Campaign for Single-Payer Building Up Steam in Oregon

Inspired by Vermont's success in establishing a state-run program, Health Care for All Oregon to start a grass roots public outreach campaign
The Lund Report

August 30, 2012 -- The effort to establish a single-payer system in Oregon isn't dead. A group called Health Care for All Oregon has existed in Oregon for about 20 years, but its corporate identity was
passed on to a newly formed group this January, said Dr. Mike Huntington, a Corvallis oncologist who serves as the organization's chair. So far the group includes a board and a coalition of 53 groups – including healthcare organizations, community groups and labor organizations – devoted to educating the public and eventually attempting to pass legislation guaranteeing healthcare for all of Oregon's citizens.

Huntington said the renewed campaign has taken inspiration from what organizers in Vermont were able to accomplish. Single payer bills were introduced in Vermont for more than 25 years, but were
unable to get legislative approval until a widespread public education campaign around the theme of health care as a human right raised enough public interest that voters put pressure on legislators to pass the bill.

“It takes more than just very good, logical, irrefutable arguments,” Huntington said. Right now, the group is focused on talking to coalition members and in the coming months will provide training and public outreach events to discuss its public education campaign, which will still emphasize healthcare as being a human right – but also differentiate the proposed reforms from those that have already been passed at the state and federal level.

“Our focus is, first of all, educating, informing the population about the need for universal access and a good quality healthcare system, in addition to the state and federal legislation that has already been passed or is in the process of being implemented,” Huntington said. “Even with the best possible system there will be huge problems or huge deficits.”

Huntington said the Oregon Health Plan was originally designed with some tools similar to those used in countries with single-payer care systems, including a list of procedures that should be prioritized for coverage, with immunizations and other preventive treatments taking highest priority. That reform was hamstrung because officials intended to fine-tune the list every year based partly on public input, which violates a clause in the Americans with Disabilities Act, which prevents the state from discontinuing coverage for services it has covered in the past.

“There were a number of reasons it was shackled, really, that had little to do with how well it was designed,” Huntington said.

Part of the success of the campaign message is that it's simple, Huntington said, adding that proponents of healthcare reform have to become more comfortable speaking in sound bites. Even so, he added his own qualifier to the message:

“I would qualify that 'healthcare is a human right,' it doesn't mean you get an MRI if you have had back pain for two weeks,” Huntington said. “It means you get the healthcare you need, when you need it.”

“Conservative critics would respond, Healthcare is not a human right,” said Portland anesthesiologist Dr. Samuel Metz, who’s involved with coalition but clarified that he was speaking on his own behalf to The Lund Report. “Here's where I'm in the minority: I believe we can be more successful if we point out that providing healthcare is not a goal, it's a tool.”

Even if people are ideologically opposed to the idea of providing healthcare for others, pointing out that they're already paying for care for the uninsured – in the form of higher insurance premiums and higher costs for services – can help persuade them that providing insurance upfront will help control those costs.

In 2011, House Bill 3510 – which was introduced by Rep. Michael Dembrow (D-Portland) proposed single-payer healthcare in Oregon – failed, but went further than sponsors expected. Part of the problem, Metz said, was that the bill's sponsors were mostly Multnomah County Democrats, but some Republicans showed interest in its potential to control costs: he estimated that 40 percent of the cost of healthcare is administration. Metz also noted that CEOs of three major Oregon insurers – Providence, Kaiser and Legacy – have been quoted on record as favoring single-payer healthcare, even while lobbyists for the insurance industry fought it.

“These are all fairly insightful people, and they're not speaking for the industry,” said Metz, adding that the Canadian healthcare system actually started with one province – Saskatchewan – creating a single- payer system, with several others following suit until the country decided to nationalize the program.

“We're the only country that lets 44,000 people die each year because they don't have insurance. We think it's normal in the United States that if your insurance won't pay, you have raise $150,000 at a bake sale. We think that's normal,” Metz said. “It doesn't have to be this way.”

