The best policy remains "Improved and Expanded Medicare for All": a single universal "All America" insurance pool. There should be no issues of adverse selection. Everybody-in and Nobody-out. It would be paid for by the same progressive taxation we pay for other federal government goods and services including social security, military security and payment on the interest of the national debt. There would guaranteed and automatic enrollment. In addition to getting rid of the problem of adverse selection there would be the savings from getting rid of the private insurance companies as a wasteful unnecessary intermediary. There would be the additional cost savings benefit from monospony (single buyer, multiple sellers) in paying for services, equipment and drugs. There would be added benefits of global budgeting and strategic planning.

So that is the policy that we are still fighting for.

As single-issue advocates, it is the role of PNHP and others to advocate for what we believe is the best policy. It is not our role to engage in short-term mediocre compromise (there are plenty of well-funded folks out there doing that).

Now as to what our tactics and strategy should be to get from here to there is another question...?

Before the Clinton's in 1994, we were there fighting for real universal health care, including the modern single payer proposal dating back to at least 1989. After their defeat, not by us, but by the predicted double-dealing of the corporate forces that they thought they had on board (while rejecting even having us in the room), we were still there.

During the interregnum, from 1994 to 2008, when nobody else was fighting for real universal health care, we were still there building the grass roots, doing the research and developing policy.

Thanks to us, between 2003 and 2009 national independent polls from the Washington Post/ABC, AP/Yahoo, NY Times/CBS, and others show 60-70% for single payer (essentially all the 2009-2010 polls claiming to show 70% support for public option were support for single payer; but never mind).

Since the 2008 election, during the recent health care reform fight, we have been there pulling the debate from the left, while the forces of greed and reaction were fighting against change. Whether we were welcome to the table or not, we were there. Even while the candidate that had promised a public option and no mandates, and full transparency with no back room deals or rule by corporate lobbyists, had become the president cutting secret deals with Pharma and giving up on public option while pushing for mandates to buying knowingly defective over-priced for-profit private insurance.

And while acknowledging that there are some benefits in the reform that did pass, we will still be there fighting for real reform forward: We still believe that the "reform" will not control individual costs; you will still be paying too much, with out of pockets costs acting as a barrier to seeking and getting the care you need, while still being subject to medical bankruptcy if you get sick. It will not control total system costs with more being paid individuals, families, businesses, local and state government, as well as the federal government over time. It will not result in universal insurance coverage nor universal health care access.

And yes, too much of the reform is still de facto support for the insurance companies. And you still cannot make a profit insuring sick people.





But there is a legitimate debate to be had about what the tactics and strategy should be moving forward.

What should we keep doing the same as before?

What should be doing new or differently?



Just some examples:

How should we go about grass roots organizing? We have been creating local and state organizations, and working with progressives. PNHP specifically targets medical students, residents and physicians, working with their education system, conducting grand rounds, meeting with medical societies, writing letters and editorials, trying to get into the media. On a separate track has been getting statements and resolutions endorsing single payer in general and the HR-676 bill proposal by various organizations such as (but not limited to) unions, health professional organizations and even state and local legislatures. What else should we doing in America outside in of the beltway?

How should we play the Washington game? So far, it has consisted primarily of having a bill (e.g., HR-676) and getting congress-critter to sign on as co-sponsors. One specific apparent mistake was having the lead sponsor (Conyers) be chair of the wrong committee (Judiciary). Clearly to help get a bill actually moved, to say nothing of OMB analysis, it needs to have stronger targeted sponsorship within the appropriate committee. What else should we be doing inside the beltway?

Who do we reach out and ally with? Who will have us on mutually agreeable terms?

Who, in addition to the insurance companies, do we criticize?

Should there be a separate PAC spun-off to funnel money to candidates who support single payer?

Should we oppose, endorse, or be neutral or silent about limited expansion of Medicare say to those between the ages of 50-65, especially when it is based on a "purchase as insurance" model and not paid for by universal taxation model, as in the Grayson proposal?

Should we oppose, endorse, or be neutral or silent about "all-Payer" as a step-wise interim reform, such as already exists in Maryland, wherein all insurers (private, Medicare, etc) pay the same reimbursement rates for the same services rendered at any hospital?

Should we oppose, endorse, or be neutral or silent about other suggested reforms around payment mechanisms, such as limitations and reform around physician fee-for-service.

The ability, or not, of the so-called Accountable Care Organization model (Kaiser, Mayo Clinic, Cleveland Clinic, Geisinger, etc.) to deliver comprehensive care at lower cost and higher quality? Is it valid? Does it have much relative importance? Even if valid, can they be expanded and spread around enough to become a large enough part of the American system to make a real difference. Is this something for single payer advocates to oppose, endorse, or be neutral or silent about?

The validity, relative importance, and other issues around the Dartmouth Atlas and "over-treated" and controlling unnecessary or counterproductive specialty care and hospital services. Is this something for single payer advocates to oppose, endorse, or be neutral or silent about?

What is the utility of other reforms, that are happening to a limited degree to increase access to services, such as the expansion of NHSC and Community Health Centers. Can they be expanded and spread around enough to become a large enough part of the American system to make a real difference? Is this something for single payer advocates to oppose, endorse, or be neutral or silent about?

Another reform out there is to better control the number of number doctors going into different specialties (e.g., more into primary care; less plastic surgeons). This could involve more active control over the absolute and relative number of residency and fellowship training positions, as well as changing reimbursement rates so that primary care pays better and some specialty and procedure-based care and hospital care get less than they do now. Is this something for single payer advocates to oppose, endorse, or be neutral or silent about?

Within any given practice or service, there could be higher reimbursement rates for practicing in inner city ghetto and rural and other "undesirable" places with high unmet need; and similarly lower reimbursement for practicing in Bel Air and Park Avenue. Is this something for single payer advocates to oppose, endorse, or be neutral or silent about?

Similarly, the wider use of nurse practitioners and physician assistants and other health care workers related to changes in state-practice acts and what is a reimbursable service. Is this something for single payer advocates to oppose, endorse, or be neutral or silent about?





As an example of blogosphere crowd-sourcing I urge you to provide your input and suggestions in comments below (and would appreciate this diary getting rec'd up, so as to get the most input and comments possible).

Peace & Health