Robber Barons: When Healthcare meets Business and Politics

“In any case, seeing care for certain groups as an excessive cost reflects an arguably perverse way of thinking about health care in terms of human need. […] In other words, care for the sick is an economic burden only in health care systems where profit is the bottom line and public services are underfunded and politically unsupported – that is, systems in which only market logic is considered legitimate.” -Julie Guthman, Weighing In: Obesity, Food Justice, and the Limits of Capitalism

While the American economy remains deeply depressed with wages and other labor compensation down, corporate profits are at a record high thanks to and at the expense of their employees by taking more than their fair share of the economic pie. The economy and politics of the past generations focused not on capital versus labor but distribution issues between workers namely the gap between the more and less educated workers or the astronomical incomes of a few in finance and other fields. While the finance bandit remain ahead of the financial game, the wage gap between college educated and everyone else has stayed the same since the early 199os. As Paul Krugman explains, Robots and Robber Barons, even before the financial crisis college graduate incomes were the same as the previous decade with profits increasing at the expense of the workers including those with skills that were suppose to get them ahead in the present day economy. Krugman gives two possible explanations: Technology has led to a disadvantage for labor as human workers are being replaced by robots or high technology manufacturing which does the job cheaper and faster than their predecessors displacing workers of all kinds and the increasing effect of monopoly power as Barry Lynn and Phillip Longman of the New America Foundation argue “that increasing business concentration could be an important factor in stagnating demand for labor, as corporations use their growing monopoly power to raise prices without passing the gains on to their employees.”

As Erik Brynjolfsson and Andrew McAfee argue in their book, Race Against the Machine, that similar displacements are taking place in many other fields even services like translation and legal research where many of these jobs are high skill, high wage which demonstrates the negative impact of technology on not just menial work. The early 19th century economist David Richardo known for the theory of comparative advantage, which makes a case for free trade, presents the argument that the capital intensive technologies of the Industrial Revolution could make workers worse off for a  least a while foreshadowing what modern scholars would say has happen for several decades. The idea of the robber barons may be a distant one for most people, however these type of business magnate still exist as monopoly power has made a grand return after the anti-trust enforcement largely feel apart during the Reagan years never really recovering and deregulation seems to be the way of the world today.

By the late 1800s, the derogatory term robber baron applied to wealthy and powerful 19th century American businessman who used what were considered to be exploitative practices to amass their wealth. According to Wikipedia, these practices included “exerting control over national resources, accruing high levels of government influence, paying extremely low wages, squashing competition by acquiring competitors in order to create monopolies and eventually raise prices, and schemes to sell stock at inflated prices to unsuspecting investors in a manner which would eventually destroy the company for which the stock was issued and impoverish investors.” The term combines the sense of a criminal e.g. robber and illegitimate aristocracy as a baron is an illegitimate role in a republic. U.S. political and economic commentator Matthew Josephson made the term popular during the Great Depression in a 1934 book with the same title giving credit for the term to an 1880 anti-monopoly pamphlet about railroad magnates. Like the Germans before him, Josephson alleged American big businessmen amassed their huge fortunes immorally, unethically and unjustly just as the medieval German lords did who charged tolls on ships crossing the Rhine without adding anything of value. The term took off during the Great Depression as people became increasingly disillusioned with big business leading to much public scrutiny of business practices.

However after the Depression, business historians led by Allan Nevins challenged this view of American big businessmen by proposing the “Industrial Statesman” thesis. Nevins argues against Josephson’s theory in his book,  John D. Rockefeller: The Heroic Age of American Enterprise (2 vols., 1940),explaining while Rockefeller engaged in some unethical and illegal business practices, this should not overshadow the order he and other Gilded Age capitalists brought to industrial chaos and the stability imposed on competitive business making the United States a powerful economic entity by the 20th century. The debate continues about the morality of certain business practices with many modern industrialists, media moguls e.g. Rupert Murdoch and Donald Trump and powerful individuals in the political arena and those who control media e.g. Vladimir Putin in Russia and Silvio Berlusconi in Italy referred to as robber barons by their critics.

The campaign for universal funded health care has been around for nearly a century in the United States with advocates hoping that they were on the verge of success yet always just out of reach of their goal ending in utter defeat, while other developed countries have had some form of social insurance nearly as long as the U.S has been trying to get it. Some European countries started with compulsory sickness insurance e.g. for workers in Germany in 1883 with other countries following suit including Austria, Hungary, Norway, Britain, Russia, and the Netherlands followed all the way through 1912  and other countries subsidized the mutual benefit societies that workers formed among themselves e.g. Sweden in 1891, Denmark in 1892, France in 1910, and Switzerland in 1912. The primary reason for these programs in Europe was income stabilization and protection against wage loss due to sickness rather than payment for medical expenses. However these programs were not universal, they were vehicles of maintaining incomes and buying political allegiance of the workers. The British and German systems developed by conservative government to keep out socialist and labor parties, while using the insurance against the cost of sickness as a way to turn benevolence to power.

The United States, during the same period from1883 to 1912, took no steps to subsidize voluntary funds or make sick insurance compulsory as it was left up to the states and the states in turn left it up to voluntary and private programs. The U.S. did choose to provide some voluntary funds for their members in case of sickness or death, but no legislative or public program existed in the late 19th or early 20th century. In the Progressive Era during the early 20th century, reformers worked to improve the social condition of the working class, yet unlike European countries, the working class did not have the power nor backing for a broad social insurance as labor and socialist parties were much more fragmented than in Europe. Thus the first proposal for health insurance did not come into political debate under anti-socialist sponsorship as it did in Europe. During the Progressive Era, President Theodore Roosevelt supported health insurance reform due to the belief that no country could be strong whose people are sick or poor, but the initiative for reform came from outside the government with Roosevelt’s successors, conservative leaders mostly, postponing for twenty years the leadership needed to more extensively involve the government in social welfare management.

In 1906, the American Association of Labor Legislation (AALL), a progressive group, led the charge for health insurance and whose mission was to reform capitalism. The committee on social welfare decided to focus on health insurance drafting a bill in 1915 to limit coverage to the working class and all others that earned less than $1200 a year, including dependents. The services, according to Karen S. Palmer MPH, MS, of physicians, nurses, and hospitals were included, as was sick pay, maternity benefits, and a death benefit of fifty dollars to pay for funeral expenses with the costs were to be shared between workers, employers, and the state. In 1914, reformers wanted physicians to help formulate the bill and the American Medical Association (AMA) supported the AALL proposal. The group found well known physicians who were sympathetic and wanted to support as well as help in securing the legislation. By1916, the AMA board approved a committee to work with AALL therefore a united front on behalf of health insurances began. However in 1917 while AMA House of Delegates favored compulsory health insurance proposed by AALL, state medical societies opposed it. Over time, disagreements began to pop up as the method of paying physicians came under dispute leading to the AMA leadership denying it had favored the measure at all.

In addition, the president of the American Federation of Labor denounced on many occasion compulsory health insurance as unnecessary paternalistic reform creating a system of state supervision over people’s health. The organization felt that a government based insurance system would weaken unions by taking away their role in providing social benefits thus their main concern was maintaining union strength. In line with the American Federation of Labor, the commercial insurance industry opposed the reform effort in the early 20th century which provided working class families paid death benefits and covered funeral expenses  making up the backbone of the insurance business. This presented a major conflict as the reform health insurance plan could cover these expenses using the money wasted by commercial insurance policies to have their army of insurance agents to market and collect on the policies. Since this idea would pull the rug out from under the multi-million dollar commercial life insurance industry, they opposed the national health insurance proposal.

