• Steve Horn

In continuing bafflement: the photo above was taken on Saturday at a health care town hall meeting held in Mt. Vernon by Democratic Congressman Rick Larsen, of Washington's 2nd District.



You'd think this anecdote from a Paul Krugman column that ran six days ago would have already put a stop to the nutty "Guv'mint Out Of My Medicare!" line of dissent, simply by shaming the teabaggers into logical coherence:

There was a telling incident at a town hall held by Representative Gene Green, D-Tex. An activist turned to his fellow attendees and asked if they “oppose any form of socialized or government-run health care.” Nearly all did. Then Representative Green asked how many of those present were on Medicare. Almost half raised their hands.

But apparently certain of the reform-hating masses have yet to realize that it's utterly embarrassing to have a public meltdown about the government taking over Medicare—because, again, the government already runs Medicare (and it's a pretty damn popular program).

Dr. Steve Horn, who took the mind-exploding photo at the Larsen event on Saturday, is chair of the political science department at Everett Community College. He submitted this response to the event:

I was one of more than a thousand interested local citizens who turned out for the town hall meeting with 2nd District Representative Rick Larsen this Saturday afternoon in Mt. Vernon. Though I wasn’t sure what to expect given the coverage of heated meetings around the country over the last week, all things considered with regard to the style of participation, I ended up unexpectedly proud of my fellow Washingtonians.

There were none of the shenanigans that have been marring events set up to discuss health care reform in other parts of the country. For the moment, at least, it looked as if we might be able to do this. That is, we can have a free and open discussion, and even disagree passionately with each other, without things deteriorating into a shouting match (or worse).

This isn’t to suggest that there weren’t a few extremists in the crowd or a few tense moments. A handful of attendees handed out literature purporting to detail President Obama’s “Nazi health care proposal,” and there was the random “Larsen is a traitor” placard here and there. But most came to listen, ask questions, make statements, boo proposals they didn’t like, and cheer those they did. This is all perfectly fair game in a democratic forum, and the exercise as a whole felt much closer to the kind of town hall meeting Norman Rockwell might have had in mind than what we’ve been seeing on our television screens. This is important because Congress’s August recess comes at a crucial moment in the health care debate, arguably the most important domestic public policy discussion in several generations. Much of what happens when the House and Senate return to Washington D.C. may hang in the balance over what transpires around the country this month in public forums such as the one Larsen held on Saturday.

With regard to the substance of the debate, however, I have to draw back a bit on my civic pride. And unfortunately, this is really where it counts, because it will be very difficult to have a meaningful conversation about our reform options if we don’t agree on some basic facts and points of emphasis. This is obviously a national problem given that the Los Angeles Times actually felt the need to run a headline Tuesday that read “Obama says 'death panels' aren't on his healthcare overhaul agenda.”

More generally and back in Mt. Vernon, I was taken aback by the number of comments — and cheers of approval — about government’s inability to do anything right. These folks seemed painfully unaware that Medicare and Social Security remain wildly successful and wildly popular. In fact, if revolt of the masses is really what you want, start by trying to take away those government programs from people. Perhaps there is some confusion about the nature of these services? I can only hope that the man holding the “Keep the Guv’mint out of my medicare” placard was being ironic.

So, if we are to act pragmatically, free from the dead weight of ideological true belief that we Americans have always avoided in our most heroic moments, we really do need to move away from the Reagan era notions that government can’t accomplish anything positive, or that private sector solutions are always better, always more efficient. As it happens, Medicare — yes, it’s a government program — has long operated with only around three percent of its revenue going to administrative costs compared to many times that invested by the typical private insurance company.

How does the private health care industry spend your premiums? Often, as was emphasized by recent testimony before Congress, to pay for private bureaucrats who serve no other apparent purpose but to cherry pick healthy applicants and deny claims to paying customers. They’re also spending approximately $1.4 million a day to defeat meaningful reform, effectively supporting a status quo which leaves the United States health care system ranked 37th in the world (37th!), and, according to a landmark study by the Institute of Medicine, results in the unnecessary deaths of more than 18,000 American citizens each year because they do not have insurance and can’t gain access to proper care.

Back to Medicare, related bluster about the looming financial collapse of the program is only correct so far as it is linked to the health care system as a whole. Exploding costs will indeed bust the federal budget if nothing is done. But this reflects a systemic problem that is not confined to the public sector. Any talk about “runaway costs” for Medicare has to confront the fact that it has been significantly better at holding costs down over the last 40 years than has the private sector (and research suggests that claims about Medicare “cost shifting” to the private sphere are overblown). Princeton’s Paul Krugman, winner of the most recent Nobel Prize in economics, estimates that “if insurance premiums had risen ‘only’ as much as Medicare spending, they’d be 1/3 lower than they are.”

When Saturday’s town hall conversation centered on specific aspects of pending health care legislation, things weren’t much better. There may be good arguments against the so-called “public insurance option,” but none of them seem to be percolating into public discussions. Instead, there was way too much talk about “government takeover” of the health care system, and far too many who seem to think that anything that involves pooling our resources together has to be bad, representing yet another perilous step down the “road to serfdom.”

