As the country prepares for open enrollment October 1st in the insurance exchanges of the Affordable Care Act (aka Obamacare), a small group of dedicated artists and politicians in Pennsylvania have been working toward a broader solution. Catalyzed by a study by Professor Gerard Friedman of the University of Massachusetts at Amherst that estimated savings of $17B for Pennsylvania with a single payer approach, State Senator Jim Ferlo and an energetic group of young artists in Pennsylvania, decided they needed a comprehensive statewide system that would offer affordable health care to every citizen in Pennsylvania.
In March 2013, PA Senator Jim Ferlo and Representative Pam DeLissio re-introduced SB400, a bill Ferlo had introduced a year before to little fanfare and support. This time, Ferlo garnered support from a businessman and former Republican legislator, David Steil, as well as the activist group HealthCare4AllPA.
Noting the economic impact study, Steil said "As a business owner, we must get business out of health care because it perpetuates an already financially unsustainable system. A single payer system costs less, promotes free market principles, and creates jobs by improving the delivery of health care."
Chuck Pennacchio, the Executive Director of Health Care4All PA, had publicized the groundbreaking economic impact study, which had been authorized by SR 267 in 2010 with a remarkable degree of bipartisan support at the time (68% of PA state senators --all 20/20 of Democrats and almost half of Republican senators, 14/30).
While Senator Ferlo was working the legislature this time, Julie Sokolow, a young artist, began collecting the stories of other young artists in need of affordable and quality care. She wondered if other artists had the same problem with lack of health insurance as she did, artists who worked part-time or in service industry jobs without insurance. She realized that the concept of single payer had not really clicked with her generation, so she made a short video that told the stories of other artists like herself without insurance or access to care, and linked their lack of access to the very core of what a healthy democracy requires - active, healthy voters. Her group won an "emerging artist" award from the Looking@Democracy competition hosted by the MacArthur Foundation and Illinois Humanities Council.
The enthusiasm and interest generated by this short video led Julie's group "Healthy Artists" to work with HealthCare4AllPA. With the support of pediatrician and HealthCare4All activist, Dr. Scott Tyson, the young artists were able to create over 30 documentary shorts in a year's time, exposing the struggles of uninsured Pennsylvanians. With the organizational support of Healthcare4All and the passion and creativity of the artists, they were able to keep what had seemed like a quixotic venture alive and well in the political arena. It didn't hurt that filmmaker and progressive celebrity Michael Moore gave them a prominent place on his website earlier this year.
While the goal of Healthy Artists is a single payer approach to health insurance, they view Obamacare as a step in the right direction and have been promoting the expansion of Medicaid and the state exchanges. As they point out, the ACA encourages individual states to experiment with single-payer universal health care. States can apply for an innovation "waiver" and start implementing their own plans starting in 2017. Vermont Governor Peter Shumlin led the way when he signed Green Mountain care into law in 2011, establishing a road map for a state-level single-payer system. To achieve their goals, Vermont needs a waiver from the federal government to do health care their way, but their biggest obstacle will be finding a source of revenue to support Green Mountain Care. Will the people of Vermont support additional taxation in order to offer access to health care to all of their citizens?
Pennsylvania is one of 22 states in an organized national single-payer network, ready to utilize the provision in the ACA allowing for innovation as of January 1st 2017. The single payer advocates in Pennsylvania envision single-payer eventually replacing the exchanges, because they rightly view health insurance as being significantly different from access to health care. For example, if you purchase a bronze plan through the ACA exchanges, you are technically insured. However, you might have a significant deductible, so that even after you have purchased insurance, you still have financial barriers.
While there are a variety of efforts around the country to promote single payer health care, the definition of single payer remains opaque and confusing to the public. To some, it simply means getting rid of private forprofit insurance companies; to others it means public financing of health care; and still others, free care. But the term "single payer" usually refers to the method of collecting revenue, usually by the government through taxation, to pay for and administer health care services for a specific population.
Our own program for the elderly, Medicare, uses a single payer financing approach. But while Medicare uses tax money to pay for health care for people over 65, it contracts with private insurance companies and private providers to actually deliver the care. Certain Medicaid programs in California use public financing to organize and administer a publicly run insurance program for eligible residents in specific counties. These "county organized systems" have the "franchise" to deliver care to the Medicaid population in their area. They are single payers, although the providers who give the care are usually private practitioners.
Whether or not single payer means a purely publicly financed and delivered system, or some variation of public control, there is yet another version of single payer that will work through the state ACA exchanges. Just last week the first of twenty-four non-profit "insurance companies" opened their doors for business around the country. These insurance-company startups or 'co-ops' created by the Affordable Care Act say they're ready to battle the establishment, stay in business, and change health care.
"What we're doing is a big part of the ACA story," said John Morrison, president of the National Alliance of State Health CO-OPs. "We bring a completely different paradigm to health care finance. We're not interested in making as much money as we can. We're not interested in making profits. What we are interested in is making consumer patients healthy and saving money."
In New Mexico, alone, the co-op approach has provoked private insurance companies to lower their prices. But co-ops cannot use federal money to advertise their plans, and it is not clear the residents of the states in which co-ops are being offered will actually sign up.
It seems unlikely that co-ops or state based programs like the one in Vermont will take over American health care any time soon. Nor will private forprofit insurance companies like Aetna or the for-profit Blues go out of business either. However, after having killed the "public option" for Obamacare, it would be truly ironic for conservatives if publicly financed and/or delivered health care ended up getting new energy from the implementation of the Affordable Care Act.