I hope we have the will to change things, but as you point out the whole system is so fragmented, it is hard to even identify all the players. One thing that never gets mentioned, is that even with government funded single payer insurance, private health insurance will not go away. I think we need to stress that for those that can afford it, it will still be available. I wouldn't mind knowing what is going on with private insurers in the UK and Canada and how that fits in with their systems.

Maggie,

It's very convincing. But tell me if I'm wrong about the reality on this front:

It's a fight that's going to be had on both the state and federal levels, no matter what. The federal debate will be a long one. States, antsy to get something done, will try their own programs in the meantime. Maybe we should accept the fact that there's no way to stop that.

Here's one thing that would be worrisome, though -- say a state implements a plan that's really popular among its residents. Then the feds come up with something. It's popular nationally but not in our hypothetical state. Will that state fight the national plan, even in court? Will people in other plans not support the federal plan because some state is doing it better?

I'm sure that reformers will be working at all levels. I think that means we're in for a big local vs. federal fight.

thosethingswesay.blogspot.com

I have to say that this post was very informative, and included a lot of good factual information, but I find the rhetorical push wanting.

As I see it, Dr. Mahar starts by making a number of good points as to why health care reform is needed in general, and I'm certainly not going to argue with those. She then, rather obliquely, slides into why it has to be national:

First, individual states don’t have the clout needed to negotiate discounts with drug-makers --or to prevent insurers from dropping patients once they get sick.

I'm sympathetic to this argument, because despite what Sallie Marston says (sorry, geography inside joke), scale does matter. However, there is nothing that says that states which implement similar systems can't band together for additional bargaining power. They do it with Powerball, why not here?

Secondly, as the dismal history of Medicaid shows, poor states simply don’t have the money needed to provide access to quality care. We need national insurance—with everyone paying into the same pool-- so that wealthier states can help those that are poorer.

From a pure public policy level, this makes sense, but when policy hits politics, I think it frequently breaks down. When one is looking only in the world of health care, sure it makes sense that poorer states will be thrilled to have their health insurance subsidized. But history of similar programs shows that owing to the complex political economies of local politics, these federal income sharing programs paradoxically generate political animosity in poorer states. The standard way for the nationally-focused left to respond to this is to grouse about people "voting against their economic interests," but often times at the local level, these individual decisions make perfect sense, simply because the national effect of subsidized whatever gets washed out by local effects when it comes to the individual.

And aside from that, talking about "poor" states is really a misnomer. There are really a very small handful of states (I'm thinking 4-5 at most) that really lack the resources to at least implement some level of substantial health care reform. I'm writing from North Carolina, the 40th ranked state in median household income, and I don't have any trouble imagining statewide health care programs that radically improve care in this state. In fact, North Carolina has done just that several times over the past couple of decades. (It helps still having a state government dominated by Democrats.)

But when it comes to designing and delivering healthcare, it’s not just poor states that fail. In April, Public Citizen Research released a report which demonstrates just how inadequate state-run Medicaid programs are.

I don't get this particular one. Every state in the country has problems with its Medicaid programs -- fine, I buy that. But what is it about a national program that would make all of this better? I'm not making an anti-Washington argument here, but I fail to see the pro-Washington argument. More on this below...

Maybe states will do a somewhat better job when trying to fashion a healthcare system for the entire population—and not just the poor. But conservatives will use any short-comings (and believe me, there will be many) as evidence that when the government gets involved in healthcare inevitably, it fails.

This is the argument that makes the least sense to me. First of all, it's a defeatist argument. I'm sick of progressive policy makers putting their tail between their legs and sulking off whenever a conservative says something nasty about them. Or worse, they get red in the face and the spittle starts flying. Look, rhetorically defending these programs is part of politics in a democracy. Any program has to be rhetorically defensible. Sniffing that politics should be left out for good policy is, frankly, anti-democratic and elitist. When it comes to something as touchy as health care, whatever your policy is, you'd better have a plan for how you're going to defend it.

But more importantly, while I've noted that scale matters above, the underlying assumption here is that when things get to the Federal level, something magical happens with politics and funding. But the political will for health care reform at the national level is exactly equal to the sum of the political will in all of the states together.

From the cuts and bruises I have from political fights in local politics, I tend to feel that programs ought to be implemented at the lowest level of government possible. Local programs have a number of advantages over broader ones, largely owing to the increased connection each individual voter feels to the process. This means that those programs are far more sustainable -- you may criticize Medicaid, but If there's a good argument for kicking it up to the next level, fine, But I don't see that for health care reform. I'm with Nathan Newman on this one.

