On Feb. 11, I posted to this list [Dr. Flowers naysays state-level activism] asking Kip to respond to the problem posed in a TruthDig article Dr. Flowers wrote. It concerned the tension between activists working on a state level and those focused on the national level to achieve one-payer health care. See https://www.truthdig.com/articles/path-national-improved-medicare/
Here’s what I posed on Feb. 11, with a request that Kip help us out with his perspective:
“[This article claims] that one-payer activism focused on winning at a state government level is counterproductive. Instead, concentrating all American activists’ political pressure to pass HR 676 is the best strategy—this is a position I do not subscribe to at all. I will gladly pass on to my acquaintance the opinion of Kip, or any other person, regarding the TruthDig article.”
Today, Kip has provided a detailed response. I am grateful that he took the time to write out his refutations. It helps us all improve our thinking about the national fight compared to the state fight to liberate ourselves from the cruel tyranny of the “insurers.”
Thanks, Kip!
Diane J. Peterson
White Bear Lake, Minnesota
=============================================================
Sent: Saturday, February 17, 2018 11:35 AM
Subject: Re: [MN_SP] Dr. Flowers naysays state-level activism
I'm tired of hearing this tedious argument. I took some time to write the essay below. Diane, feel free to publish my remarks anywhere you like.
Kip
I'll address Margaret's arguments in the order she presented them:
(1) Argument: Nancy Pelosi doesn't want single-payer heard in Congress, so she urges the naïve single-payer advocates to peddle their fantasies at the state level.
My answer: Who cares? Pelosi will grasp at any excuse to avoid doing her part to promote single-payer. In any event, her contemptuous remark doesn't demonstrate that she supports state action for the reason Margaret stated -- that it will reduce pressure on Pelosi and other members of Congress to enact HR 676. It just indicates she doesn't want to support HR 676. But in the unlikely event she was proposing state-level action in order to reduce support for HR 676, her argument backfires: State action anywhere builds support at the federal level, and vice versa (see more on this below).
(2) Argument: It isn't true that Canada can serve as a model for the US. In Canada, single-payer was achieved province by province, but single-payer in America won't be achieved state by state. Margaret quotes Don McCanne, someone I admire but disagree with on this issue:
Kip
I'll address Margaret's arguments in the order she presented them:
(1) Argument: Nancy Pelosi doesn't want single-payer heard in Congress, so she urges the naïve single-payer advocates to peddle their fantasies at the state level.
My answer: Who cares? Pelosi will grasp at any excuse to avoid doing her part to promote single-payer. In any event, her contemptuous remark doesn't demonstrate that she supports state action for the reason Margaret stated -- that it will reduce pressure on Pelosi and other members of Congress to enact HR 676. It just indicates she doesn't want to support HR 676. But in the unlikely event she was proposing state-level action in order to reduce support for HR 676, her argument backfires: State action anywhere builds support at the federal level, and vice versa (see more on this below).
(2) Argument: It isn't true that Canada can serve as a model for the US. In Canada, single-payer was achieved province by province, but single-payer in America won't be achieved state by state. Margaret quotes Don McCanne, someone I admire but disagree with on this issue:
"Saskatchewan began with a tabula rasa. They were able to create a de novo single-payer system."
My answer: The argument that single-payer is only possible in a jurisdiction with a "tabula rasa" -- a vague term I take to mean a state or country without an entrenched insurance industry and numerous government programs already in place -- is an argument against achieving single-payer anywhere in the modern world. If you buy that argument, you should go home and stop trying to tell the rest of us what to do because you've already made up your mind single-payer cannot happen anywhere -- not Minnesota, not California, not the US. There is no virgin territory left for single-payer systems to spring up in. None of us -- not those of us who fight at the state level, not those of us who fight at the federal level, not those of us who fight at both levels -- have the luxury of working in "tabula rasa" jurisdictions.
