My Wellstone Notes

By Sara

Back in 1990, one of the reasons Paul Wellstone got elected was because he stood firmly on Single Payer Health Care.  He got belittled by Hillary both during the 1992 Campaign, and then when she put together her monster proposal which as we remember went no-where.  Paul went along with the little proposals that followed on, but he didn't give up on the universal model...what he did was try to take lessons from the failure and put those in his pocket so as to understand any revival of possibilities. 

Now he is gone -- and Josh Marshall seems to be trying to revive things by putting forward essays from various perspectives.  So I will take advantage of The Next Hurrah to cite my notes on Wellstone's critique as I understood it of what was first proposed in 93-94, and what might work.

When elected in 1990, Paul had no idea how strong the anti-Universal lobby really was.  He quickly found out.  In a residual way it included labor which at that time still was able to guarentee members benefits, and thus a reason to remain in the fold, but he also did not understand the power of the insurance industry that creams off at least 20% of the medical care budget as profit for investors, nor did he understand how Indian Tribes would fight Universal -- because they thought it would abdicate their treaties that promised medical care till the sun refused to set, or however they worded it.  As he put it -- Nitch protection was the game.  Of course that left lots of folk out of the Nitches, including many who thought they had one. 

So he started sketching out how the next effort might work, and that is what I want to outline here.  Clearly this is a point of departure for debate -- Paul isn't around anymore to lead this thing. 

Paul came to think the critical line was between the finance of supply which included medical research, education, making the menu of necessary services -- all of which he thought should be funded federally and administered more or less federally, and actual provision of services to people -- and he came to believe that should be the province of State Government, but not directly.  He thought each state should have something like a Health Board of Regents much as a Public University is elected by a Legislature for longish terms, with designations as to who and what should be represented on such a board -- but that a health board of regents should "own" the delivery system.  The Hospitals, the Clinics, and the ability to establish contracts for services with all providers.  He believed that one could do a transition from "private sector" to state owned sector much easier if the whole thing became state politics rather than Federal Politics.  He thought many "for profit" entities would bid on state contracts -- and gradually migrate to understanding that the service could not be done on a huge profit margin, and that industry would adapt.  States would gradually abolish for-profit entities in favor of non-profit structures.  (Minnesota for instance still does not permit any for profit Hospital or Clinic in the state.  Yea, I know, Mayo Clinic -- but it remains non-profit.)  Paul thought State Health Regents would have the ability and the power to essentially determine what resources needed to be in what communities, and gradually construct for themselves the ability to set job descriptions, set resource allowcations, and then contract for these with a high degree of specificity.  In fact Paul hoped that groups of Medical Specialists would hire themselves business managers who would negotiate in their interests, but negotiate with the State Regents who would be obligated to provide Universal care by Federal determination. 

Paul had another concern -- the failure of States to expand Medical Education to meet projected needs.  He discovered that the US expected third world countries to provide about 20% of the MD Personnel necessary for the US, and considerably more of the technical and nursing personnel.  He believed states needed to be required to educate the necessary personnel -- but that the Feds needed to do the 40 or 50 year projections as to how many.  Bioscience education is expensive, and many states import third worlders as opposed to paying the costs of educating their own.  (And why should the US recruit AIDS specialist Nurses trained in  South Africa??? -- come on, answer that one.)  You mean we can't afford to train our own? 

Paul recognized that virtually all who go to the Masters or PHD level in science have full tuition grants plus stipends for expenses,  -- with one great exception, Medical Students are expected to take out loans against future income for education.  This reinforces the fee-for-service system of medicine.  To change that, Paul thought all Medical Ed ought to be on Contract -- free, but with an obligation to serve over a long time period where needed and as needed.  Integrated with State Regents who define where services are needed, this would gradually move providers to the places where services are required.   But Paul believed we were under training by a factor of 30% depending on third world to train for us and supply to us -- and that pissed him off.  In the end he thought each state ought to be responsible for training personnel to meet something plus of their population's needs.  Essentially he thought the major costs or education and training ought to be born by the feds -- but shared with states that had adequate slots. 

Essentially Paul thought that State Legislatures ought to be very politically sensitive to problems with delivery of services.  They are more able to be voted out if they fail.  He didn 't think it should be direct -- thus the Regent's idea, but close.  But he though by pushing the commercial providers out into a universe where essentially one was looking for not for profit providers, the existant industry would adapt. 

Paul also recognized that states comprehended services differently.  In Minnesota he was looking at local hospitals that were converting from general practice to treating drug and booze problems, because that was what paid -- but local health needs didn't pay.  He believed that a state Regent would be able to properly structure such.   Any system, in his estimation ought to be able to design a local comprehensive program. 

From what I see that Josh Marshall is going to publish -- and I am glad that he is putting it forward -- I don't think anyone is putting forward the notion of incorporating the states into the plans at the core of it.  Paul thought that the secret to getting to there was vesting the states with much of the game.  He thought that was what made 93-95 fail.  essentially he thought that trying to accomodate all the DC lobby and defined "players" was the kiss of death.  Putting it at the state level in terms of what services you want delivered and how -- that would get to the right sized solution. 

Was he Right or Wrong in his argument and observations as of the late 90's?  My sense is that if we study the issue, we don't need 20 candidate plans at all.  What we need is a citizen's concept of what is necessary, and then a response.  I think Paul moved from ideology to pragmatic ideas, and it is sad he just left pieces of it, and we have to fill in and argue the rest. 

