Colin Powell pitches single-payer health care in U.S.

Former Secretary of State Colin Powell has waded into the health care debate with a broad endorsement of the kind of universal health plan found in Europe, Canada and South Korea.

�I am not an expert in health care, or Obamacare, or the Affordable Care Act, or however you choose to describe it, but I do know this: I have benefited from that kind of universal health care in my 55 years of public life,� Powell said, according to the Puget Sound Business Journal, last week at an annual �survivors celebration breakfast� in Seattle for those who, like Powell, have battled prostate cancer. �And I don�t see why we can�t do what Europe is doing, what Canada is doing, what Korea is doing, what all these other places are doing.�

Europe, Canada and Korea all have a �single-payer� system, in which the government pays for the costs of health care.

Some Democrats who strongly advocated for, and failed to get, a single-payer system in the 2010 Affordable Care Act, still believe the current law doesn�t go far enough to reform the US health system.

A retired four-star general and former chairman of the Joint Chiefs of Staff, Powell told the audience about a woman named Anne, who as his firewood supplier, faced a healthcare scare of her own. Anne asked Powell to help pay for her healthcare bills, as her insurance didn�t cover an MRI she needed as a prerequisite to being treated for a growth in her brain. In addition, Powell�s wife Alma recently suffered from three aneurysms and an artery blockage. �After these two events, of Alma and Anne, I�ve been thinking, why is it like this?� said Powell.

�We are a wealthy enough country with the capacity to make sure that every one of our fellow citizens has access to quality health care,� Powell. �(Let�s show) the rest of the world what our democratic system is all about and how we take care of all of our citizens.�

Powell, who has taken heat from Republicans for twice endorsing President Obama�s election and reelection bids, said he hopes universal healthcare can one day become a reality in the U.S. �I think universal health care is one of the things we should really be focused on, and I hope that will happen,� said Powell. �Whether it�s Obamacare, or son of Obamacare, I don�t care. As long as we get it done.�

Single Payer Is Getting a Second Life as Obamacare Frustration Peaks

From the Daily Beast –

Could anger at the Obamacare rollout make Americans more receptive to a kind of Medicare-for-all system? That�s what activists are hoping�and they�re plotting a state-by-state fight.

As the rollout of Obamacare clunks forward, activists who opposed the law from the beginning say it is time to seize the moment, to tear down the current health-care edifice and start anew, especially now as frustration with the law�s implementation is reaching a peak.

These are not Tea Party activists but advocates for a single-payer health-care system who say some of the problems with the launch of the Affordable Care Act�in addition to built-in problems with the law itself�have made the American public more receptive than ever to a Medicare-for-all kind of coverage system.

On Monday, Sen. Bernie Sanders (I-VT) introduced the American Health Security Act, which would require each state to set up a single-payer health-care system and would undo the exchanges that have plagued Obamacare. Meanwhile, various state-led efforts are under way that advocates hope will sweep the country statehouse by statehouse, as soon as lawmakers see the advantage of a single-payer system. In Vermont, for example, lawmakers have set aside the financing and are already preparing to adopt a single-payer system when the federal government permits it, which according to provisions of the Affordable Care Act will be in 2015. In Massachusetts, Don Berwick, a former top Obama administration health official, is basing his campaign for governor on bringing a single-payer system to the commonwealth. And advocates in New York, Maryland, Oregon, and around the country say they see new energy around their cause.

�As the president fully understands, the rollout has been a disaster, the website has been a disaster,� said Sanders in an interview moments after his bill was introduced in the Senate. �But the truth is, even if all of those problems were corrected tomorrow and if the Affordable Care Act did all that it was supposed to do, it would be only a modest step forward to dealing with the dysfunction of the American health-care system. When you have a lot of complications, it is an opportunity for insurance companies and drug companies and medical equipment suppliers to make billions and billions of profits rather than to see our money go into health care and making people well.�

Democrats conceded that Republican efforts to sabotage Obamacare with endless lawsuits and by declining to set up state-run exchanges have damaged the law�s popularity, but they say the confusion will lead the public inevitably to conclude that a simple single-payer system, one that avoids malfunctioning websites and complicated gold/silver/bronze options, is preferable. Advocates pointed enthusiastically to a tweet last month from John Podesta, the former Clinton White House chief of staff who is joining President Obama to help with health care��Just applied online for Medicare. Took 5 minutes. Single payer anyone?��calling it proof that wild-eyed radicals are not the only ones supporting single payer. The notion is gradually becoming more mainstream among the Democratic establishment, advocates said.

�I think the thing that is most interesting about government is that populism gets its biggest support not from Democrats but from what Republicans do,� said former Pennsylvania governor Ed Rendell, who stressed that he did not count himself among the populist members of the Democratic Party. �They torpedo the Affordable Care Act, and I believe we will now have single payer in this country within the next 15 years.�

Opponents to single payer certainly have reasons to believe the momentum is on their side. Further meddling with the American health-care system, after not just the botched rollout of the Affordable Care Act but also the grueling five-year fight to get there, seems unlikely. But proponents of single payer pointed to polls that show a majority of Americans want some version of Medicare for all. It is up to Democratic pols to show leadership on the issue and risk defying the powerful health-care industry, advocates said.

�It is not possible to put together a good program unless you antagonize the powers that be,� said Dr. David Himmelstein, one of the leaders of Physicians for a National Health Program. The White House, he added, �largely played an inside-the-Beltway game in passing Obamacare. They refused to rally the American people for something truly radical which every poll shows that the American people really want.�

Sanders joked that he expected to have his bill passed by chambers of Congress and ready for President Obama�s signature by the time he returns from Nelson Mandela�s funeral in South Africa, but few proponents see much hope of gaining traction for single-payer health care in a Congress that has struggled to pass a routine budget.

Instead they are turning to a legislature-by-legislature fight in statehouses across the country. Advocates in New York and California said they were counting on labor unions� opposition to the Affordable Care Act�some labor leaders have feared that their members may pay higher premiums under the law and have pushed for exemptions. In Vermont, a single-payer bill passed in 2011, and Dr. Deb Richter, the president of Vermont Health Care for All, said that if anything, the passage of Obamcare slowed the group�s work there.

