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Healthcare Roundtable: With Exclusion of Single Payer, What Opportunities Remain for Meaningful Reform?

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While much of the healthcare debate in Washington and the media has focused on the proposal to create a government-run insurance program, the legislation being considered includes many other provisions that could change how healthcare is delivered in this country. We host a roundtable with three guests who have been closely following the debate: Lois Uttley, co-founder of Raising Women’s Voices for the Health Care We Need; Elisabeth Benjamin, vice president of Health Initiatives at Community Service Society of New York; and Dr. Oliver Fein, president of Physicians for a National Health Program. [includes rush transcript]

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This is a rush transcript. Copy may not be in its final form.

JUAN GONZALEZ: While much of the healthcare debate in Washington and the media has focused on the proposal to create a government-run insurance program, the legislation being considered includes many other provisions that could change how healthcare is delivered in this country.

To talk more about the current legislation, we’re joined by three guests who have been closely following the debate.

AMY GOODMAN: Lois Uttley is the co-founder of Raising Women’s Voices for the Health Care We Need. Elisabeth Benjamin is vice president of Health Initiatives at the Community Service Society of New York. And Dr. Oliver Fein is president of Physicians for a National Health Program. Dr. Fein is a professor of clinical public health at Cornell University and a practicing internist.

Elisabeth Benjamin, let’s begin with you. I mean, I think if you walked up to anyone on the street and said, “Can you explain these bills that have been introduced?” they would have really no idea. What are the essentials of these bills?

ELISABETH BENJAMIN: The essentials of the bills — there are sort of four major prongs to the bill. But both — I mean, all of the bills are trying to solve the fundamental problem, which is nearly 50 million Americans do not have health insurance, and two-thirds of all American bankruptcies are related to medical debt. So our healthcare system is in crisis, costs are escalating at a sort of never-ending level, and we need, as a country, to sort of grapple with this issue. So the four — both the House and Senate are trying to push forward legislation through the leadership that contain four major principles.

The first principle is that everyone would be required to have some form of insurance. Individuals will be required to carry insurance. Employers may either be required to offer insurance, as the House would propose, or they will be assessed and have some kind of penalty if they don’t, as the Senate would propose. And if people do not, as individuals, they will be subject to fines.

The second major provision is that there will be an insurance marketplace, an exchange. So there’d be — right now, you try to buy health insurance on the open market, if you’re an individual or a small business, good luck. You will need a broker. The broker gets a cut from the insurance company, so they’re not really on your side. And it’s very opaque. You can’t properly comparison shop. What the exchange will do is list all the benefits that are offered in a sort of comparable way across different carriers. And then, the poorest folks will have Medicaid, so they will not be in the exchange, and then everybody who’s from moderate poor up to upper income will be able to go to the exchange. But if you have job-based coverage, you just stay with your current job-based coverage. So it’s only for people — the sort of 50 million folks that don’t have coverage. And for people — because the prices of insurance are so expensive — $12,000 for an individual in New York State, $24,000 for a family on the open market — what the exchange will do is offer subsidies from the government that will help you buy these — the insurance products that are offered through there.

The third thing the health reform would do is curb the most egregious insurance practices. We’ve all heard the horror stories about someone with a past history of cancer. That’s called a pre-existing condition. They are not offered coverage. The insurers are able to deny that — not in New York, but in other states. That would be eliminated. There would be no such thing as benefit caps, so if you need a transplant, you’d be able — and you hit a $100,000 lifetime cap, that would be eliminated. And the most egregious rating abuses would also be eliminated. And what we mean by “rating” is they can charge you more if you’re older, if you smoke, if you’re a family, whatever. They get to charge you more. Those most egregious practices would be curbed.

And then the final thing is this whole controversy over the public plan, which I think we’ve gone into fairly well. The Senate is proposing that states would be able to opt out. That’s Senator Reid’s most current proposal. And the House is saying, no, we’ll just have a national public plan.

JUAN GONZALEZ: But there are — there are five proposals now, three in the House and two in the Senate, and they are vastly different in a lot of aspects, aren’t they?


JUAN GONZALEZ: They have these basic unities, but then, within them, for instance, the amount of premiums that people would have to pay differ dramatically, whether older people would pay higher premiums than younger people also differs dramatically. Could you talk about some of these differences in them?

