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You'd think that when the country is in economic crisis, and when there's a national consensus that the health care crisis threatens the nation's fiscal survival, there'd be very little room for smoke.

Not so, according to Allen S. Brett, author of the recent article "'American Values' — A Smoke Screen in the Debate on Health Care Reform" (New England Journal of Medicine, July 29, 2009).  He makes the convincing case that a simple rhetorical sleight of hand has prevented honest discussion of the benefits of a single-payer plan, and even arguably threatens efforts to include a public option in the current health care bills.

This smokescreen arises from the baseline assumption that the "claim that single-payer health care — a Canadian-style Medicare-for-all system — is antithetical to 'American values."

The underlying premise is that an identifiable set of American values point incontrovertibly to a health care system anchored by the private insurance industry. Remarkably, this premise has received very little scrutiny.

Brett convincingly takes apart the three pillars of anti-single-payer rhetoric in a very lean and effective article that centers around the coveted American need for "choice" (Not to mention its corollary claim that people in government-run systems have none).

1. Single-payer somehow limits "choice of physician, hospital, or clinic."

In fact, Brett says, the opposite is true: a single-payer system removes obstacles to such choices. And the current system gives us all the evidence we need for the many ways in which the private insurance industry limits these choices. He says:

For such choice, a single-payer system beats the competition hands down. Incremental reforms preserving the private insurance industry and employer-based insurance would probably perpetuate the restricted choice of health care providers that many Americans already encounter: private plans typically limit access to certain physicians or hospitals, and physicians often refuse to accept certain plans. In contrast, single-payer proposals eliminate those restrictions.

2. Single-payer would eliminate the choices of insurance providers

Well, yeah. That's the concept of choice that the industry most fears to lose, because right now a few companies enjoy powerful control over what consumers get for their money. Currently they behave like a trust in fixing prices and options, and they work very hard to limit care. And they behave as if the insurance industry, rather than medical care, is the end goal. As Brett says,

Here it is important to acknowledge that insurance is only a means for collecting and disbursing health care funds — not an end in itself. The key question is therefore whether private insurance is superior to single-payer insurance in achieving the desired end of efficient, cost-effective health care.

The lower administrative costs of a single-payer system (as low as 3 % for Medicare, for example) mean that money can be spent on medical procedures rather than advertising campaigns. That's a choice I can live with.

3. A single-payer system will limit choice of treatments

As is widely known by anyone who has private insurance, the industry already devotes a lot of time and personnel hours to getting in the way of patients' treatment, or shedding clients altogether. The goal of cutting costs already means painful discussions of necessary versus unnecessary treatment. As Brett says,

This choice is system-neutral, pointing to neither single-payer nor alternative systems. Any reform initiative must control spending; unproven or unnecessary medical interventions should not be available in any system.

It's worth repeating that the private insurance industry does this every day.

Equal Opportunity and Fairness are American Values.

Brett concludes by challenging critics who say that the very idea of single-payer is antithetical to a unique American value system, that it violates the rugged individualism that defines the American character. Citing the book Benchmarks for Fairness in Health Care Reform, (Daniels, Light and Kaplan, 1996), he reminds us that individualism is just one of many American values.

I took a look at Benchmarks, which I'd never seen before. Daniels et al point out that a commitment to equal opportunity, fairness and justice are also important American values with a long history.

The existance of Medicare and Medicaid show that Americans are not so uncommitted to social justice or fairness or support of others in need as the ungenerous [individualistic] view suggests. Although we fall well short of living up to the values we claim to have, the ungenerous attack on American values overreaches and oversimplifies. It fails to explain our support for Medicare and Medicaid, but more than that it fails to explain why the majority of working people do not act in their own interest by improving their own security and extending universal coverage to each other. We should seek better explanations for why we do not have a universal health insurance scheme, after several close encounters, than merely blaming people for being too selfish and claiming that universal coverage is alien and un-American."

Brett concludes his article by telling us to look beyond the smoke screen, and that we ask the important questions based on what exactly we want a health insurance plan to accomplish.

Will the system care for us when we’re sick and help prevent illness when we’re well? Will we have access to medical care throughout our lives without risking financial ruin? Will we be able to navigate the system easily, without jumping through unnecessary hoops or encountering excessive red tape? Will health care spending be managed wisely? Health care reformers owe Americans a system that best addresses these questions — not one that merely pays lip service to ill-defined "American values."

This is just a summary of his excellent article--I hope you'll have a look. I missed it last week when it came out, though searching today revealed that there was one diary, briefly, that reported his article.