�We had all the momentum going on the single-payer side, and it was really slowed by the Affordable Care Act,� she said. A state measure similar to Obamacare faltered, she added, because it lacked the appropriate enforcement mechanisms. Now, with the law set to take effect in 2015, advocates are working to calm fears among Vermonters who have been scared off by talk of �socialized medicine.�

�We have all of the right ingredients, but there is a lot of room for mischief. You can confuse people, freak them about rationing and all of that stuff,� said Richter. She said she thought Obamacare�s failure to deal with the spiraling cost of health care would lead more and more people to see the logic of single payer.

�I think that eventually most states will recognize this,� she said. �We keep talking about how the health-care system is unsustainable. We haven�t reached that point yet, but when health care starts eating up 25 percent of GDP and you have hospitals failing, they will look for guaranteed financing, and the only way you get there is through a single-payer system. It is not a matter of if but of when.�

Single Payer Is Getting a Second Life as Obamacare Frustration Peaks

From the Daily Beast –

Could anger at the Obamacare rollout make Americans more receptive to a kind of Medicare-for-all system? That�s what activists are hoping�and they�re plotting a state-by-state fight.

As the rollout of Obamacare clunks forward, activists who opposed the law from the beginning say it is time to seize the moment, to tear down the current health-care edifice and start anew, especially now as frustration with the law�s implementation is reaching a peak.

These are not Tea Party activists but advocates for a single-payer health-care system who say some of the problems with the launch of the Affordable Care Act�in addition to built-in problems with the law itself�have made the American public more receptive than ever to a Medicare-for-all kind of coverage system.

On Monday, Sen. Bernie Sanders (I-VT) introduced the American Health Security Act, which would require each state to set up a single-payer health-care system and would undo the exchanges that have plagued Obamacare. Meanwhile, various state-led efforts are under way that advocates hope will sweep the country statehouse by statehouse, as soon as lawmakers see the advantage of a single-payer system. In Vermont, for example, lawmakers have set aside the financing and are already preparing to adopt a single-payer system when the federal government permits it, which according to provisions of the Affordable Care Act will be in 2015. In Massachusetts, Don Berwick, a former top Obama administration health official, is basing his campaign for governor on bringing a single-payer system to the commonwealth. And advocates in New York, Maryland, Oregon, and around the country say they see new energy around their cause.

�As the president fully understands, the rollout has been a disaster, the website has been a disaster,� said Sanders in an interview moments after his bill was introduced in the Senate. �But the truth is, even if all of those problems were corrected tomorrow and if the Affordable Care Act did all that it was supposed to do, it would be only a modest step forward to dealing with the dysfunction of the American health-care system. When you have a lot of complications, it is an opportunity for insurance companies and drug companies and medical equipment suppliers to make billions and billions of profits rather than to see our money go into health care and making people well.�

Democrats conceded that Republican efforts to sabotage Obamacare with endless lawsuits and by declining to set up state-run exchanges have damaged the law�s popularity, but they say the confusion will lead the public inevitably to conclude that a simple single-payer system, one that avoids malfunctioning websites and complicated gold/silver/bronze options, is preferable. Advocates pointed enthusiastically to a tweet last month from John Podesta, the former Clinton White House chief of staff who is joining President Obama to help with health care��Just applied online for Medicare. Took 5 minutes. Single payer anyone?��calling it proof that wild-eyed radicals are not the only ones supporting single payer. The notion is gradually becoming more mainstream among the Democratic establishment, advocates said.

�I think the thing that is most interesting about government is that populism gets its biggest support not from Democrats but from what Republicans do,� said former Pennsylvania governor Ed Rendell, who stressed that he did not count himself among the populist members of the Democratic Party. �They torpedo the Affordable Care Act, and I believe we will now have single payer in this country within the next 15 years.�

Opponents to single payer certainly have reasons to believe the momentum is on their side. Further meddling with the American health-care system, after not just the botched rollout of the Affordable Care Act but also the grueling five-year fight to get there, seems unlikely. But proponents of single payer pointed to polls that show a majority of Americans want some version of Medicare for all. It is up to Democratic pols to show leadership on the issue and risk defying the powerful health-care industry, advocates said.

�It is not possible to put together a good program unless you antagonize the powers that be,� said Dr. David Himmelstein, one of the leaders of Physicians for a National Health Program. The White House, he added, �largely played an inside-the-Beltway game in passing Obamacare. They refused to rally the American people for something truly radical which every poll shows that the American people really want.�

Sanders joked that he expected to have his bill passed by chambers of Congress and ready for President Obama�s signature by the time he returns from Nelson Mandela�s funeral in South Africa, but few proponents see much hope of gaining traction for single-payer health care in a Congress that has struggled to pass a routine budget.

Instead they are turning to a legislature-by-legislature fight in statehouses across the country. Advocates in New York and California said they were counting on labor unions� opposition to the Affordable Care Act�some labor leaders have feared that their members may pay higher premiums under the law and have pushed for exemptions. In Vermont, a single-payer bill passed in 2011, and Dr. Deb Richter, the president of Vermont Health Care for All, said that if anything, the passage of Obamcare slowed the group�s work there.

�We had all the momentum going on the single-payer side, and it was really slowed by the Affordable Care Act,� she said. A state measure similar to Obamacare faltered, she added, because it lacked the appropriate enforcement mechanisms. Now, with the law set to take effect in 2015, advocates are working to calm fears among Vermonters who have been scared off by talk of �socialized medicine.�

�We have all of the right ingredients, but there is a lot of room for mischief. You can confuse people, freak them about rationing and all of that stuff,� said Richter. She said she thought Obamacare�s failure to deal with the spiraling cost of health care would lead more and more people to see the logic of single payer.

�I think that eventually most states will recognize this,� she said. �We keep talking about how the health-care system is unsustainable. We haven�t reached that point yet, but when health care starts eating up 25 percent of GDP and you have hospitals failing, they will look for guaranteed financing, and the only way you get there is through a single-payer system. It is not a matter of if but of when.�

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Medical Journal Goes To The Dogs

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An Outsider on the Inside

Though battling terminal illness, Tim Carpenter is still busy moving Congress left.

