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I want to take a moment and address those of you who have been asking why Health Care for America Now is not focusing on creating a single-payer health insurance system.

I was a leader of the fight for single-payer reform during from 1988 to 1994. I co-wrote with Richard Gottfried - then and now the Chair of the Health Committee of the New York State Assembly - the only fully-financed single-payer billto ever pass a state legislative body in the country. I shared the responsibility with Assemblyman Gottfried for presenting single-payer at twelve debates sponsored by Governor Mario Cuomo in 1991 on healthcare reform proposals. I wrote a training manual and talking points for candidates for Congress to use in running on single-payer in 1992. I could go on, but you get the idea.

So what happened to me? Five years ago,I sat down to write a history of the struggle to win a single-payer system. (Will it be Déjà vu All Over Again? Renewing the Fight for Health Care for All Tales, Hopes and Fears of a Battle-Scarred Organizer [pdf]). Here's what I wrote in the preamble to that article:

I intended to write this piece as a cautionary tale for both the new generation of organizers for universal health care and the veterans of the last fight. To my surprise, the writing led me to a fresh understanding of the paradox of achieving universal health care in the United States: the political debate about health care reform is turned upside down once the debate turns from the problem state to the solution stage. At that point, people become more scared about what they will lose from reform than what they will gain. This conclusion led me to reframe my view of how we go about organizing for universal health care, and - to my even bigger surprise - to outlining a new proposal for comprehensive reform.

I wrote at the time: "So here's my proposal, in a nutshell: provide everyone in the country with the option, and the means of paying for, coverage through Medicare or through private insurance."

One point of this approach was not to scare people away from reform or to make it easier for the opponents of reform to panic the public. I realized we could reassure people about change  by building on what people are familiar with - both private insurance and Medicare's public insurance plan.

A lot of what I wrote at the time also had to do with the need to reaffirm the positive role of government in America. To do that, we need to demonstrate that government can better people's lives in real ways. Even though it might make us feel good, stating our ideological position in the hope that people will eventually come around is not effective. We need to win real changes that show government can work in positive ways.

Here is HCAN's official position:

The goal of Health Care for America Now is to build a national movement to win the implementation of health care reform that meets the principles in our Statement of Common Purpose. We believe that a properly designed single-payer bill is one way of doing that but not the only way. Many of the organizations that belong to HCAN support single-payer reform and have endorsed HR-676. But in joining HCAN, they recognize that the major focus needs to be on winning quality, affordable health care for all rather than advocating for only one approach. Health Care for America Now believes that the big divide in our country on health care is between those of us who believe that there needs to be substantial government involvement in guaranteeing quality, affordable health care for all and those who think that the solution is to rely ever more on an unregulated private market.

Our goal is to have the United States provide a guarantee of good, affordable health coverage to all its residents. That's the bottom line. A national health insurance plan (single-payer) is one way to accomplish the goal, but it's not the only way. In fact, one of the myths about health care around the world is that "everyone but us has single-payer." In fact, single-payer is the way Canadians provide a government guarantee of good health coverage. Other countries - including the European countries usually held up as models - do it differently, with all sorts of variations of public, private, and non-profit insurance and socialized medicine. But what's true in all these countries is that health care is guaranteed and regulated as a public good.

We need to keep our eye on the prize and on the real debate. It would be great - a progressive dream - if the political debate were between putting everyone into a government health insurance plan (single-payer) and having a very large public insurance plan along with regulated private insurance (which is what the HCAN principles say). But the real debate is between those of us who believe that health care is a public good where government has to guarantee quality, affordable coverage and those who think that the problem with the health care system is that the market's not working, and if we gave people a voucher to buy unregulated private insurance, it would solve everything.

That's why the focus of our grassroots campaign in 2008 is our Which Side Are You On? statement. It lays out two very different visionsfor reform: "Quality affordable health care for all" or "On your own with private insurance". That's what America has to decide.

