Editor's note: Flavio Casoy, interviewed here, is a medical student about to enter his residency with a mental health specialty. He has been a long-time activist for universal healthcare.
PA: One of the big buzz words that we are hearing is “the public option.” However, there seem to be a lot of different ways to define that. Could you begin by helping us understand what a public option means? What are some of its variations, and what do you see as the ideal public option?
FLAVIO CASOY: The reform proposal, that is the broader health care reform proposal that is being discussed, includes something called an insurance exchange, where individuals who are not covered by public programs such as Medicare or Medicaid or by the VA or the military, along with individuals who are not getting health insurance from their employers, will be able to go to sign up for an insurance plan. This has been experimented with in Massachusetts, where there are no so-called public options. In Massachusetts this insurance exchange is called The Connector. What resulted there is that people who are looking for an exchange plan often have not been able to find a plan that allows them to get the care they need without high co-pays and high deductibles. In the Massachusetts system, health care costs have continued to rise because there is no incentive for private plans to control costs.
Another form of public option would be a Medicare-like option that would be in the mix along with the private plans in this kind of exchange. There are many formulations of what this could look like. So what would happen? People would be able to purchase into this public plan, and the public plan would create pressure on the private plans to control costs and make sure that the benefit packages and quality of service that are provided are at par.
The ideal system, in my opinion, would be something that very much resembles Medicare. Medicare, as you know, is the insurance program for people who are 65 and over (it also covers a few other disabilities). In a Medicare-like public program, people would be able to buy into it, and it would be run through the Federal government. If there was ever a shortfall in the amount of money coming into the program via premiums, the Federal government would be able to pay in and help make sure that costs are controlled for users. The other thing about this style of program is that it is administratively very simple. The Medicare program has a much lower overhead cost than any of the private insurance programs. If we are talking about cost control, we want cost control to come from administrative savings and the elimination of excessive profits, not from a reduction in services or benefit packages for people.
Other possibilities for a public program, in ways which, I think, would make it worse, include having the program run through a third party. This public program would be outsourced to a private entity to run, similar to what happens with the Medicare Advantage programs. This is worse, because it brings in a different entity that is more inefficient than having it run by the government. Also, there is the possibility that the program would be forced to be entirely financially self-sustaining, and then all of the costs of the program would have to come out of the premiums that are charged to people. This is interesting in a way, but there is a risk that the program could be just as unaffordable as the private plans. And definitely, for people who are low income, we want subsidized plans.
The other possibility that is being discussed is having a public program similar to the Medicaid program but run by the states. This also creates inefficiencies and differences in quality. These three approaches were just put forward in a White Paper from the Senate Finance Committee as the three types of public programs that are being considered. Now, we also have to keep in mind that it is very possible we will have a health care reform proposal on the table that does not include a public program, and that in my opinion would be the worst of all possible worlds.
PA: Why, in your view, is the health care reform issue so significant this year?
CASOY: This an interesting point, because, of course, the health care reform fight is about winning health care reform that works for the American people and improves the situation for everyday workers. There is no question that we are in the middle of a health care meltdown, but there is another side to it as well, which is that the Republicans have chosen this issue to try to break the Obama presidency. The forces of the far right have definitely mobilized and are spending a lot of money to see that nothing in the health care agenda goes forward.
Why is this? The President ran on this issue, and the success or failure of this administration depends on its ability to pass a health care reform plan that the American public accepts. So even issues that are very non-controversial, such as assessing the effectiveness of medical treatments, are being fought tooth and nail by the far right. In fact, there is a new multimillion-dollar movement called Conservatives for Patient Rights that was started just to fight research on the effectiveness of medical treatments.
I really see the health care fight right now as sort of the opening shots of the midterm elections in 2010. If we are able to maintain the victories of last November and consolidate the defeat of the far right, it will be much easier to win further reforms in health care that will make health care even more accessible and more affordable for everyday workers. But it is also very important for all the other policy issues that we care about, such as the right for workers to organize, card-check neutrality, regulation of the financial system, funding for education, environmental reforms, and so on. This issue is the linchpin. If we are able to win a victory in health care, I think we will be able to consolidate the Obama presidency and win a lot more progressive reforms in Congress.
