Marjorie Colson of Madison was an early supporter of Tammy Baldwin. She was there when Baldwin announced in June 1997 her first run for the U.S. House of Representatives, on a wooden platform in front of UW Hospital.
A member of the senior advocacy group Dane County SOS, Colson remembers standing alongside an uninsured farmer and an uninsured grad student, sounding the trumpet for universal health coverage and Tammy Baldwin.
"We all got up and talked about Tammy and her ability to get us a decent health system - single payer, single payer, single payer," she says, repeating that day's mantra, before adding a sad epilogue: "She just didn't do it."
"I thought she'd do better than she has," Colson says. "She's been a disappointment to a lot of us."
Baldwin, 47, who spoke last weekend at a rally at the state Capitol, has made universal health coverage the cornerstone of her congressional career. But after a decade in office, little has changed. When she went to Washington in 1999 as the first woman to represent Wisconsin in Congress, 38.7 million Americans had no health insurance, according to the Centers for Disease Control. In 2008, the count was 43.8 million - one in seven Americans - and climbing.
It would be unfair, of course, to blame that on Baldwin. But with her party in control, a sympathetic president in office and health care reform on the table, now is the best shot Baldwin will get. What is she doing to deliver on all those old campaign promises?
"We'll see. The jury is still out," says Bobby Peterson, an attorney with ABC for Health, a Madison-based public interest law firm. "This is her issue. And she really does have to deliver here. It's some pressure on her. She's one person in a big House. But it's her issue."
Some think Baldwin has already left her mark and is poised to make an even bigger one. Robert Kraig, program director for Citizen Action of Wisconsin, says: "When the history of this is written, I think Tammy's role will be recognized as huge."
Tammy Baldwin's desire to reform health care was planted at an early age. "I don't usually tell this story," she says in a recent interview at her Madison office. "When I was 9 years old, I had a rare childhood disease that required three months of hospitalization and a year of outpatient care."
The illness was myelitis, which causes swelling along the spinal chord. Baldwin's maternal grandparents, who raised her, had health insurance, which they thought covered their granddaughter. They were wrong.
"I got great quality care," she says. "I had a wonderful doctor. But the insurance my family needed and relied on turned out to not be there at all."
Tammy's family was socked with a huge medical bill, and her illness made her uninsurable.
Throughout her political career - including the Dane County Board (1986-1994) and the state Assembly (1993-1999) - health care issues have continued to resonate.
In the Assembly, Baldwin won some victories for expanded health care. She helped pass laws that protected health care workers who report abuses; provided services to disabled who had significant incomes; and set rules for buyouts of life insurance policies before death.
In Congress, health care remains a priority. "With a few exceptions, it's been the number-one issue I've heard from my constituents," Baldwin says. "Health care was always number one, until 9/11, then terrorism briefly took over. And this is in a state with a relatively high level of insurance coverage."
Baldwin was a featured speaker at the 2004 Democratic National Convention in Boston, and used the opportunity to tout health care reform: "The most sacred tenet of the Physicians Oath is 'First, do no harm.' But every day, Americans are facing great harm:workers who can't afford their premiums, small-business owners who can't provide benefits to their workers, seniors who can't afford their prescriptions, families who can't see their doctor of choice."
For several years running, Baldwin has proposed the "Creative Federalism Act," designed to encourage states to expand coverage of the uninsured by trying innovative programs funded through federal grants. The idea was to see what works and what doesn't. But the bill always died in committee.
There have been some victories. Last year, Congress passed bills she supported to provide cancer screening for low-income women and remove restrictions for stem-cell research.
Baldwin has also been a sponsor to a single-payer bill introduced regularly by Rep. John Conyers Jr. (D-Michigan).
Single-payer health care nationalizes health insurance (though not the health care industry). Everyone would pay for insurance through taxes; everyone would be covered in one big pool; and doctors and hospitals would be reimbursed from the same fund. Australia and Canada both have single-payer systems.
It's what a lot of people in Madison who are pushing for health care reform would like to see. And it's what a lot of other people insist is not going to happen.
Picking it apart
The bill that the House of Representatives is now considering, America's Affordable Health Choices Act, is a far cry from single-payer. At 1,018 pages long, it's also anything but simple - and still being tweaked.
The proposal would create a public insurance plan that would compete with private ones. People could keep their private insurance or join the public plan. Employers with a payroll above $250,000 would be required to offer insurance, or pay a sliding fee to the federal government, to help fund the public plan. Companies with payrolls of less than $250,000 would be exempt.
