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The Elephant in the Room: My Meeting With Senator Baucus

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Nursed by the debate on health care reform which arose in the Democratic primaries over a year ago, and growing with abandon as the Presidency of Barack Obama moved from hope to reality, my activism on behalf of fundamental health care reform has been expressed in these pages as a passionate advocacy for single payer, Expanded Improved Medicare For All.. So you can imagine my surprise last Tuesday when I found myself mingling with a small group of insurance company executives, hospital chain administrators, venture capitalists, kings of the wine industry, Democratic fundraisers, green energy pioneers, one bankruptcy vulture capitalist, and "He-Who-Had-Eight-Single-Payer-Advocates(yikes! like me!)-Arrested", Senator Max Baucus. First, the prologue: As documented in an earlier blog, it began with an invitation to attend a $10,000 per person Democratic Senatorial Campaign Committee fundraiser at which Max Bucus would be the guest of honor. After soliciting your input, much internal debate, and some considerable negotiation to reduce the price of admission to a point which wouldn't take food off the table (but still put me in the dog house with my wife) I decided to attend. Meanwhile, as I prepared how I would present myself in such an unfamiliar venue, (I got a haircut, trimmed the beard, brought my good clothes to the cleaners) and consulted with friends and other single payer advocates about how I might engage Senator Baucus, a group of activists was quietly organizing a protest. When the host of the event called me, having read my blogs and clearly a bit anxious about my role within the gathering, I assured him I would maintain the privacy of all involved and I called a few whom I thought might be considering a protest to explain that I could not be involved in any planning and preferred not to know if anything was in the works. How a $10,000/person fundraiser works: Arriving only five minutes after the start time at the venue, a home located centrally in one of San Francisco's nicest, though not ostentatious, neighborhoods, I was greeted by two sights: Valets with plainclothes security officers nearby and a crowd of chanting single payer activists-- nurses, doctors, and others totaling about 35 in all-- waving signs as they marched out front. I tried to divert my eyes, afraid I would be sucked in by someone I might recognize and anxious, for the purpose of my participation in the meeting which was to be held inside, that I remain separate from the protesters. Nevertheless, I recognized one, an old childhood friend, who was carrying a video camera. He gave me this footage today: Quickly escorted inside I found myself in a lovely large living room with original art on the walls, transformed into a dining room, sparsely furnished but for a long table set elegantly for about twenty. A couple other guests had already arrived and were visiting near the front of the room, glancing out the windows at the protesters. An adjoining room, which must normally have been the dining room, was empty. Several additional young men and women stood about, political staff I assumed. As more guests trickled in black and white dressed wait staff circulated bringing cocktails, wine, soda, and an array of delicious appetizers (seared scallops, Chinese soup spoons laden with mango salad to name a few). With each guest provided with a nametag it was easy to circulate, dropping in on conversations, exchanging civilities. As the room began to fill I found myself able to initiate conversation about health care reform with a number of different guests. The head of a major insurance company public relations department, with his CEO standing nearby, argued that the fundamental problem leading to excessive health care costs had little to do with insurance company overhead and profits (only reaching 16% of premiums, he claimed) but had to do with doctors providing unneeded care. My argument that it would be more rational and effective to begin by eliminating those costs which did not contribute to health care (advertising, marketing, product development, profits) failed to gain his approval, but he seemed to accept and perhaps even be pleased with the component of the Obama/Baucus health care reform proposals which would eliminate the multitude of different "products" that insurers may offer. (Really no surprise, such limits will decrease corporate overhead without necessarily forcing reductions in premiums.) Not everyone at the meeting was focused on health care. I had a couple of brief but stimulating conversations with a leading venture capitalist in the field of "green" energy. At one point, another physician, a leader in lifestyle-based treatment of cardiovascular diseases, turned to me with the banal opening, "So, you are a doctor, too..." in order to escape hearing a bankruptcy investor drone on about the differences between the failures of General Motors and Chrysler. In the time before the Senator arrived, the conversation was cordial and sociable, but it was always clear why everyone was there. Although there were a few jokes about the similarity of my name to the San Francisco Giant outfielder Aaron Rowand, we were not there to discuss baseball. I took advantage of every conversation I could to push discussion of health care reform, and specifically, of the single payer option. The protesters outside helped. Although I was careful not to associate myself with their protest action directly, I admitted repeatedly that my previous posting on The Daily Kos might have been a factor in leading to the protest outside. Some seemed to hold back surprise when I pledged my allegiance more to the policies supported by the protestors than to those supported by the Senator, but all were civil and most were ready to engage in substantive conversation. The fact that there were more people outside protesting than were inside schmoozing gave me credibility: I was not just a crackpot who managed to slip by security, but I was a spokesman for a deeply felt and carefully considered policy position. When Senator Baucus arrived-- tall, dignified, warm-he greeted a number of guests by first name and chatted amiably for a few minutes before he was ushered into the nearly empty neighboring room. As he took up position at the end of the room in front of a large