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An Open Letter to California Single Payer Advocates Who Oppose ABX1 1

Stephen-D.-Schear.gif By Stephen D. Schear
A Longtime Single Payer Advocate

This letter is addressed to those individuals and groups who believe as I do that a single payer model of health care financing would be the most efficient and effective method for attaining universal health care in California and the United States. In 1987, I was the principal author of the Health Access plan, the first serious single payer proposal for California. I helped draft Proposition 186, the 1994 statewide single payer initiative. I was one of the leaders in the effort to obtain the million signatures necessary to put Proposition 186 on the ballot. After 186 made the ballot, I traveled for months throughout the state and spoke on television and radio in support of 186. In 1995, I participated in the conference which founded Health Care for All California (HCA), the organization created to promote single payer in California. Since then, I have continued to be active in efforts to achieve universal health care. I am currently co-chair of the national Universal Health Care Action Network (UHCAN), although this letter is written as a personal message and not on behalf of UHCAN or any other organization.

I present my credentials as an advocate of single payer because I want you to understand that this letter is written with the purpose of moving our state and nation toward universal health care and toward a single payer financing mechanism for delivering that health care.

From my perspective, California’s single payer movement is currently engaged in political activity which is damaging the possibility of achieving universal health and winning single payer. I do not question the integrity or intelligence of those who believe that single payer advocates should oppose ABx11, the compromise reform proposal advanced by Governor Schwartznegger, Assembly Speaker Fabian Nunez and Senate leader Don Perata. I do question the wisdom of that position. Passage of ABx1-1 will take California closer to both universal health care and single payer. I understand that many of you reading this letter are fully convinced that single payer advocates should oppose ABX1 1. I ask you to read this with an open mind and to reconsider your opposition to ABX1 1.

ABX1 1 Creates the Foundation for a More Rational Health Care System: Reducing the Fear Factor

Repeated polling, focus groups and experience have demonstrated that fear is the emotion that keeps most voters from supporting proposals for universal health care, including single payer.

Most of us consider our access to health care as one of the most important things in our lives. It directly impacts our ability to survive, to work, to enjoy life and to protect the lives and health of our families. Our concern about our health care should and does provide a motivation to support improvements in our health care system. Unfortunately, it also creates fear about changes which might threaten our access to the health care we now have. The fear of losing what we have is obviously far more of a factor for those who have health insurance than those who don’t. Most registered voters do have health insurance. The vested interests who oppose changes which might threaten their power or profits have used fear to defeat Proposition 186 and every other effort to enact universal health care in this country.

Enactment of ABX1 1 will reduce the fear factor because it will reduce the distance between where we are now and universal care in multiple different ways. It will reduce the number of uninsured Californians; require significant and uniform contributions by employers, providing new revenue for health care for the currently uninsured; expand public programs for the uninsured; create a statewide purchasing pool for employers; and require insurers to provide coverage without regard to preexisting conditions.

It has been estimated that ABX1 1 will cover 80% of the currently uninsured. According to a Lewin group study sponsored by Families U.S.A., nearly 13 million Californians did not have health insurance during some period of time in 2006-2007. Approximately 7 million Californians do not have health insurance currently and over 5 million Californians continuously lack coverage. Even if ABx11 covers only one-half of the uninsured, it will provide coverage to 3 to 4 million additional Californians.

If ABX1 1 is enacted and covers half of the uninsured population, with a large statewide purchasing pool, voters will be less frightened that a single payer plan would be too expensive, too reliant on government, and “too good to be true.” If half of the uninsured have been covered by one reform, it is much easier to visualize and accept that the other half of the uninsured could be covered by further rationalizing the system with a single financing agency.

