Tag Archives: Medicare for All

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.

It’s Not Just Complicated…

Trump generated a lot of well-deserved criticism–not to mention sarcasm–for his recent expression of surprise at the complexity of health policy, saying “Who knew it was so complicated?” The universal response was “Apparently, everyone but you!”

Which brings us to the bill currently before Congress.

Virtually every headline about Paul Ryan’s proposed ACA replacement has been negative: NBC’s said bluntly “Experts: The GOP Healthcare Plan Just Won’t Work.”

While their objections vary depending on their ideological goals, the newly introduced American Health Care Act (AHCA) is facing an unrelenting wave of criticism. Some experts warn that the bill is flawed in ways that could unravel the individual insurance market.

Among other problems, the article pointed out that the bill is almost certain to reduce overall coverage and result in deductibles increasing. It will also phase out Obamacare’s Medicaid expansion. Older, sicker and lower-income patients will be the bigger losers.

The headline of the Washington Post’s Plum Line was equally direct: “The New Republican Health-Care Plan is Awe-Inpiringly Awful.”  

Noting that Trump had campaigned on a promise to replace the ACA with “something terrific,” Paul Waldman, who authors the Plum Line, observed that the bill is

so far from terrific that there doesn’t seem to be anyone other than House Speaker Paul D. Ryan (R-Wis.) himself who thinks this bill isn’t a disaster. It’s being attacked not just from the left but from the right as well. Heritage Action and the Club for Growth, two groups that exist to browbeat Republicans into upholding hard-right principles, have just come out against it.

Waldman marveled that

House Republicans have accomplished something remarkable: They have written a bill that would make every problem they’ve complained about much, much worse. If there’s any saving grace, it’s that almost no one will be happy about it, except for the wealthy people to whom it gives a gigantic tax cut.

So… Republicans are going to drastically reduce the number of Americans with health insurance while increasing costs pretty much across the board:  individuals, state governments and the federal government will all pay more. According to insurance experts, the bill will also do enormous damage to the insurance market. The GOP is evidently willing to inflict all that pain in order to give rich people a tax cut.

The problems with the bill range from the ludicrous to the outrageous, and you can all decide for yourselves which parts you find more horrific or ridiculous, but as a number of observers have pointed out, the promises of a genuine Republican replacement for Obamacare were always impossible to keep.

Today’s GOP is an increasingly uncomfortable amalgam of true believers who oppose the very notion that government has an obligation to provide access to health insurance, and who are working frantically to eliminate Medicare and Medicaid, and the party’s realists, who know that taking health insurance away from Americans who finally have been able to access it–not to mention Medicare recipients– is political suicide.

That’s a political fence that can’t be straddled.

What Ryan and his minions are trying to do is square the circle: drastically reduce coverage while pretending they are doing no such thing.

Some day–if and when sanity and a modicum of honesty return to American government– the United States will join virtually every other first-world country and provide universal coverage. I’ve previously posted about the multiple benefits and clear superiority of Medicare for All.

In 2006, the Economist—hardly a leftwing publication—had this to say about the U.S. healthcare system:

“America’s health care system is unlike any other. The United States spends 16% of its GDP on health, around twice the rich country average, equivalent to $6,280 for every American each year. Yet it is the only rich country that does not guarantee universal health coverage. Thanks to an accident of history, most Americans receive health insurance through their employer, with the government picking up the bill for the poor (through Medicaid) and the elderly (through Medicare).

[…]

In the longer term, America, like this adamantly pro-market newspaper, may have no choice other than to accept a more overtly European-style system.”

Obamacare was a step in the right direction, but America still spends more per person on healthcare than any other country–and we still rank 37th in outcomes. (If our infant mortality rate was as good as Cuba’s—Cuba’s!—we would save the lives of an additional 2,212 babies every year.)

Other countries have opted for more efficient–and more humane– national systems.

In 2017 America, we are still arguing over whether healthcare should be viewed as a right (or at least a utility), or whether we should continue to treat it as a consumer product, available to those who can afford it and “tough luck” to those who can’t.

That circle can’t be squared.

 

Medicare for All

I’ve been interested to see how frequently the comments to this blog end up discussing (and debating) America’s health care system–even when the ostensible subject of that day’s post is something entirely different.

(As I was typing the phrase “healthcare system,” I was reminded of a graduate student—a hospital administrator—who corrected my use of that term. “America doesn’t have a healhcare system,” he said. “We have a healthcare industry” and it’s not the same thing.)

I often share insights from my cousin, a respected cardiologist who also spent many years teaching medicine. He recently sent me a thoughtful analysis of that healthcare industry, and the prospects for fixing what everyone realizes is unsustainable. I particularly like his introduction to the issue:

When considering the best way to solve our country’s medical care woes, I am reminded of Churchill’s famous statement about democracy as a form of government, in which he stated in effect: It’s a terrible system, but everything else is worse. This same statement might apply to a single payer system in medical care, for it probably beats everything else, as I explain below.

He noted that a truly effective system will require cost controls, including tort reform, the excessively high cost of drugs, inappropriate use of expensive tests and treatments, and several others. He is convinced that these issues can be resolved, and that a single-payer system (for example, “Medicare for All”) is both inevitable and the best solution:

In an article on why a single-payer system would be our best solution, Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and an architect of the Affordable Care Act (ACA), contended that although the ACA has been “a step forward for the country,” it “does not deal with the problem of waste and complexity in the system,” as he feels a single-payer system would. I can personally attest to the complexity of the system with the many headaches provided by a dizzying array of differing insurance forms pertaining to treatments, hospital admissions and a multitude of other issues.