If we lose this, I think it will be much more difficult for us to win other policy reforms. As we have seen in the past, after the defeat of big health care fights, Republicans and the far right come back in strength. When we lost the health care fight in 1994, there was the Gingrich revolution which set the stage for years of a reactionary Congress that put us on the defensive. So this is not only a fight for health care reform. It is also an important political fight to make sure that we consolidate the victory over the far right.
PA: Could you talk a little bit about your personal experience with this issue, and why you have become involved so closely and speak so passionately about it?
CASOY: I am graduating from medical school this year, and I am about to start a residency in psychiatry. Physicians in training really are on the front lines of the collapse in the health care system. Most of us work in academic medical centers, county hospitals, or community clinics, where the people who are not able to access care, or the people who may have insurance, but not insurance that covers all the care they need, turn when they cannot get care. It doesn’t mean that these settings provide bad care. It is just that they tend to collect a lot of folks who cannot afford care, and not being able to access health care when you need it close to your home really creates a situation that is untenable for millions and millions of Americans.
I see my patients, who may have issues that are not that complicated to solve, but who continuously state they cannot get better, because maybe they cannot afford their prescription drugs, or they cannot afford this particular procedure that their insurance plan will not cover, or who go bankrupt because their insurance plan does not cover the full costs of their care. When I go to bed at night I see the dozens of faces of people who died or got sick, people who did not get better because of our broken health care system. These are people who could get better, but they don’t.
My chosen specialty is mental health, and the mental health of the population is most definitely interwoven with the social context in which they live. Since the beginning of the economic collapse, we have seen a lot of people develop new mental illness, new depression, new anxiety, and new addictions. This is because they are put under stress that they cannot cope with, and the lack of access to health care is contributive to this. So instead of getting care at the beginning of their illness, they try to cope with it on their own, are unable to, and come to get care when they are really disabled. This is troubling and saddening.
This is why providers, physicians and nurses need to be front and center in the fight for healthcare. This is the way to take care of our patients. One-on-one is important and will continue to be important for the care of our patients, but we need health care reform, and without health care reform it is hard to take care of the people we care for in the way they should be cared for, in a way that respects their dignity and respects their humanity.
PA: One obstacle to winning meaningful health care reform is problems with the unity among advocates for health care reform. How do we build bridges between different communities of health care advocates in order to preserve or strengthen unity and avoid the sharp kinds of divisions that deplete our resources?
CASOY: That is a good question. In the depths of the Bush years, when there was no real opening for health care reform, for change that would actually lead to significant improvements in people’s lives, I think that many of us took the position that we just had to put out a banner and promote what we thought was best. And that hasn’t changed. I think all of us agree that a health care system that includes everyone from birth to death, through a single public program that guarantees access to health care, is the best solution. But what we see now is a new political moment, where we can move toward this goal in a significant way, and we have to understand the political context in which we find ourselves.
We won an historic victory against the far right last November, and we can consolidate this. At this point in time, while we do have an opening to move toward a single-payer system, we don’t have the base to win an outright single-payer system. There are dozens and dozens of very passionate and very energetic single-payer activists out there, who are going great work in promoting the system that actually works. But there has to be a comprehension that even though we are not at the moment now to actually win this, we are at the moment to take a significant step towards it.
This means making the transition from thinking like we did during the depths of the rule of the far right to this new political moment. It takes time to understand that there has been a change. Now I do not want at all to attack the passionate single-payer supporters – they do great work – but I do think more and more people are coming to understand that victory on a public option, even though less ideal than single-payer, will keep the way open for us to win single-payer eventually. I do not think there is necessarily a point of contention between the two positions.
There are many strong single-payer supporters, who deeply involved in the progressive movement, a movement that is fighting not just for health care but for a lot of other issues as well. We have to maintain open lines of engagement. On the political front, we should work for a public option, but still, on the educational front, on the activist front, we need to keep telling people about the benefits of single-payer. There are ways to work on both simultaneously, and I think to have a single-payer supporters out there talking about single-payer is not necessarily counterproductive to winning the public option. However, we need to build mass support around a public option, if we want to win the most progressive option we can.
