By KIP SULLIVAN, JD (1)

I attended the Medicare-for-all town hall meeting at Sabathani Community Center in Minneapolis on the evening of July 18. It was convened by Rep. Ilhan Omar, whose congressional district is roughly coterminous with Minneapolis. Rep. Pramila Jayapal (D-WA) the chief sponsor of the Medicare for All Act of 2019, was her guest, along with four local speakers, including Dr. Dave Dvorak, an emergency room physician representing Physicians for a National Health Program (PNHP), and Rose Roach, the executive director of the Minnesota Nurses Association (MNA).

For a small-d and big-d democrat like me, it was a very encouraging event. It was encouraging to see four or five hundred people, almost all of them white, cram themselves into an auditorium on a hot summer night to support a Muslim Congresswoman under vicious attack by our reckless president. It was encouraging to hear Representatives Omar and Jayapal and the other speakers discuss a complex and important topic with so much passion and yet so much civility. And for me, a long-time organizer for single-payer legislation, it was an opportunity to assess firsthand out how prominent leaders of the single-payer movement present the Medicare-for-all solution to the public.

The setting

When I drove up to the Sabathani Community Center around 6:40 that Thursday night, the presence of the Minneapolis police was obvious. I saw one squad car parked right next to the only open door (the one on the east side), two others sitting side by side in the parking lot on the east side, and a fourth right in front of the main entrance (which was locked) on the south side. 

Ilhan’s online invitation to this event indicated anyone wishing to attend had to pre-register online. The necessity of checking who had registered created a long line that at times extended outside the east door. After about a ten-minute wait, I entered the auditorium. It was already so jammed it was hard to find a seat with a decent view of the stage. I counted ten TV cameras set up in the back, and one more in front. As I headed down the aisle looking for a seat, I asked the camera man near the aisle what station he was with. He said “CBS.”

I was hoping to make contact with someone on Ilhan’s or Pramila’s staff while I was there. I wanted to talk to them about the three hearings on the Medicare for All Act of 2019 (HR 1384) that had been held in the US House of Representatives over the preceding three months. In my view (and in the view of other single-payer supporters who saw all or most of those hearings), they hadn’t gone well. Claims by opponents about whether and how HR 1384 would cut US health care expenditures, including the claim that HR 1384 could only cut costs by slashing doctor and hospital income to the bone, had been left either unanswered by the bill’s proponents, or were simply denied without explanation or documentation. Witnesses supporting Medicare-for-all focused almost exclusively on how bad the US system is. They said almost nothing about how HR 1384 will cut health care costs (it will do so primarily by reducing the extravagant administrative costs generated by our byzantine system), while the opponents of HR 1384 did the reverse – they used up almost none of their time telling legislators how bad our system is and used almost all of their time making false or exaggerated claims related to HR 1384 costs. [1]

Within a few minutes after I entered the auditorium, it was clear I would not be making contact with any staff people prior to or during this event. There was just too much controlled mayhem, the representatives and other speakers were nowhere in sight, and those who appeared to be staff were moving at high speeds. I decided I would wait till the meeting was almost over, then leave in time to catch staff outside in the hallway before they had to deal with the departing crowd.

The opening speeches

The crowd gave Rep. Omar a standing ovation when she stepped onto the stage at 7:05 pm and approached the podium. An expressionless man had already taken up a position behind the podium. You can see him to Ilhan’s left in the opening minutes of this video The only motion he makes is with his head; he is scanning the audience continuously. He is obviously a security guard. His presence was the only visible sign of security inside the building.

After some opening remarks that were frequently interrupted by applause, Ilhan introduced Pramila, who gave a warm, high-energy speech. Pramila began by noting that the total number of cosponsors on her bill, HR 1384, is now up to 118, and celebrating the three hearings held so far. These were historic hearings, she said, which is absolutely correct. Then she said the hearings had gone well. I didn’t expect her to criticize the hearings in public, but I was disappointed to hear her spin the outcomes so aggressively. She quoted a reporter who approached her after one of the hearings who said, “Aren’t you surprised?” Pramila said she replied, “Surprised about what?” The reporter said, “Surprised that the hearing was a detailed discussion about a real plan”?

I am baffled that anyone could think that. Not one of the pro-single-payer witnesses, and to the best of my recollection, not one of the Democrats on the three committees, discussed so much as a single section of HR 1384 at any of the three hearings. In fact, the pro-single-payer witnesses didn’t even mention the bill’s number. The only witnesses who actually discussed specific sections of HR 1384 were the opponents. But Pramila said she agreed with the reporter.

She announced that the next hearing will be in the Energy and Commerce Committee this fall. 

To her credit, Pramila stated that HR 1384 would save money by reducing administrative waste and profit. But rather than state the size of the savings her bill would achieve in the form of reduced administrative costs and how her bill would do that, she listed a few examples of administrative costs – excessive profits reaped by the drug industry and three or four examples of payments to insurance company CEOs in the tens of millions of dollars annually. These sums are tiny compared to the $400 to $500 that research indicates a single-payer system could save annually in the form of reduced administrative costs.

