Medicare for All – Sheila Kennedy

Can You Stand A Re-Run?

I was looking through some old posts–trying to find one for a friend who’d asked me to dig it up–and came across a number of “golden oldies” that, unfortunately, remain relevant. I was particularly struck by a post from back in 2018 that married two persistent issues: national health care and vote suppression.

Here was what I wrote then.

________________-

Thom Hartmann from Independent Media has written a column that is both provocative and persuasive.

If he’s right, it would also explain what I have thus far found inexplicable: why the GOP is so dead-set against a national system that would expand access to healthcare to all Americans.

Now we know why the GOP is truly terrified of Medicare for All; it will wipe out the Republican Party’s control of the House, Senate, White House, and most state governments. Because it could make it very easy for every citizen over 18 to vote.

Here’s how it works.

In Canada, every citizen has a Canadian government-issued “Health Insurance Card” … It’s largely only available to citizens, as all citizens are eligible for the Canadian Medicare system; everybody else has to work out other insurance options (yes, there are insurance companies in Canada). And in most provinces, the card has your photo and works as an ID card as well as a driver’s license or passport.

In Canada, that health insurance card is also a voter ID card.

As a Canadian explained to Hartmann, the health insurance card is unlike other government issued identifications, such as driver’s licenses, because virtually all Canadian citizens from all socioeconomic backgrounds have them. They can be used as photo IDs for flying domestically, buying alcohol and–most importantly– voting!

Among other voter suppression tactics, the GOP has spent the last decade fighting a war on (virtually non-existent) “voter fraud.” The party has used this largely fabricated concern to pass voter ID laws that make it hard for people who don’t drive –due to old age, lack of ability to afford a car, or in some cities (not mine), convenient public transportation–to cast a vote.

In 2016, Donald Trump won Pennsylvania, Michigan and Wisconsin by razor-thin margins far smaller than the number of voters purged and/or turned away at the polls.

The Brennan Center documents a 33 percent increase in voters purged during the 2014-1016 election cycle (16 million), compared with the 2006-2008 cycle (12 million purged), as the GOP has made ID and purges (along with fear mongering about brown-skinned people) their main electoral strategy. In just the past year, as many as an additional 14 million voters have been purged from rolls nationwide, while over the past two decades every Republican-controlled state has introduced rigid ID laws.

But with a national ID system in place that’s universally used because it’s the key to getting your health care and medications, there’s no need for “voter registration” and thus no ability for the GOP to purge voters. Voter registration, after all, is a practice we largely got after the Civil War because Southern white politicians warned of “voter fraud” being committed by recently freed black people, and some Northern states used it to prevent poor whites from voting.

In some places in the United States, voter registration just never caught on: North Dakota never bothered to put such a system into place; you just show up at the polls with ID to prove you’re both a citizen and resident, and vote. And with a national Medicare for All ID, every citizen could easily vote, everywhere.

Hartmann insists that the GOP’s adamant opposition to universal coverage is partly based upon the party’s realization that the universal ID such coverage would require would allow everyone to vote.

True or not, it’s hard to argue with Hartmann when he says that Medicare for All would allow America to join the rest of the developed world, by having both a national health care system and a functioning democracy.

_____________-

Given what appears to be the average IQ of today’s GOP establishment figures, Hartmann may have been giving the party pooh-bas far too much credit for strategic thinking. Republicans probably oppose a national health insurance program simply because “those people” would benefit. Still, such a program would, as he notes, provide Americans with a universal “Voter ID.”

Yet another reason to support joining the rest of the civilized world…..

Comments

Health Costs And Benefits

Americans have been arguing over health care (actually, health insurance) for my entire life–and as I frequently mention, I’m old. Every time the federal government has extended access to health insurance, conservative politicians have insisted that America cannot afford it.

“Medicare for All” proposals invariably meet with outrage–and disinformation. In addition to insistence that universal health care would bankrupt the country, opponents used to warn that extending access would ruin what they say is the “best medical care in the world.”

