The annual Commonwealth Fund study has found once again that the U.S. stacks up last in five measures of healthcare -- quality, efficiency, access to care, equity and healthy lives, compared with Britain, Canada, Germany, Netherlands, Australia and New Zealand. All these countries spend a fraction on health care compared with the U.S.
The new health reform law could address some of these deficiencies. But the findings are under attack from defenders of the status quo who claim in part that the problem is not in our health care system, but in our poverty rate.
Countries do have to do a number of things right to actually improve health:
1. Cover everyone for ready access to health care, to nip problems before they escalate, and to control chronic conditions with medicines or lifestyle changes.
2. Treat acute cases by well trained teams that have access to information about how to diagnose and treat hospitalized patients safely, and have the financial and organizational incentives to do so.
3. Reduce inequities that aggravate poor health, particularly economic differences between rich and poor, and social discrimination based on race, gender, sexuality, disability, etc. The stress of relative powerlessness takes a physical toll and compounds the lack of resources that can buy healthy circumstances: Violence-free neighborhoods where outdoor exercise is safe, healthy food and time to prepare it, spending on social programs like education and income support, information about sexual and physical health, as well as good health care.
4. Finally, it should be affordable so that everyone can use it, including those who need it most. This usually means authorizing the government to play a major role in negotiating prices with the health care industry.
U.S. is deplorably deficient in these areas of performance. And it doesn't all happen in lower-income states like Mississippi. Access is unquestionably a function in part of coverage and is equally wretched in California (where policy has been held hostage for decades to arcane but effective rules against social spending) as in the south. Preventable hospitalizations for chronic conditions vary by county as well as state and reflect poor access to primary care as well as demographic variables. Patient safety is a function of systems, and adequate staffing. Outside of the VA system, our acute care hospitals have insufficient standards for safe and efficient performance, which compromises patient safety and outcomes. In addition, uncontrolled high prices for overuse of medical technology drives the costs of care in the U.S.
Does all this, or even the promise that it will improve as reforms are implemented, justify cutting payments to disproportionate share (DSH) hospitals, as the new law proposes? Very debatable.
However. Let's grant that the U.S. has a higher percent of poor people than other countries, that people of color are disproportionately poor, and that poorer people in the U.S. tend to be in worse health. Dr. Richard Cooper, for one, suggests that the main reason we are outspending the world on health care is that we are spending more money taking care of our poor who are sick.
To the extent that this is true, it is only possibly the case because we take care of poor people in the worst possible way - not through universal access to timely primary care, but through crisis medicine when even U.S. standards generally would not tolerate outright denials of care.
We should have fewer poor people. Race should no longer be associated with poverty. Relatively lower income should no longer determine the degree of power and control over life circumstances that are in turn associated with longevity and good health (nor for that matter should gender, sexuality, religion, or most demographic factors and lifestyle choices; age of course is the exception.). We should not only continue to document these pernicious trends, we should turn our scholarship and advocacy to redressing them. Furthermore, our health care system can contribute to social equity, and presently does poorly.
An unspoken argument is that poverty and race account not only for our higher health care spending butt also for our worse health outcomes, so it will not help to look to reforms of the health care delivery system for solutions. I don't know whether rates of medical errors or C-sections (or misuse of neonatal intensive care units) are higher in the U.S. than in, say, Finland. I know that they are higher than they should be, that they are not disproportionately prevalent in "poverty ghettos," and that they contribute to unjustifiable costs and poor outcomes. Reforming the health care delivery system should not be an excuse for failing to remedy social inequalities. Pointing to inequalities cannot divert attention from the inefficiencies and remediable deficiencies in our delivery system.
The new health reform law and ongoing HHS initiatives make reasonable efforts to acknowledge and address access, inequalities, and delivery system reforms. They won't be as successful as they could be in a single payer system like Medicare and the VA, but even a single payer system in the U.S. would have to implement the kind of delivery and organizational reforms that are now before us.
Friday, June 25, 2010
Quiz: Why Are Medicines Too Expensive and Cigarettes Too Cheap? Clue #1: The Trans Pacific Partnership (!?) Clue #2: You're Not Authorized to Know
It's 2005. Three southern Pacific countries including oil-rich Bunei get together with Chile and craft a trade agreement (on the edge of your seat yet?). The "P4"do not include standard U.S. trade rules that escalate drug prices and promote smoking. They do include some weak provisions on labor and the environment.
Fast forward to June 2010. No politician in the U.S. wants to run for reelection during a job-busting depression pushing for another free trade agreement. But tobacco giant Philip Morris, U.S.-based drug companies and other corporate interests think it would be just the thing.
So the U.S. invites the "P4"- Brunei Darussalam, Chile, New Zealand and Singapore - to join up in a Trans Pacific Partnership (TPP) with the United States, Australia, Peru and Viet Nam. The second round of talks descends on San Francisco from June 14-18, aiming for a "high-quality, 21st century agreement that builds on the standards of P4, setting it up as a platform for a regional trade agreement." (The first round was in Melbourne in March; next meeting set for Brunei in October.)
With a trade agenda in flux and facing demands for a voice in trade policy from public health, labor, environmentalists and consumers, the U.S. Trade Representative invited the Center for Policy Analysis on Trade and Health (CPATH) and colleague "stakeholders" to come inside. Sort of. Here's what we found.
The week's activities raised questions about whether there may be new opportunities in this Administration for shifts in trade policy, on public health, labor, development and the environment. US staff were consistently available and insisting that the Administration wanted a new era of transparency and consultation. Further they signaled that they wanted better labor standards; they were open to concerns about tobacco control, though they also said that some members of Congress would be ready to put the brakes on.
CPATH organized a press conference on opening day, where SF Supervisor Eric Mar and public health advocates called for removing tobacco from the negotiating table. We got good coverage, as did events organized by labor and environmental groups, and PETA. (The SF Board of Supervisors passed Supv. Mar's related resolution on June 22.)
While stakeholder groups have convened at the site of trade negotiations in the past, this time we were afforded the use of facilities inside the meeting area, and the opportunity to make presentations. Highlights of the week included well-attended presentations to the delegates by CPATH, the AFL-CIO, Public Citizen, IFG and others.
CPATH's presentation to trade delegates took place on the evening before the final day of negotiations. We identified the threats to health and health care posed by uneven and unsustainable development; investor-state rules that empower corporations to bring trade charges against governments; and rules that undermine tobacco controls, access to affordable medicines, and commitments on health care and health-related services. Every delegation attended except for Vietnam. The response was overwhelmingly positive.