Under the proposal, everyone would be required to sign up for an insurance plan, with low-income people paying reduced rates for the public plan. The act would set up an insurance exchange to help businesses and employees find the best deals. And households that make more than $350,000 a year would see their taxes increase.
In mid-July the Congressional Budget Office released a report saying that it would cost $1 trillion over 10 years to pay for the coverage called for in the bill - and that 17 million non-elderly residents would remain uncovered (about half of those would be undocumented residents).
"My fear is that it's quite a complicated proposal and it's going to get picked apart a bit," says Peterson of ABC for Health. "That's already happening."
Peterson thinks the debate was framed wrong, as public versus private options. "The reformers missed an opportunity to say, 'We're working on a public-private partnership, publicly financed at certain levels, but privately delivered, with assurances of oversight and enforcement.'"
Still, Peterson says the proposal is less complicated than what the country now has - a myriad of insurance programs, often regulated by different governmental agencies, each with its own rules and red tape.
"Congress is moving in a direction to help everyone," he says. "They're tying to create larger pools, rather than small risk puddles."
Kraig of Citizen Action of Wisconsin calls the current proposal "an extremely good starting point." In particular, he likes the public plan and the way it's being funded.
Baldwin, with her seat on the Energy and Commerce Committee and its Health Subcommittee, is in a position to influence the bill, and has already done so. She proposed two amendments, which the committee accepted. The first creates an educational campaign about the importance of advance care planning. The second creates a "grant program for educational institutions to develop mental and behavioral health training programs."
In the ongoing reform debate, Baldwin is pushing nine issues. She wants to: give states the freedom to be innovative; build public health infrastructure; have a veterinary component (to protect the country's food supply, not give free medical care to Fido); include intensive health care for chronically ill children; encourage advance care training; address the national shortage of nurses; extend comprehensive care to the most vulnerable; increase community-based services; and reduce health disparities for gay, lesbian and transgendered people.
Baldwin believes Wisconsin can be a leader in some of these areas. For instance, it's the only state that secured a public option when Congress added a drug plan to Medicare in 2003. That's because it already had one - SeniorCare, which is very popular here. (The publicly run program gives prescription assistance to elderly.) Says Baldwin, "SeniorCare is a brilliant example of why we need a public option."
Peterson says ABC for Health has been lobbying Baldwin to push for consumer and patient advocacy mechanisms in the bill. Under the current system, the rules change depending on who regulates whatever plan someone happens to be on. And patients often have no clear understanding of where appeals can be made. Even just figuring out why coverage was denied can be a Herculean task.
"For people under 60, it's kind of the wild, wild West," he says. "I'd like to see clearer opportunities for enforcement of the rules."
Expenses and frustrations
Marjorie Colson's special treat to herself last August went horribly wrong. "Once a month," she says, "I allow myself an Arby's lunch with a chocolate milkshake."
But on Aug. 23, the milkshake slipped out of her hand in the elevator, spilling. Colson - who turns 85 in August - in turn slipped on the milkshake and, as she says, "ended up in the red wagon." She got a spiral fracture down the length of her femur, painful and debilitating at any age.
Colson ended up spending nine months in the hospital and three nursing homes. "My most recent brush with the health care system here has not endeared it to me."
Colson is covered by a combination of Medicare and Tricare (military insurance she got through her husband). But during part of her recuperation in a nursing home, she was dropped from Medicare due to a technicality.
"Medicare pays for what it calls rehabilitative care, most of which takes place in a nursing home," she says. "But they pay only if the provider can show the patient is improving."
Unfortunately, Colson needed to heal before she could start physical therapy. "I had to lie flat in my bed," she says. "So by law, Medicare has to drop me." And the costs started adding up. Colson says she ended up with bills around $20,000.
Her expenses and frustrations are all the worse because Colson has seen a better system. In 1970, she and her family lived in the United Kingdom for a year. The family paid 14 pounds (roughly $20) a month for health care, which is government run.
Her family was healthy and didn't need much medical attention. But Colson remembers going in to have some prescriptions filled. She got an appointment in one day. When she showed up, the waiting room was empty and there was no receptionist. Instead, the doctor came out to greet her. They chatted leisurely about her health.
"No insurance card, no money changed hands, and no waiting time," she says. "I was in and out."