That claim that “we’re number one” has diminished considerably, as more people have recognized that we’re actually number thirty-seven or thirty-eight, and that the only people who receive the “best” medical care are people who have lots of money. But Republicans have continued to insist that America just can’t afford universal coverage.

Which brings me to a very interesting report in The Hill, titled “22 Studies Agree: Medicare for All Saves Money.”

The evidence abounds: A “Medicare for All” single-payer system would guarantee comprehensive coverage to everyone in America and save money.

Christopher Cai and colleagues at three University of California campuses examined 22 studies on the projected cost impact for single-payer health insurance in the United States and reported their findings in a recent paper in PLOS Medicine. Every single study predicted that it would yield net savings over several years. In fact, it’s the only way to rein in health care spending significantly in the U.S.

All of the studies, regardless of ideological orientation, showed that long-term cost savings were likely. Even the Mercatus Center, a right-wing think tank, recently found about $2 trillion in net savings over 10 years from a single-payer Medicare for All system. Most importantly, everyone in America would have high-quality health care coverage.

The studies found that Medicare for All would eliminate three-quarters of the estimated $812 billion the U.S. now spends on health care administration. Administrative costs in the United States are so high because insurance companies–and there are hundreds, if not thousands of them– individually negotiate benefit rules and rates with thousands of hospitals and doctors. They also require different billing procedures , use different forms and have different rules for submitting claims.

The studies estimate that savings from Medicare for All would be about $600 billion per year. And that’s not including savings on prescription drugs, estimated to be another $200 or $300 billion a year if we paid about the same price as other wealthy countries pay for their drugs.

Even more savings are possible in a Medicare for All system because, like every other wealthy country, we would have a uniform electronic health records system. Such a system generates additional savings because system problems would be easier to detect and correct. A uniform claims data system helps reduce health care spending for fraudulent services. In 2018, total U.S. health care costs were $3.6 trillion, representing 17.7 percent of GDP.

The “cherry on top” of these calculations? Savings were calculated assuming the elimination of deductibles and out-of-pocket expenses.

The article also pointed to something that is not widely understood: government already pays approximately two-thirds of all American health care costs. A few years ago, when I participated in a multi-disciplinary study, the calculation was that some seventy percent of all health costs were being paid for by some unit of government– not just via Medicare and Medicaid, but also through the VA, CDC awards of research dollars, federal, state and local health care programs, coverage for government employees (including thousands of employees of public schools and universities), and ACA tax subsidies for private insurance.

A more expansive and accurate cost/benefit analysis would also include things like the decline in bankruptcies–some 50% of personal bankruptcies are due to medical costs not covered by insurance.–and evidence that crime and other forms of social discord decline sharply when social safety nets improve.

Here’s my question: if Medicare for All improves health care and costs less, what is the real reason so many Republicans oppose it?

Comments

Path Dependency And Political Naiviete

One of the lessons we should–but don’t–learn from history is that revolutions almost never succeed in replacing the systems being rejected with those that are more to the liking of the revolutionaries.

Revolutions can and do change the identity of the people in charge. The American Revolution got rid of King George and English authority, for example–but it didn’t change fundamental attitudes about individual rights, or a legal system based on common law, or accepted ways of doing business.

Short of revolution, efforts to effect big changes in the way a society functions inevitably come up against social inertia and stubborn resistance to changes in habitual ways of seeing and doing. Paul Krugman–no apologist for neoliberalism–was recently interviewed by Ezra Klein, and explained why he supports the more incremental, less radical proposals on health care.

A lot of things we think of as being very left-wing are actually extremely popular — like higher taxes on rich people. But other things requiring ordinary middle class people to change aren’t ever easy to do.

Systems that are very different from our own on health care all have deep historical roots. There is enormous path dependence in policy. The systems that countries have on health care, retirement, and most other stuff has a lot to do with decisions that were made generations ago. And it’s very hard to shift to a radically different path. So incrementalism tends to rule everywhere.

Krugman points to polling that says that a public buy-in to Medicare is very popular, but a replacement of private insurance that is not voluntary is not.