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Christen, thank you for doing the article. The rest of my comments will be to the two doctors. First, I dispute Dr. Metz' statement that "44,000 people die each year because they don't have insurance". There are a lot of statistics out there, comparing various different countries and their health care systems and outcomes, but lack of insurance does not necessarily equate to lack of health care. Dr. Metz, please cite some un-biased sources for that one, and prove it to us. I do agree that those without health insurance often have difficulty getting seen and treated for a reasonable price, although it is mandated that anyone must be seen in the emergency room, for emergencies, whether they can pay or not. There are various places that meet the need for affordable medical care, and there should be more of them. My office is such a place. Nobody made me do it, either. Second, it has not been proven that "providing insurance upfront will help control these costs". Doctors Huntington and Metz, please show us unbiased statistics that show that more insurance brings down costs. That has not been historically true. Third, under single payer, doctors, please tell us who it is that says "No" to patients, because someone must. Please tell us who it is that decides what is and isn't needed, because someone must, and it isn't always clear-cut. There is liability risk to the doctor, and medical risk to the patient, when someone other than the patient says "No". We all know that many people who don't pay anything at the time of service tend to use more health care resources, and come in more often, and those patients who must pay for medical care usually ask good questions! There are statistics that back this up, but it is easily observed daily in doctor offices and emergency rooms around the country. Fourth, under your ideal single payer scenario, would you doctors out-law any patient or doctor privately consulting or treating outside the system? The only two systems that I am aware of that do that are Canada and North Korea. Canadians come to the U.S. if they want to jump the line or get something special, but they aren't allowed to pay privately in most provinces. Outlaw choice and competition, is that what you want? Or, make anyone going outside the system pay twice, as we do with schools? Fifth, Dr. Metz talked about raising $150,000.00 with fund raisers in the U.S. for health care (sounds like maybe for a bone marrow transplant). In Canada, they just turn it down, if they feel that it is "experimental". You aren't allowed to pay for it, and you aren't allowed to have it. Sixth, of course the health insurance companies are interested in going the single payer route! Their actuarial risk keeps going up, and they could have the taxpayers take on that risk, and just be well-paid government contractors. Finally, doctors who support full funding by the taxpayers of their own nice paychecks for seeing all comers, won't ever again worry about having to give away services for free or reduced rates to indigent patients, and won't have to worry about keeping their practices full by taking good care of people. However, they will be so busy because it is "free", that they will demand a limitation to their hours, and they will also demand a limitation to their malpractice liability. See someone over lunch, or after hours? No, so sorry.... Their loyalty will be, and must be, to those who pay them. Those doctors who do a great job will be paid the same as those that do a poor job. Doctors who don't have a passion for excellence will have a cushy deal. Those who do have that passion will grow increasingly frustrated at the endless rules, and the lack of ability to go the extra mile for patients. That's OK, though; if they quit, cheaper "providers" will happily take their place. I also predict public sector unions for doctors under this scenario, with demand for paid malpractice insurance as a benefit. After all, an appropriate wage, working conditions, and limitation of hours must be human rights, also, even for doctors! Sounds like nirvana? Not for patients with anything unusual or serious, or patients who are "old", or those who have better things to do with their time than navigate the system and wait. Not for doctors who took their oath seriously to put their patients first, either. You two doctors were trained as scientists; please use your scientific training and look at your biases and look at whether your statistics might be flawed, before trying to subject the citizens of this state to the equivalent of chemotherapy. Look at long-term side-effects, too. Thank you.

I don't know what source Dr. Metz had in mind for the 44K figure, but a study in the peer-reviewed American Journal of Public Health estimated the number of deaths in 2005 to which lack of insurance contributed could be as high as 44,789. And I'd observe, the number of uninsured has grown since 2005. I don't like the idea of selling single payer by dumbing it down, it leaves the program too vulnerable when it inevitably crosses groups with an interest in maintaining the status quo. There are big questions wrapped up in single payer, to answer them without public consent is in the long term to answer them without public support. But there is no question that major reform was needed and that the pre-ACA system was unsustainable. Running through your points:
  • The pre-ACA system was rampant with inflation, with health care growing on average 2.4% faster than GDP since 1970. As a share of the economy health care grew from 7.2% to 17.9%. If you wonder why we have no money for anything, from schools to bridges and everything in between, I think our health care system is suspect number one.
  • Who do you think has been saying "no" to patients all along? I think the Wall Street Journal put it best back in 2003: "Health-care rationing occurs every day in the U.S., in thousands of big and small decisions, made mostly out of sight of patients, according to rules that often aren't consistently applied… The people who make these decisions are harried doctors, Medicaid functionaries, hospital administrators, insurance workers and nurses. These are the gatekeepers of the American health-care system, the ones forced to say 'no' to certain demands for treatment."
    It's not obvious why that process is worth defending.
  • Should doctors under single payer be allowed to see private paying patients? Good question! But we can answer it any way we want, there is no mandate that we slavishly follow some other country's program.
  • How do we decide what treatments to cover, and what happens when they're not? Good question! But see the above quote from the WSJ that describes the status quo. Again, it's not obvious that what we do now is in any way defensible. Also see, "big questions that single payer advocates can't answer when they sell a dumbed down program."
Lets look at the long term consequences of the status quo. We pay more than anyone else in the world for a life expectancy that's just a little worse than Costa Rica's. Really, it's not obvious why that is defensible.