Tim Carpenter is the national director of Progressive Democrats of America (PDA). Founded in 2004 in the aftermath of Rep. Dennis Kucinich�s (D-Ohio) presidential run, the group works what it calls an �inside-outside� strategy�aimed at translating the activism of outside social movements into progressive legislation in Congress. PDA works closely with progressive advocacy groups and about a dozen activist members of the Congressional Progressive Caucus, aiming to push the 72-member voting block to take more aggressive stances on issues as diverse as the welfare state, healthcare, trade and foreign policy. This year, PDA has lobbied Congress and helped organize rallies against reductions in Social Security and pushed for a so-called Robin Hood tax on financial transactions.

A native of Southern California, Carpenter is a longtime activist with history in the grassroots campaigns against anti-nuclear power, the Catholic Worker movement and Democratic Socialists of America. When he is not on the road organizing, he lives with his family in western Massachusetts.

Do progressives in Congress have anything to learn from the Tea Party?

Progressives can learn a lot from the Tea Party in regards to the inside-outside strategy of holding elected officials accountable. The Congressional Progressive Caucus took a number of missteps and miscues leading up to the Affordable Care Act. We should never have abandoned the fight on single payer. We should have never opted for a public option. We divided our forces much too early. What we can learn from the Tea Baggers is to hold elected officials accountable and not give up�certainly not before we�re deep into a fight.

You have been working with the Progressive Caucus since the founding of PDA in 2004. How effective is the caucus?

The Progressive Caucus has been a landing point for progressive activists who are working inside the Democratic Party. If you�re working an inside-outside strategy, you have to have a base to come home to, and the Progressive Caucus has offered us that. In reality, of those 72 members, only about 10 are what we would call leaders within the Progressive Caucus. Our work as Progressive Democrats of America is to strengthen those who are leading. To have a place where we as progressives can come together and work is important. Over the course of the last year or two under the leadership of Rep. Keith Ellison (D-Minn.) and Rau�l Grijalva (D-Ariz.), we�ve seen the more progressive wing of the caucus hold the line, particularly in regard to making sure that no missiles were tossed into Damascus.

Some critics of the Progressive Caucus suggest that it would be more effective to have a smaller, more aggressive caucus. What do you think?

I agree. I would rather be in a meeting with 10 people who want to make a difference, get out and lead than be in a room with 60 people who call themselves progressives. I would rather surround myself with those who are willing to roll up their sleeves and go out and risk defeat. An aggressive, focused, principled caucus that held the line on single payer would have served our movement much better through this fight over the Affordable Care Act.

Steve Cobble, a co-founder of PDA, makes this analogy of the horseshoe, saying there are issues in Congress where you can link the left of the Progressive Caucus with some Tea Party, libertarian-minded Republicans. Is that an effective strategy?

We have political opportunities in this Congress, whether it�s the horseshoe analogy or in bed with strange bedfellows�whatever you want to term it. There are libertarians and Tea Baggers out there who agree with us that it�s unconscionable to spend the resources we do on the military budget. And we find agreement on not going into Syria. So if you can find the votes and if you can put together a majority to prevent our president from taking us into an unnecessary, illegal war, you�re going to take those votes wherever you can get them.

What kind of small victories are achievable in this political landscape?

I�m a glass-half-full person, so it�s not that difficult for me to find those little victories, beginning with the food stamp program. We began that fight when the Democratic Party leadership was absolutely silent. We had a phone call with Rep. Jim McGovern (D-Mass.) when PDA activists were delivering letters every month to their members of Congress in defense of food stamps. McGovern told us the Democratic Party leadership was silent on this question and that it was important that we simply have a vote of conscience to save the food stamp program. By the time it went on to the floor, we thought we had 133 votes but ended up with 188 votes [out of a possible 218 needed to win]. That was a victory. A vote of conscience in which 188 folks stood up to save food stamps. At the same time as we were garnering those votes, we were doing street actions in front of the offices of the Democratic leadership, Chief Deputy Minority Whip Debbie Wasserman Schultz (Fla.), Minority Whip Rep. Ste- ny Hoyer (Md.) and Minority Leader Nancy Pelosi (Calif.). By the time the Farm Bill came back around again then for a vote, all of those members in the leadership were on the floor voting to kill that bill.

An example of a major victory would be Syria. Again, our Democratic leadership was silent. Our president was willing to risk another war. And again activists around the country, led by Rep. Barbara Lee (D-Calif.), pushed Congress not to use military force but to begin a course of diplomacy.

What do you say to the critics on the Left who would claim that the PDA mission is ultimately hopeless, that the Democratic Party is not going to be reformed, and that if you really want to build progressive political power, it necessarily has to take place outside of that framework?

We live in a two-party system. Until we change the political realities of our two-party system, whether it be until we can get real public financing or until we can get real proportional representation, the playing field will be skewed. Before we have a third party, we need a strong second party. We�re the insurgency inside the Democratic Party fighting to return it to its progressive roots. We are hopeful that, through the work we do, we can begin to engage on the inside with those who are now on the outside and encourage them to do what they can to level the playing field.

A lot of PDA folks were part of Dennis Kucinich�s 2004 campaign for president. How important do you think it is in 2016 to have a progressive presidential candidate?

That�s a big debate. We need to be realistic. We are not going to elect a progressive president in 2016, just as we weren�t going to elect a progressive president in 2004, though Kucinich certainly didn�t want to hear it at the time. But if we�re going to transform the Democratic Party it�s important that we put in place a vision of what the Democratic Party can look like under a progressive presidency. So for that reason alone we need to have a horse in the race in 2016 who will challenge Hillary Clinton, the presumptive nominee. We need to re- mind folks that Hillary was wrong on the war in Iraq and she was wrong on trade. There are a lot of issues that as progressive Democrats we would want to challenge her on.

The Democratic Party, at its roots, is a progressive party. So my hope is that we would have a candidate who will be the standard-bearer for the progressive Democrats. I see the tide turning. It�s imperative that the progressive movement run a strong, articulate progressive candidate and campaign in 2016.

Given that you are waging an uphill battle against cancer, have you been preparing for what�s going to happen with PDA?

You�re definitely putting the elephant in the room in talking about the fact that I�ve got a terminal illness. It�s a question we�re wrestling with. The short answer is we honestly don�t know. We�re not a card-carrying organization; we�re a community of people. We�re going to meet in February as a community and we�ll talk about it. The work�s going to continue and I hope to be as productive, or even more productive, as we move on to the 2014 election season.

