"What will it take to achieve real health care reform?"
Richard Kirsch, Executive Director of Citizen Action of New York has written an insightful, detailed analysis "If Wishes Were Horses: The False Promise of the Massachusetts Health Plan." Especially because the Massachusetts legislation was widely hailed across the country as a 'miracle' and a 'model' of bipartisan cooperation, as well as 'universal health care' and a 'solution,' etc., thoughtful criticism of the plan helps us all; I hope people take time to read it closely.
Kirsch dissects the Massachusetts plan thoroughly. He identifies the provisions that will help the poor, aspects we should celebrate, and also exposes the roots of the "false promise." He places the plan in contemporary context and reviews the history of similar efforts as well his own efforts in New York. He offers his honest reflections and recommendations.
Yet Kirsch discounts, rather than returning to embrace, the single payer national health insurance proposal. He resurrects the phrase that single-payer is not "politically feasible," which is by now an old saw. But where this once sufficed to dispense with the idea, and thus ignore it, discussion of a public national health insurance system can be dismissed no longer. We see this when Kirsch asks:
"If the fundamental flaw in the Massachusetts plan is that it maintains the private insurance system and accelerates the pressure toward consumer driven health care, does that mean that the only solution is a national health insurance plan?"
Significantly, he answers his question by striking a reluctant, not dismissive, chord: "Not necessarily." Kirsch elaborates:
"The advantages of single-payer are clear and go well beyond the elimination of excess administrative costs that is too often the prime rallying point of single-payer advocates. National health insurance provides the basic structure for universal coverage: everyone is automatically covered in one large pool. It provides the tools for systemic affordability: setting prices; controlling supply; limiting out of pocket costs; directing funds towards high quality care. But these goals, all of which stem from the concept that health care is a public good rather than a private commodity, can be achieved in various measures with systemic changes that don't require a single-payer system."
And yet, while Kirsch acknowledges crucial strengths of the single payer proposal, he retreats to a position in defense of private health insurance:
"So in proposing a public program that fits the American experience, and therefore has some chance of becoming law, I recommend a system that utilizes Medicare and regulates private insurance. Under such a system every American would be guaranteed health care from Medicare or private insurance."
Is this really how we might avoid "more false promises" like the ones in Massachusetts? Even in the best case scenario, won't the preservation of our private health insurance corporations lead to more health care injustice, with inequalities of care accelerating, polarizing and ultimately crystallized in a two-tier system? Can the American profit-driven health insurance industry really be regulated into treating health care as a "public good?" If that were to happen, wouldn't that industry, at least as we know it, cease to exist?
In other words, if one sees, as Kirsch does, that selling health care as a private commodity is a fundamental flaw for social policy, as it is in the Massachusetts plan, then it really is time to come back to single-payer. There is no right way to do a wrong thing.
Kirsch suggests that one can find examples of developed nations where private health insurance coexists happily alongside public health insurance, thanks to heavy government regulation of the health insurance industry. Besides the question of whether it might be "politically feasible" for American insurers to be regulated into changing their spots -- or perhaps their souls -- this idea seems, at best, lost in translation.
Mostly, "private" insurance companies in other countries are actually non-profit firms which are not only highly regulated but which exist only because government finds it advantageous, and efficient, to work through them. They are not politically powerful agents, as are insurance companies in this country. In countries like France private insurers are sidelined. In a few nations, like Switzerland, regulation means that the government has the power to dictate how much each insurer may charge for premiums as well as the amount of profit it may make on basic coverage -- none. In Britain, parallel private insurance spurs the underfunding of the NHS, undermining it. In Canada lately there is a lawn sign that sums it up: "Don't Privatize Medicare!" With Medicare "Part D" - D for debacle - those signs apply just as well here in the US. Like Medicare Part D, and just as Kirsch finds in the Massachusetts plan, for most developed nations, treating health care like a private commodity remains the germ of the problems.
This gets back to the point about what is "politically feasible." Consider what we're up against this way -- a profitable, powerful private insurance industry, alongside behemoth pharmaceutical and medical technology industries -- a three-headed Cerberus. Kirsch identifies what nourishes the monster (health care as a private commodity) as the source of our ills. He identifies basic health insurance coverage for all as the necessary next step toward reorganizing the American health care system along the lines of a public good. He then proposes, like Hercules at his twelfth labor, that if we keep private health insurance, there is a way to tame the beast and harvest from it the public interest. Well, OK -- but a great myth.