In 1917, the U.S. entered World War I and anti-German fever rose due to government commissioned articles denouncing “German socialist insurance” and opponents of health insurance asserting it was a “Prussian menace” not consistent with American values, according to Karen S. Palmer’s A Brief History: Universal Health Care Efforts in the US. In California, the California Social Insurance Commission recommended heath insurance, proposing that the legislation be enabled in 1917 and then held a referendum. New York, Ohio, Pennsylvania and Illinois all made efforts as well on the health insurance front. Unfortunately due to the Red Scare immediately following the war, the government tried to root out the last vestiges of radicalism allowing opponents of compulsory health insurance to take advantage of the opportunity to link health reform to Bolshevism thus burying the idea under anti-Communist propaganda. This marked the end of the debate until the 1930s. According to Palmer the failure of the Progressives to achieve their goal lies in the opposition from doctors, labor, insurance companies and business. In addition, the inclusion of funeral benefit was a nail in the coffin threatening the enormous structure of the commercial life insurance industry. The political naivete of the reformers in dealing with special interest groups opposition, ideology, historical experience and political contest played a role in shaping how these groups identified and expressed their interests.

In the 1930s, the focus shifted from stabilizing income to financing and expanding access to medical care as the medical costs for workers were a more serious problem than lost wages from sickness. The health care costs in the 1920s began to grow mostly because the middle class started to seek hospital serves and hospital costs started to increase leading to medical care taking a larger chunk to of the family budget than wage loss. Concerns over medical cost and distribution led to the formation of a self created privately funded group called the Committee on the Cost of Medical Care (CCMC). The committee found funding from 8 philanthropic organizations including Rockefeller, Millbank and Rosenwald foundations which had its first meeting in 1926 and ceased meeting in 1932. The CCMC was made up of fifty economists, physicians, public health specialists, and major interest groups. Their research found that more medical care for everyone was needed publishing their findings in 26 research volumes and 15 smaller reports over a 5 year period, Palmer explains. The CCMC wanted more national resources to go to medical care seeing voluntary not compulsory health insurance as a means to cover these costs with most of its members opposing compulsory health insurance yet no consensus within the committee was reached. The AMA looked at the report as a radical document advocating socialized medicine and the JAMA editor calling it “an incitement to revolution.”

During the 1930s, Franklin D. Roosevelt made two attempts to try and make  some sort of health reform bill stick. President Roosevelt’s tenure in office spanned from 1933 to 1945 and includes such events as World War I, Great Depression, the New Deal and the Social Security Bill. Unfortunately, FDR’s Committee on Economic Security feared that the health insurance bill opposed by the AMA would threaten the passage of the entire Social Security legislation causing them to remove it due to the fact that millions were out of work and unemployment insurance took priority over old age benefits. Roosevelt made one more attempt at national health insure with the Wagner National Heath Act of 1939. The proposal grew out of Roosevelt’s Tactical Committee on Medical Care established in 1937 where the technical committee’s reports were the building blocks of Senator Wagner’s bill, the National Health Act of 1939 gave support for a national health program funded by federal grants to states and administered by states and localities. The election of 1938 brought a conservative resurgence and any further social policy much more difficult. Like the AALL campaign, the movement in the 1930s ran into the declining fortunes of the New Deal and then WWII, Palmer states.

 The 1940s saw a revival in the idea of national health care reform with little if any making the progress expected from supporters. During this time, Henry Sigerist, an influential medical historian at Johns Hopkins University,  played a major role in medical politics and who wanted a national health program to include compulsory health insurance. Several of his pupils became key figures in the public health, community and preventative medicine field as well as health care organizations e.g. Milton Romer and Milton Terris who formed the medical care section of the American Public Health Association which served as a national meeting ground for health care reform. The Wagner Bill evolved and shifted from a federal grant proposal to a national health insurance proposal. Introduced in 1943, the revived and altered bill was named Wagner-Murray-Dingell Bill calling for compulsory national health insurance and a payroll tax. In 1944, the Committee for the Nation’s Health was a group of representatives of organized labor, progressive farmers, and liberal physicians who made up the lobbying group for the Wagner-Murray-Dingell Bill with some prominnet member being Senators Murray and Dingell, the head of the Physician’s Forum, and Henry Sigerist. Opposition to the bill was enormous even launching a red baiting attack on the committee saying its key policy analyst, I.S. Falk, was a liaison between the International Labor Organization (ILO) in Switzerland and the United States government. The ILO was red baited as “an awesome political machine bent on world domination” and going as fair as to say the United States Social Security Board was part of an ILO subsidiary as Palmer tells it. Although the bill was heavily debated both in government and nationally with increasing opposition, the bill never made it to Congress despite its reintroduction for the next 14 years yet if it had passed it would of established compulsory national health insurance funded by payroll taxes.

After FDR’s death, Truman became president with his tenure from 1945 to 1953 being characterized by the Cold War and Communism. With the support of the president, the issue of health care took center stage in national politics during some of the most virulent anti-Communist attacks and the early years of the Cold War with the opposition acquiring new strength. The result was the entanglement of compulsory health insurance in the Cold War allowing opponents to make “socialized medicine” a symbol of the Communist influence in America. While FDR made the push for health care in 1938, Truman’s plan for national health insurance in 1945 was different due to his strong commitment to a single universal comprehensive health insurance plan. FDR’s plan in 1938 called for a separate reform of medical care for the needy, while Truman’s plan called for a single egalitarian system including all classes of society and not just the working class. Truman emphasized that this was not “socialized medicine” even dropping the funeral benefit that contributed to the defeat of national insurance in the Progressive Era. His plan received mixed reactions from Congress with some seeing it as solicalist politics, while others having no mixed feeling at all because they hated it such as the AMA, the American Hospital Association, the American Bar Association, and most of then nation’s press. The AMA saw the proposal as leading to doctors being slaves to the system even though Truman stated that doctors could choose their method of payment. In 1946, the Republican took control o f Congress and had no interest in enacting national health insurance as it was to them part of the large socialist scheme. With Truman’s successful re-election in 1948 and push for national health care, the  AMA assessed their members an extra $25 each to resist national health insurance and in 1945 spent $1.5 million on lobbying efforts making it at the time the e most expensive lobbying effort in American history. Again, the AMA and supporters were successful in linking socialism and national health insurance due to a rise in anti-Communist sentiment in the last 1940s and the Korean War beginning. As a result, Truman’s plan and hope died in a congressional committee leading to a health care system where private insurance was for those who could afford it and public welfare services for the poor. With another defeat under their belt, advocates for health insurance turned to hopes of hospital insurance for the aged which would become Medicare.

Looking at the historical battle up to this point, healthcare has been left up to the individual rather than left to the state to provide, while the many failures of compulsory health insurance continue to have a common theme. After WWII, private insurance systems expanded and provided coverage for enough groups that held influence in American to prevent any great agitation for the national health insurance in the 1950s and early 1960s, while union negotiated health care benefits served to cushion workers from the impact of costs and undermine the compulsory health insurance movement. The failure to gain a compulsory insurance program follows the failures of those that came before for much of the same reasons, which according to Palmer, includes “interest group influence (code words for class), ideological differences, anti-communism, anti-socialism, fragmentation of public policy, the entrepreneurial character of American medicine, a tradition of American voluntarism, removing the middle class from the coalition of advocates for change through the alternative of Blue Cross private insurance plans, and the association of public programs with charity, dependence, personal failure and the almshouses of years gone by.” The next several years saw the focus shift to unions providing health insurance, the Hill Burton Act of 1946 related to hospital expansion, medical research and vaccines, the creation of national institutes of health and advances in psychiatry.