At the same time, the usual shroud of secrecy surrounded the details of the talks. Morning stakeholder "briefings" were held by the U.S. chief negotiator Barbara Weisel, which focused broadly on what topics were being discussed, without any information on the content. The delegates were using "bracketed text" as the basis for some of their deliberations, but the U.S. would not make this text available for us to see.
This points to a key difference in access and participation between "stakeholders" and official trade advisers; stakeholders may participate in broad discussions about topics under consideration, whereas official U.S. trade advisers review and comment on U.S. negotiating positions and actual text to be negotiated. CPATH's national Campaign for Public Health Representation has focused on bringing public health advisers onto U.S. trade advisory committees, to balance the overwhelming representation by corporate interests. HR 2293/S 1644 seek to change this imbalance legislatively.
This is the perfect time for a campaign to add Congressional co-sponsors to HR 2293/S 1644, which will in turn add public health and consumers to trade advisory committees.
Fast forward to June 2010. No politician in the U.S. wants to run for reelection during a job-busting depression pushing for another free trade agreement. But tobacco giant Philip Morris, U.S.-based drug companies and other corporate interests think it would be just the thing.
So the U.S. invites the "P4"- Brunei Darussalam, Chile, New Zealand and Singapore - to join up in a Trans Pacific Partnership (TPP) with the United States, Australia, Peru and Viet Nam. The second round of talks descends on San Francisco from June 14-18, aiming for a "high-quality, 21st century agreement that builds on the standards of P4, setting it up as a platform for a regional trade agreement." (The first round was in Melbourne in March; next meeting set for Brunei in October.)
With a trade agenda in flux and facing demands for a voice in trade policy from public health, labor, environmentalists and consumers, the U.S. Trade Representative invited the Center for Policy Analysis on Trade and Health (CPATH) and colleague "stakeholders" to come inside. Sort of. Here's what we found.
The week's activities raised questions about whether there may be new opportunities in this Administration for shifts in trade policy, on public health, labor, development and the environment. US staff were consistently available and insisting that the Administration wanted a new era of transparency and consultation. Further they signaled that they wanted better labor standards; they were open to concerns about tobacco control, though they also said that some members of Congress would be ready to put the brakes on.
CPATH organized a press conference on opening day, where SF Supervisor Eric Mar and public health advocates called for removing tobacco from the negotiating table. We got good coverage, as did events organized by labor and environmental groups, and PETA. (The SF Board of Supervisors passed Supv. Mar's related resolution on June 22.)
While stakeholder groups have convened at the site of trade negotiations in the past, this time we were afforded the use of facilities inside the meeting area, and the opportunity to make presentations. Highlights of the week included well-attended presentations to the delegates by CPATH, the AFL-CIO, Public Citizen, IFG and others.
CPATH's presentation to trade delegates took place on the evening before the final day of negotiations. We identified the threats to health and health care posed by uneven and unsustainable development; investor-state rules that empower corporations to bring trade charges against governments; and rules that undermine tobacco controls, access to affordable medicines, and commitments on health care and health-related services. Every delegation attended except for Vietnam. The response was overwhelmingly positive.
At the same time, the usual shroud of secrecy surrounded the details of the talks. Morning stakeholder "briefings" were held by the U.S. chief negotiator Barbara Weisel, which focused broadly on what topics were being discussed, without any information on the content. The delegates were using "bracketed text" as the basis for some of their deliberations, but the U.S. would not make this text available for us to see.
This points to a key difference in access and participation between "stakeholders" and official trade advisers; stakeholders may participate in broad discussions about topics under consideration, whereas official U.S. trade advisers review and comment on U.S. negotiating positions and actual text to be negotiated. CPATH's national Campaign for Public Health Representation has focused on bringing public health advisers onto U.S. trade advisory committees, to balance the overwhelming representation by corporate interests. HR 2293/S 1644 seek to change this imbalance legislatively.
This is the perfect time for a campaign to add Congressional co-sponsors to HR 2293/S 1644, which will in turn add public health and consumers to trade advisory committees.
Saturday, May 22, 2010
Practical Guide to Health Care Reform
by Ellen Shaffer and Judy Norsigian
(published in Salon, May 22, 2010: http://www.salon.com/news/opinion/feature/2010/05/22/progressives_practical_healthcare_guide/index.html)
Two months after it became law, many progressives are still simmering over healthcare reform, convinced that it did too much for private insurers and too little for average Americans. The stakes are high: Demagogues on the right are whipping up fear of the new law in hopes of big gains in the November elections — and counting on progressives to stay home.
It would be a tragic mistake for progressives to play into the right's hand like this. While we share the long-term goal of a universal "Medicare for all" system, too many on the left are ignoring the important improvements to access and quality of care that the new law will achieve — and the policy space that it creates to go further in the future. In particular, we believe four major myths have unduly undermined progressive enthusiasm for the new law:
Myth: Progressive activists should ignore or undermine the new law, which will get us to single payer more quickly.
Reality: An effective political movement requires both idealistic foot soldiers and politicians capable of achieving the art of the possible.
For now, this means fighting hard to protect what we’ve gained while also fighting for more on the public option, on abortion and on immigrant inclusion. Building the power to change the system involves winning victories that make a real difference in people’s lives, thus encouraging them to fight on. With healthcare reform, Democrats won a huge victory, fueled by millions of activists who need to get a pat on the back — and then get back to work. Women in particular have important reasons to stay active, including the need to defend new laws that prohibit insurance companies from discriminating against them.
It's also worth remembering that sitting out this fall's elections because of healthcare reform would mean handing control of the country back to the most extremist Republican Party in history.
Continue reading
Myth: The new law won’t save money because the insurance industry is still standing.
Reality: The law begins to address the major drivers of excess healthcare costs: the overuse and high prices of new technologies and drugs, and social and economic inequalities.
The health insurance industry is predatory, dishonest and parasitic. It contributes to unnecessary administrative complexity that drives up costs. We’d be better off without it. However, it has had the unenviable and only faintly achievable remit of negotiating with the rest of the healthcare industry, which is equally inefficient.
The new law gives us a lot to work with. We spend 16 percent of our GDP on healthcare, more than any other industrialized country, but our health outcomes are worse than most of them. Americans use fewer doctor visits and prescription drugs; we just pay much more for every procedure and every prescription. The U.S. trains more specialists, who charge more than primary care clinicians and also drive some of the inappropriate use of acute care. As a result, the U.S. experiences more hospitalizations for chronic illnesses like hypertension and diabetes — conditions that could be prevented and treated at a lower cost and with better results by appropriate primary and preventive care. And maternity care that underutilizes midwifery care frequently results in worse outcomes.
