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GRAY MATTERS: Medicare for All

Posted Oct 16 2010 5:30am

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman ( bio ) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here . Saul's Reflections column , in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

When I read that so many Americans don’t understand, don’t like or worse, don’t care about the health insurance reforms that were so hard to come by, I can’t help thinking of that wonderful, climactic scene in On The Waterfront in which Marlo Brando recalls a prize-fight he deliberately lost and tells his brother Charlie that he could have won that bout. “I coulda been a contender,” he says.

I believe people could have been more enthusiastic about the reforms, such as they are, if Barack Obama had not been so quick to compromise with big drug and insurance companies. He could have fought to give us, the American people, the change he promised - a universal health care bill they could understand, like the one he was for before he became president.

Why do today’s Democratic presidents (e.g., Bill Clinton) believe they must move to the middle to govern? Franklin Roosevelt and Ronald Reagan, whom Obama praised as transitional presidents, didn’t do that.

We could have had a less complicated, more easily understood bill without all the ifs, ands, buts and loopholes that the insurance and drug industries are wiggling through as we speak. It’s downright sad that so many good Democrats in Congress are running away from the reforms in the coming election.

Or, they’re having a hard time explaining and defending their votes for the thousand page Patient Protection and Affordable Care Act (PPACA), most of which won’t take effect for three more years by which time these lawmakers and the president will have had to run again.

In September, six months after the reforms became law and despite the administration’s efforts to publicize its accomplishments, the Pew Research Center reported that only 38 percent of the public approves of the law, while 45 percent disapproves and rather than wait to see if it works, 32 percent favor repeal.

The same poll, however, found large majorities of older Americans (69 percent) adamantly opposed to a Republican proposal to replace Medicare with vouchers for beneficiaries to use to pay for their care.

The popularity of Medicare, even among younger people, should have told the Obama White House which way to go with health insurance reform. An Associated Press poll in late September reported that 61 percent of respondents believe Obama should have gone further to change the system. A Kaiser survey found only a slight increase in support for the reforms.

I can understand why so many people are lukewarm towards the health reforms. They watched as the president, in order to get some cooperation from PhaRMA, the Pharmaceutical Research and Manufacturers Association, and America’s Health Insurance Plans, AHIP, the insurers, steadily gave in on key issues and then gave away the possibility of a public option, like Medicare.

A public option, as the president himself said, would have given consumers more choices and some leverage over the big insurers to bargain on premiums and hold them to the new regulations. Obama would have earned more support from the people who voted for him.

But now we know from former Senator Tom Daschle, among others, that Obama was ready to cave in on that issue early when PhaRMA and AHIP demanded that in exchange for their support. Daschle admitted as much in his account of the health reform battle in his new book. He later partially retracted his admission in an interview, but others knew the truth.

Senator Russ Feingold (D-Wis.) has said that there was no public option in the final bill because the White House never pushed for it unambiguously. Thus, the health care we’ll get is almost completely privatized, dependent on the insurance and drug companies, all of which can look forward to record profits because the reforms mandate that millions must buy insurance with premiums subsidized by Washington.

Despite the criticism from the right, the government is not taking over health care as much as it is trying (vainly) to regulate insurance companies in return for guaranteeing them tens of millions more customers.

To be fair those regulations, if enforced, will eventually help get coverage for most of the 50.7 million Americans who are uninsured, an increase of 4.3 million over last year. For when the reforms took effect on September 23, its supporters were able to point to some positive effects of the health insurance reforms:

• Covering young adults until age 26
• Helping people with chronic conditions by ending lifetime limits on new policies
• Covering children with pre-existing health problems
• Expanding preventive care such as free flu shots, mammograms and colon exams for persons not on Medicare

But as Daschle wrote for Kaiser Health News, the top-heavy complexity of the law and the resistance to it by insurers and several states have made it necessary for Kathleen Sibelius, the Health and Human Services Secretary to issue additional regulations, guidance and clarifications to keep up with puzzled inquiries from consumer groups and lawyers for providers who read the fine print, looking for ways to dodge the letter of the law.

As a result, she has sought to set up temporary “high risk pools” run by the states and the federal government to cover adults with pre-existing conditions who have been unable to get insurance. She has appealed to insurers who have sharply raised premiums or refused to cover children; six companies, including Anthem, Aetna, Cigna and Humana say they’ll stop writing policies for children not also covered by their parents’ policies.

A reader informs me that insurers are denying coverage for neurological testing of children, thus preventing diagnoses.

And insurers have lobbied furiously with state insurance commissioners to avoid the requirement that they spent 80 to 85 percent of premiums on health care. As a result, USA Today reports, Sibelius has had to issue 30 waivers to companies and their insurers, including Cigna, who say they can’t meet those requirements. The White House said it was the best way to keep people insured until the law fully takes effect in 2014.

Medicare went into effect a year after its passage in 1965. And even now, with four parts (A, for hospitalizations; B, for outpatient services; C, for Medicare Advantage - comprehensive, partly private coverage; and D, prescription drugs), it is not as complex as the Affordable Care Act. I’m attaching here a handy list of Medicare health and drug plans [pdf] for every state.

By 2019, when the ACA is to be fully implemented - if it is not whittled away by Republican enemies who don’t believe government should play a role in health care - there will still be 23 million uninsured, and there will have been 500,000 deaths among them. So says Dr. Henry Abrons, of the Physicians for a National Health Program in California.

Those figures, derived from the Census report, he added,

“underscores the urgency of going beyond the Obama administration and swiftly implementing a more fundamental reform – a single payer national health insurance program, improved Medicare-for-All.”

Right-wing critics charge that the Affordable Care Act is a foot in the door to get Medicare For All. Let’s hope they’re right.

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