However in 1958, Rhode Island congressman Aime Forand introduced a new proposal to cover the hospital cost for the aged on social security. The AMA decided to launch a  massive campaign to paint the government insurance plan as a threat to patient doctor relationships, unfortunately by focusing on the aged the terms of the debate changed for the first time. The major grass roots efforts of seniors forced for the first time an issue onto the national agenda. To counter these efforts, the AMA introduced the “eldercare plan” which was a voluntary insurance with broader benefits and physician services. In response, the government proposed legislation to expand the original proposal to cover physician services which came to be known as Medicare and Medicaid. According to Palmer’s A Brief History: Universal Health Care Efforts in the US:

 ” The necessary political compromises and private concessions to the doctors (reimbursements of their customary, reasonable, and prevailing fees), to the hospitals (cost plus reimbursement), and to the Republicans created a 3-part plan, including the Democratic proposal for comprehensive health insurance (“Part A”), the revised Republican program of government subsidized voluntary physician insurance (“Part B”), and Medicaid. Finally, in 1965, Johnson signed it into law as part of his Great Society Legislation, capping 20 years of congressional debate.”

Palmer summarizes what history has taught us about the struggle in the United States for a universal health care program and the subsequent reactions to roadblocks that have prevented such legislation from passing through the hurdles:

(1) Henry Sigerist reflected in his own diary in 1943 that he “wanted to use history to solve the problems of modern medicine.” I think this is, perhaps, a most important lesson. Damning her own naivete, Hillary Clinton acknowledged in 1994 that “I did not appreciate how sophisticated the opposition would be in conveying messages that were effectively political even though substantively wrong.” Maybe Hillary should have had this history lesson first.

(2) The institutional representatives of society do not always represent those that they claim to represent, just as the AMA does not represent all doctors. This lack of representation presents an opportunity for attracting more people to the cause. The AMA has always played an oppositional role and it would be prudent to build an alternative to the AMA for the 60% of physicians who are not members.

(3) Just because President Bill Clinton failed doesn’t mean it’s over. There have been periods of acquiescence in this debate before. Those who oppose it can not kill this movement. Openings will occur again. We all need to be on the lookout for those openings and also need to create openings where we see opportunities. For example, the focus on health care costs of the 1980’s presented a division in the ruling class and the debate moved into the center again. As hockey great Wayne Gretzky said, “Success is not a matter of skating to where the puck is, it is a matter of skating to where the puck will be.”

(4) Whether we like it or not, we are going to have to deal with the persistence of the narrow vision of middle class politics. Vincente Navarro says that the majority opinion of national health insurance has everything to do with repression and coercion by the capitalist corporate dominant class. He argues that the conflict and struggles that continuously take place around the issue of health care unfold within the parameters of class and that coercion and repression are forces that determine policy. I think when we talk about interest groups in this country, it is really a code for class.

(5) Red-baiting is a red herring and has been used throughout history to evoke fear and may continue to be used in these post Cold War times by those who wish to inflame this debate.

(6) Grass roots initiatives contributed in part to the passage of Medicare, and they can work again. Ted Marmor says that “pressure groups that can prevail in quiet politics are far weaker in contexts of mass attention — as the AMA regretfully learned during the Medicare battle.” Marmor offers these lessons from the past: “Compulsory health insurance, whatever the details, is an ideological controversial matter that involves enormous financial and professional stakes. Such legislation does not emerge quietly or with broad partisan support. Legislative success requires active presidential leadership, the commitment of an Administration’s political capital, and the exercise of all manner of persuasion and arm-twisting.”

(7) One Canadian lesson — the movement toward universal health care in Canada started in 1916 (depending on when you start counting), and took until 1962 for passage of both hospital and doctor care in a single province. It took another decade for the rest of the country to catch on. That is about 50 years all together. It wasn’t like we sat down over afternoon tea and crumpets and said please pass the health care bill so we can sign it and get on with the day. We fought, we threatened, the doctors went on strike, refused patients, people held rallies and signed petitions for and against it, burned effigies of government leaders, hissed, jeered, and booed at the doctors or the Premier depending on whose side they were on. In a nutshell, we weren’t the sterotypical nice polite Canadians. Although there was plenty of resistance, now you could more easily take away Christmas than health care, despite the rhetoric that you may hear to the contrary.

(8) Finally there is always hope for flexibility and change. In researching this talk, I went through a number of historical documents and one of my favorite quotes that speaks to hope and change come from a 1939 issue of Times Magazine with Henry Sigerist on the cover. The article said about Sigerist: “Students enjoy his lively classes, for Sigerist does not mind expounding his dynamic conception of medical history in hand-to-hand argument. A student once took issue with him and when Dr. Sigerist asked him to quote his authority, the student shouted, “You yourself said so!” “When?” asked Dr. Sigerist. “Three years ago,” answered the student. “Ah,” said Dr. Sigerist, “three years is a long time. I’ve changed my mind since then.” I guess for me this speaks to the changing tides of opinion and that everything is in flux and open to renegotiation.

The 1970s saw a lot of action on the universal health care front, but like its predecessors, any kind of reform faced opposition leading to more add ons to existing coverage plans. In 1970, three proposals for universal health insurance financed by payroll taxes and general federal revenue were introduced to Congress e.g. in February, Representative Martha Griffiths (D-MI) introduced a bill without cost sharing under the AFL-CIO, in April, Senator Jacob Javits (R-NY) introduced a bill to extend Medicare to all with existing cost sharing and coverage limits, in August, Senator Ted Kennedy (D-MA) introduced a bipartisan bill without any cost sharing and the following month a corresponding bill was introduced in the House by Representative James Corman (D-CA). In September 1970, the Senate Labor and Public Welfare Committee held the first congressional hearing in 20 years on national health insurance. Kennedy in January of 1971 began his decade as chairman of the Health subcommittee of the Senate Labor and Public Welfare Committee introducing a bipartisan Kennedy Griffiths bill for universal healthcare, but in February President Nixon has his own limited health insurance reform including private health insurance employer mandate and federalization of Medicaid for the poor with dependent minor kids. Hearing were held on national health insurance by the House Ways and Means Committee and the Senate Finance Committee, however no bill found support from the committee chairmen Representative Wilbur Mills (D-AR) or Senator Russell Long (D-LA). In October 1972, Nixon signed the Social Security Amendment of 1972 extending Medicare to those under 65, severely disabled for over two years or have end stage renal disease and gradually raising the Medicare Part A payroll tax from1.1% to 1.45% in 1986. Nixon won reelection in 1972 over the only Democratic presidential nominee in history to not be endorsed by the AFL-CIO, Senator George McGovern (D-SD), who cosponsored the Kennedy Griffiths bill and did not make national health insurance a center piece of his campaign. In October 1973, Long and Senator Abraham Ribicoff (D-CT) introduced bipartisan bill for catastrophic health insurance coverage for workers financed by payroll taxes and federalization of Medicaid extending to the poor without dependent minor children. In February of 1974, Nixon proposed more comprehensive health insurance reform including private health insurance employer mandate and Medicaid replacement by state run health insurance plans available to all with income based premiums and cost sharing. In April, Kennedy and Mils introduced a bill very similar to Nixon’s expanded plan with both plans being criticized for their substantial cost sharing by labor and senior citizen organizations.