The cost-control torch ultimately needs to pass to the government, the only purchaser with sufficient countervailing power to negotiate effectively with the drug, hospital and medical device industries, and with clinicians. This is what a single-payer system would do, and the new law punts on this part. But it does use the power of Medicare and other government programs to shift toward system changes that control costs by improving quality. These changes include making comparative effectiveness research available and expanding primary care and prevention. It sets a global budget for Medicare, which must be achieved without reducing benefits or increasing costs for beneficiaries.
The other significant driver of our crummy health outcomes is the social and economic inequalities that derive from our Wild West brand of capitalism. Expanding coverage for more affordable healthcare will smooth some of these edges and improve health.
To be clear: Without a national budget of some sort, money saved through these policies will likely be shifted and spent elsewhere in the healthcare system. The pilot programs that the new law creates will provide lessons for how to improve care while reducing costs — valuable information for future reform efforts.
Myth: The insurance industry is still standing because President Obama made a backroom deal.
Reality: The president made a well-publicized deal with the entire healthcare industry, which is still a force to reckon with.
The healthcare debate revealed and reinforced important information about where power resides. Vast swaths of the U.S. are still in the grip of Republican or ConservaDem representation in Congress. Democratic campaign funding schemes bolster this arrangement by siphoning party funds from progressive to Blue Dog candidates. Progressive challengers are sprouting up in primaries around the country in response. (Bill Halter, take a bow.)
The healthcare industry accounts for one-sixth of the U.S. economy and remains enormously powerful. It includes pharmaceuticals, insurance, medical devices, hospitals and other institutions, and some groups of clinicians. Employers know that they pay less for healthcare in other countries with more equitable systems, but keeping healthcare benefits rooted in employment helps to discipline workers, who might otherwise unionize or change jobs. And more than ever, the corporate-owned, corporate-dominated media are a barrier to any meaningful population-wide comprehension of why patients and the public are being fleeced and abused, and what can be done about it.
Among the key players in the debate, on both sides, there just wasn't an appetite for major changes in how the system functions. For instance, some of the stronger unions are firmly ensconced in the same hospitals whose budgets would likely take a haircut under more substantial reform.
Remarkably, the public stuck with the issue, breathing life back into the public option time and again. As late as February, the netroots mobilized 1.2 million contacts to Congress on a single day. But no organization ever had a credible strategy for mobilizing the massive uprisings required to get rid of the insurance industry, nor did any uprising materialize spontaneously.
This left the fulcrum of power for change at the White House. Clearly, the White House calculated early on that it needed to buy all possible peace from the healthcare industry and the U.S. Chamber of Commerce. Doing so would give it time and space to nudge the issue into the public’s view long enough to establish support, before the inevitable attacks flooded the media (which they ultimately did). In the end, the administration and congressional leaders reasonably calculated that the whole enterprise could evaporate at any moment, and they didn't want to gamble on losing any votes.
Obama's reluctance to push for a bolder final law — one that included the public option, abortion and immigrant inclusion — was surprising and disappointing. But in the end, progressives should appreciate that he overcame obstacles that have sunk every reform effort over the past 100 years and managed to sign a bill into law. Now the challenge is to build on the law — to recognize the institutional changes that the law enacts, while pushing for more fundamental reform.
Myth: The country is ready to go for a Medicare-for-all single-payer system, run by the government.
Reality: The country has mixed feelings about the government. While only the public sector can truly create affordable coverage for quality care for everyone, we need to contest with corporations for the policy direction of the state.
Progressive movements in the U.S. have often battled both the government and capital. The New Deal and the Great Society marked a coda in U.S. history, characterized by aggressive activism by the federal government in the interest of the majority of the population. This heritage, perhaps now resuscitated by the Obama administration, was damaged by the “credibility gaps” of the Vietnam era, undermined by the Reagan years, and ravaged by the Bush administration.
Since 1980, the prevailing economic agenda has represented the triumph of "free" markets. The exercise of state power to defend corporate interests has been presented as a benefit to society at large: It preserves our individual freedoms and the "right" to buy an unlimited array of cheap products. In return, we are asked to consent to cuts in taxes, social services, and spending on education and health, under the pretext that it’s good for us to compete for these basic human necessities.
It is possible that within the confines of the law we just passed, a law that is both compromised and a compromise, the Obama administration intends to introduce accountability and responsiveness to the public into its healthcare policymaking. Health and Human Services Secretary Kathleen Sebelius is seeking public comment about her regulatory authority to set insurance rates. She is deciding how to define "unreasonable" rate increases and whether in fact all rates should be regulated. These are important issues that advocates and the public can and should be addressing.
Where to From Here?
With the new law, we have won policy space to further challenge corporate control, including control of the healthcare system. Limits on the insurance industry’s ability to bilk and fleece the public now include: laws; an energized public that wants to see the laws enforced; and an administration that has already taken enforcement action and gives every indication of continuing to do so. We have won major advances in coverage for healthcare and maybe for affordability.
The short- and longer-term benefits of the law could discredit the scare tactics at the center of the Republicans’ campaign to repeal the law within months. The Medicare program will not go broke at a faster rate but will be sounder financially, as will our economy overall. The misgivings expressed even by the likes of Obama supporter Merle Haggard — “I’m afraid we just can’t afford it” — should give way to the preponderance of evidence that the law will in fact reduce the deficit, once it trickles out. Many benefits will begin to roll out immediately, including lower prescription drug costs for seniors and expanded coverage for young adults. Little will change — as promised — for the overwhelming majority of Americans who are covered by self-insured or commercial health plans through large employers.
Progressives need a strategy that combines jiujitsu with direct action, and that distinguishes between necessary compromises and sellouts. We have to reach out to congressional districts currently represented by ConservaDems or Republicans and win over some of the population that straddles the middle of the road. Our culture of political debate should aim to attract and develop supporters who are savvy and well-informed to surmount the formidable obstacles we face. Progressives must move forward together. We still have the same goal: equitable, quality, universal, affordable healthcare.
Ellen R. Shaffer, Ph.D., MPH, is co-director of the Center for Policy Analysis, which sponsors the EQUAL campaign for Equitable, Quality, Universal, Affordable healthcare. Judy Norsigian is the executive director of Our Bodies, Ourselves in Boston.