I can't help feeling that this debate is more than anything a war of words. People want health reform, and don't seem that concerned about how it's delivered as long as it covers everyone and cuts costs.

But with a fortune in advertising money backing it up, the insurance industry is going to make the rhetorical war a very hot one indeed. We'll need to fight the smokescreen, and take apart their claims word by word, or they'll succeed in fooling people yet again.

Originally posted to political junquie on Sun Aug 02, 2009 at 08:11 AM PDT.

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Comment Preferences

  •  Sadly, yes. It's not 'teh stoopid'. nt (2+ / 0-)
    Recommended by:
    shaharazade, political junquie

    Those who labour in the earth are the chosen people of God. - Thomas Jefferson

    by Ezekial 23 20 on Sun Aug 02, 2009 at 08:16:03 AM PDT

  •  thanks for the article (5+ / 0-)

    great link!  and to think it was written by a Southerner!

    Allan S. Brett, M.D.
    From the University of South Carolina School of Medicine, Columbia.

    although he is a  "damn Yankee" which is a Northerner who STAYS! (a "Yankee" is a Northerner who visits)

  •  If Americans want it - it's not unAmerican (5+ / 0-)

    seems pretty straightforward to me.

    This is a Christian country. Why, so is hell - M.Twain

    by mydailydrunk on Sun Aug 02, 2009 at 08:30:27 AM PDT

    •  Well said! (3+ / 0-)
      Recommended by:
      CoolOnion, sc kitty, mydailydrunk

      Maybe polls should ask the baseline question "Are you Un-American?" before asking how folks feel about health insurance options. ;} (/snark)

    •  limbaugh and spawn decide what is unamerican (1+ / 0-)
      Recommended by:
      political junquie

      to a large degree and the left lets them say so by allowing them to have the biggest soapbox in the country, 1000 radio stations using public airwaves but protected by call screeners, to repeat lobbyist talking points 24/7 while claiming to have the pulse of the nation.

      it is unamerican because they have been saying so for 20 years since they beat the clintons on this issue, and the left ignores it and waits for the internet revolution because listening to those blowhards gives them headaches.

      it is unamerican because they say so and americans don't protest at their local radio  stations for filling their communities with those lobbyist lies.

      ignoring the talk radio monopoly continues to be the biggest political blunder in decades

      by certainot on Sun Aug 02, 2009 at 09:25:28 AM PDT

      [ Parent ]

      •  As you say (0+ / 0-)

        it's difficult to protest on their media due to call screeners. But there are ways of getting around them and gaining the public's ear.

        I've heard that there's a campaign to organize a free health clinic on the Mall in DC this September or October, and we have the power to combine that with a rally either there or locally to get people involved, and get local papers to start covering the issue.

        And we have the gift of Michael Moore's SiCKO and Bill Moyers recent interviews and stories, that are dramatic, persuasive and well-argued and worth screening at home with a few friends.

        Start organizing! The wingnuts may have a megaphone (carefully controlled by corporate interests), but local actions often speak louder.

        •  i say there may be no better place than RW radio (0+ / 0-)

          stations when it comes to groups protesting and getting local media

          it would be different and it might force the limbaugh dems in those red states to choose between limbaugh and obama if they started seeing their names on signs there.

          and there are 1000+ RW stations out there - some near everyone.

          ignoring the talk radio monopoly continues to be the biggest political blunder in decades

          by certainot on Sun Aug 02, 2009 at 09:48:20 AM PDT

          [ Parent ]

  •  If single payer is (6+ / 0-)

    un-American, then so is Medicare and so is our national Defense.

    Yet, I don't hear any right-wingers complain as loudly about getting rid of Medicare and our national defense.

  •  Of course it is! (5+ / 0-)

    Just like Medicare and the VA!  So there!

  •  The diarist is an optimist (3+ / 0-)

    Equal Opportunity and Fairness are not necessarily American values.

    And that is why I don't think that single payer will fly.  While Canadians (or Swedes or other Europeans) are content to wait their turn in line, Americans believe that we have a god given right to be able to cut in line if we have the money to pay for it.

    This believe is so strong, that many people would prefer having a system where this right is preserved over a better system where everyone would have to wait their turn.

    "I am not a member of any organized political party. I am a Democrat." - Will Rogers

    by wayward on Sun Aug 02, 2009 at 08:40:00 AM PDT

  •  the best thing about the article (2+ / 0-)
    Recommended by:
    CroneWit, Abra Crabcakeya

    that you point out, in my opinion, is the issue of choice of a hospital or physician. That is absolutely not part of the Canadian system.

