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  March 21, 2010

What happened to health care reform?

A collection of TRNN stories on the fight to reform US health care system
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Donna Smith is a community-based journalist, organizer and legislative advocate for National Nurses United and the California Nurses Association and for the single-payer, Medicare for all reform.

Dr Mandy Cohen Executive Director of Doctors for America and a primary care physician. Prior to joining Doctors for America, Dr. Cohen was the Deputy Director of Comprehensive Women’s Health at the Department of Veterans Affairs in Washington DC. Dr. Cohen received her medical degree from Yale University.


PAUL JAY, SENIOR EDITOR, TRNN: Welcome back to The Real News Network. I'm Paul Jay in Washington. Joining us again to talk about health-care reform are Donna Smith—she's with the National Nurses United and the California Nurses Association—and Doctor Mandy Cohen. She's executive director of Doctors for America. And just to remind you, if you didn't see the first segment, which you really should before you watch the second segment, but just in case, we're having a conversation about health-care reform. Both my guests are for health-care reform. And we're going to talk about how the heck did we get here, because if you go back to when President Obama was elected, and not far from here, there were I don't know how many hundred thousand people cheering for change we can believe in, and it wasn't so long ago. So what happened?

DONNA SMITH, NATIONAL NURSES UNITED, CALIFORNIA NURSES ASSOCIATION: Well, that's a wonderful question. I'm betting they're asking themselves that sometimes, those who are looking at the political falling-out of the last year. What's interesting to me is they just didn't trust how much support there was for real significant change in this country. I think that they—you know, to President Obama's credit, he wanted to reach out to the other side of the aisle and have this great attitude of bipartisanship. But that's not what the American people elected when they elected him. They really wanted change, significant change. We had seen eight years of the status quo in this country and real problems for American families and workers and people trying to secure health care, and they really gave a mandate for a big change.

JAY: Well, is it possible that the person that didn't believe in change we can believe in was President Obama?

SMITH: I don't believe that, though. Maybe I should be more cynical, and maybe folks who watch this on the left will say, "Oh my gosh, I can't believe that Donna really has any belief that President Obama has a deeper vision for this country," but I want to believe that he does, still, and I think most people still want to believe that he does. I think you get into the Washington mentality where you want to act with members of Congress like you're going to act in concert with them and get things done, and what he didn't estimate well—I think what his team didn't estimate well for him is how much support he had from the American people for making really significant change and doing it relatively quickly. I think they launched into this "We're going to have everybody's input." They heard a little bit of clamoring from this tea party right wing, very right-wing conservative, a little clamoring from those people. The mainstream media elevated that to a very large degree over and above what the millions of Americans who wanted significant health-care reform were saying. And all of a sudden we have this move to really tamp down on what we're doing with health-care reform—a real mistake.

JAY: I don't understand some of the loss on the PR front. My sister-in-law is a pediatric neurosurgeon in West Virginia, and she has a practice where people are coming from, you know, the hills of West Virginia, bringing their kids with brain tumors and other kinds of problems, and she gets phone calls saying, "I can't bring my kid for the appointment today, 'cause I can't fill up the gas tank; and when I can afford to put the gas, I'll make another appointment." And she's quite sure these people are voting Republican. And when she asked, are you—talks about health-care reform, well, then they say, "Well, I don't want to lose Medicaid." And they're convinced they're going to lose Medicaid. When you have the pulpit of the presidency, and, you know, maybe you don't have Fox, but you've got the rest of the media to talk through, how do they lose this propaganda war?

DR. MANDY COHEN, DOCTORS FOR AMERICA: No, we lost the message. I totally agree. You know, some say it's because "reform" doesn't fit nicely onto a bumper sticker. "No" fits great onto a bumper sticker—"just say no". But reform is complicated, and I get that. It needed to be explained in simple terms, and how this was going to be better for the American people in terms of regulating the insurance company, expanding and stabilizing Medicaid, and, you know, an investment in public health, an investment in primary care. You know, and those simple things really got lost in the message, and was just fear of change really took over. And I agree that the right got elevated.

JAY: But you hand the whole thing over to Senator Baucus. Nobody knows what the heck the legislation is.

COHEN: Right, and the message is totally—.

JAY: But doesn't that show sort of lack of commitment? Like, why would you give most of your signature piece of legislation to Baucus?

COHEN: Well, I mean, I appreciate that we said bringing—you want to hear all the ideas, you want this—we're changing a—we're doing a very comprehensive piece of legislation. You want to hear all ideas; you want to bring everyone to the table. But then you need to, you know, move forward, and if this is going to be about politics and not about people, then you just need to move forward. And so I think, like, polling has showed that if people know what's in the bill, if you talk about the specifics, they like it, but when they hear the word "health-care reform", it's taken on a negative connotation.