After Nixon resigned in 1974, President Gerald Ford called for health insurance reform yet was met with resistance from special interest groups specifically AMA. Mills tried to advance a compromise of Nixon’s plan, but gave up after half of his committee backed the American Medical Association (AMA) “Medicredit” voluntary tax credit plan. In December 1974, Mills resigned from the Ways and Means Committee and was followed by Representative Al Ullman (D-OR) who opposed payroll tax and general federal revenue financing a national health insurance program. In January 1975, during the worst recession in four decades since the Great Depression, Ford promised to veto any health insurance reform forcing Kennedy to return to his original universal national health insurance bill. With one third of its sponsors gone after the election in 1974, the AMA replaced its “Medicredit” plan with an employer mandate proposal similar to Nixon’s 1974 plan. While Ford in 1976 proposed the addition of catastrophic coverage to Medicare to offset by increasing cost sharing, Democratic presidential candidate Jimmy Carter proposed in April of 1976 health care reform to include parts of Kennedy’s universal health insurance bill.

Unfortunately, President Carter explained to Kennedy that his bill had to be changed to preserve a large role for private insurance companies to minimize federal spending before payroll tax financing and phase is it in so not to interfere with balancing the federal budget. Kennedy and organized labor compromised making the requested changes, however in July 1978 broke with Carter when he would not commit to a single bill with a fixed schedule for phasing in comprehensive coverage. The next two years saw much debate and proposed solutions in the form of variations on the same theme according to Wikipedia article History of health care reform in the United States:

“In May 1979, Kennedy proposed a new bipartisan universal national health insurance bill—choice of competing federally-regulated private health insurance plans with no cost sharing financed by income-based premiums via an employer mandate and individual mandate, replacement of Medicaid by government payment of premiums to private insurers, and enhancement of Medicare by adding prescription drug coverage and eliminating premiums and cost sharing. In June 1979, Carter proposed more limited health insurance reform—an employer mandate to provide catastrophic private health insurance plus coverage without cost sharing for pregnant women and infants, federalization of Medicaid with extension to the very poor without dependent minor children, and enhancement of Medicare by adding catastrophic coverage. In November 1979, Long led a bipartisan conservative majority of his Senate Finance Committee to support an employer mandate to provide catastrophic-only private health insurance and enhancement of Medicare by adding catastrophic coverage, but abandoned efforts in May 1980 due to budget constraints in the face of a deteriorating economy.”

The only reform during the 1980s was the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) which amended the Employee Retirement Income Security Act of 1974 (ERISA) giving some employees to continue coverage after leaving employment.

During the nineties, President Bill Clinton’s administration held health care reform as a major priority headed up by First Lady Hilary Clinton, but met with the same resistance as the many before it with the 1993 Clinton health care plan never reaching its potential. The Health Security Express bus tour started at the end of July 1994 involving supporters of President Clinton’s national health care reform. Several buses leaving from different points across the United States criss-crossed the country stopping in many cities with their final destination being the White House in Washington D.C. on August 3, 1994. During these stops, the bus riders talked about their personal experiences, health care disasters and why it was important for all Americans to have health insurance. The riders in the end were greeted by the president and first lady on the White House South lawn for a rally on Wednesday, August 3, 1994 which was broadcast globally by international networks.

The new millennium led to further rallying by advocates of a universal health care system and as always was met with more red tape than actual bipartisan debate. In 2000 the Health Insurance Association of America (HIAA) partnered with Families USA and the American Hospital Association (AHA) to draft a proposal intended to reach some common ground in expanding coverage for the uninsured. In 2001, a Patients’ Bill of Rights was debated in Congress providing patients with an explicit list of rights concerning their health care taking some inspiration from the Consumers’ Bill of Rights and applying it to health care. The mission was to ensure the quality of care of all patients by preserving the integrity of health care processes. Standardizing the nature of health care using this method only led to many interest groups rejecting the bill e.g. American Medical Association (AMA) and the pharmaceutical industry. As a result the Patients’ Bill of Rights failed to pass in Congress in 2002 due to a couple of stumbling blocks within the bill e.g. providing emergency medical care to anyone regardless of insurance states and the right of patients to hold their health plan accountable for any and all harm done. However, Bushed signed into law the Medicare Prescription Drug, Improvement, and Modernization Act which included a prescription drug plan for elderly and disabled Americans. During the 2004 presidential election, George Bush and John Kerry offered up a health care proposal as part of their campaigns with Bush’s plan more modest than Senator Kerry’s plan. By several estimates, the cost and impact of increased coverage and funding requirements of the Bush plan would both be lower than those of Kerry’s more comprehensive plan.

From 2006 to 2008 just before the election, the focus shifted from a universal plan to trying to reform the current system. In 2006 the HIAA was succeeded by the America’s Health Insurance Plans (AHIP) who proposed a set of reform proposals followed by another set in 2007 guaranteeing access to coverage in the individual health insurance market and a proposal for improved quality and safety of the U.S. health care system. The latter was probably in response to Rep. John Conyers, Jr.’s (D-MI) United States National Health Care Act (HR 676) introduced in January 2007 in the House of Representatives and so fair garnered as of October 2008, 93 co-sponsors. In addition in January 2007, Senator Ron Wyden introduced the Healthy Americans Act (S. 334) in the Senate which has 17 cosponsors as of October 2008. According to the Organization for Economic Cooperation and Development’s report, Economic Survey of the United States 2008: Health Care Reform, published in December 2008:

1) Tax benefits of employer-based insurances should be abolished.

2) The resulting tax revenues should be used to subsidize the purchase of insurance by individuals.

3) These subsidies, “which could take many forms, such as direct subsidies or refundable tax credits, would improve the current situation in at least two ways: they would reach those who do not now receive the benefit of the tax exclusion; and they would encourage more cost-conscious purchase of health insurance plans and health care services as, in contrast to the uncapped tax exclusion, such subsidies would reduce the incentive to purchase health plans with little cost sharing.”

The History of health care reform in the United States (Wikipedia) explains two very different approaches to health care in December of 2008:

“In December 2008, the Institute for America’s Future together with the chairman of the Ways and Means Health Subcommittee Pete Stark launched a proposal from Jacob Hacker who is co-director of the U.C. Berkeley School of Law Center on Health that in essence said that the government should offer a public health insurance plan to compete on a level playing field with private insurance plans. This was said to be the basis of the Obama/Biden plan. The argument is based on three basic arguments. Firstly public plans success at managing cost control (Medicare medical spending rose 4.6% p.a. compared 7.3% for private health insurance on a like-for-like basis in the 10 years from 1997 to 2006). Secondly public insurance has better payment and quality-improvement methods based on its large databases, new payment approaches, and care-coordination strategies. Thirdly it can set a standard against which private plans must compete which would help unite the public around the principle of broadly shared risk while building greater confidence in government over the long term.

Also in December 2008, America’s Health Insurance Plans (AHIP) announced a set of proposals which included setting a national goal to reduce the projected growth in health care spending by 30%. AHIP said that if this goal were achieved, it would result in cumulative five-year savings of $500 billion. Among the proposals was the establishment of an independent comparative effectiveness entity that compares and evaluates the benefits, risks, and incremental costs of new drugs, devices, and biologics. An earlier ‘Technical Memo’ published by AHIP in June 2008 had estimated that a package of reforms involving comparative effectiveness research, health information technology (HIT), medical liability reform, ‘pay-for-performance’ and disease management and prevention could reduce U.S. national health expenditures ‘by as much as 9 percent by the year 2025, compared with current baseline trends.'”

During the presidential election of 2008, both the democratic and republican presidential candidates offered a health care position. John McCain’s plan focused on open market competition rather than government funding with tax credits and for those who are denied coverage proposed working with the state to create a “Guaranteed Access Plan”, while Barack Obama called for a universal health care system which called for the creation of a National Health Insurance Exchange that included both private insurance plans and medicare like government run options with guaranteed coverage regardless of health status but only for adults as parents would have to cover their children. The Philadelphia Inquirer and The Des Moines Register reported that the two plans had different philosophies describing John McCain’s plan as making insurance more affordable and Obama’s plan as making it possible for more people to have health insurance. A poll in early 2008 found voters supporting Obama listed health care as their second priority and voters supporting McCain listed it as fourth tied with the war in Iraq and Affordability being the primary health care priority for both. Obama voters were more likely than McCain voters to believe government can do much more about health care costs.