A New Worry Looms Online For The Affordable Care Act

Listen to the Story

Weekend Edition Saturday

3 min 16 sec Playlist Download Transcript   Enlarge image i

Insurance companies say they are finding numerous mistakes on a digital form that's essential for signing up through HealthCare.gov.

AP

Insurance companies say they are finding numerous mistakes on a digital form that's essential for signing up through HealthCare.gov.

AP

Saturday is the day the Obama administration promised it would have HealthCare.gov working smoothly for the majority of people who need to sign up for health insurance.

As the Obama administration scrambles to fix the glitch-plagued site, experts are beginning to worry about another problem that may further impair the rollout of the Affordable Care Act.

Health insurance companies say they're seeing numerous errors in a form that plays a vital part in the enrollment process. The problems are manageable so far, but many worry about what will happen if enrollment surges in the weeks to come.

The 834

It's safe to say that the vast majority of consumers have never heard of an 834 EDI transmission form, despite its crucial role in the process of signing up for health insurance. It's a kind of digital resume that tells an insurance company's computer everything it needs to know about an applicant, says Bob Laszewski, a health policy consultant.

"It contains all of the person's enrollment information, all the information that [an] insurance company needs to get this person entered as a policy holder," Laszewski says.

The 834 has been around for a long time. The architects of the Affordable Care Act intended for it to play a central role in the sign-up process, says Tim Jost, a professor of law at Washington and Lee University.

"The 834 information is information the insurers have to have to get people enrolled in coverage, which of course is the point of going through the marketplace," Jost says.

Multiple Mistakes Make Insurers' Jobs Harder

But health insurance companies say the 834s they are receiving from applicants on the federal and state exchanges have sometimes been riddled with errors, Laszewski says.

"Duplicate enrollments, people enrolling and unenrolling, inaccurate data about who's a child and who's a spouse, files just not being readable," he says.

Highmark Blue Cross Blue Shield of West Virginia has been steadily processing new customers ever since the launch of Obamacare this fall. But Highmark President Fred Earley says mistakes in the 834s are making the job harder.

"We've had some situations where the records don't track, or we've seen duplicates," Earley says. "We've had situations where we'll get a record to show that someone canceled coverage when we've never had a record to show they enrolled in the first place."

Earley says his firm has been dealing with the problems by calling up state and federal officials and correcting the mistakes. The exact cause of the problems is unclear. The Obama administration has been slowly making fixes, and officials say they're making progress. But Laszewski says the fixes are not fast enough.

"The error rates have been falling," he says. "HealthCare.gov has been making progress, but we're not to the point yet where people can trust that high-volume enrollment can occur and we won't have serious customer service problems."

Laszewski says the test will come over the next few weeks. People who want coverage to begin on Jan. 1 have until just before Christmas to sign up, and there's likely to be a surge of new applicants in the weeks to come.

"What happens if we start getting hundreds of thousands or millions of people signing up by the Dec. 23 deadline, and the insurance industry is receiving hundreds or thousands of these a day?" he says. "That's what everyone's worried about."

Share Facebook Twitter Google+ Email Comment More From Health Care Health CareWhite House Optimistic At Deadline To Fix ObamacareHealth Care3 Stories From HealthCare.gov UsersHealth CareHow Will We Know If HealthCare.gov Is Fixed?Health CareA New Worry Looms Online For The Affordable Care Act

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Small Businesses Get One-Year Delay In Health Insurance Process

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The Single-Payer Alternative

Rush Limbaugh�s take on the disastrous rollout of the Affordable Care Act could, ironically, warm the hearts of those at the other end of the political spectrum. He contends that President Obama knew all along that the Affordable Care Act would crash and burn, but pushed it through so that the conflagration would clear the way for single-payer health insurance.

The conspiracy charge sounds deranged, but problems with the new health insurance system may indeed revitalize demands for more substantive reforms, which many policy makers and voters set aside in the putative interests of political pragmatism. Whatever the advantages of a single-payer system such as that currently administered by Medicare, one view held, American voters were unlikely to get behind it.

Yet one of the greatest advantages of a single-payer system � its relatively low administrative costs � has been thrown into sharp relief by problems registering with the new health exchanges. Andwhile Republicans despise the Affordable Care Act despite its conformity with many of their earlier proposals, their proposed changes (other than simple rollback) look complicated, kludgy and costly to administer.

The malfunctioning website has magnified problems inherent in coordinating enrollment across many different companies in many different exchanges in cooperation with many different government agencies. The harmonization challenges are orders of magnitude greater than those faced by a single company or a single state, making streamlining difficult. Improved software can do only so much.

In theory, competition and choice should increase efficiency. In practice, health insurance companies are able to take advantage of the complexity and uncertainty surrounding health care choices to make comparison shopping very difficult.

Lack of clear information about the prices of medical procedures, combined with a proliferation of insurance options whose potential benefits will be strongly affected by unpredictable events (such as being involved in an automobile accident or developing cancer), put consumers in a weak position.

The process of negotiating relationships with new health care providers because old ones are �out of network� is physically and emotionally exhausting. Insurance companies benefit from promoting policies that are difficult to understand and make consumers fearful of any change in their coverage. That fear and aversion has spilled over into the transactions required for many people to benefit from the Affordable Care Act.

David Himmelstein and Steffie Woolhandler, co-founders of Physicians for a National Health Program, regularly assert that elimination of the huge paperwork and overhead imposed by private insurance companies could save enough to cover the estimated 31 million of Americans who will remain uninsured under the Affordable Care Act.

My fellow Economix blogger Uwe E. Reinhardt, expanding on this theme, notes that the Institute of Medicine of the National Academy of Sciences recently estimated excess administrative costs of $191 billion, again more than enough to attain truly universal health care coverage.

Most such estimates are limited to the monetary costs incurred by insurers, doctors and hospitals and don�t include the value of the time that health care consumers must devote to managing a torrent of inscrutable paperwork that can become truly frightening for the critically ill.

Even if its rollout becomes more expeditious, the Affordable Care Act does little to reduce the incentives that companies have to barricade themselves behind high information and transaction costs. In the financial sector, I previously noted, this perverse incentive is described as �strategic price complexity.�

A complicated new program applied to a complicated old industry makes it hard for everyone to figure out exactly what they will be getting relative to what they are paying. As a result, many ordinary people and small businesses fall prey to redistributional paranoia.

