ON THE ROAD FOR SINGLE PAYER: ADVENTURES OF PNHP’S

NATIONAL PRESIDENT

Oliver Fein, M.D.

PresidentPhysicians for a National Health Program

Professor of Clinical Medicine and Public HealthAssociate Dean

Office of Affiliations and Global Health EducationWeill Cornell Medical College

February 2010

DISCLOSURES

Dr. Oliver Fein has no relevant financial relationships with commercial interests.

Dr. Oliver Fein would like to acknowledge

the assistance of Dr. Margaret Flowers in the

preparation of slides for this talk.

WHAT ROAD? • Toronto • Philadelphia• Phoenix, Arizona• Pittsburgh • San Francisco • New Haven • Boston• San Diego• Atlanta• Chicago• Toledo• Columbus• Miami• Minneapolis• Indianapolis • Houston, Texas• Portland, Oregon• Birmingham, Alabama • Louisville, Kentucky

WITH WHOM:?

• Joanne Landy

former Executive Director

PNHP NYMetro Chapter

• Ali Thebert

Chapter Organizer

National PNHP

WHAT ADVENTURES?Portland, Oregon

Friday, January 29th

10:00 – 10:15 AM Live radio interview on KPOJ

Sunday, January 31st

7:30 – 12:50 PM Fly from NYC to Seattle to Portland

2:00 – 3:00 PM Meet with the Ecumenical Ministries of Oregon

3:30 – 5:00 PM Radio Taping with Bill Resnick – WBOO

5:15 – 6:00 PM Dinner with PNHP Organizers: Peter Mahr, Paul Gorman, Mike Huntington and Paul Hochfeld

6:00 – 7:00 PM TV Taping with Lisa Stiller, Community Media

7:00- 10:00 PM Single Payer Soiree with music by Bob Wicklineand The Nurses Band; the “Mad As Hell Doctors”Tour review; Key note – Oliver Fein

WHAT ADVENTURES?Portland, Oregon

Monday, February 1st

8:00 – 8:45 AM Morning Report at Providence Medical Center

9:00 – 10:00 AMMeeting with Labor Leaders: AFL-CIO, AFSCME, CWA, ONA, IBEW, Jobs with Justice

10:45 – 11:45 AM Editorial Board of the Oregonian newspaper: MaryKitch and David Sarasohn

Noon – 1:30 PM OHSU: Student-Faculty Forum

2:30 – 3:30 PM Portland State University: undergrads

4:00 – 5:00 PM Senator Merkley’s Office: Marybeth Healey

5:00 – 6:30 PM Core Activist Dinner

7:00 – 9:00 PM City Club Forum on Health Reform with RobertDannenhoffer, former President of OMA; Eric Fruits, Cascade Policy Institute, Rajiv Sharma,Professor Economics, Portland State.

WHAT ADVENTURES?

Portland, Oregon

Tuesday, February 2nd

9:00 – 9:15 AM Live radio interview, Aurora, Oregon

10:30 – 9:00 PM Fly from Portland to Denver to NYC

WHAT VALUE?• Chapter building event

• PNHP connects to other activistorganizations: religious, labor, student

• Contacts with local newspaper: OpEds,letters to the editor, expert resource

• Political contacts: PNHP as resource

• Fund raising

• Personal: never stay in a hotel

WASHINGTON ADVENTURES

• At the White House

• In Congress

• Working in coalitions

• PNHP Washington staff

PNHP IN WASHINGTON • Robert Zarr, M.D., Chapter Chair

• Danielle Alexander, intern (July 2008 – June 2009)

• Nick Skala, judiciary intern (June – August 2009)

• Margaret Flowers, M.D., Congressional Fellow (July 2009 – present)

LEADERSHIP CONFERENCE FOR GUARANTEEDHEALTH CARE (LCGHC)

November 2008

• Physicians for a National Health Program

• California Nurses Association

• Healthcare-Now

• Progressive Democrats of America

WASHINGTON ACTIVITY

Working to get “a seat at the table” at every opportunity

• January 20th – Health Care for All Inaugural Ball

• January 28th – Congressional briefing Health Care Economics

• February 25th – Congressional Briefing State-based Reform

PRE - WHITE HOUSE HC SUMMIT

• Thursday, February 26th

No single-payer advocates invited

• Friday, February 27th Phonathon to the White House

• Monday, March 2ndPress release and call for demo

WHITE HOUSE SUMMITWHITE HOUSE SUMMIT

PRE - WHITE HOUSE HC SUMMIT

• Tuesday, March 3rd John Conyers invited

• Wednesday, March 4th 4 PM: Oliver Fein, PNHP President, called by White House

WHITE HOUSE HEALTH CARE SUMMIT

March 5, 2009

PARTICIPANTS (150)