My answer: The argument that single-payer is only possible in a jurisdiction with a "tabula rasa" -- a vague term I take to mean a state or country without an entrenched insurance industry and numerous government programs already in place -- is an argument against achieving single-payer anywhere in the modern world. If you buy that argument, you should go home and stop trying to tell the rest of us what to do because you've already made up your mind single-payer cannot happen anywhere -- not Minnesota, not California, not the US. There is no virgin territory left for single-payer systems to spring up in. None of us -- not those of us who fight at the state level, not those of us who fight at the federal level, not those of us who fight at both levels -- have the luxury of working in "tabula rasa" jurisdictions.
(3) Argument: The Employee Retirement and Income Security Act (ERISA) "is a major obstacle" because it "prohibits states from regulating employee benefits."
My answer: This might be true depending on how state single-payer legislation is written. The Attorneys General of Ohio and Minnesota issued opinions on this question in the 1990s at the request of single-payer organizations in those states. Both AGs concluded that a state single-payer law that relied on general taxes, for example a corporate income or payroll tax, would not violate ERISA. The AGs said only a state tax that was triggered by the failure of corporations to insure particular employees would violate ERISA. Granted, this is only two opinions from state AGs, but I'm pretty sure there are no AG opinions saying the opposite. The wisest statement one can make on this topic is that ERISA is a vague law and the decisions about it by the federal courts are also vague and hard to predict and, therefore, no one should say with any certainty that ERISA will or won't be a problem for a particular state single-payer bill.
Margaret cites a 2016 US Supreme Court case in which the court stated Vermont could not force self-insured employers to report claims data to a database Vermont set up in 2005. This is not a relevant case. No state single-payer bill at the state level I know of proposes to make self-insured employers report data to the single-payer board on how much medical care their employees got. Why on earth would any bill require that? But just in case there are some nutty single-payer advocates out there thinking about tucking a provision into their bill requiring state-mandated reporting by employers, here's a warning: Don't do that, and in case you were also thinking about putting peas in your ears, don't do that either.
My second answer to this argument is that a state single-payer bill will be overturned by the courts on ERISA grounds only if a company with standing sues in a federal court. It's hard for me to imagine why 3M or General Mills, to take two examples of Minnesota-based, multi-state employers who might sue to overturn a Minnesota single-payer law if the law reduced the financial burden of health insurance for those companies (by, for example, relying heavily on a progressive income tax). If the single-payer law raised either no funds off corporate taxes or raised some funds from corporate taxes and those taxes were lower than the premiums corporations are paying now, what corporation in its right mind would sue? There are some firms out there that might not be in their right minds that would sue solely on ideological grounds, but even an ideologically motivated plaintiff would have to show harm in order to have standing.
(4) Argument: States must balance their budgets, the federal government does not have to do that.
My answer: This is an odd argument. It assumes that the federal government's ability to go into debt alleviates pressure on Medicare and other federally financed health insurance programs and, conversely, that the states' inability to go into the red prevents states from financing health insurance and other programs. Neither portion of that statement is true. If the necessity of a balanced budget were fatal or detrimental to state-level programs, how is it that states have financed myriad expensive programs ranging from transportation to Medicaid to national guards to schools since the nation was formed?
(5) Argument: States can't enact "pure" single-payers, ergo, they can't achieve "the bulk" of savings achievable by a "pure" single-payer.
My answer: Margaret doesn't tell us what she means by "pure." I assume she means an impure single-payer is one administered (at any level of government) that does not include every citizen within that government's jurisdiction. By this definition, Medicare would be an impure single-payer because it insures only 15 percent of the US population and, because it doesn't insure the other 85 percent, it can't achieve "the bulk of the savings" achievable by a pure national single-payer (one which covers all 330 million Americans).
This is a true statement: Medicare is not an ideal single-payer for several reasons, one of them being it covers only the elderly and some of the disabled. And because it doesn't cover everyone, it can't cut costs as effectively as a Medicare-for-all system would.
