We are accustomed to bullying in America. It seems to be the tactic most favored in the political arena, too. School kids are being taught the nasty consequences of bullying – but adults seem to need a refresher course. Over recent years we have seen thuggery such as that evidenced in Town Hall meetings by the “Tea Party” that roughed up people the majority did not want to hear.

What has become even more disheartening is the adoption of those same “rules of the game” by so-called progressives. This is the story of how those tactics recently caused the death of a major piece of highly-valued legislation in California. The long-term consequences will not be known for months, maybe years.

In 2004 then-State Senator Sheila Kuehl introduced the most ambitious legislation in the history of California health care – a state single-payer plan. Long sought by a coalition calling itself Health Care for All, various groups had formed and occasionally cooperated to pursue the bill through several legislative sessions, passing both houses only to be vetoed by then-Governor Arnold Schwarzenegger.

In 2008, with Kuehl termed out, the bill SB 810 was eagerly adopted by Sentor Mark Leno. However, he began his march through the legislature with a crop of new legislators who had no history with the bill or with Sen. Leno. It was a somewhat more conservative bunch who required significant fiscal evidence that the bill would save the state money and be affordable to individuals and families. Single payer supporters paid little attention to educating these new legislators since the bill had passed handily before. But these were different people, different times.

In late 2010 the main group pursuing passage of the bill, the State Strategy Group (SSG), agreed that to help move the bill, they would create and fund a panel of experts who would do a new fiscal analysis. The SSG knew it would cost about $250,000 to get this done well – and they agreed it was a top priority.

Without a new fiscal analysis, the bill began to bog down, not passing the Assembly in its first foray under Leno. In response to that loss, and to a perceived threat from federal health care reform, the SSG began to challenge Sen. Leno’s “dedication”, question Senate and Assembly supporters’ “commitment”, and became more and more angry that things were not materializing as they had projected.

At the behest of one member group in the SSG, the majority decided suddenly to by-pass SB 810 and take single payer to the ballot as a proposition. The member group’s policy director boasted they were ‘best buddies” with new Governor Jerry Brown and that as a result, “Jerry will get it on the ballot for us.” Another SSG member pointed out that such a move was illegal, that the Governor had no such power and that it would require a supermajority 2/3 vote of the Legislature to move it to voters because of the fiscal implications. Either that or they had to find $2-3 million for a signature campaign to put it on the ballot themselves. That wet- blanket assessment did not sit well with SSG.

After continuing for several months to insist “Jerry can do it” the SSG finally realized that Brown either couldn’t or wouldn’t get the proposition on the ballot. The SSG shifted focus to the very expensive signature campaign and full-tilt election battle towards which all fund raising efforts were directed.

By late summer 2011, the diversion of attention to the ballot meant that not one dime was allocated to the promised fiscal analysis. Despite having created an impressive panel of health economics experts, no study was ever produced. Ultimately the SSG raised no money for the ballot either, and the group angrily and grudgingly refocused again on passing the bill.

That anger at discovering there was no instant gratification spilled over into a corrosive and suspicious hostility toward Senator Leno. The SSG members suddenly developed amnesia about the fiscal study they had promised to fund, and relations between these now-grudging backers and the Senator’s office got increasingly tense. Supporters showed up unannounced demanding explanations of plans, abused the staff right down to the receptionist, and made clear they did not trust the Senator to keep the focus.

Despite the bombardment of hostility from supposed allies, Senator Leno continued to push the bill. When it predictably bogged down over lack of fiscal clarity, both the senator and Senate leadership used up political capital still getting it onto the Senate floor. However, at the floor vote, five members abstained, and the bill did not pass. Abstentions came from mostly newer senators who could not ascertain the fiscal implications of this massive health care realignment and were highly dubious the state or individuals could afford this extensive new program.

As a favor to the author and supporters, SB 810 remained “on call” for reconsideration of the floor vote to buy time for further negotiations. Senators and staff worked on getting a “courtesy vote” when a member with doubts still votes “yes” to keep it going. At least two courtesy votes were in the works – all that were needed to pass the bill – when the progressive bully machine cranked up, and the shit hit the fan.

Furious single payer supporters claimed that senate leadership had “sold out” and a massive wave of phone calls was unleashed on an unprepared senate – members, staff, and again, even receptionists.

They were inundated with screaming, threatening, angry demands that they vote for the bill. Staff were not spared. No calls were polite – they were angry and snide, shattering one young intern unprepared for personal assaults on her character and politics. Other, older staff were also unnerved by how incredibly rude the supporters of the bill were to the very people they wanted to have vote for it.