The difference between you and Randy lies in his belief that the monied people will Swift Boat health care, the way that the civil war in Iraq has become a war against Al-Qaiida, which it clearly isn't.

Republican has shown a genius for making things into their opposite, the media has swallowed it line, hook ans sinker. I am worried.

I think it will take a crisis to trigger anything at the national level. And no, despite the awful state of American health care, we have not yet reached crisis levels. The average American is totally oblivious to the true cost, and terrible waste, within the system because they are subsidized by their employers.

Corporations, who created the mess by subsidizing health care years ago in order to prevent the emergence of community/state/national plans, are now weighed down and send jobs abroad to avoid the cost. Yet as long as they still subsidize their remaining employees the average voter is protected from reality.

A second issue is that most Americans still cling to the belief that anything American must, by definition, be superior ... just how receptive would they be to being told that the French [gasp!] arguably have the world's best health care system. It just seems so "un-American" to rely on the state for anything: the ideology that the "market knows best" is deeply ingrained here and provides fertile ground for resistance to anything vaguely social.

Mix these two things together and we have a recipe for fear ['I sense something is wrong but don't quite know what it is'] without hope ['no one else has fixed this so we'll have to live with it'] which makes for the kind of volatile and populist politics that produces little result but muddies the waters.

The fact that huge numbers of our fellow citizens have no coverage does not sway voters because they are fearful of the cost burden of a new, and by definition massive, social program.

So not only is the burden on reformers to prove the system isn't working, but we have to prove also that the social programs work and are more efficient than markets in some cases.

Good luck! As I said I think it will take more of a crisis to break the dam.

'All Life is Problem Solving'

I'm hopeful too--though I think it may take a little longer, say the end of the next president's first term.
It's very important that we do it right.
If we let private insurers, drug makers etc. hi-jack the plan (in other words if we compromise with them) we'll wind up with a
system that is just as wasteful, just
as unaffordable, and just as inequitable as what we now have.

Michael--
Thank you for the long, thoughtful post.
It raises interesting points, and I
want to do justice to it in my reply.
Unfortuantely, I have to run right now, but just wanted to let you know that I'll come back to it (and other interesting comments on this thread) a little later.
mm

By the way, a little history might help.

The Interstate Highway System was the largest public works project in US history at the time.

FDR proposed it, to spur commerce. His idea was to make it self-funding, via eminent domain buyout of a 2-mile wide band of frontage, which would be resold to retail businesses at a profit.

Single payer could also be sold as a boost to commerce. Think what will happen when US businesses can again hire workers, and compete with foreign competition, without the burden of employer-funded health care? I don't hear much talk of this, but I'll betcha FDR would have talked about it.

I find Maggie's post compelling. I don't see it as dumping on state efforts, and I found that really an annoying straw man, in fact, in Nathan's post. The point is rather to seize the moment, with growing national support, and work for a national plan. Absent that, local failures will spoil the moment, rather than build toward success.

Nathan's arguments have a slippery feel to me, too, because they rely arbitrarily as the need arises on the success or failure of local action. Want something done? Go to the states! Want something done nationally? Well, let state programs bomb, so that businesses will press harder for a national plan! There may be truths buried in this, but it's a sleazy argument.

Michael does something similar. We shouldn't worry about failure at the state level, because that's cowardice. But we should worry about national opposition. Cries of "that's cowardice" are always ugly, from Iraq to the domestic realm. But it's surely not cowardice, not when the GOP has consistently used their own bad government to justify hatred of government the keeps them in power, in a vicious circle. 

The problem of opposition in poorer states, raised by Michael, shouldn't hide that richer states, too, go through periods of shortfalls and must balance budgets, as K. Drum notes.

And generally we have a cost containment problem aside from a serious problem of inequities on which we all agree. The elimination of private insurance, as Maggie often points out, is only part of the first problem. That is, the administrative costs are huge, and we can hope to drive them down slowly by giving people the option to chose the government program and by forbidding insurers to maintain the rules, of denying care, that rely on such administration.

However, there's also the problem of a system that rewards the most costly health care. That won't change easily. Even with universal health care, it'll inherit a lot of awful precedent and practice, including financial pressure from hospitals themselves, for inertia that European programs didn't face. That means higher costs in the foreseeable future, and it can lead to failure. But I'd rather see a federal system here simply because I think it has the best shot at having across the board reimbursement guidelines. So that's another reason state programs alone might end up in trouble.

Also, Michael's argument that the political will is the sum of the local political wills is both false and hardly in accord with the the whole system of federal government. If we thought states were enough to express the popular will, we'd have left the Articles of Confederation intact. And it's factually wrong, when there are so many states not acting, so much public anger, and so many presidential candidates making this a core issue for their campaign.

