“SINGLE PAYER, MEET ALL PAYER: THE SURPRISING STATE THAT IS QUIETLY REVOLUTIONIZING HEALTH CARE” by David Dayen

Ben Jealous, former president and CEO of the NAACP, announces his bid to be the Democratic party’s nominee to challenge Republican Gov. Larry Hogan on May 31, 2017, in West Baltimore.

July 24 2017 (theintercept.com)

ONE UNHERALDED REASON for Trumpcare’s many difficulties was a sea change in public opinion. A new Associated Press poll finds that 62 percent now agree the federal government has a responsibility to provide health coverage to all Americans, up from 52 percent in March. Republicans looking to take away coverage ran headlong into this wave of support for a bigger governmental role in health care.

“Once you get something for pre-existing conditions, etc., etc. — once you get something, it’s awfully tough to take it away,” President Trump concluded.

Indeed, when Kansas Republican Jerry Moran issued the statement that effectively killed the bill’s hopes, his opposition was described in the press as having come from a conservative direction. And while it was cloaked in right-wing rhetoric around choice, the politics of the statement leaned decidedly left. “We must now start fresh with an open legislative process to develop innovative solutions that provide greater personal choice, protections for pre-existing conditions, increased access and lower overall costs for Kansans,” said Moran, fully aware that protections for pre-existing conditions, couples with lower overall costs, require a robust government intervention in health care.

Capitalizing on the new politics, progressive groups have distributed a “People’s Platform” that includes a Medicare-for-All single-payer system. And in state capitols, activists have demanded single payer, hoping a demonstration project proving the concept will catch fire, the way a universal system in Saskatchewan in the 1940s migrated to the rest of Canada.

The movement has won some incremental victories, but has yet to get over the top. Vermont passed the framework legislatively and then abandoned it. Colorado’s quiet effort was crushed at the ballot box. California has spent 25 years trying to pass something without success, and this year’s effort is stalled. A Medicaid buy-in bill in Nevada this year drew a veto from its Republican governor. New York’s odd conservative control of the Senate seems to foreclose a solution there in the near term.

There is one state, however, where a combination of fewer institutional barriers and existing health care structures could make health-care-for-all an achievable reality: Maryland.

It will take a grassroots groundswell and electoral victories, especially in next year’s governor’s race. One prominent gubernatorial candidate, former NAACP president Ben Jealous, has ardently endorsed single payer. “We have the opportunity in this state to make sure that we don’t have any more neighbors burying loved ones because they didn’t have access to health care,” Jealous said at an event where Sen. Bernie Sanders endorsed him for governor.

If elected, Jealous would face fewer procedural obstacles than those that have dogged California in its long battle to establish a single-payer system. While Maryland, like California, has robust Democratic supermajorities in the legislature, there is no two-thirds requirement to raise taxes, and no budgeting straitjacket mandating certain percentages of state spending to education or other priorities.

And while states do need federal waivers to incorporate programs like Medicare into a state-run program, Maryland is the only state to already hold a Medicare waiver. It enables a unique system known as all-payer rate setting, which serves as the basis for universal health care in several industrialized nations. In other words, while other states would have to begin from scratch to overhaul their health care systems, Maryland has a head start.

MARYLAND IS THE only state in America where all hospitals must charge the same rate for services to patients, regardless of what insurance they carry. There’s some variance between hospitals, but every patient in a particular hospital pays the same. Other states experience huge, seemingly random differences in hospital costs, depending on the insurer (or lack thereof).

Maryland’s Health Services Cost Review Commission has set hospital reimbursement rates for over 40 years. The state obtained a federal waiver to include Medicaid and Medicare in its all-payer system, with the goal of keeping cost increases below Medicare growth. And it’s worked, creating the lowest rate of growth in hospital costs in America.

In 2014, to prevent hospitals from making up profit margins through volume, Maryland tweaked the system, adding global budgeting. “The traditional way it worked, every hospital got a rate card,” said Joshua Sharfstein, an associate dean at Johns Hopkins’s Bloomberg School of Public Health, and a former head of Maryland’s Health Department. “Now you get a number, which is the total revenue for the year.”

Because the global budget doesn’t change based on the number of admissions, this creates hospital incentives toward better outcomes. “It makes the health system focused on keeping people healthy rather than just treating illnesses,” said Vincent DeMarco, president of the Maryland Citizen’s Health Initiative, a state advocacy group. That includes increased preventive treatment, using case managers to connect patients to primary care, eliminating unnecessary tests, and encouraging good health outside the hospital walls.

