Tag Archives: Medicare for All

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.

 

 

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.

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.

Religion, Social Justice And Medicare For All

These are difficult days for genuinely religious folks–the ones who understand their theologies to require ethical and loving behaviors.

The 2016 election highlighted the glaring hypocrisies of Evangelical Trump supporters; more recently, it’s Catholics who are cringing. In Pennsylvania, a grand jury found the Church had concealed 70 years of sexual abuse by over 300 priests. Here in Indianapolis, the administration of a Catholic high school learned that a longtime, much-loved guidance counselor is in a same-sex marriage, and demanded that she divorce her wife or resign.

Not exactly ethical or loving behaviors.

On the other hand, dozens of local Catholics, including alumni of that high school, are publicly and vigorously supporting the counselor, and others are prominent advocates for social justice, and for programs to help the poor.

Local Catholics are also prominent advocates of establishing a “Medicare for All” chapter in Indianapolis.

In an essay for the National Catholic Reporter, law professor Fran Quigley argues eloquently that faith communities–including his– need to make a moral case for universal health care.

Mark Trover of Indiana had a job and access to health insurance, but the premiums and co-pays were too high for him to afford. A doctor had prescribed medicine for his dangerously high blood pressure, but the cost was high and Trover stopped filling the prescription — right up until the time he suffered a stroke that left him permanently disabled.

Karyn Wofford of Georgia has type 1 diabetes, and has often been forced to ration the insulin she needs to survive. The cost of the medicine has risen over 1,000 percent in recent years, and the 29 year-old knows there are many other Americans who have suffered and even died from diabetic ketoacidosis because they could not afford the medicine. “Having access to diabetic supplies and insulin, to feel okay when I wake up in the morning — that’s my dream,” she wrote for the T1 International blog.

These stories represent the status quo of U.S. health care. Even after the Affordable Care Act, there are over 28 million people in our country living completely without health coverage, a group disproportionately made up of people of color. Among those who do have insurance coverage, nearly a third are enrolled in high-deductible insurance plans that can force them to skip filling prescriptions or go without other necessary care.

These stories–and the millions of Americans who have similar ones–are shameful reminders that the United States lags behind virtually all other industrialized countries when it comes to the health of our citizens. Ironically, we are far more religious than citizens of countries that run circles around us when it comes to health care.

As Fran documents, however, religious leaders are finally mobilizing:

In response to the mean-spirited and fiscally self-sabotaging efforts to repeal the Affordable Care Act last year, faith groups raised their collective voice, and to great effect. Dozens of denominations and organizations from a wide range of faith traditions issued joint statements, mobilized their members, and conducted a dramatic Capitol Hill vigil. They brought a morally powerful foundation to the resistance to Affordable Care Act repeal efforts.

As a March 2017 letter signed by leaders of 40 faith organizations said, “The scriptures of the Abrahamic traditions of Christians, Jews, and Muslims, as well as the sacred teachings of other faiths, understand that addressing the general welfare of the nation includes giving particular attention to people experiencing poverty or sickness.”

That shared mandate compelled us as people of faith to act to preserve the Affordable Care Act, which has expanded care to millions of Americans who needed it. Now, those same sacred teachings require us to speak out with just as much urgency to fully repair the gaps left behind even after the act is preserved.

All major religious traditions recognize a responsibility to provide for the poor and the sick–and while the ACA is an important step in the right direction, it falls far short of being universal. What is needed is a single-payer system like those in other first-world countries.

Legislation packaged as “Expanded and Improved Medicare for All” has over 120 co-sponsors in the U.S. House of Representatives and support from a growing number of senators, reflecting polls that show a majority of Americans support a single-payer system.

But the will of the people does not always translate into changed policies, especially when heavily financed lobbyists and campaign contributors from insurance and pharmaceutical companies block the path. That is where the faith community comes in. The economic argument in favor of a single-payer, universal health care system is undeniably powerful, but the moral case for health care as a human right is even stronger. The faith community stands in the ideal place to advance that moral argument.

I encourage those reading this to click through and read the article in its entirety, or even one of my earlier posts, which comes to the same conclusion. I especially encourage you to attend the inaugural meeting of the Medicare for All Group next Thursday, August 23d, to be held at 6:30 at Indianapolis’ First Friends Church.