To me, all the evidence and arguments Maggie has laid out are important, but it's stark enough just in layman's terms. I'm not willing to wait for 50 states to pull this off, any more than I want to roll back Roe v Wade on the grounds that local action is more godly or that I'd like to be sitting here now waiting for Medicare or social security to exist in all 50 states if the nation hadn't acted long ago. Or sure, Nathan's right to talk about a history of state movements even in civil rights. But can he conceivably be denying the huge difference the LBJ laws were? Is he too young to know what "states rights" were a code name for?

So sure, everyone push for what they can, nationally and locally. But don't go proclaiming how the plea for universal health care is misguided and any less pressing. When I hear that from Nathan, I can't help wondering if he's just unwilling to let go of a status quo so depending on employers, lest his movement lose an essential draw to potential members in unionizing. That's great, as I want unions to grow, but if it throws me on the junk heap, I'm unhappy.

John

http://www.haberarts.com/

By the way, how many of us remember way back when, when notions like preemptive war would make a decent American shudder, and couldn't even be imagined to be associated with the United States of America, except as its victim?

That's been not even a decade ago, by my recollection.

A big part of Orwell's point in 1984 is how quickly and dramatically the vocabulary, not just of words, but of ideas, can change, and that changing words, strange though it may seem, is key to changing ideas.

The only way to make socialist ideas broadly acceptable is to make the idea of, and the word, socialism, broadly acceptable.

repeats above--sorry

Michael--

First let me admit that I'm always a little wary of what you term "rhetorical push." I believe that persuasion should rely on substance, argument, and passion--not rhetoric.

So let me try to address the substance of your arguments--
On states "banding together" I really don't think you realize how powerful Big Pharma is. It has backing from Big Money-- powerful Wall Street investors who appreciate the fact that , on average, it has been the most profitable industry in the country for many, many years.

Even when some of the largest hospitals in the country have banded together, they can't get reasonable discounts from Big Pharma.

The only entity that has succeeded is the VA--the largest healthcare provider in the country.

Medicare has the clout to do it, but the Bush administration made sure that the msot recent Medicare bill explicitly prohibited Medicare from trying to get discounts. Why would the administration want to call attention to the embarassing fact that, unlike every other government in the developed world, we don't even attempt to negotiate? Because conservatives were concerned that drug prices had gotten so high--and Medicare was under so much financial pressure--that Congress might now be willing to to give Medicare the power that it gave to the VA.

On the road to national health reform, I think that this is one of the first bills that might pass in a new administration.

On poor states. See the Medicaid report that I referred to: it defines "poor states" by median income. Using that definition, you'll see the poorest states also have the poorest Medicaid programs.

States often object to federal welfare programs because people see them as entitlement programs for the very poor, or minoirities--not the middle class. A federal health care program that covers everyone is likely to be as popular as Medicare. (The only states that objected to Medicare on the grounds that it was a federal program were Southern states that feared Medicare would force integration of hospitals. Which it did.)

Why do even relatively wealthy states have such a hard time funding Medicaid? Because they can't run deficits and are not very good about building up reserves during boom years. (While at Barron's I wrote about state economies and finances and am painfully aware of how states operate.) When the business cycle turns, they find themselves short of cash-- and Medicaid and Schip are among the first places they trim.

The federal govt, on the other hand, can run a deficit. I'm not a huge fan of deficits, but they have a purpose. In this case, the ability to run a deficit means the federal govt could sustain a national heatlh care plan even in lean times--until the savings begin to kick in.(See my comment on Nathan's second post above)

By the way,part of the savings will come from electronic medical records--and ultiamtely heatlhcare IT will need to meet national standards. We don't need regional or state by state IT. Think of the early history of cell phones in this country.

On the points in your last couple of paragraphs-- they seem to be going off on a tanget that I can't quite relate to. I'm not sure how they apply to my argument. But Jhaber does respond to them in his comment below.
Again, thanks for taking the time to think about all of this.

Another thing we need is a program to challenge this "gang" at the primary level and get rid of them! They're no use to us as progressives and they make it impossible for Democrats to "brand" ourselves in support of any progressive agenda.

As “Unsettled Scores” points out, a pregnant woman in a family of three needs to have an annual income of less than $22,128 in order to qualify for Medicaid in Wyoming, while her Minnesota counterpart can be covered with an income of up to $45,650.

I'm impressed and convinced (that didn't take much) by the entire column.  The paragraph I blockquoted struck me because it called to mind another situation which seems to have interesting parallels.

