PAUL KRUGMAN VS. WHO?

Anyone who has read the New York Times will likely recognize the gentleman on the right: He's Paul Krugman, Nobel Prize winning Economist and Columnist for the Times. It would be hard to be more distinguished than he. 

I'd be surprised if many of my readers recognized the gentleman in the left: He's Don McCanne, MD, who in addition to being a physician, has been all his life a student of health policy.  He currently serves as Chief Policy Fellow for the Physicians for a National Health Plan PHNP), a body in which he served as President in 2002 and 2003. There is no more passionate advocate for Single-Payer than Dr. McCanne, and I read his daily blog with the deepest respect.  

On Sunday, March 17, the Texas Tribune published Patrick Sviteck's story about Beto O'Rourke's pivoting on his healthcare plan preference:

In Iowa, Beto O'Rourke works to find his footing on health care

Sviteck explains that O'Rourke, never more than luke-warm towards the notion of Single-Payer, seemed more comfortable embracing a policy considerably to the right of  it -- Medicare for America.  Sviteck quotes him:

"It responds to the fact that so many Americans have said, ‘I like my employer-based insurance. I want to keep it. I like the network I’m in. I like the doctor that I see,'" O'Rourke said. "It complements what already exists with the need that we have for millions of Americans who do not have insurance and ensures that each of them can enroll in Medicare. It then suggests additional investments in that program so it becomes the program of choice, and people who have private insurance migrate over to the Medicare system."

Someone questioned him:"So the greed has to stay in the insurance industry in your opinion?"

Beto paused, then said that he didn't see it as a function of greed. "I think I have to be respectful to people who just shared with me what I shared with you: They like the program they’re in, they like the insurance that they have," O'Rourke said. "If we become too ideological or too prescribed in the solution, we may allow the perfect to become the enemy of the good. And there are fellow American human lives depending on us finding a solution."

Upon reading this,  Dr. McCanne posted a very passionate statement about 

The-Fallacy That You Can Keep The Insurance You Have

He says that virtually nobody in this country does. "The obvious point" he writes, "is that people do not have stable health care coverage throughout their lives." And as he makes clear, there are too many reasons why the insurance companies change, or their policies do, or the networks do.  I suggest you read his article I've linked above: I never knew there were so many reasons why the insurance you have can and will change, but I can testify that in my lifetime that has been my experience.  

And as for that shibboleth "freedom of choice," you have to go along with whatever your employer chooses to give you -- if he chooses anything. You get the doctors and the network that your employer chooses. But as McCanne says, with Single-Payer, you don't have to worry about doctors being in your network; You can choose any doctor, any hospital you want: they're all in the same network!  (This would be very much unlike Medicare for America, if it devolves into a two-tiered system -- one more pricey than the other -- those who belong to the medicare tier might find themselves priced out of the tier whose pricier doctors might not want to treat them. That sort of thing is happening as I write this. There is a physician in Kingston, well thought of,  whose receptionist told me: "Of course Doctor doesn't take Medicare. That's what you have? You should have told me from the get-go, and not wasted my time!" Luckily for Carol and me, we could find quite a few other good doctors in Kingston who do take Medicare.)

Thus this argument for Medicare for America -- that you can keep the insurance you have -- is, in McCanne's opinion, based upon a fallacy. And, as I said in my most recent post, Medicare for America, in my opinion, would be unlikely to last long, if for no other reason that no billion dollar company is going to sit quietly by while it is being put out of business -- however slowly. They'll deploy every dollar they have to lie, distort, and bribe.

Despite all this, Paul Krugman believes that eventually most of the Democratic candidates will be persuaded to move rightward and and embrace Medicare for America. In  his recent opinion piece,

Don't Make Health Care a Purity Test

Krugman asks, 

But even if optimistic claims about Medicare for All are true, will people believe them? And even if most people do, if a significant minority of voters doesn’t trust the promises of single-payer advocates, that could easily either doom Democrats in the general election or at least make it impossible to get their plan through Congress.

And he points out that -- just as there is more than one way to skin a cat -- there are in the world many ways proven successful in providing universal healthcare. "Every two years," he says,  "the Commonwealth Fund provides an invaluable survey of major nations’ health care systems. America always comes in last; in the latest edition, the three leaders are Britain, Australia and the Netherlands. 