    I'm quite concerned about all this focus on "hospital systems" as the way to deliver healthcare, with the focus on places like Mayo and Cleveland Clinic. I don't think that should be the model for everyone, and I say that as a long employed, salaried doctor. Adherence to a system that pays your salary limits your choices as a physician, and limits your ability to advocate the best options in treatment for your patients. Believe me, I've seen it.

    That's one thing about the Canadian system that most people don't get: providers are independent actors, docs are actually paid on a fee for service basis (although they are capped) and choices are open. Yes, it's highly regulated but the choices not only belong to the patients, the choice of providers to whom to refer is also up to the individual primary care provider.

    I've long said that Pres. Obama's perspective is colored by the fact that Michelle long worked for a large healthcare system. I'm not saying he's compromised, but that her experience, which she undoubtedly shared with him, gives only one perspective on the issue. We need to be looking at the limitations of those kinds of systems, too, not just at the advantages.

    The Mayo experience is not widely reproducible; they haven't even been able to reproduce it themselves outside of Rochester.

    Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

    by stitchmd on Sun Aug 02, 2009 at 08:48:45 AM PDT

    •  Just to clarify (2+ / 0-)
      Recommended by:
      stitchmd, costello7

      My understanding is that the Canadian system allows perfect freedom of choice--doctor and institution. But your second sentence seems to say the opposite.

      Though further down you say (and I agree),

      That's one thing about the Canadian system that most people don't get: providers are independent actors, docs are actually paid on a fee for service basis (although they are capped) and choices are open.

      Just want to be clear as it confused me at first.

      •  very sorry, mistyped (2+ / 0-)
        Recommended by:
        costello7, political junquie

        I meant to say any restriction was not a part of the Canadian system. I edited and didn't read it thoroughly. I apologize.

        The Canadian system does allow for freedom of choice, without restriction, except maybe regional (the system is administered by the provinces, as I understand it.) For the most part, physicians and hospitals are independent actors. And that allows physicians to act in the best interest of their patients. Salaried docs are going to be limited in that.

        Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

        by stitchmd on Sun Aug 02, 2009 at 08:57:18 AM PDT

        [ Parent ]

  •  Single-Payer is un-corporate-American...nt (4+ / 0-)
  •  I agree that single payer is antithetical to (2+ / 0-)
    Recommended by:
    political junquie, Ezekial 23 20

    American values. Not those values stated in our Declaration Of Independence , our Constitution ,and pother statements of an extraordinarily egalitarian set of ideals. Antithetical to the true values held by that group of americans who have their boots on the necks of the rest of us , and those who serve them with the slavering greed of those convinced that they , too , will be rich Someday.
       Those true American Values are to get everything you can and can get away with , regardless of the cost to others.Manipulate the laws of the land so that lying and theft are legal , if they serve the purpose of making the rich richer.Kill people ,  especially non - whites whenever their continued existence and refusal to be enslaved reduces corporate profits.And maintain a superior , hypocritical fiction as to one's motives and true values .

  •  It's time to push Medicare for All (4+ / 0-)

    Or at least "Medicare for anyone who wants it."

    As evidenced by comments Obama and others are getting, along the lines of "keep your government hands off my Medicare," Medicare is popular, even with right-wing Republicans.

    Since Republicans don't seem to know that Medicare is "government health care," and since some of us on the left have been lobbying for H.R. 676 since 2004, maybe the best bi-partisan plan is Medicare for All.

    If you like you insurance, keep it.  If you're uninsured, buy into Medicare.

    Watching Pete Sessions and reporting from the Taliban-controlled 32nd Congressional District of Texas.

    by CoolOnion on Sun Aug 02, 2009 at 08:59:24 AM PDT

  •  Great Single-Payer diary! (4+ / 0-)

    And I'm glad to see that you rely on a New England Journal of Medicine article, written by a doctor, no less!

    Now that Pelosi has committed to bringing HR 676 (Medicare for All) to the floor for debate and a vote, there is a real opportunity for citizens to have a voice in the debate.  David Swanson (founder of )posts often on single-payer her at dKos, and a  

    Thanks for writing such an intelligent diary on the subject!

  •  The problem is that we (2+ / 0-)

    already have all the things that the right warns about when it comes to national healthcare.

    1. Single-payer somehow limits "choice of physician, hospital, or clinic."

    My answer We already have limits in choice when it comes to physicians, hospitals, and clinics. Insurance companies decide where we will go for care. Also doctors choose because increasingly a lot of medical practitioners have decided to stop accepting insurance at all. Doctors choose what insurances to take and which ones to not accept. So really I don't see how we have much "choice" now.

