Trojan Horse Legislation Could Derail Single-Payer in Massachusetts

A devious piece of legislation quietly introduced in Massachusetts on January 18 appears on its surface to usher forward the fight for single-payer health care in the state, but in reality, undermines the struggle by placing health industry lobbyists in charge of a study of single-payer’s implementation.

Here’s a scenario that is now possible: A constituent in the Third Middlesex State House district in Massachusetts calls his or her elected representative in the State Legislature and demands action on single-payer. On the phone, Rep. Kate Hogan (a Democrat) can truthfully tell the caller that she has done so. In fact, she can boast that she introduced a single-payer bill that would create a commission to study the policy. Likewise, her cosponsors can do the same if pressed on the issue by constituents or journalists. The constituent hangs up the phone, happy to know her representative is on top of the issue.

Here is the problem. The constituent may not be aware that the study Hogan introduced in the Massachusetts Legislature (HD. 3448), which establishes “a special commission to study the implementation of single-payer health care in the Commonwealth,” is quietly designed to derail the policy rather than study it impartially. It is Trojan horse legislation that gives tremendous power to the lobbies representing the very industries that profit off the multipayer system, enabling them to help craft the study.

The bill calls for a commission with “a representative of the Massachusetts Health and Hospital Association, a representative of Blue Cross Blue Shield of Massachusetts, a representative of the Massachusetts Association of Health Plans, a representative of Health Care for All; and two persons who shall be appointed by the governor.”

This tactic is not unique to Massachusetts. Comparable situations have occurred (or are occurring) in states such as Hawaii and New York. Advocates of health care justice nationwide will need to find effective ways to fight this death-by-task-force tactic — an example of the varied ways the health industry can influence prospects for bold health reform.

The local group Mass-Care, which supports single-payer in Massachusetts, released a statement lamenting the makeup of the committee to Truthout:

The commission proposed in HD3448 appears to be dramatically biased against single-payer. Several members are direct or indirect appointees of the Governor … [and it] includes representatives of two powerful corporate lobbies representing the private insurance industry…. Six members of the commission would be appointees of the leadership of the House and Senate, including the co-chairs of the Health Care Financing Committee. This is the committee that has prevented the advance of Medicare for All bills for many years…. Why is there no place at the table for those representing direct care providers, low-income folks, people with chronic illnesses or disability, senior citizens? Why is there a representative for employers but not for working people? Why are there no representatives of organizations that advocate for single-payer?

Massachusetts Republican Gov. Charlie Baker comes straight out of the health sector; he was CEO of Pilgrim Health Care for years. The Massachusetts Health and Hospital Association is the main lobby for the state’s hospital industry. Their home page shows Gov. Baker attending one of their events:

Blue Cross Blue Shield is that state’s largest insurance provider while the Massachusetts Association of Health Plans is the primary lobby for private insurers. These groups’ opposition to single-payer health care is very well known. Even the lone health access advocacy group listed, Health Care for All Massachusetts, has strong financial ties to the industry, especially from Blue Cross. It is best known for its advocacy of the individual mandate/exchange method it helped pass in 2006 (RomneyCare) — the very basis of the Affordable Care Act. It has never supported single-payer health care. In fact, it is arguably the health access advocacy group most identified with market solutions such as the individual mandate.

“The bill is designed to give Democrats cover, to give an appearance of supporting single-payer without actually doing so,” said Gerald Friedman, an economist at the University of Massachusetts, in an interview with Truthout. “Indeed, it is worse than a delaying tactic because the makeup of the commission ensures that it will reach conclusions hostile to single-payer. The bill is a direct threat to the single-payer movement.”

Truthout reached out to Rep. Hogan several times for comment. She did not respond. Neither did several other legislators listed as co-sponsors. A representative of the Massachusetts Hospital and Health Association told Truthout the group is “looking into the legislation.”

Adding to the confusion is that Hogan’s bill was released right around the same time as organizers were rallying for other single-payer bills that were introduced with the cooperation and support of local single-payer groups. The introduction of statewide single-payer legislation (S.D.2062) is always a big deal for organizers, who use the opportunity to rally for co-sponsors and public support. In recent years, local single-payer advocates have also supported a study of single-payer in very different legislation. Sen. Julian Cyr and Rep. Jennifer Benson originally introduced “An Act to Ensure Effective Health Care Cost Control” in the last session. A similar bill (SD.2172) has been filed this year as well. This is a unique approach that would require the state’s nonpartisan Health Policy Commission, “an independent state agency” mandated to “monitor and improve the performance of the health care system,” to measure the impact that single-payer would have on costs and delivery of care in Massachusetts.

Under this study, the health policy commission would establish benchmarks, and if they prove more effective than the current system over a three-year period, they would be mandated to act further, the bill says.

“This bill would allow us to give proof as to the differences between what we spend now, and what we would spend under single-payer,” said State House Rep. Jennifer Benson, the bill’s sponsor, in an interview with Truthout in 2017. “Finland has [the] same population and they are quite capable of managing on their own. Why can’t [Massachusetts] do it?”

What is especially odd, however, is that several co-sponsors to Hogan’s bill are strong single-payer supporters, including Cyr and Benson. This legislation would seem to contrast with their views on the issue. But as of press time, none of these sponsors had clarified if their support was genuine or a mix-up, as some advocates have speculated behind the scenes.

“It barely needs to be said, but allowing health insurers to investigate their own replacement is the ultimate case of foxes guarding the henhouse,” said Benjamin Day, executive director of Healthcare-NOW!, in an interview with Truthout. “Health insurers should not even have a say over our access to care, since they make more money the less care they cover, and they have no place in developing an ethical health care system.”