"What’s remarkable about those top three is that they have radically different systems. Britain has true socialized medicine — direct government provision of health care. Australia has single-payer — it’s basically Bernie down under. But the Dutch rely on private insurance companies — heavily regulated, with lots of subsidies, but looking more like a better-funded version of Obamacare than like Medicare for All. And the Netherlands actually tops the Commonwealth Fund rankings."

Krugman then asks,  "So which system should Democrats advocate? The answer, I’d argue, is the system we’re most likely actually to create — the one that will play best in the general election, and is then most likely to pass Congress if the Democrat wins." 

He concludes, "To me, then, Medicare for America — which lets people keep employment-based insurance — looks like a much better bet for actually getting universal coverage than Medicare for All. But I could be wrong! And it’s fine to spend the next few months arguing the issue. What won’t be fine will be if activists make a no-private-insurance position a litmus test, declaring that anyone advocating a more incrementalist approach is no true progressive, or maybe a corrupt shill for the medical/industrial complex. As you might guess, my concerns aren’t drawn out of thin air; they’re things I’m already hearing."

So the next few months will be anything but boring! And the thing is: I'm really not 100% sure of where I am on all this.  In the readers comments section -- which I strongly urge you to read -- readers give their views about Krugman's opinions. In the first New York Times Pick, you can read:

"Private insurance is mostly there to say No, you can’t have that, but if you do, we’re not going to pay for it. And we currently pay through the nose for these companies to tell us that. Who in their right mind is “satisfied” w that? Only stupid people or people w ties to the health insurance industry. No, private health insurance, w the possible exception of “boutique” brands for the wealthy, should be abolished. I don’t often disagree w Mr. Krugman, but this time I do. Wholeheartedly. Is my view impractical? Let’s forget the polls and vote on it."

After reading this, I thought, "yes, yes! Those !*#@*! [the healthcare companies] should not be rewarded for what they've put us through! I agree 100 percent! But then I read:

"One of the problems that Progressives will have in selling Medicare for All is that they have made a compelling case for the utter corruptibility of politicians due to money in politics. The GOP over the years has made a much less honest but electorial effective case that "liberal elites" cannot be trusted. And Trump has demonstrated the weaknesses in oversight, check and balances, and the value of facts in our system of government in the face of extreme partisanship and the conservative media ecosystem. "So how do you convince the rightfully skeptical, currently insured but potentially persuadable, to let OUR Federal government take this much control over health care NOW? "Explaining all the positives of Medicare for All is easy relative to the challenge of explaining how THIS government, that will without question still be highly partisan in 2020 and still awash in big donor money, is capable of pulling this off. "Have a robust debate. If Medicare for All resonates with a solid majority of voters across a majority of states that's great. I hope it goes that way. "But if not, keep in mind that our democracy may not survive another 4 years of Trump and McConnell. Medicare for All is not the hill to die on. [Emphasis added]

After reading this, I think, OMG, of course, of course! This makes sense!

Let our good doctor, the esteemed Don McCanne -- only one year younger than I -- have the last word about what we activists for Single-Payer must bear in mind:

This is a time for PASSION. We have to get this message out there.

As with everything else, he is so right about this, too.

Dio

PS: If you'd like to leave a comment -- and I encourage you to do so -- simply click on the "number of comments" area, and share your thoughts in the "comment rectangle" that appears.

PPS: We know that there are plenty out there who have stories to tell -- stories of your trying to cope with our dysfunctional healthcare system. Trouble is, we don't know what these stories are! That's where you come in. If you have a story to tell, you can email me at indivisible12401@gmail.com. You can be as anonymous as you like. Thanks!

THE NEW YORK TIMES IS 

NOT ALWAYS GOSPEL

On February 2nd, Jonathan Martin and Amy Goodnough in the New York Times wrote an article that unsettled me. I provide a link to it below:

Medicare For All Emerges as Early Policy Test

Prior to reading it, I had managed to feel that somehow there might be hope in our country's finally adopting a genuine single-payer program. But the article left me feeling that there was no way our elected Democrat representatives would spring for it -- or anything like it. But then I read an email circulated by Maggie Veve, an activist in the New Paltz area. What she said made so much sense that, with her permission, I'm reprinting it here:

This is a conventional article, not a good one: it's misleading (cost) and therefore, biased. In addition, the content is expected. 