• Congress

• Community/Consumers

• Stakeholders

SUMMIT GOALS

• Transparency

• Bipartisanship

Congressional responsibility

WHITE HOUSE HEALTH CARE SUMMIT

March 5, 2009

FORMAT

1:00 – 1:45 PM Plenary (C-Span)

2:00 – 3:15 PM Breakout Groups(Bi-Partisan)

3:30 – 4:45 PM Theater in the Round(Congress Responsibility)

THE HAND SHAKE

“Glad you are here.”

“Give my best to Dr. Quentin Young.”

WASHINGTON ACTIVITY

• March 5th – Sanders announces S. 703

• March 14th – Senate HELP: stakeholders Dr. Quentin Young

• March 25th – White House Doctors: Dr. David Himmelstein

• April 1st – Congressional Briefing: Private Health Insurance in the U.S.

BAUCUS-13 ARRESTS

• May 5th – Senate Finance Roundtable

8 Arrests

• May 12th – Senate Finance Roundtable

5 Arrests

SENATE FINANCE SENATE FINANCE COMMITTEECOMMITTEE

Dr. Margaret Flowers, Pediatrician from Baltimore

Dr. Judy Dasocvich, internist from St. Louis

THE NURSES COME TO THE NURSES COME TO TOWNTOWN

OUTCOMES OF CIVIL DISOBEDIENCE

• Mainstream Media begins to cover Single Payer – Ed Schultz: MS-NBC– Bill Moyers: PBS

• June 3rd – Meeting with Senator Baucus

• June 9th – Hearing at House Education and Labor Conyers, Angel, Tsou and Jenkins testify

• June 11th – Margaret Flowers at Senate HELP

SINGLE PAYER VOICES

• June 24th - Dr. Young testifies at House Ways and Means

• July 16th - Anthony Weiner announces an Amendment to HR 3200 which would substitute HR 676

• July 21st - Dr. Aaron Carroll appears on the Colbert Report

• July 29th - Dr. Woolhandler testifies on medical bankruptcy

• July 30th - Single Payer Rally at the Capitol: Dr. David Scheiner

• July 31st - Nancy Pelosi agrees to allow Weiner’s Amendment to be introduced in the House

SUMMER LOBBYINGSUMMER LOBBYING

•Doctors, Nurses and Advocates from around the country came to D.C . throughout June and July.

•PNHP opens Washington office!

AUGUST ACTIVITY

• Rep. Anthony Weiner meets with PNHP and decides to request a CBO analysis of his Amendment

• Bullies take over many Town Hall meetings• Single payer is heard at many Town Hall and

congressional representative meetings• David Scheiner takes to the air waves • Ted Kennedy dies

SEPTEMBER ACTIVITY

• Sept 8th - Congress returns to Washington

“Mad as Hell Doctors” leave Portland

• Sept 9th - Obama addresses Congress and the nation

• Sept 21 -25th - Health Care Justice week

• Sept 30th - “Mad as Hell Doctors” arrive in Washington

MAD AS HELL DOCTORS MAD AS HELL DOCTORS TOURTOUR

26 STOPS IN 22 DAYS

WHITE RIBBON RALLY AT THE WHITE HOUSE

Memorial to Dead, 9/21-27/2009

OCTOBER - NOVEMBER(Mobilization for Health Care for All)

• Single payer movement shifts focus from Congress to private health insurance

• 115 arrests in 18 cities

• International Human Rights Day: demos in 34 States

HOUSE PASSES HR 3962November 7th

•220 for vs. 215 against

•Positives- Medicaid expansion to 150% fpl- Public option (although puny) - Surtax on the wealthy- Curb on Medicare Advantage

•Negatives - Uses Mandate Model- Leaves 18 million uninsured- No State Single Payer option- No real cost controls - Implementation date: 2013- No Weiner Amendment- Stupak Abortion Restrictions

PNHP WRITES THE SENATEDecember 22, 2009

“It is with great sadness that we urge you to vote against the health care reform legislation now before you. As physicians, we are acutely aware of the unnecessary suffering that our nation’s broken healthcare financing system inflicts on our patients. We make no common cause with the Republicans’ obstructionist tactics or alarmist rhetoric. However, we have concluded that the Senate bill’s passage would bring more harm than good.”