bjfecola, I am glad that you thought some of my questions and concerns were good, and although I am NOT an expert on the statistics, I think that your thoughtful response deserves to be answered. Those are tricky statistics, trying to determine deaths related in part to lack of health insurance. I would have to check with friends who know the stats up one side and down the other, and will do so. First, however, I want to say that although you seem to think that I am defending the status quo, I absolutely do NOT defend the status quo. I think that PPACA is the status quo on steroids (more layers of rules, rules, and more rules), and that single payer sounds great by comparison. I just think it is sad if that is really the best we can do, because single payer will either create a two tier system, or outlaw choice. If you have not yet read "2 Days That Ruined Your Health Care" by William C. Waters III, MD, I invite you to read this short, non-partisan book on the history of the results of government policy on the practice of medicine. He describes very accurately why the prices for health care have become uncoupled from value, and even calls it the "health care money laundry", and I agree with that assessment. Unfortunately, single payer still does not fix this problem, and there would still be too many hands in the cookie jar (sorry for mixed metaphors). Rationing occurs when someone other than the receiver of goods and services cannot meet the demand for some reason. It is not rationing when the receivers of goods and services decide not to purchase for some reason. Another neat thing about that book I mentioned is that is goes over some of the health care systems in other countries (there is an amazing amount of variation). No question, we don't want the most vulnerable to have a lack of options, but putting all of us into the safety net might just drown us all, certainly financially-speaking, not to say what harm would befall our health.

Kathleen, it doesn't mean anything to compare policy alternatives such as the ACA or single payer to fantasyland, where everyone gets what they want and compromises don't exist. The relevant comparison is the status quo, because in the real world that is what we're stuck with in the absence of reform. Is the "freedom" in our current system worth its cost?

bjcefola, I thought you were being serious, and now that you have said that I am comparing ACA and single payer to "fantasyland", I see that you are not serious. This response, then, is mostly for those who seriously want to know about this issue of single payer. Of course, we have to compare single payer and ACA with the "status quo", which is quite bad, and the "status quo" certainly is NOT freedom; not at all (bjcefola, I don't think that you read what I wrote). However, there absolutely are small pockets of freedom in health care in the USA. Patients who actually pay for their own care, AND care about quality, seek them out. I meet those people all the time! There is an actual market within this country, not just overseas, for affordable, quality health care services. Most people are probably unaware that it even exists. It will be there unless and until it becomes illegal (and how sad would that be!). So, if single payer goes through in Oregon, would all physicians be mandated to participate? Would all residents be mandated to participate? What if some physicians decide that they would get out of medicine or move away, rather than participate? Would they be forced or drafted? If so, how many hours would they be required to work? How many hours might they be allowed to work on the side, in private practice? Also, what would happen to the economy of the state? How many businesses would leave or close? Would any new businesses come into the state? We have, for many years, dating back at LEAST to 1942, experienced all the results of massive government tinkering in the health care economy, to supposedly make things better, and the end result is to make things worse and more expensive in the long run. I don't think that you understand the trajectory of Medicare, for example. What IS fantasyland is the idea that single payer will be good in the long run. It is all about power for various different groups (53 groups are affiliated with Health Care For All Oregon!). The doctors who endorse single payer are also very self-serving. People want to think that their health care is "free", but whether they pay taxes or not, it costs them dearly when paid via government, in ways they cannot even see. Single payer is built on a bunch of lies, to be blunt. Where else would anyone urge you to hand over increasing quantities of money (oh, it's someone else's money, you say), and then say "trust us" to give it back when you really need it (and THEY will decide if and when you really need it and deserve it)? Who really cares about you as an individual patient in such a system? I love living in beautiful Oregon, but I don't think I could live in this state anymore, if it actually finishes off freedom in health care.

