Politics and Health Reform:Lessons From a Year in

Washington, D.C.

James Floyd, M.D.Global Health Seminar

University of WashingtonFebruary 12, 2010

Disclosures/Background

• Advocate for a government-financed system of national health insurance– “single-payer”

• Spent 2008-2009 in Washington D.C. working at Public Citizen, a national consumer-advocacy organization

What I’m Not Going to Talk About

• Specific details of various reform proposals• What’s happening in Congress right now• Problems with our health care system other

than insurance– Fee for service reimbursement of physicians– Pharmaceutical and medical device development,

regulation, and marketing– Management of chronic diseases, long-term care

• Policy

Life expectancy, OECD countries, 2003

65

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Hu

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Slo

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pu

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Cze

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lan

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Gre

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Ge

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Fin

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Italy

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Life Expectancy: OECD Countries

Spending: OECD Countries

Administrative Spending

• NEJM 2003;349:768– Administrative costs of health care in the U.S. and

Canada in 1999• insurance overhead• employers’ costs to manage benefits• administrative costs to hospitals, practitioners, etc

– Percentage of total health care costs• US 31%, Canada 17%• approx. $400 billion in wasteful administrative

spending in 2009

The Problem, in a sentence

• The U.S. has a fragmented health care system that is inefficient and fails to consistently deliver good care, leaving a large portion of the population without adequate access

A Solution, in a sentence

• Create a publically-financed system of national health insurance that covers all necessary care for everyone– Financed through progressive taxation– Eliminates private health insurance and investor-

ownership of facilities– Would remove barriers to access and incentives

that result in unnecessarily costly care– JAMA 2003;290:798

HEALTH REFORM

A Brief History

• 1883: Germany, 1st national sickness fund– Income stabilization rather than medical care– Rest of Europe soon followed

• Progressive Era: American Association for Labor Legislation– Opposed by AMA, AFL, and insurance industry– WWI, Anti-German sentiment, Red Scare

A Brief History

• 1926-32: Committee on Cost of Medical Care– Increased costs medical care, middle class– Economists, MDs, public health, interest groups– Recommended more national resources go to

medical care, but opposed NHI

• 1935: Social Security Act, New Deal– Health insurance left out because of opposition

A Brief History

• 1943: Wagner-Murray-Dingell Bill– First real bill for national health insurance, funded

by payroll taxes

• Truman: Supported a single national health insurance system to include all classes– Cold War: Red Scare again, “socialized medicine”– Opposed by AMA, AHA, ABA, mainstream press– AMA launched most expensive lobbying effort in

American history

A Brief History

• 1965: Medicare and Medicaid– Again, opposition from the AMA– But strong grassroots support from seniors

• 1970s: “Crisis” of cost and access– Resumed interest in national health insurance– Nixon: comprehensive coverage through

employer mandate and public plan for unemployed

– Watergate, economic recession

A Brief History

• Clinton: Task Force on National Health Care Reform– Employer mandated coverage through HMOs,

publicly funded coverage for the unemployed– Opposition from same forces

• 2008: Barack Obama elected President, Democratic majorities in House and Senate

Who stood to lose?

Conflicts of Interest

Conflicts of Interest

The Media

• Coverage of single-payer in mainstream media was minimal– Editorial policy/bottom line?– Not considered newsworthy?– Lack of context?– Did not fit into political narrative?

A Breakthrough

Then Disappointment

Public Opinion

Success?

Where does social justiceor human rights fit in?