ELISABETH BENJAMIN: Well, the House three bills have just been consolidated with Nancy Pelosi into one bill. So that will -— what used to be called the House Tri-Com is now one, so — hopefully. And I think with the introduction of her bill, it will now be subject to floor amendments.

You are right that the House bill is different than the Senate bill, in the sense that the House bill would offer more generous subsidies to moderate-income people than the Senate bill. But at the end of the day, the subsidies are not enough under each — either bill. And that’s because President Obama, in his famous speech after Labor Day, said, “We can’t spend more than $900 billion.”

AMY GOODMAN: Let’s go to that clip.


AMY GOODMAN: This was a speech before the joint session of Congress. This is the part where he refers to the amount of money that we won’t go beyond.

    PRESIDENT BARACK OBAMA: Add it all up, and the plan I’m proposing will cost around $900 billion over ten years, less than we have spent on the Iraq and Afghanistan wars and less than the tax cuts for the wealthiest few Americans that Congress passed at the beginning of the previous administration. Now, most of these costs will be paid for with money already being spent — but spent badly — in the existing healthcare system. The plan will not add to our deficit. The middle class will realize greater security, not higher taxes. And if we are able to slow the growth of healthcare costs by just one-tenth of one percent each year — one-tenth of one percent — it will actually reduce the deficit by $4 trillion over the long term.

AMY GOODMAN: That’s President Obama addressing the joint session of Congress on healthcare. Elisabeth Benjamin?

ELISABETH BENJAMIN: Well, the problem with the $900 billion number is that it actually means that we don’t have enough to subsidize coverage for folks. If we did a robust public option, we’d grab $80 billion. It now seems like that’s off the table. So we need to find the money to have enough subsidies for working people.

Why is that? Well, let’s do the math. So you have a family of three at 300 percent of poverty. They earn $55,000 a year. They spend $15,000 in taxes. They spend $14,000 in, you know, rent. They spend $20,000 on childcare. They spend $7,000 on food. And guess what? They’re already in debt. If you add in healthcare costs, which then they’re — even with the subsidies, they’re really in debt. And if they have a medical catastrophe, even with the caps — which is great that they’re adding, in health reform, caps on your maximum out-of-pocket exposure — you’re going to be in debt at the end of the year. And that’s the problem. They don’t have enough money to actually subsidize people, unless they really drive down insurance costs. The only way you really drive down insurance costs is through a public plan, or the other alternative is not even try to do this complicated thing, building on the current employer-driven structure.

DR. OLIVER FEIN: That is to say…

AMY GOODMAN: Which takes us to Dr. Oliver Fein, Dr. Ollie Fein, who is head of Physicians for a National Health Program.

DR. OLIVER FEIN: Right. And what we propose is essentially a Medicare-for-all program, right? Obama had a choice, really. He could have decided to build on what we have, correct. That’s what he said he was doing. But he went down the pathway of subsidizing what I think is a defective product at this point: private health insurance. He could have gone down the pathway of taking Medicare, probably the most popular health insurance program in the United States, and saying we should spread that to all people in the United States.

And if he had done that, we feel that studies show that you wouldn’t have to increase the cost to the middle class. The overall cost to the system actually would be a savings of close to $400 billion per year, mind you. And we’ve got that money, for instance, because we’re spending $1 trillion in Iraq and Afghanistan, OK, per year. So we have the possibility, it seems to me, if we went in the direction of a Medicare-for-all program, to really make this affordable to all people in the United States.

Now, Anthony Weiner from New York —-

JUAN GONZALEZ: Congressman from Brooklyn.

DR. OLIVER FEIN: —- Congressman for Brooklyn, Queens —-

JUAN GONZALEZ: And Queens, yes.

DR. OLIVER FEIN: —- has decided he’s going to introduce an amendment to HR 3200, the Pelosi bill, in which he would substitute a Medicare-for-all bill. And this really will give an opportunity for us to see how many people in Congress actually support this approach to reforming healthcare. We think that there will probably be a substantial number of people that will, in fact, support this.

JUAN GONZALEZ: But many of the progressives who do support Medicare for all have also said, well, the public option, if we get that, will at least be an entry into a future reform of the system. What’s your sense of that argument that they’re putting forth?