And James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of the forthcoming book Talking About SINGLE PAYER!, argued that a single-payer system is “a more economical way to use healthcare resources. You could reduce expenses and still improve quality. That’s a tremendous opportunity that you don’t have in many other fields.” Of course, as he pointed out, this would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000. (Maybe these same workers could be involved in more productive work such as restoring our nation’s wobbly infrastructure!) But Dr Burdick also maintains that a single payer system would likely restore doctors’ authority. And those who favor this system say that for all practices, administrative costs would plummet because there would be only one set of payment rules and forms, with the result that prior authorizations, narrow networks, and out-of-pocket payments would be eliminated.

He also reports that there is growing physician support for a single-payer system. For example, a 2014 survey of Maine physicians conducted found that nearly 65% of respondents preferred the single-payer option over trying to fix the current system—up from 52% in a 2008 survey.

Interestingly, a majority of the population (51%) now supports Medicare for all, according to a national poll released this past year.

In reality, a government-run single-payer system is the only way to provide effective basic medical health therapy and management, but for those who desire a higher level of care—and can afford it—there should be a private-pay system, contrast with the Canadian system. This would, de facto, constitute a two-tiered system. This might be objectionable to egalitarians that wish to have a “one size fits all” system, but would be the most pragmatic approach.

Usually those against single payer system trot out the usual vague objections that we are becoming “socialistic.” But what about our current Medicare system, is that not socialistic? I might add further that I personally have worked at a VA hospital, and, despite all the current noise, found that once patients were able to access the system, the care is quite good. Its main problem seems to be gaining initial entry into an overburdened system in a timely manner. By contrast, it is highly unlikely that a random assortment of for-profit HMOs would do a better job serving the high-utilization health needs of our veterans.

His conclusion–with which I concur:

Whether we like it or not, basic healthcare is like a utility—something everyone needs, and, in the best interest of our society, everyone should receive. Although there are many variations of the general theme as I have enumerated above, we are moving inevitably toward a single payer system. When it finally arrives, I believe everyone will be relieved, if not pleased, even including the Republicans!

Is the Individual Mandate Constitutional?

The most controversial provision of the Affordable Care Act  is undoubtedly the individual mandate–the requirement that almost everyone carry health insurance.

Why a mandate? As the LA times said, “A mandate is key for reducing the ranks of the uninsured, who often turn to emergency rooms for care, driving up everyone’s costs. Spreading the costs—among healthy and sick—is also the only way to make the reforms work.” Health economists agree–in order for this reform to work, it has to include the mandate. So—It’s necessary, but is it constitutional?

According to most constitutional scholars, yes. Here’s the analysis:

Congress has authority both to regulate commerce among the several states, and to “lay and collect taxes to provide for the general welfare.” The Senate bill requires that citizens purchase qualifying health coverage; if they don’t, they pay a tax penalty. Exemptions are granted for religious objections, financial hardship and a variety of other reasons. The House bill didn’t impose a “mandate” per se, but amended the Internal Revenue Code to levy a “tax on individuals without acceptable health coverage.” Functionally, the two provisions are essentially the same. (Interestingly, opponents concede that Congress could lawfully establish single-payer (Medicare for All, say), and tax us to pay for it.)

In 1944, Supreme Court established that insurance is an economic activity that falls within Congress’ regulatory power. More recently, the Lopez and Gonzales cases clarified how the Court understands “economic” and “non-economic” activities within the context of Commerce Clause. In Lopez, Court held that Congress exceeded its authority by legislating against guns near schools; in Gonzales, it ruled that the act of growing marijuana at home could be regulated by the federal government even though the conduct was not itself economic, because the larger interstate “regulatory scheme would be undercut unless the intrastate activity were regulated.” As one scholar has summarized, “ If health insurance is itself an ‘ingredient’ of interstate commerce and ‘self-evidently’ within Congress’ Commerce Clause authority, the statutory goals for broadening, making more efficient and less costly, and otherwise improving health insurance coverage, fit equally within that authority.

Further, the individual mandate requirement easily qualifies as a ‘necessary and proper’ means of achieving those goals, under the standard first articulated by Chief Justice Marshall [in 1819] and adhered to since: “Let the end be legitimate, let it be within the scope of the constitution, and all means which are appropriate, which are plainly adapted to that end, which are not prohibited, but consist with the letter and spirit of the constitution, are constitutional.”

The Federalist Society and other opponents of the mandate have argued that refusal to purchase insurance is inactivity, and thus not subject to regulation. How, they ask, can government regulate a decision not to act?  But as judges have noted who upheld the mandate, people who refuse to buy insurance are not doing “nothing.” They are gambling that they won’t need coverage, or they are deciding to self-insure. In either case, they are also deciding to game the system, making the overall program unworkable.

Refusal to purchase health insurance would be analogous to refusal to pay social security and Medicare taxes or, at the state level, refusal to purchase auto insurance.

Most constitutional scholars believe the mandate will be upheld; others–noting the ideological tilt of several of the Justices–are less certain, although they agree that precedents would ordinarily require such a result.

Ironically, since opponents of the mandate are making the case that ONLY a single-payer system is constitutional, a victory for opponents might actually result in the enactment of a single-payer system, since the multiple markets we’ve been operating under are simply not sustainable.

Works for me.