modern oil painting it became clear that there was a plan: Each guest was to join him, one-by-one, for a photograph and a brief "personal" conversation. One guest handed him a copy of a book he had written; one thanked him for his contributions to the promulgation of information about the health "effects" (i.e. "benefits") of wine, one promised to support his efforts on health care reform against the attacks of more anti-reform elements in the health insurance industry, one stressed the importance of supporting expansion of primary care as a cost control mechanism... I let him know that my sympathies were with the protesters and that I could not understand why he could not have allowed us to testify at his hearings rather than have us arrested for attempting to be heard. I told him of a patient of mine, a poorly-controlled diabetic who finally managed to get his diabetes under control, after years of my failure to get him to achieve this goal, when he moved from California to the Kingdom of Tonga, where "medicine is free." A seat at the table After the formalities of the one-on-one, it was time to eat. I despaired somewhat upon finding my assigned seat, on the same side of the table as the Senator, as far away as possible. If the conversation was to be informal, I would have no ability to speak my peace. But at a $10,000 per person fundraiser, no one comes to chit chat and the host, knowing that, quickly laid my worries to rest. Each who wanted, he explained, would have a chance to engage the Senator in front of the group with questions or comments. Those who spoke first made it easier for me: Each spoke for several minutes, some simply with effusive praise for the Senator, but most making their case for health reform designed the way they wanted it. When my turn came, Senator Baucus asked me to repeat for the group the story of my Tongan diabetic. I demurred and instead emphasized with a few examples the waste imposed on providers of health care services by the private employer-based insurance system. I called upon him to bring supporters of single payer into the discussion. I tried to let him know that we are not crazies, but that we are educated, thoughtful people who have looked carefully at the health care system and find that the administrative waste created by the insurance industry is strangling our health care system. The discussion engendered by my comments was more profound than any other discussion at the event and colored the discussion of other topics as well. Yet this was not because what I had to say was so profound. Instead, it was because single payer health reform was the elephant in the room. It is the elephant in the room whenever health reform is discussed because in America (i.e., Medicare, the Veterans' Administration Health System, and our neighbors in Canada) a single payer structure has been shown to be superior to other models of health care finance for maintaining control of costs, providing patient and provider satisfaction, and offering the prospect of universal coverage. Barack Obama knows this. He has told us this over and over again. The way insurance company executives whiningly explain that they only take 16% off the top of premiums for their work show us that they know this. And Max Baucus, in his very carefully chosen and frequently repeated words with which he has dismissed the prospect of single payer health care reform, "It cannot pass," rather than "You are wrong" has let us know that he gets it too. In this meeting, with protesters outside and a single payer advocate inside, I felt that he really does get it, but is so driven by the political desire to get it done that he, like so many others, just cannot address the elephant in the room. So what do we do? First, we need to make sure that those who are aware of the elephant in the room (especially our legislators and the President) face the issue and consider it. As the conservative economist Milton Friedman said:
. . . it is worth discussing radical changes, not in the expectation that they will be adopted promptly but for two other reasons. One is to construct an ideal goal, so that incremental changes can be judged by whether they move the institutional structure toward or away from that ideal. The other reason is very different. It is so that if a crisis requiring or facilitating radical change does arise, alternatives will be available that have been carefully developed and fully explored.
We need to insure that single payer is in the mix, even if Senator Baucus is right and it is not going to happen now. We need to lay the groundwork for future change and establish a standard by which any incremental change should be measured. The most important lesson of my meeting with Senator Baucus was that the combination of action both inside and outside is far more effective in stimulating action and discussion than either approach alone. So we must not let up. We must push for a national single payer health program, marshalling the arguments, demonstrating the research that illustrates the superiority of this approach. We must demand a side-by-side comparison of the costs and benefits of a single payer approach with other proposed changes to our health care system. In the current environment we must insure that any "public option" which is established is one which shares enough features with a single payer plan that its success could provide a hint of what a true single payer plan might offer. A hobbled public option, set up to fail through adverse selection or an inability to take advantage of the administrative efficiencies of a public entity could lead to a worse outcome than no reform at all. On the other hand, a national program which encourages state and regional experimentation with variations on the theme of universal coverage that could include single payer programs, might lead to real change. And finding a way to incorporate single payer themes (a strict limitation on the varieties of health plan products, global hospital budgeting) into the system could lead to more substantial cost savings. cross-posted at The Daily Kos:
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Dr. Aaron Roland is a practicing family physician who years ago abandoned Yale Law School and a career in politics for a life on the front lines of primary care. Now, seasoned by years of work in a private practice of marked ethnic and economic (more...)
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