By Howie Hawkins
Spurred by rising in health care costs and concern that many Americans still lacked health insurance despite the enactment of Medicare and Medicaid in 1965, three basic models of federal health care reform were debated in the 1970s.
The conservative model mandated employer-based private insurance and market competition to control costs. Proposed by President Richard Nixon, it became the Republicans’ approach in the coming decades and was finally adopted in 2010 with the Affordable Care Act under President Barack Obama, albeit in an even more conservative form.
Nixon’s plan had a stronger employer mandate and it federalized funding of an expanded Medicaid-type program rather leaving the decision to expand and help fund Medicaid to the states as Obamacare did.
The liberal model was the proposal spearheaded by Sen. Edward Kennedy (D-MA) for National Health Insurance (NHI) in which the federal government would pay for privately-delivered medical services for all, what is today commonly called Medicare for All.
The democratic socialist model was the proposal of Rep. Ron Dellums (D-CA) for a National Health Service (NHS) in which both the funding and the delivery of medical services would be provided through a public agency directed by elected Community Health Boards. The impetus and support for this model came from veterans of the civil rights, anti-war, and student movements of the 1960s New Left who prioritized “participatory democracy” and “community control.”
The New Left healthcare reformers ridiculed NHI as “The Great Leap Sideways,” arguing that cost control and patient care would be sacrificed in a system where private doctors, hospitals, and other healthcare providers would feed at the public trough to maximize their profits by raising prices, cutting care, and monopolizing markets in a new “Medical Industrial Complex.”
Today’s continued high inflation of health care costs, persistent gaps in coverage, and corporatization of all aspects of health care delivery have proven that the New Left critique of NHI was prescient.
The more progressive wing of the health care reform movement campaigned for the Dellums bill until, at a 1986 retreat in New Hampshire in the midst of the conservative Reagan years, leading NHS advocates decided to retreat to the NHI model, which they would soon brand as “single payer” to avoid the socialistic connotations of public funding.
They believed that the American public and Congress would find the single payer system more acceptable because it was already operating right next door in Canada.
They also hoped that doctors, whose professional associations had long resisted healthcare reform, would find single payer acceptable or even preferable because they could continue to work in their own private practices while the government would pay for their services, relieving them of the costly and time-consuming burden of billing and collecting fees for services from a myriad of corporate insurance plans that frequently resisted paying.
People at that 1986 retreat would soon be central to the formation of Physicians for a National Health Program (PNHP) in 1987, which has been a major force behind the Medicare for All bills introduced into Congress since the 1990s.
Dellums kept his NHS bill in the congressional legislative hopper from 1977 until he retired in 1998, but progressive healthcare reformers had shifted their focus to the NHI model — until recently.
In the March 31, 2022 issue of The Nation, five doctors who have been longstanding leaders in PNHP published an article entitled “Medicare for All Is Not Enough.”
These doctors explained that NHI assumed a tax-funded universal insurer would pay for services delivered by independent doctor practices, hospitals, and other locally-owned providers of medical services. The problem today is that most doctors have become employees of large corporations and most hospitals are corporate subsidiaries.
In today’s healthcare system, NHI would funnel public payments to corporate owners who put profits before patients. Private insurers have been joined by a host of new corporate middlemen, often owned by Wall Street private equity firms, across the entire healthcare system, including doctor practices, hospitals, hospices, nursing homes, urgent care clinics, dialysis clinics, imaging facilities, ambulance companies, and home care agencies.
Corporatization is also intruding into public health insurance programs provided by Medicare and Medicaid and even the Veterans Health Administration (VHA), which is a NHS for veterans with its public hospitals and publicly salaried providers. Already 70% of Medicaid and 51% of Medicare participants are in private plans and over a third of VHA patients are outsourced to private contractors.
Liz Fowler, President Biden’s Director of the Center for Medicare and Medicaid Innovation, a former health care industry executive who was a principal author of Obamacare, has set a goal of putting all Medicare and Medicare patients into privatized managed care plans by 2030. A PNHP study found that overpayment to private Medicare Advantage plans compared to traditional Medicare was 31-35%, or $124-$140 billion, in 2022.
The PNHP doctors writing in The Nation argued that NHI is “necessary but not sufficient” and that it is time to revive Dellums’ NHS proposal. They said, “Communities, not corporations, should own our nation’s vital health care assets.”
Another longtime PNHP leader, Dr. Margaret Flowers, wrote much of the health care policy paper for my Green Party presidential campaign in 2020 in which we advocated for the immediate adoption of NHI, followed by a 10-year transition to build out a NHS (“Medicare for All as a Community-Controlled National Health Service” at howiehawkins.us). Dr. Flowers advocated for a NHS in her interview in the November/December 2023 Capitol Hill Citizen.
Dellums’ NHS proposal would provide to all US residents all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, hearing, prescription drugs, and medical supplies.
The services would be provided for free to patients in publicly-owned clinics and hospitals. Health care providers would be public employees of the NHS. Patients would have free choice of doctor and hospital.
The costs of the system would be paid through progressive personal and corporate income taxes, savings from the reduction in administrative costs by replacing the complex billing and reimbursement overhead in a multi-payer system with a single public payer, and savings from replacing the inflationary fee-for-service system with pre-paid budgets for public hospitals and clinics.
In the only study comparing the costs of private insurance, NHI, and NHS, the NHS model was the least costly.
Other studies have shown that with a reasonably progressive tax structure for a single payer system, 95% of households would pay less in healthcare taxes than they do now for healthcare taxes plus premiums, deductibles, co-pays, and out-of-pocket expenses for uncovered services.
A central feature of Dellums’ NHS proposal was its democratic structure. At the community level of approximately 25,000 to 50,000 residents, two-thirds of a Community Health Board would be elected by residents and one-third by the community’s healthcare workers.
These community boards would oversee outpatient care provided in community health centers, prioritize preventive services, and empower communities, especially traditionally under-resourced communities, to receive and hold accountable an equitable distribution of health care resources.
The community boards would appoint one worker and two consumers from their community to a District Health Board, which would oversee inpatient services in a general hospital in a district of 100,000 to 500,000 people.
The district boards would in turn appoint a district worker and two consumers to a Regional Health Board that would oversee a regional medical center providing specialized medical services and tuition-free education of doctors, nurses, and technicians in a region of 500,000 to 3 million people.
The regions would each appoint one worker and one consumer to a National Health Board for overall planning and coordination of the system, including the collection of revenues through the federal tax system and their distribution on a per capita basis to the other levels, with supplemental allocations to meet special health care needs.
It is time to again expand the health care reform agenda from NHI socialized insurance for privatized care to a fully socialized and democratic NHS – publicly funded, publicly administered, and publicly delivered.
Speaking to nurses, veterans, and other constituents at an April 2019 rally at the Bronx against proposals privatize the VHA, Representative Alexandria Ocasio-Cortez (D-NY), reassured the crowd that public payment for private delivery of health care in the Medicare for All proposal would not change the VHA’s public delivery system for veterans.
AOC then added that she thought the civilian health system should be fully public like the VHA. “If you ask me, I would like VA for All,” she said to cheers.
AOC and other progressives in Congress could take the first step in that direction by re-introducing Dellums’ bill for a National Health Service.
Originally published in the print-only Capitol Hill Citizen‘s February-March 2024 Edition
