A “Single” solution?

Question 1, which would recommend the city council endorse universal health care, inspires heated debate

By Sam Pfeifle

Judging by the slickly produced and expensive television ads blanketing the local television stations, Question 1 on Portland’s upcoming municipal ballot doesn’t have a chance in Hell. “Question 1,” a menacing male voice intones throughout prime time, “is a horrible idea.”

Such, of course, is the tone of the political debate nowadays: no one can simply differ in opinion. They must characterize the other side as chock full of morons, idiots, or (in this case) bleeding heart liberals who want to save us all from ourselves.

Heaven forbid the City of Portland engage in a rational debate over the merits of universal health care — a program that has been instituted in 26 of the 29 most industrialized countries, but which is a “horrible idea.” No, the folks at Citizens for Sensible Health Care Choices would rather spend Anthem Blue Cross’s money (the major funder of the commercials) on sensationalist messages of “higher taxes,” “fewer choices,” and “wip[ing] out your current health plan” (most advocates of Question 1 would say to those charges: “Of course that would happen, and that’s a good thing.” But we’ll get to that later).

The grandstanding is unfortunate because there’s certainly a debate to be had here. There’s a chance that universal health care — a system whereby each and every one of us could go to any doctor in the state with the same simple insurance card and get the care we need free of charge — could work. It could save us some money, both as consumers and as a state. It would definitely provide health care to the 160,000 Mainers that don’t currently have it. But it’s certainly no panacea.

For many, universal health care is a move toward socialism, a wholesale disavowal of our capitalist market, which has served us pretty damn well in many regards. It would create bigger government — much bigger. And for some, there’s something frightening about that much medical information being in the hands of the government. But it’s certainly not the herald of Armageddon.

The opportunity is here for both sides to take a look at this not-so-radical idea and really evaluate it on its merits and versus the alternatives. It may end up being something they absolutely have to do down the line, as everybody generally agrees that we don’t want Maine’s health care system to, as Maine Insurance Commissioner Alessandro Iuppa warned this summer, “collapse in five years.” We’ve already seen Harvard Health Care pull out of the state, Tufts stop issuing new policies, and Anthem bump up rates 30 percent. It may well be that private insurance companies decide they simply can’t make a profit here. Clearly, the status quo isn’t serving anyone.

You might be wondering exactly why this debate is so heated already. As the ballot will read on November 6, “this question is an advisory referendum question only, the results of which do not bind the Portland City Council.” And we’d only be advising city council to pass a resolution anyway, “supporting creation of a system of universal health care.” In fact, the only person who would be burdened by additional work is Jerry Cayer, the city’s director of Health and Human Services, who would have to issue a three-part report each July 1, “concerning the benefits of the enactment of such a system of universal health care.” Oooh, sounds expensive. Not so says Cayer: “I think we could accomplish this with our current makeup within the department. It wouldn’t cost the City of Portland anything.”

If we’re advising to support or not support something that may or may not come to fruition, and it won’t affect the budget, why all the vitriol?

“Because it is symbolic,” says Harlan Baker, chair of the Portland Democratic Committee, and one of the chief organizers of a symposium being held October 25 (see listings under “talks” for details) concerning universal single payer health care. “The thing about symbolism is that sometimes it can determine how people feel, and I think that’s why the opposition is out to nail it.”

People care about how Portland votes because single payer health care in Maine is a very real possibility. In fact, just this past legislative session, the Maine House passed LD 1277, an “Act to Establish a Single-payor Health Care System,” sponsored by Representative Paul Volenik of Brooklin (D). Health care reform advocates rejoiced — until the bill was stripped down in the senate so that it would only form a commission to study the feasibility and affordability of universal health care in Maine. Though that’s still a pretty big deal. The commission is under mandate to return findings in March that show the state can save five percent off the current system of Medicare, Medicaid and the like. If they do that, there’s a very real chance that universal health care could be instituted in Maine.

Especially if Portland — Maine’s biggest and most diverse city — comes out in favor of the plan. That’s why both camps see this as a very important vote.

