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Medicare For All — advocate Donna Smith debates libertarian Shikha Dalmia

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PAUL JAY, SENIOR EDITOR, TRNN: Welcome to The Real News Network. I’m Paul Jay in Washington. Last year on March 23, President Obama signed into law the Patient Protection and Affordable Health-Care Act. Next week in Washington, we’re expecting the Republicans in the House to try to undo that legislation, mostly a symbolic move, as President Obama will likely veto anything like that. At any rate, the city will be debating, once again, health care. Now joining us to give their view of the issue of repealing the act, but even more so their view of what they would like health care to be in America, is–joining us here in Washington–Donna Smith. Donna works as a community organizer and legislative advocate for the California Nurses Association, whose 85,000 members across the country were early champions of a single-payer program. Donna’s also very well known for her role in Michael Moore’s 2007 movie SiCKO. Thanks for joining us, Donna.


JAY: And also joining us from Detroit is Shikha Dalmia. She’s a senior analyst for the Reason Foundation, a nonprofit think tank that says it promotes free minds and free markets. She also writes for Forbes and writes regularly for Reason Magazine. Thanks for joining us, Dalmia.


JAY: So, Dalmia, let’s start with you. Would you like this health-care act repealed? And if so, why?

DALMIA: Yes, I would like to have it repealed, although there’s not a Hades snowball’s chance that it will in fact be repealed. The reason I would like it repealed, actually, are twofold. One is an economic reason and one is a more philosophical reason. The economic reason is that you can’t cram 35 million people or however many people they’re talking about into our current broken systems and not have the country go bankrupt in one way or another. But the more basic reason is that under Obamacare, I think there will be a real loss of civil liberties for all Americans. The–you know, it’s called the Patient Protection and Affordable Care Act, and every part of that is wrong. It’s not going to protect patients. It’s going to force patients to buy health coverage under threat of garnishing their wages or even putting them in jail. And it will dictate to insurance companies, the private sector, under what conditions they have to sell coverage to patients. So it will increase government control over our lives to such a great extent that, you know, anybody who cares about liberty or civil libertarians can’t be for Obamacare.

JAY: Okay. Donna?

SMITH: The nurses probably take a little different view of this. The nurses of National Nurses United, 150,000 strong across the country, feel, felt very strongly that this law moved in the wrong direction in the first place. But this effort to repeal is really political theater. I think that maybe our other guest would agree with me on that score. And we really would like to see it go beyond where we sit with this act and take this to a place where patients are not forced to purchase a defective product, which is private health insurance, sold to all of us to protect our health and wealth, which may well do neither thing. We’ll be purchasing that, with some penalty if we don’t purchase it. And so many Americans who have found out under private health insurance plans that they may not get the care that they need, it’s dictated more by what the company will deny or cover, which doctors you can see under their plans–your choices are so very limited out in that private sector that’s supposed to not control us, which becomes very controlling. So [what] the nurses would really like to see is, if we had our druthers, let’s attach an amendment to the repeal that would replace it with an improved and enhanced Medicare-for-all plan.

JAY: Okay. So let’s–just to stake out the ground clearly for our audience, ’cause they might be a little confused, ’cause the California Nurses Association–or National Nurses United now–you were for, essentially, Medicare for all, otherwise known as the single-payer system,–

SMITH: Correct.

JAY: –and something more akin to something like a Canadian system. Am I right so far?

SMITH: Yes, yes, except the Medicare program in this country is not the Canadian system. The Medicare system really is public financing and private delivery of health care. And we don’t say that there aren’t problems and issues with Medicare that need to be fixed and solved. There are, because obviously there are issues about physician reimbursement, there are issues about people who take advantage of the system, there are all sorts of issues surrounding Medicare that need to be taken care of. However, the access issues, the issue of having access to care, is one issue that gets solved by allowing everybody to have access.

JAY: Okay. Before we move on to what both of you would like to see, Shikha, let me just ask you, is there anything in this health-care act you like?