I'm not a specialist in history of medicine or medical economics.  But I do know quite a bit about labor history, the history of unionization, and history of regulations involving occupational safety.  I think what I want to say boils down to this:  Capital is a lot more fluid than labor.

The parallel I see begins with the situation after the passage of the Taft-Hartley Act, especially section 14(b), which allowed individual states to enact "Right to Work" laws.  This was perhaps the greatest defeat organized labor ever had.  If one looks at the map in the Wikipedia article I've linked to above, one notices a few things.  Wyoming is a "Right to Work" state.  Minnesota is not. 

If we look at a table of Comparative Infant Mortality, States with "Right to Work" laws generally have higher infant mortality rates and states without "Right to Work" laws, generally have lower infant mortality rates.  While it takes a while to ferret out the statistics (a neat project for a graduate student, not an old history professor) the website Trust for America's Health is fascinating for anyone interested in public health issues.  It allows one to pick a state and track the health of its citizens.  Again, comparing the map of "Right to Work" states against the rest, the pattern seems to hold true. 

If we look at income disparity, the same thing.  If we look at industrial decline,--well, "ay, there's the rub".  Following World War II New England de-industrialized and cotton factories fled to "Right to Work" states.  Hard to remember that, while globalization completes the de-industrialization of the United States.  One could argue that the shape globalization took (this is not an anti-globalization screed) was affected by the weakness of the labor movement caused by "Right to Work" laws--which set labor policy at the state level (Bill Clinton's Arkansas is a "Right to Work" State). I've very carefully put "Right to Work" laws in quotation marks every time, because this is precisely the kind of re-framing reflected in calling Inheritance Taxes "Death Taxes".  Ugh!  Will we ever learn?

But I digress.  Here's my real thesis.  Localizing policy issues can start a rush to the bottom.  Labor history shows this.  Health systems cost money, lots of money.  The money needs paying by someone.  The same corporate forces which augmented their profits by fleeing unionized states first, and the United States altogether later, will  endanger the Progressive States unless health policy, including health insurance policy, is set at the national level; establishing an even playing field. 

aMike

p.s.  Why are the Progressive States progressive?  Because they're union-friendly.  Without "Right to Work" laws, progressive policies are much easier to pass.

I wouldn't define it as socialism because I don't really agree that is what is going on here. We have a mixed government and the mix has become dysfunctional since government has been hijacked by the radical right. We've always been a country where a community might band together and build a school, or a hospital or a college or a library. There's nothing whatever new about any of that and it need not get in the way of capitalism either. If you can build a hospital in common why can't you allow people to use it in common? The really strange part of the system is insurance. It really isn't necessary. It is just an accident of history that insurance got in the middle of medicine. It's not even a very long history. Modern medicine is relatively new and so is health insurance. Why it's become a sacred cow after such a short life is owed more to marketing and lobbying than ideology.

Re: When interests rates return even to historical levels (which will then only be a brief stop on the way to historical highs) deficits will become an even bigger problem.

The Bush tax cuts are due to sunset soon. While Congress may keep some of them (the middle-class friendly ones) by and large we will be returning to the tax regieme of the 90s. Will this not also mean we will have less need of Chinese or other financing from abroad? Also, everyone seems to forget that public financing of most healthcare would also mean an end to private financing of most healthcare, so overall we would not be engaging in new spending but simply shifting an existing spending flow. Finally, I see no evidence that interest rates are going to be going either up or down in any significant way. They seem to have found a stable set point (which is close to their historic norm, excluding the high-inteest 80s from the mix) and I expect them to fluctuate around that set point for the foreseeable future.

aMike--
I couldn't agree more. All of these things correlate--right to work laws, whether a state is willing to take care of its poor, whether it is willing to take care of its sick etc., etc.

Minnesota is an exceptional state in many ways. It's part of what many health care experts refer to as "Canada South"--which includes a chunk of the Northwest as well as northern New England (north of Massachusetts.)

At the other end of the spectrum, states like Texas, Florida . . . all of the states that rank in ten or twenty in the Medicaid study. And it is much easier for conservatives to pass legislation in these that would never, ever pass Congress.

Healthcare is too important to leave to the discretion of the states. Both Schip a Medicaid have suffered because many states simply refuse to come up with their share of the funding. Conservaitives took over teh Schip legislation and purposefully made it block grant law so that it would be up to the states whether or not they provided care for poor children.

At one point, Florida has so many children had so many children on its wait list for Schip (children who qualified for the plan, and in many cases were sick) that it made the papers, and became a huge scandal. So what did Florida's legislators do? They abolished the wait list. Now no
one knows how many kids in Florida qualify for Schip and aren't getting the benefit.