If you ask Dr. Duncan Wright, the head of the Maine Labor Party and much of the impetus behind this ballot referendum, the benefits of universal health care are as simple as ABCD:

A

— Accessible to all, and that access is guaranteed. “People can see that the market works well in some areas of life, so they think it should work well with health care,” says Wright.

“You can imagine if our fire department was built on the market model: they roll up to the fire and before they put it out they ask, ‘do they have the hook and ladder option or do they have the less expensive trampoline option?’ No one would imagine doing this in these areas, but we’ve somehow carried over in to health care ideas from the parts of social life where markets work well.”

B

— Best quality of care. “We have good hospitals,” says Wright, “we have good clinicians, but what we need to solve is the chaotic administration of the health care insurance system, which is currently getting in the way of the sick getting healthy.”

C

— Choice of doctor, no HMO-like doctor mandates. Universal health care will keep more doctors in business. “You have to guarantee hospitals that they’re going to be paid,” reasons Wright. “Rural hospitals are closing because their income is unstable. They have too many patients without insurance. They don’t have a guaranteed source of income. We’ll keep them open.”

D

— Decreased cost. “Right now there’s 16 percent overhead and profits for the companies operating in the US, versus one percent for Canada [which has universal health care],” says Wright. “We’re spending $900 per person on overhead, they’re spending $200 a year per person on overhead.” The logic goes, if we take away the profit motive, take away the myriad paperwork and forms, we’ll wind up with a cheaper, more efficient, health care system.

“If you look at how other industrial countries have solved the problem of health care, 26 out of 29 have chosen a guaranteed universal health care system,” says Wright. “The others are Mexico, Turkey, and the United States. And the failure of us to do this isn’t just inconvenient, it also causes us to live shorter lives. Our life-expectancy is two years shorter than the rest of those countries. And among the factors in there, lack of insurance is a significant factor. When you don’t have insurance, your risk of dying goes up 20 percent.” Wright also notes that the World Health Organization ranks the US 37th in the world for efficiency of health care delivery. That’s not good considering we spend twice as much per capita as everyone else.

There is obviously opposition to such thinking, and in Portland that opposition is headed up by Mark Cenci, chair of the Maine Libertarian Party (it is interesting that this battle may provide a little limelight for the Laborites and Libertarians, two low-profile political parties). He has problems with Wright’s assertions, though he isn’t adverse to seeing health care made available to all.

“I understand the intent and I share the intent,” says Cenci. “I differ on the mechanism of providing it to the people.” In particular, he disagrees with the notion proposed by Laborites and others — though worded so as to not expressly be said on the ballot — that access to health care is a basic human right. “I have the right of free press,” offers Cenci, “but I don’t have the right to tell [a newspaper] that [they] have to get me a certain amount of column inches. I have a problem with so-called rights that impose obligations on others.”

As for how we do go about finding health insurance for those that can’t afford it, “I don’t have the perfect answer for that,” he says. “Even in the best free-market situations we’re always going to have people in need. If we need to set up a system of charities, university hospitals, the government providing health care to poor people, I wouldn’t object to any of those. The salient point is that we’d like to see more effort put towards providing insurance to people that have none, rather than stripping away policies from people that have them. Let’s augment what is a wounded but still walking insurance system. That would be something that I would support.”

Cenci just doesn’t feel that single-payer is the answer. “This makes no economic sense whatsoever,” he says. “This does nothing to cure the out of control health care costs. We have gone completely to a third party payment system, individuals have no power over the spending of their dollars.” This is the Libertarians’ major problem with our current health care system — that everything is paid by a third party (i.e. the insurance company), and the doctor and patient no longer have power over the structure of care provided.

“When you’re the only one paying,” reasons Cenci, “you tend to demand more.” He cites a 1984 study by the RAND Corporation (a respected think tank, whose CEO recently addressed NATO on the subject of terrorism) which studied people in the late ’70s and early ’80s who either paid for all of their health care needs, co-paid, or paid for none of it. The study showed that those who paid none took advantage of health care more often (hard to believe, eh?), but the kicker was that those who visited the doctor more often weren’t necessarily healthier, which contradicts the statistics Dr. Wright cites that show Americans living two fewer years.