(published in Salon, May 22, 2010: http://www.salon.com/news/opinion/feature/2010/05/22/progressives_practical_healthcare_guide/index.html)
Two months after it became law, many progressives are still simmering over healthcare reform, convinced that it did too much for private insurers and too little for average Americans. The stakes are high: Demagogues on the right are whipping up fear of the new law in hopes of big gains in the November elections — and counting on progressives to stay home.
It would be a tragic mistake for progressives to play into the right's hand like this. While we share the long-term goal of a universal "Medicare for all" system, too many on the left are ignoring the important improvements to access and quality of care that the new law will achieve — and the policy space that it creates to go further in the future. In particular, we believe four major myths have unduly undermined progressive enthusiasm for the new law:
Myth: Progressive activists should ignore or undermine the new law, which will get us to single payer more quickly.
Reality: An effective political movement requires both idealistic foot soldiers and politicians capable of achieving the art of the possible.
For now, this means fighting hard to protect what we’ve gained while also fighting for more on the public option, on abortion and on immigrant inclusion. Building the power to change the system involves winning victories that make a real difference in people’s lives, thus encouraging them to fight on. With healthcare reform, Democrats won a huge victory, fueled by millions of activists who need to get a pat on the back — and then get back to work. Women in particular have important reasons to stay active, including the need to defend new laws that prohibit insurance companies from discriminating against them.
It's also worth remembering that sitting out this fall's elections because of healthcare reform would mean handing control of the country back to the most extremist Republican Party in history.
Continue reading
Myth: The new law won’t save money because the insurance industry is still standing.
Reality: The law begins to address the major drivers of excess healthcare costs: the overuse and high prices of new technologies and drugs, and social and economic inequalities.
The health insurance industry is predatory, dishonest and parasitic. It contributes to unnecessary administrative complexity that drives up costs. We’d be better off without it. However, it has had the unenviable and only faintly achievable remit of negotiating with the rest of the healthcare industry, which is equally inefficient.
The new law gives us a lot to work with. We spend 16 percent of our GDP on healthcare, more than any other industrialized country, but our health outcomes are worse than most of them. Americans use fewer doctor visits and prescription drugs; we just pay much more for every procedure and every prescription. The U.S. trains more specialists, who charge more than primary care clinicians and also drive some of the inappropriate use of acute care. As a result, the U.S. experiences more hospitalizations for chronic illnesses like hypertension and diabetes — conditions that could be prevented and treated at a lower cost and with better results by appropriate primary and preventive care. And maternity care that underutilizes midwifery care frequently results in worse outcomes.
The cost-control torch ultimately needs to pass to the government, the only purchaser with sufficient countervailing power to negotiate effectively with the drug, hospital and medical device industries, and with clinicians. This is what a single-payer system would do, and the new law punts on this part. But it does use the power of Medicare and other government programs to shift toward system changes that control costs by improving quality. These changes include making comparative effectiveness research available and expanding primary care and prevention. It sets a global budget for Medicare, which must be achieved without reducing benefits or increasing costs for beneficiaries.
The other significant driver of our crummy health outcomes is the social and economic inequalities that derive from our Wild West brand of capitalism. Expanding coverage for more affordable healthcare will smooth some of these edges and improve health.
To be clear: Without a national budget of some sort, money saved through these policies will likely be shifted and spent elsewhere in the healthcare system. The pilot programs that the new law creates will provide lessons for how to improve care while reducing costs — valuable information for future reform efforts.
Myth: The insurance industry is still standing because President Obama made a backroom deal.
Reality: The president made a well-publicized deal with the entire healthcare industry, which is still a force to reckon with.
The healthcare debate revealed and reinforced important information about where power resides. Vast swaths of the U.S. are still in the grip of Republican or ConservaDem representation in Congress. Democratic campaign funding schemes bolster this arrangement by siphoning party funds from progressive to Blue Dog candidates. Progressive challengers are sprouting up in primaries around the country in response. (Bill Halter, take a bow.)
The healthcare industry accounts for one-sixth of the U.S. economy and remains enormously powerful. It includes pharmaceuticals, insurance, medical devices, hospitals and other institutions, and some groups of clinicians. Employers know that they pay less for healthcare in other countries with more equitable systems, but keeping healthcare benefits rooted in employment helps to discipline workers, who might otherwise unionize or change jobs. And more than ever, the corporate-owned, corporate-dominated media are a barrier to any meaningful population-wide comprehension of why patients and the public are being fleeced and abused, and what can be done about it.
Among the key players in the debate, on both sides, there just wasn't an appetite for major changes in how the system functions. For instance, some of the stronger unions are firmly ensconced in the same hospitals whose budgets would likely take a haircut under more substantial reform.
Remarkably, the public stuck with the issue, breathing life back into the public option time and again. As late as February, the netroots mobilized 1.2 million contacts to Congress on a single day. But no organization ever had a credible strategy for mobilizing the massive uprisings required to get rid of the insurance industry, nor did any uprising materialize spontaneously.
This left the fulcrum of power for change at the White House. Clearly, the White House calculated early on that it needed to buy all possible peace from the healthcare industry and the U.S. Chamber of Commerce. Doing so would give it time and space to nudge the issue into the public’s view long enough to establish support, before the inevitable attacks flooded the media (which they ultimately did). In the end, the administration and congressional leaders reasonably calculated that the whole enterprise could evaporate at any moment, and they didn't want to gamble on losing any votes.
Obama's reluctance to push for a bolder final law — one that included the public option, abortion and immigrant inclusion — was surprising and disappointing. But in the end, progressives should appreciate that he overcame obstacles that have sunk every reform effort over the past 100 years and managed to sign a bill into law. Now the challenge is to build on the law — to recognize the institutional changes that the law enacts, while pushing for more fundamental reform.
Myth: The country is ready to go for a Medicare-for-all single-payer system, run by the government.
Reality: The country has mixed feelings about the government. While only the public sector can truly create affordable coverage for quality care for everyone, we need to contest with corporations for the policy direction of the state.
Progressive movements in the U.S. have often battled both the government and capital. The New Deal and the Great Society marked a coda in U.S. history, characterized by aggressive activism by the federal government in the interest of the majority of the population. This heritage, perhaps now resuscitated by the Obama administration, was damaged by the “credibility gaps” of the Vietnam era, undermined by the Reagan years, and ravaged by the Bush administration.
