My Wellstone Notes

By Sara

Back in 1990, one of the reasons Paul Wellstone got elected was because he stood firmly on Single Payer Health Care. He got belittled by Hillary both during the 1992 Campaign, and then when she put together her monster proposal which as we remember went no-where. Paul went along with the little proposals that followed on, but he didn't give up on the universal model...what he did was try to take lessons from the failure and put those in his pocket so as to understand any revival of possibilities.

Now he is gone -- and Josh Marshall seems to be trying to revive things by putting forward essays from various perspectives. So I will take advantage of The Next Hurrah to cite my notes on Wellstone's critique as I understood it of what was first proposed in 93-94, and what might work.

When elected in 1990, Paul had no idea how strong the anti-Universal lobby really was. He quickly found out. In a residual way it included labor which at that time still was able to guarentee members benefits, and thus a reason to remain in the fold, but he also did not understand the power of the insurance industry that creams off at least 20% of the medical care budget as profit for investors, nor did he understand how Indian Tribes would fight Universal -- because they thought it would abdicate their treaties that promised medical care till the sun refused to set, or however they worded it. As he put it -- Nitch protection was the game. Of course that left lots of folk out of the Nitches, including many who thought they had one.

So he started sketching out how the next effort might work, and that is what I want to outline here. Clearly this is a point of departure for debate -- Paul isn't around anymore to lead this thing.

Paul came to think the critical line was between the finance of supply which included medical research, education, making the menu of necessary services -- all of which he thought should be funded federally and administered more or less federally, and actual provision of services to people -- and he came to believe that should be the province of State Government, but not directly. He thought each state should have something like a Health Board of Regents much as a Public University is elected by a Legislature for longish terms, with designations as to who and what should be represented on such a board -- but that a health board of regents should "own" the delivery system. The Hospitals, the Clinics, and the ability to establish contracts for services with all providers. He believed that one could do a transition from "private sector" to state owned sector much easier if the whole thing became state politics rather than Federal Politics. He thought many "for profit" entities would bid on state contracts -- and gradually migrate to understanding that the service could not be done on a huge profit margin, and that industry would adapt. States would gradually abolish for-profit entities in favor of non-profit structures. (Minnesota for instance still does not permit any for profit Hospital or Clinic in the state. Yea, I know, Mayo Clinic -- but it remains non-profit.) Paul thought State Health Regents would have the ability and the power to essentially determine what resources needed to be in what communities, and gradually construct for themselves the ability to set job descriptions, set resource allowcations, and then contract for these with a high degree of specificity. In fact Paul hoped that groups of Medical Specialists would hire themselves business managers who would negotiate in their interests, but negotiate with the State Regents who would be obligated to provide Universal care by Federal determination.

Paul had another concern -- the failure of States to expand Medical Education to meet projected needs. He discovered that the US expected third world countries to provide about 20% of the MD Personnel necessary for the US, and considerably more of the technical and nursing personnel. He believed states needed to be required to educate the necessary personnel -- but that the Feds needed to do the 40 or 50 year projections as to how many. Bioscience education is expensive, and many states import third worlders as opposed to paying the costs of educating their own. (And why should the US recruit AIDS specialist Nurses trained in South Africa??? -- come on, answer that one.) You mean we can't afford to train our own?

Paul recognized that virtually all who go to the Masters or PHD level in science have full tuition grants plus stipends for expenses, -- with one great exception, Medical Students are expected to take out loans against future income for education. This reinforces the fee-for-service system of medicine. To change that, Paul thought all Medical Ed ought to be on Contract -- free, but with an obligation to serve over a long time period where needed and as needed. Integrated with State Regents who define where services are needed, this would gradually move providers to the places where services are required. But Paul believed we were under training by a factor of 30% depending on third world to train for us and supply to us -- and that pissed him off. In the end he thought each state ought to be responsible for training personnel to meet something plus of their population's needs. Essentially he thought the major costs or education and training ought to be born by the feds -- but shared with states that had adequate slots.

Essentially Paul thought that State Legislatures ought to be very politically sensitive to problems with delivery of services. They are more able to be voted out if they fail. He didn 't think it should be direct -- thus the Regent's idea, but close. But he though by pushing the commercial providers out into a universe where essentially one was looking for not for profit providers, the existant industry would adapt.

Paul also recognized that states comprehended services differently. In Minnesota he was looking at local hospitals that were converting from general practice to treating drug and booze problems, because that was what paid -- but local health needs didn't pay. He believed that a state Regent would be able to properly structure such. Any system, in his estimation ought to be able to design a local comprehensive program.

From what I see that Josh Marshall is going to publish -- and I am glad that he is putting it forward -- I don't think anyone is putting forward the notion of incorporating the states into the plans at the core of it. Paul thought that the secret to getting to there was vesting the states with much of the game. He thought that was what made 93-95 fail. essentially he thought that trying to accomodate all the DC lobby and defined "players" was the kiss of death. Putting it at the state level in terms of what services you want delivered and how -- that would get to the right sized solution.

Was he Right or Wrong in his argument and observations as of the late 90's? My sense is that if we study the issue, we don't need 20 candidate plans at all. What we need is a citizen's concept of what is necessary, and then a response. I think Paul moved from ideology to pragmatic ideas, and it is sad he just left pieces of it, and we have to fill in and argue the rest.