JAY: Well, one of the critiques that comes from Donna's crowd is that because they didn't come out with—. First of all, "Medicare for all" is a bumper sticker. It's pretty easy to get your head around. But also, in terms of cost-cutting, you can really just show where Medicare-for-all cuts costs, 'cause you look at the Canadian example and European examples, how much cheaper the health-care systems are, that whatever was coming out of Baucus and all these other committees, it was, one, so complex, and so many holes in it in terms of cost-cutting, that you couldn't actually sell it.

COHEN: So I think while "Medicare for all" does fit on a bumper sticker, I think going a little bit beneath that, you know, Medicare does have its own problems, so you need to be fixing those problems, too. So I don't think it's as simple as just saying, "Open up Medicare for everyone." So I think that there are significant challenges that we would have in the Medicare system. It's going to go broke in 2017 right now with the people who are in it. So, I mean, we'd have to think very hard about—. And some of the changes that are in the reform bill are thinking about changing Medicare in order to sustain its life and change the way they pay doctors, and do different sorts of pilot programs in order to change the delivery system. So you need to think about, you know, improving Medicare before you can think about expanding it to all. But I do agree that, you know, the president, the Great Communicator, you know, hasn't communicated. But I admire him for his leadership in taking this challenge on. It's been, you know, decades, and sometimes you try and you fail.

JAY: Okay, I'm going to interrupt you, 'cause we're not going to [inaudible] he gets enough praise.

COHEN: Alright. Fair enough.

JAY: 'Cause the issue of Medicare and the slogan "Medicare for all" is not just a historical question that, you know, he could have/should have. What do you do next? Both of you were telling me that this piece of legislation, you know, it's not perfect, you know, it's a starter house, or you have to hold your nose to support it, but it's better than nothing. But both of you were saying the fight's just beginning. So what are you going to fight for? So Mandy's saying Medicare for all maybe isn't the thing to be fighting for now, either.

SMITH: We don't agree. We agree Medicare-for-all is the thing to fight for, an improved Medicare for all; we would agree with that. One of the reasons I think it's clear to know is that one of the reasons Medicare has some financial problems—there are a couple of reasons. First of all, the sickest and the oldest are in the pool right at the moment, in the Medicare pool. You know, in this country, people who are severely disabled and people who are over 65 are the ones who are getting Medicare. Those are also the groups that get the most costly health care. If we had everybody in the Medicare pool, that's the same basis we base wanting to mandate private insurance is the large-pool factor. Another problem for Medicare [inaudible] was the Medicare Advantage plans. They cost 14 percent more than straight Medicare, and that's because a huge rip has to go to private insurance companies—they have to make their profit out of these Medicare Advantage plans, and they essentially take a pure Medicare offering, where people can choose their own providers, and create, like, a PPO [preferred provider organization]. So, anyway—.

JAY: We've heard a lot about this, but this debate is sort of more primary, because Medicare-for-all means close down private insurance companies, unless they're doing some kind of secondary insurance, as you see in Canada. But in terms of lifting the main load, okay. So—'cause I want to know whether you guys are going to be on the same page and what the next fight is about it, 'cause—

SMITH: And we're taking it to the states as well.

JAY: —'cause you want everybody on board saying, "Medicare for all."

SMITH: The nurses also did an interesting study that they released last January about the economic impact of extending Medicare to everyone, and it would actually be a giant—you know, people worry about, oh my gosh, we'd lose all these jobs in the private insurance industry, when in fact, if you study all the sectors that would be impacted by everybody in this country having access to health care in an equal way, there'd be a net job creation of 2.6 million jobs.

JAY: Okay. So, Mandy, everyone gets on board with Medicare-for-all is the next up, or no?

COHEN: I always think it goes so much deeper than who pays. And it's how you pay and how you set up that delivery system. I think that that's where our challenges lie ahead in changing the culture of medicine, in changing the delivery system, and go beyond—. You know, there are advantages to administrative simplifications and things like that when you simplify a system and have one entity that's paying, but it's so much more than that. And I think there are things in this reform bill right now that are going to change Medicare for the better, change some of the delivery systems for the better, to set us on a road to make our system better. But there are other places in the world that have better health-care systems that are more efficient, less costly, good outcomes like Sweden, like Switzerland, that work on a hybrid system where it's private and public. So, you know, it doesn't have to be all-or-nothing.

JAY: Well, the Canadian system is more or less private delivery with public insurance, so in that sense the Canadian system is hybrid, too. But the primary issue is: do you cut out private insurance companies or not? Because the Medicare-for-all gang are saying they're part of the problem and they're not going to be part of the solution. You agree with that?

COHEN: No. I think that we could do regulation, that we haven't given a good shot at doing regulation in the market of what we have right now. And so I want to at least see—let's see how that goes before we think about a very complicated way of dismantling a system that's certainly very entrenched, thinking about how would we dismantle that system and move to something else, without having people have disruption in their coverage and a disruption of their relationship with their doctor. You know, let's have this process move forward. And I think that's what's on the table right now, and I think that's why, you know, there is consensus that this isn't the place where we need to start.

JAY: Mandy?