This effort is a timely reminder that sincere “people of faith”–all faiths–are working for social justice. They don’t make as much noise as the theocrats and hypocrites, and they aren’t as newsworthy, but these efforts remind us that there are also a lot of good people in those pews.

Anticipating Unanticipated Consequences

These are horrific political times. It’s hard not to be depressed–every day, it seems, we wake up to a new assault on what we thought were American values, new evidence of deplorable behaviors and attitudes we thought we’d left behind, new efforts to roll back hard-won progress.

But.

We need to remind ourselves that the turbulence and upheaval we see around us is not a new phenomenon. Times of social transition are typically unsettled and contentious. (Think of the Sixties, not to mention the Industrial Revolution, the Civil War…). The question is: what comes next? What are we transitioning to? 

My own prediction–based on history and a lot of hope–is that the election of Trump will prove to be a turning point, that the resistance and increased activism we are already seeing will grow more pronounced, and the political pendulum will swing back toward sanity and concern for the common good. The problem is, in the meantime, Trump and the Congressional GOP are doing incalculable damage to the environment, to the rule of law, to the economy and to America’s place in the world.

Yesterday, McConnell finally unveiled the Senate’s Trumpcare bill, and it is even worse than the House version; it proposes to take health care from millions of struggling Americans in order to give a huge tax break to the rich.

Despicable as it is, I’m not the only person who sees potential for eventual progress lurking in short-term disaster. Take Ezra Klein’s recent article for Vox, “Republicans are about to make Medicare-for-All Much More Likely.”

On Friday, McConnell reportedly “delivered a private warning to his Senate Republicans: If they failed to pass legislation unwinding the Affordable Care Act, Democrats could regain power and establish a single-payer health-care system.”

History may record a certain irony if this is the argument McConnell uses to successfully destroy Obamacare. In recent conversations with Democrats and industry observers, I’ve become convinced that just the opposite is true: If Republicans unwind Obamacare and pass their bill, then Democrats are much likelier to establish a single-payer health care system — or at least the beginnings of one — when they regain power.

And if the GOP successfully unwinds Obamacare, the Democrats are far more likely to regain power in 2018. As Klein says,

The political fallout from passing the American Health Care Act — which even Donald Trump is reportedly calling “mean” — will also be immense. In passing a bill that polls at 20 percent even before taking insurance away from anyone, Republicans will give Democrats a driving issue in 2018 and beyond — and next time Democrats have power, they’ll have to deliver on their promises to voters. Much as repeal and replace powered the GOP since 2010 and dominated their agenda as soon as they won back the White House, if the American Health Care Act passes, “Medicare for all” will power the Democratic Party after 2017.

The bubble that Congressional Republicans occupy has become so divorced from the reality of American life and opinion–so in thrall to a (shrinking) base that is itself divorced from reality–that they no longer connect with most Americans. And presumably, the Democrats will have learned some important lessons from their experience with the ACA.

If Republicans wipe out the Affordable Care Act and de-insure tens of millions of people, they will prove a few things to Democrats. First, including private insurers and conservative ideas in a health reform plan doesn’t offer a scintilla of political protection, much less Republican support. Second, sweeping health reform can be passed quickly, with only 51 votes in the Senate, and with no support from major industry actors. Third, it’s easier to defend popular government programs that people already understand and appreciate, like Medicaid and Medicare, than to defend complex public-private partnerships, like Obamacare’s exchanges….

Obamacare was the test of the incrementalist theory, and, politically, at least, it’s failed. Democrats built a law to appeal to moderate Republicans that incorporated key ideas from Mitt Romney’s Massachusetts reforms, and it nevertheless became the single most polarizing initiative of Obama’s presidency. All the work Democrats did to build support from the health care industry has proven to be worth precious little as Republicans push their repeal plan forward. And the complex public-private design of the Affordable Care Act left the system dependent on the business decisions of private insurers and left Democrats trying to explain away premium increases they don’t control. The result is a Democratic Party moving left, and fast, on health care.

“I have been in contact with a lot of Democrats in Congress,” says Yale’s Jacob Hacker, who is influential in liberal health policy circles, “and I am confident that the modal policy approach has shifted pretty strongly toward a more direct, public-option strategy, if not ‘Medicare for all.’”

As bleak as our current political environment is, Klein and others see Ryan, McConnell and our clueless President unwittingly sowing the seeds of fairer and more cost-effective policies.

The accuracy of that prediction, of course, depends upon the strength, savvy and persistence of the Resistance.