Medicare 2.0: Doctors group urges health care for all

Dr. Oliver Fein, president of the 16,000-member Physicians for a National Health Program, thinks the civil rights movement of the 21st century will be health care.

As health policy reform moves up the domestic agenda of the president and Congress, a single-payer, government-run program appears to be off the table. But Fein, who was in the Twin Cities last week to launch the Hazardous to Your Health! series at St. Catherine University, thinks the single-payer concept is gaining momentum in the United States.

He urges skeptics to think of a single-payer system as Medicare 2.0 or a new and improved Medicare for All. Fein, an internist and professor at Weill Medical College of Cornell University, explained his reasoning in a Q&A with MinnPost.com.

MinnPost: One report says that those at either end of the health policy spectrum — a single-payer, government-run plan on one end, a free-market approach on the other — are being marginalized in Congress and the administration. Is there any way to revive a single-payer proposal at this point and how would your group go about doing that?

Dr. Oliver Fein: We have been very active in attempting to do that over this period, and what we would say, frankly, is that actually we’ve gotten more visibility during this time, more discussion of single payer over the last six months than we’ve had before. So whether people say that we’re marginalized or not, the fact of the matter is there seems to be more actual discussion of single payer. What I think is really interesting is that although Sen. [Max] Baucus says that single payer is off the table, at the minimum, we’re the elephant under the table. Everybody is referring to us.

So, you have someone like [Health and Human Services Secretary Kathleen] Sebelius now saying we’ll create a public option that will not go to single payer. You have Republicans saying that the thing they fear is single payer; you have a whole variety of discussion that’s going on that keeps referring to this thing called single payer. Probably one of the real problems is there’s not enough of a definition for the public to make an assessment about what that really is.

MP: Would you like to explain that?

OF: I think there are certain principles that really define what single payer is. The first is automatic enrollment in a national plan, which would lead to universal coverage. What we have now are discussions of universal coverage favored by the health insurance industry — provided that there’s a mandate to buy their product. There’s every evidence that that is not going to lead to universal coverage.

Dr. Oliver Fein
med.cornell.edu
Dr. Oliver Fein

Principle two is that benefits ought to be really comprehensive. There’s a lot of discussion that single payer should be a basic package. We think it ought to be a comprehensive benefit package going from prevention, doctor, hospital, pharmaceuticals, to dental, mental health — all medically necessary services.

Principle three is that these things should be publicly financed; that means one would not use insurance premiums for financing. Premiums are really regressive because the president of a company pays the same as the secretary of a company. That seems to us grossly unfair because the incomes of those two parties are so different. So, we would propose either a payroll tax the way the Medicare program, Part A, is funded, or a mix of payroll and income taxes so that you have a progressive way of paying for health insurance. The only way you can do that is through public financing.

The fourth principle is single payer, and what that means is we’re really able to eliminate the administrative waste that occurs when you have multiple payers. The Medicare program has an overhead of about 3 percent in contrast to private health insurance which, on average, has an overhead of 20 to 30 percent. It’s not just the insurance overhead, but every hospital has to have a large billing department to deal with the multiple payers. In my personal office, I have to hire extra people to deal with prior approval, denials of claims, each insurance company having different regulations and different things that I have to fill out.

Single payer would eliminate all of that. A study published in the New England Journal shows that $300 billion could be redirected if we went from a multi-payer system to a single-payer system. That would cover everyone who’s uninsured and many of the people who are underinsured because they have high deductibles — without costing the overall system more. And that’s the real dilemma that the Obama administration is facing right now with their notion of mandates.

The fifth principle is maximizing choice. Under our present private insurance system, health plans limit you to their network of doctors and network of hospitals and you have to pay more if you go out of network or not get covered at all. Many employers offer only one plan — 42 percent of employees in America are offered only one plan. That doesn’t increase choice. The program in the country now with the most choice is Medicare. You have a choice of physician, a choice of hospital; so, again, single payer would lead to increased choice.

The final principle is essentially that this system would be delivered through a nonprofit, privately controlled system. Doctors would not be employed by the government; hospitals would not be owned by the government. What you have is public financing and collection of money by the single payer, but the private delivery system would continue.

So, then people usually ask me is there a model for this, any place in the world that does this? And I respond, “Yes, right here in the United States. It’s the Medicare program.” The traditional Medicare program is very much what we’re talking about. It needs improvement and better coverage. Dental care isn’t covered, for instance; nursing home care isn’t covered; the prescription drug benefit is a real problem because you have to use a private insurance company. The Medicare program can’t negotiate directly with pharmaceutical companies. Medicare is structured on an 80-20 rule where the beneficiary has to come up with 20 percent of the cost. I would eliminate that.