The international evidence is that it’s just very hard for to make radical changes in social programs. The shape of them tends to be fixed for a really long time. US Social Security is widely held up as a role model of doing it right because we got it right at a time when things were still pretty amorphous and uninformed. On the other hand, our health care system is a mess because of decisions we made around the same time that left us with bad stuff entrenched in the system.

The operative word is “entrenched.”

Wikipedia begins its discussion of “path dependency” thusly: “Path dependence explains how the set of decisions people face for any given circumstance is limited by the decisions they have made in the past or by the events that they experienced, even though past circumstances may no longer be relevant.”

Multiple studies of path dependence confirm that previous policy decisions that have since become “the way we do things” generate enormous inertia. Studies of welfare policies, especially, have concluded that significant changes can be made only in exceptional situations. (It isn’t only politics. Studies of how technologies become path-dependent demonstrate that so-called “externalities”–habits, really– resulting from established supplier and customer preferences can lead to the dominance of one technology over another, even if the technology that “loses” is clearly superior.)

It is one thing to compare the mess that is America’s health system with the far better systems elsewhere and acknowledge that we got it wrong. In an ideal world, we would start from scratch and devise something very different. But we don’t live in an ideal world; we live in a world and country where most people fear and resist change– even change to something that is clearly superior.

No president can wave a magic wand and effect overnight transformation. FDR and Truman both pushed for forms of national health insurance and failed. Nixon also favored it. President Kennedy supported Medicare and Johnson finally got that done in 1965–after the trauma of an assassination. All other efforts failed until 2010, when Obama and Pelosi (barely) managed to get the Affordable Care Act passed. Even that compromised legislation triggered ferocious opposition, including bills that weaken it and litigation that aims to overturn it.

People who think we just have to elect a candidate who recognizes what a better system would look like, and empower that person to wave his or her magic wand and give us a “do-over,” aren’t simply naive. They’re delusional.

The question–as always–isn’t just what. It’s how.

All of the Democrats running for President know we need single-payer. Not all of them are willing to acknowledge that we face enormous barriers to getting it done. And only one, to my knowledge, has outlined a plan to overcome path-dependency and get us from here to there.

That isn’t being “moderate.” It’s being realistic.

Comments

A Doctor’s Prescription

As the primary battles heat up, “Medicare for All” (or in Mayor Pete’s more “do-able” formulation “Medicare for All Who Want It”) has become perhaps the hot-button issue.

The Trump Administration continues to wage war on the Affordable Care Act, a/k/a Obamacare–part of Trump’s determination to erase anything and everything Obama accomplished– and thanks to Mitch McConnell’s success in placing partisans on the federal bench, that attack may succeed.

Anyone who follows the news, or has a Facebook feed, knows what we “consumers” think, and polling confirms that large majorities of Americans would welcome some form of national, universal healthcare. But what about doctors? What do medical professionals who have to work within today’s uneven patchwork of a system have to say?

I asked my cousin, the cardiologist whose insights I periodically share.

I encourage you to click through and read his post in its entirety, but I want to share several observations that I found particularly telling. The first is his reminder that we don’t go “shopping” for healthcare the same way we shop for a new pair of shoes.

Although comparison shopping makes sense when we buy a product like an automobile, such market forces do not apply to health care. Negotiation of prices of various treatments is seldom available, especially not for the complex needs of the desperately ill who consume a large share of resources. Multiple private insurance plans obscure this issue even further.

He then cites a recent study that found a significant part of the variation in medical spending–and more than half of all Medicare spending– to be determined by capacity rather than by medical need.

And speaking of cost…

In contrast to the ACA’s requiring private insurers to spend at least 80-85 percent of their revenue on delivery of health care, more than 98 percent of Medicare’s expenditures are so devoted. Estimates vary, but one-quarter to one-third of our current costs are driven by insurance company overhead, profits, and the administrative costs. Roughly half of these costs would be recovered under single-payer and could instead be devoted to the delivery of meaningful health care.

And then there are drug prices.