SENATE LETTERcontinued

....“Some paint the Senate bill as a flawed first step to reform that will be improved over time, citing historical examples such as Social Security. But where Social Security established the nidus of a public institution that grew over time, the Senate bill proscribes any such new public institution. Instead, it channels vast new resources - including funds diverted from Medicare - into the very private insurers who caused today’s health care crisis. Social Security’s first step was not a mandate that payroll taxes which fund pensions be turned over to Goldman Sachs!”

PNHP’s CONCERNS• Fortification of private insurers

• Anti-abortion provisions

• 40% tax on high cost health plans

• Reduction of Medicare payments ($43 billion) to safety net hospitals

• Millions left with inadequate insurance with an “actuarial value” as low as 60%

SENATE PASSES HR 3590December 24th

•60 for vs 39 against

•Positives- Medicaid expansion to 133% fpl

•Negatives- Uses Mandate Model - Leaves 23 million uninsured- No State Single Payer option - No public option - Excise tax on health insurance- No real cost controls - Implementation date: 2014- Undocumented immigrants - No Sanders Amendment- Nelson Abortion Restrictions

THE MEANING OF THEBROWN ELECTION

It was about health reform: Surge afterhe declared himself the 41st vote

• Rejection of mandate to buy privatehealth insurance – a defective product

• Opposition to taxing health benefits

• Fear of Medicare cutbacks

RESPONSE TOSTATE OF THE UNION

If you have a better idea for health carereform, let me know!

• PNHP says its single payer -improved Medicare for All

• Dr. Margaret Flowers was arrested trying to present ouralternative to the President

• February 22nd: The President presents his plan. It looks most like the Senate’s.

OBAMA PLAN• Individual mandate: subsidies up to 400% FLP

(premiums 2 to 9.5% of income)• Penalties: 2014 - $95 or 1% income; 2016 - $695 or

2.5% income• Hardship waiver: income < $18,700 for couple; or

premiums > 8% of income; American Indian• No employer mandate: penalty of $2,000/worker

for businesses with more than 50 employees• HI exchanges state-based in 2014; no public option• Medicaid expansion to 133% FPL; feds cover entire

costs 2014 to 2017; 95% 2018-2019; 90% in 2020• Donut hole in Medicare Part D closed by 2020• Illegal immigrants prohibited from exchanges• Abortions: if subsidized, two separate checks• Insurance Regulations: no pre-existing condition

exclusions or annual/lifetime limits by 2014• Excise tax on employer-sponsored plans with

premiums over $10,200/$27,500 starts 2018• Medicare payroll tax increase from 1.45% to 2.35%

for those with incomes over $200,000/$250,000

HOW WAS 2009 DIFFERENT? (different from 1993-1994)

• Deals were negotiated with privatehealth insurers and Big Pharma

• President delegated bill writing to Congress

• Senate and House passed bills

But the real difference was that the singlepayer alternative-Medicare for All- was heard!

WHAT’S NEXT?• Educate, Educate, Educate• Outreach to other groups: Labor, Religious, Political• Peer organizing within our professional organizations• Grassroots organizing in our communities• Movement building: Connect the dots• Expand media outreach to community newspapers• State single-payer organizing• Encourage single-payer candidates

Reframe our message“Improved Medicare for All”

• What do we mean by improved Medicare?• How do we describe delivery system reform?

