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HCAN can't, and furthermore they won't

In Xanadu did Kubla Khan
A stately pleasure-dome decree :
Where Alph, the sacred river, ran
Through caverns measureless to man
Down to a sunless sea.

On waking from an opium-induced sleep, so the story goes, Coleridge hurried to capture on paper the fantastical world he had dreamed [or hallucinated, depending on who you ask]. He was rudely interrupted while at this task, and when he returned to it, all was gone but the fragment we have today.

I can't help it. There's a little tiny video running in my brain, of a person from Porlock knocking at the window, frantically motioning to Sam, enticing him away from his scribblings whenever I read this portion of Richard Kirsch's preamble to his Will it be Deja vu All Over Again?

To my surprise, the writing led me to a fresh understanding of the paradox of achieving universal health care in the United States: the political debate about health care reform is turned upside down once the debate turns from the problem state to the solution stage. At that point, people become more scared about what they will lose from reform than what they will gain.

This seems both logical and intuitive [which is why I defended truthiness as a communication technique in an earlier discussion] and there may even be real actual studies demonstrating this, but nowhere in his 16-page lauding of Medicare the idea and Medicare the word does Kirsch actually test his conclusion, or even reference someone else's work on fear of change. Instead, the notion has interrupted Kirsch in the midst of his writing something else, in kind of a reverse of Coleridge's Xanadu vanishing when his writing is interrupted by RL.

That's okay, I'm inclined to give everyone the benefit of the doubt, especially since he seems to have penned this piece as both cautionary and inspirational tale. And he does say lots of nice things about single-payer in general and Medicare in particular and even why expanding Medicare to cover all of us is The Way. But in the end he comes to Medicare for all, na ga happen and so I took a little trip through Google Land to see if I could find out why.

After several hours, over several days, of poking around the ether, the evidence I found was scant, but it looked like Kirsch had taken his twin ideas Medicare = bad word and change >> fear as Truth, and set out to look for A Better Way.

And comes up with GAC -- Guaranteed Affordable Choice. Gak. See pages 5-7 for the bad words and the good words, determined, apparently, by a few focus groups in Orlando, Florida; Columbus, Ohio; Concord and San Diego, California; and Denver, Colorado.

Ooooh! They let Floridians in on the decision making! That should scare you.

So, anyways... it all sounded like hand-waving to me, but I'm being kind compared to one Krisch's critics over at the PNHP blog, Kip Sullivan:

(In 2006, a group that Richard helped form called the Herndon Alliance began cranking out junk science that allegedly supports Richard’s claims. Obviously, given the timing of Richard’s decision to abandon single-payer—either 2003 or 1993—the Alliance’s junk science could not have played a role in that decision.)

Sullivan goes on, at length, to rip Kirsch up one side and down the other but you should read it all anyway. While you're there, you should read the other 4 essays critiquing HCAN from all angles.

A few quotes that I'd like to highlight:

Nicholas Skala --

The core of Richard Kirsch’s argument is that reformers should forego advocacy of a proven and effective reform — single-payer — in favor of policies which have already been demonstrated to be failures, because the latter are politically expedient. In other words, because failure is politically achievable, failure should be advocated.

[... ]

Kirsch purports to dispel the “myth” that all European nations have single-payer by replacing it with a new one: that these systems preserve — as he and HCAN would — a substantial role for U.S.-style private insurance. Nothing could be further from the truth. In reality, all of these systems work only because they have regulated U.S.-style insurance companies out of existence.

Oliver Fein --

Under the HCAN plan, private health insurance would remain a nightmare for consumers and physicians with continuing co-pays, deductibles, delays, and denials of coverage. The cost of what is already the world’s most expensive system would continue to climb, with no effective cost control mechanisms in place. Those who think they are insured will still find, when they are sick, that their insurance has failed them and that they can’t afford the care they need.

David Himmelstein --

This approach reprises the format of Medicare’s ongoing privatization. Despite promises of strict regulation and a level playing field that would allow the public plan to flourish, private insurers would (as they have done in Medicare) predictably overwhelm regulatory efforts through crafty schemes to selectively recruit profitable, lower-cost patients, and avoid the expensively ill. Like the Medicare Advantage program, originally touted as a market-based strategy to improve Medicare’s efficiency, the HCAN plan would evolve into a multibillion dollar subsidy for private insurers whose massive financial power (amassed largely at government expense) would prove a political roadblock to terminating the failed experiment.

Unfortunately, proposals like HCAN’s that cede a central role to private insurers can only add coverage by adding costs. They promise savings from computerization and chronic disease care management. Yet the Congressional Budget Office has warned that there is little or no evidence for such savings.

The HCAN proposal forgoes most of the $350 billion annually in administrative savings possible under single payer national health insurance (NHI). Administrative waste is a natural byproduct of the private insurance firms that would retain a central role under HCAN’s plan. Private plans’ overhead is 12-fold higher than under NHI; the excess is squandered on marketing, underwriting, utilization reviewers and profits, and for the billions paid to executives.

Gee, thanks for all the ponies, HCAN.

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flotsam's picture
Submitted by flotsam on

Thanks for pulling all that together, hipparchia. What's particularly shocking is the faulty logic which says, "Here's what we can accomplish under the present circumstances. Let's do that, even though it's completely useless."(as Nicholas Skala points out)

It reminds me of the story of the man who is looking for his lost keys under a streetlight at night, even though the chances of the keys being under the streetlight are slim to nonexistent. But at least there's the light, and at least he's doing something....