So, what we talk about is Medicare 2.0 — an expanded program of Medicare for all and an improved program that deals with many of these other programs. That would be the way a single-payer program would operate in the United States.

MP: What is your best hope — and worst fear — about the health reform proposals floated by Congress and the Obama administration?

OF: I guess our worst fear would be that Congress would pass essentially an individual mandate that everybody had to purchase health insurance AND that there would be nothing like a public option. That would be our worst fear because what that would do is essentially act as a bailout for the private health insurance industry — just like the bailout for Wall Street, frankly. It probably would not benefit patients but benefit the industry. Private health insurers have been losing people who pay premiums because essentially employer coverage has dropped over 10 million people over the last decade. We think they’re out now for this individual mandate so that they can reverse that and have more people buy private health insurance.

When it comes to the public option, we think there are many problems with it potentially. It could become a multi-payer system where private health insurance persists — a system in which the sickest patient would be dumped into the public option. The public option would, in fact on a per-beneficiary basis, become very expensive. People would say, “Oh, the government can’t run a program.” There would be strong attempts to underfund the program; it could become a total fiasco.

The other thing that worries us a little bit is how are we going to pay for this public option and some of the proposals like taxing health benefits — why are we doing such a ridiculous thing? So we really think that’s the major dilemma for the Obama administration at this point.

MP: Your best hope?

OF: It’s really difficult to say what that would be other than that there would be an increasing awareness of the single-payer option and essentially out of all of this, an increasingly large mass movement that really begins to say, “Well, we need this kind of Medicare 2.0 type program in the United States.” I’m not impressed with the idea that that’s impossible.

One has to think of the kinds of things we thought were really impossible. If you were in the 1960s and looking at the segregation that was in our society — separate waiting rooms in bus stations, train stations … in the South, you would come to think it was impossible that segregation would be erased in our lifetimes. But in four short years because there was a civil rights movement, we got the Civil Rights Act.

My best hope is that there would be a growing awareness and mass movement for health care as a right. What I think that means is health care as a single payer. I think that is growing in the country. It’s just not yet being recognized by politicians. Politicians are, to some degree, beholden to various interest groups, and that can change if there is this growing mass movement.

The civil rights movement of the 21st century, I think, is going to be for health care as a right. 

MP: Why do you think this nation has resisted universal coverage and/or a single-payer program for so long?

OF: I think it’s an accident of history. During World War II, wages were frozen and unions couldn’t bargain for raises. But they could bargain for fringe benefits. So, what happened is that health insurance got linked to employment and that then began to expand. Government involvement in guaranteeing health care is very young in the world. In Europe, it started in post-World War II. There, the accident of history was that they were in very devastated economies and devastated societies; they were rebuilding. The decision there was we’ve got to offer medical care, in essence, as a right.

Well, we had a different model linking it to employment. Gradually, we got to 1965, the Medicare program was passed; why was that? What happened to most people when they turned 65? They retired. They lost their health insurance because they were no longer working for an employer. So, we instituted single-payer national health insurance for the elderly.

Now, we have many more formidable interest groups that have built up since 1965 — the private health insurance industry, the pharmaceutical industry who really worry that they’re at jeopardy if we go to single payer — and they’re probably right. So I think it’s no mystery why things have moved a little slower here. The problem is it’s not sustainable in a global world, and in a global world, which is really the way things are moving, we’re going to see single payer in the United States. It’s inevitable.

Casey Selix, a news editor and staff writer for MinnPost.com, can be reached at cselix[at]minnpost[dot]com.

Readers: What do you think is the cure for the nation’s health care system? Share your thoughts in Comments below.

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Comments (15)

  1. Submitted by Glenn Mesaros on 06/22/2009 - 06:37 am.

    Harper’s magazine, long a bastion of Democratic Party liberal intellectual thought, has decisively broken with President Barack Obama, in the cover-story of its July 2009 edition, titled “Barack Hoover Obama: The Best and the Brightest Blow It Again,” by Kevin Baker. The article draws an extensive parallel between President Obama and President Herbert Hoover, and a sharp distinction between Obama and Franklin Roosevelt. Here are some relevant excerpts.

    “Much like Herbert Hoover, Barack Obama is a man attempting to realize a stirring new vision of his society without cutting himself free from the dogmas of the past—without accepting the inevitable conflict. Like Hoover, he is bound to fail…

    “Still worse is Obama’s decision to leave the reordering of the financial world solely to Larry Summers and Timothy Geithner, both of whom played such a major role in deregulating Wall Street and bringing on the disaster in the first place. It’s as if, after winning election in 1932, FDR had brought Andrew Mellon back to the Treasury. Just as Herbert Hoover could not, in the end, break away from the best economic advice of the 1920s, Barack Obama is sticking with the ‘key men’ of the 1990s. The predictable result is that, even as he claims to recognize the interlocking nature of the problems facing us and vows to solve them as a whole, the president is in fact abandoning most of his program, at least for the time being…

    ” Barack Obama is moving prudently, carefully, reasonably toward disaster.”