I just want to stress that there doesn’t have to be a fight among progressive activists. It is my hope that single-payer supporters and progressive, not exclusively single-payer supporters, can come to terms with this, and understand that there are different tactics, and that we all need to come to together around making sure that the far right defeat is consolidated, so we can keep the avenues to victory open.
PA: I wanted to go back to the issue of mental health. It is something that affects tens of millions of Americans, who have problems with depression and other disorders and who need drugs or counseling, but they cannot get their insurance to cover it. How important is including a serious discussion about mental health in health care reform in your view?
CASOY: It is critical. The insurance industry makes it very difficult to take care of patients who have serious mental illnesses, and not just patients with mental illness. Therapy and seeing a counselor or a psychiatrist can be a preventive measure as well. Everyone can develop a mental illness with enough pressure. I know that, for example, in terms of inpatient care for people who have severe depression or are bipolar, or have thought disorders like schizophrenia, it is hard to keep someone in a hospital for more than a few days, and that is not sufficient to make sure that the person is out of the crisis and that the medications are working. So it is very important to have a serious conversation about mental health within the health care reform fight. There was an initial first step towards improvement with the Mental Health Parity Act that passed earlier this year, which mandates that insurance companies cover mental illness in comparable ways to medical illnesses, but a lot more is needed, especially among the uninsured.
If we are talking about covering new people with health insurance, there are a lot of services that are needed by the most vulnerable people. For example, a significant portion of the homeless population are people with mental illnesses, and here we are not talking about folks with insurance. We need significant investment in the community mental health system, significant investment in social work services, and significant investment in community housing, so that people who are very vulnerable can access the care they need, and return to have fulfilling lives where they are productive in society. You know, most people with mental illnesses don’t die of mental illness; they die of medical illnesses, because they are so vulnerable, because they can’t access any services. And this is a big concern.
It is impossible to separate medical care or physical care from mental health care, because they are so closely intertwined. Someone who has a severe mental illness will also have medical problems like everyone else, diabetes, hypertension, and heart disease, and, vice versa, people with severe medical illnesses often need mental health care to cope with their medical illness, so it has to be in one package. And it’s not just medical and mental, we also have to talk about dental care in this same package. These three things are inextricably linked, and we need to make sure that every person has the services they need to stay healthy and productive and have a fulfilling life.
PA: Finally, as you probably noted, health insurance and other related industry leaders, were at the White House recently, and they talked to the President and made a special offer. “We are going to control costs voluntarily,” they said. What do you make of that offer – its potential consequences or opportunities?
CASOY: As the administration says, you now have the insurance industry, the hospital industry, the American Medical Association, and the pharmaceutical industry talking about how they are committed to controlling costs. This is interesting, because it seems that they are not going to try to block every reform proposal like they did in the past, but we have to be very cautious. The last thing they want is a reform proposal that controls costs by reducing their profits. They want costs to be controlled by reducing benefits or reducing eligibility for people, and we have to make sure that when we talk about health care reform, we win a reform that expands access and is more affordable for people. If we are going to control costs, that is going to have to come at a cost to these private for-profit interests.
I think it is interesting that they are trying to make public signs that they are committed to reform, but we have to be careful not to depend on their good will for full reform, because their first priority is that they are out there to make money. And the only way a lot of these insurance plans make money is by denying care, so we have to be very careful. We have to support the President’s initiative for cost control, but we can't trust these industries to the point where we abandon a public option, for example, or stop making demands on the insurance industry to lower the costs of care, or stop insisting on negotiating the price of prescription drugs with the pharmaceutical companies.
All of these things are critical, and we can't take it at face value that they will do these things on their own. They are saying this to protect themselves in the health care reform fight, so we have to make sure we get the necessary regulations that protect Americans in the long run, despite what they say about trying to cut costs on their own.