But is that any reason to oppose creating Medicare in the first place? Of course not. Medicare is the nation's most efficient insurance program, public or private. (That reputation is, of course, being endangered as we speak by managed care proponents and privatization buffs, but that's not an issue relevant to this discussion.) It has not only cut costs because it is a (less than ideal) single payer, but it has reduced suffering for millions of elderly and disabled Americans. (Note that I'm not arguing for any old incremental reform. To be worth fighting for, an incremental reform like Medicare should move us away from the profit-driven multiple-payer system and toward a government single-payer system. Medicare did that. The same cannot be said of the Affordable Care Act. It has reduced suffering for millions of people, yes, but it moved us in the wrong direction -- it helped entrench the insurance industry even more deeply.)
At the Minnesota level, an impure single-payer is presumably one that covers only the 4 million Minnesotans who are not in one of the federally financed programs, namely Medicare, Medicaid and the VA. Minnesota might well fail to get the federal government to allow Minnesota to merge those three programs into a state program and thereby cover all 5.2 million Minnesotans in one program. Does that mean a single-payer for 4 million people could not cut costs with the standard single-payer tools:
*replacing the insurance industry and wiping out all their extra admin costs,
* setting hospital and nursing home budgets,
* negotiating fees for doctors,
* negotiating price ceilings on drug companies and equipment manufacturers, and
* exercising more intelligent control over spending on capital facilities like ERs and MRIs?
Of course not. A state single-payer could achieve substantial cost containment.
Could a state cut costs as deeply as a national single-payer? Of course not. Smaller states in particular are at risk of being unable to achieve substantial cuts in both prices and administrative waste, in part because their negotiating leverage with drug companies and providers will be less, and in part because their providers will treat an above-average percent of tourists and workers from surrounding states and they will have to bill for those patients. But arguing against less-than-ideal single-payers at the state level is the equivalent of arguing that Medicare should never have been enacted because it was an "impure" single-payer. Yes, Medicare is impure -- it failed to incorporate Medicaid, the VA and all privately insured Americans in one fell swoop. But will anyone to the left of Ted Cruz really argue we should never have enacted Medicare for any reason, much less that it isn't a "pure" single payer?
Fomenting debates about whether a single-payer can be a single-payer if it doesn't merge all insurance programs into one is a waste of time. Yes, let's debate how effective a smaller single-payer can be versus a larger one, but let's ignore those who tell us states can't enact single-payers.
If we're going to worry about the integrity of the "single payer" label, let's focus our ire on those who seek to bestow the label on multiple-payer bills -- bills that leave in place the insurance industry or insurance companies dressed up as something new ("integrated delivery systems" and ACOs). There are those on the right who refer to Obamacare and Bill Clinton's 1993 Health Security Act as single-payer proposals, solely for the purpose of inducing their base to oppose those proposals. And there are those on the left who refer to multiple-ACO/HMO bills as single-payer legislation in order to induce their base to support those bills. It's the latter bills that pose the greatest threat to the integrity of the "single payer" label. Vermont Governor Peter Shumlin's proposal, for example, was not a single-payer bill. It was a three-ACO/HMO bill. Yet since Shumlin announced he was withdrawing his support for his multiple-payer bill, the media has been filled with reports that "single payer failed in a blue state like Vermont." Similarly, SB 562 in California is not a single-payer bill. Its supporters openly admit HMOs will continue to function under SB 562 (go to page 6 of this document about SB 562 and see the answer to the question, "Is there a role for Kaiser Permanente....?" http://www.healthycaliforniaact.org/wp-content/uploads/SB-562-QA-Flyer.pdf ) And yet SB 562's supporters and critics routinely refer to it as a single-payer bill.
(6) Argument: State-level campaigns for single-payer drain energy away from the fight for HR 676 at the federal level.