Submitted by hipparchia on

i've always liked that story, too true, painfully so sometimes.

that line of skala's was my favorite in the whole post. if iwere to ever win the megamegamegalottery, i'd be sorely tempted to get it printed up on a bunch of t-shirts and send them to all the dems in congress.

Submitted by lambert on

... to the individually bolded authors?

Yes, great analysis. It fleshes out an initial point made by ... [memory failing, google failing]... the PNHP that the rhetoric came first, then the policy.

Now, maybe our discourse is so toxic that's how it has to be. If so....

[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

Submitted by hipparchia on

did you want links to each of the essays i quoted? or links to more stuff by/about each of the authors?

all 5 essays were combined into the one post. i don't know how to make links go to a particular spot inside a post, but if you provide me with instructions, i'll do that.

toxics... i was a hazmat chemist for awhile, i say we don our ppe and make our way into the hot zone.

Submitted by lambert on

... were different articles from a collection. If it's all on one page, you probably can't link to each chunk. Sigh.

If you want to ask me offline, I can explain. There is a way to link to points on a page, sometimes, but you have to know what to look for. Sometimes this is good to do because it is an aid to the reader.

[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

flotsam's picture
Submitted by flotsam on

Yes, lambert, "toxic discourse" is exactly what we're up against. When single payer health care is routinely described as "socialized medicine", the whole discussion starts at less than zero.

By very definition, we operate a "socialized" defense system in this country: from each according to his means, to each according to his needs. Last I checked, every American (theoretically) is under the same defense shield, rich and poor alike. Same with the roads and highways - "socialized" by definition, since the rich and poor get the same roads to drive on, despite the fact that the rich probably pay more taxes. Same with public education, despite local differences: "socialized". But does anybody actually call them "socialized" delivery systems? No. That term is reserved for discussions about health care, and it is indeed toxic.


leah's picture
Submitted by leah on

Even though I have a somewhat different view of HCAN, this is a well-researched, well-argued post, which adds to a genuine discussion of how to get real, fundamental reform in health care, a reform that will mean the acceptance of a guaranteed right (guaranteed by the government, which means by one another, by citizens deciding this the kind of society in which they want to live) of every American to comprehensive health care.

One problem that I don't see discussed by those who think Medicare for all is a persuasive approach, is that Medicare is in genuine trouble these days. And in the case of Medicare, unlike the case of Social Security, it isn't just a made-up "crisis" meant to kill Medicare by people who have never supported it, although John McCain has made it abundantly clear that is precisely what he has in mind, and his entire economic approach, which is to extend and deepen the economic crises we now face, and the income inequality that is quite clearly the result of Reagannomics by continuing to make the false claims of Reagan, Bush I and Bush II for keeping taxes "low," cutting them in the face of recession and in the face of prosperity; remember Bush said the whenever government is taking in a surplus it's overtaxing its citizens, but we know now that there is never a corollary corrective that when it produces huge deficits, taxes need to go up. And now that recession is a possibility the argument will be that we must cut taxes, and McCain's economic plans increases the Bush tax cuts.

The Medicare crisis has been made worse by the failure of a Republican-controlled congress and the negative efforts of the Bush administration for the the last eight years to deal with it in any way but to cut services and/or to cut fees for service to the point that most Medicare recipients have to carry a Medi-gap policy to feel any kind of security. The crisis was perfectly predictable, since Medicare is a relatively small risk pool made up entirely of members of precisely that group of Americans whom we know ahead of time are the most likely to need medical care. The problem is not that it's a government program, because we can see that opening it up to private insurers has only resulted in less efficient servicing of Medicare clients with bigger overhead costs, hence the insistence by the Bush administration on building in subsidies to private insurers to take Medicare patients.

As government-run health care programs go, the Veterans Administration is a real model of how a modernized single payer can improve quality of care even while it brings downs skyrocketing costs. Unfortunately, this is a story which is almost unknown except among health care wonks. And the Walter Reed scandal only obscured the story further, although Walter Reed is not run by the VA.

What I think has to happen is for all of us to become health wonks, then to start organizing a grassroots education campaign that lays out the information, which if done correctly should suggest that the best bang for our buck is undoubtedly some sort of single payer plan, and that such plans do not mean forgoing "choice," in the sense that you are more likely to be able to pick your doctor than in programs run by HMO.

I'll have more to say about how to advance this discussion and what I mean by "organizing" in subsequent posts.

Submitted by lambert on

And with a depth of coverage uniquely Correntian, thanks to posts like this and to DCB's daily efforts.

[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

Submitted by hipparchia on

i think the republican-controlled congress has managed to achieve a lot of its objectives in its campaign to break the parts of governement that work for the little people, simultaneously strengthening the parts that work for the already-powerful.

DCblogger's picture
Submitted by DCblogger on

I just do cut and paste. Good job. Anyone who thinks Medicare is a bad word needs to look at the recent vote where Republicans overode Bush's veto.

Submitted by lambert on

Sure, it is. But the daily posting is valuable too. Don't denigrate it!

[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

Submitted by hipparchia on

your posts have been a rich source of information and ideas for me, mostly for use irl. many thanks, and please do keep up the good work. you've provided with a number of useful sources i would never even have thought to look for.