Three years into global budgeting, the state is “meeting or exceeding” its goals, according to a January Health Affairs study. Hospital revenue growth is well below counterparts nationwide, or the growth of Maryland’s economy. Plus, state hospitals have saved $429 million for Medicare, more in three years than it targeted for five. Most important, every state hospital (all of which are nonprofit) and every insurer in Maryland are on board with the system.

If a centralized rate-setter bands every insurer together to negotiate prices, all payer can functionally act like single payer in terms of bringing down costs. All payer reduces hospital and insurer overhead, since billing costs are known in advance. And because the Affordable Care Act caps the amountsinsurers can take in as profits, lower hospital costs should flow back to the individual in the form of smaller premiums.

This is why five countries — France, Germany, Japan, Switzerland, and The Netherlands — use all-payer rate setting as the basis for their universal health care systems. These countries have been found to control costs far better than America’s fragmented system.

The system only applies to hospital payments, not primary care doctors or clinicians. However, last year Maryland submitted a “progression plan” to the Center for Medicare and Medicaid Services, with the goal of expanding the system by January 2019. That would line up with the swearing in of Maryland’s next governor.

Other states have looked to Maryland as a model. Pennsylvania has adopted global budgeting for rural hospitals. And in the wake of its single-payer failure, Vermont moved to an all-payer accountable care organization, where providers are paid based on health outcomes for the population. “In some ways it’s more radical [than single payer] if you’re able to get the incentives right,” said Joshua Sharfstein. But the true test of Maryland-style all payer is whether it can support universal coverage for every resident.

MARYLAND HAS A DISCOURAGING history with single payer. Health Care is a Human Right Maryland, an affiliate of Physicians for a National Health Program, did push a bill for several years in the state legislature. “In 2012, we had the bill in the House of Delegates, we lined up what we thought were enough votes in committee,” said Dr. Eric Naumberg, a member of the group’s leadership council. “But the leadership said you can’t bring this to the floor, and then we had seven votes instead of 12.”

Naumberg’s group has since focused on rallying support at the national level. “There are a lot of roadblocks set up for state single payer,” he said, including waivers necessary to incorporate Medicare and Medicaid and potential challenges under federal law regarding employer-based coverage.

Indeed, local politicians aren’t getting pushed yet. “I am not hearing a groundswell of support for a single-payer system or radically re-doing what we currently do,” said Shelly Hettleman, a member of the House of Delegates from Baltimore. “My constituents want to fix the system rather than totally reinvent it.”

However, with Maryland’s novel all-payer structure, you could potentially reinvent health care outcomes by merely tweaking the system. For example, expanding all payer across the health care system, along with tight regulation of insurers to keep premiums low, could mimic some benefits of single payer. Even Vincent DeMarco, who flat-out rejected the notion of state-level single payer, agreed. “If we can do that, we can achieve the same goals in a way that’s doable,” DeMarco said.

Maryland has a relatively low number of uninsured, about 6.7 percent of the population as of 2015. With a cost control mechanism already in place, getting them covered could prove cheaper and easier than other states. “I think you can combine alternative payment approaches with single payer, but you don’t hear about that much,” said Joshua Sharfstein.

Dan Morhaim, a House of Delegates member and an emergency room physician, suggested that the state could offer a benefit package he likened to tiers of coverage in education. “There’s public school, and if you are well-off you pay more to get tutored or go to private school. And you try to bring up that floor broadly and consistently.”

It would obviously still be a huge lift. Entrenched interests still see their survival attached to the status quo. While all hospitals in Maryland are not-for-profit (which is no guarantee against profit-taking), insurers, drug companies, and doctors not currently under price regulation can be expected to put up a fight. And with state balanced budget requirements, you would have to finance a state-run health plan, opening up the tax wars even though individual out-of-pocket costs could drop.

Two things work in Maryland’s favor. First, there’s the renewed support for single payer generally, particularly among progressive activists. Morhaim said that a recent op-ed he wrote for the Baltimore Sun about de-linking health insurance from employment got a wider response than he’s ever seen. “My email box flooded,” Morhaim said.

Second, there’s the promise of the Ben Jealous campaign. He can be expected to put single payer at the top of his agenda for the next year, to a public growing more open to the idea. And Jealous is not a novice at getting the seemingly unattainable done in Maryland politics, mounting lobbying campaigns that helped legalize same-sex marriage, abolish the death penalty, and pass a state version of the DREAM Act. “We are not here simply to elect me governor,” Jealous said at a recent speech. “You do not elect politicians to make change happen, you elect politicians to make it a little easier for a movement to make change happen.”

