Single Payer Not Single Payer

The people want single payer.

The corporate class answers — not single payer.

Congresswoman Pramila Jayapal (D-Washington)

The people say — single payer — get rid of all the other payers. Get rid of the insurance companies. And while you’re at it, get rid of the health maintenance organizations and accountable care organizations and value based programs and for profit hospitals feeding at the public trough..

The corporate class says — keep those corporations at the trough.

The corporate class says — better yet, public option for all.

The people say — we want Canadian style health care.

The corporate class says — Medicare buy in.

The people say — everybody in, nobody out.

The corporate class says — Medicare Advantage for everyone.

The people say — single payer.

The corporate class throws up a smoke screen with — universal health care.

The corporate class wants anything but single payer.

Why? Because single payer threatens corporate power.

Under single payer, insurance companies gone. HMOs gone. ACOs gone. For profit hospitals — gone.

At least that’s the way it was for the past sixteen years under the gold standard for single payer — HR 676.

Now, on cue, with the Democrats in charge of the House, HR 676 is being rewritten and the Democrats even want to get rid of the number 676 — and start with a new number. Not 676.

Why?

Because the “progressive Democrats” in the House want to align the House bill with Bernie Sanders bill in the Senate (S 1804).

The Sanders bill is not the gold standard for single payer. It has a number of serious defects.

The Sanders bill allows for profit hospitals and accountable care organizations and health maintenance organizations and value based programs (ACO/HMO/VBP) — all corporate talk for corporate intricacy and distraction — to continue to exist and drive up costs within the so-called single payer.

Congresswoman Pramila Jayapal (D-Washington) wants to be the new lead sponsor of the House single payer bill. Jayapal’s bill would also keep for-profit hospitals in the mix.

But Unions for Single Payer’s Kay Tillow says that for-profit hospitals have no place in a single payer system.

She points to studies showing that for-profit hospitals result in higher risks of death, higher costs, higher readmission rates, and for profit dialysis centers also have higher death rates.

Dr. Andrew Coates, former president of Physicians for a National Health Program said last year “there should be no profiteering in the delivery of healthcare.”

“Nursing homes in the U. S. are mostly owned by private-equity firms like Warburg Pincus, Bain Capital, GE Capital, the Carlyle Group, and others,” Dr. Coates said. “These corporate owners in turn hire myriad subcontractors to run every aspect of the home, from the kitchen to the janitorial service to the electronic health records to the laundry.  And at every step there is someone taking a profit out.”

In a recent article in Health Affairs, Steffie Woolhandler and David Himmelstein called on Congress to adopt HR 676’s “payment strategies and commitment to non-profit ownership of health care providers.”

“Even some who would prefer to exclude investor-owned facilities from a single-payer system worry about the cost of a buyout,” they write. “In conversations with Congressional aides, some have suggested that these costs could amount to $1 trillion or more, although none could cite a source for that figure.”

Himmelstein and Woolhandler support HR 676’s approach that explicitly proscribes payments to investor-owned facilities, and calls for their conversion to non-profit status financed by issuing bonds.

The Sanders bill made headlines in November 2018 when University of Massachusetts at Amherst economist Robert Pollin and his colleagues released a study showing that Sanders bill would achieve universal coverage and reduce total US health care spending by 7.2 percent.

The 7.2-percent figure is the net of a 12.0 percent increase in spending due to better coverage and fewer uninsured, and a 19.2 percent reduction in spending due to improved efficiency, lower prices, and reduced fraud.

But now comes Kip Sullivan of Health Over Profit for Everyone (HOPE) — a coalition of single payer groups and activists.

Sullivan and HOPE are just out with a paper analyzing Pollin’s study.  

Sullivan finds that due to defects in Sanders bill — defects not found in the gold standard bill HR 676 – the Sanders bill will not save nearly as much as Pollin says.

“The total gross savings is closer to 9 percent — not 19 percent, which means the net effect of the bill will be an increase in total spending of roughly 3 percent,” Sullivan writes.

“The first and most important defect is Section 611(b),” Sullivan writes. “That section requires the Secretary of Health and Human Services (HHS) to impose on the entire population ‘accountable care organizations’ plus three or four dozen other complex ‘value-based payment’ programs currently imposed only on the fee-for-service Medicare program. Expanding the reach of these programs from the 40 million people currently enrolled in the Medicare fee for service program to 325 million Americans of all ages will add substantially to administrative costs. Estimating the impact of these value based payments programs on administrative costs is very difficult because Section 611(b) authorizes so many of them, because research on value based payment administrative costs is almost non-existent, and because it is not clear how far and wide – in terms of geography and people covered – these programs would spread.”

A second defect in the Sanders bill identified by Sullivan is “no hospital budgets.”

“The second defect that will reduce administrative savings below Pollin et al.’s projected 9.0 percent is that S 1804 does not authorize HHS to use hospital budgets, but instead authorizes HHS to use only the current method used by Medicare — the “diagnosis related group” method — which requires hospitals to keep track of expenses for each patient.”