Late last year, I wrote an article that lays out in a lot of detail the argument for Health Care for America Now's strategy: Winning Quality Affordable Health Care for All [pdf]. I hope you'll take the time to read it. For now, I want to share with you the last two paragraphs from that piece:

We have to start where the American public is today. After seven years of the George W. Bush administration and 30 years of conservative dominance the American public is fearful about their economic status. Most Americans see the government as being corrupt, ineffective and on the side of wealthy special interests. People do not trust the government and that do not think that the government is on their side. Health care reform contains the promise to turn this around, to demonstrate that government can work for all of us, which the public interest can trump corporate interests and the "you are on your own" ethos of the new gilded age. Health care reform holds the promise to create a generation of Americans that support a government that works for everyone, just as the New Deal's advances led to four decades of activist government for the public good.


Coming off more than a quarter century of conservative domination of American politics, I am reminded that Karl Rove's hero, William McKinley, was followed by Theodore Roosevelt and the Progressive Era. Our job is to build a movement for health care reform that ignites the hopes and aspirations of the American people, the American values of opportunity and fairness. Winning real health care reform will requires a clear vision, a persistent, strategic energy and a belief in the miracle of change.  

Richard Kirsch is the National Campaign Manager for Health Care for America Now.

(originally posted on the NOW! blog)

Originally posted to Richard Kirsch on Tue Jul 15, 2008 at 11:02 AM PDT.

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Comment Preferences

  •  Why not? Because the insurance companies want (10+ / 0-)

    to stay on a government tit.  Any plan where insurance is essential to its function is a government subsidy and works program for medical data entry personnel, neither of which are necessary expenses to the delivery of health care.    
      Insurance companies are a major part of the reason health care costs so much; legislating them a continued place in the health care delivery industry at any level is insanity as defined as repeating past behavior and expecting different results.

    ...Former candidate for Congress.

    by Steve Love on Tue Jul 15, 2008 at 11:12:56 AM PDT

    •  I'm for single payer but (0+ / 0-)

      Do you think that medical data entry will go away?

      It may make it easier to streamline, but we will still need the data to pay claims.

      Numbers are like people . . . Torture them enough and they'll tell you anything.

      by Actuary4Change on Tue Jul 15, 2008 at 12:13:32 PM PDT

      [ Parent ]

      •  Yes, There is no reason that (0+ / 0-)

        we cannot computerized the bookkeeping process by linking the PAD the doctor uses as he moves from patient to patient and the payer.  That is the attraction of a single payer.  
          With fully computerized record-keeping and payment there is not reason that a doctor could not receive payment the same day she delivers the service.  We don't do that now because there are thousands of insurance companies and they are still in the paper world. A plan that is essentially universal Medicare should include upgrading every doctor with a digital capacity - something doctors have been reluctant to do because of initial costs- with the result of making the doctor's office more efficient and the whole reimbursement process instantaneous.  There is no reason that health care cannot be paid for with a system similar to that which drives our ATM network.

        ...Former candidate for Congress.

        by Steve Love on Tue Jul 15, 2008 at 12:28:37 PM PDT

        [ Parent ]

        •  Thr automation task is NOT easy (0+ / 0-)

          A friend who is a R.N. and who works as a Community Health Nurse (visiting patients at home after hospital release) has been through the process of automating their system.
          Three times over the years.
          In days of Yore CHNs typed (or paid a typist) to fill out patient records.
          Then began the process of Automating the Industry on the backs of the Nurses.
          First all were required to buy desktops (WIN 95 days), people were trained, records converted, problems arose, problems got MUCH worse. They printed it all out and went back to paper.
          Next,Nurses were provided Palm Pilots for data entry. An Initial Patient Report is  20 pages (6 1/2 x 11). That system was junked.
          2 (appox.) years ago yet another attempt. Laptops. They want the nurses to go into peoples homes with the laptop and enter the data there, make their best attempt to classify the case for payment and ship it to a new department that corrects the coding errors.