DALMIA: Not off the top of my head. I can’t think of a single thing I like about it. And just to, you know, address what Donna just said, you know, Medicare is, as she said, in every essential respect a single-payer system, and it has done an abysmal job of controlling costs. In any government-provided system, -funded system, the only way you can provide limitless access is by exploding costs. And that’s kind of the history of Medicare. When the program was enacted in 1965, it was predicted that in 1990 it would cost no more than $9 or $10 billion. The actual cost at that time was–it turned out to be about 12 times as much. So that is the basic conundrum of this system that Donna is proposing.

JAY: Okay, just before we go there, let me just get–just wanted to let go of–finish off with the act itself and what’s going to happen next week. Donna, is there anything in this act you like? Is there something worth saving in this act?

SMITH: Well, I think it would be irresponsible to not acknowledge–Bernie Sanders in the Senate fought very hard to get an expansion of community health benefits for people. And I do a lot of speaking all across the country, and one of the groups that I speak to frequently is the National Health Care for the Homeless coalition. And it works very hard to make sure that people, the least of these in our society, have access to some form of health care. And I can promise you those people across the country were very grateful that Senator Sanders got increased funding for community health centers so that people who are desperately poor and have nothing are able to access a better form of care. We also see an expansion, some expansion of people having access through the Medicaid program. Up to 400 percent of the poverty level will be able to access the Medicaid program–again, people who are oftentimes working people. We’re not talking about people who are sitting, not trying to make a go of it in our society. We have a very deep recession over the last couple of years in which a lot of really hardworking, good families are suffering and hurting. And to add to that the difficulty in receiving health care–you know, we could take Arizona as an example, where the transplants are being not funded in Arizona through their Medicaid program, their access program. Very difficult situation. Two people have died already and 96 are in the queue who may die because we–. That’s not the kind of society we are. That’s not what we’re all about. So there are some things in this act that it would be irresponsible to say are not an extension of some benefits to people who have had none.

JAY: Dalmia, if you take those issues, and also take the issue of the legislation, the part of the act that says that people with pre-existing conditions have to be covered, do you not think that these are elements worth saving?

DALMIA: You know, you’ve got to take everything in context. There are no free lunches in the world. And if you–the state budgets are already struggling with Medicaid spending in every–in literally every state budget in the country, Medicaid is the single biggest ticket item. In Michigan, you know, my state, it consumes about 25 percent of the budget. And when you have public or when you have the government funding health care and essentially relying on taxes to fund somebody else’s health care, you’re also going to put the government in a position of dictating what kind of care it is going to provide. So Medicaid, you know, in Arizona, where they are denying liver transplants to Medicaid patients, that’s exactly the kind of issue that we are going to face going forward if Ms. Smith has her way and we get single-payer in this country. As for pre-existing conditions, you know, it’s a very, very difficult issue. But, you know, I think to some extent we focus on the wrong end of the health-care stick in this country when we constantly talk about insurance coverage. I think the real issue is making health care affordable for as many people as possible. Ever since Obamacare went into effect, insurance companies have been increasing their premiums, because now they are going to be faced with mandates to cover pre-existing conditions, as well as community rating, and their only response to that is not having innovation, which you need, you know, competitive markets for. They will just raise their prices. And premiums have gone up 18 percent in some markets.

JAY: So, Donna, part of your–the argument that came from the single-payer people–actually, part of what Shikha says, you probably agree with, which is the current plan doesn’t really cut costs, which is part of the reasons you were promoting the single-payer model. So why don’t we start with that issue, which is you can’t actually cover–deal with this issue without controlling costs? So what’s your answer [inaudible]

SMITH: Well, it really is a circular argument, Paul, though, is because you can’t control costs until you deal with the issue of the way we’re financing things now. I mean, we don’t have everybody in the pool right now. We have uneven access to the pool of health-care financing right at the moment. Some people pay into insurance plans that are motivated by the bottom line. They’re not motivated by whether or not people receive health care; they’re motivated by whether or not their stockholders make money in the end. And that’s what they legally must do is make sure that their stockholders are protected, not the patients and the people who are the policyholders. So that, first of all, skims off a certain amount of money that does not go into health care. It goes into administrative costs, protecting profits. And a part of what’s happened in the health-care bill is they’ve said, well, we’re going to mandate that only a certain percentage of costs can go to those overhead costs, 80 or 85 percent is going to actually have to go to medical care. Well, the insurance companies are not dummies. They have found ways to say that our Ns and MDs who work for them, really, in the underwriting process and in administrative roles, that because they are health-care people, that that’s part of providing medical care and will figure into that percentage. So there are ways that insurance companies always find to work that. I have to respond, too, to the issue of insurance companies raising their rates. That’s deadly true, unfortunately, across the country. Ever since the Affordable Care Act passed, they’ve been raising their rates well in advance of any of the provisions taking effect.

