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GRASSROOTS ORGANIZING AS SINGLE-PAYER OR FOR UNIVERSAL HEALTH
CARE: A DISCUSSION WITH CHARLES ANDREWS, Author of "Profit
Fever: The Drive to Corporatize Health Care and How to Stop It"
Mr. Andrews,
Your 1995 book "Profit Fever" is a very important contribution to grassroots activists on Single-Payer health care. I have studied your book and know that you advise against "UHC" work per se, you seem ready to cede that language to the conservative and liberals rather than argue for the genuine clear-cut meaning of the term for working people.
I am in agreement with almost all of your arguments and highly recommend your book. I wonder if you would be interested in some limited e-discussion with me. I am open to hearing your criticism of project EINO and the website.
Sincerely, Dennis Lazof
Executive Director, Project EINO
Webmaster www.EverybodyInNobodyOut.org
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Dennis,
I have known about your fine website for some time. I presume you saw my recent essay
at labor republic. Thank you for contacting me with your questions about my preference for grassroots organizing under the banner of single-payer (SP), rather than universal health care (UHC).
The problem is not the words "universal coverage". The breakdown of the health system became apparent in the past year. It has forced all classes to think about how to change the system. Corporate interests are publicizing tiered health coverage under the label of universal coverage. There are many ways that we can show people the difference between tiered benefits and comprehensive care by a national health plan. If it's good enough for a hotel maid, it's good enough for the President.
I doubt that we have any disagreement here, but if I'm wrong, please let me know. Keep up the good work.
Regards, Charles Andrews
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Charlie,
Based on reading your book, article and your recent note, we seem to agree on almost everything. But its most interesting to discuss some things about which we seem not to agree, so I'll go right to those.
I think much of the problem actually is with the words "universal coverage" just as we suffer in this country with the misuse of the word "democracy". Both are much-abused terms, both are important even crucial concepts to my way of thinking, important for citizens to ponder and hopefully firmly embrace (more than they might seem to at present). And perhaps its important for us to protect and fight for maintained meaning to those concepts, not allowing current political hacks to overwhelm us, rendering those terms
meaningless.
I completely agree with you about tiered health coverage and furthermore believe that UHC must mean high quality care for all. This is similar to what we have learned in the universal education arena - where two-tiered education could not be a guarantee of real educational access for everyone (and eventually was so upheld by courts).
Even if I would personally like to vote in single-payer NHI, it does not necessarily follow that I think pushing for single-payer NHI is the best idea for grassroots organizing. Here we seem to disagree. I know several key state activists who would agree with this, even though they may be personally committed to a single-payer solution. Let's leave other states aside though and discuss the work in North Carolina as an example.
In NC the state UHC organization is working towards an amendment in the state constitution that would declare that all residents have the right to "appropriate health care on a regular basis" (medically appropriate is known terminology for standard of care, good quality). If they can get state legislators to commit to this (actually to force them by building up grassroots support) then why not let them make that commitment and try to fulfill the mandate leaving a role for private health insurance? Single-payer advocates would agree that fulfilling the mandate in that way would not be very easy for them. First of all it might cost twice as much to have the private industry insure any sector, it will split up the risk pool (with the industry trying to keep younger healthier people) and the industry will bail out of any situation where their profits and unlimited executive salaries become limited. They are even bailing out now from "Medicare + Choice" which was not restricting them very much at all.
If the private industry "stays in the game" after real UHC is assured as a right to the residents of the state or country, and if they are still making large profits and wasting huge sums on administration, then they and the legislators they have bought will be easy targets, especially given a level of accomplished grassroots education and action. In the mean time (the few years of continuing excesses) at least there will not be anyone suffering from un- and underinsurance. People will be able to hold the state responsible for providing health care access.
The fight for UHC along these lines is far more tenable and "winnable" in the more conservative states than would be explicit work towards a single-payer system. And the activists in these locations have frequently drawn similar conclusions. Isn't it better to allow state activists to decide the best way to move forward towards real UHC? We avoid being blasted away as promoters of "socialized medicine". The arguments then revolve only around the right to health care. If state legislators want to try and achieve genuine complete UHC with some private insurance scheme, we want to struggle against that later if we need to, not now. Lets get a commitment to health care for everyone.
Please critique. I am very interested in your response.
Dennis
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Dennis,
It helps to understand the enemy's strategy. Why are corporate interests at the national level promoting the rhetoric of universal coverage? They are not co-opting the banner of a strong national movement.