          •  I agree, it is not easy and it is really does not (0+ / 0-)

            make it easier if you have a screwed up plan or go about it in the wrong way.  Nurses are not at the top of the medical food chain: it is doctors.  You start with doctors and you have a uniform system across the nation.  Automating the system "on the backs of nurses" is PRECISELY how NOT to go about it.  [Quite frankly, I would not be surprised if the insurance companies set this system up for failure so that they would have all the data entry people as allies in the effort to make sure that a computerized single payer system is not implemented.]
              The best of systems can be sabotaged and even a half-assed system can be made made to work if people are invested in it.  Quite frankly, any system that begins with nurses is a plan destined for failure, not because nurses are morons (on the contrary, they are the rock of the health care system) but because they are not the alpha billing source except in a very few instances.
              I was ingaged in the process of migrating to a computerized system at Texas Scottish Rite Hospital in Dallas and it worked like a charm because they had an informed and trained IS department and proven and tested software.  

            ...Former candidate for Congress.

            by Steve Love on Tue Jul 15, 2008 at 02:27:54 PM PDT

            [ Parent ]

  •  Excellent question Richard. While I'm not an (6+ / 0-)

    expert, my intuition has been that a single payer system as a base with optional free market luxuary add on insurance would be the most efficient, fair, and best system.

    Our companies and workers are at an international competitive disadvantage as many of the other industrial nations have national health care.

    And what percentage of the total cost and employment in health care now is more related to billing and insurance issues rather than actual delivery of care?

    But more importantly, if we think of how tragic and unfair most health related morbidity is, which Americans (or others) should not receive basic health care, including mental health?  

    Children?  Veterans with PTSD?, the disabled, the elderly? pregnant woman, workers who develop mental disabilities based on accidental exposure to chemicals or pesticides?  Hard working folks who chance jobs or develop pre-existing conditions?

    Where do we stop the list and decide certain folks are not worthy of covering?  

    It almost seems like human rights abuse for a country as rich as ours to deny health care coverage to anyone.  

    Or put elederly and those on fixed incomes in a position to choose between food and prescriptions?

    What the heck is going on here?

    Wheres the outrage?

    The means is the ends in the process of becoming. - Mahatma Gandhi

    by HoundDog on Tue Jul 15, 2008 at 11:13:35 AM PDT

    •  You buried your lead.... (1+ / 0-)
      Recommended by:


      ...wasted on administrative costs, wasted on executive compensation and wasted on facilities already available through Medicare.

      In addition, worldwide, Medicare is the lowest per capita cost provider of medical billing, and compensation, even measured at the ridiculous budget on which it subsists today!

      Not to beat a dead horse, but the powers-that-be in the media, the pharmaceutical, medical and insurance lobbies, - and, most subversively, through Novelli at the AARP i.e., Divided We Fail - will prey upon insured peoples' 'fear of loss' until the whole economic system we have collapses. Then what?

      Fear of loss on that scale is the only way that we can sell Medicare for All, and I think we're closer to succeeding than we think.

      It's all part of the credit/finance/housing collapse. The Obama Government will have no choice but to nationalize the health care industry through emergency powers or it will implode. ...the clock is ticking.  

      "The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants." -Thomas Jefferson

      by ezdidit on Tue Jul 15, 2008 at 11:47:30 AM PDT

      [ Parent ]

      •  Medicare For Everyone!!! You're right. (2+ / 0-)
        Recommended by:
        bablhous, Actuary4Change

        As just one example, I have chronic diverticulosus.

        When I went to the emergency room years ago, without medical insurance I was billed $3,500, $2,500 was for a CAT scan.

        I am not on Medicare and just went to the emergency room for the exact same diagnostic and the hospitial billed $350.00 and my co-pay was less than $50. which I don't understand cuz I thought it was supposed to be 20%.

        I realize this isn't a completely fair comparision as the hospital may have been forced by Medicare to take a loss, but my experience is that sometimes the medicle systems vastly overcharges different demographics for the same services.  And don't count chickens to soon, because, after an emergency room visit, without coverage, don't be surprised if you get bombarded with additional private billings from half a dozen specialists, imaging companies, and test labs who happened to be in the ER at the time.

