HELENA, MT — At a town hall meeting last Thursday in Rio Rancho, N.M., the first question directed to President Barack Obama came from a woman in the audience who wanted to know why Democratic lawmakers in Washington, D.C. refuse to discuss the idea of single-payer health care.

"Why have they taken single-payer off the plate?" the woman asked to the applause of members of the crowd. "And why is Senator Baucus on the Finance Committee discussing health care when he has received so much money from the pharmaceutical companies? Isn’t it a conflict of interest?"

Those are questions single-payer advocates around the country are asking lawmakers this month as the powerful Senate Finance Committee, which Montana Sen. Max Baucus chairs, debates the future of national health care reform.

Single-payer health care — in which the federal government provides health insurance for all Americans and pays doctor, hospital and other health care bills, thereby replacing the private insurance industry — is off the table, Baucus said.

According to the group Consumer Watchdog, health insurers and pharmaceutical manufacturers alone contributed $5.5 million to the top 10 recipients in the U.S. Senate and House of Representatives during the last two election cycles. Baucus received more campaign contributions from the pharmaceutical and health insurance industries than any other sitting Democrat in the House or Senate, receiving $183,750 from health insurance companies and $229,020 from drug companies during that period.

"The lobbies of the for-profit industries for health care are enormously powerful. They want to keep single payer off of the table altogether," said Marcia Angell, former editor of the New England Journal of Medicine and a prominent single-payer advocate. "Even the president supported the single-payer system back when he was in the Illinois State Senate."

Angell said Obama dropped is support when he arrived in Washington, D.C. in 2004.

"Single-payer is simply considered not realistic for a politician. The medical industrial complex just won’t permit it," Angell said.

Baucus has been accused by Angell and other critics of stifling debate on single-payer at the behest of major political contributors in the health care industry, a charge he adamantly denies.

"Money means nothing to me. I pay no attention to campaign contributions. It makes no difference," Baucus said in an interview Friday. "I call the decisions—with respect to public policy on any subject, I don’t care what it is—as I see it. That’s the case now, that’s always been the case."

But single-payer advocates — some of whom where arrested recently after protesting their exclusion from a pair of Senate Finance Committee hearings — are convinced campaign contributions do influence Congress.

"I think in the end the public finds it very difficult to believe that an industry that contributes hundreds of thousands of dollars to a political campaign gets treated the same as the average constituent," said Carmen Balber, Consumer Watchdog’s Washington, D.C., director. "The reason we look at campaign contributions is because they tell us who has a legislator’s ear. There is no disputing that campaign contributions open the door to a politician’s office."

"Not feasible"

Those who support reforming health care while maintaining the role of private health insurance industry say the difficulties in passing any comprehensive improvements are vast. Opening a debate on a proposal to toss out the existing health care system in favor a government-financed health insurance program would only serve to quash any possibility of real reform, they say.

"Health care is one-sixth of our economy, so it is a complicated, difficult task," Obama responded to the questioner at Thursday’s town hall meeting. "[E]verybody is going to have to come at this with a practical perspective, as opposed to trying to be ideologically pure in getting it done."

Democrats, lead by Obama and Baucus, have made the passage of comprehensive health care reform a top priority of the 111Congress. Obama said he wants a bill on his desk by the end of the year. Throwing single-payer into the mix could make that a difficult goal to achieve.

"Members of Congress are focused on achieving comprehensive health care reform that covers every American, improves quality, and gets health care costs under control," said Robert Zirkelbach, spokesman for the group, America’s Health Insurance Plans, the industry’s chief lobbying group. "Right now everybody is focused on developing proposals that can work and that can get enacted. There seems to be a growing consensus on Capitol Hill that any health care reform legislation needs to be comprehensive, needs to bi-partisan, and needs to built on what’s working in the current health care system."

Obama made a similar point at Thursday’s town hall meeting.

"If I were starting a system from scratch, then I think that the idea of moving towards a single-payer system could very well make sense," Obama said. "We don’t want a huge disruption as we go into health care reform where suddenly we’re trying to completely reinvent one-sixth of the economy."

Avoiding the past

Democrats are in Congress are keenly aware of the disastrous outcome the last time they tried to reform health care and many don’t want to repeat the mistakes of the past.

In 1993 President Bill Clinton tapped first lady Hillary Clinton to head a task force to develop a comprehensive universal health care plan. After months of closed-door meetings the group emerged with a complex proposal containing more than 1,000 pages of reform measures. At the heart of the Clinton proposal was a mandate for employers to provide health insurance to all their employees, which would be delivered through regulated competition among large nonprofit health maintenance organizations.