Net result? The courtesy votes quickly withered away, the bill had to be pulled to prevent its being killed. Worse, staffers said it was highly doubtful that anyone in the Capitol who knew this story would ever put themselves in a position to work with these single-payer groups again.

After almost a decade of work, single payer seems dead legislatively in California, not just as a bill but as an issue. It died not due to insurance industry or business opposition but due to the obnoxious and outrageously bullying actions of its supporters. Nice job, BullyProgs. Nice job.

As the HCR debate continues there are still some prevailing myths that prevail over the ACA law.  Most myths are slanted right but key myths slant left as well.

1. Batshitcrazy Right Wing Myths:  Let’s get these out of the way first.  There are no “death panels”, funding for abortions, socialistic healthcare rationing, criminal penalties for not buying insurance etc.  These are all simply untrue and part of the Republican denial paradigms.
2. Personal Mandates to Buy Private Insurance is a “Republican Idea”:  No, the concept to require people to by insurance from a private entity is quite old.  Germany has required their citizens to pay into privately funded “sickness funds” for decades.  They are non-profit but administered by non-government entities.  The Dutch and Swiss already have systems in place where citizens have to buy insurance from for profit healthcare insurers.   The fact is most systems around the world are hybrid systems and for good reason.  To call it a Republican idea is not understanding how universal healthcare has evolved in the world.
3. Progressives Think They Will Have to Buy for Profit Healthcare Insurance:   Predominantly no.  What has emerged as the best part of the ACA considering the political environment is how flexible the law is when it comes to healthcare insurance providers.  All states have the ability to set up their insurance exchanges with great latitude including a few non-profit options.   States can provide a public option or even a single payer system like VT did.  The last non-profit option includes private healthcare insurers who are non-profit now like much of BCBS for example and states also have the option to develop NGOs (non-government organizations) to deliver a not for profit option.
4. I Already have Private Healthcare Insurance so the ACA Will Not Affect Me:  For mostly good reasons the ACA will effect almost every American eventually because if we do get nearly everyone covered with healthcare insurance premiums and costs will not go up on the same trajectory.   The biggest bang for the buck has always been expanding the risk pool to as many citizens as possible.   That one principle is what makes other country’s healthcare systems better and cheaper than ours.  Even the Swiss who have a very similar system to the ACA has healthcare cost that are about 70% of ours.
5. The ACA is Moot Because It will be Struck Down by the SCOTUS Anyway:  A small but significant part of the ACA is the only part of the law that possible could be struck down, the individual mandate.  When a part of a law is struck down the immediate remedy is up to the Executive Branch unless the Congress wants to pass a new bill which would be highly unlikely.   There are ways within the ACA law for HHS to make it very painful to people who want to roll the dice and game the system.  A few examples are if someone does not enroll they can be deemed not eligible for subsidies, they could be required to pay back premiums if they do require healthcare insurance after the fact or even pay stiff penalties.  Striking down the federal mandates still does nothing to prevent states from having personal mandates like MA has already and it could have the positive effect that more blue states could find it necessary to evolve faster into adding public options to their insurance exchanges and even going single payer faster.  Like the stimulus I suspect you are going to see allot of hypocrisy over the ACA in red states.

My view may be a bit optimistic but we see more and more that States have become mini-nations in this country of late and there will be many states with good healthcare systems because of the ACA.  States that do not leverage the ACA do so at their own risk.  They will end up either racing to the bottom and get worse and worse care  for their citizens or be pummeled by soaring healthcare costs.

There are still a few fundamental problems that still will exist in our healthcare system with the ACA.  Ending the personal mandate would just add one more fundamental problem because it could result in a national healthcare system that is not near universal.

I think I’ve said it 1oo times now the only thing common with universal healthcare systems around the world that are better and much cheaper than ours is that they are universal, the various ways countries provide access to healthcare insurance is truly secondary by any measure.

Myths Expertly Pointed Out by ChoiceLady

Myth: This is just “Romneycare”. No – it’s not. The MA plan charges a small premium for healthy 30-year-olds, and that is what the state subsidizes. However, to make it affordable for MA, it imposes a $5000 deductible and $10,000 out of pocket mandate per person per year. If you have a chronic condition, that can be $15K year after year after years. What’s free? Not much. The Schwarzenegger clone eliminated only TWO things from the identical plan – childhood immunizations and Pap tests. That’s it. For too many people it has turned health insurance into catstrophic care – it does not catch and treat that PRE-cancerous polyp or mole. However, it does provide cancer coverage (minus the $10K) when you’re already sick and possibly dying. HCR has a huge list of FREE tests and treatments including colonoscopies, Paps, diabetes screening and start-up advice, mammograms, etc. The deductible is variable based on the state, but it’s somewhere around $1200 which is LESS than Kaiser charges in CA now. Also medical risk – age, residence, sex – have been controlled. Today private insurance can charge 500% more for older women than younger, and reform has kept it to a much lower figure of 200% or less.