The fact of the matter is that none of the proposals considered serious contenders for approval by Congress this year are in any way far removed from the American tradition of public policy as it has evolved over the last century. Ironically, that brand of public policy helped create the richest middle-class society the world has ever seen, and set the stage for the “golden age of capitalism” during the decades following World War II. In fact, the Greatest Generation embraced much of what passes as the evil of socialism today. President Harry Truman — hardly a Stalinist — proposed a much more radical version of national health care reform in 1946 than anything Congress is seriously considering at this moment (Truman failed in large part because representatives from the South thought the plan would lead to racial integration in hospitals).

While we can apparently still have conversations without punching each other in the nose up here in Washington State, many of us seem imprisoned by a set of more recent assumptions that should have come crashing down last September, as the forces of unrestrained financial capitalism disgraced and destroyed themselves, nearly bringing the entire economy down in the process. That crash brought with it the necessity of spending public dollars to boost economic demand, which had collapsed and remains in a depressed state.

Many rightly worry about the growing public debt that has been exacerbated over the last year to deal with that crisis. But if one truly cares about national fiscal solvency, national health care reform is an unavoidable piece of the solution. Without it, it is estimated that the share of GDP we spend on our health care system (both public and private) will continue to expand rapidly in the coming years, and we will indeed reach a breaking point. Already, in 2008 we spent approximately $2.4 trillion — close to 17 percent of GDP — and our per-capita costs were almost double what any other modern industrial country pays (but they get universal coverage and we don’t). By 2016, our estimated total costs will be around $4.3 trillion. And again, the private out-of-pocket and insurance costs are moving faster than the public ones.

In the end, perhaps our best solution is one that has been taken off the table by Larsen, Senators Patty Murray and Maria Cantwell, and by the President, and that’s unfortunate.

That is to say, while reform including a strong public insurance option is a vitally important minimum if we are to take advantage of the kinds of cost controls that Medicare delivers, the evidence suggests that the best way to really hold spending down and insure everyone at the same time, is through a “Medicare for all” system (combined with reforms Democrats are working towards, including new incentives for Medical school graduates to become primary care physicians in underserved areas of the country).
As it turns out, Harry Truman had it right decades ago.

Given the fact that Canada insures all its citizens under the type of system proposed by our 33rd President, and at nearly half the US per-capita cost, it stands to reason that we could have a rather lavish single-payer system of our own with the $2.4 trillion we are currently paying. The health insurance industry wouldn’t like that. But the horse and buggy industry didn’t like the automobile either, and there is no reason we should favor an industry whose practices are driving us all towards economic disaster.

Since Canada is typically the example of choice for those advocating in favor of a single-payer system, it has come under withering and usually unfair attack by those opposing serious reform in the United States. Certainly, as with any human endeavor, there are problems. Some critics point to the fact that the Canadian system is ranked 30th in the world. That’s not that much higher than the US system. However, keep in mind that we land in the 37th position largely on the strength of Medicare and other highly successful public aspects of our system (Including the Veterans Administration, which is just pure socialism, Mrs. Palin.).

How much lower on the list would we be without that Medicare/VA boost? Certainly, there would be a lot more space between the two countries in the rankings.

One of the more entertaining criticisms of single-payer is the assertion that hip-replacement patients in Canada have to wait for surgery there than in the American system. Of course, critics fail to point out that most hip-replacement surgeries in the United States are handled under the umbrella of Medicare. Yes, we can do single-payer very well here in America, and have been for decades.

In any case, polls suggest that doctors and patients who have experienced both systems prefer the single-payer model. Perhaps the best evidence is indirect: Recently Canadians selected Tommy Douglas — essentially the father of Canada’s single-payer system — as “the Greatest Canadian.” Alexander Graham Bell finished 9th, Wayne Gretzky 10th. Does that sound like a failed system to you?

All this said, there are probably a number of paths to meaningful reform here in the United States.

Aside from a strong public option, additional keys to “change we can believe in” should center on reducing, if not eliminating, the profit motive as an incentive for providing health care insurance, and shifting incentives that tempt many doctors to over-treat patients with expensive tests, procedures, and hospital stays that have not demonstrated any connection to better health care outcomes (Note to those interested in constructing dishonest critiques of serious reform proposals: this is not a call for rationing or euthanasia!). With regard to the latter point about cutting waste out of the system, a recent and now famous investigative piece by Atul Gawande in The New Yorker demonstrated that there are stark variances in the professional culture of medical practice across the country, resulting in dramatically different levels of health care expenditure from community to community. As it turns out, the professional culture in Seattle is one of the positive examples, proof that some communities are already on the right track even though the national trend is moving in the other direction.

The bottom line in this health care debate is that something significant needs to happen. “Leave us alone” and “get the government off my back” are simply not responsible arguments. Let the town hall debates continue with that understanding.

Dr. Steven Horn is the Chair of the Political Science Department at Everett Community College, and recently completed his Ph.D. dissertation at the University of Southern California entitled “Property and Democracy: Authority in Four American Property-Rights Regimes.”