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True Believers: Selling a Single-Payer System, Despite a Lack of Buyers

Jul 07, 2009

Nurses rally in Washington on May 13th to demand better conditions for nurses as well as comprehensive health reform (Chris Zimmer-KHN).

The YouTube video shows Donna Smith pulling on a white hazmat suit and protective rubber gloves. She is going to work, trying to clean up the nation’s health insurance industry.

With a bullhorn in one hand, and a picket sign in the other, she leads a group of a dozen or so activists, similarly attired, marching outside a Chicago hotel on a windy morning last fall.

The “Health Care Hazard Cleanup Team” has come to protest an industry it sees as toxic to the health of Americans. Today’s target is an insurance company trade group that is holding a meeting inside.

“Hey, Hey, Ho, Ho,” a chorus erupts. “Private insurance has got to go.”

Smith is a cancer survivor whose personal experience with insurance has driven her to lead rallies like this one. She is a foot soldier in the battle over health care, and hers is the most radical prescription for reform.

The idea, which advocates call “single payer,” would replace private insurers with a single, tax-funded government program. They envision a system in which every American would be guaranteed coverage, regardless of ability to pay or medical history, and all patients would be free to pick their doctors.

But despite its appeal to many, single payer, as an option in the current debate in Washington, is DOA. More advocates have been arrested on Capitol Hill than have testified at congressional hearings. President Obama, who years ago said he supported the idea of single-payer, now favors bolstering the existing employer-based insurance system.

Without a seat at the bargaining table, single-payer proponents are still looking to influence the process, if only to raise red flags about proposals they say would make the current system worse. The Leadership Conference for Guaranteed Health Care, a coalition of single-payer advocacy groups, is planning a major rally in Washington on July 30 in an effort to demonstrate the widespread support they say their cause has garnered. The event coincides with the 44th anniversary of the enactment of Medicare, the federal health program for the elderly, which single-payer supporters consider a model for extending insurance to all citizens.

Some die-hards think that Congress may still turn to a single-payer plan in the event other proposals unravel. Ultimately, they believe they will prevail, because, they say, it is the only plan that expands coverage to the 46 million Americans without insurance while putting a lid on spiraling costs.

“It is really unethical for us to settle for or put forth a placebo which we know is not going to be successful in curing the disease,” says DeAnn McEwen, an intensive-care nurse in Long Beach, Calif., and a member of the California Nurses Association, a politically powerful union that supports single payer. “You just can’t compromise your principles.”

“I am not discouraged,” adds Quentin Young, national coordinator for Physicians for a National Health Program, a group of 16,000 doctors who support single-payer. “It is going to happen because we cannot afford not to do it.”

Most political experts say a single-payer plan is not feasible in the current environment. Public ambivalence about the role of government combined with the upheaval that would result from dismantling the current insurance system make radical change highly unlikely, they say. In addition, there would be strong opposition from congressional conservatives who vigorously dispute the rosy picture of single-payer benefits described by advocates.

The decision not to consider a single-payer scheme “speaks to the pragmatism not just of the Obama administration but the Democratic leadership in the House and the Senate,” says Jonathan Oberlander, a health policy expert who is now a visiting scholar at the Russell Sage Foundation in New York City. For them, a single-payer plan “would be too controversial,” especially when they’re trying to reassure anxious Americans that they can keep their existing insurance if they like it.

But for proponents, the failure of a single-payer proposal to advance shows the grip that the health care lobby has on the political process in Washington. At best, in their view, current options on the table amount to tinkering with a failed system; at worst, they further empower an already entrenched insurance industry.

Rep. John Conyers Jr., D-Mich, who has sponsored a single-payer bill, says the year-end deadline set by the White House for enacting reform legislation has made it even harder for proponents to make their case. He says he hopes to insert wording in any final bill that would make it easier for states to set up their own single-payer plans.

Some single-payer advocates, knowing their plan is dead, want Congress to include a government-run insurance option as part of overhauling the health system. Others, says Oberlander, fear it would “hurt the cause of single payer” partly because it “would defuse pressure for change.”

Passionate, if quixotic, the campaign for single-payer has a wide cross-section of supporters: There are nurses and doctors who say they are tired of seeing their patients denied care for lack of insurance; health-policy experts such as Marcia Angell, the former editor of the New England Journal of Medicine, and several dozen members of Congress who have lined up behind Conyers’ bill.

There also are frustrated ordinary citizens looking to make a statement. A newsletter publisher in West Virginia had his wife, a belly dancer, perform at a rally this spring to bring attention to the cause.