    Meanwhile, Barack’s own doctor rejects Obamacare:

    David Scheiner, a 71 year-old internist, has a practice in Chicago’s Hyde Park neighborhood, where he sees a mixture of the famous and the less fortunate. Scheiner, a Princeton graduate who had been Barack Obama’s doctor from 1987 until he became President, Scheiner says, “I’m not really sure [the President] understands what we face in primary care… He doesn’t see all the pain, its so tragic out here. I’m not sure if he’s getting the right input.” Scheiner, a strong proponent of single-payer system, criticizes HMOs, saying, “its nonsense that the private insurance companies need to be protected [from a public plan]. Why, because they’ve done such a good job?”

  2. Submitted by Richard Schulze on 06/22/2009 - 08:54 am.

    Health care is one of those areas where both popular opinion and sound public policy seem to take a backseat to protecting those stakeholders who benefit from the status quo.

    The bottom line is that the health care debate is not really being played out in the court of public opinion. If it were, Congress would pass a robust plan with a public option that was funded by raising taxes on cigarettes, booze, and people making over $250,000, and we’d live happily ever after (or not). Rather, this is a behind-the-scenes fight at the committee level, where certain senators who have ample financial incentives to please the insurance industry have a disproportionate amount of control over the process.

    I’m generally not one to carp about special interest money, seeing politics through that lens is often an overly reductive formulation that serves as a catch-all excuse any time Congress does something you don’t like. But on something like the public option, which has broad public support and which would probably reduce and not increase the long-run bill to the taxpayers, it is just about the only way to explain what’s going on in Washington.

    To be clear, not all of the opposition to the public option is the result of special interest money. Most Republicans probably oppose it on general principle, and there are a couple of Democrats, who have yet to come around to it even though they’ve taken almost nothing from the insurance industry. But the money is why, even with 59-60 votes in the Senate and a President with high approval ratings, Democrats are facing an uphill battle on the issue.

  3. Submitted by Paul Udstrand on 06/22/2009 - 09:28 am.

    The failure of Democrats to champion what is obviously the most popular, rational, and most likely to work solution to our heath care crises once again gives credence to the old complaint that the two party system has produced one coin with two faces. If they fail to produce a government run national system, look forward to yet another election cycle mucked up by third party populist candidates.

    This one reason I supported Obama over Clinton. Clinton’s plan in the early 90s was more about preserving the heath care market than it was about building a health care system. I had hoped Obama would take a different tack- we’ll see. Right now it looks like a replay with the Democrats in Congress trying to preserve existing revenue streams for the status quo rather than solving the problem. Even the dumbest legislator must realize at this point that the “markets” have failed to provide an affordable health care system. In fact, the markets failed in this regard as far back as 1962-63 when the hospitals lobbied for the creation of medicare. The market had already produced too many uninsured people who couldn’t pay their hospital bills.

  4. Submitted by L.A. Krahn on 06/22/2009 - 10:46 am.

    Well said, Dr. Oliver Fein. Thank you for this article, Casey Selix.
    Cue the “little people” now, collectively acting to holding decision makers’ feet to the fire…

  5. Submitted by myles spicer on 06/22/2009 - 11:27 am.

    Outstanding! Isn’t it interesting how much the health care industry fears Single Payer. And also those in Congress who claim “competition” in the marketplace will cure most economic ills, but do not really want competition that is too vigorous.

  6. Submitted by Geri Hetterick on 06/22/2009 - 12:11 pm.

    Dr Fein’s comments are so encouraging. He has explained so clearly how the single payer system can be financed. Medicare needs to be tweeked but has great potential for insuring everyone in this country which is vitally important. We can do this!

  7. Submitted by Steve Titterud on 06/22/2009 - 03:21 pm.

    To the health care insurers and HMOs, this issue is all about that $300 billion revenue stream, and little else. With all due respect to the author, you can ignore all the high-minded claims of principle. It’s about the money. What goes by the name of “administrative expense”, this same $300 billion, pays substantially for the legions of analysts and case coordinators whose primary responsibility is to mitigate payouts.

    From the point of view of the PUBLIC interest, the redirection of that $300 billion from the private health care bureaucracies to the actual purchase of treatment is a fantastic value. It would be an exercise in the elimination of waste. It would continue to pay dividends, year after year.