Accusations of ripoffs proliferate, along with assertions that the Affordable Care Act is unfair to young people or that it simply represents transfers from the affluent to the poor, or from whites to people of color.

The program clearly has redistributive impact, but much of it will be muted over the life cycle. People who pay more for their insurance will get more benefits in return. The biggest transfers will go from the healthy to the sick (who are sometimes poor precisely because they are sick) and from one part of the health care system (emergency room care) to another (insurance-covered routine care).

But the structure of the program seems unintentionally designed to intensify distributional conflict. Its highly means-tested subsidies create strong political resentments and contribute to very high implicit marginal tax rates on lower-income families.

A single-payer insurance system, whether based on an extension of Medicare or on the Canadian model, promises many profoundly important benefits. Right off the mark, it promises simplicity.

No wonder conservative pundits are afraid of it.

Mass. Gov. hopeful: Consider “single payer” care

From the AP –

Democratic candidate for governor Donald Berwick is pushing Massachusetts to take a second look at creating a truly universal health care system.

The former top Obama administration health care official said Thursday that the state should “seriously explore the possibility of a single payer system in Massachusetts” – a system which would effectively guarantee health coverage for all residents.

Massachusetts currently has the highest percentage of insured residents, but the system relies on a patchwork of private and subsidized care and falls short of universal coverage.

Many liberal Democrats have long said the best way to fix the health care system is to essentially offer Medicare to everyone, arguing that it would provide more coverage and is less cumbersome.

Berwick formerly headed the federal Centers for Medicare and Medicaid Services.

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When Caregivers Are Abusers: Calif. Complaints Go Unanswered

Listen to the Story

Weekend Edition Saturday

6 min 2 sec Playlist Download Transcript   Enlarge image i

Jim Fossum holds a photograph of his aunt, Elsie Fossum, who died from injuries her caregiver said were the result of a fall.

Mina Kim/KQED

Jim Fossum holds a photograph of his aunt, Elsie Fossum, who died from injuries her caregiver said were the result of a fall.

Mina Kim/KQED

Nurse assistants and home health aides provide intimate care, bathing, feeding and dressing the elderly, disabled or ill. So what happens when an abusive caregiver hurts a patient?

Public health regulators in California have been letting many complaints sit for years � even when they involve severe injuries or deaths.

'Beaten To A Pulp'

Elsie Fossum's nieces and nephews say she was the aunt you wanted to have.

"She gave us our first car," Janet Flynn remembers. Her brother, Jim Fossum, chimes in: "A '59 Ford Galaxie 500, with massive fins on it."

Flynn says their aunt, a librarian and teacher who never married or had kids, always looked chic.

Enlarge image i

Elsie Fossum's niece, Janet Flynn, and nephews Jim Fossum, left, and John Fossum, say they never heard from California's Department of Public Health following their aunt's death.

Mina Kim/KQED

Elsie Fossum's niece, Janet Flynn, and nephews Jim Fossum, left, and John Fossum, say they never heard from California's Department of Public Health following their aunt's death.

Mina Kim/KQED

"She would come for the summer with this tiny Samsonite suitcase," Flynn says. "And she would be impeccably dressed, mixing and matching, and her hair was always done. Always looked wonderful."

But on the morning of July 3, 2006, Elsie Fossum lay in a pool of blood on the floor of her bedroom at Claremont Place, a Los Angeles-area assisted living facility. The 95-year-old Fossum had lived there for two years.

Her eyes were bruising black, her lip was badly cut, and her right arm was broken. But she was alive.

The lone caregiver on Fossum's floor that night said Fossum fell, but Beverlee McPherson, a registered nurse who supervised nurse assistants at Claremont Place, suspected abuse.

"She looked like she went four or five rounds with Muhammad Ali," McPherson says.

Unable to take much food or water through her swollen mouth, Fossum died of dehydration less than three weeks later. A Los Angeles County coroner could not rule out assault and called the manner of death undetermined.

McPherson is resolute.

"Oh, I'm 100-percent convinced she didn't fall out of bed, 100 percent," she says. "If you saw this woman's face, I mean, her entire face was beaten to a pulp."

'Staying On Top Of Complaints'

Emergency room nurses who treated Fossum at a nearby hospital also suspected abuse. The hospital quickly notified the California Department of Public Health, the agency responsible for decertifying nurse assistants who violate standards of care.

Cases Closed With No Action Taken

The number and rate of license revocations against nursing assistants and in-home health aides suspected of abuse have plunged, while cases closed without action have increased.

Enlarge image i Center For Investigative Reporting/KQED Center For Investigative Reporting/KQED

But internal documents obtained by the Center for Investigative Reporting show department investigators shelved Fossum's case for six and a half years.

CDPH Director Ron Chapman blames the delays in handling complaints on a backlog of more than 900 cases that piled up between 2004 and 2008.

"There were a number of reasons for that backlog, including poor management decisions during that time," Chapman says.

The department implemented a plan in 2009 to address the backlog, says Chapman, who was sworn in to his position in 2011.

"In the two years that I've been in the job, there's now new management from top to bottom, and we're staying on top of all the complaints as they come in," he says.

Yet the number of nurse assistants facing disciplinary action following complaints has dropped, from 27 percent a few years ago to 9 percent last year.

Chapman says he sees no evidence that addressing the backlog has undermined the quality of the department's current work, but Marc Parker, who headed the investigations section for nine years, says he was forced to cut corners.

"Hundreds of cases were closed, hundreds, with nothing but a phone call," he says.

'A Failure To Protect'

Parker says without visits to facilities, investigators are unable to see the layout of a room, conduct impromptu interviews, or assess a person's body language. Parker retired in December of 2011, earlier than planned.

"I could not protect the public any longer," he says. "There was just a failure to protect the most vulnerable people in our state from abuse and neglect."

A Sudden Drop

The California Department of Public Health is required to notify the attorney general's office when its investigators find evidence of crimes, especially violent acts, at health care facilities. After 2009, the department all but stopped sending patient abuse deaths to state prosecutors.

Enlarge image i Center For Investigative Reporting/KQED Center For Investigative Reporting/KQED

Public health regulators are required to report all suspected crimes to the state attorney general. In the seven years before addressing the backlog, the department referred an average of 37 deaths a year. Last year, they referred three. The year before that, two.