There is even a single-payer rap song. Sample lyric: “Come from the land of milk and honey, insurance companies are addicted to money.”

Smith, 54, may seem an unlikely candidate to lead an attack on the health-care status quo. She grew up in suburban Chicago in what she describes as “a very Republican family.” Her father was a pharmaceutical salesman. Her mother campaigned for Donald Rumsfeld when he was a congressman from suburban Illinois.

(Chris Zimmer-KHN)

Like many other single-payer supporters, though, she comes to the fight seeing herself as a victim of the insurance system.

She and her husband landed in bankruptcy court, she says, snowed under by bills when he had a series of heart attacks and she developed uterine cancer. She was a newspaper editor in South Dakota; he was a machinist. Besides jobs, they had plenty of health insurance, or so they thought.

She became a full-throated single-payer advocate after she and her husband were featured in “SiCKO,” the 2007 Michael Moore film about the health care crisis.

Attending the New York premiere, she ran into a busload of nurses who saw the event as a vehicle for promoting a single-payer plan. The nurses persuaded the Smiths to come along on a road trip to other cities where the film was being released.

“Seeing the intensity of purpose the nurses showed for the issue was eye-opening,” she says. She began speaking to groups around the country about her film role and her personal experience, and even testified before Congress. The California nurses made her an organizer and legislative advocate in their Washington office.

A single-payer system, Smith says, is an elegantly simple solution.

Private insurance and federal programs such as Medicare and Medicaid would be rolled into a single national health program. People would pay taxes instead of premiums to finance the system.

Millions of middle-class families would see the cost of health-care decline, supporters contend. As with some other proposals Congress is considering, the rich would pay more. Billions of dollars in administrative costs and executive salaries would be saved by eliminating the tangle of for-profit insurers. Those savings, the thinking goes, would be large enough to cover most if not all of the nation’s uninsured.

But that is a provocative thesis. Some health-care experts say those savings are vastly over-stated, and that single-payer advocates don’t have a plan for dealing with rapidly rising health-care costs that are at the root of the crisis. “It is nonsense, absolute nonsense,” says Stuart H. Altman, professor of national health policy at Brandeis University. “The reason health care costs are high is that we spend a lot of money on health care. It is not all on the insurance side.”

Critics of single-payer plans say they would concentrate too much power in government, including decisions on which treatments qualify for funding. And as taxpayer-funded programs, opponents argue, they’d face budget-cutting pressure that could lead to rationing of care.

Robert Book, a senior research fellow at the Heritage Foundation, puts it more strongly. He wrote in an April issue brief that a "single payer system" would inevitably result in lower payments for physicians and other health care providers, which ultimately would lead to "reduced access and lower quality health care for future generations" of Americans.

Countries with national health programs, says Uwe Reinhardt, a health policy expert at Princeton University, have tended to short-change them. “There is a tendency to under-fund them,” he says, “and so care ends up falling short of the ideal.”

Smith concedes that single-payer may not be perfect but she says it is far superior to any other proposal out there. She is a relentless and ubiquitous promoter of the cause – blogger, street activist and talking head. You can see her on YouTube donning her hazmat outfit or being interviewed about single payer by Bill Moyers on PBS.

She has helped produce a series of videos aimed at dramatizing aspects of the health care debate. She appears in one video speaking from downtown Chicago in the shadow of the Blue Cross Blue Shield headquarters. The building is getting a major facelift.

“In a single payer system you won’t see waste like this,” she says in the video. “We won’t need to build massive structures that keep the for-profit engine going.”

Smith says she has spoken in 42 states and the District of Columbia about the virtues of single-payer. In a regular column on the Internet, she has compared the damage caused by the health insurance industry to the Holocaust. She signs her posts: “Donna Smith, American SiCKO.”

Her overarching message is that people who are responsible and financially secure can be wiped out when a health crisis hits. “I did everything I was taught to do as a middle class person,” she says. “I was educated, worked hard, raised my kids … Yet when illness hit that was not enough.”

Smith says she is now cancer free. She also has insurance through the nurses’ union. Her husband, who has Medicare through a private plan, is having continuing health problems, and is wrestling again with his insurer.

She admits she is frustrated with the way Congress has dismissed what she views as the most just and noble option for reform.

“Women’s suffrage was not easy. The civil rights struggle was not easy. This one is not going to be easy, and it is probably not going to be won right now,” she says.

“But I still have tremendous hope,” she adds. Ultimately, she says, paraphrasing words of Martin Luther King Jr., “the long arc of history bends toward justice.”





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