If Kirsch's recommendation seems logically contradictory, even more curiously, he contemplates the Herculean social force that it will take to change the American health care system in order to organize it around the best interests of its patients. Surely that force would be capable of delivering single payer reform. Even further in line with the single payer demand, he wants to see sweeping change, real strides instead of baby steps. Kirsch concludes transcendently, reiterating the theme of health care as a public good:
"What will it take to achieve real health care reform? It will take a major shift in the nation's politics. As long as our political agenda is dominated by the champions of privatization and the opponents of government regulation, we will have no chance of enacting reforms that realize the objectives of universal coverage and systemic affordability. Instead, we will get more false promises like that of Massachusetts, a law that has some positive provisions based on the concept that health care is a public good, but is flawed and doomed to failure by its core assumption that health care is a private commodity."
Ultimately, working my way through Kirsch's analysis seemed a bit like observing a dramatic exploratory surgery -- the sick patient rushed to the OR after failing medical treatments -- where the surgeon masterfully dissects, keenly exposes the malignancy, proposes the instruments to resect the tumor ... and then hesitates, wishing he could give the medications one more chance. Nevertheless Kirsch's closing words return to his deep conviction that the patient can be saved:
"There are no shortcuts. Wishing won't make it so. Winning real health care reform requires a clear vision, a persistent, strategic energy and a belief in the miracle of change."
A major shift in American politics is well underway. We should see the Massachusetts plan as a result of its shift, as well as a driver. Not a "miracle in Massachusetts" but a measure of a struggle in which real reform can be won -- a process that has the power to yield the "miracle of change." Massachusetts gives us a measure of acceptance of the idea that health care is a public good. That idea is winning the day. Yet Massachusetts also shows us that the insurers retain the capacity to hijack that idea, co-opt it and use it to reinforce the status quo.
The demand for single payer national health insurance -- which leaves no role for private insurance companies to treat health care as a private commodity -- is the clear vision with the strategic power to realize the change we all need.
Richard Kirsch, please come back.
Andrew D. Coates, MD
Kirsch dissects the Massachusetts plan thoroughly. He identifies the provisions that will help the poor, aspects we should celebrate, and also exposes the roots of the "false promise." He places the plan in contemporary context and reviews the history of similar efforts as well his own efforts in New York. He offers his honest reflections and recommendations.
Yet Kirsch discounts, rather than returning to embrace, the single payer national health insurance proposal. He resurrects the phrase that single-payer is not "politically feasible," which is by now an old saw. But where this once sufficed to dispense with the idea, and thus ignore it, discussion of a public national health insurance system can be dismissed no longer. We see this when Kirsch asks:
"If the fundamental flaw in the Massachusetts plan is that it maintains the private insurance system and accelerates the pressure toward consumer driven health care, does that mean that the only solution is a national health insurance plan?"
Significantly, he answers his question by striking a reluctant, not dismissive, chord: "Not necessarily." Kirsch elaborates:
"The advantages of single-payer are clear and go well beyond the elimination of excess administrative costs that is too often the prime rallying point of single-payer advocates. National health insurance provides the basic structure for universal coverage: everyone is automatically covered in one large pool. It provides the tools for systemic affordability: setting prices; controlling supply; limiting out of pocket costs; directing funds towards high quality care. But these goals, all of which stem from the concept that health care is a public good rather than a private commodity, can be achieved in various measures with systemic changes that don't require a single-payer system."
And yet, while Kirsch acknowledges crucial strengths of the single payer proposal, he retreats to a position in defense of private health insurance:
"So in proposing a public program that fits the American experience, and therefore has some chance of becoming law, I recommend a system that utilizes Medicare and regulates private insurance. Under such a system every American would be guaranteed health care from Medicare or private insurance."