“Despite these two defects, Pollin et al. relied, inexplicably, on research based on the Canadian system to derive their estimates of administrative savings under S 1804. This would have been appropriate if the object of Pollin et al.’s study had been HR 676, the Expanded and Improved Medicare for All Act.”

“HR 676 does not contain a section like Section 611(b), and it does authorize the use of budgets for hospitals. Nor does the Canadian system contain these two defects – the Canadian system does use hospital budgets, and it does not impose the value based  payments authorized by Section 611(b). Pollin et al. aggravate their misuse of research based on the Canadian system by failing to notify readers they did that.”

In response to the Sullivan critique, Pollin says that he and his co-authors are clear that while the study focused on the Sanders bill, it didn’t focus exclusively on the Sanders bill.

“My basic response to Sullivan’s critique is that he makes one huge mistake right from the get-go,” Pollin told Single Payer Action. “That is, he assumes that our 200-page study is only about the September 2017 Sanders bill, and that the sole purpose of the study is to assess in detail, up or down, the various components of the Sanders bill.  But we state multiple times that this is not the way we have chosen to focus the study.”

“This study provides an economic analysis of the Medicare for All Act of 2017, which was introduced before the United States Senate by Senator Bernie Sanders (S. 1804),” the authors write on page one of the 200 page study. “Our analysis also addresses, more broadly, a range of issues that need to be examined seriously in considering any specific proposals for a single-payer health care system for the United States.”

Pollin says that he is quite clear in the report that accountable care organizations “are not providing a viable model for achieving cost savings” and that the authors “make absolutely clear that we are opposed to Section 611.”

As for Sullivan’s statement that the authors “inexplicably use research on Canada’s system,” Pollin says that “our use of Canada (and other countries) as case studies is only inexplicable to Sullivan himself, since he seems to think that we have a right only to evaluate what is explicitly stated in the 9/17 Sanders bill and nothing else.”

“But that was never the approach of this study. To me at least, it actually makes no sense at all to bother to write a 200-page study on one draft of one bill, as opposed to analyze the main concepts and literature in depth,” Pollin said.  “Drafts of bills come and go. The 9/17 Sanders bill will be among the many drafts of Medicare for All that will come and go. Our aim in writing the study was to study the potential cost savings available through introducing a viable Medicare for All system that learns from the best examples of other countries as well as within the U.S.”

Sullivan said he agreed with Pollin the most fundamental issue is whether Sullivan made a “huge mistake” assuming his report was an “economic analysis” of S 1804.

“The obvious question then, is: If in fact his report was not an analysis of S 1804, what bill or proposal is he claiming would cut administrative costs by the equivalent of 9 percent of total spending, and cut total spending by 19 percent?” Sullivan asked.

“I disagree that I made a huge mistake,” Sullivan said. “The report is filled with claims that the proposal that will lead to a 19 percent gross savings is S 1804. Here is the opening sentence from his press release — “A team of economists from the University of Massachusetts Political Economy Research Institute (PERI) has found that the Medicare for All Act of 2017, introduced to the United States Senate by Senator Bernie Sanders … could actually reduce health consumption expenditures by about 9.6 percent while also providing decent health care coverage for all Americans.”

“I could send along many other examples of statements by Pollin and his allies that his report was an analysis of S 1804.”

“But let me concede for the sake of argument that I completely misconstrued the constant references to S 1804. Could you ask Pollin to address this question: If S 1804 was not the version of Medicare for All mentioned in the title of this report and mentioned dozens of times in the report and recent statements to the media, what version did Pollin analyze that will lead to a 19 percent gross savings and a 9.6 percent net reduction in consumption expenditures?”

We did ask Pollin.

“As I wrote before, and as we say in the study, we used the Sanders bill as an initial jumping off point,” Pollin said. “But we also were analyzing the concept of a single-payer health care system — Medicare for All — more generally.  I can’t explain why that wasn’t clear to Sullivan. It wasn’t a problem with any of the twelve reviewers of the study, who went over multiple drafts of our work. This particular issue never once came up. This is so, even while many, many other issues did come up.  If you look at the final statements of the reviewers. some of them continued to have significant differences with us.”

“But nobody said ‘this study is about the Sanders bill and only about the Sanders bill, and I will therefore evaluate the work from that perspective.’”

“It seems to me that this should be clear when we explore in some detail alternative approaches to implement global budgeting and capitation — two proven techniques for cost containment.  As we say in the study, there are vague references in the Sanders bill to developing global budgeting. Nothing is fleshed out, clearly, so we tried to lay out some alternative approaches. Moreover, we talk about introducing utility-type regulations for hospitals — something that isn’t in the Sanders bill at all. We talk about the experience in Taiwan as providing valuable lessons for implementing single-payer in the U.S. There is obviously nothing in the Sanders bill about Taiwan per se, or Canada per se, or France, per se.”

“In the end, it seems to me that we are arguing about how we structured our study — which is substantially a critical review of the relevant literature. I never saw the study as just referring to one draft of one bill and that only.  Sullivan apparently is insisting that this is the way that one has to understand our study. But again, one more time, I personally wouldn’t see all that much value in focusing our study in that way.”