JAY: Which is the opposite of what was supposed to happen, because the bigger pool was supposed to lower rates.

SMITH: And blaming it. It’s–what’s interesting to me is I talked to a person this week who said that they saw Karen Ignani, head of America’s Health Insurance Plans, walking through one of the congressional buildings this week just happy as a clam. She is so happy. And they’re happy. You know, they’re going to have this–millions and millions more customers. So, you know, while they’re arguing and saying this is so bad for them and this is awful, they’re going to have millions more customers compelled to pay high rates for insurance. The insurance coverage will actually in many cases look worse for people. They’ll have higher premiums and less coverage, so that it basically looks more like catastrophic plans, high deductibles, high co-pays, high out-of-pocket expenses. So here are the insurance companies getting these huge amounts in premiums and patients potentially getting less care. That is definitely not the direction we need to go in. Where under a Medicare-for-all, publicly funded, everybody pays into the pool. That’s one of the problems when you isolate a group of the sickest people or the people–when we’re 55 and 65 and older, we’re going to have more health problems. That’s the way it works. So if we don’t have more people in the pool, everybody in the pool to help pay for care, it’s more difficult.

JAY: Shikha, you say the fundamental issue is lowering costs. But when you look at American costs compared to Canadian health-care costs or European health-care costs, the European and Canadian costs are far, far lower, as we all know, than American costs, I think.

DALMIA: Let me stop you right there, Paul. Actually, you know, that’s one of the big canards in this whole health-care debate is that America spends 17 percent of its GDP on health care and doesn’t insure 45 million people. There is, you know, so much to be unpacked in that statement. Actually, you know, there is quite a lot that I agree with in what Ms. Smith said, but let me just address your point over here. Actually, as it turns out, every country that has, you know, a health-care system–and, you know, most European countries and Western European countries and America have some blend of a public-private system. In America, Medicare and Medicaid pick up half of health-care spending, and it is very similar in France and Germany. And all these countries are actually facing rising health-care costs. In France, which is the third most expensive system in the world, 11 percent of their GDP is spent on health care, and the costs are still exploding. Per capita health-care costs are rising just as fast in France and Germany–and faster, by the way, in England than they are rising in America. I actually have some numbers for you over here. In France, the–. Hang on just one second. Yeah. The rate of health-care spending per capita in the US is 3.6 percent, which is just a little bit higher than France and Germany and Japan, and in England it is 4.2 percent. So this idea that single-payer systems somehow don’t face exploding costs is just–it’s just not correct.

JAY: No, I don’t take think the issue–but you’re talking about the rate of increase. But in my understanding–I don’t have the numbers in front of me, but my understanding is the actual per capita expenditure in the United States is significantly higher, even if the rate of increase is similar. Is that not true?

DALMIA: Well, that was true–and this is the Kaiser study that I’m referring to–that America, you know, faced–the basic rate was much higher in the US, per capita spending was much higher, until 1990. Since then, actually, it has slowed down considerably. I don’t know what it is right now, but it is–you know, I’m sure it’s higher than these other countries, but it is not way, way out of line as it’s projected to be.

SMITH: The United States still spends nearly double per capita on health care than any other country on the face of the planet does, and yet our health outcomes are terrible in comparison. We’re still ranking in the 37th, 38th position according to World Health Organization statistics and what we actually achieve in terms of our–.

DALMIA: In what, Donna? What are we ranking so low in?

SMITH: We’re ranking low in infant mortality, we’re ranking low in life expectancy, we’re ranking low in those areas that you would expect, if you had a health-care system spending nearly double per capita what the rest of the world is spending, you certainly wouldn’t be ranking low in those areas.