If ABX1 1 is enacted, some of the arguments that have been used against single payer in the past twenty years will be defused. The opponents of single payer have always argued that the tax on employers would do terrible damage to California’s business climate. If ABX1 1 is enacted, the tax on employers will be put in place and that argument will be eviscerated. Likewise, the enactment of a statewide purchasing pool through ABX1 1 would help negate the argument that a government purchasing agency – the essence of single payer – would be inefficient or ineffective. Giving individuals with pre-existing conditions equal access to insurance coverage through ABX1 1 should effectively eliminate the argument that it will be too expensive to cover these individuals through single payer. Finally, and perhaps most importantly, the amount of new taxes that will need to be imposed to enact single payer will be substantially reduced if not entirely eliminated. Wouldn’t it be nice to be able to campaign for single payer without having to campaign for substantial new taxes to fund it?

Creating Structural Building Blocks for Single Payer

Aside from its impact on the minds of voters, ABx11 creates structural building blocks that rationalize the health care system and therefore would make a transition to single payer easier.

Single payer proponents tend to downplay the difficulties of making the transition from our current haphazard, chaotic health care non-system to a smoothly efficient single payer system. However, it would not be an easy task to set up an effective single administration which would incorporate 7 million uninsured Californians into the system; transfer coverage of another 31 million Californians into the same system; enact and defend in the courts employer tax contributions; and accomplish the multiple other tasks involved in creating a single payer system which truly meets the needs of a state larger than most of the countries of the world.

ABX1 1 would not eliminate all the difficulties of making the transition to single payer, but it would certainly make the process easier. The statewide purchasing pool formed under ABX1 1 would create an administrative platform from which a single payer administration could be launched. The fact that coverage would only need to be provided to one to four million uninsured persons after ABX1 1, rather than seven million, would substantially reduce the need for additional sources of revenues. The inevitable legal challenges based on ERISA to a statewide tax on employers will be addressed if ABX1 1 is passed. If the ABX 1 1 employer tax survives an ERISA challenge, then single payer advocates will not need to worry about losing a primary source of revenue during the initial phase of implementation of single payer. If the ABX1 1 employer tax loses an ERISA challenge, then single payer advocates can take that ruling into account in developing alternative methods of generating revenue.

Defeating Incremental Reforms Does Not Build Support for Single Payer

In 1980, when I was a young lawyer working in a law collective in East Oakland, we had a discussion about the presidential campaign. One of the collective members argued that we should support Ronald Reagan rather than Jimmy Carter because Reagan’s election would result in the Revolution coming sooner, because he would expose the flaws in capitalism. Reagan won, but the Revolution did not come any sooner. We did end up with massive tax cuts for the rich, cutbacks in Medicaid and Legal Aid, and generally disastrous consequences for the poorest Americans. The idea that making things worse or leaving conditions bad generates support for monumental changes has generally proven to be an illusion.

Defeating ABX1 1 will not result in single payer arriving any sooner. Support for single payer will not increase because the health care system stays terrible or gets worse. Our health care system has been inefficient, expensive and unfair for the last 20 years and those conditions have not generated the support necessary to make single payer a reality in a single state in the union.

In California, support for single payer is created by the educational and organizing work which has been done in the past and which Health Care for All, the California Nurses Association and other organizations continue to do. There may be some increased support for single payer now as compared to 1994. However, we remain far from the level of popular support necessary to win single payer (including the necessary funding) either in the legislature or through an initiative. Opposing ABX1 1 will win no new allies or adherents for single payer.

Winning Incremental Reforms Will Not Delay or Defeat Single Payer

The argument that the passage of ABx11 will delay or defeat single payer appears to assume that there is a rising tide of support for single payer; that victory for single payer is therefore within reach in the next several years; and that the ABX1 1 reforms will defuse political momentum in that direction. This is wishful thinking.

I attended the Health Care for All rally in Oakland which was took place near the culmination of HCA’s campaign of 365 days of organizing in cities throughout California. In Oakland, probably the most progressive large city in California, there were about 40 people and little energy. After 11 years of organizing by HCA, and more than that by the CNA, there is no massive flow of grassroots support or the kind of financial backing required to enact single payer in California. This is not intended to negate the work of HCA, the CNA or any other organization. The dedication of the single payer forces has been successful in building formal support for SB 840 within most of the Democratic Party. However, we remain far short of what we need to actually achieve single payer: the support of a fully-committed two-thirds majority in both houses, plus the Governor, plus sufficient support and financial resources to defeat the referendum that would almost certainly follow the passage of a single payer bill. Nor do we have the political support or financial resources to win an initiative battle.

