A year ago health care was in crisis. Americans were dying at a rate of 45,000 per year due to lack of access to health care. Change was urgently needed. Because we have extensive experience with health systems, we could have had a very informed debate. The U.S. has a market-based system (private insurance-controlled health care), a single payer system (Medicare), and a socialist system (the Veterans Administration). We could have asked which worked best, which covered the most people, which was least expensive, and which produced the best health outcomes. This fact-based discussion could have resulted in an efficient, effective national health system, moving the U.S. up from its current dismal ranking of 37th in the world.
But that debate never happened. In the end, we got the pre-ordained decision: market-based health insurance was further enshrined with all its administrative and bureaucratic costs, its unfairness and inability to provide health care to all.
Over the last year, Democratic and Republican partisans in and out of government made the debate on health a misleading one. False distractions like "death panels" and "a government takeover" kept the right wing and Republicans fomenting and angry when neither was occurring. On the left, the public option, always miniscule and never really on the table, was the primary focus of non-profits aligned with the Democratic Party.
Republicans continue to proclaim socialism and a government takeover of health care, while Democrats are high-fiving each other and proclaiming they’ve achieved the equivalent of Social Security, the Civil Rights Acts, and Medicare. However, when the fog lifts, we will see the system has not changed much: health care will still be dominated by profit-driven insurance companies; more public money will go to executive salaries and private industry profits; tens of millions of people will remain uninsured; and costs will continue to increase.
The centerpiece of the reform—subsidizing the insurance industry, forcing Americans to buy their overpriced product, and more deeply embedding the insurance market’s control of health care—was barely debated. Only after passage of the bill is a debate beginning on whether this is within the constitutional power of government.
Of course, the corporate media are behind it, not surprisingly since it is in the interests of corporate power. But never before has the federal government required Americans to buy a product. Where does this precedent lead? Should Americans be forced to buy a retirement plan from JPMorgan or Bank of America to ensure retirement security?
The U.S. already gives hundreds of billions annually in corporate welfare through crony capitalism, disguising it with "free market" rhetoric, not even counting the massive bailouts of last year. This new form of corporate welfare will extend the big business/big government connection in new ways and further the pay-to-play politics of Washington, DC, with more corporate money polluting politics.
The new health-care bill forces Americans to buy a corporate product that is overpriced and flawed. Americans could be required to pay up to 9.5 percent of their income on insurance that will only cover an average of 70 percent of their medical expenses. In addition, insurance companies are allowed to deny care with no court review of that decision. As a result, someone with insurance, paying an expensive premium, could still find themselves bankrupt.
What Did We Get?
There were some attempts to fix insurance abuse, but every fix had a poison pill added by the insurance industry. A good example is that the insurance industry will no longer be able to deny care for pre-existing illness. The poison pill is that the industry can charge people who do not meet their wellness guidelines double what they charge others. And, if you are older, they can charge triple. So, while you cannot be denied insurance, will you be able to afford it?
We also got expansion of coverage. The largest source of expansion is Medicaid with 16 million more people covered. But Medicaid is woefully underfunded, paying doctors such poor reimbursements that many refuse Medicaid patients. And Medicaid does not cover all health needs. States are already stretched thin trying to pay for Medicaid, resulting in more cuts to services and lower payments to doctors. The federal government’s financial assistance ends in 2016.
The other expansion of coverage depends on forcing people to buy insurance. For many people, the penalty in increased taxes will be more affordable than health insurance. Many businesses may also find that it is much cheaper to pay a small fine than to provide insurance. Without a public option, more people will be pushed into the individual insurance market where costs are rapidly increasing.
Perhaps the change that will have the most positive impact is one produced by Senator Bernie Sanders—the expansion of funding by $12.5 billion for community health centers, allowing them to double the patients they see. Community health centers are the foundation of primary care for residents of rural areas and inner cities, providing basic services such as blood and dental work for about 20 million U.S. residents.
Where Do We Go From Here?
Two detailed reviews of the bill have come from National Nurses United and Physicians for National Health Program, so I’m not going to review it here. Perhaps more important than the specifics is that, for the first time in U.S. history, the law codifies the view that all people should have access to health care. Sadly, this bill does not achieve that goal. Once fully implemented, it will leave 23 million (at best) without health insurance and tens of millions more with inadequate insurance because they are on Medicaid or their private insurance does not fully cover them.
What should real reform advocates do now? The first step is to know what we want. Public dollars should only go to health care, not to insurance expenses, profits, and bureaucracy. That means we should fight for a national health program based on expanded and improved Medicare for All so we can effectively provide care to everyone in the United States. There are already many strong organizations working for real reform: Health Care Now!, Physicians for National Health Program, Single Payer Action, National Nurses United, Progressive Democrats of America, and Prosperity Agenda. Polls consistently show majority support for a single payer national health program, so we are further along than many realize.
We need to build a foundation of broad-based education and an understanding that you cannot compromise with or effectively regulate the insurance industry. All the traditional activist tools have a role in the single payer movement: lobbying, litigation, voter initiatives, state-level reform, protest, civil resistance, and elections to achieve our goals. The single payer movement needs to challenge incumbents in primaries and general elections. The latter may be where we have more power. The movement must be independent of either political party.
One lesson we should learn from this year is we cannot count on any ally in Congress until we build a movement. Now that the Democrats have further enshrined the insurance industry, some will urge that we work within that framework to improve the law, but tinkering with the insurance industry is insufficient. Indeed, a particular spotlight needs to be kept on the insurance industry. Their behavior will not change with the new law. Single payer advocates need to continue to highlight their abuses, denials of care, excessive executive salaries, rapid increases in premiums and cutbacks in coverage. Tools like shareholder actions, boycotts, and divestiture need to be used. When abuses occur, the movement needs to use tactics like sit-ins at insurance companies to show that people are angry.
It is critical that the momentum of the movement that favors improved Medicare for All not be slowed by a law that protects the status quo, even if it’s called reform. The task of providing health care to all as a birthright remains.