After Pramila finished, each of other four speakers made five-minute speeches. Rose Roach, director of MNA, did a good job in the space of a minute rebutting the lie that Medicare-for-all can save money only by lowering doctor and hospital income. She explained the three elements of any true single-payer system that are necessary to reduce administrative costs – one payer, budgets for hospitals, and uniform fee schedules for physicians – all of which would be authorized by HR 1384.

Dr. Dave Dvorak, the ER doc, described the part of his job he likes the least – creating bills for his patients. He said after seeing each patient, “I … sit at my work station to put in the orders…, blood work, x-rays, IVs, medication. With each click of my mouse, I’m also compiling that patient’s line item bill in real time…. Weeks later they’re going to get that bill in the mail. They will go dizzy looking at the lines on the page.” Will the patient understand the bill? Almost certainly not. Will he or she be able to pay it? Often the answer is no, or only with great sacrifice. 

Discussion with the panel

Dave told me before the event that Ilhan’s staff had asked the speakers to suggest questions that Ilhan could ask the panel to discuss. The first question Ilhan posed went to Pramila. “I want you to touch on the distinction between your bill and the Senate bill [introduced by Bernie],” she said, “and why the ‘public option’ was not adequate.” Pramila discussed only two differences between her bill and Bernie’s – the worse coverage for long-term care in Bernie’s bill, and the longer phase-in period in Bernie’s bill (four years versus two in her bill).

Those are not the most important differences between the bills. The most important differences are that Bernie’s bill, S 1129, authorizes risk-bearing entities called “accountable care organizations” (ACOs) while HR 1384 would repeal the ACO statute, and S 1129 does not authorize hospital budgets while HR 1384 does. Those are the most important differences because they mean Bernie’s bill can’t save a half-trillion dollars annually in the form of reduced administrative costs. To put it in terms of the three elements Rose reviewed, S 1129 is missing one payer and hospital budgets (for a longer discussion of these two defects in S 1129, see my previous article on ). Without real cost containment, something (possibly the long-term care services Pramila was talking about) will be cut from the coverage.

Pramila did a good job of explaining why a “public option” is not a good idea.

Ilhan asked Rose to comment on what Medicare-for-all means to labor. Rose noted how many nurse strikes in Minnesota are now triggered by disagreements over health insurance and how difficult it has become for unions to negotiate for decent coverage. She said employers are not happy with our system either, and that employers and unions have “a common enemy” – the insurance industry. Pramila observed she was very happy with union support for HR 1384. We have a “phenomenal labor coalition,” she said. She said the support was coming from unions some of which hadn’t previously supported single-payer legislation. The unions she listed included “SEIU, AFT, NEA, UAW, the mine workers, [and] ILWU.” (It wasn’t clear which of these unions she meant to say had not previously supported single-payer legislation.)

At this point Pramila said the CEO of a big employer will soon announce his support for HR 1384.

Ilhan asked Dave a question I had urged Dave to pass on to Ilhan’s staff: Was it true that HR 1384 can only cut costs by slashing provider income? Dave responded beautifully. He began by saying what Pramila should have said in her opening remarks – 30 percent of all US health spending goes to administrative costs, and half of that could be saved with HR 1384. He summarized quickly the three elements Rose had mentioned (one payer, budgets for hospitals, and uniform fee schedules for doctors), and noted that spending on drugs will be reduced as well. He then offered another illustration of excessive administrative costs: Duke University Medical Center has 962 beds, but they have to hire 1,600 people to bill the insurance industry. He noted finally that the complexity of billing in our multiple-payer system is a significant cause of physician burnout. Great answer! [2] 

At about 8:20, Ilhan asked for questions from the floor. The second question was a variation on the question Dave had just addressed. This question was, Is it true HR 1384 will bankrupt rural hospitals? Rather than help the audience understand the answer to that lie, Pramila simply said, “No.” Perhaps she was thinking that Rose and Dave had already addressed this issue sufficiently. Rose and Dave had in fact done a good job, but they spoke quickly about a complex topic. It wouldn’t have hurt Pramila to take a little more time on this all-important issue.

After one more question from the audience, I headed out to the hallway to see if I could find someone on Ilhan’s staff. I found a very helpful aide in his twenties standing by himself by the registration table. I told him I lived in Ilhan’s district, that I had been involved for three decades in the fight for single-payer, and that I wanted to speak to whoever handled health policy in Ilhan’s office. I explained why. I said I didn’t think the hearings on Pramila’s bill had gone well and I wanted to find out why. He gave me the name of Ilhan’s health policy specialist as well as his card with his email address on it.