None of the three major Democratic candidates for president is promoting a single payer system, although each of them has expressed support for universal health care. This is important for two reasons. First, it indicates that even if the Democrats win this year’s election, it is highly unlikely that even the first steps toward a single payer plan will be adopted by the federal government in the next four years. Second, the Democrats’ positions undoubtedly reflect polling and focus groups which show that the American public is not yet ready to accept a single payer plan.

Given that single payer is still years away, ABX1 1 will not delay or defeat single payer. Rather, as discussed above, it will lay both the political and structural foundation for later efforts to achieve single payer.

The Question Is How AbX1 1 Compares to the Status Quo, Not How It Compares to Single Payer

The opposition to ABX1 1 focuses on the alleged defects in the proposal: the individual insurance mandate, the lack of effective cost controls, the continued existence of private insurance and the lack of universal coverage. There is no question that ABX1 1 lacks the elegance, simplicity, efficiency and comprehensiveness of single payer. However, the defects in ABx11 are minor compared to what it will achieve.

The mandate for private health insurance is relatively meaningless, especially since ABX1 1 includes a provision that people can be excused from the mandate if buying health insurance would constitute a financial hardship. The government is not going to prosecute individuals for a lack of health insurance. The other “problems” with ABx11 are only problems if you compare ABX1 1 with single payer. Although there is not much in the way of cost control in ABX1 1, at least it requires insurers to spend 85% of their premiums on health care, a small advance in limiting private insurance waste. ABX1 1 will not achieve universal coverage, but it expands coverage far more than any legislation since Congress passed Medicaid and Medicare in 1965.

Most importantly, if we defeat ABX1 1, we will not have single payer. We will have what we have now: no effective cost controls, 7 million uninsured, private insurance companies that are free to decline coverage to those who are ill or who have preexisting conditions and no required employer contributions for health care. The question that is before us is whether California residents would have better and healthier lives if ABX1 1 passes. ABX1 1 would improve the health access of millions of Californians and begin the formation of a more rational and equitable system. ABX1 1 looks great in comparison with the status quo.

Compassion Requires Support for ABX1 1

The opposition to ABX1 1 is built on theories of political change and high hopes for the future flowering of the single payer movement. The theories and aspirations of single payer advocates, no matter how noble or well-intentioned, cannot outweigh the concrete damage that will be done if ABX1 1 is defeated. The millions of Californians who lack health insurance need help now, not just the hope of someday reaching the promised land of single payer. One of my daughters is a Buddhist and teaches me that we should be guided in our activities by love and compassion for all sentient beings. Compassion for the millions of people who would gain access to health insurance through ABX1 1 requires its support.

This Is an Unusual Opportunity Which Should Not Be Missed

In 1992, two years before Proposition 186 was on the ballot, the California Medical Association put Proposition 166 on the ballot. Prop 166 would have required all employers to provide health care to their employees, a straight employer mandate. Health Access joined with the insurance companies to campaign against Proposition 166. The theory behind our opposition was essentially the same as the opposition to ABX1 1. We thought that if Prop 166 passed, it would delay or defeat the adoption of single payer. I actively campaigned against Prop 166, an action I now regret.

I have no doubt that Californians would have been far better off if Proposition 166 had won and been implemented. Millions more people would have had health insurance for the past 15 years. Employers’ resistance to single payer would certainly be far less now if they had been required by law to provide health care to employees since 1992.

This year is the best opportunity I have seen for a major advance towards universal health care In my 28 years as a health activist in California. The constellation of events is unusual and may not be repeated for many years. We have a popular Republican Governor who has decided to support substantial health care reform for his own purposes, along with a Democratic majority in both houses of the Legislature, and an agreement by the Governor and the Democrats to support ABX1 1. Because of the alliance of the Democrats with Schwarzenegger, we have a good chance of winning ABX1 1 if it is placed on the ballot, even in the face of opposition from the insurance companies and other vested interests.

