Single-payer: Dembrow presents a road forward

T.A. Barnhart

Single-payer didn’t do much in the 2011 Oregon Legislature: a noon rally on the Capitol steps followed by a hearing in the afternoon, and then HB 3510 was shelved for the session. No one expected anything different, not even sponsors. After all, the Leg’s real business with health care that year was to set up the exchange that would be the first in the nation under Obamacare. Single-payer got a courtesy hearing and no more.

2013 is a different story. Not because anyone expect the Leg to pass single-payer, not even it’s #1 champion, Rep Michael Dembrow. But while 2011 was one-and-done, 2013 is going to be one-and-just-begun.

The difference is HB 3260. More on that in a bit.

Single-payer in 2013 is offered in HB 2922, the Affordable Health Care for All Oregon Act. I spoke with Rep Dembrow about it; once again, he’s the chief sponsor of that bill, with 23 co-sponsors (up from 11 two years ago). What, I asked, does HB 2922 do?

HB 2922 lays out the Affordable Health Care for All Oregon Act, which is our vision at this point for what Single Payer would look like in Oregon. It gives the picture, writ large, of what a single-payer program would look like with an Affordable Health Care for All Oregon Board, the kinds of procedures that it would cover, how would money interact with the health care transformation in terms of delivery.

HB 2922 lists the elements of a universal health care system in Oregon, including eligibility criteria (single-payer is not tied to employment, or even residency: having a job in Oregon makes people eligible). HB 2922 also establishes an oversight board and directs the Oregon Health Authority to provide staff support for the board. The Board’s responsibilites and powers are detailed in the bill, but, as noted above, Dembrow is under no illusions that it will pass. He expects it to receive a hearing in late April or May, in both the House and Senate if possible. But the bill will go no further.

That does not mean progress on moving to a single-payer system in Oregon comes to a halt like it did two years ago. This time, supporters have HB 3260 which, Dembrow believes, is on-track to pass this session. In discussing HB 2922, Dembrow told me:

It’s still is lacking specifity in some areas, most notably funding. That’s something we’re leaving up to the study bill to nail down.

The study bill is HB 3260, and it was drafted so that single-payer will move forward in tangible, meaningful ways between legislative sessions. HB 3260 commissions a study of various methods to finance delivery of health care in Oregon. The bill sets out a list of criteria against which to compare various options; the four options put forward in the bill are:

1. Single-payer
2. Public option competing with private plans
3. Cover Oregon (the exchange; what will be the status quo beginning in 2014)
4. Any other plan or plans the study group determines meets the bill’s criteria.

In looking at different financing options, the bill’s sponsors are “hoping this study will come up with the best options for Oregon”. The study’s results would not only present the details of financing the different options, but it would “lay out the basic principles of what universal health care would look like in Oregon”.

In short, says Dembrow, given the goals established in HB 2922 (pdfs of both bills are attached below), what is the best funding model that would assure those are met? Dembrow has confidence in what the study will find, but he’s not locked into his position at this point:

I feel pretty confident that single-payer will come out as being the most effective and the most affordable for Oregon, but if the people doing the study recommend another plan or come up with some kind of hybrid, assuming that the methodology is right and the analysis is right, then I’m willing to accept that as we revamp the current 2922 in a subsequent session.

In discussing why there is no real push for single-payer at this point, apart from the reality of the politics, Dembrow explained: Under the Affordable Care Act, states are pre-empted from enacting a single-payer system prior to 2017 (including Vermont, which can apply for a waiver but is unlikely to receive one). While he described this provision of the law as “discouraging”, he does understand why it’s in place: to give the ACA time to be implemented fully and to allow the exchanges to accomplish their goals of providing universal care while attempting to bring down costs and premiums.

Further, Dembrow sees a silver lining to being forced into holding off another four years before a single-payer system can be brought on-line in Oregon. Because Oregon has the kind of “vigorous” initiative system that Vermont does not, a single-payer plan will end up before the voters, one way or another. In order to present a system that voters will be confident enough to support, backers will have to show Oregon voters that they have

…a model that can work and that the funding makes sense. People won’t vote for it if they think it means they’re going to spend a lot more on health care than they currently are.

Dembrow asserted that a generalized study done by a research center in Washington, DC, gives an early indication that single-payer can provide full coverage at the same cost being spent on health currently (including premiums, government costs, co-pays, etc). HB 3260 will examine not only costs of health care in Oregon but review studies done by other states, like Vermont, in order to present as full and clear a picture of possible of how Oregon should proceed with funding health care after the first few years of the exchange.

Dembrow believes that the study proposed by HB 3260 will open the door to single-payer in Oregon as it did in Vermont:

We have to keep our eye on the ultimate vision of where we need to be.The ACA is a cobbled-together system, which is not a system. If our goal is to come up with something that is going to be easy for people, that is going to be affordable for people, that will cover everyone, then we need a system that is truly system. That is comprehensive.

For Vermont, it was their study that really moved things forward for them. We’re following in their footsteps to a large extent. … Both in looking at their initial push, one which looks at health care as a human right, and making that the center of their campaign, and then accompanying that with their study that showed a path to actualize that human right; I think we’re doing the right thing by following their footsteps.

By the time the 2015 Legislature convenes, of course, not only will the study under HB 3260 be completed, the state will have a year of running the exchange under its belt. Single-payer supporters will be in a much stronger position to advocate for that further change — if the assumptions of Dembrow and other single-payer advocates pan out.

In the meantime, Dembrow said that if Oregonians want to see single-payer become the way we pay for health care (and as Liz Baxter, who is head of Cover Oregon, the health care exchange, continuously reminds people: single-payer is not health care; single-payer is a way to pay for health care), they have to get involved in the organizing and educating activities headed up by Health Care for All Oregonians and other groups. And one of the most important things that backers of single-payer need to do is get accurate information about Cover Oregon – the exchange – to Oregonians.

We have to do everything we can to make people aware of the exchange, get people signed up for the exchange. Make them aware of the big expansion of Medicaid. … My big fear, a lot of people’s big fear, is that over the next few months we’re going to see an on-going effort by the insurance companies to jack up their rates to build up their reserves based on the argument that now that they have to cover everyone, you can’t exclude anyone, their costs will go up dramatically. And so they have to build up their cushion. The impact of that on ordinary Oregonians is going to be really tough.

Not only does he expect the insurance companies to wage a struggle to increase rates, he worries that a failure to keep rates down will cause an over-reaction, not only to Obamacare but the entire concept of universal health care. The health care debate, he thinks, has resulted in one widely shared consensus, that Americans support and want Medicare. Michael Dembrow believes that the push for single-payer is an extention of the support for Medicare — Medicare For All.

Finally:

Once people see how [the Medicare-for-all] model works, once they see that framework, they become very excited. Then they ask the question, what can I do to make this move forward?

And the answer to that, he says, is simple: “Become part of the movement. Spread the word.”

Here are the two bills as currently available on the Leg's website

HB 2922, Single-payer

HB 3260, Health care financing study

The House Health Care Committee (Rep Greenlick, Chair; Rep Keny-Guyer & Rep Thompson, Co-chairs) will hold a hearing on HB 3260 this Friday, April 5, at 1pm in Hearing Room E. The hearing will be streamed on the Leg's website.

By T.A. Barnhart April 03, 2013