As you know, the managed care regime broke down over the last year or so (double-digit premium inflation, consumer rebellion against HMO methods, the jump in the numbers of uninsured with the costs that brings). This situation compelled corporate interests to look for a new arrangement. Many of them lean to offering everyone (sometimes, requiring everyone to get) tiered benefits: a miserable safety net for the poor, more or less spotty coverage based on ability to pay for the middle income strata, and comprehensive care for the rich. Via the Chamber of Commerce (with Sweeney's help), columnist David Broder, and similar channels, corporate interests promote tiered benefits with the rhetoric of universal coverage.
Equality of health care is a question of principle: one comprehensive package of benefits for everyone -- if the care is good enough for a hotel maid, it's good enough for the governor.
A distinct question of strategy is: work now for a national health plan (or a state equivalent), or decide now to go through two stages, namely, enact a declaration in the constitution, then insist on implementation?
You accept the principle of equality and advocate the two-stage strategy. There is a problem that the strategy may corrupt the principle. For example, a constitutional clause of "appropriate health care on a regular basis" is not, as I read plain English in the political sphere, the same thing as a uniform, comprehensive package of benefits for everyone. If you don't make the principle of equality in health care plain from the beginning, you would abandon it in reality.
As far as evaluation of strategy goes, the two-stage strategy obviously has to achieve both stages, not just the first one.
Given agreement on these considerations, I would hardly tell activists in each state what they should be doing. Most recently, my modest contribution has been to add to the voices exposing the corporate scam of universal coverage. For an example of what this work acomplishes, here's a brief report from the Democratic convention in Maine:
"An amendment to the Democratic Party Platform was brought forward recently [first weekend in June 2002]. The amendment changed the language from Universal Health Care to Universal Single Payer Health Care. After passionate speeches from the floor in favor. The question was called and amendment passed unanimously or almost there was only one person who voted against the amendment out of approximately 500 but it remains to be seen if she was an actual delegate to the convention."
Now 500 people in Maine are clear and committed. I suppose if they ran into huge obstacles fighting for a state health plan, they might want to fall back to a two stage strategy, or regroup and do something else. On the other hand, if the core of Maine health care activists had started with the two-stage strategy, how would they have pulled 500 people away from the tune being sung by Anthem and other corporate interests?
Sincerely, Charles Andrews
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Charlie,
You make several good points, with many of which I could quickly agree. Again, I'll skip quickly over the several important points you make from HMO history and tiered benefits, because I think you are absolutely correct. First of all, in an attempt at brevity in my last note I misrepresented the NC legislative example to you. So your critique of that example was not wholly relevant.
The bill in NC actually includes
three main provisions. There is the constitutional amendment recognizing the right to health care AND then there are the provisions of developing and implementing a plan (each with a definite deadline). So the same bill that will bestow HC access as a right requires implementation in a fixed time frame. The popular mobilization is then for one bill at one time that covers all the ground through implementation and will not be subject to the problem of two-stages which you raised.
You make an important point about the language of "appropriate health care on a regular basis" and I think that indeed the NC group should look more carefully into that. I continue now with a few comments I have not brought up with you earlier about working towards SP or UHC.
The example of the Maine Dem Platform is an interesting one. I have contended in a few recent conversations with other activists that one important advantage for a state organization to work towards UHC rather than SP might be that it directs the audience's (state populace's) attention towards a right we all share and a need we all have, rather than towards an argument about financing the solution. With announcement of a SP bill people will immediately ask what "single-payer" is, or they will immediately challenge SP and only thereafter engage activists in discussion of the "universality" aspect. I would suggest that SP as a focus disadvantageously shifts the argument away from where most laypeople could most easily see the benefits. I'm not sure the Maine approach resolves this.
A second disadvantage of organizing as SP explicitly is that it still does not exclude excessive corporate profits from the system, since it only IMPLIES more possibility for public regulation and oversight. Hospitals, pharmaceutical production/distribution and medical instrumentation production/distribution would not necessarily change with public financing of health care. So the activist is setting up the battlefield in such a way that gives the opponent a much greater advantage and does so without even solving the problem of excessive profits, extracted shareholder benefits and egregious CEO salaries/perks.
I have been forcefully recommending "Profit
Fever" to other grassroots UHC activists. Its unfortunate so few people in progressive politics have written analyses of failures in such an honest and insightful way as you have. I think its rather important that we don't repeat the same mistakes over and over again.