Jealous’ boldness has already moved Democratic primary opponents in his direction, of which there could be as many as seven. Alec Ross, a Hillary Clinton adviser during the 2016 campaign, who has a controversial plan to have investors loan working mothers money for child care, says he supports a state-based public option. Liberal State Sen. Rich Madaleno endorsed a public option as well, and has said he would “treat health care as a human right.”

Madaleno’s website rejects the idea that states can manage a single-payer plan alone. “One of the cornerstones of single-payer is that the government can negotiate and enforce prices. States can’t do that, only the national government,” it reads. But Maryland actually does precisely this kind of negotiation for hospitals, and could expand it.

Jealous’s nomination, followed up by the defeat of incumbent Republican Larry Hogan in November, would at least put single payer on the agenda in a state with a lot of relative advantages to getting it done. He would have a lot of policy support, with a deep well of knowledge in leadership roles at nonprofit hospitals, as well as from the many members of the part-time legislature who work in the health care system when not in session.

Would Maryland politicians be willing to fight for single payer? “I think the political system would be willing to take that on if the person who argued for it won the election,” Morhaim said. “It’s up to the voters.”

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CONTACT THE AUTHOR:

David Dayendavid.dayen@​gmail.com@ddayen

“SF Supervisor Peskin ramps up drive to rename Justin Herman Plaza [aka Chelsea Manning Plaza]” by J.K. Dineen

July 27, 2017 (sfgate.com)

For decades, Justin Herman Plaza has been a place where protesters gather to march up Market Street, an open space for skateboarders to grind and BMX riders to do flips, the site of mass pillow fights on Valentine’s Day and where Cal football fans rally before the Big Game against Stanford.

Now the plaza is subject of something less physical — its very name.

This week, Supervisor Aaron Peskin introduced a resolution recommending that the Recreation and Park Department strip mid-century redevelopment czar Justin Herman’s name from the plaza, temporarily renaming it Embarcadero Plaza while city policy makers come up with a new moniker.

Herman, who died of a heart attack in 1971, was a driving force behind the redevelopment that displaced thousands of residents — mainly African Americans and Japanese Americans — from 60 city blocks of the Western Addition and Fillmore district in the 1960s. His policies also moved mostly poor people from parts of Chinatown and South of Market.

Peskin said that Herman, who presided over the San Francisco Redevelopment Agency from 1959 to 1971, “personified a dark chapter in modern San Francisco history.”

“This is a public admission that the city made mistakes” in its urban renewal policies of the 1950s and 1960s, Peskin said. “This is a cathartic and important first step in a two-step process.”

While the renaming seems to have broad political support — all 10 of Peskin’s colleagues co-sponsored the ordinance at Tuesday’s board meeting — the effort will inevitably prompt a re-examination not just of Herman’s role in the city history, but also a debate over whose name the space should bear.

“When you name a street or a monument or a park after a person, you are making a statement about what the community values,” said Rachel Brahinsky, a professor of urban studies at the University of San Francisco who has studied Herman’s legacy. “It’s a way of deciding which side of history the city wants to uphold.”

Even before Peskin’s resolution there were campaigns to rename the space after another person. One group wants to call it Maya Angelou Memorial Plaza, after the late poet who spent her formative years in San Francisco and was the city’s first African American street car conductor.

A competing faction wants it to be called David Johnson Plaza, after the 90-year-old African American photographer and community activist known for his black-and-white photographs that captured the Fillmore district before parts of it were bulldozed.

Ironically, one public official who will play a role in the renaming process worked as a special assistant to Herman in the late 1960s. Recreation and Park Commission President Mark Buell did stints in Herman’s office in 1966 and ’67 and again in 1970, after returning from the Vietnam War.

Buell would support renaming the plaza, even though he says Herman was a complicated leader who did a lot of good for the city. He said that removal of thousands of families and destruction of Victorian buildings in the Western Addition was wrong, even if many of the units were dilapidated and owned by predatory slumlords.

“I would be the first to say it was a flawed approach,” Buell said. “The flaw was the cultural disruption of the community, that part of the fabric of the city.”

He said that Herman was “a product of his time.” The urban renewal program Herman oversaw — similar to what Robert Moses carried out in New York — was driven by federal government programs offering two-thirds of the funding to rebuild “deteriorating communities.” That enticement led to the destruction and rebuilding of big chunks of many cities.