Myth: Obama refuses to permit single payer and hates it. Wrong. He just gave Vermont an early waiver to implement single payer there in 2014 and praised it highly. Even single payer advocates in other states did not KNOW this (I saw a story, but it was pretty small). You can confirm this on Bernie Sanders’ Senate “newsroom” web site. Vermont can go for it in 2014 as their state option. http://sanders.senate.gov/newsroom/news/?id=2bdb32a3-4c32-4ecb-98cf-9642d61ef52b

Myth: Obama refuses a public option. Wrong. Right from the beginning, the High Risk Pool WAS a public option. If you were uninsured and denied coverage privately, you went into the pool. If you were poor, it was Medicaid. If you were over a certain income, it was insurance that cost a fraction – less than half – of private rates, sometimes even less than that. Anecdotal information leads us to think that although they are not “supposed” to, those covered by private insurance via employers are dropping it due to the cost, applying to private insurers who are disallowing anyone with a pre-existing condition, and then moving into the High Risk Pool. We don’t have data, but time will tell if this is creating, by fiat, a public option. It’s what we always expected, by the way.

Myth: People who are mandated to have insurance will pay through the nose. Nope – unlike the MA plan, there is not a flat rate you pay. You will be subsidized on a sliding scale, paying from 1-9 percent of your income up to 400% of the Federal Poverty Level ($88K for a family of four). Current estimates are those outside employer or group coverage are averaging 15% at the UPPER end of that scale, more at the lower ends. BTW – for reasons I cannot explain, this subsidy is EXACTLY that which appeared in the one fianance version of California’s single payer health legislation. Was it taken from that bill? I think we will never know, but it’s identical.

Myth: insurance companies will get rich and fat off private purchases. Not likely – state review boards are encouraged (CA is creating the law now – AB 52) to give rate increase review to departments of managed health care and/or insurance commissioners. All increases will have to be justified and thus can be rejected. Only states with no concern for citizens would refuse to establish a rate review process that works for all people.

Myth: we are doling out major bucks to pharmaceutical companies. Nope. The chaos of private intervention in drugs is coming to an end, and the government will by 2014 have scaled down costs, closed the “donut hole”, and forced drug companies into providing rational rates and broad generics to keep down both individual and societal costs. Pharma HATES this.

The Republican PR machine reminds me of the con man who would stand on soap boxes on the dusty Main Street in western towns years ago, shouting to the gathered group of curious onlookers about how his Miracle Tonic would cure everything from baldness to pneumonia.

As they embark on their Kill Medicare Snake Oil Campaign, these Republican political pawns of the wealthy, knowing full well that the budget they passed killing Medicare is opposed by over 70% of Americans AND over 50% of Republicans, are prepared to step up on those soap boxes across the nation and sell their snake oil to what they see as a gullible public.

PlanetPOV has used its vast undercover network to provide the following transcript from the first trial of this  campaign by the GOP in Sheep’s Mount, Wyoming.

“Step right up! What I’m holding in my hand here may look like poison, it may taste like poison, it may act like poison but, my friends, this is the only thing that will save you from the doom that’s coming! That’s right, the end is near and the only thing that can save you is this amazing, miracle elixir that we call, “Republican Ryan’s Remarkable Remedy”! Just swallow this and all your worries will drift away! No more worries about making doctor’s appointments and say goodbye to those annoying operations and treatments!

My friends, budget deficits want to kill your granny but the ingredients in Republican Ryan’s Remarkable Remedy, which include only the finest hand-picked tax cuts for the wealthy and the essence of denied hopes and dreams for the middle class and poor, will take care of all of that before you can say” The Black Plague”!

To you older folks I say, don’t be a slave to reason or instinct! Don’t let concern for other generations make up your mind for you! I swear on the life of my own sweet elderly mother, this potion won’t kill anyone over 55! Take it today and save yourself! You show your love for your grandkids in so many other ways, from hard candy to scratchy woolen sweaters, you do enough for them so protecting their standard of living and their health when they’re your age is just spoiling them. You are the last generation of seniors that really deserve health care, you’re far more special than your kids, your grandkids or the families they’ll have! Don’t be shy to stand from the highest walker and shout, “I’m old! I’m selfish! Get used to it!”