Since 1980, the prevailing economic agenda has represented the triumph of "free" markets. The exercise of state power to defend corporate interests has been presented as a benefit to society at large: It preserves our individual freedoms and the "right" to buy an unlimited array of cheap products. In return, we are asked to consent to cuts in taxes, social services, and spending on education and health, under the pretext that it’s good for us to compete for these basic human necessities.
It is possible that within the confines of the law we just passed, a law that is both compromised and a compromise, the Obama administration intends to introduce accountability and responsiveness to the public into its healthcare policymaking. Health and Human Services Secretary Kathleen Sebelius is seeking public comment about her regulatory authority to set insurance rates. She is deciding how to define "unreasonable" rate increases and whether in fact all rates should be regulated. These are important issues that advocates and the public can and should be addressing.
Where to From Here?
With the new law, we have won policy space to further challenge corporate control, including control of the healthcare system. Limits on the insurance industry’s ability to bilk and fleece the public now include: laws; an energized public that wants to see the laws enforced; and an administration that has already taken enforcement action and gives every indication of continuing to do so. We have won major advances in coverage for healthcare and maybe for affordability.
The short- and longer-term benefits of the law could discredit the scare tactics at the center of the Republicans’ campaign to repeal the law within months. The Medicare program will not go broke at a faster rate but will be sounder financially, as will our economy overall. The misgivings expressed even by the likes of Obama supporter Merle Haggard — “I’m afraid we just can’t afford it” — should give way to the preponderance of evidence that the law will in fact reduce the deficit, once it trickles out. Many benefits will begin to roll out immediately, including lower prescription drug costs for seniors and expanded coverage for young adults. Little will change — as promised — for the overwhelming majority of Americans who are covered by self-insured or commercial health plans through large employers.
Progressives need a strategy that combines jiujitsu with direct action, and that distinguishes between necessary compromises and sellouts. We have to reach out to congressional districts currently represented by ConservaDems or Republicans and win over some of the population that straddles the middle of the road. Our culture of political debate should aim to attract and develop supporters who are savvy and well-informed to surmount the formidable obstacles we face. Progressives must move forward together. We still have the same goal: equitable, quality, universal, affordable healthcare.
Ellen R. Shaffer, Ph.D., MPH, is co-director of the Center for Policy Analysis, which sponsors the EQUAL campaign for Equitable, Quality, Universal, Affordable healthcare. Judy Norsigian is the executive director of Our Bodies, Ourselves in Boston.
Wednesday, March 24, 2010
Historic
Yay! We passed the bill! No question about it, seeing the House pass the health reform bills, and watching the President sign one of them, felt like moments of triumph. Despite our many many reservations, so many of us have worked so hard over the last year to achieve this victory! From my own work with the remarkable network that has sprung up around EQUAL, and my colleagues at KPFA; to the hard work of women's groups, progressive organizations, and public health; to the members of Congress who took on enormous obstacles: we all have a claim to this step forward. Speaker Nancy Pelosi clearly deserved major credit for working the bill through the Democratic caucus.
But there are bitter disappointments. The public option failed though it was and is popular. Reproductive rights and immigrants' rights are under assault. Corporations are gaining legal as well as de facto rights. The rabid right, while possibly diminishing and cornered, is nevertheless frightening. The opposition leadership is fanning the flames of hate, divisiveness and willful ignorance, as they experience defeat for the first time in a decade. Members of Congress are heckling each other, the President and the public. One staff member described the atmosphere as “vicious.”
It’s not all over yet, even on the most pragmatic level. The Senate will debate all week, and Republicans will attempt every possible maneuver to derail the proceedings.
Both the President and Rep. Dennis Kucinich framed the victory as one that could begin to reverse 30 years of regressive Reagan-era policies. While the details of the bill are largely technical, and far from revolutionary, one has only to think back to the tsunami of corporate opposition that buried similar proposals in the Clinton era to appreciate the potential significance of this accomplishment.
The legislation itself offers significant improvements for health coverage for many, while ducking the most far-reaching controls on costs. The immediate benefits this year include a tax credit for small businesses that offer insurance, a ban on pre-existing condition exclusions for children, the elimination of copayments for preventive care, and a $250 rebate to Medicare beneficiaries who fall into the prescription drug plan’s doughnut hole. In 2014, 16 million people will begin coverage through Medicaid (called MediCal in California), and millions more will be able to buy insurance through pools created by new state-based exchanges. The plan will limit insurance plans’ ability to gouge sick enrollees in the small group market.
The public option would be a crucial factor in controlling costs and holding insurance companies accountable. Like Medicare and other public programs, the public option was envisioned as an entity with the clout to demand lower prices from health care providers, and also a real alternative for people seeking an escape from the predatory insurance industry. Its absence leaves a gaping hole in the program’s viability.
There’s no similar dispassionate analysis of the harm inflicted on women and immigrants. At best, the bills strengthen existing prohibitions on spending federal funds on abortion and for the first time intrude on the right and ability to buy abortion coverage with private dollars; and exclude tax-paying immigrants from health benefits others enjoy. These assaults are driven purely by vitriol.
The job for progressives is to rejoice in the prospects that may be opening up, and to stay angry about what we have lost, while taking a cold, hard look at the power dynamics that landed us here. A map of the House vote suggests a huge geographically-based divide in the U.S., with representatives from the more isolated middle of the country accounting for most of the Republicans, and the 34 Democrats who voted no. Can progressives win primaries against ConservaDems in those districts? A number of organizations are chomping at the bit to find out.
We have to come up with strategies to deepen and consolidate the public’s approval of Medicare as a model for a stronger public role in the health care system, and link state based and national campaigns to pursue it.
Challenging sexism, racism and homophobia will be problematic in an era of economic recession. But our communities are organized and articulate. Winning the power to defend and advance our interests is not an option; our opponents have their knives drawn, in some cases literally.
Quoting Rep. Dennis Kucinich:
“We're at a pivotal moment in American history, and in contrast to a crippled presidency, I have to believe that this effort, however imperfect, will now have a broad positive effect on American society, and make possible many things that might not have otherwise been possible. Once this bill is signed into law, more Americans are going to be aware of this as they ask, What's in it for me? And as they become more familiar with the new law, more people will be accepting this bill. The president will have a stronger hand in domestic and international affairs, and that will be good for the country.”
Is this President up for it, and up to it? Are we? The coming months will tell.
But there are bitter disappointments. The public option failed though it was and is popular. Reproductive rights and immigrants' rights are under assault. Corporations are gaining legal as well as de facto rights. The rabid right, while possibly diminishing and cornered, is nevertheless frightening. The opposition leadership is fanning the flames of hate, divisiveness and willful ignorance, as they experience defeat for the first time in a decade. Members of Congress are heckling each other, the President and the public. One staff member described the atmosphere as “vicious.”