Buell also cited Herman’s positive accomplishments: He was ahead of his time in hiring a diverse workforce. He personally paid for Bayview leader Eloise Westbrook to go to Washington, D.C., to lobby for increased funds for public housing in a San Francisco that — even in the 1960s — was far too expensive for many people. He also battled hotel owners over the Yerba Buena redevelopment and pushed for integrated affordable housing in Diamond Heights.

Buell also said Herman wasn’t operating in isolation — he carried out his duties under three mayors, who had ideas of their own.

“There is a lot of blame to go around,” Buell said.

San Francisco resident Julie Mastrine, a performance artist who has spent a lot of time at Justin Herman Plaza, has gathered more than 11,000 signatures to rename the plaza. At first she said that she thought Angelou would be an appropriate namesake but became more of a Johnson partisan after learning more about the photographer.

Either way, she wants it changed. “It upset me that this place I enjoy so much is named after someone I don’t think should be honored in this way,” she said.

Meanwhile, Johnson’s wife, writer Jacqueline Sue, put together a package of information about her husband and has been lobbying members of the Board of Supervisors. Johnson, who was originally from Jacksonville, Fla., turns 91 next Thursday. He came to San Francisco after serving in the Navy to study with Ansel Adams and in 1971 sued the San Francisco school district over desegregation enforcement.

He said he gets a kick from the idea the plaza might one day bear his name.

“I think it’s a splendid idea,” Johnson said. “If it’s going to happen, it’s good that it’s happening now. Not next year or five years from now.

“I never met Mr. Herman,” Johnson said. “But I met a lot of the results of his work. Many of my friends lived in those fantastic, beautiful Victorians in the Fillmore. That entire area got wiped out.”

David Glassberg, a University of Massachusetts history professor, said naming public spaces after individuals “calls attention to places and keeps the memory alive of people who otherwise might be forgotten.”

At the same time, he said, there is a logic to naming parks or plaza after “something that makes it easier to find.”

“Embarcadero Plaza is not a bad name,” he said.

J.K. Dineen is a San Francisco Chronicle staff writer. Email: JDineen@sfchronicle.com Twitter: @sfjkdineen

“This Plan is Your Plan, This Plan is My Plan” (with a tip o’ the hat to Woodie Guthrie)

This plan is your plan / This plan is my plan

From Mendocino / To Escondido

Healthcare for all is / All we’re asking

This plan was made / For you and me.

 

Oh, single payer / It is a great plan

It covers health care / Throughout our life span

The status quo? Whoa! / It’s gotta go!  So…

This plan was made for you and me.

 

Billions we’ll save on /Administration

We’ll lower costs through / Negotiation

With what we save we’ll / Treat every patient

This plan was made / For you and me.

 

Our politicians / Often resists change

‘Cause contributions/ They like to a-rrange

They dine with corporate chums / And then throw us the crumbs

This plan was made for you and me.

 

We’ve got the money / Don’t doubt it honey

But so much flows to / Insurance companies

We’re gonna pool our wealth / Invest it in our health

This plan was made / For you and me.

 

It covers dental / It covers vision

For all our children/ And men and women

No need for co-pays / Farewell deductibles!

This plan was made/ For you and me.

 

It’s all-inclusive / It’s universal

It really isn’t / So controversial

Now we pay more for less / We’re tired of this mess!

This plan was made / For you and me!

 

Lyrics:  Health Care for All – Marin

Matier & Ross: Brown buddy Phil Tagami on list of would-be Oakland cop watchdogs

Phil Tagami at the site of a development at the Oakland Army Base in Oakland, California, on Wednesday, Sept. 23, 2015. Photo: Connor Radnovich, The Chronicle

Photo: Connor Radnovich, The Chronicle.  Phil Tagami at the site of a development at the Oakland Army Base in Oakland, California, on Wednesday, Sept. 23, 2015.

July 24, 2017 (sfchronicle.com)

In all, 153 candidates have applied to join Oakland’s new seven-member Police Commission overseeing officer misconduct investigations — including some very familiar names on both sides of the issue.

Those looking to serve on what is likely to be a high-profile panel include:

•Downtown developer and Jerry Brown buddy “Shotgun” Phil Tagami, who tells us that “after a three-year break from public service, I want to help where I can.”

During the 2011 Occupy riots [emphasis added], the onetime Port Commission member made national news for guarding his Rotunda building with a shotgun. More recently he’s been in the headlines for suing Mayor Libby Schaaf and the city over Oakland’s ban on coal going through the $250 million shipping complex he is building near the port.

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