The health care industry went on the offensive and spent millions on legislative campaigns and on the infamous "Harry and Louise" TV ads, which claimed that the Clinton plan would force Americans to "pick from a few health care plans designed by government bureaucrats." In the end the Clinton plan was scrapped, embarrassing Democrats in the process and relegating health care reform to the back burner for more than a decade.

Michael Lighty is president of the California Nurses Association, a group pushing single-payer health care. Lighty said the ghosts of the 1994 debate are still wandering the halls of the Capitol today.

"Hillary Clinton and President Clinton took single payer off the table much more dramatically than Baucus has, yet everyone draws the lesson that because of 1994 we can’t do single-payer," Lighty says. "They should draw a different lesson from the Clinton-era struggle. The lesson is we didn’t fix the problem. We didn’t offer a solution that works and so no one wanted it. That’s the risk they run this time going down the road they’re currently going. They won’t solve the problem, it’ll ruin their credibility even if it’s enacted, and that’s much greater risk."

A group called Conservatives for Patients’ Rights has already begun running ads on national cable TV warning of a government-run health care system. According to the Boston Globe, the group hired the same public relations firm that created the Swift Boat Veterans for Truth campaign that attacked Sen. John Kerry’s Vietnam War record during the 2004 presidential election.

Changing positions

In 2003, while campaigning for the U.S. Senate, then-candidate Obama told an audience at an AFL-CIO conference that he is a proponent of single-payer health care.

"I can see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent…of its gross national product on health care, cannot provide basic health insurance to everybody," Obama said.

Obama said he wanted to see single-payer be enacted, but that in order to do so Democrats would have to control Congress and the White House.

Three years later, in an interview with liberal political columnist, pundit and author David Sirota — a former chief political advisor for Gov. Brian Schweitzer — Sen. Obama backed off his support for single-payer. In a 2006 article in The Nation magazine, Obama told Sirota that although he "would not shy away from a debate about single-payer," right now he is "not convinced that it is the best way to achieve universal health care."

"His political preconditions have been met, he said he would never shy away from the debate, and that’s exactly what the administration via Max Baucus is doing," Sirota said.

Proposals:

"The Baucus Plan"

Baucus has taken a leading role in driving health care reform and last fall he outlined a road map for his health care proposal in a 98-page white paper entitled "A Call to Action." In it, Baucus advocates for national health care reform similar to the system in place in Massachusetts. The proposal calls for an individual mandate, whereby all Americans would be required to hold a health insurance policy or face a penalty. Those who are happy with their existing coverage could remain with their current insurance company. Those who don’t have insurance or aren’t happy with their coverage could join a nationwide insurance pool. Under Baucus’ proposal, insurers would not be allowed to discriminate based on pre-existing conditions.

"The public option"

Both Baucus and Obama have expressed support for a public insurance option that would compete with private insurance plans. The Senate Finance Committee is considering two public options, but Republicans and Democrats on the committee remain at philosophical odds over the idea of a public plan.

In one proposal, the public option would act similar to Medicare but would be expanded to include more people and would be administered by the Department of Health and Human Services.

Under the second proposal, a public option would be administered through multiple regional third-party administrators, and would report to HHS. They would establish networks of doctors and hospitals and negotiate payments.

"Single-payer"

H.R. 676, sponsored by Rep. John Conyers, D-Michigan, would create a publicly financed, privately delivered health care system by expanding the existing Medicare program to all Americans. Under the proposal, the single-payer would cover all necessary medical services, including primary care, inpatient care, outpatient care, emergency care, prescription drugs, durable medical equipment, long term care, mental health services, dentistry, eye care, chiropractic, and substance abuse treatment. Patients would retain their choice of doctors, providers, hospitals and clinics.

Owners of investor-owned insurance companies would be compensated through a 15-year government buyout.

The cost of the program would be funded in part by a progressive payroll tax, by increasing the income tax for the top 5 percent of income earners, and reductions in administrative costs of current health care plans.

S. 703, by Sen. Bernie Sanders, D-Vermont, is similar to its counterpart in the House. The major difference is that under the Senate version, the program would be administered by states in accordance with standards set by the Department of Health and Human Services.

Reach Tribune Capitol Bureau Chief John S. Adams at 442-9493, or [email protected]