WHAT’S NEXT?Practical projects

• A City Council resolution• Impact on college undergraduates

of not having single payer• Teaching single payer in high schools• Workforce implications of moving

from multi-payer to single-payer• Contacts with business community

CONTACTS AND REFERENCES

• PNHP-NY Metro: www.pnhpnymetro.org

• PNHP National: www.pnhp.org

• Bodenheimer TS, Grumbach K, Understanding Health Policy: A Clinical Approach. McGraw-Hill, 2005

• Fein O, Birn AE. (editors), Comparative Health Systems. Am Jour Public Health 2003; 93: 1-176

• O’Brien ME, Livingston M (editors), 10 Excellent Reasons for National Health Care. New Press, 2008

• Geyman J, Do Not Resuscitate: Why the Health Insurance Industry is Dying and How We Must Replace It. Common Courage Press, 2008

PHYSICIANS FOR ANATIONAL HEALTH PROGRAM

(PNHP)

29 East Madison Street

Suite 602

Chicago, Illinois 60602

312-782-6006

www.pnhp.org

OBAMA’S FATEFUL CHOICE

• He did not want to “start from scratch”

• He had two fundamental choices: 1) to build on the public sector (Medicare) or

2) to build on the private sector

• He chose to try to reach universal coverage byexpanding private insurance

Employer mandate

Public option**

Individual mandate*

* “each eligible individual must enroll in an applicable health plan for the individual and must pay any premium required with respect to such enrollment.” (S.1775)

** “you can choose to enroll in the new public plan”

Medicare

??

EMERGING CONGRESSIONAL PLANA MANDATE MODEL

Everyone is required to have health insurance or pay a penalty. “You can keep what you have.”

1. Employer mandate (if payroll > $750,000) House: penalty=8% of payroll Senate: penalty=$750/employee

2. Individual mandate House: penalty=2.5% adjusted gross income Senate: penalty=$1500/family

3. No regulation of insurance company premiums, deductibles, co-pays or payment and denial practices.

EMERGING CONGRESSIONAL PLANHow to Reach Universal Coverage

6. Expand Medicaid eligibility to all below 133% FPL

7. Creation of an “insurance exchange”- Limited to uninsured and small employers

8. Subsidies (“affordability credits”) in the exchange

up to 300% or 400% of federal poverty level

9. “Hardship waiver” for those who cannot afford premiums: they can remain uninsured

10. Public option only available in the exchange

Only starts in 2013

WHAT HAPPENED TO THEPUBLIC OPTION?

The original “robust” Plan

• Open enrollment• Medicare-like: backed by the Fed govt• 119 million members (Lewin)

The Congressional Plan

• Restricted enrollment (only the uninsured)• 10 million members (only 5% of population) • Self-sustaining: follow same rules as private

insurers

BOTTOM LINE ONTHE CONGRESSIONAL PLAN

If it does pass in some form, it will:

• Make the world’s most expensive healthcare system even more costly

• Not achieve universal coverage

• Not make affordable insurance available

• Leave millions underinsured

• Not control the continuing growth in costs

Why? Because it doesn’t really change the way we pay for health care

PRIVATE INSURANCE BAILOUT

• Employer based health insurance enrollmentis declining: 15-17 million over 10 years

• Mandates increase private insurance enrollment

• Significant percent are young and healthy

• Government subsidies to assist low/moderateincome families will further increase privateinsurance enrollment

CONCLUSIONS• A system based in private insurance plans

-- will not lead to universal coverage-- will not create affordable insurance

• A Medicare for All System-- can provide comprehensive services

while costing no more than present-- can provide tools to control costs in the future

If a mandate plan is passed, the problems of the health care system will not go away. Real health care reform will continue to be essential

We Can’t Wait Another 16 Years! We Need Real Health Care Reform Before

the Premium Takes All our Income!

Source: American Family Physician, November 14, 2005

Today

WHY CONTINUE TO ADVOCATE FOR SINGLE

PAYER?

• The economic crisis calls for government stimulus of the economy

• Everyone benefits: the uninsured, the underinsured,and everyone else who is insecurely insured

• Employers will be relieved of the burden of rising health care costs/retiree benefits and unfair competition from employers who don’t offer HI

• Every other industrialized country has done it• It is morally the right thing to do!

CONTACTS AND REFERENCES• PNHP-NY Metro: www.pnhpnymetro.org

• PNHP National: www.pnhp.org

• Bodenheimer TS, Grumbach K, Understanding Health Policy: A Clinical Approach. McGraw-Hill, 2005

• Fein O, Birn AE. (editors), Comparative Health Systems. Am Jour Public Health 2003; 93: 1-176

• O’Brien ME, Livingston M (editors), 10 Excellent Reasons for National Health Care. New Press, 2008

• Geyman J, Do Not Resuscitate: Why the Health Insurance Industry is Dying and How We Must Replace It. Common Courage Press, 2008