My answer: This argument ignores a fundamental rule of good organizing: People's organizations (as opposed to organizations that merely ask for contributions) thrive on action (cf Saul Alinsky's Rules for Radicals). As a general rule, it is harder to keep people involved in an organization when the targets are few and far away, and easier when the targets are numerous and closer to home. A fight limited solely to enactment of federal legislation presents fewer targets and, therefore, fewer opportunities for action, than a state-level campaign, and even fewer than a campaign focused on both state and federal lawmakers. By pulling more people into the fight for single-payer and keeping them involved, state-level single-payer campaigns boost the federal campaign.
Kip Sullivan
My answer: This might be true depending on how state single-payer legislation is written. The Attorneys General of Ohio and Minnesota issued opinions on this question in the 1990s at the request of single-payer organizations in those states. Both AGs concluded that a state single-payer law that relied on general taxes, for example a corporate income or payroll tax, would not violate ERISA. The AGs said only a state tax that was triggered by the failure of corporations to insure particular employees would violate ERISA. Granted, this is only two opinions from state AGs, but I'm pretty sure there are no AG opinions saying the opposite. The wisest statement one can make on this topic is that ERISA is a vague law and the decisions about it by the federal courts are also vague and hard to predict and, therefore, no one should say with any certainty that ERISA will or won't be a problem for a particular state single-payer bill.
Margaret cites a 2016 US Supreme Court case in which the court stated Vermont could not force self-insured employers to report claims data to a database Vermont set up in 2005. This is not a relevant case. No state single-payer bill at the state level I know of proposes to make self-insured employers report data to the single-payer board on how much medical care their employees got. Why on earth would any bill require that? But just in case there are some nutty single-payer advocates out there thinking about tucking a provision into their bill requiring state-mandated reporting by employers, here's a warning: Don't do that, and in case you were also thinking about putting peas in your ears, don't do that either.
My second answer to this argument is that a state single-payer bill will be overturned by the courts on ERISA grounds only if a company with standing sues in a federal court. It's hard for me to imagine why 3M or General Mills, to take two examples of Minnesota-based, multi-state employers who might sue to overturn a Minnesota single-payer law if the law reduced the financial burden of health insurance for those companies (by, for example, relying heavily on a progressive income tax). If the single-payer law raised either no funds off corporate taxes or raised some funds from corporate taxes and those taxes were lower than the premiums corporations are paying now, what corporation in its right mind would sue? There are some firms out there that might not be in their right minds that would sue solely on ideological grounds, but even an ideologically motivated plaintiff would have to show harm in order to have standing.
(4) Argument: States must balance their budgets, the federal government does not have to do that.
My answer: This is an odd argument. It assumes that the federal government's ability to go into debt alleviates pressure on Medicare and other federally financed health insurance programs and, conversely, that the states' inability to go into the red prevents states from financing health insurance and other programs. Neither portion of that statement is true. If the necessity of a balanced budget were fatal or detrimental to state-level programs, how is it that states have financed myriad expensive programs ranging from transportation to Medicaid to national guards to schools since the nation was formed?
(5) Argument: States can't enact "pure" single-payers, ergo, they can't achieve "the bulk" of savings achievable by a "pure" single-payer.
My answer: Margaret doesn't tell us what she means by "pure." I assume she means an impure single-payer is one administered (at any level of government) that does not include every citizen within that government's jurisdiction. By this definition, Medicare would be an impure single-payer because it insures only 15 percent of the US population and, because it doesn't insure the other 85 percent, it can't achieve "the bulk of the savings" achievable by a pure national single-payer (one which covers all 330 million Americans).
This is a true statement: Medicare is not an ideal single-payer for several reasons, one of them being it covers only the elderly and some of the disabled. And because it doesn't cover everyone, it can't cut costs as effectively as a Medicare-for-all system would.
But is that any reason to oppose creating Medicare in the first place? Of course not. Medicare is the nation's most efficient insurance program, public or private. (That reputation is, of course, being endangered as we speak by managed care proponents and privatization buffs, but that's not an issue relevant to this discussion.) It has not only cut costs because it is a (less than ideal) single payer, but it has reduced suffering for millions of elderly and disabled Americans. (Note that I'm not arguing for any old incremental reform. To be worth fighting for, an incremental reform like Medicare should move us away from the profit-driven multiple-payer system and toward a government single-payer system. Medicare did that. The same cannot be said of the Affordable Care Act. It has reduced suffering for millions of people, yes, but it moved us in the wrong direction -- it helped entrench the insurance industry even more deeply.)
