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How Did We Get Here?
Author: Raine    Date: 11/27/2013 16:17:14


Patient Protection & Affordable Care Act (PPACA, ACA) is widely misunderstood, and as we know the misunderstanding has been accelerating by less than truthful information being submitted to the public by those that would wish to see it go away.

Again, as we saw in the lively debates of 2008-10 many are calling for single payer as an ideal substitute for what we have rolling out as our new system, designed as stated in its title: A program where Americans are protected from predatory insurance and have access to affordable health care. The system we had before the law was signed by the President in 2010 was a mess. It's been well-documented, here on this blog and in other places. It's easy to forget that we were in a deep recession in 2009, and insurance companies were making record profits at the same time as dropping customers.
In the midst of a deep economic recession, America's health insurance companies increased their profits by 56 percent in 2009, a year that saw 2.7 million people lose their private coverage.

The nation's five largest for-profit insurers closed 2009 with a combined profit of $12.2 billion, according to a report by the advocacy group Health Care for American Now (HCAN).
Now that the Exchange has begun, there are many complaints of people having their insurance cancelled, and how the President broke his promise -- how quickly we forget and look wistfully back to the good old days of of 3 years ago...
Eric Bolling denied that anyone in the United States has ever been deprived of health care. He's wrong -- millions of people have been denied care or have had their insurance coverage rescinded, denied, or altered by insurance companies due to pre-existing conditions, policy loopholes, and various other reasons.
In 2009, a Harvard Study estimated that 45,000 people a year died from lack of coverage. From the way many news outlets cover the ACA, it seems they would have us believe that ObamaCare started on October 1, 2013, with a horrible, terrible and rocky beginning. That's just not true. It started rolling out in October 2010 when it mandated, among other things, that parents could allow their children to stay on their plans until the age of 26. From the very beginning of the PPACA's implementation there has been a constant drum to *Repeal and Replace* It's not just from conservative quarters. Some on the left want to repeal and replace as well. They want Single Payer.
Single-payer advocates favor scrapping private health insurance and enrolling everyone in a program akin to Medicare with a comprehensive set of benefits that is financed through taxation, one whose primary focus is providing medical care, not earning profits.

To them, the messiness of Obamacare's infancy was inevitable; the law is built upon a fragmented health care system and a private insurance industry that they believe, by definition, is focused on profit first and the needs of its customers second.

"What you're seeing right now is the kind of compromise that was reached, kind of cobbled together, for the Affordable Care Act," said Sen. Bernie Sanders (I-Vt.) a vocal single-payer supporter who voted for the bill in 2010 after shelving his amendment to create a single-payer plan. "What's happening now just reinforces to me that what we need is a simple system focused on providing health care," he said.
Vermont is well on it's way to single payer, also known as universal coverage.
The plan, which was signed into law May 2011, is part of Vermont's larger health insurance overhaul. It is currently undergoing a three-phase implementation, and is expected to be fully in operation by 2017. The lengthiest delay stems from the need for federal waivers, which would allow for funds from the Affordable Care Act to be pooled with Vermont's own health insurance program. This should not be a problem, however, as Governor Shumlin has stated President Obama personally expressed interest in allowing Vermont to institute its own plan, claiming, "We want the states to be laboratories for change."
For supporters of single payer it would be natural to ask the question, why not every state? Why not just go all-in with Medicare For All? Why not a system like Canada? I know that I personally have asked those questions myself. Canada can actually give us good answers as to why we as a nation simply cannot just flip to single payer. That country's current health system didn't happen overnight. It didn't happen in a year or even a decade, arguably it's evolved for over a century. It'd been evolving for decades until it was signed into as the Canada Health Act of 1984. The true beginning to Canada's health care system began with a single state -- or province.
It was not until 1946 that the first Canadian province introduced near universal health coverage. Saskatchewan had long suffered a shortage of doctors, leading to the creation of municipal doctor programs in the early twentieth century in which a town would subsidize a doctor to practice there. Soon after, groups of communities joined to open union hospitals under a similar model. There had thus been a long history of government involvement in Saskatchewan health care, and a significant section of it was already controlled and paid for by the government. In 1946, the Co-operative Commonwealth Federation government in Saskatchewan passed the Saskatchewan Hospitalization Act, which guaranteed free hospital care for much of the population. Tommy Douglas had hoped to provide universal health care, but the province did not have the money.
Alberta followed soon after, providing the foundation that is the Canada Health Act. Much like Saskatchewan and Alberta, it appears that Vermont is leading the way towards universal coverage. I still believe that we can achieve something like single payer in the United States, but it simply cannot happen by scrapping what we have in this nation. That means including and understanding what was in place before the passage of the ACA. Like Canada, the answers to how we get to a nationalized health care system lies in how we have operated in the past. The history of reform begins with change, that is true. Canada took one path, other countries have taken a different one. Great Britain's National Health Service evolved under a much different circumstance than it's European neighbor, France. The NHS was intended to be temporary and was to be disassembled after World War II -- it stayed though -- people liked it as it served the population's needs. France needed to figure out how to improve its nation's heath system after the devastation of the war as well. They opted to expand what they already had in place: a payroll tax-payer funded system. Before the ACA was written, when we were still calling it Health Care Reform (HCR), many wondered and debated the path that should be taken. To this day, people still debate where we should go. The answer depends on where we have been and where we are.