It’s not all over yet, even on the most pragmatic level. The Senate will debate all week, and Republicans will attempt every possible maneuver to derail the proceedings.
Both the President and Rep. Dennis Kucinich framed the victory as one that could begin to reverse 30 years of regressive Reagan-era policies. While the details of the bill are largely technical, and far from revolutionary, one has only to think back to the tsunami of corporate opposition that buried similar proposals in the Clinton era to appreciate the potential significance of this accomplishment.
The legislation itself offers significant improvements for health coverage for many, while ducking the most far-reaching controls on costs. The immediate benefits this year include a tax credit for small businesses that offer insurance, a ban on pre-existing condition exclusions for children, the elimination of copayments for preventive care, and a $250 rebate to Medicare beneficiaries who fall into the prescription drug plan’s doughnut hole. In 2014, 16 million people will begin coverage through Medicaid (called MediCal in California), and millions more will be able to buy insurance through pools created by new state-based exchanges. The plan will limit insurance plans’ ability to gouge sick enrollees in the small group market.
The public option would be a crucial factor in controlling costs and holding insurance companies accountable. Like Medicare and other public programs, the public option was envisioned as an entity with the clout to demand lower prices from health care providers, and also a real alternative for people seeking an escape from the predatory insurance industry. Its absence leaves a gaping hole in the program’s viability.
There’s no similar dispassionate analysis of the harm inflicted on women and immigrants. At best, the bills strengthen existing prohibitions on spending federal funds on abortion and for the first time intrude on the right and ability to buy abortion coverage with private dollars; and exclude tax-paying immigrants from health benefits others enjoy. These assaults are driven purely by vitriol.
The job for progressives is to rejoice in the prospects that may be opening up, and to stay angry about what we have lost, while taking a cold, hard look at the power dynamics that landed us here. A map of the House vote suggests a huge geographically-based divide in the U.S., with representatives from the more isolated middle of the country accounting for most of the Republicans, and the 34 Democrats who voted no. Can progressives win primaries against ConservaDems in those districts? A number of organizations are chomping at the bit to find out.
We have to come up with strategies to deepen and consolidate the public’s approval of Medicare as a model for a stronger public role in the health care system, and link state based and national campaigns to pursue it.
Challenging sexism, racism and homophobia will be problematic in an era of economic recession. But our communities are organized and articulate. Winning the power to defend and advance our interests is not an option; our opponents have their knives drawn, in some cases literally.
Quoting Rep. Dennis Kucinich:
“We're at a pivotal moment in American history, and in contrast to a crippled presidency, I have to believe that this effort, however imperfect, will now have a broad positive effect on American society, and make possible many things that might not have otherwise been possible. Once this bill is signed into law, more Americans are going to be aware of this as they ask, What's in it for me? And as they become more familiar with the new law, more people will be accepting this bill. The president will have a stronger hand in domestic and international affairs, and that will be good for the country.”
Is this President up for it, and up to it? Are we? The coming months will tell.
Saturday, March 20, 2010
Health Reform Debate Devolves (Further)
It's not just about the money. It's about fairness, and equality, and how profoundly our political culture is infused with the imperatives to keep us divided on the most fundamental bases. Our economic and legal systems have been engines of great progress, and also of divisions by class, race, gender, and all manner of measures of privilege and powerlessness.
It is not the same thing that anti-reform protestors on Saturday spat at Rep. Emmanuel Cleaver, and hurled a racial epithet at Rep. John Lewis, and an anti-gay slur at Barney Frank; that there is now consideration of an Executive Order strengthening even further the ban on federal funding for abortion - a life-crushing measure for millions of women - to win votes for health reform; and that the health reform package would extend no benefits to the undocumented workers who, parenthetically, pay taxes and have by and large been wrenched from their homelands by our own destruction of their domestic agricultural economies. Each of these injustices has its own history of oppression, and its heroes, heroines and triumphs.
But aren't we ready, really, to turn a tidal wave of shame and intolerance against the hate-mongers who are fanning these divisions? It's time to demand apologies, resignations, reparations, from right wing demagogues whose time-worn tactics threaten us with real harm, physical and otherwise, and attempt to keep us divided and to deflect attention from the bankruptcy of their own ideas.
Passage of the House health reform bill would be a landmark event in the march toward human justice and equality. We will no longer take it for granted that where we work should determine whether we get health care. Corporations will have to rely on their many other resources to discipline the workforce. More of us will enjoy longer and healthier lives, with greater security. The health care system itself will be constrained in its ability to penalize us for being women, for being older, for being sicker.
Let's turn our attention this Sunday not just to the vote on the House floor, but also to the march for immigrants' rights in Washington, D.C. And building on that, let's continue the momentum we began in November, 2008, to envision and implement an agenda that unites and lifts up all of us.
It is not the same thing that anti-reform protestors on Saturday spat at Rep. Emmanuel Cleaver, and hurled a racial epithet at Rep. John Lewis, and an anti-gay slur at Barney Frank; that there is now consideration of an Executive Order strengthening even further the ban on federal funding for abortion - a life-crushing measure for millions of women - to win votes for health reform; and that the health reform package would extend no benefits to the undocumented workers who, parenthetically, pay taxes and have by and large been wrenched from their homelands by our own destruction of their domestic agricultural economies. Each of these injustices has its own history of oppression, and its heroes, heroines and triumphs.
But aren't we ready, really, to turn a tidal wave of shame and intolerance against the hate-mongers who are fanning these divisions? It's time to demand apologies, resignations, reparations, from right wing demagogues whose time-worn tactics threaten us with real harm, physical and otherwise, and attempt to keep us divided and to deflect attention from the bankruptcy of their own ideas.
Passage of the House health reform bill would be a landmark event in the march toward human justice and equality. We will no longer take it for granted that where we work should determine whether we get health care. Corporations will have to rely on their many other resources to discipline the workforce. More of us will enjoy longer and healthier lives, with greater security. The health care system itself will be constrained in its ability to penalize us for being women, for being older, for being sicker.
Let's turn our attention this Sunday not just to the vote on the House floor, but also to the march for immigrants' rights in Washington, D.C. And building on that, let's continue the momentum we began in November, 2008, to envision and implement an agenda that unites and lifts up all of us.
Monday, March 15, 2010
Thank You Dennis Kucinich
Let’s face it, politicians can be exasperating. Politicians who run for President get a level of exposure that would make most of us run for cover.