To you middle aged and younger folks out there, don’t think about what I just said, think about what I’m saying now! How can you know for sure that Medicare will be there for you when you get old? If you take Republican Ryan’s Remarkable Remedy, you will know for sure, I guarantee it! You may ask, “How does Republican Ryan’s Remarkable Remedy work on impotence and Medicare?” Let’s start with Medicare. Here’s what it’s gonna do, if you buy this formula, you’ll get a $15, 000 voucher to pay any private insurance company for health insurance. Now, you might ask, “What if the only policies I can find ten years from now are $25,000 a year and I can’t afford the extra $10,000 in cash? What if the only policies I can find at $15,000 have a $10,000 or $20,000 deductible? What if very few doctors are willing to take the payment amount provided and I’d have to drive hours to see a doctor…but what if I’m too ill or old to drive?” To all of those questions I say, don’t worry about all of that, it’ll make you sick then you’ll really have something to worry about.

So step right up today, it only costs only one thin vote! Hey, you’re too young to vote, get away kid, ya bother me! The rest of you, don’t wait before it’s too late, buy Republican Ryan’s Remarkable Remedy now! You won’t see another deal like this in your lifetime, I mean it!”

Our congress has made known one path to a balanced budget and what they refer to as “prosperity” for the American people.  It is a path that is wrought with pain and sacrifice for the vast majority of Americans and extreme wealth and comfort for the rest.  The proposal calls for tax cuts for the top brackets and a near annihilation of social services that the poor, sick, elderly and disabled rely on.  Their lives literally depend on these services.

The first major change is to replace Medicare with a voucher system that would provide seniors with a fixed amount of money to purchase insurance from private insurance companies.   The second is changing Medicaid to block grants to states for them to offer a fixed amount of services to the poorest and most vulnerable people in the nation.  Neither of these options are as robust as the current programs.  There will not be sufficient support for our most vulnerable people and their quality of life will be severely reduced by it.

So what does this amount to?  I believe it amounts to the wealthiest among us along with their wholly owned congressmen making a determination that the vast majority of Americans are nothing more than capital for the wealthiest among us.

Is this what we want for America?  I sincerely hope not.  The American people who believe that they are individuals and that they are valuable to society must unite under a common banner or risk becoming Disposable Americans.

Main Things I Learned and My Take

• Healthcare systems around the world that work come in all kinds of flavors and colours but they are all universal. Blanket statements like European healthcare is all single payer and not for profit could not be further from the truth.
• We have great healthcare in this country for people who get healthcare. But accessibility to that healthcare and the costs help make us one of the unhealthiest people in the western world.
• For our healthcare system to be better and less costly the insurance component that fuels it must be as Universally paid into as possible. What percentage of those components are public, private are truly secondary.
• Healthcare systems around the world that fit the countries culture are most effective.
• The hidden gems inside the ACA include; the option that states can use non-profit private insurers in the exchanges, now healthcare insurers have to pay 80% of their premiums toward claims and the trials the government will be able to run with Medicare to solve the fee-for-service problem.
• Not for profit insurance works to lower costs whether it’s a private system administering it like Germany or a publicly administered system like France.
• Killing provisions in the ACA that would prevent near universal insurance coverage just undermines the efficacy of all the other legislation in ACA.
• Fee-for-service payouts with Medicare needs to be adjusted for the long term stability of that program.  The fee-for-service model most private insurance use as well is one of the reasons more medical students opt for becoming medical specialists rather than primary care physicians.   It also is one of the reasons why providers order much more medical tests than other systems around the world alone with fear of medical malpractice.
• Giving states more flexibility in implementing and managing their healthcare systems could be the best way to fit the current healthcare law into a state’s or region’s culture.   My guess is you would have much better systems in progressive states and race to the bottom systems in conservative states.
• Universal, universal did I say universal?  Making the system as universal as possible is the key step to make a more affordable system with better outcomes.

Short Summaries of a Few Universal Healthcare Systems Around the World

The Netherlands – I start with their system because it breaks the mold from what Americans think about European healthcare systems. The Netherlands is now almost entirely private. They have adopted a regulated competition model. Yes they make you buy healthcare insurance from private industry that makes a profit.  They public healthcare to cover the poor and elderly like we do.

The way it works is private healthcare must all offer a basic level of healthcare insurance that is regulated by the government. Costs of these policies are regulated to some extent but insures can compete mostly by lowering their internal costs. If you want additional coverage you can buy it but for about half of all Dutch people they get it through their employer.