I urge all single payer advocates to support ABX1 1 and not to take actions which will contribute to its defeat.

Posted on January 13, 2008

Comments

Sorry, but this scares the hell out of me.

I am afraid of the Government managing anything. Our state government is responsible for squandering billions of dollars in waste. Rather than audit themselves and stop the bleeding of our tax money they ask for more. Every state department is guilty of end of the year spending sprees that buy unneccessary inventory and fluff because they are convinced they will get shorted the next year. That should be pretty simple to fix. It's an accounting flaw they refuse to address. Fix that and no more budget deficit.

The state of California was managing the prisons system medical. All that was required was "humane and basic medical". They failed miserably in handling 173,000 inmates and the whole prison system medical is now under the control of the Federal Government. Over a 12 year period the state ignored 77 court orders to fix it. They did nothing. Inmates dieing from very curable and preventable illnesses. There is 38 million people in CA. They couldn't handle 173,000. I DON'T WANT THE STATE MANAGING MY HEALTHCARE THANK YOU.

This all sounds wonderful to alot of people that don't have insurance but in reality when you take the private sector out and install government programs, all that will result is waste and chaos.

Posted by: Morris1 at January 13, 2008 10:01 AM

What a lame fantasy.

With single-payer "advocates" like this, who needs opponents?

Instead of peering into your crystal ball to discern the effect that ABX1 1 might have on the minds of voters, you could just as easily read tea leaves to discover how single-payer would fare if, instead of putting all their energy into crafting a giveaway to the insurance industry, the Speaker, SEIU and others had focused instead on achieving single-payer.

Posted by: JN at January 13, 2008 01:07 PM

Schear thinks that somehow forcing more people into private insurance will make them less afraid of single-payer, and ease the way to its eventual enactment. As someone who lost a loved one to the idiotic U.S. system and has since become an activist for change, I read his letter wanting to see his point — but it's not congealing.

How will strengthening health insurance companies via mandates help people get past their fear of universal health care -- a fear promoted by health insurance companies?

Schear writes:

"...The mandate for private health insurance is relatively meaningless, especially since ABX1 1 includes a provision that people can be excused from the mandate if buying health insurance would constitute a financial hardship. The government is not going to prosecute individuals for a lack of health insurance. The other “problems” with ABx1 1 are only problems if you compare ABX1 1 with single payer. Although there is not much in the way of cost control in ABX1 1, at least it requires insurers to spend 85% of their premiums on health care, a small advance in limiting private insurance waste. ABX1 1 will not achieve universal coverage, but it expands coverage far more than any legislation since Congress passed Medicaid and Medicare in 1965."

How can a mandate that further strengthens the key malignant element in our system be meaningless? It's like mandating that Sicilian shop owners buy protection from the Cosa Nostra in an effort to strengthen the state police.

Additionally, how can reform be sustainable if it includes generous subsidies for insurance profits and duplicated administration? And 15 percent is generous, considering that Medicare can do it for 3 percent. Beyond which, experience in the Midwest would suggest that the insurance industry has nothing to learn from Enron when it comes to their ability to cook the books. Won't this more likely set back the cause for universal health care? Won't people think, 'Well, we tried that, and it wasn't affordable, was it?'

Mandates to buy insurance from an industry with as bad a record as the U.S. health insurance industry is not a good plan. Their primary responsibility is to their stockholders, not their patients. It's a set-up for failure.

I appreciate Mr. Schear's great work to reform the U.S. health care system, but I'll have to respectfully disagree on this one.

Posted by: Kristen Hannum at January 14, 2008 08:23 AM

Unfortunately I don't have time to go into details, but the real fantasy here is that single payer will somehow be a panacea. Do we need changes in the current system? Yes. Are health insurance companies evil no.