Drug prices must be controlled: Acceptable drug lists vary widely among health plans. Negotiated prices depend strongly upon the buyers’ purchasing volume. Only a single-payer system enables the kind of unified bulk purchasing of drugs and medical devices that would give the buyer adequate power. A model for this structure exists today here in the Department of Veterans Affairs (VA). Due to governmental authority to negotiate drug prices for the VA, it pays roughly half the retail price of drugs.

I italicized that last sentence, because it astonished me. No wonder other countries allow government to negotiate drug prices–and we can all guess why Congress expressly forbids our government to do the same.

But what about doctors’ pay? Shouldn’t doctors’ incomes compensate them for those years of medical training and residencies? Wouldn’t we lose medical personnel under a national system?

A recent analysis found that a single-payer model does not lead to a loss in physician income, allowing for care-givers to receive adequate reimbursement of expenses plus fair profits, while ensuring value for taxpayers. Streamlined billing under single payer would also save physicians vast overhead costs, enhanced by reducing the need for the many employees to fulfill the varied requirements and forms of the private insurance companies. Moreover, physicians might best be compensated with regular salary-type payments rather than the current “fee for service” model, which encourages excess medical tests and procedures that drive up costs without providing better outcomes.

And finally, what about private insurance? Opponents of a single-payer system warn that people who love their current coverage (these are people I’ve yet to encounter, but I’ll assume for the sake of argument that someone, somewhere, actually likes Anthem, et al) would lose it. My cousin seems to be recommending Mayor Pete’s “Medicare for All Who Want It” approach. He also makes a point that Kamala Harris made in a recent interview:

The population of the U.S. would likely require additional tiers of care provided by private insurers, which might add extra services to basic care such as private room selections, lower waiting periods for non-urgent problems, elimination of co-pays, long-term care, dental care, etc.

The bottom line: the doctor has diagnosed America’s current approach to healthcare as deathly ill and probably terminal. You can read his prescription in its entirety at the link.

Comments

About Those Right-Wing Judges…

As most of you know by now, a conservative judge in Texas struck down the entire Affordable Care Act, ruling it unconstitutional.

The decision is a reminder that when judges are appointed on the basis of party loyalty rather than legal acumen, the results can hurt a lot of innocent people.

Legal scholars who have reviewed the decision believe it is badly flawed and will be overturned, but Daily Kos recently enumerated the consequences should it be upheld.

The most obvious loss would be that part of the law that forbids insurance companies from excluding coverage of pre-existing conditions. But as the author noted, if the law were really to disappear, that’s just a part of what would be lost.

As many as 17 million people could lose their coverage in a single year. The 15 million people covered under Medicaid expansion could lose their coverage. The improvements to Medicare that have saved the program billions of dollars—and reduced prescription drug costs for seniors—would be erased. Young people wouldn’t be able to stay on their parents’ insurance until they’re 26. The ban on annual and lifetime caps would be gone, and medical bankruptcies would escalate. Having lady parts would again cost women more than men, and being over age 50 would cost everyone more again. Limits on out-of-pocket costs would be gone. The tax credits that 9 million people are receiving to help them pay premiums would be gone.

The post focused on the political fallout of the threatened losses. (Even Republicans concede that the issue hurts them.) But the real lessons aren’t partisan.

There are two obvious “take-aways” here.

First is the incredible amount of damage that can be done by elevating ideologues to the bench. This sort of “smash and burn” judging is a direct result of viewing the federal courts as a partisan political prize rather than a constitutional safeguard to be protected by the appointment of dispassionate, knowledgable and qualified legal scholars.

The second is equally obvious. As important as the ACA is, as much of a step forward that it represents, it falls far short of what Americans need and most other wealthy countries have long had. Not only is it vulnerable to the sort of judicial assassination we’ve just experienced, it is simply insufficient.

It would be poetic justice–not to mention actual justice–if this effort by a radical judge prompted Congress to pass Medicare for All, or at least a “public option” allowing citizens of all ages to “opt in” to the program.

Comments