The Netherlands spends just 9% of GDP on health care compared to 16% in the US, breaking down to about 3,100USD per capita compared to 6,700 USD per capita in the US and their healthcare system is consistently ranked much higher than ours.

France – The French have the gold standard healthcare system but that gold standard. No other system around the world quite shows how the culture of the country and the culture of the healthcare system defines how it works more than France. The whole culture of healthcare is vastly different in France compared to the US.   French healthcare does not even start in the doctors office it really starts in their educational system. All college and medical school is paid for by the government. The system is based on a public system but still the vast majority of French still opt to buy supplemental private coverage.

By almost every measurement the French healthcare system is one of the top 5 in the world.

England – England is one of the few western countries that has true socialized medicine. It’s system is most consistently the lowest cost healthcare system in the western world for this reason. The main problem with any nationalized system like England’s NHS is that it’s often underfunded since it’s only funded by tax revenue.  So in effect the effectiveness of the system is more dependent on the current pols in power.  This is true in all healthcare systems to some extent but nationalized medicine by it’s very nature is more vulnerable to current politics.  The access and availability to specialists is a major concern in England because it is run like a government HMO where all decisions much go through your GP. Do not miss understand me it’s a good system especially for workers but they have more problems than some hybrid systems.

Obviously access is second to none but very much Americans would accept the limitations of the UK system when it comes to wait times and especially freedom of choice.

Germany – Germans have had universal healthcare longer than any country in the world with the first system starting in the late 19th century.  Employers and individual pay into “sickness funds” that are run by private non-profit insurers and independent of government.   Similar to the co-ops some congress people proposed and part of the ACA within the exchanges.  However many people buy supplemental private insurance.   Again the German system is less costly and has better outcomes than our system.

If I had my choice I would eventually model the American healthcare system after the German system instead of totally public single payer because I think it fits our culture best.

Switzerland – I saved the Swiss system for last because it’s closest to the system that we are implementing now with the ACA. The Swiss system is the second highest cost system in the western world but still over 30% cheaper than ours. The Swiss much purchase healthcare insurance or employers must buy it for the employee. No doubt the Swiss has a pro-business culture and that’s why they opted for a private employer based system. Things that are best out our system are best about the Swiss system. Wait times are the shortest and you have the most freedom to see doctors of your choice.

There are allot of structural differences in healthcare systems around the world compared to the US that are caused by inadequacy of universal coverage and our fee-for-service model.  Most countries with universal healthcare have a higher ratio of primary care physicians to medical specialists, much less medical testing, less medical procedures and of course much less visits to ERs or critical care centers.

Last Word on Single Payer

My opinion is single payer, Medicare for all, would just not fit the current culture in most states and certainly not the country as a whole.   Whether people like to admit it or not you would be forcing people to give up their current healthcare insurance whether they like it or not.  My guess is this would be even more unpopular than individual mandates.  In red states the GOP would starve the system like they do with Medicaid now and create shortages as a way to fit a sick self fulfilling prophecy.   The political climate and even economic climate in this country is far different from when Medicare or even Medicaid were established.  Back then the vast majority of seniors and the poor just did not have healthcare coverage of any real kind so implementation of a new system was much easier.

Medicare shows that even the single payer model can be inefficient when you base it on fee-for-service like it is now.  Public single payer simply does not have the resources to manage payouts for the sickest individuals to providers.  One of the worthwhile components private healthcare insurers have now are case managers.  Yes Medicare can manage broad provider costs well but do poorly on an individual basis.  For single payer to work even in states that support it they would have to substantially change their payout models to providers.

Thanks to the president giving states flexibility recently in developing their universal healthcare insurance delivery systems at least the beginning of single payer models can be adopted by individual or groups of states.  Since states like California and New York are the size physically, financially and geographically as many European countries they would be excellent areas to begin expanding something akin to a public option that can evolve into a more single payer system.  From a purely social science perspective it would be a huge social experiment to see how blue states and red states develop their healthcare systems.   There are probably two big unintended consequences of a more state based system.  First the GOP would set up competition models that could lead to a race to the bottom system where healthcare coverage is nothing more than minimal catastrophic healthcare coverage.  The ACA provides many buffers that should prevent this from happening but you would still need to trust states to enforce these standards.   Second there is a chance that providers would flee to states that don’t manage their payouts to providers.  Again we see this with Medicare where fewer and fewer providers participate in that system.

I got my information from a variety of sources and can supply individual sources upon request.