Impressions

I became a single-payer proponent in 1989, the year “single payer” entered the lexicon. The previous year, the Minnesota legislature had voted down a bill called Healthspan, a bill proposed by a coalition I staffed. The bill would have paid for health insurance for people who didn’t have it. The legislature’s excuse was Minnesota could not afford Healthspan. The lesson the coalition and I took away from that defeat was that it is pointless to propose universal coverage to a group of lawmakers without simultaneously proposing cost containment.

As I drove home from the Sabatahani Center on July 18, 2019, nearly 30 years later, I cast my mind’s-eye over those last three decades. I recalled that when we first began, many legislators at the state and federal level refused to accept our claim that the US health care system was in crisis. In the 1990s, to overcome that resistance, we had to spend valuable time in our public statements and presentations telling horror stories about people who couldn’t get the health care they needed. But that was then, this is now. By no later than the turn of the millennium, that battle was over. Even diehard opponents of universal health insurance admit these days that the crisis is real – that our system continuously inflicts suffering on millions of people.

Today the number one challenge for all of us who care about universal coverage is to help voters understand that it’s possible to achieve universal coverage without raising total spending on health care, and possibly even lowering it. The great majority of Americans no longer need to be told our system sucks; the vast, vast majority know that. But because the vast majority do not yet have a clear understanding of how a true Medicare-for-all bill like HR 1384 will cut costs, a substantial portion of that majority are vulnerable to scare tactics, such as the claim that hospitals will go dark all over America if HR 1384 is enacted. What Americans need to hear now is a clear explanation of how HR 1384 will cut costs.

The town hall meeting at Sabathani demonstrated how far the single-payer movement has come since 1989 – the speakers were articulate and animated, the crowd was revved up, and the media coverage was wall-to-wall. But it also illustrated a problem – the single-payer movement is devoting too much time to describing the problem and not enough time to describing the solution. With the exception of Rose and Dave, the speakers spent 95 percent of their time telling everyone what we already know – the system is inefficient and unjust – and very little time helping people understand why only a single-payer bill can cut costs and thereby make raising taxes to finance universal coverage politically feasible and morally justifiable.

The identical problem is afflicting the hearings on HR 1384 in Congress.

The next day, Friday, July 19, I fired off an email to the Omar staffer who gave me his card. I asked him if I could meet with someone on Ilhan’s staff to discuss the hearings. 

 [1] The three hearings in the House held during the spring and early summer of 2019 were held by the Rules, Budget, and Ways and Means committees. Broadly speaking, there were two reasons why the hearings did so little to educate members of Congress and the public about how HR 1384 would reduce costs: (1) The committee chairs decided that HR 1384 would not be the only proposal on the agenda, and when witnesses and committee members did discuss “Medicare for all,” it wasn’t clear whether they were referring to Senator Sanders’ version, Rep. Jayapal’s version, or something else; (2) the witnesses selected to testify in favor of HR 1384 devoted most of their time to telling horror stories and almost no time to the details of HR 1384, and, partly as a result, they were not prepared to rebut the predictable lies and exaggerations offered by opponents of HR 1384. Like the pro-HR-1384 witnesses, committee members who were sympathetic to HR 1384 were woefully unprepared to discuss the details of HR 1384 and to assist the pro-HR-1384 witnesses in rebutting the predictable attacks on the bill. 

At the Rules Committee hearing, for example, one of the opposition witnesses, Charles Blahous (author of a report published by the Mercatus Center which is funded by the Koch brothers), argued that “Medicare for all” (he did not cite HR 1384) would slash provider incomes by 20 to 40 percent, and Republican Rep. Tom Cole of Oklahoma claimed this would endanger hospitals, especially rural hospitals. Neither of the two witnesses chosen to testify in favor of HR 1384 rebutted this claim. Neither of those witnesses called committee members’ attention to the actual language in HR 1384 (it does not require reducing provider payments to Medicare levels or to any other specific level), and neither presented evidence demonstrating that physician and hospital administrative costs will drop substantially under HR 1384.

The myth that hospitals and clinics will close if Medicare-for-all becomes law didn’t start with these hearings, but the hearings gave it more credibility. Here is how former Rep. John Delaney articulated the myth to a national audience during the first debate
among Democratic presidential candidates on June 26, two weeks after the last of the three hearings took place: “[W]e’re basically supporting a bill that would have every hospital closing.”

Media coverage of the hearings reflected the superficial nature of the debate. For example, the day after the June 12 Ways and Means Committee hearing, The Hill reported, “The hearing was mostly partisan and light on substance….”

 [2] Here is a more precise answer to the lie that HR 1384 would save money only or primarily by reducing hospital and physician income. HR 1384 will reduce nominal provider payment rates, but it does not authorize or require reducing net provider income. Because HR 1384 will reduce provider overhead substantially (it will cut hospital overhead, for example, from approximately to 25 percent of hospital expenditures to roughly half that amount), the single-payer (which in the case of HR 1384 is the Department of Health and Human Services) can, if it chooses to, reduce provider payment rates without reducing net provider income.