DR. OLIVER FEIN: Well, we’re a little bit worried that it’s a very puny, very weak entry into the field. In contrast to what Elisabeth said, my sense is — and CBO, by the way, the Congressional Budget Office, says — that only ten million people will enroll. And do you realize that anyone who has insurance now, Juan, cannot go into the public option? They have to be people who don’t have insurance. And the result is that I think very few people will actually be entitled to enroll.

AMY GOODMAN: Now, you, Dr. Ollie Fein, of course, are an advocate for single payer. What about Kucinich’s amendment, which has states voting whether they can offer single payer?

DR. OLIVER FEIN: Well, this will be another amendment that will be offered on the House floor — and, frankly, Bernie Sanders is going to introduce it into the Senate, as well — which would give states the option to, in fact, institute a single-payer approach. But what’s required there is, number one, that states would be able to use both Medicare and Medicaid money and, frankly, have the ERISA exemption. That is to say —-


ELISABETH BENJAMIN: Employee Retirement Income Security Act.

DR. OLIVER FEIN: Security Act. This is an exemption that allows multi-state, self-insured companies to be out of any kind of state regulation. And they tend to be the most wealthy companies. And if you exclude them from being in a state single payer, you really don’t have a viable plan.

AMY GOODMAN: So, because you’re for single payer, what are your thoughts now on public option, the way it’s coming out in the House, the way it’s coming out in the Senate? Are you saying don’t support either?

DR. OLIVER FEIN: Well, it’s hard, you know? But I think, generally, we’re very -— number one, we don’t know what’s going to come out, but generally, our concern is that people really don’t know the consequences of what is being proposed. And I think, again, Elisabeth is right that unless the subsidies are substantial, what we’re going to get are health insurance policies, if they’re affordable, that are Swiss cheese policies, high deductibles before they go into effect, large co-insurances so people will have to pay a lot out of pocket for care. It’s a defective product. And that really troubles us and, I think, has the potential to trouble the Democratic Party in the long run.

JUAN GONZALEZ: And Lois Uttley, you’ve tried to focus principally on how this — the various proposals might affect the health insurance needs of women, who are often discriminated against by the existing insurance system. Could you talk about how those proposals are shaping up?

LOIS UTTLEY: Sure. In fact, we’re concerned about women and our families, so it’s not just women we care about. But there are some important gains for women in the current legislation. For example, in the individual insurance market, where you have to go buy your own health insurance if you don’t have it from an employer, many states now allow insurance companies to discriminate against women by charging us more. It’s called gender rating. And it means that insurance is not so affordable for women.

Women also have a real problem with that pre-existing condition issue —- if you’ve had breast cancer, if you have asthma or diabetes. And some particular ones for women are just shocking. There are some states that allow insurers to charge you more if you’ve been a victim of domestic violence. And so, this -—

AMY GOODMAN: How do you charge more?

LOIS UTTLEY: You charge a woman more if she has a history of being a victim of domestic violence.

AMY GOODMAN: It’s a pre-existing condition.

LOIS UTTLEY: It’s a pre-existing condition, right. Pregnancy, as well, and particularly if you’ve had C-section delivery in the past. The insurance companies figure, “Well, she had a C-section once, so she might have one again, and those are more expensive. We don’t want her.” So either they deny you the health insurance, or they charge you more. And that’s just discriminatory. So that would actually be prohibited under this legislation. It’s an important gain for women.

Another important gain for women is that maternity care would be mandated. You would be shocked at how many insurance plans do not include maternity care. You would think it’s a given, but it’s not.

And lastly, for women, I want to mention the issue of many women, in fact, a quarter of women, have what’s called dependent health insurance coverage. This means they get it from a husband or a partner. And if you get divorced, you’re in big trouble. You lose your dependent health insurance coverage. Or if your husband dies. Or if maybe your partner is older than you are and becomes eligible for Medicare, all of a sudden you’re left with nothing. So at least this would provide a backstop for those women. They’d be able to go into the insurance marketplace and get a policy.

AMY GOODMAN: I want to ask you about the “A” word, abortion, how abortion fits into the current healthcare debate. This is what President Obama had to say last month in his speech before Congress.