Thanks so much, Dennis
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Dennis:
The North Carolina bill was indeed at the Web address you gave. It still looks like a two-stage strategy to me though. First, people must pass a constitutional amendment declaring that "health care is a fundamental right." The amendment also gives the legislature a few years to enact a plan.
Let's take a sceptical attitude about the honorable members of the legislature for a moment. What if the legislature does not meet the deadline? What if legislators claim the plan meets the constitutional requirement but in fact is a disaster? Only the most naive would trust that a legal action at the state supreme court is going to make the sovereign legislature behave. People will need to mobilize again to prevent the legislature from enacting a bad plan and calling it a solution to the constitutional requirement. So it appears that we are back to the choice between a one-stage or a two-stage strategy.
The rest of your remarks concern how to define single payer itself and how to present it. We agree, any plan that provides comprehensive, uniform care for all has to be about more than the financing mechanism. The label has been "single payer," but specific proposals necessarily cover more ground than financing. Proposals circulating today differ in important respects on substantial particulars other than financing.
As for presentation, we also agree that it is not effective politics to present the main attraction of a national health plan (or a state equivalent) to be its financing, to be the projected cost savings to society and most individuals. However, universal coverage is not a sufficient main attraction by itself. Lots of people have coverage and do not make a high priority of covering the uninsured.
A better main thrust would attack all the principal failures of marketized health care; your latest email lists several of them. Then present an alternative to today's mess that is a real plan, takes power back from "market forces," and provides comprehensive uniform care for all, presenting the various features as parts of the whole.
Sincerely, Charles Andrews
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Charlie,
I can't see how you (even with a full dose of scepticism) can call the NC bill a two-stage strategy - since it assures as well as any legislation ever could that UHC will be the responsibility of the state, a right of all citizens and be implemented by some reasonable fixed date.
1) The doubts you raised like the legislature failing to meet their deadline, failing to enact a plan that fulfills what they have been mandated to fulfill, the unlikelihood of favorable state supreme court action and the possible need of citizenry to mobilize again are indeed all quite possible. BUT they are just as likely to ensue from any SP bill. We have, in fact, witnessed in Canada the rollback of fully covered medical treatments in some provinces (Alberta) and a very real threat of further inroads at present from private health insurance corporations. The need of the populace to remain actively involved and ready to mobilize on behalf of their rights, once granted, has been true in education, voting etc and will be true with the right to health care. But your criticisms have no relation that I can see to the issue of organizing the effort for genuine UHC vs. SP.
2) Of course, its true, as you wrote, that any complete plan will have something to say about financing and something about "universality". This also does not bear on the point I made in the previous note. My point was about focus and emphasis based on how the movement presents itself in its title, at the top of its brochure, in its first line of explanation, at the title of the referendum and in the way it will be first introduced to much of the public. "Presentation", as you put it, can be either complete and in-depth or short and broad, what the grassroots activists will have available though at any given moment, however, is usually out of its control. In many contexts it will have to make a good first impression. Beginning a discussion on the basis of SP health care may get the discussion off on the wrong track to gain the wide public support it deserves.
3) I don't agree with your point about covering the uninsured being unimportant to Americans, or that it is not becoming ever more important. Several polls have shown it is important in fact. Furthermore, once the grassroots education is underway to explain the threat of underinsurance, and gaps in insurance timing to all working Americans there will be only a few people concerned only with their momentary happenstance of being employed and covered (while healthy and having no great health care needs). Furthermore the demographics in the country of aging baby boomers indicates a growing trend towards prioritizing health insurance for all Americans, throughout their lives. Ditto the double-digit premium increases we're seeing.
4) I don't believe SP being presented in a plan is necessarily much stronger anti-market than a properly worded UHC. Private and for-profit involvement in every aspect of health care other than insurance will not necessarily be touched just because a plan is SP. The prospect for regulation of the various industrial sectors is just as likely to occur following from genuine UHC legislation.
The organization in NC will be futher considering the two-tier criticism you offered. They are interested in probing whether there is any better language than "appropriate health care on a regular basis". Do you have any suggestions in this?
Best wishes, Dennis
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Dennis,
Thank you for this discussion. I think the exchange will be clear to any careful reader.
I am not a lawyer. We need something like a declaration that the State of [name] guarantees a single standard of health coverage to every resident, with a comprehensive package of benefits providing all medically appropriate care, and which is revised no less than annually by democratic means. Ideally, the legislation would define comprehensive, but I do not have good wording for that right now.
Regards, Charles Andrews
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