But Dennis Kucinich is taking a drubbing for doing what more progressives should be doing: standing up for a public option as part of the health reform bill, and demanding an ERISA amendment.
This is not a simple matter of getting the health reform bill passed. Passing a health reform bill is a bare minimum requirement for the U.S. to make progress towards an acceptable level of social justice and it should be done. Today’s “Hill” reports that the votes in play are - well, most of them. There are presently 114 Democrats declaring hesitation about the bill:
Firm No, Leaning No, Likely No (36)
Firm Yes (2)
Leaning Yes (5)
Undecided (71)
We’ll come back to this.
Last November, 219 Democrats voted to pass a health reform bill, 39 voted No. The bill included a public option, and also included odious provisions limiting access to abortions. Now the speaker needs 216 “yes” votes to pass a scaled back version of the bill, with fixes in the form of a budget reconciliation bill. That means she can lose 37 Democrats.
Some history
Congressman Kucinich voted for the House bill when it went through the Education and Labor Committee. That bill included a public option and an amendment he proposed to the Employee Retirement Income Security Act (ERISA), to permit states to implement single payer systems without facing a court challenge by employers.
Employers like ERISA, they like ERISA’s provisions that preempt state legislation on employment-related health care benefits, and they would be just as happy not to see any changes to it. Passing the amendment through the Committee was not an easy task, and it came about because Republican members of Congress joined some progressives to vote yes, doubtless alert to the fact this provision alone could swell Republican political contributions, and possibly sink the bill if it came before the full House. Nevertheless, the majority of the Committee voted to accept the amendment. Under normal circumstances, that would indicate it would show up in the bill that went to the House for a vote.
You didn’t see that amendment in HR 3692. That’s because in the interim the Chamber of Congress wrote to the House leadership and pledged to oppose the entire bill if it included the ERISA amendment. The House leadership crafted a bill they thought would pass, and that did not include any changes to ERISA. This was before the recent Supreme Court decision giving corporations expansive rights to influence politics. Mr. Kucinich voted “No” on the final bill.
Getting to the Public Option
Now Mr. Kucinich says he would like to discuss changing his vote to a Yes. He wants 2 things in the House bill: A public option. And the ERISA amendment.
Turns out the majority of Americans agree with him. The most popular part of the bill is the public option, and with good reason. Skeptical as we are of the government, allergic as we are to wonkitude, we have no doubt whatsoever about what lies in store for us if we have to start forking over our premiums to the private insurance industry without the option to vote with our feet. We’ll agree to pay up to get close to universal coverage. But we want a safe, affordable haven. The public option offers that, or at least the structural hope of something like that. Despite all that, we hear no end of excuses and proclamations from our elected leaders about why we can’t have it. Last week, a local health advocacy group picketed Kucinich in his district for threatening to vote No on a bill without the P.O.
Kucinich isn’t holding out for a boondoggle, or a minority vendetta. He’s staking a claim for a policy most people want. There are 114 votes in play. One of them belongs to a progressive. Let’s see about moving the other 113. Then we can come back and thank Dennis for voting Yes on a bill we actually helped to shape.
But Dennis Kucinich is taking a drubbing for doing what more progressives should be doing: standing up for a public option as part of the health reform bill, and demanding an ERISA amendment.
This is not a simple matter of getting the health reform bill passed. Passing a health reform bill is a bare minimum requirement for the U.S. to make progress towards an acceptable level of social justice and it should be done. Today’s “Hill” reports that the votes in play are - well, most of them. There are presently 114 Democrats declaring hesitation about the bill:
Firm No, Leaning No, Likely No (36)
Firm Yes (2)
Leaning Yes (5)
Undecided (71)
We’ll come back to this.
Last November, 219 Democrats voted to pass a health reform bill, 39 voted No. The bill included a public option, and also included odious provisions limiting access to abortions. Now the speaker needs 216 “yes” votes to pass a scaled back version of the bill, with fixes in the form of a budget reconciliation bill. That means she can lose 37 Democrats.
Some history
Congressman Kucinich voted for the House bill when it went through the Education and Labor Committee. That bill included a public option and an amendment he proposed to the Employee Retirement Income Security Act (ERISA), to permit states to implement single payer systems without facing a court challenge by employers.
Employers like ERISA, they like ERISA’s provisions that preempt state legislation on employment-related health care benefits, and they would be just as happy not to see any changes to it. Passing the amendment through the Committee was not an easy task, and it came about because Republican members of Congress joined some progressives to vote yes, doubtless alert to the fact this provision alone could swell Republican political contributions, and possibly sink the bill if it came before the full House. Nevertheless, the majority of the Committee voted to accept the amendment. Under normal circumstances, that would indicate it would show up in the bill that went to the House for a vote.
You didn’t see that amendment in HR 3692. That’s because in the interim the Chamber of Congress wrote to the House leadership and pledged to oppose the entire bill if it included the ERISA amendment. The House leadership crafted a bill they thought would pass, and that did not include any changes to ERISA. This was before the recent Supreme Court decision giving corporations expansive rights to influence politics. Mr. Kucinich voted “No” on the final bill.
Getting to the Public Option
Now Mr. Kucinich says he would like to discuss changing his vote to a Yes. He wants 2 things in the House bill: A public option. And the ERISA amendment.
Turns out the majority of Americans agree with him. The most popular part of the bill is the public option, and with good reason. Skeptical as we are of the government, allergic as we are to wonkitude, we have no doubt whatsoever about what lies in store for us if we have to start forking over our premiums to the private insurance industry without the option to vote with our feet. We’ll agree to pay up to get close to universal coverage. But we want a safe, affordable haven. The public option offers that, or at least the structural hope of something like that. Despite all that, we hear no end of excuses and proclamations from our elected leaders about why we can’t have it. Last week, a local health advocacy group picketed Kucinich in his district for threatening to vote No on a bill without the P.O.
Kucinich isn’t holding out for a boondoggle, or a minority vendetta. He’s staking a claim for a policy most people want. There are 114 votes in play. One of them belongs to a progressive. Let’s see about moving the other 113. Then we can come back and thank Dennis for voting Yes on a bill we actually helped to shape.
Friday, March 12, 2010
Three Things Worth Fighting For: A Public Option. Women’s Rights. Single Payer.