Gilberg Wesley Purdy--
You make a number of excellent points.
First, states are going to be wary of driving businesses away (particularly medium-sized business that do not now provide healthcare benefits) if they burden them with the cost. They are much more likely to put the burden on the indivdiual-and then let insurance companies sell them low-cost policies that are nearly worthless in terms of what they cover. But then the state can announce: "Everyone's covered."

You are also right that currently, other countries are subsidizing our debt by buying our Treasury bills--even though the dollar is falling in value (which makes our
Treasuries less valuable.) But already China is beginning to pull back, as will other countries.

At that point, the only way to entice foreign investors adn countries to keep buying U.S. Treasires will be to raise the interest rates that Treasuries pay--which will make it all the more expensive for us to carry our debt.

So I, too, am concered about the deficit. That said, I think you are wrong about one thing: long-term (or even medium term) national health insurance does not have to add to the deficit.

Right now, many, many health care economists agree that one out of three of our health care dollars are wasted, year after year, on over-priced drugs and devices, unncessary treatments and hospitalizations, redundant tests, etc. That's $600 million a year, year after year.
Part of the problem is that, in our profit-driven heatlh care system, everyone is selling, and selling hard. And when it comes to healthcare, supply drives demand. (I've written an article about this in "Dartmouth Medicine" which you can find easily by just Googling my name and "Dartmouth Medicine" "Spring 2007." It's the best thing I've written since the book. )

There is more than enough money sloshing around in the system to cover everyone with good comprehensive insurance. Think of it this way--other developed countires manage to cover all of their citizens and provide as good--or sometimes better--care than we do at an average of half the cost. Why couldn't we do it at an average of 66% of what we are spending now? A combination of consolidation--and standing up to the interests that are over-charging us is "all" we need to do. I

I realize it's a lot to do, but it's something every other developed country has done. Why can't we?

(I think of that point in time, in the 19th century, when we insisted that we couldn't abolish slavery --even though the U.K.
and other countries had--on the grounds that "it's different here. We have to have the slaves--that could never happen here." )

OF course, if we reform healthcare we will not reap those savings all at once. But a universal heatlh plan can cut the waste--just as the VA has (the VA provides excellent care at about half of what Medicare spends.)

Finally, conservatives who want to privatize Medicare and Social Security constantly talk about the crisis we'll face when the baby-boomers age. But as Princeton economist Uwe Reinhardt points out, they are not going to age all at once. We're talking about a generation born over nearly two decades. We're not going to wake up one morning and find the streets filled with little old ladies.

Moreover, upper-class and upper-middle class boomers are going to age very, very slowly. All of those people who started jogging in the 70s, also gave up somking, and meat. In the 80s and 90s, they joined gymns. By and large, today they are in very good health for their age.

Less wealthy boomers--who can't afford a gym, didn't have time to jog, and live in communities where everyone eats meat,plus lots of carbs-- are not in such good health. They will age sooner. But when you step back and look at the big picture, you see the two groups aging at a different rate over a period of perhaps 40 years.

It will be a surprisingly gradual process.

Exactly. Everytime someone says, "But Americans will never accept government-controlled medicine," I say "We already have government controlled medicine. It's called Medicare."

Re: So what did Florida's legislators do? They abolished the wait list. Now no
one knows how many kids in Florida qualify for Schip and aren't getting the benefit.

Yes, that was a scandal, and it can be laid at the feet of Jeb Bush (everything that family touches turns to dung) and a legislature that should have been voted the national laughingstock. (We Florida residents could tell tales that would amuse and appall. Even the rightwing papers down here were outraged by the 2003 legislature's ghastly performance)
Serious efforts are being made now to fix the problem. The legislature is still a bit out to lunch (though thank god for term limits! the worst clowns have had to retire) but the new governor, that rarest of creatures, a common sense Republican, is learning how to crack the whip in Tallahassee and expanding healthcare coverage (for everyone not just children) is high on his agenda. I actually expect Florida, which is not really, or at least not entirely, a Southern state, may become one of the innovators in this area in the next few years.

By the way someone suggested that states might satisfy themselves by requiring individuals to buy worthless policies. But would that be in the states' best interest? Who would pick up the tab when people overran their policy limits? While it would not surprise me to see some states allow high deductible/HSA combination I suspect that self interest would force the states to require pretty much 100% coverage at the major-med or catastrophic level.

Maggie Mahar

I stand with you

Let me know how I can help recognizing my long term goal is prevention

Be Well,

Dr.Rick Lippin
http://medicalcrises.blogspot.com

You've been blogged!

Just wanted to let you know that this article has been covered on the Health Care Reform Now! blog, a companion to the new book by George Halvorson.