Featuring Dr. Stephen Kemble, psychiatrist, board member of Physicians for a National Health Program and member of One Payer States, discussing healthcare reform in Hawaii and Vermont with host Brenda Gazzar.
This is part two of a two-part series.
Hawaii, Vermont & Single Payer: What went wrong?
—– TRANSCRIPT —–
Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar.
What attempts have been made in Hawaii to get universal health care? Is it more effective to go for a federal or state-based Medicare-for-All system? To find out, we spoke to Dr. Stephen Kemble, who has trained in both internal medicine and psychiatry. He serves on the board of Physicians for a National Health Program.
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Welcome to Code WACK!, Dr. Kemble!
Q: Tell us about your work with the Hawaii Health Authority. Why was it created?
Kemble: The intention of Hawaii Health Authority was to move eventually to a single-payer system but the way the law was written, which I think was very wise, is they set it up as an Authority that’s responsible to the people of Hawaii, and reports to the (state) legislature and the governor and the administration to try to find a pathway to get to universal health care that’s as cost effective as possible. And it doesn’t say you have to do it a certain way so it leaves it up to the Hawaii Health Authority to deal with the situation on the ground and come up with a best plan.
Our idea was to start with Medicaid, take it back from the managed care organizations, have the state assume control of Medicaid the way it used to be before 1994 so that we could design the foundation for a universal plan. Then you take state and county employees and retirees, and you include them because the state has control of that. Then you use insurance regulation to require commercials in the insurance market to offer the same thing. So you have the same care delivery system, the same network, the same fees, the same formulary, the same prior authorization policies. The same insurance product for all payers, which is called an all-payer system. That’s what they have in many European countries, in Japan and other countries. So they regulate them to require them to offer the same thing. That would get us very close to a single-payer system. It would be technically an all-payer system but that was the idea that the Hawaii Health Authority developed.
Q: Got it. So what happened with that?
Kemble: Well, what happened is that the Hawaii Health Authority was appointed in 2011, the law was passed in 2009. We then had a Republican governor. It was passed over her veto and she refused to implement it. So then we got a Democratic governor who did implement it. I was one of the original appointees, but at the same time Obamacare passed and the governor had been a friend of Obama’s parents when Obama was born.
And he wanted Hawaii to be the flagship in implementing Obamacare. And he didn’t have any money in his budget to do that with — so he went to the insurance companies for money and he took the budget that the legislature gave to the Hawaii Health Authority which is only $100,000. And he gave it all to this new commission that was run by the insurance companies to implement the Affordable Care Act and he threw us under the bus, and never listened to anything we said.
We met for two-and-a-half years, issued three reports to the governor and legislature on a roadmap for how to get from where we are to a universal cost-effective system. All of it was ignored and all but three members quit because it wasn’t going anywhere and we stopped meeting regularly. .The interest in the Hawaii Health Authority is revived as a result of Bernie Sanders and interest in single payer, and I’ve been working with the Democratic Party and we’re making a big push to get it reactivated and do what the law says it’s supposed to do and follow the game plan that we laid out a decade ago…The best way to manage risk is to spread it across as many people as possible, and the ultimate is single payer.
Q: Thank you. Tell us about your work with One Payer States, which is working to pass state-based Medicare for All plans, and how their approach differs from that of other advocates like Physicians for a National Health Program, which is working to pass a federal Medicare-for-All plan?
Kemble: One Payer States is an organization that started about maybe 10 or 12 years ago to push for single-payer legislation at the state level, and you can’t really do single-payer at the state level because a lot of the money comes from the federal government and that requires acts of Congress to change.
But like our all-payer idea with the Hawaii Health Authority, you can come pretty close if you have the right policy so that’s what we’re pushing for — as close as we can get to single payer at the state level. And of course in Canada, their single-payer programs started with Saskatchewan. They did it in one province. It worked well and then spread to the whole country, so maybe it will break that way in the U.S. Maybe it won’t but we should be pushing at the state level, at the national level both looking for wherever we can get a breakthrough.
Q: Aha. Can you describe some of the obstacles states have faced in trying to get to single-payer?
Kemble: Well, part of the problem is that many states want to do single payer but they end up doing something that really isn’t anywhere close to single payer. Vermont is a prime example of this. When they tried to do single payer they realized that they couldn’t get Medicare money because it was federal.
They also had IBM as one of their biggest employers and they’re a national corporation, and they have a national insurance plan that wouldn’t be part of the Vermont plan so there are too many big chunks that were missing. So they changed it to be a fill in the gaps plan and when you fill in the gaps you expand coverage which is nice, but you don’t achieve any administrative savings. All the complexity of the existing system is left in place, you’re actually adding a new layer of complexity in order to expand coverage but there’s no savings in it. So when they got to trying to budget it out it would have broken the state budget and they abandoned it, but it was never a single-payer proposal.
To get to single payer, you have to get rid of all the middlemen. You have to have the state or the federal government paying for care directly with no financial middlemen who are those risk-bearing insurance companies in between the source of the money and the providers of care.
Thank you, Dr. Kemble. Learn more about One Payer States at OnePayerStates.org and Physicians for a National Health Program at PNHP.org.
Find more Code WACK! episodes on ProgressiveVoices.com and on the PV App. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for health care reform around the country. I’m Brenda Gazzar.
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