrocketed, until government efforts to control costs caused insurance companies to simply pass on the costs to employers in the form of higher premiums for their employees. Companies responded in turn by cutting benefits, introducing co-pays and turning to health maintenance organizations to control costs by denying care. The doctors’ worst fear, losing sovereignty over medical decisions, was realized through the insurance companies that they were responsible for creating.
This brings us to our current circle of hell, where an employer’s threat to cut benefits leaves many unions close to helpless in contract negotiations, where people with the dreaded “pre-existing condition” are denied meaningful coverage and where the existence (or non-existence) of national health care or employer-sponsored insurance goes a long way towards determining a company’s competitiveness in the global economy.
This January, I’ll be taking an elective class with Dean Robinson that will be exploring the United States’ lack of a national health service and its impact on our health, wealth and democracy. Quadagno’s “One Nation Uninsured” is the first book assigned. Others are Kawachi and Kennedy’s “Health of Nations: Why Inequality Is harmful to Your Health” and Sered and Fernandopulle’s “Uninsured in America.” For my paper, I will be taking a look at some trade union health clinics, particularly the Amalgamated’s (now UNITE HERE) and the NY Hotel Trades Council’s, which was inspired by Hillman’s example. These socialized medicine-in-miniature not only provide comprehensive health services, but they keep costs so low that employers actually offer up concessions in order to take part.
The lesson here, I think, is that while we might succeed in creating a single-payer health care system like Canada’s (particularly as health care becomes more of a crisis), inflation and price-gouging will be crippling until we take the profit out of the system and nationalize health care services to serve the interests of the people, not the corporations.