 I am sure you know that politicians test the waters and politicians run scared. They run scared with the Green New Deal (GND) too. We will see the same when the fuel industry really hits back hard against the GND. It's just easier to run from Medicare for All because the fight is on with heavy hitters of the for-profit health establishment. They know health care cost is a non-partisan issue and that hearings will occur in the House. So the industry is clearly afraid of losing profits and wants to scare the populace with "socialism", "bankrupting the economy", "no choice", "long waits" to distract from the radical / root causes of the true cost of the current system. We cannot afford NOT to do what every other developed nation provides for their citizens. I think we need to educate the populace and push for what we think is right ("imagine the best of what is possible"/Deray McKesson). I also believe the narrative can be turned around by fearless belief in the right thing to do.

For an example of this fearless belief in the right thing to do, Maggie  provides a link featuring AOC answering Chris Cuomo's challenge: "How are you going to pay for all this healthcare, this Green New Deal you want?" AOC answers him with words that are for the ages:

AOC Dumbfounds Chris Cuomo

Not satisfied with that, Maggie then forwards her letter to Elissa Krauss, in these parts the lead organizer and advocate for the NYHA and Single-Payer in general. And Ms. Krauss replies with an email that nails it:

Thanks for including me in the conversation. Some thoughts:

   1.The regular Dems oppose Medicare for All. The Dem Congressional Campaign Committee specifically forbade candidates from mentioning single payer. Antonio Delgado has made clear that he does NOT favor Medicare for All. He wants a public option. More on that later.

  2. It is true that the Mercatus Center projected cost of Medicare for $32 trillion WITH A SAVINGS OF $2 trillion over 10 years. In other words, even a right wing think tank had to acknowledge that Medicare for All would cost LESS than current costs for health care. 

  3. NYHA would save New Yorkers billions in health care costs. Instead of premiums, deductibles and co-pays New Yorkers would pay a progressive tax on payroll and non-payroll income, that tax can be less than what they are currently paying.

  4. Two studies agree that NYHA would save money for New York and for New Yorkers. The RAND study agrees that single payer would cost NY less than current costs. It mistakenly predicts that some low-income New Yorkers would pay more for health care than they do now.  That’s because RAND’s analysis is based on a hypothetical tax structure that is not truly progressive and assumes that all New Yorkers would have to pay a tax. The Friedman study presumes that no tax would be paid on incomes less than $25,000.

   5. Exactly how the NYHA tax would be calculated remains to be seen.  First the bill needs to pass. Then the very important details need to be worked out. But the bill specifies a progressive tax. Remember- current private health insurance is a regressive tax. Note – NYHA is improved Medicare for All. No premiums, deductibles or co-pays,

   6. For single payer advocates I think the message of this article has to be – we have to embrace taxes as a cost-effective way to provide care to all. The fiction that all taxes are bad has been promulgated by opponents of government who have taken over the national government at the same time as they are trying to dismantle it. We need taxes. Taxes pay for police, firefighters, roads, bridges, and schools among other things. These important basics of society are all suffering because of the successful myth that taxes are inherently bad. Remember in Europe those higher taxes pay for free public education from Pre-K through college, access to medical care for all, paid family leave, longer vacations, etc.

   7. Public option. PNHP [Physicians for a National Health Plan] opposes a public option for the simple reason that if private insurance companies were competing against the government then we would see an expansion of what we are seeing now. The government provides care for the sickest, oldest and poorest. With a public option private companies could go further in limiting who they would cover and focus on the younger, healthier and richer. We would end up with an even worse two-tier system than we have now.

      So those are some thoughts on the NYT opinion piece. It is true that some studies show that when people are told that Medicare for All would increase taxes or end their private insurance, some get scared. BUT those questions do not tell them that their costs would be lower and their access to care increased.

      Let’s continue this conversation. Henry Moss is better than I am at covering these issues. I’m sure he’d be glad to come back to New Paltz to do another presentation.

Elissa

Personally, I don't believe that anybody could be much better in covering these issues than Elissa.

What  more can I say? After 57 years of marriage, I've learned to listen to women smarter than I am.

Hurray for Maggie!

Hurray for Elissa!

Hurray for AOC!

With women like these -- and thank God there are plenty of 'em -- we're in good shape!

Dio

PS: If you want to leave a comment -- and I hope you will -- simply click on the number of comments area and share your thoughts in the "comment rectangle" that appears.

PPS: If you'd like to share your story, I'd like to help you. You can share it publicly -- if you're up to it -- or privately, with only your representative knowing it. Either way, you would be helping the cause. Our current medical system is hurting people.  If you are one of them, you deserve to be heard. You need to be heard.  Thanks!