Since then, she's been a fervent advocate for a single-payer system and has been lobbying for it. She likes Baldwin, but is nonetheless disappointed.
"Tammy is not a leader. We're looking for a Jim McDermott or a Dennis Kucinich - as feisty as they come."
Kucinich, D-Ohio, spoke against the Affordable Health Choices Act, saying, "It further entrenches the existing for-profit, insurance-based system by handing even more money over to the insurance industry." (Though it should be noted that Kucinich has also failed to deliver single payer.)
Larry Dooley, a member of the Wisconsin Green Party's coordinating committee, agrees Baldwin should be banging the drum for single payer. "I would have said it [wasn't possible] before the last election cycle," he concedes. But now Democrats have 60 senators, a House majority and the presidency. "Why isn't it practical now, when they hold all the cards?"
Baldwin says she still thinks a single-payer system is the best solution. She hopes the current reforms are first steps in that direction. But, she says, it's not feasible to push for it now.
"If we push only single payer, we're likely to get nothing because of the people who say they don't support it and have dug their heels in," she says. "Let's push for this first step of health care reform."
Ben Manski, executive director of the Madison-based Liberty Tree Foundation, a democracy reform group, outlines two ways of getting things done in Congress. One way is to make friends, bide your time and gain seniority until you can shape the agenda. The other, which he favors, involves using one's office to build reform movements, like Wisconsin's "Fighting Bob" La Follette, the leader of the Progressive movement.
Manski says Baldwin has, until recently, taken mainly the "make friends" approach. But he thinks she's shifting toward a more populist approach, as demonstrated by last weekend's rally at the Capitol, which he says is "a good way to strengthen the movement for universal health care."
"You're not going to get major reform on any issue," he says, "without a movement that challenges the system to its core." He adds, "'What would La Follette do?' is a good question for any Wisconsin politician to ask."
In taking a pragmatic, conciliatory approach, Baldwin is in step with President Obama. But she admits there are times when she wishes the president were more forceful.
"When I've met with [Obama] he's clearly articulated his support for a public plan," she says. But the notion of direct competition has come under furious fire from insurance companies, and Obama has at times signaled he might be willing to do without it. Baldwin says, "I think he should draw a line in the sand on his support of a public option."
Baldwin sees two ways the country could evolve from the proposed reforms to a single-payer system. First, "If we get the public plan right and it becomes popular, then we could pivot to a single-payer system."
A second way is through state innovation. If a state creates a single-payer system and proves it works, it could be expanded nationally.
Baldwin's cautious approach strikes some observers as prudent.
"Single payer isn't necessarily impossible," says Kraig, "But if you want health care reform this year, you're not going to get single payer through Congress."
Kraig thinks Baldwin has done an excellent job working the system in Washington. "Anyone can vote right, but Tammy has been fighting on the inside to make sure this is as good a bill as possible," he says. "She's put a lot of energy pushing this in the right direction."
Baldwin knows that this is probably the best shot she'll get at meaningful health care reform. She knows that the stakes are high, that people back home are counting on her.
"I've got lots of fears," she admits. One of those is gridlock. "Another fear is we lose the battle on a public option and payment reform and you get an expanded version of an already dysfunctional system."
Health care by the numbers
- Number of Wisconsin residents who were uninsured at some point during 2007 and 2008: 1.2 million (Families USA)
- Number of employed Wisconsinites who lack health insurance: 250,000 (Families USA)
- The average amount Medicare spent in 2006 on each enrollee in the Madison region: $6,416 (The Dartmouth Atlas of Health Care)
- In the United States overall: $8,304
- Wisconsin's overall infant mortality rate: 6.4% (Kaiser Family Foundation)
- For African American infants: 16.4%
- Increase in state health insurance premiums from 2000 to 2008: 90% (Families USA)
- Average age of Wisconsin nurses: 47.6 (Wisconsin Center for Nursing)
- Amount the health industry has spent lobbying Congress from 2007 to early 2009: 1.38 billion (Center for Responsive Politics)
- Campaign donations received by Tammy Baldwin from health professionals in the 2007-08 campaign: $88,445 (Center for Responsive Politics)
- The average amount U.S. representatives received from health professionals in the 2008 election cycle: $62,498 (Center for Responsive Politics)
- Tammy Baldwin's rank in the House in the amount of contributions from health professionals: 98 (Center for Responsive Politics)