At the Minnesota level, an impure single-payer is presumably one that covers only the 4 million Minnesotans who are not in one of the federally financed programs, namely Medicare, Medicaid and the VA. Minnesota might well fail to get the federal government to allow Minnesota to merge those three programs into a state program and thereby cover all 5.2 million Minnesotans in one program. Does that mean a single-payer for 4 million people could not cut costs with the standard single-payer tools:
*replacing the insurance industry and wiping out all their extra admin costs,
* setting hospital and nursing home budgets,
* negotiating fees for doctors,
* negotiating price ceilings on drug companies and equipment manufacturers, and
* exercising more intelligent control over spending on capital facilities like ERs and MRIs?
Of course not. A state single-payer could achieve substantial cost containment.
Could a state cut costs as deeply as a national single-payer? Of course not. Smaller states in particular are at risk of being unable to achieve substantial cuts in both prices and administrative waste, in part because their negotiating leverage with drug companies and providers will be less, and in part because their providers will treat an above-average percent of tourists and workers from surrounding states and they will have to bill for those patients. But arguing against less-than-ideal single-payers at the state level is the equivalent of arguing that Medicare should never have been enacted because it was an "impure" single-payer. Yes, Medicare is impure -- it failed to incorporate Medicaid, the VA and all privately insured Americans in one fell swoop. But will anyone to the left of Ted Cruz really argue we should never have enacted Medicare for any reason, much less that it isn't a "pure" single payer?
Fomenting debates about whether a single-payer can be a single-payer if it doesn't merge all insurance programs into one is a waste of time. Yes, let's debate how effective a smaller single-payer can be versus a larger one, but let's ignore those who tell us states can't enact single-payers.
If we're going to worry about the integrity of the "single payer" label, let's focus our ire on those who seek to bestow the label on multiple-payer bills -- bills that leave in place the insurance industry or insurance companies dressed up as something new ("integrated delivery systems" and ACOs). There are those on the right who refer to Obamacare and Bill Clinton's 1993 Health Security Act as single-payer proposals, solely for the purpose of inducing their base to oppose those proposals. And there are those on the left who refer to multiple-ACO/HMO bills as single-payer legislation in order to induce their base to support those bills. It's the latter bills that pose the greatest threat to the integrity of the "single payer" label. Vermont Governor Peter Shumlin's proposal, for example, was not a single-payer bill. It was a three-ACO/HMO bill. Yet since Shumlin announced he was withdrawing his support for his multiple-payer bill, the media has been filled with reports that "single payer failed in a blue state like Vermont." Similarly, SB 562 in California is not a single-payer bill. Its supporters openly admit HMOs will continue to function under SB 562 (go to page 6 of this document about SB 562 and see the answer to the question, "Is there a role for Kaiser Permanente....?" http://www.healthycaliforniaact.org/wp-content/uploads/SB-562-QA-Flyer.pdf ) And yet SB 562's supporters and critics routinely refer to it as a single-payer bill.
(6) Argument: State-level campaigns for single-payer drain energy away from the fight for HR 676 at the federal level.
My answer: This argument ignores a fundamental rule of good organizing: People's organizations (as opposed to organizations that merely ask for contributions) thrive on action (cf Saul Alinsky's Rules for Radicals). As a general rule, it is harder to keep people involved in an organization when the targets are few and far away, and easier when the targets are numerous and closer to home. A fight limited solely to enactment of federal legislation presents fewer targets and, therefore, fewer opportunities for action, than a state-level campaign, and even fewer than a campaign focused on both state and federal lawmakers. By pulling more people into the fight for single-payer and keeping them involved, state-level single-payer campaigns boost the federal campaign.
Kip Sullivan
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