In March 2009 AHIP proposed another set of reforms intended to address waste and unsustainable growth in the current health care market as follows:

“(1) An individual insurance mandate with a financial penalty as a quid pro quo for guaranteed issue;

(2) Updates to the Medicare physician fee schedule;

(3) Setting standards and expectations for safety and quality of diagnostics;

(4) Promoting care coordination and patient-centered care by designating a “medical home” that would replace fragmented care with a coordinated approach to care. Physicians would receive a periodic payment for a set of defined services, such as care coordination that integrates all treatment received by a patient throughout an illness or an acute event. This would promote ongoing comprehensive care management, optimizes patients’ health status and assist patients in navigating the health care system;

(5) Linking payment to quality, adherence to guidelines, achieving better clinical outcomes, giving better patient experience and lowering the total cost of care.

(6) Bundled payments (instead of individual billing) for the management of chronic conditions in which providers would have shared accountability and responsibility for the management of chronic conditions such as coronary artery disease, diabetes, chronic obstructive pulmonary disease and asthma, and similarly;

(7) A fixed rate all-inclusive average payment for acute care episodes which tend to follow a pattern (even though some acute care episodes may cost more or less than this).”

On May 5, 2009 U.S. Senate Fiance Committee held hearing on Health care reform with no supporters of the single payer health care system invited, but did feature Republican senators and industry panelists who argued against expanded health care coverage. As a result the prevention of a single payer option discussion caused doctors in the audience to protest. There were at the time several bills in front of Congress dealing with health care reform, but one in particular, The Affordable Health Choice Act before the House of Representatives had two major points of contention: should the government provide a public insurance plan option to compete head to head with private sector insurance and  should comparative effectiveness research be used to contain costs met by the public providers of health care. Some Republicans argue that private insurers will not be able to compete fairly with public insurance options thus opposed it. In addition, republican do not want comparative effectiveness research used to limit coverage in any public sector plan regarded as rationing by the back door. Democrats do not believe that this would happen and refused to introduce a clause to prevent it because it would limit the right of the DHHS to prevent payments for services that clearly do not work. Republican amendments, in line with AHIP’s thinking, to the bill would not prevent the private insurance sector from citing CER to restrict coverage and apply rationing of their funds which creates a competition imbalance between public and private sector insurers. The short bill called the Patients Act 2009 has not been enacted yet.

On June 15,2009, the U.S. Congressional Budget Office (CBO) released a preliminary analysis of the major provisions of the Affordable Health Choices Act estimating the ten year cost to the federal government would be $1 trillion. Over the period between 2010 and 2019, the CBO estimated the bill would reduce the number of uninsured Americans by 16 million, however the Associated Press reported that the CBO gave Congressional officials a figure of $1.6 trillion for the cost of a companion measure developed by the Senate Finance Committee. In response, the Senate Finance Committee delayed action on its bill in order t$1.0 trillion causing the debate over the Affordable Health Choice Act to become more personal than political. Congressional Democrats were shocked by the estimate and the uncertainty surrounding the estimates only raised the confidence of Republicans who are critical of Obama’s approach to health care. However, in a June New York Times editorial, economist Paul Krugman argues that universal health coverage is still affordable saying, “The fundamental fact is that we can afford universal health insurance–even those high estimates were less than the $1.8 trillion cost of the Bush tax cuts.” In a different approach to a publicly funded health care programs, the Obama administration announced in August 2009 that they would support a health insurance cooperative as a result of the deep political unrest between Congressional Republicans and town hall meetings across America. However in June of 2009, NBC News and the Wall Street Journal survey found 76% felt it was important to give people a choice of both public and private plans for health insurance. Journalist Ben Smith called mid 2009 “The Summer of AstroTurf” as various groups on both the pro and anti reform side organized and coordinated their efforts.

A few states have taken it upon themselves to move toward a universal health care coverage plan, e.g. Minnesota, Massachusetts and Connecticut, in particular the Massachusetts 2006 Health Reform Statute and Connecticut’s SustiNet plan to provide quality, affordable health care to state residents. The influx of more than a quarter million newly insured residents has resulted in overcrowding in waiting rooms and overworked primary care physician who are in short supply in Massachusetts, while in other state a large number of people, but not all, are covered by reimbursing hospitals and other health care providers using a charity care scheme with New Jersey employing the latter strategy. Several single payer referendums have been proposed at the state level, but have not passed e.g. California in 1994, Massachusetts in 2000, and Oregon in 2002. The state legislature of California has twice passed SB 840, The Health Care for All Californians Act, a single-payer health care system. Both times, Governor Arnold Schwarzenegger (R) vetoed the bill, once in 2006 and again in 2008. The percentage of residents uninsured vary by state with Texas having the highest percentage of uninsured residents at 24% and New Mexico a close second at 22%. While states are working to improve the system, so much more can be done as the role of the state in the health care system includes being  a purchaser and regulator of health care plans and providers. One municipality, San Fransisco, California, has established a programs to provide health care to uninsured residents called Healthy San Francisco.

Some states are leaps and bounds ahead of others in establishing a health care system which benefits its residents. In July 2009, Connecticut passed SustiNet with the goal of achieving health care coverage for 98% of its residents by 2014. The SustiNet law established a nine member board to recommend to legislature by January 1, 2011 the details of and implementation process fro self insurance health care plan. The recommendations, according to the Office of Legislative Research, must address: “(1) the phased-in offering of the SustiNet plan to state employees and retirees, HUSKY A and B beneficiaries, people without employer-sponsored insurance (ESI) or with unaffordable ESI, small and large employers, and others; (2) establishing an entity that can contract with insurers and health care providers, set reimbursement rates, develop medical homes for patients, and encourage the use of health information technology; (3) a model benefits package; and (4) public outreach and ways to identify uninsured citizens.” The board must further establish committees to make recommendations to about “health information technology, medical homes, clinical care and safety guidelines, and preventive care and improved health outcomes.” In addition, the act establishes an “independent information clearinghouse to inform employers, consumers and the public about SustiNet and private health care plans”, while creating a “task force to address obesity, tobacco usage and health care workforce issues.” Another state, Vermont in May 2011, was the first state to pass legislation for a single payer health care system known as Act 48 which makes health care in the state a “human right” and lays responsibility squarely on the state to provide health care which meets the needs of Vermont’s citizens. The state is currently in the study phase of how to implement it.

According to Michael Moore, now infamous for his controversial views on various topics including gun control and 9/11, here are a few facts from his 2007 documentary Sicko which takes an in depth look at global healthcare with emphasis on the for profit non-universal American healthcare system and the idea of a utopian society where universal healthcare provides for its people by examining the non-profit universal health care systems of Canada, the United Kingdom, France and Cuba.
There are nearly 50 million Americans without health insurance.

“The Centers for Disease Control and Prevention actually reported that 54.5 million people were uninsured for at least part of the year. Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2006. Centers for Disease Control.
The amount of uninsured is rising every year, as premiums continue to skyrocket and wages stagnate. From 2004 to 2005 the number of uninsured rose 1.3 million, and rose up nearly 6 million from 2001-2005. Leighton Ku, “Census Revises Estimates Of The Number Of Uninsured People,” Center on Budget and Policy Priorities, April 5, 2007

There are four times as many health care lobbyists as there are members of Congress.

“According to the Center for Responsive Politics, in 2005 there were 2,084 health care lobbyists registered with the federal government. With 535 members of Congress, that’s 3.895 lobbyists per member.”