Yes, there are profits involved that could be considered 'waste' along with marketing costs etc. But the government would still be responsible for paying claims and dealing with health care providers. How efficient will the government be? People point to Medicare but Medicare is not free first of all (Part B which covers most claims). On top of that, Medicare has extreme limits on what it covers which is why private health insurers sell Medicare Supplement plans (or Medigap).

Single payer sounds good because it sounds painless. Hey everyone is covered isn't that great. But what happens if it ends up costing more than we thought? We can't borrow any more than we are. And what about physicians? Physicians already decline Medicare and Medicaid patients because their reimbursement schedules are too low. What if we lose good physicians to other states?

Finally, the health insurance companies do not like ABX1. Do you really think they want to have to take anyone that applies for coverage (no underwriting)? How many businesses would like to take on someone they know for a fact they will lose money on?

If taking out the middle man is such a good thing, why don't we let the State take over all our insurance, auto, homeowners etc. After all, isn't there the same waste in these industries? The difference is health insurance companies are dealing with costs that are rising more than the rate of inflation and people aren't happy about that.

There is a lot more to consider here than just the greedy money-grubbing middle men.

Posted by: Tim at January 14, 2008 08:37 AM

Since Stephen has mis-stated the basis of CNA's opposition to ABX11 and has distorted key elements of the bill, here are some points to correct the record:
~polling shows strong support for Medicare-style, government guaranteed healthcare for all financed publicly, most recently in the AP/Yahoo poll in December showing 65% support;
~ABX11 does not require "significant and uniform" employer contributions: the 1 -6.5% is substantially less than the 10-14% paid by employers who currently provides benefits and risks setting a lower bar;
~the expansion of public programs under ABX11 is primarily taxes funding the purchase of private insurance, which is unlike Medicare/single-payer and does nothing to build toward that model;
~insurers can charge whatever they like in order to maintain profits and continue denials of care under ABX11, despite "guaranteed issue;"
~ABX11 preserves and enhances the multi-tiered system of the status quo, with access, quality and choice based on ability to pay;
~better federal reforms are likely to be enacted before this flawed, politically expedient distortion of reform collects enough revenue to go into effect in 2010, particularly if a candidate is elected who doesn't favor mandating the purchase of private insurance;
~since it doesn't define benefits, control costs or effecwtively stop denials of care by private insurers, it is impossible to say whether it actually improves the status quo except for the insurers and other organizations that support it based upon the spiffs they have negotiated;
~rather than accepting the parameters of "reform" established by the Governor with the worst record on healthcare of any in the US, we could do better in 2010 by electing a Democratic governor;
~CNA has never asserted that defeating ABX11 improves the chances for single-payer, except that ABX11's (legal, policy and political) flaws undermine the preception that government can actually solve the problem.

Posted by: Michael Lighty at January 14, 2008 12:13 PM

Remember this the term Universal Access is a code word which sends the message to keep the Health Insurance giants involved in the system. The US spends 50% more per capita on health care costs than it's nearest rival Canada. That is solely attributed to the absurd profits that Health Insurance Companie reap.

The absurdity of ABX11 comes in the form of the individual mandate. Eighty percent of the people don't have health insurance coverage because their employers do not provide it. Like people who work in fast food resturants and Walmart. So where will these people get the money from to purchase Health Insurance under ABX11 ? Does ABX11 guarrantee an increase in the minimum wage ? Does ABX11 provide vouchers to those people ? And furthermore why should the state of California be subsidizing the profits of the Health Insurance giants.

The root of the Healthcare woes in the US points in one direction Straight to the Health Insurers that is why "Universal Access" is a total fraud. Nothing short of a Single-Payer System will address the needs of the American Public.

SAY IT.......Single Payer !

Posted by: Bob Marston at January 23, 2008 05:29 PM

Many good points are made. As a medical student, and daughter of uninsured parents, and sister of an uninsured brother, and numerous uninsured cousins, I also worry about making the right decision. I can honestly say, a piece of paper saying my loved ones are covered, IF they can afford it, because there are no minimum benefits, no premium limits, etc, MEANS NOTHING.
PAPER COVERAGE does not equal greater access to care. Please realize that.