        The means is the ends in the process of becoming. - Mahatma Gandhi

        by HoundDog on Tue Jul 15, 2008 at 12:06:05 PM PDT

        [ Parent ]

  •  Calif. SB-840 passed both houses (0+ / 0-)

    of the Calif legislature. The only thing keeping it from being signed into law was Arnold Schwarzenegger signature. He vetoed it. To bad Garamendi wasn't governor that day.

    I'd like to point out that the insurance companies in at least some of the E.U. is either severely regulated or are none profit organizations. I sincerely doubt that the U.S. insurance companies would go along with such restrictions. I think it would be easier to go single-payer than to get them to change.

    •  Regulation (0+ / 0-)

      We support regulation of the insurance industry, but we feel a public plan needs to be part of the solution as well.

      •  I support eliminating them. (1+ / 0-)
        Recommended by:

        Because I think the narrative is more clear. Giving the public too many policy choices will just provide the insurance industry the best opportunity to come out on top.

        Single-payer is pretty easy to explain and defend to the average person. The average person understands what cutting the middleman out of the equation in order to save 28-30 percent. Lets not muddy the waters with "nuance".

        People understand less expensive. They understand less bureaucracy and paper work. One reason the Clinton plan failed back in 1993 was that it was too complicated. But, the health insurance industry sure were willing to make things clear for the American public weren't they? Those TV ads with the couple at there kitchen table sure had an effect didn't they?

    •  Health insurance is already heavily regulated (0+ / 0-)

      But it's left to the individual states, many of which do a very bad job of setting and enforcing rules.

      Note that McLame's so-called plan includes the provision that a company licensed in any state can write insurance anywhere.

      If you are lucky enough to live in a state with an active and intelligent insurance department you can forget about having it protect you.

      Numbers are like people . . . Torture them enough and they'll tell you anything.

      by Actuary4Change on Tue Jul 15, 2008 at 12:19:35 PM PDT

      [ Parent ]

  •  I've asked the same question (2+ / 0-)
    Recommended by:
    bablhous, LillithMc

    Phase 1) Streamline and modernize Medicare, reducing administrative costs and fraud.
    Phase 2) Expand Medicare to replace all current public health programs, relieving states of the burden of their own systems, absorbing the VA healthcare system (making vets care portable to the doctor of their choice, for a change), replacing Medicaid, the government health insurance plans, etc). Offer good coverage levels, reasonable copays (the normal $10-15 for an office visit, $25 for a specialist, that sort of thing) and no premium. For combat veterans, negotiate with private insurers for "gap" coverage to eliminate all out-of-pocket costs.
    Phase 3) Expand Medicare eligibility to all U.S. Citizens and permanent residents, while eliminating the obligation on employers to offer health coverage. Most will immediately drop their plans (a bigger economic boost than the larget business tax cut ever imagined), and most Americans will move into the public system by choice. Private primary insurance may hang on awhile, but I imagine most insurers will move to "gap" coverage, which assumes much less risk and is consequently much more profitable in the long run (primary care gets "profitable" only when you start denying care).

    "There is danger from all men. The only maxim of a free government ought to be to trust no man living with power to endanger the public liberty." - John Adams

    by Jaxpagan on Tue Jul 15, 2008 at 11:41:40 AM PDT

  •  pushing for a solution (2+ / 0-)
    Recommended by:
    LillithMc, Richard Kirsch

    I have always believed that a single payer system would be the best kind of health care reform, and when I was working on health care in the Clinton White House, I pushed hard to make sure single payer advocates were heard and were involved in our discussions. In great part due to those efforts, the final Clinton health plan had many of the provisions advocated by single payer proponents.
    Now, if Obama is elected along with a Democratic congress, we will have another shot at passing something. I have been consulting with Richard and HCAN as to how we can pass something, and how we can try to make the final bill as progressive as possible. We should make every effort possible to get as good a bill as possible passed, to have something that totally changes the rules of the game. But we've got a narrow window to act, and to have a chance we have to be smart and strategic about what we accept and what we don't. I think Richard's formulation on how to give us our best chance possible is a good one.  