Hillary Clinton became the second largest recipient in the Senate of health care industry contributions.

“As she runs for re-election to the Senate from New York this year and lays the groundwork for a possible presidential bid in 2008, Mrs. Clinton is receiving hundreds of thousands of dollars in campaign contributions from doctors, hospitals, drug manufacturers and insurers. Nationwide, she is the No. 2 recipient of donations from the industry, trailing only Senator Rick Santorum of Pennsylvania, a member of the Republican leadership. ‘Raymond Hernandez and Robert Pear, “Once an Enemy, Health Industry Warms to Clinton,’ New York Times, July 12, 2006.”

Drug industry money to members of Congress, and the president, who led the effort to pass the Medicare Part D prescription drug plan.

“‘The health industry gave $14 million total to the eleven elected officials largely credited with negotiating the bill. Pharmaceutical company PACs, employees, and their families gave more than $3 million in campaign contributions to (those) eleven elected officials.’ Buying A Law: Big Pharma’s Big Money and the Bush Medicare Plan, Campaign Money Watch, January 2004.

The elderly could end up paying more for their prescription drugs than they did before under Part D – and a majority of senior citizens could still pay over $2000 a year.

“For all patients, Medicare covers 75 percent of the first $2,250 worth of drugs. But after that, coverage drops to zero – and doesn’t resume until the patient hits $5,100 in expenses. Then Medicare kicks in again, paying 95 percent of costs. But it’s this gap – of almost $3,000 – that many sick and disabled seniors call unaffordable.” Medicare’s ‘Donut Hole,’ CBS News, July 26, 2006.
‘Over the past year, Part D drug prices have increased several times faster than the rate of inflation. Families USA analyzed the prices for 15 of the drugs most frequently prescribed to seniors. We examined prices for each of the plans offered by the largest Part D insurers, which together cover about two-thirds of all Part D beneficiaries. We then compared the lowest available Part D price for each drug in April 2006 with the lowest available price for the same drug in April 2007. The lowest price for every one of the top 15 drugs prescribed to seniors increased, and the median increase was 9.2 percent.'” Medicare Part D Prices Are Climbing Quickly, Families USA, April 2007.

Fourteen Congressional aides went to work for the industry; Billy Tauzin left Congress to become CEO of PhRMA for a $2 million annual salary.

“‘Retiring Rep. Billy Tauzin, R-La., who stepped down earlier this year as chairman of the House committee that regulates the pharmaceutical industry, will become the new president and CEO of the drug industry’s top lobbying group…Public Citizen, a non-profit consumer advocacy group, called Tauzin’s hiring “‘yet another example of how public service is leading to private riches.'” Tauzin gets a pay package reportedly worth at least $2 million a year, making him one of the highest-paid lobbyists in Washington.’ ‘Tauzin switches sides from drug industry overseer to lobbyist,’ USA Today, December 15, 2004..”

Tommy Douglas, who pioneered Canada’s health care system, was heralded as the nation’s singular most important person.

“‘In November 2004, Canadians voted Tommy Douglas the Greatest Canadian of all time following a nationwide contest. Over 1.2 million votes were cast in a frenzy of voting that took place over six weeks as each of 10 advocates made their case for the Top 10 nominees in special feature programs on CBC Television… . From his first foray into public office politics in 1934 to his post-retirement years in the 1970s, Canada’s ‘father of Medicare’ stayed true to his socialist beliefs — often at the cost of his own political fortune — and earned himself the respect of millions of Canadians in the process.’ ‘The Greatest Canadian,’ CBC, 2004.”

Canadian “wait times” not nearly as long as some try to allege.

‘Gerard Anderson, a Johns Hopkins health policy professor who has spent his career examining the world’s healthcare, said there are delays, but not as many as conservatives state. In Canada, the United Kingdom and France, “‘three percent of hospital discharges had delays in treatment,”‘ Anderson told The Miami Herald. ‘”That’s a relatively small number, and they’re all elective surgeries, such as hip and knee replacement.'” John Dorschner, “”Sicko’ film is set to spark debate; Reformers are gearing up for “‘Sicko,”‘ the first major movie to examine America’s often maligned healthcare system,’ Miami Herald, June 29, 2007.”

Drugs in England only cost $10.

“For much of 2006, the standard charge for a prescription was £6.65. ‘The cost of an NHS prescription in England is to rise by 15p to £6.65 from the start of April.’ ‘Prescription charge to rise 15p,’ BBC News, March 13 2006.
From April 1 2007 to present, the charge is £6.85. ‘There are many unacceptable inequities and anomalies in the present system. Although around four out of five prescriptions are exempt (see below for list of exempt categories), the price of a prescription (£6.85 from 1 April 2007) often hits those who cannot afford such charges. There are many people with chronic conditions who are not exempt and those on low incomes find it very difficult to pay. This causes a disproportionate levy on a limited section of the population.’ British Medical Association, ‘Funding – Prescription Changes,’ March 2007.”

After losing 42,000 civilians in eight months during a vicious bombing campaign during World War II, Britain pulled together and instituted a National Health Insurance program in 1948.

“‘The Blitz was September 7, 1940 through May 11 1941.’ ‘42,000 civilians are estimated to have died during the campaign, with over 50,000 injured, and around 130,000 houses destroyed.’ See, ‘Remembering the Blitz'”
‘The NHS was set up in 1948 and is now the largest organisation in Europe. It is recognised as one of the best health services in the world by the World Health Organisation but there need to be improvements to cope with the demands of the 21st century.’ ‘About the NHS,’ NHA website

In a study of older Americans and Brits, the Brits had less of almost every major disease. Even the poorest Brit can expect to live longer than the richest American.

“‘The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer. Within each country, there exists a pronounced negative socioeconomic status (SES) gradient with self-reported disease so that health disparities are largest at the bottom of the education or income variants of the SES hierarchy. This conclusion is generally robust to control for a standard set of behavioral risk factors, including smoking, overweight, obesity, and alcohol drinking, which explain very little of these health differences… Level differences between countries are sufficiently large that individuals in the top of the education and income strata in the United States have comparable rates of diabetes and heart disease as those in the bottom of the income and education strata in England.’ (See also Table 1 – for example, prevalence of diabetes among high-income Americans is 8.2 per thousand, while it’s 7.3 among low-income Brits.) Banks, Marmot et al., ‘Disease and Disadvantage in the United States and in England,’ Journal of the American Medical Association, 2006;295:2037-2045.”

A baby born in El Salvador has a better chance of surviving than a baby born in Detroit.

“According to the United Nations Statistics Division, Population and Vital Statistics Report, the rate of infant deaths per thousand in El Salvador is 10.5. ‘Table 3, Live births, deaths, and infant deaths, latest available year, June 15, 2007.’
According to the Michigan Department of Community Health, the rate of infant deaths for Detroit is 15.9 per thousand. ‘Number of Infant Deaths, Live Births and Infant Death Rates for Selected Cities of Residence, 2005 and 2001 – 2005 Average,’ Michigan Department of Community Health Web Site

Companies that no longer offer pensions to new employees.

“These can be found on a list prepared by the Center for Retirement Research at Boston College. Pension Change Fact Sheets, In addition, the Pension Rights Center has also compiled a near-comprehensive list. Companies That Have Changed Their Defined Benefit Pension Plans

Like Canadians and Brits, the French live longer than we do.

“The 2006 United Nations Human Development Report’s human development index states the life expectancy in the United States is 77.5, the United Kingdom is 78.5, France is 79.6, and Canada is 80.2. Human Development Report 2006, United Nations Development Programme, 2006 at 283.