SMITH: "Disruption", you know, I hear that, and I so respect what you're saying, Mandy, but we look back to how, when Medicare was first implemented in this country for people 65 and over in the 1960s, within one year, people—you know, they had predicted all these calamities with how people would get signed up. Within one year, the people who were eligible for Medicare, 98 percent of them were signed up within a year. There was very little disruption, except in a good way, you know, of extending care, and poverty in seniors dropped significantly after people had access to Medicare. So there's no reason to think that those things wouldn't be extended. There would be disruption for the private insurance industry, certainly. There would be disruption for people who have been used to that framework of trying to deliver—you know, deliver—. Think about most patients and the frustration of going through an insurance company as really the bureaucrat that comes between you and your doctor; it isn't anybody in the government, and it isn't—it's people in the insurance industry.

JAY: Well, to put words in Mandy's mouth, they might argue it's already been shown this isn't feasible, given the reality of American politics. So why doesn't everybody get on board for stronger regulation? 'Cause even if what you're saying is true, you can't get it now.

SMITH: We've proven a lot that regulation doesn't work with the insurance industry so far. The nurses released a study in California where the insurance industry self-reported their denial rates on claims. And nothing, really, in this legislation really goes at that core issue, denial of insurance claims. You know, you can force an insurance company to say no pre-existing conditions; you can say that you're not going to have—you're going to have to cover everybody who comes to you for care; you can't rescind policies later on based on someone having an illness you don't want to cover; you can do those kinds of—. There is nothing that keeps them from denying care once somebody's already one of their customers. This is one of the major problems for patients in this country. And if you go to the point where you start to limit their medical loss ratio, which is what they call all of us—we're "medical losses" when we use the private insurance industry. You know, we're losses. If you limit the amount of medical loss you can have, they're going to make money. I promise you they're going to make money. Listen to Anthem Blue Cross this week. We've heard all about them wanting to raise rates 39 percent in California in the individual insurance market, part of what resulted in President Obama going forward with this wanting to regulate what [inaudible] the states regulate insurance increases.

JAY: So, Mandy, regulation—.

COHEN: Well, I think you're missing one important piece of what's in the health-reform legislation is a minimum standard of benefits. Right now there's a lot of junk insurance out there, and one of the regulation is really setting a floor. Like, you need to have a minimum benefit package. And so I think that gets at a lot of the concern about denials of care and disruption of relationships. So I actually think it's going to improve [inaudible] relationship between a doctor and the patient, because there's going to be this floor set, so that we know we have at least a minimum set of benefits—not only that, but a huge investment in prevention like no other. And, if anything that came out of the summit, there was great agreement that we need to do more on prevention and public health. Let's start there, like, if this all goes away in the next several months, and we'd best come back and be doing prevention and public health investment, because there was certainly 100 percent agreement all around the table, lots of heads bobbing, saying, yes, we need to do prevention, you know, we need to public health, we need to do, you know, primary care—that's what we need to be doing. And so, you know, those are the things that I think are going to strengthen the relationship between doctors and patients, and you get that through the reforms that are on the table right now.

JAY: Quick last word.

SMITH: We just worry so much. You know, we've seen this track record from the insurance industry. The nurses have watched it. The docs have watched it, too. You know, their track record isn't good in allowing Americans, at twice the cost of any other industrialized nation on the planet—at twice the cost, our health outcomes aren't very good, right in the middle of the Olympics, right now, the Winter Olympics. And we often say, if this were the performance of the American Olympic team, we'd fire them all. You know, if you really looked and we were paying twice as much for our Olympic athletes and they were finishing 37th in the world, we would say, oh my gosh, fire them all, let's start this over again.

JAY: Well, you might say the same thing for the people that led health-care reform in this town. This is not a gold-medal performance here.

SMITH: Well, and I have to say, you know, when I look at minimum standards—I just want to address that a little bit as a patient. I'm going to take myself out of the role as working for the nurses. I'm one of those people who had health insurance, health-care savings account, and Aflac disability insurance, and I still ended up bankrupt because of my cancer and my husband's heart disease. And when I look at the minimum standards here, it's still not going to prevent families like mine—you know, when you talk about you'll only have a maximum of an $11,000 out-of-pocket every year, I think, my God, do they seriously have such a disconnect with the American people that they don't know that $11,000 can force a family into bankruptcy? That's what's going to continue to drive this discussion forward. We're not done with health-care reform. Even if they pass this, no matter what they pass, we can't be done. The American folks are still going to be suffering and hurting.

COHEN: [inaudible] I think the important thing to take away from all this is that while we have, you know, differences in sort of the recipe to get where we're going, you know, we want to go and we want to make progress, we want to take that step forward. And I think you heard agreement that, you know, this is the first step forward. And so I'm glad that Donna was on the Hill giving that message today. We are actually going to be doctors and nurses together on March 22 bringing that same message: you know, health reform needs to happen for our patients.

JAY: Thanks for joining us.

COHEN: Thank you for having us.

JAY: And thank you for joining us on The Real News Network.


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