bjcefola, here are some other sources of statistics and opinions for you, since you seem to be serious about the facts: Sure, there are plenty more studies and opinions out there, and many of them have bias. That is why it is a challenge to sort through them, and then see if there are other solutions besides single payer that would preserve freedom (which single payer does NOT) AND improve overall health outcomes in our country. To me, single payer means no longer believing in freedom. I think that we should be asking why health insurance is so expensive, and are there other ways to bring down that cost without force or coercion from government. The traditional answer to regulating cost is competition and choice. It could work with health insurance, if the government would allow it, including allowing individuals to choose what they do and don't want in their policies. All of those mandates increase cost. The health insurance industry is totally in bed with the government, and would remain so with PPACA (Obamacare) or single payer (as government contractors with no real risk). Who gets short-changed? Yes, the patients. Everyone is "covered", but someone besides the patient and their doctor decides what is necessary. And the doctor no longer really works for the patient. Sounds to me like a Faustian Bargain.

nbenton, you are right about costs of health care being way too high, but before you talk about "control" of the costs of new drugs and technologies (by government, of course), you may want to "peel the onion" and take a look at WHY the costs are too high. The prices are part of a giant game, where all participants in provision of medical goods and services must try to "maximize the reimbursement" (according to complex coding schemes and complicated rules) from a third party payer instead of providing value. Governments can force price controls, but that generally always results in shortages. The better way is to get better value for the money, and government has always been VERY bad at that. Consumers (who care about quality and availability as well as price) do a great job of that, by voting with their feet and their wallets. We almost completely lack that effect in health care. It is possible, if we allow it. Currently, we essentially do not allow it. Consumers of health care and health insurance need WAY more choices, and our government needs to allow them, instead of adding more taxes on drugs and medical devices.

Single-payer health care has resulted in rationing and long waits for health care in other countries such as the UK and Canada. Oregonians should expect the same if the state adopts a similar plan. For an interesting comparison of health systems in other countries, I recommend: "The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World" On a more philosophical level, the idea of a single-payer system is based on the premise that there is some mythical "right" to health care. This is a very dangerous and deeply flawed idea. Rights are freedoms of action (such as the right to free speech or the right to contract), not entitlement claims on goods and services that must be produced by another. Anytime a government attempts to guarantee a "right" to health care, it can only do so by violating the actual rights of doctors, hospitals, and other providers who must provide that care, and the rights of taxpayers forced to pay for others' care against their will.

Sometimes. Policing (protection of private property, enforcement of contracts, protection of life, things like that) is a core function of government. If the fees/taxes were too high, and police extended their roles too far, it could violate rights of the taxpayer. Firefighting might be more complicated, but some of the same things apply.

Single payer systems don't work. There is no magical formula that can force human beings to make it work. That's the beauty of being an American and our constitutional recognition of the individual, as created by God. When you get sick, there is no amount of insurance that will cure you. You could be as wealthy as Steve Jobs, and all the money in the world or insurance will not cure you. The cause for the increase in health care is not as simple as the price of drugs or new machines. It is the influence of government in the sweet deal of health care that has nothing to do with health, and everything to do with making money on money. You go to the hospital and think that, because it's a "non profit", that this makes them special. All this does is allow them the tax break from over charging patients and then writing off what they cannot collect as a "charitable donation". Consequently, they get huge tax write-offs, but the collection agencies, and the insurance billing coders and the hospital execs all make big money. In the mean time, you and your insurance company dance around inflated charges, and probably even fraudulent charges. They count on us not reading our bills, because, after all, someone else is paying, right? Do Oregonians just not believe the horror stories from Canada? It is only one of two true single payer systems, North Korea is the other. Want to loose your freedom? Start by giving up your health care decisions to the government.