"We don't understand that decline in numbers," Chapman says. "It's very concerning to me and we are looking into it." He says his staff is drafting agreements with the attorney general's office to improve communication.

As for Elsie Fossum's suspicious death, department investigators closed her case this year, and decided no action was warranted against her caregiver.

Also this year, however, the Los Angeles County Sheriff's Department opened a homicide investigation into Elsie Fossum's death. Her caregiver is the sole person of interest. Chapman now says he's willing to review the case.

Elsie Fossum's nephews and niece say they never heard from the Department of Public Health. Flynn says their calls and emails to state agencies and local police have turned up little information.

"I would think that this would be very chilling to anyone who has loved ones in a facility, especially if you think safeguards are in place and you think that staff are qualified and that this is being regulated, and this I find chilling," Flynn says.

This story was co-reported by Ryan Gabrielson at the Center for Investigative Reporting.

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FAQ: Where Medicaid's Reach Has Expanded — And Where It Hasn't

This is one of several explainers to help consumers navigate their health insurance choices under the Affordable Care Act, or as some call it, Obamacare. Click here for answers to other common questions. Have a question we missed? Send it to health@npr.org. We may use it in a future on-air or online segment.

Could I be eligible for Medicaid now?

The Affordable Care Act greatly expanded the number of people who qualify for Medicaid, the state-run health insurance program for people with low incomes. Previously, it was difficult for anyone other than pregnant women, parents and children to qualify. The law expands eligibility in ways that will allow many more people, including single and childless men or women, to qualify.

How do I know if I'm eligible for Medicaid?

The law extends eligibility to all adults under the age of 65 whose modified adjusted gross incomes fall below just under $16,000 for individuals and $32,500 for a family of four.

In states that decided not to participate in the Medicaid expansion, the rules are different and vary from state to state. About half of the states opted out of the Medicaid expansion, which is something that the U.S. Supreme Court gave them permission to do. In those states, the income cutoff to be eligible for Medicaid is generally much lower than what was set in the Affordable Care Act, so fewer people will qualify. And if you're a childless adult, you're most likely not eligible in states that rejected the Medicaid expansion.

To find out the income cutoff in your state, check out the tables here.

Or, just try signing up for coverage at your health insurance exchange. The exchange will calculate if you are eligible for Medicaid in your state, and if you are, direct you to the proper state agency to get signed up. (Click here for our FAQ on how to navigate the exchanges).

How do I know if my state has expanded Medicaid?

The following states have said yes to the Medicaid expansion:

Arizona, Arkansas, California, Colorado, Connecticut, Delaware, D.C., Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Dakota, Oregon, Rhode Island, Vermont, Washington, West Virginia

The following states have said no to the Medicaid expansion or not yet decided:

Alabama, Alaska, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Wyoming

This list is current as of Sept. 30, 2013. Check here for updates.

What if my state didn't expand Medicaid?

If your income is too high to qualify for Medicaid under your state's rules, you can still try enrolling at an insurance exchange. You may not qualify for subsidies, though. The subsidies are for people whose income falls between 100 percent of the federal poverty level ($11,490 for an individual) and 400 percent ($45,960).

If you make too much to qualify for Medicaid but too little to qualify for subsidies on the exchange, then you are exempted from the new mandate to carry health insurance. (See our FAQ on the individual mandate here.)

If that's your situation � you're poor and still have no health insurance � you can still seek health care with other safety net providers, such as federal community health centers and free clinics run by local nonprofits.

See other Frequently Asked Questions on the Affordable Care Act:

Understanding The Health Insurance Mandate And Penalties For Going Uninsured All About Health Insurance Exchanges And How To Shop At Them A Young Adult's Guide To New Health Insurance Choices What Retirees And Seniors Need To Know About The Affordable Care Act How Obamacare Affects Employers and How They're Responding

Additional coverage from NPR Member Stations:

California (KQED, San Francisco) California (KPCC) California (KXJZ Capital Public Radio, Sacramento) Colorado (Colorado Public Radio) Massachusetts (WBUR, Boston) Minnesota (Minnesota Public Radio) Georgia (WABE, Atlanta) New York (WNYC) Oregon (Oregon Public Broadcasting) Pennsylvania (WHYY newsworks.org) Texas (KUHF) Texas (KUT, San Antonio)

This FAQ was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health-care policy research organization. The Kaiser Family Foundation is not affiliated with Kaiser Permanente.

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More From The Affordable Care Act, Explained

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FAQ: Understanding The Health Insurance Mandate And Penalties For Going Uninsured

This is one of several explainers to help consumers navigate their health insurance choices under the Affordable Care Act, or as some call it, Obamacare. Click here for answers to other common questions. Have a question we missed? Send it to health@npr.org. We may use it in a future on-air or online segment.

So I have to carry health insurance?

Yes, just about everyone is required to have insurance as of Jan. 1, 2014, or else they'll be liable for a tax penalty. That coverage can be supplied through your job (including COBRA or a retirement plan), public programs such as Medicare, Medicaid or the VA, or an individual policy that you purchase.

What is the penalty for not having health insurance?

The penalty for not having health insurance, at least for 2014, is up to $95 per adult and $47.50 per child or 1 percent of your taxable income � whichever is greater. It does go up substantially in a couple of years, eventually to a maximum of 2.5 percent of taxable income. The amount you owe will be pro-rated to reflect the number of months you were without coverage.

If you owe the penalty, it is assessed on your 2014 income tax form that's due April 15, 2015. And that's how the government finds you � it asks on your income tax form if you had health insurance. People who have it will get some sort of certificate of coverage from their health insurers. If your income is so low that you do not file a tax return, you are exempt from paying the penalty.

Can I go to jail if I don't have health insurance?

No, you can't go to jail for not paying the penalty; the government can't even garnish your wages. The most the IRS can do is withhold your tax refund.

What if I don't have health insurance and I get sick or have to go to the emergency room?

If you don't have insurance, you'll get a bill, just as it's always been. If you can't pay, the hospital or other health care provider will still try to collect from you, although there are some provisions of the law aimed at discouraging some of the most aggressive collection tactics that have been used in the past. If they don't collect, the health care provider would have to eat the cost. That's why hospitals were so anxious to have most people covered by insurance, so they could stop having to provide so much free care to people who couldn't pay.

Can I wait until I get sick to sign up for insurance?