ELEVATOR LANGUAGE

From Don McCanne of the PNHP (Physicians for a National Health Plan) comes today's very timely CNN bulletin, followed by his comment:

CNN

January 30, 2013

Democrats distance themselves from Harris' call to eliminate private health plans

By Alex Rogers, Manu Raju and Elizabeth Landers

The emerging 2020 presidential campaign has deepened the Democratic party's divide over how the government should cover all Americans, further exposing the differences between those who want a total overhaul of the health care system and those who prefer a more incremental approach to fix it.

Sen. Kamala Harris of California renewed the party's debate over single-payer health care in a CNN town hall Monday, saying she's willing to end private insurance, which more than 170 million Americans use.

"It would take a mighty transition to move from where we are to that," said Sen. Dick Durbin, the chamber's No. 2 Democratic senator in leadership.

"What most of us said we would support is a Medicare type plan -- a not-for-profit public plan that is available for everyone," said Durbin of Illinois. "I think that's a good first step."

Sen. Tim Kaine, the 2016 Democratic vice presidential nominee, claimed that "about 80%" of those who get insurance through their employers like their private insurance plan.

"I'm not going to say you have to give it up," Kaine said. "I think the idea is to offer a nonprofit insurance plan as an option."

Of eliminating private health insurance, Sen. Dianne Feinstein, Harris' senior Democratic colleague from California, said, "Well I'm not there."

Sen. Gary Peters, Democrat of Michigan, said he believes lawmakers should expand the ability for people to buy into a version of Medicare, adding he's a co-sponsor to a bill by Kaine and Sen. Michael Bennet of Colorado that would do just that. Sen. Chris Murphy, Democrat of Connecticut, plugged another bill that would expand access to Medicare, calling it "a lot more politically palatable and ultimately more popular than statutory prohibition of private plans."

CNN on Kamala Harris and Fellow Democrats' Response

==

Comment by Don McCanne

Now that Medicare for All has become such a popular concept, many seem to believe that all we need to do is elect more Democratic senators and a Democratic president and we're in. But if you listen carefully, most Democratic politicians give lip service to Medicare for All, but when you pin them down on policy they actually support a Medicare buy-in - a public option - and most of them support the continuation of offering the private Medicare Advantage plans. They also support allowing employers to offer their own private health plans. We are not even close to enactment of a bona fide Single Payer Medicare for All program.

Everyone needs to get busy perfecting their elevator speeches so we can explain why we must not allow private insurance plans to be options in our health care financing. If we were to allow them under Medicare for All, the entire single payer financing infrastructure crumbles, perpetuating an inefficient, fragmented financing system that impairs health care access, and often results in personal financial hardship. In contrast, a Single Payer Medicare for All program would ensure access and affordability for everyone. The secret? Saving hundreds of billions of dollars by reducing the profound administrative excesses of our fragmented, dysfunctional financing system, along with exercising the monopsonistic purchasing power of our own single public payer. See if you can convert that into elevator language.

Here's my try at an "elevator language" pitch: "Private insurance exists to make money -- charging more and providing less, and often forcing you to see the doctors in their network. But if you want to see the doctor you want, and get the care you need -- even if you have no money to pay for it, then Single Payer is the way to go. And -- as a bonus -- you'll be helping  the government save billions in wasteful overhead. But if you believe that any Private Insurance is going to be 'non-profit,' then I've got a bridge to sell you."

And -- if the elevator is going up more than a few floors, you could add: "Sure, Single-Payer isn't free. You pay according to your means. If you have nothing, you pay nothing. If you're in the top-most two percent -- you'll pay more for healthcare than you do now. But most of us will pay a lot less -- and we'll all get a lot more."  

I'd love it to hear your elevator pitches. Do please leave them as comments, or, if you like,  email them to me at  indivisible12401@gmail.com.  I hope I'll get lots of them -- that should be fun!

Dio

PS: If you'd like to leave a comment -- and I hope you will -- simply click on the number of comments area and share your thoughts in the "comment rectangle" that appears. Thanks!

NOT THE WAY TO CONTROL COSTS

In my post of 12/21/2018 (Why Is American Healthcare Se Expensive -- Part Two), I cited my heroes Woolhandler and Himmelstein, who said, "Medicare's (and other payers') Pay for Performance initiatives impose substantial costs on providers, with no evidence that they've improved patients' outcomes in any setting." [Emphasis added.]

