1. The private insurance industry can’t meet the public’s needs. 2. The employer-sponsored insurance system is continuing its long decline. 3. Incrementalism that builds on our multi-payer, market-based system has not been able to control health care costs over the past 30 years, and won’t do so in the future. [To read more about incrementalism, click here.] 4. Business may revolt if it finally decides that it can’t contain its health care costs without single payer. 5. Labor may also revolt when it sees more clearly that affordable health care is becoming even more elusive. 6. State and federal governments will not be able to sustain their increasing burdens of health care costs as the safety net further deteriorates and other priorities intervene. 7. Support for a national health insurance program is growing among physicians and other health professionals. 8. We can expect a strong backlash from a growing part of the population that begins to understand that the new health care “reform” law (PPACA) won’t make them any better off, and in fact will leave many worse off. 9. We ignore lessons from health care systems in other advanced countries at our peril.

A RECENT DISCUSSION OF INCREMENTALISM This discussion occurred subsequent to Don McCanne reporting and commenting on views put forth by President of Families USA, Ron Pollack. You can request daily quotes from Don at mccanne1@home.com  This discussion began with the February 21, 2001 Wall Street Journal article, "The Have-Nots" by Rhonda L. Rundle and Shailagh Murray. Don McCanne made comments on this article and Ron Pollack commented on Don's comments. Subsequently: Comments by Dr. Ida Hellander These are from the PNHP (single payer) perspective. Comments from Ramon Castellblanch These are entitled "You can't get there from here." That incrementalism cannot add up eventually to universal health care On to further comments by Dr. Uwe Reinhardt Final comments about what the US needs with a (realistic, pessimistic?) view of the political will  needed to bring about the required change. ORIGINAL INTERCHANGE: Regarding the collaboration between Families USA and the Health Insurance Association of America the article described conclusions from the early meetings:  It's impossible to do comprehensive reform that will cover everyone. There must be no threat to the current, employer-based system. It's best to build on successful existing programs, rather than to create new ones. There isn't enough money to cover everyone. And the low-income population should be targeted first."  Ron Pollack, Families USA president said: "If you look at the history of health reform, all the stake-holders come in with their first-choice proposal. If they don't get it, they walk away - their second choice being the status quo. It's that dynamic we want to change. We're trying to make a virtue out of second choice."  In response, Don McCanne made the following points: Point 1 to: "It's impossible to do comprehensive reform that will cover everyone.":  A health care system that is specifically designed to include everyone does, in fact, include everyone. When you begin with that premise, it is impossible to do comprehensive reform that will NOT include everyone.  Point 2 to: "There must be no threat to the current employer-based system.":  This statement is based on the assumption that we will keep our existing sick system intact, a system that receives a major portion of funding through employment related health benefit packages. Analysts across the political spectrum agree that many of the defects in our system are related to this employment linkage of coverage. A rational health care system design would surely exclude employment linkage.  Point 3 to: "It's best to build on successful existing programs, rather than to create new ones.": A system that is unable to allocate effectively our abundant health care resources can hardly be qualified as "successful." The middleman health plan industry that has created an intrusive, private bureaucracy, characterized by egregious administrative waste, stands as an example of an UNSUCCESSFUL approach to health care management. The structural design of our system should assure that there will be a very high probability of success in delivering health care to everyone.  Point 4 to: "There isn't enough money to cover everyone.": 14% of our GDP, far more than any other nation devotes to health care, isn't enough? What is enough? 20%? 30%? 85%? We have excess capacity in our system now. The marginal costs of adding care for those that are left out are almost negligible. There IS enough money now, and more could be added if we decided that we wanted to shift funds from other sectors of our economy.  Point 5 to: "And the low-income population should be targeted first.": Comprehensive reform should target everyone. Selecting out the low-income population as a separate target will always result in a lower level tier of care for this segment. Designing a comprehensive system that is best for each of us will be the only way that we can assure adequate access and coverage for low income individuals.  Overall: According to Mr. Pollack, all of the stake-holders walk away if they don't get their first choice, and so we need to make a virtue out of second choice. But there is only one stake-holder that counts, and that is the patient. The only ethical mission of all other stake-holders is to serve the health care needs of the patient as effectively as possible. That may result in second choices for the other stakeholders, but that is a compromise that we must make in order to have first choice for the patients. A structural design that promotes this mission should be our common goal. We need to put back on the table the one reform that would lay the foundation for a system that places the patient first, and that is to establish a publicly administered, universal risk pool.  Mr. Pollack responded to Don's quote and comments: Those of us who toil in the incremental vineyard do not disparage, or even forget to laud, the necessary goal of universal coverage. We do, however, view the much-needed goal as one that is only likely, in the foreseeable future, to be achieved on a step-by-step basis. Thus, the criteria we articulate focus on how to analyze what should happen next in the step-by-step approach, and our strategic judgment is that we must not overreach (at the peril of yet another, empty-handed failure). One other perspective needs to be emphasized. Movements are generally built on successes, not failures. To the extent that we continually overreach and end up empty-handed, we discourage people from joining our movement; successes, on the hand, build confidence and give people a sense that their work is not in vain. Those of us who are building our efforts accordingly should not be the source of ire from those who are less involved in incremental improvements. We all want to keep the flame burning for universal coverage.  Source: http://www.defendhealthcare.org/DiscussIncrement.html   Part Two - Comments from Ida Hellander, M.D. Executive Director of Physicians for a National Health Program These comments were made following the initial interchange between Don McCanne, MD and Ron Pollock, President of Families USA. If you define the problem as the uninsured (and decide that you can't confront the power of the insurance and drug lobbies), you end up with a solution like that proposed by the HIAA and Families USA. Buy more insurance, especially from companies represented by the Health Insurance Association of America.  This solution won't work, however. Ron Pollack's quote about the status quo being everyone's second choice comes from a lecture by Princeton economist Uwe Reinhardt to the US Chamber of Commerce. Reinhardt's lecture focused on the failure of incrementalism -- and specifically tax policy changes -- to ever achieve universal coverage, and concluded with the statement along the lines of "even Mother Theresa couldn't make incrementalism work."  We at Physicians for a National Health Program (and most Americans) define the problem as a greater health care crisis caused by market-based medicine and for-profit health care. 80% of Americans say the US health system is driven by "greed". They are right. The uninsured are a tragic symptom, along with rising costs and rapidly deteriorating quality, of a greater problem. The solution is not simply "universal coverage" but not-for-profit national health insurance with a ban on Wall Street/investor-owned providers (e.g. for-profit HMOs, hospitals, managed mental health firms, etc.).  There is a myth that single payer national health care activists are asking for "too much" in a "single leap". This is nonsense. The US health system has evolved in several stages, and the passage of Medicare and Medicaid in 1965 could be said to be the largest necessary leap. Government spending is already a majority of all health spending, and new bills pass every year for coverage for one serious disease or another (e.g. AIDS, breast cancer, etc.). The next leap -- eliminating insurance firms from the coverage of the relatively healthy, wealthy, and young -- is simply one of the last leaps to resolving the health care crisis. Source: http://www.defendhealthcare.org/DiscIncrB.html