Is this really how we might avoid "more false promises" like the ones in Massachusetts? Even in the best case scenario, won't the preservation of our private health insurance corporations lead to more health care injustice, with inequalities of care accelerating, polarizing and ultimately crystallized in a two-tier system? Can the American profit-driven health insurance industry really be regulated into treating health care as a "public good?" If that were to happen, wouldn't that industry, at least as we know it, cease to exist?
In other words, if one sees, as Kirsch does, that selling health care as a private commodity is a fundamental flaw for social policy, as it is in the Massachusetts plan, then it really is time to come back to single-payer. There is no right way to do a wrong thing.
Kirsch suggests that one can find examples of developed nations where private health insurance coexists happily alongside public health insurance, thanks to heavy government regulation of the health insurance industry. Besides the question of whether it might be "politically feasible" for American insurers to be regulated into changing their spots -- or perhaps their souls -- this idea seems, at best, lost in translation.
Mostly, "private" insurance companies in other countries are actually non-profit firms which are not only highly regulated but which exist only because government finds it advantageous, and efficient, to work through them. They are not politically powerful agents, as are insurance companies in this country. In countries like France private insurers are sidelined. In a few nations, like Switzerland, regulation means that the government has the power to dictate how much each insurer may charge for premiums as well as the amount of profit it may make on basic coverage -- none. In Britain, parallel private insurance spurs the underfunding of the NHS, undermining it. In Canada lately there is a lawn sign that sums it up: "Don't Privatize Medicare!" With Medicare "Part D" - D for debacle - those signs apply just as well here in the US. Like Medicare Part D, and just as Kirsch finds in the Massachusetts plan, for most developed nations, treating health care like a private commodity remains the germ of the problems.
This gets back to the point about what is "politically feasible." Consider what we're up against this way -- a profitable, powerful private insurance industry, alongside behemoth pharmaceutical and medical technology industries -- a three-headed Cerberus. Kirsch identifies what nourishes the monster (health care as a private commodity) as the source of our ills. He identifies basic health insurance coverage for all as the necessary next step toward reorganizing the American health care system along the lines of a public good. He then proposes, like Hercules at his twelfth labor, that if we keep private health insurance, there is a way to tame the beast and harvest from it the public interest. Well, OK -- but a great myth.
If Kirsch's recommendation seems logically contradictory, even more curiously, he contemplates the Herculean social force that it will take to change the American health care system in order to organize it around the best interests of its patients. Surely that force would be capable of delivering single payer reform. Even further in line with the single payer demand, he wants to see sweeping change, real strides instead of baby steps. Kirsch concludes transcendently, reiterating the theme of health care as a public good:
"What will it take to achieve real health care reform? It will take a major shift in the nation's politics. As long as our political agenda is dominated by the champions of privatization and the opponents of government regulation, we will have no chance of enacting reforms that realize the objectives of universal coverage and systemic affordability. Instead, we will get more false promises like that of Massachusetts, a law that has some positive provisions based on the concept that health care is a public good, but is flawed and doomed to failure by its core assumption that health care is a private commodity."
Ultimately, working my way through Kirsch's analysis seemed a bit like observing a dramatic exploratory surgery -- the sick patient rushed to the OR after failing medical treatments -- where the surgeon masterfully dissects, keenly exposes the malignancy, proposes the instruments to resect the tumor ... and then hesitates, wishing he could give the medications one more chance. Nevertheless Kirsch's closing words return to his deep conviction that the patient can be saved:
"There are no shortcuts. Wishing won't make it so. Winning real health care reform requires a clear vision, a persistent, strategic energy and a belief in the miracle of change."
A major shift in American politics is well underway. We should see the Massachusetts plan as a result of its shift, as well as a driver. Not a "miracle in Massachusetts" but a measure of a struggle in which real reform can be won -- a process that has the power to yield the "miracle of change." Massachusetts gives us a measure of acceptance of the idea that health care is a public good. That idea is winning the day. Yet Massachusetts also shows us that the insurers retain the capacity to hijack that idea, co-opt it and use it to reinforce the status quo.
The demand for single payer national health insurance -- which leaves no role for private insurance companies to treat health care as a private commodity -- is the clear vision with the strategic power to realize the change we all need.
Richard Kirsch, please come back.
Andrew D. Coates, MD
posted by Andy at Wednesday, May 17, 2006
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