This would seem to conflict with the assertions of those touting what they claim is the success of Medicare’s Hospital Readmissions Reduction Program (HRRP) in lowering risk-adjusted readmission rates for targeted conditions at general acute care hospitals.

But now (in January, 2019) comes a Paper in Health Affairs titled Decreases In Readmissions Credited To Medicare’s Program To Reduce Hospital Readmissions Have Been Overstated. The  Paper's abstract presents a statistical analysis far beyond my sphere of competence. But Don McCanne of the PNHP (Physicians for a National Health Program) comments:  "This study shows that, at a minimum, the benefits of penalizing hospitals for readmitting patients have been tremendously overstated."  Moreover, he points out the additional concern that

patients are often held on observation status rather than being readmitted, sometimes to avoid the readmission penalties. This can significantly increase out-of-pocket costs for the patient since they are billed as outpatients (Part B), with greater cost-sharing, rather than as inpatients (Part A). More importantly, there is also the risk that the patient may receive less care as an outpatient when the patient's condition warrants full inpatient services. Thus the readmission reduction program may be causing significant patient harm, both physically and fiscally.

In conclusion, he states :

The government bureaucrats and the policy community are fixated on these various programs that they just thought up out of the blue that supposedly would control spending, even though their track record overall is dismal. Yet they keep avoiding a proven solution that would reduce our uniquely outrageous administrative waste that costs hundreds of billions of dollars. That solution is a single payer national health program, an improved Medicare that would cover everyone. We should at least enact that and then we could examine other innovations as long as they are designed to truly benefit patients.

Of course he is right:  Single-Payer would save administrative costs more reliably than any of  our government's fiscal schemes, which have proved so far to be, in  McCanne's words, "a dismal failure."  But whether Single-Payer in New York State (NYHA) would control non- administrative costs -- such as hospitals gaming the system in order to make profits, and whether payments to hospitals would reflect current market realities (e.g. regional differences in payscales, etc.) and different standards of excellence (e.g. Memorial Sloan Kettering vs a provincial outfit like Poughkeepsie's Vassar Hospital) has not yet, to my knowledge, been figured out.

The last time I checked, the House of Representatives proposal for Single-Payer adopted Woolhandler and Himmelstein's suggestion that medical facilities such as hospitals should NOT be privately owned and should be compensated NOT by procedure, but should be publicly owned and compensated globally for operating expenses, with capital expenses (MRI machines, etc) awarded by government grants, not by any profits or surpluses, which they would not be supposed to make.  Sanders' Senate Bill keeps the current setup, where hospitals are expected to make profits and are tacitly encouraged to game the system in order to do so. But the House proposal, as I understand it, is currently being rewritten, with results yet to be announced. And how the NYHA would treat these matters is yet to be determined.

With all these uncertainties, why go to single-payer, or for that matter any new system?  The answer is simple: Our current system is fiscally unsustainable and morally bankrupt. Single-Payer seems the best avenue forward. Inaction is not an option. Hence this blog.

Dio

To make a comment, (and we encourage you to do so), simply click on the number of comments area, and share your thoughts in the "comment box" that appears. Thanks!

MODIFIED RAPTURE!

In Gilbert & Sullivan’s MIKADO, the male romantic lead, Nanki-Poo, is appalled to learn that the girl he loves, Yum-Yum, is to marry someone else.  But when she tells Nanki-Poo than she doesn’t love her fiancé,  her lover exclaims, “modified rapture!”

Just so, when I heard yesterday that Nancy Pelosi supports holding hearings on "Medicare for all," I had an all-too-brief surge of elation.  According to THE HILL, “Pelosi had said last year only that Medicare for all would ‘have to be evaluated’ and is ‘on the table,’” but now...was Pelosi actually saying that the status of Single-Payer had risen from the theoretical to the possible, which the political art might somehow make real? This was worth celebrating, EXCEPT:

•      Doug Henwood of JACOBIN magazine says that “we have this coalition now developing in Congress of Democrats opposed to any idea of single-payer,  so not obvious at this point.”
•          We have Democrats in the House who – like Joe Kennedy III – talk a good game about healthcare being a right and not a privilege – but, at the end of the day betray why they may be less than enthusiastic about it.  Kennedy, for example, says he’s concerned that – among other things – it could negatively affect investor - owned hospitals, which include Catholic hospitals in Massachusetts.  He doesn’t mention that he has taken $348,000 in campaign donations from Big Pharma, and that he owns stock in a pharmaceutical company one of whose medications – which fights Hepatitis C – costs $1000 per pill.
•         Among the ones who say they actually are for some form of “universal healthcare,” there is little agreement as to what form it should take. (See my earlier post “Various Flavors of Healthcare Reform.”)