    1. Single-payer would eliminate the choices of insurance providers

    Now here is an area where, if the insurance companies were smart, they would have jumped at the chance. If I were a CEO for an insurance company I would have gone to Obama and proposed a shift in my business model. Instead of deciding what to cover I'd tell Obama, yes, go ahead with single payer; but I'd like my company to provide customer service and process payments. That way the insurance companies stops making decisions of who to treat and not to treat but still makes money from processing claims. I'm surprised that Obama didn't even consider proposing that.

    1. A single-payer system will limit choice of treatments

    That already happens. Insurance companies make those decisions all the time. And although you didn't argue this point people have long waiting times too here in the US.

  •  yes, 1000 radio stations have said so for 20 yrs (2+ / 0-)
    Recommended by:
    onanyes, political junquie

    limbaugh and hannity and sons have been given the  biggest soapbox in the country, ignored by and protected from the left by call screeners, to spew lobbyist talking points for 20 years from 1000 radio stations to a crowd the size of the one that voted for obama.

    yes, it is unamerican because they say so. to  a large degree the talk radio monopoly decides what is and what isn't acceptable in america. it was limbaugh and sons who beat the clintons on health care- harry and louise were just ticks on his ass.

    ignoring the talk radio monopoly continues to be the biggest political blunder in decades

    by certainot on Sun Aug 02, 2009 at 09:15:27 AM PDT

  •  I thought we won the bogus (2+ / 0-)

    culture war? The illogical arguments that are being used are more of the same bs. The entrenched entities that own the place, define Americans and their Dream by the most fearful greedy and ignorant of the populace.

    The smokescreen of what people want is in actuality just propaganda to allow the pols to feign compromise when in actuality the too bigs are running the show. Health care for profit is an oxymoron. Health insurance is extortion. If you can't pay the vig for their 'product' you are denied access and if you need medical help and haven't paid the vig you lose everything you worked for and own.... Sadly the service you get is what they decide based on the spread sheets. This is not free market, this is extortion...this is denial of basic human rights..  

    "The basic things expected by our people of their political and economic systems are simple. They are:

    Equality of opportunity for youth and for others.

    Jobs for those who can work.

    Security for those who need it.

    The ending of special privilege for the few.

    The preservation of civil liberties for all.

    The enjoyment -- The enjoyment of the fruits of scientific progress in a wider and constantly rising standard of living.

    These are the simple, the basic things that must never be lost sight of in the turmoil and unbelievable complexity of our modern world. The inner and abiding strength of our economic and political systems is dependent upon the degree to which they fulfill these expectations.

    Many subjects connected with our social economy call for immediate improvement. As examples:

    We should bring more citizens under the coverage of old-age pensions and unemployment insurance.

    We should widen the opportunities for adequate medical care.

    We should plan a better system by which persons deserving or needing gainful employment may obtain it."
    From the "Four Freedoms"
    Franklin D. Roosevelt's Address to Congress January 6, 1941

    "And if my thought-dreams could be seen They'd probably put my head in a guillotine" Bob Dylan

    by shaharazade on Sun Aug 02, 2009 at 10:26:30 AM PDT

  •  Single Payer is the "way out". (3+ / 0-)

    Health Care costs Americans three times what
    it's worth.
    The insurance industry has a death grip on
    the throats of Americans.
    They are taking food from the mouths of our babies.
    They have made a habit out of "buying insurance".
    It has all been done by selling FEAR.  
    We are afraid that they will take the security of
    "having health insurance" away from us.  
    And we have bought it "hook, line and sinker.
    If we need a guarantee that we will be "cared for"
    there is only one guarantor to be had--ourselves.
    "Ourselves" is us.
    We, the people must use our only guarantor, our
    government, to bring us back from the brink of
    financial disaster.
    Have you ever wondered why there are so many
    health insurance companie?
    It is a very profitable scam.
    Get out NOW.

  •  single payer sucks (1+ / 0-)
    Recommended by:
    political junquie

    I just know that it does. :-)

    Seriously, Paul Krugman talks about single payer in his book "Conscience of a Liberal" and points out that on economic grounds, it is the best system.  But he also sees it as politically unviable and thinks that we can approximate it by the health exchange/public option stuff.

    When liberals saw 9-11, we wondered how we could make the country safe. When conservatives saw 9-11, they saw an investment opportunity.

    by onanyes on Sun Aug 02, 2009 at 11:58:46 AM PDT

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