The productivity rate per hour in France is higher than in America.

“According to the Organisation for Economic Co-operation and Development, ‘France has a higher labor productivity (GDP per hour worked) than the United States. ‘OECD in Figures 2005, 2005/Supplement 1 at 84.
‘Britain has yet to catch up with its rivals on productivity. Gordon Brown, the chancellor, has long wished to close Britain’s productivity gap with other countries. It is proving a long haul. In 2004, output per hour worked was 19% higher in France, 15% higher in America and 5% higher in Germany than it was in Britain.’ ‘Poor show; International comparisons,’ The Economist, January 21, 2006.”

French policy on childcare and household assistance for new parents.

“According to the French-American Foundation comprehensive review of child care, ‘For non-working parents or parents who work part-time, haltes garderies (drop-in centers) provide part-time, occasional, and drop-in care. Haltes garderies are also subsidized (by municipality and the National Family Allowance Fund), with parents paying a portion of the costs based on a sliding scale (parents pay an average of $1 per hour). … For working parents [there are] licensed family day care providers (assistants maternelles), licensed babysitters at home (social security costs and salaries subsidized by the National Family Allowance Fund).’ Peer, Shanny., ‘The French Early Education System,’ French-American Foundation, November 13, 2003.”

There is a company in France, SOS Medecins, which will perform doctor house calls at any time.

“SOS Medecins has an English website, viewable here.”

The government initially refused to pay for the health care of 9/11 volunteers, because they were not on the government payroll. It remains difficult for the volunteers to access the $50 million fund that has been appropriated for their care.

“The Department of Defense and Emergency Supplemental Appropriations for Recovery From and Response to Terrorist Attacks on the United States Act provided a total of $175 million for workers compensation programs – $125 million to NYS Workers Compensation Review Board, and an additional $50 million to reimburse the NYS Uninsured Employers Fund, including for benefits paid to volunteers. However, there have been major delays in getting money to volunteers. See. e.g. ‘Statement of Robert E. Robertson, Director, Education, Workforce, and Income Security Issues,’ ‘September 11, Federal Assistance for New York Workers’ Compensation Costs,’ United States Government Accountability Office, (GAO-04-1068T) September 8, 2004.
‘With strong advocacy from New York’s Congressional Delegation and labor leaders, a portion – about $52 million – of the $125 million in federal funding that had been allocated for administering workers compensation claims was re-allocated to provide some funding for medical treatment programs, but it will only meet a fraction of the need. Congress approved the legislation authorizing this funding in late December 2005.’ Devlin Barrett, ‘Congress Gives New Life to 9/11 Programs,’ Newsday, December 22, 2005.
A $52 million fund for volunteers was eventually established, but experts agree it’s inadequate. The New York Times reported on September 6, 2006 that ‘Dr. John Howard, who was named the federal 9/11 health coordinator in February, has already said that the $52 million the federal government has appropriated for treatment late last year is inadequate. He said in an interview yesterday that the new study will very likely mean that the gap between funds and the need for them is going to grow.’ Anthony DePalma, ‘Illness Persisting in 9/11 Workers, Big Study Finds,’ New York Times, September 6, 2006.”

American officials claim that detainees at Guantanamo Bay receive excellent health care.

‘They go out, they do sick call on the blocks three times per week, care for them there, if they can… We have diabetes. We have high blood pressure, high cholesterol. Those detainees — we’ve created a population health database so that we can track those detainees to make sure we’re seeing them frequently, monitoring their labs and their overall health.’ Statement of Navy Commander Cary Ostergaard. ‘Hearing Of The House Armed Services Committee Subject: Detainee Operations At Guantanamo Bay,’ June 29, 2005.
‘Detainees receive medical, dental, psychiatric, and optometric care at U.S. taxpayers’ expense. In 2005, there were 35 teeth cleanings, 91 cavities filled, and 174 pairs of glasses issued.’ ‘Ten Facts About Guantanamo,’ Department of Defense, September 14, 2006.

Cuba is one of the most generous countries in providing doctors to the third world.

“‘WHO statistics show that the incidence of AIDS in Cuba is the lowest in this hemisphere, and there are now more than 800 Cuban doctors in Haiti alone working to control the AIDS epidemic. President Castro has offered an almost unlimited number to be sent to Africa, to be paid by the Cuban government with only a small stipend from the host countries.’ ‘President Carter’s Cuba Trip Report By Jimmy Carter,’ May 21, 2002.
‘The close friendship between Cuban leader Fidel Castro and Venezuelan President Hugo Chavez has netted Venezuela a loan of 20,000 Cuban health workers — including 14,000 doctors, according to the Venezuelan government — who work in poor barrios and rural outposts for stipends seven times higher on average than their salaries at home. Castro has vowed to send Chavez as many as 10,000 additional medical workers by year’s end.’ ‘As Cuba Loans Doctors Abroad, Some Patients Object at Home,’ Boston Globe, August 25, 2005.
‘President Evo Morales on Friday heeded the wishes of six visiting U.S. senators by acknowledging the positive effects of American aid in his country – but added that Cuban doctors had had a greater impact on Bolivia than their U.S. counterparts… [I]n a Friday interview with Bolivian radio network Fides, Morales said the assistance of Cuban leader Fidel Castro – who has sent Bolivia some 1,700 doctors and paramedics this year alone, setting up free hospitals and eye clinics throughout Bolivia — outshines the United States’ own medical aid.’ ‘Morales Says Cuban Doctors top U.S. Medical Aid,’ Boston Globe, December 29, 2006.”

In the U.S., health care costs run nearly $7,000 per person. But in Cuba, they spend around $251 per person.

“United States health spending per capita is $6,697 per person according to Catlin, A, C. Cowan, S. Heffler, et al, ‘National Health Spending in 2005.’ Health Affairs 26:1 (2006). As with the number of uninsured, the number continues to increase and is projected to be $7,092 per capita in 2006, $7,498 per capita in 2007 and reaching $12,782 by 2016, according the Department of Health and Human Services Center for Medicare and Medicaid Expenditures, National Health Expenditures Projections 2006-2016,
The 2006 United Nations Human Development Report says Cuba spends $251 per capita on health care. Human Development Report 2006, United Nations Development Programme, 2006.

In Cuba, access to health care is universal.

“‘Cuban dissatisfaction with their personal lives does not mean they are negative about the revolutionary government’s achievements in health care and education. A near unanimous 96 percent of respondents say that health care in Cuba is accessible to everyone. Gallup polls in other Latin American cities have found that on average only 42 percent believe health care is accessible.’ Gallup/ Consultoría Interdisciplinaria en Desarrollo, ‘Cubans Show Little Satisfaction with Opportunities and Individual Freedom Rare Independent Survey Finds Large Majorities Are Still Proud of Island’s Health Care and Education,’ January 10, 2007.”

Cuba has a lower infant mortality rate and a longer average lifespan than the United States.

“The 2006 United Nations Human Development Report’s human development index states the life expectancy in the United States is 77.5, and is 77.6 in Cuba. Human Development Report 2006, United Nations Development Programme, 2006 at 283.
According to the United Nations Statistics Division, Population and Vital Statistics Report, the rate of infant deaths per thousand in Cuba is 6.2 per thousand, and in the United States is 6.8. ‘Table 3, Live births, deaths, and infant deaths, latest available year, June 15, 2007.'”

18,000 Americans will die this year simply because they’re uninsured.

“According to the Institute of Medicine, ‘lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States. Although America leads the world in spending on health care, it is the only wealthy, industrialized nation that does not ensure that all citizens have coverage.’ Insuring America’s Health: Principles and Recommendations, Institute of Medicine, January 2004.