DALMIA: You know, life expectancy is actually–let me just say, it’s not a very good metric to judge any health-care system. What–because life expectancy is affected by a whole lot of factors that have nothing to do with your health-care system. It has to do with violence, you know, the rate of violence in the country. It has to do with health-care, you know, with eating habits, obesity, the basic health profile of a population. So that’s actually not a very good metric. What is a good metric is actually survival rates. When somebody does get an illness, how well does the health-care system do to make them well? And on those metrics, both a Lancet study as well as an OECD study have rated the US actually very high. When it comes to breast cancer survival rate, prostate cancer survival rate, the US actually does the best of anywhere in the world.

SMITH: In some disease groups, those people who can access care do have better outcomes, but not in all disease groups. I looked at a study recently that was part of T. R. Reid’s health care around the world. He took a look at all the systems around the world and where we were performing poorly and where we were performing better. And you have to factor in, too, how many people aren’t even in the loop for us, those people who are dying because they can’t access care. Up to 45,000 every year die simply because they can’t access care, not because they got the wrong care. We could talk about medical errors in this country, too, and it would just surge those numbers beyond belief, what happens in this country. But in other measures, when you look at systems like Great Britain–and I’m not advocating that we have the British health-care service here. People often say that, oh, people want it to be just government-owned health care. That’s not what we’re saying when we talk about Medicare for all in this country. But if you look at measures of heart health and other areas that we do have significant health issues with in this country, other countries that have single-payer systems are performing at a better or equal level than what we’re performing, and we’re spending twice as much and we’re allowing 45,000 of our fellow citizens to die every year without accessing any care at all. That’s pretty significant. That’s a failure in a health-care system, in our view.

JAY: Shikha, let’s go back to your first point, which you say is one of principle, that to tell people how to spend their health-care money is a denial of their civil rights. So explain what you mean by that.

DALMIA: What I mean by that is that, you know, once this individual mandate goes into effect in 2014, which if Obamacare [inaudible]

JAY: Can I interrupt you for a second? You would make this argument whether it’s under this act or a health-care-for-all, single-payer system. Either one, if people are being told they have to finance this national system, you’d make the same argument. Is that correct?

DALMIA: Well, you know, single-payer is a little bit more complicated, because there, actually, you know, you don’t have the government forcing everybody to buy coverage. It just takes your taxes, and then it just gives you coverage. That’s not what we have under Obamacare.

JAY: Okay. Well, Donna’s advocating that.

DALMIA: [inaudible] other civil libertarian concerns under a single-payer system, but not quite this one. This is a problem, you know, quite specifically with Obamacare, where the government will tell you that you have to set aside x amount of your income to purchase private coverage. And I completely agree with Donna on this, that this is essentially–you know, gives a captive audience to insurance companies. Now, there’s a reason for it. Insurance companies are being asked to carry a very, very heavy load over here. They are being asked to cover preexisting conditions. They are supposed to offer coverage without any lifetime caps, you know, on the amount of coverage, and they are expected to cover all kinds of benefits, from hair prostheses to in vitro fertilization. And when you make these kinds of demands on companies, you know, doctors are not going to work free for them. Somehow the costs have to be paid.

JAY: You’re saying you actually don’t think it’s a civil right issue if you have a Medicare-for-all type of plan which is simply included in your normal taxes. You’re saying that–whether–you might not like it, but you don’t say that’s a civil rights violation.

DALMIA: Well, that particular aspect is not a civil rights issue. There are other civil rights issues. Now, you know, to go back to, for instance, France and Germany and some of these other, you know, single-payer systems, over there it is not like, you know, as Donna and other proponents of single-payer suggest, that, you know, it is all between your doctor and the patient as to what kind of care you get. No. Government bureaucrats dictate all kinds of things.