It was tempting to think that the Bush presidencies were an error from which we’ve now recovered. It’s increasingly apparent that there are deep structural fissures in our society that, like the earthquakes in Chile, have not played themselves out. Unlike that force of nature, we can do something about it – but it will take some work. Here are three tests that demand our commitment:
1. The public option. Americans want an alternative to the predatory insurance industry. They aren’t ready to mandate turning the whole apparatus of paying for health care over to the government, and we’re not going to talk them into it this year. But they damn well want a safety valve from corporate insurance.
Now, the public option is a new entity. We can predict with certainty that it will have lower administrative expenses and won’t pay profits or million dollar bonuses to executives based on denying needed care. The finer points are less certain.
But critics on the left who have consistently contended that the public option could never work seized with relish a 10-page memo dashed off by the Congressional Budget Office to House Ways and Means Chair Charles Rangel on October 29, 2009, stating that the public plan would likely enroll only about 6 million of 30 million newly covered lives. This estimate itself rested on some questionable assumptions. The House bill (in Sec. 213) tightly constrained the grounds for variation in premiums. In Sec. 322, it also limited the amount the public plan could pay to providers. Nevertheless, CBO said the public plan would have higher premiums than other plans in the new Exchanges:
That estimate of enrollment reflects CBO’s assessment that a public plan paying negotiated rates would attract a broad network of providers but would typically have premiums that are somewhat higher than the average premiums for the private plans in the exchanges.
In addition CBO stated that:
The public plan would have lower administrative costs than… private plans but would
probably engage in less management of utilization by its enrollees and attract a less healthy pool of enrollees. (The effects of that “adverse selection” on the public plan’s premiums would be only partially offset by the “risk adjustment” procedures that would apply to all plans operating in the exchanges.)
These unsubstantiated assumptions were not repeated in CBO’s extensive (167-page) examination in December, 2009, of the factors involved in speculating on the effects of possible reforms.
We need a public option. Progressives should fight as hard as we can for the most robust possible public plan. A new public entity that could enroll up to 31 million is estimable, next to 25 million in the Veterans Affairs system, 45 million in Medicare, 49 million in Medicaid, and millions more in other federal programs. It is just a step, but it is potentially a step forward.
2. Women’s rights. Abortion restrictions were voted down in the Senate, 54 – 45, scant days before Nelson bludgeoned them back in. But the House does not have a reliable pro-choice majority. The state of Utah has criminalized miscarriages if there is a claim that they are related to an attempted abortion.
I repeat: The state of Utah has criminalized miscarriages if there is a claim that they are related to an attempted abortion.
The attack on reproductive rights is not, it turn out, a side show in health reform. It is a major shot across the bow. The assault is serious, it is not going away, and progressives are going to have to fight about it, hard.
3. Single payer. Unlike the abortion issue, health reform is not a step backwards for state single payer efforts. Employers have been using ERISA (the Employee Retirement Income Security Act) for decades to block state reforms that would make them pay up for health insurance. Crusading Dennis Kucinich could still fight to get his ERISA amendment in the final bill, opening an important new avenue for states, and eliminating likely long court battles.
Happily, progressives are figuring out that if we want a progressive Congress, we need to run progressive candidates. Challengers are showing up in Democratic primaries against Bart Stupak and other pretend Dems, and organizations are springing up to support them. It will take more than the election of November, 2008, to recover from decades of neoliberal politics and corrupt economics. Passing health reform is the step we can take in the next few weeks. Fighting to make it work will be one of the projects we dig in for over the next few years.
1. The public option. Americans want an alternative to the predatory insurance industry. They aren’t ready to mandate turning the whole apparatus of paying for health care over to the government, and we’re not going to talk them into it this year. But they damn well want a safety valve from corporate insurance.
Now, the public option is a new entity. We can predict with certainty that it will have lower administrative expenses and won’t pay profits or million dollar bonuses to executives based on denying needed care. The finer points are less certain.
But critics on the left who have consistently contended that the public option could never work seized with relish a 10-page memo dashed off by the Congressional Budget Office to House Ways and Means Chair Charles Rangel on October 29, 2009, stating that the public plan would likely enroll only about 6 million of 30 million newly covered lives. This estimate itself rested on some questionable assumptions. The House bill (in Sec. 213) tightly constrained the grounds for variation in premiums. In Sec. 322, it also limited the amount the public plan could pay to providers. Nevertheless, CBO said the public plan would have higher premiums than other plans in the new Exchanges:
That estimate of enrollment reflects CBO’s assessment that a public plan paying negotiated rates would attract a broad network of providers but would typically have premiums that are somewhat higher than the average premiums for the private plans in the exchanges.
In addition CBO stated that:
The public plan would have lower administrative costs than… private plans but would
probably engage in less management of utilization by its enrollees and attract a less healthy pool of enrollees. (The effects of that “adverse selection” on the public plan’s premiums would be only partially offset by the “risk adjustment” procedures that would apply to all plans operating in the exchanges.)
These unsubstantiated assumptions were not repeated in CBO’s extensive (167-page) examination in December, 2009, of the factors involved in speculating on the effects of possible reforms.
We need a public option. Progressives should fight as hard as we can for the most robust possible public plan. A new public entity that could enroll up to 31 million is estimable, next to 25 million in the Veterans Affairs system, 45 million in Medicare, 49 million in Medicaid, and millions more in other federal programs. It is just a step, but it is potentially a step forward.
2. Women’s rights. Abortion restrictions were voted down in the Senate, 54 – 45, scant days before Nelson bludgeoned them back in. But the House does not have a reliable pro-choice majority. The state of Utah has criminalized miscarriages if there is a claim that they are related to an attempted abortion.
I repeat: The state of Utah has criminalized miscarriages if there is a claim that they are related to an attempted abortion.
The attack on reproductive rights is not, it turn out, a side show in health reform. It is a major shot across the bow. The assault is serious, it is not going away, and progressives are going to have to fight about it, hard.
3. Single payer. Unlike the abortion issue, health reform is not a step backwards for state single payer efforts. Employers have been using ERISA (the Employee Retirement Income Security Act) for decades to block state reforms that would make them pay up for health insurance. Crusading Dennis Kucinich could still fight to get his ERISA amendment in the final bill, opening an important new avenue for states, and eliminating likely long court battles.
Happily, progressives are figuring out that if we want a progressive Congress, we need to run progressive candidates. Challengers are showing up in Democratic primaries against Bart Stupak and other pretend Dems, and organizations are springing up to support them. It will take more than the election of November, 2008, to recover from decades of neoliberal politics and corrupt economics. Passing health reform is the step we can take in the next few weeks. Fighting to make it work will be one of the projects we dig in for over the next few years.
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