    The essential problem is that the private interests fighting to hang on to this revenue stream have far more influence on our national legislature than the public interest.

  8. Submitted by Bernice Vetsch on 06/22/2009 - 04:04 pm.

    I fear that the current git-er-done attitude can leave us stuck with a horrendously expensive (while still NOT universal), complex, bureaucratic nightmare of a system that most of us do not want. It cannot fail to continue, for instance, the continued rise in insurance company profits, as noted in this excerpt from a Letter to the Editor of the NY Times (June 19):

    “I was disturbed to see your editorial suggest that the blame for ‘ever rising premiums” falls primarily on physicians. Let’s give credit where credit is due.

    “Between 2000 and 2007, the 10 largest publicly traded insurance companies increased their profits 428 percent, from $2.4 billion to $12.9 billion, according to Securities and Exchange Commission filings.

    “During the same period, the number of insurers fell by nearly 20 percent, largely becaue of a huge wave of mergers that led to stunning consolidation. And premiums increased by more than 87 percent, rising four times faster than the average American’s wages.”

    Do those in government who are pushing to continue control of our health care by these greedy folks believe that factors other than profit have motivated their annual premium price rises? the 2 million-plus “payment deniers” employed nationwide? the establishment of “networks” within which we must find doctors or go without payment?

    Dr. Fein is so, so right.

  9. Submitted by Deborah Calvert on 06/22/2009 - 05:15 pm.

    The cure is honest regulating. This is my story:
    Beware Sun Healthcare Group Inc., where my mother was harmed by known broken equipment they refused to repair while even commited to a California state injunction. We notified the DOJ but They (Dept of Justice) turned a blind eye. So did the Dept of Health. WHY? My mother suffered a horrific death. Then I was fooled, lied to, maniuplated, coerced and threatened in mediation. I filed malpractice against my attorney Daniel Leipold for neglecting to file court papers properly for wrongful death, elder abuse and pain & suffering(duh!)– then he sadly died 2 weeks later. I won the case. But SUN cheated California taxpayers out of millions of dollars in fines the injunction would have cost them had the DOJ done their job. Their own medical director, Dr L Scott Stoney, confirmed the broken equipment killed my mother and quit over the lack of response from SUN’s management. They make profits for their shareholders but at the cost of elder abuse and manslaughter.
    Do we really want this in American any longer? Please reform nursing homes along with healthcare.
    Deborah Calvert, daughter of Evelyn Calvert, Newport Beach, California

  10. Submitted by dan buechler on 06/22/2009 - 05:45 pm.

    There’s also a good reason why the current git er done attitude is prevalent in the White House. Rahn Emmanuel is a pragmatist and if you push the envelope too far it rips. This is a very successful administration with consumer friendly car cafe standards and new credit card rules. Most of the smart democratic constituents are not pushing their own smaller agendas at the risk of losing a pie by attempting to grab two. For deeper political analysis on this read the latest NY Review of Books. An article full of undisclosed and off the record comments from current white house insiders.

  11. Submitted by dan buechler on 06/22/2009 - 05:57 pm.

    The latest Harpers magazine issue has been discreditied by Andrew Leonard another pragmatist. Read “how the world works”.

  12. Submitted by Susan Lesch on 06/22/2009 - 11:57 pm.

    Nice article. Thanks.

    I’d be happy with a system with employees who knew what it cost. A couple years ago I called three places in Minneapolis and asked how much they charged for several common things. I think University hospital won my business but everyone I talked to there failed (utterly and repeatedly) to know what it cost.

  13. Submitted by Bernice Vetsch on 06/23/2009 - 02:15 pm.

    #11 Karin — Although health industry jobs would be lost, it would be over a ten-year phase-in period and would probably be mostly through attrition.

    Re #8 (me) — I should have mentioned that the author of the NY Times Letter to the Editor is David Balto, a senior fellow with the Center for American Progress.

    Their web site, http://www.americanprogress.org, features a June 2009 state-by-state report on Health Care Competition. In Minnesota, Blue Cross/Blue Shield controls 50% of the health insurance market and Medica (United Health Group) 30%. Since United Health is also the Medicare insurance sold by AARP, United Health probably controls well over the 30% Medica share.

    Public option or not, the Daschle/Baucus/Obama plan is a sellout to the industry.

  14. Submitted by dan buechler on 06/23/2009 - 04:02 pm.

    #11 your story is too true. There is little solidarity anymore to be honest I think it was gone in 1965. I was only 7 then but the social capital has been steadily eroding. Many of us have such long lifespans now that our countries are literally charting unknown waters. Our social policy to the large baby boom demographic largely worked many jobs and services were created to employ that group. The only people I know who really felt secure worked in health care or were unionized.

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