    PRESIDENT BARACK OBAMA: And one more misunderstanding I want to clear up, under our plan, no federal dollars will be used to fund abortions, and federal conscience laws will remain in place.

AMY GOODMAN: That was President Obama. Your response, Lois Uttley?

LOIS UTTLEY: Well, obviously, as a women’s health advocate, I was dismayed to hear him say that. But what he’s reflecting is a compromise that’s been agreed upon on Capitol Hill that the existing policies, the status quo on federal funding of abortion, would be maintained in this legislation. So, women who are on Medicaid, no federal funding would go towards abortion services for those women. There are some states, like New York, where state money is used to — and that would continue under this bill. What it would allow is women who buy private insurance policies through that exchange would be able to buy policies with abortion coverage in them.

And here’s the key issue that’s being debated right now in the House, and it’s a huge issue, is what if you’re a woman buying an insurance policy, a private policy in the exchange, and you need a public subsidy to afford it? Could you use that public money? The answer is no. The funds would have to be segregated. So the public subsidy would go in one pot, your private premium dollars would go in another pot, and only the private premium dollars could pay for the abortion coverage. Some anti-choice folks in the House, especially Representative Bart Stupak from Michigan, are trying to make this even worse — and Orrin Hatch in the Senate. They want to make abortion coverage into a rider that you would have to buy separately. Now, I would ask you, how many women would buy an abortion rider when they’re often used for unplanned pregnancies? Unplanned is the whole idea. So we think that would be a terrible step back, and we urge Speaker Pelosi to hold firm against any attempts to further erode abortion rights.

JUAN GONZALEZ: Elisabeth, I’d like to ask you about another hot-button issue: immigrants. How are immigrants treated in the various bills, both those who are here legally as well as those who are here illegally or undocumented?

ELISABETH BENJAMIN: Immigrants are treated horribly. That’s all there is to it. Even in the House bill, which is most — I mean, first of all, undocumented folks are just off the table. No one will even talk about it. There’s nothing to be done, to be addressed, addressing undocumented immigrants. And, in fact, in order —- one of the ways to pay for health reform is to claw back money that’s disproportionate share hospital funding money that funds things like the Health and Hospitals Corporation, public hospitals in New York City and others, which basically use that money to pay for providing care for undocumented folks. So that’s a horror show, to be frank.

For lawfully present immigrants, it’s also quite bad. After federal welfare reform in the mid-’90s, people who already had their green cards, paying taxes, working, are not allowed to get publicly funded coverage, federally funded coverage, Medicaid coverage, whatever. And that bar was reversed under the Child Health Plus Restoration Act at the beginning of the year, and it looks like we’re not even going to be able to get that same reversal in the House bill, and it’s not, again, on the table in the Senate. So -—

JUAN GONZALEZ: But the bar on legal immigrants will be for five years?

LOIS UTTLEY: Five years. So they would not be eligible to get subsidized coverage for the first five years they’re in the country. And it’s very punitive, and it’s very — actually, it’s not smart, because immigrants are working, very healthy people. We want them in the system. They should be encouraged in the system. They’ll bring down health insurance premiums for everybody. I mean, I don’t mean to talk about immigrants as a monolith, but, you know, as a rule, this would be, in fact, a very important, you know, group to have in play. And our country is doing the wrong thing here.

AMY GOODMAN: There was an example recently that was brought out in the Huffington Post Investigative Fund. Lois Uttley, I wanted to ask you about Christina Turner, drugged and raped by two men in 2002 after taking anti-HIV drugs prescribed by her doctor as a preventative measure. She was denied health insurance. The HIV drugs, Turner was told, raised too many questions, health questions, for her insurer. What do you do in these cases?

LOIS UTTLEY: Well, again, the ban on pre-existing conditions, you know, denial for pre-existing conditions, would certainly help. The general discrimination against women, against anybody who is perceived as being HIV-positive, is outrageous. It’s an insurance company abuse. That’s why we’re seeing all these demonstrations against insurance companies and why we need a public option, because a public option would be fairer, and it would be cheaper — not as cheap as we would like, because we’re not getting the robust public option, but we need it. And we need the opportunity for women and for other people who are discriminated against to be able to get a fair, affordable health insurance policy.

