Those of us who care about health care reform in America have different goals. Barack Obama wants to make health insurance more affordable and available. Johm McCain wants to, uh, cut taxes or something. Many of us, me included, would like to boot the private health insurance companies out of the business and institute government-sponsored single payer health care.
The question for single-payer advocates is, how do we get there? It often seems impossible in today's risk-averse Washington. Fortunately, liberals have a long-time champion who has provided an answer: Ted Kennedy. The recent diagnosis of Sen. Kennedy's malignant brain tumor offers Congress and the American people the chance to properly honor this great lion of the Senate by following his lead and passing the most important goal of his political career: universal health care.
Sen. Kennedy, along with Rep. John Dingell, has over the past several Congresses submitted the Medicare for All Act. In the 110th Congress, the Kennedy/Dingell Medicare for All bill is labeled S. 1218 and H. 2034. In the past three congresses Rep. John Conyers has introduced the better-known alternative H.R. 676, known as the United States National Health Insurance Act (or the Expanded and Improved Medicare for All Act). In doing so, these three veteran lawmakers show the way to single-payer for Americans using the existing model for government-sponsored health insurance.
The Kennedy/Dingell bill is found at the S. 1218 link above, but here's the summary:
Medicare for All Act - Amends the Social Security Act to add a new title XXII (Medicare for All) under which: (1) each eligible individual is entitled to benefits which include the full range and scope of benefits available under the original fee-for-service program under parts A (Hospital Insurance) and B (Supplementary Medical Insurance) of title XVIII (Medicare), with parity in coverage of mental health benefits, subject to appropriate cost sharing; (2) each enrollee is free to choose his or her own doctor and private health plan; and (3) benefits are similar to or no less than the health benefits coverage under FEHBP (Federal Employees Health Benefits Program).
Establishes the Medicare for All Trust Fund.
Amends the Internal Revenue Code to impose: (1) on the income of every enrolled individual a tax equal to 1.7% of wages received in excess of $25,000; (2) on every employer an excise tax equal to 7% of the wages paid to each enrolled employee; and (3) on the self-employment income of every enrolled individual, a tax equal to the applicable percentage of the self-employment income for such taxable year in excess of $25,000.
Sets forth provisions governing application of this Act to collective bargaining agreements.
Neither Kennedy nor Dingell's bill has attracted any cosponsors or actions beyond referral to committees, but it is important to note the financing provisions. It asks for a rough doubling of the Medicare tax from enrolled individuals, along with a payroll tax (or contribution) from the employer. 7% of wages is actually a bargain for employers, since the most recent available data from 2005 show employer costs for health care coverage ranging from 10.6% to 14.2%, depending on the size of the employer (Fig. 6.) Kennedy and Dingell's bill establishes the principle that single payer can ask for a contribution from employers that is substantial, but still saves them money and provides some security about costs. It is voluntary for employers and employees to opt into, and leaves open the option of private insurance as well.
John Conyers' H.R. 676, by contrast, goes much farther toward a national single payer system, as its title implies. It has attracted 90 cosponsors so far in this Congress. Here is the summary for that bill:
United States National Health Insurance Act (or the Expanded and Improved Medicare for All Act) - Establishes the United States National Health Insurance (USNHI) Program (the Program) to provide all individuals residing in the United States and in U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, prescription drugs, emergency care, and mental health services.
Prohibits an institution from participating in the Program unless it is a public or nonprofit institution. Allows nonprofit health maintenance organizations (HMOs) that actually deliver care in their own facilities to participate in the Program.
Gives patients the freedom to choose from participating physicians and institutions.
Prohibits a private health insurer from selling health insurance coverage that duplicates the benefits provided under this Act. Allows such insurers to sell benefits that are not medically necessary, such as cosmetic surgery benefits.
Sets forth methods to pay hospitals and health professionals for services. Prohibits financial incentives between HMOs and physicians based on utilization.
Establishes the USNHI Trust Fund to finance the Program with amounts deposited: (1) from existing sources of Government revenues for health care; (2) by increasing personal income taxes on the top 5% income earners; (3) by instituting a progressive excise tax on payroll and self-employment income; and (4) by instituting a small tax on stock and bond transactions.
Requires the Program to give first priority in retraining and job placement and unemployment benefits to individuals whose jobs are eliminated due to reduced administration.
Establishes a National Board of Universal Quality and Access to provide advice on quality, access, and affordability.
Provides for the eventual integration of the Indian Health Service into the Program.
The text of Conyers' bill answers a lot of questions, though it's worth noting several features where Conyers' bill differs from Kennedy's and Dingell's:
- Funding is somewhat vague as to specific taxes compared to Kennedy's. This is probably wise, as tax rates required to fund health care will have to rise until costs can be successfully contained.
- It prohibits for-profit provider networks from receiving payment.
- It prohibits private insurers from offering competing coverage. This is a key point in successful national health plans overseas, including the private insurer-friendly Swiss model.
- It establishes an administrator and a dedicated funding stream to run the National Health Insurance Program.
- It establishes a National Board of Universal Quality and Access tasked with overseeing access, quality, capital outlay, provider reimbursement, budgeting and funding adequacy, and other vital issues. This Board is named by the President and confirmed by the Senate, providing a degree of autonomy which is vital to insulate the program from day-to-day political meddling.
These features, to my mind, make Conyers' bill a far superior alternative as a practical outline for national health care. It chokes off for-profit providers and insurers, minimizes political interference and meddling (though not as strongly as I'd like), and establishes the dedicated funding stream that takes health care out of the normal haggling over the Federal budget, which has almost strangled Britain's NHS several times over its life.
I do have a few quibbles with Conyers' bill. I'd prefer to see the administrator made fully autonomous, on the model of the Social Security Administration, rather than existing under the Secretary of HHS. The independent board in Conyers' bill seems potentially too toothless to be really effective. Conyers doesn't provide for a break-in period, as Kennedy's does with covering children and the 55-65 age group first; some incrementalism may be more politically palatable to Congress. I'd also like to see some snappier nomenclature, like calling the program Americare or the National Health Care Plan. It's also far enough from Medicare that applying that name seems a little disingenuous. But on the whole Conyers' bill fits my model of how single-payer should look in America today.
How do we get from here to there? Please consider joining a campaign to convince Sen. Kennedy, Rep. Dingell, and Rep. Conyers to join forces and combine their bills. Rep. Conyers, particularly, should be asked to consider naming his bill for Ted Kennedy, as the title of this diary suggests. I'd love to see this community start wheedling and pressuring and begging all the candidates we meet and come in contact with to push them to support Conyers' bill, and to support the idea of naming it for Kennedy. If you have any clout in the Obama campaign or with any other candidate, please start talking this issue up with the campaign, to try to get your candidates on board.
In the next Congress, if we have larger majorities and a new progressive Democratic president, there could be few more appropriate ways of celebrating our victory than giving an old liberal hero the ultimate victory of his career, and an accolade worthy of his service.