Meanwhile everyone seems to agree that Single-Payer would save this country money. Even Koch’s Mercatus institute, in an attempt to slam the concept, estimated that in ten years it would cost this country $32 trillion -- which happens to be $2 trillion LESS than what it would cost us if we kept spending at the rate we’re spending now!  And the latest confirmation of the Single-Payer idea – from the Political Economy Research Institute (PERI) -- estimates that, when stabilized, a single-payer plan would save this country 15%-16% of GDP. 

PERI’s report -- Economic Analysis of Medicare for All – was subjected to Peer Reviews, all of which were uniformly positive:

                      Peer Review of PERI Economic Analysis of Medicare for All                    

In their review, my heroes, Woolhandler and Himmelstein, together with the redoubtable Adam Gaffney, pointed out that, based on their own researches,  PERI’s estimates of savings were less than they probably would be, while their estimates of expenses were greater than they probably would be.  In contrast to these conservative estimates,  according to Woolhandler et al,  was the optimism of Peri’s estimate of the time it would take to achieve much savings, if for no other reason than the challenge of reducing to a single computer architecture the daunting welter and variety of systems now being used.

But from my point of view, a very cogent observation was also made by Alison Galvani, who pointed out that while Medicare was pretty good at controlling prices, it wasn’t very good at controlling overuse of high-tech procedures (see my post: Why is American Healthcare So Expensive?).  She pointed out that the same McAllen doctors who, with their Medicare Patients, went through the roof in prescribing procedures that were unlikely to help, were much more conservative when it came to the Blue Cross/Blue Shield patients. He cited an article by Luisa Franzini in Health Affairs, which touted Blue Cross/Blue Shield’s supervisory measures  -- prior approval for elective procedures, and case managers for any case likely to cost $50,000 or more, and so on.  She also mentioned what I felt was one of the most important factors: "Private insurers have the advantage of a “threat point” at which they can ultimately refuse to contract for services to specific physicians or hospitals—something that Medicare cannot do."

I wondered what indeed could rein-in the entrepreneurial ambitions of Doctors.  In outfits like the Mayo Clinic or the Cleveland Clinic, Doctors are on salaries, so that nothing distracts them from focusing on the patient, who comes first.  It turns out that this way, outcomes are better while expenses are less.  Does this mean that Single-payer is going to require all Doctors to be on salaries? I wouldn’t hold your breath waiting.

But there is one economy that Galvani doesn’t mention:  As Woolhandler, Himmelstein, and Gaffney point out, that PERI analysis uses the House version’s approach to Hospitals, Clinics, Dialysis Centers:  the gradual take-over of all such privately owned facilities so that ultimately they are publicly owned,  (no stockholders) and directed NOT to make a profit.  The profit incentive being removed, these facilities are no longer incentivized to game the system and are supported globally, the way we support firehouses.  It’s a great idea, though Joe Kennedy III isn’t likely to be pleased with it.

The action in congress is thus likely to be fascinating and extremely consequential.  But that doesn’t mean we should ease up on our own efforts. Don McCanne,  a physician who writes a blog for the Physicians for a National Health Program (PNHP), writes the following:

“The hearings will be part of the process, but it is important that we continue with our other advocacy activities as well. Special targets should include politicians who do not yet seem to understand why single payer is an imperative, and politicians who profess to be advocates but who could be swayed to support detrimental reform policies in a perversion of the process of political compromise. We need to continue to work with politicians who are already fully on board, but we should also continue our efforts to educate those who say they are opposed, if,  for no other reason, they might accept defeat more readily were they to understand the clear social benefit of Medicare for All.  Also we cannot let up in the least in our efforts to educate the public at large. Grassroots efforts will continue to be an essential component of the reform effort.”  (Emphasis added)

This paragraph contains marching orders for all of us.  As the discussions intensify, both in Albany and D.C., our efforts must likewise grow stronger and more passionate.   On the day when Single-Payer passes in New York State, we all will experience not modified, but complete rapture!