“The bill is, once again, pretty vague on critical issues that matter, such as how to implement global budgeting. So we tried to make a very broad concept more specific. In reality, if the issue moves forward in a serious way, either in California, some other states, or at the national level, we will inevitably need to flesh out the approach to global budgeting and capitation in far greater detail than can be put into a bill.”

But Sullivan wouldn’t let Pollin off the hook.

“Pollin cannot have it both ways,” Sullivan wrote. “He cannot claim in press releases and in numerous interviews, and he cannot stand by and watch others state in articles and interviews, that his study demonstrates that S 1804 will achieve universal health insurance and lower health care spending by a precise number (9.6 percent), then turn around and say his study did not examine S 1804 but instead examined ‘a jumping off point’ or a ‘concept.’”

“Here again is the opening sentence from the press release Pollin et al. published to announce their study of S 1804:

“A team of economists from the University of Massachusetts Political Economy Research Institute (PERI) has found that the Medicare for All Act of 2017, introduced to the United States Senate by Senator Bernie Sanders, is not only economically viable, but could actually reduce health consumption expenditures by about 9.6 percent while also providing decent health care coverage for all Americans.”

“Where in the above excerpt do you see any warning that the PERI report analyzed a ‘jumping off point’ because ‘nothing is fleshed out,’ or a mere ‘concept’? Where in the entire press release or the entire report,for that matter, are readers warned the report is not an examination of S 1804, but is instead an examination of ‘the concept of a single-payer system,’ whatever that means? Where is ‘the concept of a single-payer system’ laid out in the report? It’s not there.”

“I could cite numerous other statements by Pollin and his supporters that state the report examined S 1804, not a ‘concept’ or a ‘jumping off point,’ whatever those phrases mean.”

“There is a simple solution. Pollin should issue a press release saying exactly what he is trying to communicate to me using the words he uses with me. The press release could say, ‘I want to clarify that our report on the Sanders bill, S 1804, did not estimate the economic impact of the Sanders bill, S 1804, as odd as that might sound. Instead, our report examined a ‘jumping off point’ and a ‘concept.’”

Why is this back and forth between Pollin and Sullivan important?

Because single payer activists are rightfully concerned that Jayapal is going to slice and dice HR 676 to align it with the defective Sanders bill.

They are concerned that Jayapal is showing her draft only to a few single payer activists — and only on condition that they not share it. (Last month, HOPE called on Jayapal to release her draft bill. She refused.)

That’s why Jayapal probably doesn’t want to keep the number HR 676.

(Nowhere in their 200 page study of single payer do Pollin and his co-authors mention HR 676.)

The Seattle newspaper The Stranger reported last week that Jayapal said that her bill will be so different from HR 676 “that they might not even use the same bill number.”

Also of concern to single payer activists is the role of the National Nurses Union, which paid for the Pollin study and funds a number of single payer groups, and which has signed neutrality agreements with for profit corporate hospital chains, including HCA.

In a 2011 Wall Street Journal article titled Union Enter Pacts to Boost Members, Kris Maher reports that “the Service Employees International Union and the California Nurses Association are signing so-called neutrality agreements with the chains, in which the hospitals don’t object to organizing and the unions don’t conduct negative campaigns against the employers or try to organize workers at certain hospitals.”

“Since April 2010, the SEIU and the CNA have organized roughly 10,000 nurses and other hospital workers at Nashville, Tenn.-based HCA Inc., one of the nation’s biggest hospital chains.”

“HCA agreed to let the unions organize workers at 20 hospitals in Florida, Texas, Missouri and Nevada without employer interference, according to a summary of agreement reviewed by The Wall Street Journal.”

“Under terms of the year-long pact, which took effect April 1, 2010, HCA agreed to provide the unions lists of employees, to allow them on company property and to hold expedited elections. It also agreed not to support efforts by employees to decertify the unions at any hospitals.”

“In return, the unions agreed to refrain from broad negative campaigns against HCA or trying to organize workers at other HCA hospitals. Since April, the CNA has organized more than 5,000 nurses at 13 HCA hospitals in those four states and didn’t lose any elections. The SEIU has organized more than 4,500 HCA staff.”

One question is being raised by some single payer activists — did the nurses’ agreement to refrain from broad negative campaigns against HCA or other for profit hospitals impact single payer bills at the state and national levels, all of which, with the exception of HR 676, are riddled with loopholes to keep the for profits and ACOs and HMOs and and value based programs in the game?

Only a handful of single payer activists have seen the Jayapal legislation. But if it’s anything like the Sanders bill or the California single payer bill, it’s not single payer.

You can call it single trough, because the for profit corporations and multiple payers will still be feeding at the public trough. But it’s not single payer, the way HR 676 is single payer.

That’s why single payer activists aren’t waiting around. They are shopping HR 676 in the House, trying to find a “progressive Democrat” to sponsor single payer.

(Via the Single Payer Action newswire.)

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