The American Medical Association distributed a record featuring Ronald Reagan discussing the evils of socialized medicine.

“Ronald Reagan’s recording was widely available in the 1960s, and was a part of the American Medical Association’s ‘Operation Coffee Cup,’ a coordinated rebuttal to Democrats’ push for Medicare. Max Skidmore, ‘Ronald Reagan and Operation Coffee Cup: A Hidden Episode in American Political History,’ Journal of American Culture, vol. 12. 1989.”

$100 million spent to defeat Hillary’s health care plan.

‘”Even before debate began in Congress, a powerful coalition had been cobbled together to fight Clintoncare, as opponents labeled it – congressional Republicans, the insurance industry, the pharmaceutical industry, the National Federation of Independent Businesses, the Business Roundtable, the Christian Coalition, the conservative radio talk show network. Those groups spent between $100 million and $ 300 million to defeat it. And the battle was fought like a presidential campaign – with a TV advertising campaign, a network of field operatives and public relations experts to lobby members of Congress back in their districts.’ Rob Christensen, ‘Who killed health care reform? Answer: Everyone,’ News & Observer, June 19, 1996.
‘In 1993-94, the Health Insurance Association of America, a trade group, spent about $15 million on advertising to defeat Clinton’s proposed overhaul of the nation’s health care system.’ John MacDonald, ‘Proponents, Opponents Join Battle Over Drug Price Limits,’ Hartford Courant, June 21, 2000.

The United States is ranked #37 as a health system by the World Health Organization.

“‘The U. S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the report finds.’ ‘World Health Organization Assesses The World’s Health Systems,’ Press Release, WHO/44, June 21, 2000.”

Health industry companies accused of wrongdoing in Sicko.

“Aetna: ‘Aetna Inc. … settled with the plaintiffs, which include the medical associations of California and Texas. Aetna agreed to pay the plaintiffs $120 million.’ Milt Freudenheim, ‘Class-Action Status Is Upheld for Doctors Suing Insurers,’ New York Times, September 2, 2004. See also, Susan Beck, ‘HMO Postmortem,’ American Lawyer, October 10, 2003. Settlement Agreement,
Blue Cross/Blue Shield: ‘Sixty-seven Blue Cross/Blue Shield companies across the nation have paid the United States a total of $117 million to settle government claims that Medicare made primary payments for health care services that should have been paid by the Blue Cross/Blue Shield private insurance companies, the Department of Justice announced today.’ ‘Blue Cross/Blue Shield Companies Settle Medicare Claims, Pay United States $117 Million, Agree To Share Information,’ Department of Justice News Release, October 25, 1995.
Cigna: ‘Cigna Corporation, [has] settled with the plaintiffs, which include the medical associations of California and Texas. … Cigna agreed to pay $85 million.’ Milt Freudenheim, ‘Class-Action Status Is Upheld for Doctors Suing Insurers,’ New York Times, September 2, 2004.
‘HCA Inc. (formerly known as Columbia/HCA and HCA – The Healthcare Company) has agreed to pay the United States $631 million in civil penalties and damages arising from false claims the government alleged it submitted to Medicare and other federal health programs, the Justice Department announced today. … Previously, on December 14, 2000, HCA subsidiaries pled guilty to substantial criminal conduct and paid more than $840 million in criminal fines, civil restitution and penalties. Combined with today’s separate administrative settlement with the Centers for Medicare & Medicaid Services (CMS), under which HCA will pay an additional $250 million to resolve overpayment claims arising from certain of its cost reporting practices, the government will have recovered $1.7 billion from HCA, by far the largest recovery ever reached by the government in a health care fraud investigation.’ ‘Largest Health Care Fraud Case In U.S. History Settled; HCA Investigation Nets Record Total Of $1.7 Billion,’ Department of Justice News Release, June 26, 2003.”

Executive Compensation

“Michael B McAllister earned $3.33 million in compensation as CEO of Humana. ‘Forbes 2006 Executive Pay list,’ April 20, 2006.
John W Rowe earned $22.2 million in compensation as CEO of Aetna. Rowe has since left Aetna. ‘Forbes 2004 Executive Pay list,’ April 21, 2005.
Bill McGuire has stock options worth $1.6 billion at the end of 2005, as CEO of UnitedHealth Group. Robert Simison, ‘SEC Investigates UnitedHealth Over Stock-Options Practices,’ Bloomberg News, December 27, 2006; Michael Regan, ‘Business 2006: Who Won, Who Lost,’ Associated Press,December 26, 2006.”

The nineteenth century Robber Barons who inspired the icon Rich Uncle Pennybags of Monopoly fame have now found their way over the years into American households even more so prominently into the healthcare arena, according to sociologist, Joan Retsinas’ Robber Barons Enter Health Care. Robber Barons were the reverse Robin Hoods taking from the poor to enrich their own lives and well being, while many fell victim to the massive infrastructure built on the backs of the workers who built it. As Retsinas and many other sociologists and professionals have stated the game of Monopoly is not only a game but a business model of sorts as the ruthless are rewarded for their acquisition and destruction of their competitors. The idea that greed is good is found throughout society and its many working with healthcare becoming an ever increasing casualty. Great wealth has been built and continues to be built due to the simple fact that the healthcare industry is not in the business of a cure but in the business of treating as their is more money in treating than curing an illness. While many countries have been able to stem the tide of greed, the United States continues to fall prey to the Robber Barons who have now set their sites on healthcare and all its components making it nearly impossible to find a way to regulate the industry meant to benefit the whole not the few. While the Affordable Care Act has prevented several of the old avaricious methods e.g. exclusions involving pre-existing conditions, low “ceilings” on benefits, high profit margins, limited coverage for every day malady, the health care industry continues to make large returns at the expense of enrollees. As Retsinas reports, a recent fraud sweep charged a 107 people including many well paid clinicians such as phyisicans, nurses and therapists with swindling Medicare out of $452 million in false claims with another sweep in September of 2011 charging 91 people with bilking $295 million by billing for care not provided, for non-existent patients and overbilling. Phillip Morris has also been hit hard in the United States yet has bounced back by marketing its cigarettes around the world with little concern for the well-being of its clients. Since 1965 when the Surgeon General declared smoking unhealthy, the company has fought over restrictions in advertising, sales to minors, warnings on cigarette packages and has lost with states raising taxes, banning smoking in public places even suing and winning against Big Tobacco. With only 19% of Americans smoking and the Marlboro Man, an icon for Big Tobacco, becoming rather passe, Phillip Morris has turned to the unhooked and young overseas market already dealing with many other healthcare crises…adding one more wouldn’t hurt or at least  right away. Smoking has increased overseas as governments struggle to block the sales of cigarettes to their people e.g. Phillip Morris went to court to block the edicts of Uruguay, Australia and Norway.

The efforts to prevent further corruption in the global healthcare system requires international cooperation with all health system stakeholders working together e.g. public authorities, payers, providers, professional associations, citizens etc. The World Bank defines corruption as the “abuse of public office for private gain” such as the use of power and influence by health practitioners, officials and organizations for self-enrichment conflicts with their public roles. According to the World Health Organization, corruption can be subdivided into bribery, theft, bureaucratic or political corruption, and misinformation for private gain. The task at hand is not a simple one as there are many challenges to developing a truly effective system of auditing and accountability that would expose corruption and subsequently deal with the problem at hand. The procedures and guidelines used must be transparent and explicit, while anti-corruption laws ans regulations must be strictly enforced. The quality of the care should also be measured accordingly in order to weed out corruption with respect to government and medical institutions through clearly defined patient rights making it easier to register and investigate complaints from beginning to end through the courts.

5 thoughts on “Robber Barons: When Healthcare meets Business and Politics

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