Cuomo’s Commission on Universal Access Undermines New York Health Act

Advocates in New York were less timid in their response to Gov. Andrew Cuomo’s proposed Commission on Universal Health Care, which he announced in his budget. Assemblyman Richard Gottfried, the chair of the health committee and a long-time sponsor of the New York Health Act — which would implement single-payer across the state — was pointed in his attack on Governor Cuomo and his refusal to take his bill seriously.

“This commission gimmick is just an attempt to take the New York Health Act off the table and kick the can down the road. The RAND Corporation and other consulting organizations have done professional studies of the New York Health Act,” he told Truthout. “They almost all report that single-payer would give everyone better coverage, do it more effectively than any alternative, and save billions.”

Physicians for a National Health Program’s NYC-Metro chapter, also responded negatively to Cuomo’s approach.

“The New York Health Act would accomplish the Governor’s goal of providing universal affordable health care access. Yet, instead of highlighting this plan that can realize his goal, he has chosen to form a commission to study ‘options.’ Indeed, the first option on his list to be considered is ‘strengthening New York’s commercial insurance market,’ the very structure that is responsible for the exorbitant costs of our broken health care system,” the group said in a statement. It urged legislators not to support the commission but to move forward on the existing plan for single-payer.

The state’s single-payer movement saw its prospects improve once the New York State Senate was taken over by pro-single-payer Democrats in the 2018 midterms. For many years, this legislation died in the more conservative Senate. A RAND study found the bill would be viable, cover everyone and save money. Yet, in more than 300 pages in the budget Cuomo only had a few hundred uninspired words on expanding “access” to health care:

“We certainly don’t want a ‘study’ commission made up of insurance industry representatives,” Gottfried said.

A group of business and health interests who oppose the New York Health Act, called Realities of Single-Payer, applauded Cuomo’s proposal.

“Convening a Commission for Universal Access to Health Care to identify policy options to improve access to care and strengthen New York’s commercial insurance market is a pragmatic and progressive approach to attaining universal coverage,” the group said.

“An Utterly Dishonest Process”

Stephen Kemble of Hawaii is an adviser and board member for Physicians for a National Health Plan and a prominent researcher and advocate in Hawaii. He told Truthout about his own troubling experiences dealing with the politics of health care task forces in his home state, dating back to 2009, before the passage of the Affordable Care Act.

Hawaii passed a law in 2009 to create the Hawaii Health Authority, intended to set overall health policy and design a universal health care system, Kemble told Truthout. Kemble was appointed as a member of this committee when it was finally staffed under Gov. Neil Abercrombie in 2011.

“I will say it was an utterly dishonest process,” Kemble said in an interview. “Suggestions from the physicians and other direct care providers on these committees asking for relief from the practical obstructions to care being encountered on the front lines were systematically ignored … [and] we got entirely insurance company-centered reforms with no administrative relief or cost savings at all.”

This dysfunctional system was further complicated when Hawaii tried to implement the Affordable Care Act changes around the same time, with the Health Transformation Initiative.

“When Obamacare passed, [Governor] Abercrombie wanted Hawaii to be a flagship state in implementing it, since he had known Obama’s parents from before he was born, and he considered himself to be close to Obama. He had no money in his budget for a new Health Transformation Initiative, so he went to the insurance companies and big hospitals for funding, and also took the $100,000 budgeted for the Hawaii Health Authority and gave it to his Transformation initiative,” Kemble said.

The result, he said, was “higher overhead cost; a steadily worsening physician shortage; a demoralized, burned-out physician work force; declining access to care for patients; increasing reliance on urgent care centers and ERs for primary care; and continued rise in health insurance premiums and Medicaid-managed care payments of 5-10 percent a year or more. Obviously, this ain’t working.”

More recent efforts in Hawaii have also been plagued by similar issues. In 2018, there was a debate over HB1896, which proposed a task force to analyze ways to increase access to health care, including single-payer. While the bill did not become law, the testimony submitted to the State Legislature is telling.

Dennis B. Miller, an advocate for single-payer, said he opposed the law only because it has a “flawed premise that the individuals, agencies, and insurance companies who are responsible for the administrative component of our current healthcare costs are the same people who can lower those costs. This flies in the face of reason,” he testified in 2018. “To lower the cost of healthcare, this task force must hire outside the circle of those people, agencies, and insurance companies who created a system with runaway cost increases.”

Meanwhile Kaiser Permanente, a massive provider with billions in revenue, suggested that the “committee consider adding a representative from the Hawaii Association of Health Plans as a member of the Health Care Access Task Force.”

This, much like the Massachusetts bill, would give industry stakeholders with tremendous capital and power the ability to dictate the public’s perception of single-payer (with a de facto endorsement from the state legislature).

The Weaponization of Health Care Studies

Studies are an essential part of the single-payer movement. We rely on them to demonstrate the inequities and inefficiencies of the status quo health care system, to help deal with potential complications and to assess how the policy would impact health access in a specific state. Sometimes they are a vital part of the process of advocating for statewide single-payer, especially since the economics of single-payer do yield considerable savings, largely from eliminating administrative waste and increasing consumer bargaining power over prescription drugs.

As momentum for single-payer develops in states across the U.S., however, it is important for the public to understand how commissions and studies can become weaponized. Not all studies and commissions are designed to help. If single-payer is to get a fair hearing, it is important that powerful industry stakeholders are not the ones calling the shots. The emphasis needs to be on patients and the public good — not profits for powerful interests and campaign donors.

“Studies are great — we can always do more studies,” Adam Gaffney, president of Physicians for a National Health Program, told Truthout. “But I think we are past the time for more studies. It is time to act.”