No. You can't just sign up when you're sick and facing big medical bills. Otherwise that's what everyone would do. The exchanges under the Affordable Care Act have been designed pretty much the same way most employer insurance plans are: There's an open season every year when you can buy or change plans, and that's generally the only time you can buy or change plans. This year's open season is a lengthy one � it runs from Oct. 1 to March 31, 2014. In future years it will begin in October and end in December of each year.

Is there anybody who doesn't have to have insurance?

Yes, the government has identified exemptions. Individuals who cannot afford coverage because the cost of premiums exceed 8 percent of their household income or those whose household incomes are below the minimum threshold for filing a tax return are exempt. People experiencing certain hardships, including those who would have been eligible for Medicaid under the health law's new rules but whose states chose not to expand their programs, also are exempt.

Other exempt groups include prisoners, Native Americans eligible for care through the Indian Health Service, immigrants who are in the country illegally, people whose religion objects to having insurance coverage, members of a health care sharing ministry and individuals who experience a short coverage gap of less than three consecutive months.

If you are seeking an exemption for incarceration, membership in an Indian tribe or health care sharing ministry, you can apply through the health insurance exchanges or make a claim when you file taxes. If you are claiming economic hardship or a religious exemption, you must get an exemption certificate from the online insurance exchange. If you are claiming that coverage is unaffordable, that you are in the United States without proper documentation or that you have a coverage gap of less than three months, you can make the claim when you file your 2014 taxes in 2015.

See other Frequently Asked Questions on the Affordable Care Act:

All About Health Insurance Exchanges And How To Shop At Them A Young Adult's Guide To New Health Insurance Choices What Retirees And Seniors Need To Know About The Affordable Care Act How Obamacare Affects Employers And How They're Responding Where Medicaid's Reach Has Expanded � And Where It Hasn't

Additional coverage from NPR Member Stations:

California (KQED, San Francisco) California (KPCC) California (KXJZ Capital Public Radio, Sacramento) Colorado (Colorado Public Radio) Massachusetts (WBUR, Boston) Minnesota (Minnesota Public Radio) Georgia (WABE, Atlanta) New York (WNYC) Oregon (Oregon Public Broadcasting) Pennsylvania (WHYY newsworks.org) Texas (KUHF) Texas (KUT, San Antonio)

This FAQ was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health-care policy research organization. The Kaiser Family Foundation is not affiliated with Kaiser Permanente.

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More From The Affordable Care Act, Explained

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Please keep your community civil. All comments must follow the NPR.org Community rules and terms of use, and will be moderated prior to posting. NPR reserves the right to use the comments we receive, in whole or in part, and to use the commenter's name and location, in any medium. See also the Terms of Use, Privacy Policy and Community FAQ.

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FAQ: A Young Adult's Guide To New Health Insurance Choices

This is one of several explainers to help consumers navigate their health insurance choices under the Affordable Care Act, or as some call it, Obamacare. Click here for answers to other common questions. Have a question we missed? Send it to health@npr.org. We may use it in a future on-air or online segment.

So I have to carry health insurance?

Yes, just about everyone is required to have insurance as of Jan. 1, 2014, or else they'll be liable for a tax penalty. That coverage can be supplied through your job (including COBRA or a retirement plan), Medicaid or the VA, or an individual policy that you purchase. The penalty for not having health insurance, at least for 2014, is up to $95 per adult and $47.50 per child or 1 percent of your taxable income � whichever is greater. It does go up substantially in a couple of years, eventually to a maximum of 2.5 percent of taxable income. For more on the health insurance mandate and penalties, see this FAQ.

How long can I stay covered by my parents' insurance?

Nearly all young people can stay on their parents' plan until age 26, even if they're married, financially independent and no longer live with their parents. Young adults who are offered coverage through their own jobs can choose that plan or stick with their parents' plan if they prefer.

What if my parents don't have insurance or are buying subsidized coverage at an exchange is cheaper than staying on my parents' insurance?

Almost anyone can shop for coverage on the health insurance marketplace. But you will only be eligible for subsidies to reduce the cost of coverage under certain circumstances. If your parents don't claim you as a dependent on your tax return and your own income is between 100 and 400 percent of the federal poverty level ($11,490 and $45,960 in 2013), you could be eligible for premium tax credits on the exchange. But if your parents do claim you as a dependent, your eligibility for subsidies will be based on your family's income, not just your own.

Is there any reason not to sign on with my parents' plan?

Apart from general cost and coverage considerations, there are a few specifics to keep in mind when weighing a parent's plan. If you are studying or working in areas away from your parents' home, there may be no local providers who are in their insurance network, and going to out-of-network doctors or hospitals can be expensive. If you're healthy, delaying a doctor visit until you return home may not be a problem, but if you have chronic conditions that may not be feasible.

In addition, if you plan to become pregnant while on your parents' plan, you should check to make sure maternity benefits are covered. Although by law most group plans must provide maternity coverage for employees and their spouses, children aren't protected by the law, and employers don't always provide coverage.

What if my parents are on Medicare? Can I join them?

No. Medicare is primarily a program for individuals who are 65 and older. There's no family coverage available.

I'm a college student. How does the Affordable Care Act affect me?

The first thing students need to know is that if they DO have student insurance through their college or university, that's been deemed to satisfy the requirement that individuals have health insurance starting in 2014.

Then there's the question of what happens if you can't afford the insurance your school offers or what to do if your school doesn't offer coverage.

First, if you're a full-time student and you're not working, or if you're working just part-time, you probably don't earn enough to trigger the requirement to have health insurance. It applies only to people who earn enough to have to file income taxes; that's just under $10,000 this year for a single person under age 65.

What if you DO want health insurance? One popular part of the law lets young adults stay on their parents' health insurance plans until they turn 26. And in states that opt to expand Medicaid, that's an option for college and graduate students that hasn't been available before. It's for people who earn up to 133 percent of poverty, or about $15,000 a year for an individual. But only about half the states are planning to expand Medicaid.

Even the Bronze plan is too expensive for me. Are there other options?

People up to age 30 will have the option of buying a catastrophic plan that will cover only minimal services until they meet a deductible of roughly $6,400. The premium is usually much lower than the other plans. After the deductible is met, the plan covers the 10 essential health benefits � a kind of "safety net" coverage in case you have an accident or serious illness, according to the Healthcare.gov website. Catastrophic plans usually do not provide coverage for services like prescription drugs or shots. And there are other limits.