How does further entrenching the insurance industry in our healthcare system make it easier to defeat them later??

Are more people covered, with Medi-cal expansion, well with this budget the Gov plans to cut Medi-Cal programs, which everyday have lower reimbursements and doctor's won't accept.

Single payer is the only answer, I would argue possibly for incremental reform if it would truly make a difference for millions of people. It won't. People will buy into an expensive, broken system, which cost so much they won't afford the co-pays and deductibles, and won't get preventive care.

As far as the 85%, they're private companies, do they really disclose truly where there costs go? They claim $$ for marketing as part of "direct care." Come on, are we really that naive, now we believe they're numbers? AND WHO will regulate them, who will police the insurance industries, where is that written, will it be the Governor? Look what happened to California's electric crisis with deregulation.

Bottom line: My family will still not be able to afford care, they will likely be exempt, which means they end with nothing. And for those who will they end up with a worthless piece of paper claiming they're covered, at a fraction of "reasonable and customary amounts" with restrictions, with limitations/exclusions, out of pocket costs, denials, co-pays, high max out of pocket costs, essentially people will buy something they will think hard about actually using for say prevention, because it's too damn expensive.

Single payer is the only real change, this is the illusion of change. Your Buddhist daughter would say, compassion and love should not blind us to reality, and that living the eightfold noble path with right actions, right thoughts, right words, right livelihood, means living with integrity, and sometimes that means standing for what is best for all, not a few. The Dalai Lama and Tibetan people did not surrender to China, even if it would have alleviated suffering in the short term, because it wouldn't have truly, and they are asking for what is right and just. Buddhists above all understand the interconnectedness of all things, all beings, and stand for the liberation of all peoples, not some at the expense of the rest.

Posted by: T Velo at January 24, 2008 12:11 AM

When will politicians get it? People don't buy health insurance because they can't afford it! Trying to force us to buy health insurance or face heavy fines is EXTORTION!It is free money for the insurance companies and for those who are faced with fines it is taxation, plain and simple! For the argument we have to buy car insurance, we have a choice to use other means of transportation, also we can buy car insurance for a fraction of the cost of health insurance.

Posted by: Inge Scott at January 25, 2008 11:31 PM

Posted by: Inge Scott at January 25, 2008 11:32 PM

Why try to re-invent the wheel? Just copy one healthcare system that already works better. Canada and most of Europe have systems that cost less and deliver better care, none of which resemble California's proposed healthcare system reforms. Canada's would be an easy one to adopt, they already pay for 30-40% of their healthcare through the private sector and personal insurance. Most fear mongerers try to say Canada is some sort of socialist or communist state, they have a healthy private healthcare system too !

Posted by: HealthcareReviews.com at February 4, 2008 07:26 AM

Stuart Altman, considered one of the preeminent experts national health policy, developed Altman’s Law to explain why change has not occurred in the united states. Altmans Law goes as follows:

“Almost every American and advocacy group supports some form of Universal Health Insurance—But if it’s not their preferred version, their second best alternative is to maintain the status quo”

Thus, the competing factions for healthcare reform stand in the way of incremental betterment by maintaining the status quo.

Striving for the perfect system is evil to betterment. Regardless of which system is better there were 18,000 preventable deaths last year due to the lack of health insurance, increased coverage is increased coverage. Can we please stop fighting and start changing.

Posted by: Areo Saffarzadeh at February 8, 2008 01:04 AM

forcing more people into private insurance will not make them less afraid of single payer.i like the article because it is informative.thanks.

carol smith
Addiction Recovery California

Posted by: carol smith at July 1, 2008 05:50 AM

forcing more people into private insurance will not make them less afraid of single payer.i like the article because it is informative.thanks.

carol smith
Addiction Recovery California

Posted by: carol smith at July 1, 2008 05:51 AM