Are you still with me?

This article was written in 2009 and provides incredible insight and understanding to what we are seeing now. (I highly recommend reading the entire piece.)
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” In the battles between Betamax and VHS video recorders, Mac and P.C. computers, the qwerty typewriter keyboard and alternative designs, they found that small, early events played a far more critical role in the market outcome than did the question of which design was better. Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. (snip)

With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are “remembered,” continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one.
He goes onto say:
There’s a similar explanation for our employment-based health-care system. Like Switzerland, America made it through the war without damage to its domestic infrastructure. Unlike Switzerland, we sent much of our workforce abroad to fight. This led the Roosevelt Administration to impose national wage controls to prevent inflationary increases in labor costs. Employers who wanted to compete for workers could, however, offer commercial health insurance. That spurred our distinctive reliance on private insurance obtained through one’s place of employment—a source of troubles (for employers and the unemployed alike) that we’ve struggled with for six decades. (snip)

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our economy. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.

That kind of constraint isn’t unique to the health-care system. A century ago, the modern phone system was built on a structure that came to be called the P.S.T.N., the Public Switched Telephone Network. This automated system connects our phone calls twenty-four hours a day, and over time it has had to be upgraded. But you can’t turn off the phone system and do a reboot. It’s too critical to too many. So engineers have had to add on one patch after another.

The P.S.T.N. is probably the shaggiest, most convoluted system around; it contains tens of millions of lines of software code. Given a chance for a do-over, no self-respecting engineer would create anything remotely like it. Yet this jerry-rigged system has provided us with 911 emergency service, voice mail, instant global connectivity, mobile-phone lines, and the transformation from analog to digital communication. It has also been fantastically reliable, designed to have as little as two hours of total downtime every forty years. As a system that can’t be turned off, the P.S.T.N. may be the ultimate in path-dependence. But that hasn’t prevented dramatic change. The structure may not have undergone revolution; the way it functions has. The P.S.T.N. has made the twenty-first century possible.
Our system is path-dependent. It can and has evolved since the ACA rolled out in 2010. It's a huge leap forward, but like the P.S.T.N., we cannot just scrap everything and start all over with single payer. We can, however, work towards that goal. We're building upon a system that we already have by improving what works and removing what hurts the population. We can't go back to the broken system the ACA was designed to fix. Perhaps Vermont is a sign of things to come. Massachusetts proved the path-dependent process works. That system provided the foundation to what we now call ObamaCare. Maybe that same process will take place with Vermont leading the way to single payer.

It can't happen overnight, but it can happen. I support single payer and I truly appreciate our allies like Senator Sanders and Representative Grayson, but the reality, for me at least, is that this will take time and patience.

Thanks Obama.


57 comments (Latest Comment: 11/27/2013 23:20:28 by BobR)
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