 

   

Comments

[Mauimom]

Have you contacted Al Franken with this? [VERY good job, BTW.] He's a HUGE Wellstone fan, and with him running for Senate in MN, there's a chance for this to get more traction, both in MN and across the nation.

Thanks again.

[greenhouse]

Thanks again Sara. I can't tell you how much I appreciate your pieces and the education you provide so graciously.

[stillonmt]

I still would like to see each senator, representative and all of their staffs given $600 a month to buy health insurance on the open market and deal with the insurers and physicians. Then I would like to see 5000 uninsured put on the federal government health plan. Compare their experiences two years later. I really think that single payer coverage would be possible.

[Primordial Ooze]

Very nice. I love that you put out Paul's work to build upon. Thank you.

ps the ecologist in me says it's "Niche"

[Mimikatz]

Niche. It's French, I believe.

Over 60 years ago one of my uncles wrote a paper on why health care should not be done for profit. He was right. The only way to get from here to there is to make the non-profit sector sufficiently attractive. Many doctors like the Kaiser system because their judgment isn't questioned and they don't have to justify anything they order to some bean counter. They are free to just practice medicine, and that is worth somewhat less pay.

The idea of fully paid medical education in return for x numbers of years in underserved communities is good. This is another way to make "non-profit" medicine attractive. If the for-profit outfits have to charge more to cover their highly paid doctors and administrators, they won't be competitive.

But the key seems to be to require community-based rating. This disallows cherry picking, where companies profit by dumping the sickest people and refusing to pay for care for the rest. If there were reasonable alternatives where people knew they would get good care, like Kaiser, why pick one of the companies that hassle about everything?

In short, focus on taking the profit out of for-profit medicine, and we will be able to make some progress.

[MarkC]

Thanks for such a lucid representation of Wellstone's ideas on health care reform/repair.

[greenhouse]

ps, the philospher in me says nietzsche... doh!

[theexog]

As a Canadian living in the US I am astonished that Americans actually believe the hype that the insurance industry flings around when trying to make everyone afraid - seems that fear is the best weapon they all have. Healthcare in Canada may not be perfect, but its worlds apart from the mess in this country, and no one there has to worry about going bankrupt or losing their house if they get cancer. The United States is the only industrialized country in the world that doesn't have some form of universal and not-for-profit healthcare - just because the insurance and pharma industries have apparently purchased every member of congress (with the exception of those wise few like the late Sen. Wellstone) doesn't mean that the American people have to just take what's dished out by their "government". Its time to get out in the streets and start yelling blue murder - remember, there are more of us than there are of them.

[Sara]

Maulmom -- Franken thoroughly understands Wellstone's experience with this set of issues, and if and when he is elected, I am sure he will pick up much of what Paul left on the table. They were friends from before Paul ran in 1990, and Franken did charity shows for the Wellstone Campaign that year that kept the phones hooked up and the lights on. In the half quarter Franken just reported, the 1.3 million he raised is .2 million more than the whole 1990 Wellstone campaign cost!!! And the whole idea that Al should run for the Wellstone Seat next year emerged from discussion during a break of the board for Wellstone Action among Al, Walter Mondale and others -- but it originated with Molly Ivins who just blurted out -- "Al, you ought to move home and run for the Senate." So yea, if he wins it will be yet one more grand idea that can be ascribed to Molly. In the summer of 2002 Paul was saying that if he won re-election he wanted to write another book about the practical politics of getting to a Universal Single Payer system -- and what I've outlined above were ideas he was playing around with at the time of his death. I think Franken has or will inherit most of Wellstone's close advisors and will see the need to push forward many of his ideas but with a Franken Flavor.

But what's really important, I think about all this is the understanding Wellstone developed of the institutional barriers to major reforms of the Health Care Industry. How to design it (so as to achieve mass acceptance) and how to understand the power of the opposition is just so missing in the normal debates.

[Rob]

Hi Sara: I really enjoy your perspective on things. Here's just a bit of history about how this happened in Canada, which I know about because my grandfather chaired the committee that planned the introduction of public hospital insurance in Ontario beginning in 1958. My grandfather was a member of the generation that came back from WWII determined that things would be different ... collectively, they undertook six national projects that represent that foundation for Canada's social infrastructure even to this day. (For details about that, see canadawewant.ca) In the case of health, the federal government offered in the late 50s to co-fund 50% of the cost of public hospital insurance. Under the Canadian constitution, health is a provincial responsibility, so each province had to decide for itself whether to go along. The conservative Premier of Ontario at the time, Leslie Frost, was a member of my father's congregation in Lindsay Ontario. He agonized over this decision, since he knew it would be expensive. Then the Premier got a letter from his private insurance company informing him that his private insurance would be cancelled in a few weeks on his 65th birthday. This probably didn't really influence his decision, but he spent the next two years claiming it did. How would you like to be the clerk who sent out that letter.

This is obviously much too long a story to tell here, but what is relevant to your point is that in Canada this transition was done in stages under the control of the provinces ... the first stage being public hospital insurance that covered medical care in hospitals, and the next stage, ten years later, being public health insurance that covered all medical care. Canada's single payer system has in fact 10 single payers (leaving aside the territories for now) ... each of the 10 provinces administers its own payments system.

Overall, this works well and is efficient. But the key issue we face now is that doctors are paid piece rate by procedure, and we really need a transition to a system that provides as much incentive to promote health as it currently does to treat disease. But that's an even longer story.

We sincerely hope that our American friends solve this problem in your country, since as a society you are paying 20% more than anyone else for lower population health outcomes ... and that is not good for you nor your Canadian friends.

[katz deli]

The deli owner in me says knish.