DR. OLIVER FEIN: But the problem —-


DR. OLIVER FEIN: The problem, Lois, is that they’re going to make that public option behave like an insurance company, right?

LOIS UTTLEY: I agree. I agree.

DR. OLIVER FEIN: That’s a real difficulty. And maybe the whole paradigm of insurance is wrong. Just think of it. You buy car insurance or house insurance, you hope you’ll never have to use that insurance, right? I mean, you don’t want your house to burn down. You don’t want to get into a car accident. Health insurance is -— you know, it’s the wrong term, right? We don’t want health insurance, because we all know at some point in our life we’re probably going to get sick. And, in fact, we want younger people to use preventive services. We want people to use their insurance.


DR. OLIVER FEIN: Which is the exact opposite of, you know, what most insurance is about. That’s why we talk about a national health program, Medicare for all, again, trying to get out of the insurance paradigm. For instance, in Medicare, you don’t pay premiums, per se, for the Part A part of it. It’s part of your, you know, payroll tax.

AMY GOODMAN: And can you get there from here, Medicare for all from what — from the public option, if it is passed as it is in the Senate and the House?

DR. OLIVER FEIN: I fear — I fear that it’s going to be very hard to get there from — through the public option.

LOIS UTTLEY: Well, we’re certainly not — we’re not getting there now, because we’re not seeing Congress leaping tall buildings in a single bound. They’re just not going to do it.

ELISABETH BENJAMIN: Well, I think the problem for Congress is this: 94 percent of American voters have job-based coverage or some other kind of coverage, and they are scared. If they — I mean, this is what people say, what the pollsters say. You know, I’m not sure if this is right or not, but the pollsters tell us that folks are scared to have too radical of change. I mean, me, I’m not scared. I want radical change. But I don’t think I’m going to get it. And I don’t think — unfortunately, Congress is not, you know, an avant-garde entity. And so, I think that —-

DR. OLIVER FEIN: But it depends on the -—

AMY GOODMAN: And there — well, each and every one of them are well insured.


DR. OLIVER FEIN: But it depends on the pollsters that you look at. So you get an NBC, you know, New York Times poll that said, “Would you prefer the current system or a Medicare-like system run by government, financed by taxpayers?” — two words that I thought would put most Americans off, on some level — and what you get is, you know, 60, 65 percent — it depends on the year that this poll has been given — in favor of a Medicare-like program. And again, I think, you know, what we needed was a Democratic president, a Democratic Congress, and I thought we could get this, actually.

ELISABETH BENJAMIN: I think what’s really clear is that it was wrong to take single payer off the table at the beginning, I mean, just because I think we would have had a much better and more well-informed debate. I think we would have more money to do whatever the outcome was. And it’s actually an out —- we did ourselves, as a country, a disservice by taking it off the table at the beginning.

AMY GOODMAN: Is there a place for activism right now?


ELISABETH BENJAMIN: Two different trails, I mean, I would say.

DR. OLIVER FEIN: Yeah. What you see — one place for activism that’s real simple is the Weiner amendment. Let’s be sure that it — you know, Nancy Pelosi still has to let it come onto the House floor. And so, I think a lot of pressure should be placed on Pelosi.

AMY GOODMAN: And there are people being arrested all over the country in front of health insurance companies.

DR. OLIVER FEIN: And secondly — secondly, what we have, it seems to me, right now is a major force, similar, it seems to me, to the civil rights period, where people really feel this is a life-and-death issue for them and that private health insurance companies are really the barrier to getting us to a national health program.

ELISABETH BENJAMIN: There’s also — there’s also another —

AMY GOODMAN: We have ten seconds.

ELISABETH BENJAMIN: OK, there’s another area for activism. If you care about immigrant and immigrant coverage, you need to contact your House of Representatives. And if you care about the affordabilities, the current proposal is to do more for middle-income people at the expense of super-low-income people. That will really hurt folks. We need to contact the Senate.

AMY GOODMAN: We’re going to have to leave it there. Elisabeth Benjamin, I want to thank you for being with us, vice president of Health Initiatives at the Community Service Society of New York. Lois Uttley, thanks for being with us, co-founder of Raising Women’s Voices for the Health Care We Need. And Dr. Oliver Fein, president of Physicians for a National Health Program, professor of clinical public health at Cornell University.

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