According to Healthcare.gov:

In the Marketplace, catastrophic plans are available only to people under 30 and to some low-income people who are exempt from paying the fee because other insurance is considered unaffordable or because they have received "hardship exemptions". Marketplace catastrophic plans cover 3 annual primary care visits and preventive services at no cost.

Can young adults qualify for Medicaid?

Depending on your income and where you live, some young adults may qualify for Medicaid under the law's provisions that expand coverage to individuals with incomes up to just under $16,000. States can decide whether to adopt the expansion; about half have done so. (See our FAQ on the Medicaid expansion here.)

See other Frequently Asked Questions on the Affordable Care Act:

Understanding The Health Insurance Mandate And Penalties For Going Uninsured All About Health Insurance Exchanges And How To Shop At Them What Retirees And Seniors Need To Know About The Affordable Care Act How Obamacare Affects Employers And How They're Responding Where Medicaid's Reach Has Expanded � And Where It Hasn't

Additional coverage from NPR Member Stations:

California (KQED, San Francisco) California (KPCC) California (KXJZ Capital Public Radio, Sacramento) Colorado (Colorado Public Radio) Massachusetts (WBUR, Boston) Minnesota (Minnesota Public Radio) Georgia (WABE, Atlanta) New York (WNYC) Oregon (Oregon Public Broadcasting) Pennsylvania (WHYY newsworks.org) Texas (KUHF) Texas (KUT, San Antonio)

This FAQ was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health-care policy research organization. The Kaiser Family Foundation is not affiliated with Kaiser Permanente.

Share Facebook Twitter Google+ Email Comment More From The Affordable Care Act, Explained HealthFAQ: Where Medicaid's Reach Has Expanded � And Where It Hasn'tHealthFAQ: How Obamacare Affects Employers And How They're RespondingHealthFAQ: What Retirees And Seniors Need To Know About The Affordable Care ActHealthFAQ: A Young Adult's Guide To New Health Insurance Choices

More From The Affordable Care Act, Explained

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Is Obamacare Enough?

Without Single-Payer, Patchwork U.S. Healthcare Leaves Millions Uninsured

From Democracy Now –

Despite helping expanding affordable insurance, “Obamacare” maintains the patchwork U.S. healthcare system that will still mean high costs, weak plans and, in many cases, no insurance for millions of Americans. We host a debate on whether the Affordable Care Act goes far enough to address the nation�s health crisis with two guests: Dr. Steffie Woolhandler, a primary care physician and co-founder of Physicians for a National Health Program; and John McDonough, a professor at the Harvard School of Public Health and former senior adviser on national health reform to the U.S. Senate Committee on Health, Education, Labor, and Pensions. Between 2003 and 2008, McDonough served as executive director of Health Care for All in Massachusetts, playing a key role in the passage of the 2006 Massachusetts health reform law, known as “Romneycare,” regarded by many as the model for the current federal healthcare law.

Despite Many Warnings, Antibiotics Are Still Overprescribed

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Commander In Chief, Explainer In Chief Tout Health Care Law

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President Obama joins former President Clinton to talk about the health care law, during the annual Clinton Global Initiative meeting Tuesday in New York.

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President Obama joins former President Clinton to talk about the health care law, during the annual Clinton Global Initiative meeting Tuesday in New York.

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President Obama's health care law has so far survived challenges in Congress and the courts. But its biggest test could begin next week. That's when the online marketplaces offering health care coverage to the uninsured are set to start signing people up. The question is, will they come?

Of the uninsured surveyed by NBC and the Wall Street Journal this month, only about 1 in 3 said they're likely to use the exchanges. Obama is trying to make the argument that signing up is a good deal: "In many states across the country, if you're, say, a 27-year-old young woman, don't have health insurance, you get on that exchange, you're going to be able to purchase high-quality health insurance for less than the cost of your cellphone bill."

The White House is enlisting nurses, ministers, celebrities, even radio DJs to help spread that message. On Tuesday, Obama got some help from former President Bill Clinton. The two leaders sat side by side in a pair of overstuffed armchairs at the Clinton Global Initiative for a televised � if somewhat wonky � conversation about health care economics.

It's the nature of insurance, Obama said, for healthy people to subsidize those who need more care. Clinton says that's why it's important to get healthy young people enrolled in the insurance exchanges.

"This only works, for example, if young people show up," said Clinton. "We've got to have them in the pools. Because otherwise all these projected low costs cannot be held if older people with pre-existing conditions are disproportionately represented in any given state."

Clinton understands those economics, having launched his own, unsuccessful push for universal coverage 20 years ago this week. Obama got further, pushing his bill through Congress, but he notes the battle to implement the law is far from over: "Let's face it: It's been a little political, this whole Obamacare thing."

The administration is now using social media and other tactics honed during the president's re-election campaign to promote enrollment in the health care exchanges. Obama acknowledges they're battling a multimillion-dollar advertising blitz mounted by the president's critics.

"Those who have opposed the idea of universal health care in the first place and have fought this thing tooth and nail through Congress and through the courts and so forth, have been trying to scare and discourage people from getting a good deal," said Obama.

Congressional Republicans also continue to challenge the law, which was passed over their unanimous opposition in 2010. Despite the battle being waged within the Republican ranks right now over tactics like the filibuster and a threatened government shutdown, Senate GOP leader Mitch McConnell says his party is united in its opposition to the health care overhaul.

"Obamacare hasn't even been fully implemented yet but we can already see the train wreck headed our way," said McConnell. "Major companies have been dropping the health care plans their employees have and like. And every week it seems there are new reports about glitches that will hurt families, compromise personal information, or expose the American people to fraud."

The administration has been forced to delay some elements of the law, including a requirement that large employers provide health care coverage or pay a penalty.

On the plus side, Clinton noted Tuesday the growth in health care costs has slowed dramatically in recent years, though analysts are unsure what's behind the change. Obama says if U.S. health care costs could be brought in line with other countries, it would largely fix the federal deficit and make U.S. employers more competitive.

"This has everything to do with the economy, in addition to what I consider to be the moral imperative that a mom should not have to go bankrupt if her son or daughter gets sick," said Obama.

Obama plans to deliver another health care speech Thursday, as the countdown to enrollment continues.

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