  •  Switzerland (0+ / 0-)

    There was a really good documentary on PBS a few months ago called "Sick Around the World," about six countries with universal health care, two (UK and Canada) with single payer systems and 4 (Japan, Taiwan, Germany and Switzerland) with various hybrid systems.  To my mind, Swiss system, adopted in 1990s was most like what would fly here.  Involved regulating and disciplining private insurers.  One thing, all had to provide a basic package at a set cost to anyone.

    You can view this online at  It's really interesting.  One thing is to see the ultra-conservative president of Switzerland booming out: "Healthcare is a basic right!"

    One more thing: German doctors are not happy; they feel underpaid.  But that is ameliorated by the fact that their education is free.

    "I may have fucked my life up flatter than hammered shit, but I stand here before you today beholden to no human cocksucker."

    by John R on Tue Jul 15, 2008 at 12:13:35 PM PDT

  •  In Calif. they are about to have a rally (0+ / 0-)

    for SR 840. Should I go or are you for or against? I am unclear and know how bearing false witness is  the Republican's favorite hobby.

  •  When I first read... (0+ / 0-)

    "Which side are you on?" I thought...

    Are those my only two choices?

    And then I started looking for jobs overseas. If this is the best we can expect, holy shit are we all in trouble.


    -7.88 -8,77 Just a wine sipping, brie eating, $6 coffee drinking, Prius driving, over educated, liberal, white, activist, male New Englander for Barack Obama.

    by EquationDoc on Tue Jul 15, 2008 at 01:50:53 PM PDT

  •  Whose side is HCAN On? (1+ / 0-)
    Recommended by:

    The core of Richard Kirsch’s argument is that reformers should forego advocacy of a proven and effective reform – single-payer – in favor of policies which have already been demonstrated to be failures, because the latter are politically expedient. In other words, because failure is politically achievable, failure should be advocated.

    The great wealth of literature and experience – both foreign and domestic – should leave us with no doubt that Kirsch and HCAN’s proffered reforms will not only fail to achieve anything approaching universal coverage, they will almost certainly make things worse. As Dr. David Himmelstein of Harvard Medical School points out, we’ve already heard promises that strict regulation of private insurers, placed in competition with a public plan, will demonstrate the public plan’s superiority. But the experience in Medicare has been quite the opposite – private insurers still managed to game the system and attract the healthy and profitable, to the detriment of the public system. This storyline is not confined to the United States: the private health insurer BUPA recent left the Irish market after a judge determined the company had unfairly skimmed healthier patients from the public system, and ordered the company to make adjustment payments.

    The definition of insanity is to continue to repeat the same actions, expecting a different result. Yet this is exactly what Kirsch and HCAN advocate, and the results with be predictable. Their response to evidence that the medicine they peddle is nothing more than a placebo is simply to commission more pollsters to produce charts and graphs emphasizing its political feasibility.

    In contrast, single-payer national health insurance works both on paper and in practice. Kirsch purports to dispel the "myth" that all European nations have single-payer by replacing it with a new one: that these systems preserve – as he and HCAN would – a substantial role for U.S.-style private insurance. Nothing could be further from the truth. In reality, all of these systems work only because they have regulated U.S.-style insurance companies out of existence. Even in the most privatized system, insurers are required to be non-profit, have their benefits and premiums dictated by the government, and must make "risk equalization" payments if one profits at the expense of another. We need not commission a poll in order to discern whether U.S. insurance companies are going to find such an arrangement more politically acceptable than single-payer.

    After many years in the darkness, there is a groundswell of popular support for single-payer. "The U.S. National Health Insurance Act" (HR 676) has 92 co-sponsors in the U.S. House of Representatives. The U.S. Conference of Mayors has just voted unanimously to endorse it. Twenty-five state labor federations and hundreds of union locals have backed single-payer through a grassroots campaign. The majority of physicians and two-thirds of the American public say they support single-payer when polled. To raise the white flag of surrender and retreat to a position more favorable to insurance industry interests at precisely the time when popular support and grassroots energy are on the side of true reform is the real political miscalculation.

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