Cenci offers an explanation by way of analogy: “If you had restaurant insurance and you only paid 20 cents on the dollar, you’d go out to eat a lot more. But you wouldn’t necessarily eat better.”

Cenci and the Libertarians have alternative ideas that take away the third party system and replace it with a system that gets doctors and patients reinvested (so to speak) in their health care and how it’s financed. One emerging option is called Simplecare, a non-profit organization established three years ago in Washington state.

“Basically, when somebody has insurance, all the extra administration for submitting claims costs a lot of money,” explains Keri Andrews, director of operations for Simplecare. “By removing those costs, doctors are able to charge the patient a lower cost. Insurance just increases the cost of health care for everybody, and doctors don’t get paid reasonably. A lot of times they end up getting reimbursed at lower than the cost. So, basically, what Simplecare does is remove that middle man. Doctors agree to have a fair rate charged for the services, as long as the patient agrees to pay at the time of the visit. The doctor gets reimbursed fairly and promptly and the patient doesn’t have to pay inflated costs.” Simplecare organizes all of the doctors and patients, for a nominal membership fee of $20 a year, or $35 a year for a family of eight.

Obvious questions remain: How do you afford to pay even reduced costs? What happens if I get cancer and need a million bucks to pay for it?

Simplecare and other advocates of removing the third-party system have answers. First, a family should set up a medical savings account, which is run like an IRA, whereby pre-tax dollars are put into an account, and money can only be taken out for medical expenses. Things like strep-throat visits and sprained ankles are paid out of that account.

As for the major illnesses, a family or individual should get what’s called catastrophic or high-deductible insurance, where the premiums are much lower per month, and the deductibles are much higher, but if you have that savings account, you should be able to weather the storm.

If you take the as much as $800 a month than some families pay in health care, pay $200 to the high-deductible premium, and the rest into a savings account (pre-tax, remember), it sounds like a plan that just might work.

Not so fast, say single-payer advocates. “I think it throws the insurance baby out with the bathwater,” says Wright. “What you need is a large risk pool, where the money is there when anybody gets sick . . . That’s the inspiring thing about insurance, when insurance acts as mutual aid. In terms of medical savings accounts, that divides the risk pool . . . it biases the system for people who are wealthier, who can afford it. If you start out sick, you’re already disadvantaged. It’s a system that recedes from the people who need it.”

As for catastrophic insurance, Wright says it “will bankrupt [people]. Forty percent of bankruptcies are health related. There’s a general point that’s been made many times: most people who are not independently wealthy have to keep earning money to provide for themselves and their families . . . When they get really sick, there needs to be something to help them out.”

Cenci worries that we’ll be helping people out, but that we won’t be giving them the best possible help with universal health care. He says that decisions will be made to not give the best care to the elderly, so as to save money. The decisions on who gets to see specialists will be politically motivated, rearing “the ugly head of racism and classism.” He fears that alternative forms of health care — acupuncture, chiropractic, homeopathy — won’t be covered.

And he has concerns about personal privacy. “I favor privacy,” says Cenci, “not a single database up in Augusta that can be accessed by people who are your political enemies.” He fears that what happened to Missouri Senator Tom Eagleton, dropped as vice-president from George McGovern’s 1972 ticket due to leaks of Eagleton’s treatment for depression, will happen to other political candidates not of the party in power. “And the Republicans will control that database one day,” he warns.

Wright sees this as fearmongering. Single payer gets “the insurance company out of the relationship between doctor and patient,” says Wright. “It doesn’t change the delivery system at all.”

Whether that’s true, in some ways, remains to be seen. Universal health care has never been done in the US, and certainly not in Maine. We have our own ways of doing things, like or not, and no one really knows what single payer would look like here. The state is already studying the issue and will likely return a finding that universal health care is at least feasible.

The question is: Does Portland support going forward with implementing such a plan? On November 6, we’ll find out.

Sam Pfeifle can be reached at spfeifle@phx.com.