SMITH: First of all, to say you lose that relationship, I don’t know very many patients right now who have that relationship with their doctor. There is an insurance company executive sitting in that room–talking about an elephant in the room all of the time between a doctor and a patient right now, only it happens out at the front desk. Ask any patient. They’re not getting past the front desk if they don’t show sufficient financial means to get past the front desk to see a doctor most of the time right now. Now, under a Medicare-for-all type system that was improved and enhanced and made to look a little differently, the relationship between doctor and patient is much cleaner, much clearer. You would have the program, yes, administered and decisions made by–how we will fund it, what we will fund–will be made by groups of citizens, doctors, patients, people from the private sector. They won’t be made by some government bureaucrat sitting in a room saying, oh my God, today we can’t fund whether somebody gets a strep culture or not. They’re going to be made by groups of citizens.

DALMIA: The central issue over here is that health care costs too much in this country, both if you have to pay for services out-of-pocket and health coverage.

JAY: How would you get the health-care costs down? I haven’t heard that from you.

DALMIA: Yes. Well, that’s the part I was coming to. The reason you have high health-care costs in this country is because you have very little health-care competition in this country. The customer is never at the center of actually price shopping for either the health-care product or, you know, the insurance product. What you have is, you know, either an employer-based system where the employer is picking your insurance and you don’t get to price shop, or the government is telling you, you know, what kind of health insurance you get.

JAY: What would you do about these essentially health-care monopolies?

DALMIA: But [snip] and the way to do that is–in my view, is by abolishing the system of employer-based coverage and giving that same tax treatment that employers currently get to individuals to buy the kind of health insurance or health services that they prefer. And for poor people who can’t afford to buy coverage, I am in favor of something like an earned income tax credit system, which works quite well in welfare, where the government will subsidize poor people so that they can buy their own coverage.

SMITH: Well, I think the thing that we take so seriously is the difference between health care as a commodity, something to be purchased, something to be financed, something to be industrialized, and health care as a human right. And that’s a very basic difference, I think, maybe, in this discussion. We believe, the nurses believe, that health-care is a human right. We heard president Obama say that during the campaign, and that was a great relief to many of us to hear. And then that was the last time we really heard the discussion of health care as a human right, and we started to go at the issue of how do we keep the insurance companies intact, how do we keep this system intact, how to–. And then we never addressed the issue of exploding costs that we would agree on, the guests today would agree on.

DALMIA: You–you know, what you are asking for is, you know, a repeal of the laws of economics, that somehow, you know, you can consume health care as much as you want and, you know, somebody else will pay for it or nobody will have to pay for it. It just doesn’t work that way.

SMITH: I have never and the nurses have never said that there should be a free system of health care. We get it. We get economics. We understand that. We have always said we want a progressively financed single standard of care for everybody in this country. It is possible, it is doable, just like we have public roads and public schools and other public functions that we decide as a society are beneficial to all of us. And we all pay. We pay according to our ability to pay. We pay in a fair way. We don’t expect a free ride.

DALMIA: If you socialize the payment of Medicare, you will also socialize the consumption of Medicare, which means that the patient will have no control over what kind of medical care they should get.

JAY: Let’s stop the debate now, but let’s not let go of this issue. So what we’re going to do is I invite you both to come back again. But mostly I’d like you, our viewers, write some specific questions you’d like us to take up in the debate, what examples you’d like addressed, if you have–provide references so we can provide it to our guests and they can do some research before they come. And we’re going to dig into some very specific issues in the future. And we’ll keep doing this until we seem to have come to some kind of resolution. I think it’s interesting, this debate, so far, because there’s some common ground between our guests as well. So we’ll explore more common ground as well. So please join us for the next segment of our health-care debate on The Real News Network.

End of Transcript

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Donna Smith and Shikha Dalmia

Donna Smith works as a community organizer and legislative advocate for the California Nurses Association, whose 85,000 members across the country were early champions of a single-payer program. Donna Smith is best known for her major role in Michael Moore's 2007 movie, SiCKO. Since 2007, she has co-chaired the Progressive Democrats of America's national "Health care Not Warfare" campaign.

Shikha Dalmia is the senior analyst for the Reason Foundation, a nonprofit think tank promoting free markets. Dalmia is a columnist at Forbes and writes regularly for Reason magazine. She is the co-winner of the first 2009 Bastiat Prize for Online Journalism for her columns in Forbes and Reason.

Donna Smith

Donna Smith is a community organizer and legislative advocate for the California Nurses Association.