Sunday, March 31, 2019

Medicare for All: Still a great idea!

My last several posts have all had “Medicare for All” in the title. This makes one more. Maybe I am in a rut, or maybe it is simply the most important issue confronting health care in the US. Certainly there has been a lot written about it; just a review of very recent articles in the New York Times includes a wide variety. Conservative columnist David Brooks informs us that there is “no plausible route” to get to it, and we are told by Reed Abelson and Margot Sanger-Katz that there is “no precedent” for abolishing private insurance. The angst of the Democratic Party leadership in dealing with this newly-resurgent demand from its base is also discussed at length, with the Associated Press letting us know that it is a “divisive issue for Dems”. Robert Pear tells us about Nancy Pelosi’s plan to “expand health coverage” while being sure to not cover everyone. Of course, President Trump, not to be outdone (nobody outdoes the #Trumpenik!) has now announced his own plan, to completely gut and get rid of the Affordable Care Act and its expanded coverage. This is seen as a great gift to Pelosi, who needed something coming from way to her right, and now can “pivot hard” to fight to preserve ACA from the GOP rather than fighting with her own party’s progressives.

Of course, the Trump plan – get rid of Obamacare and then, well, don’t really have a plan after that, but it will be great – makes even a lot of Republicans nervous. Gail Collins has a particularly good time pointing this out, noting that
Republicans in Congress began desperately leaking the news that they had tried to talk their alleged leader out of the idea. The Democrats were almost swooning with joy. Really, Trump could not have made them happier if he’d announced that he planned to unveil a new tax cut called Help for The Greedy Rich.’
She also observes that the President has now moved from “who knew health care was so complicated?” to “I now understand health care especially very well”. Of course, he doesn’t – in fact, he understands it much less well than most policy makers, which isn’t very well at all, but he does understand how to both appeal to his base and please the wealthy folks who control the Republican Party, and indeed much of the Democratic Party.

It is frequently pointed out that many of the people who were most helped by the ACA, in particular its provisions that allow individuals to buy insurance at community rating, prevent discrimination against those with pre-existing conditions, and expanded Medicaid, are those in Trump’s base, and that eliminating the program and leaving another 20 million people without insurance might backfire. Paul Krugman’s column “The Republicans really hate health care” is accurate, and makes this point; for example, that West Virginia was promised better health care and more coal jobs. It has gotten only a few coal jobs, but 140,000 people stand to lose health care coverage if ACA is repealed. It remains to be seen if this will translate into folks voting against him and his minions, but I wouldn’t hold my breath. Although, even the Wall St. Journal has had an op-ed by Robert Pollin advocating for Medicare for All.
So what is it with the Democrats? The concerns that are expressed by many centrist, leadership Democrats about Medicare for All, or Universal Health Care of any kind seem to be in three broad areas: 1) Is it a good thing to cover everyone? 2) What will be the price Americans pay for universal health care? 3) Is this a politically feasible possibility? It is important to recognize that the fact that these questions are being asked at all, and that there is a significant portion of the Democratic congressional delegation who support Medicare for All, and that there is huge support among the American people, is YUGE. It is a testimony to how important health care is to us, to the fact that most of us are not buying the GOP line, and to the success that Sen. Sanders had and continues to have in raising the issue and continuing to focus on it.
First, is it a good thing to cover everyone? Answer: Yes. Everyone needs access to health care, and those who need it the most are often those who are left out of current, past, and future schemes for coverage – mainly poor, or near poor, people. It might be ok to leave some people out if those advocating it, advocating incrementalism, would suggest that the appropriate people to be left of were themselves and people like themselves, or the wealthiest, who can afford to pay their own way. But no, it is always the most vulnerable. And, anyway, there is great advantage to everyone being in the same system; the wealthy and powerful will ensure that the system works for them, and if everyone is in it together, it is more likely to work for everyone. The Times has a recent article about  Sen. Sanders saying “No to incrementalism”, which for some reason makes it sound like a bad thing. It is not. Certainly not if you and your family are being the ones left out by incrementalism!
Second, what will be the price? It will cost a lot to cover everyone. The numbers that even the sponsors of HR 1384, the Improved and Expanded Medicare for All bill whose primary sponsor is Rep. Pramila Jayapal of Washington, have put forward are very large. The thing is, though, the numbers that we spend NOW, by insurers and the federal and local governments (via Medicare and Medicaid and covering all their employees), and out of our own pockets in premiums, deductibles, and co-pays are far larger! And, of course, all this money buys us neither adequate health care for lots of people who are underinsured or have insurers denying claims, or good health outcomes. The US has for decades trailed the developed world in almost all measures of population health outcomes, and led only (by far) on money spent, both in total and per capita. Much of this money can be characterized as “waste” in the sense that it does not deliver health care to anyone, but is spent on high administrative overheads and profits for insurers and providers and drug manufacturers.
Third, is it politically feasible? This is an issue with lots of components. One highlighted by several articles in the media, such as the above-mentioned ‘Abolish private insurance: no precedent’ in the Times, are the jobs that will be lost in the insurance industry. And, although it doesn’t say it, in the offices of hospital providers who have armies of workers to fight with the insurance workers about payment. An expensive zero-sum game, except it is the people who pay. Sure, these are real job losses, but when has it been right to continue a bloated, non-productive industry that screws the whole country to protect jobs? I think never, but this is just a smokescreen for protecting profits. And HR 1384 actually contains funding for job retraining. The bigger issue for Democrats is money, money from big donors, as described in another NY Times article, ‘Even Liberal Democrats Can’t Quit Wealthy Donors and Their Big Checks’, although Sanders and Warren are the exceptions. In essence, “politically feasible” is always the one put forward by those who do not want big change to try to head it.
But there is great momentum from, you know, regular people, now. We have to keep it up and demand it from our legislators and candidates, and that will make it feasible.

Saturday, March 2, 2019

Medicare for All, Compromise, and who gets left out

As the movement for Medicare for All gains steam, with the new bill, HR-1384, being introduced by Rep. Pramila Jayapal (D-WA) and 100 co-sponsors (video available on PNHP Facebook page), the attacks have, unsurprisingly, started coming. They are hard and soft, overt and subtle. The overt attacks on it from Republicans who call it “socialism” are probably the least important. They, and the folks for whom socialism is a buzzword that has them throwing up their hands in horror, were never going to support it or any effort to have universal health insurance, and are probably not going to support any less-extensive compromise. On the other hand, they could learn something by reading about the experiences of people in the all-the-other-industrialized-countries-in-the-world who have some form of universal health care. For example, the recent piece in the Washington Post by an American studying in Taiwan,  uninsured in either country, whose abdominal pain nonetheless led him to go to the ER at 3am. He was seen and given treatment in 20 minutes, had lab tests and imaging studies, was diagnosed with a stomach virus and given 2 medications, and sent off. Total cost: $80. (March 1, 2019)

The real threat, unsubtle and incredibly well-funded, is from the insurance and hospital corporations (and “non-profit” health systems) who are responsible for about 30% of all dollars spent on health care in the US being for administrative costs (including their huge profits) and not actually health care. They are a major cause of the high cost of health care in the US, and stand to lose the most if Medicare for All is implemented, because it will be funded in large part by taking that money away from them. Thus, they are highly motivated to attack any such attempt, organized to do so, and are already doing it, as clearly presented in Health Care and Insurance Industries Mobilize to Kill ‘Medicare for All’, NY Times February 23, 2019. This will ultimately be the real fight, incredibly wealthy companies that would lose a lot of money will do almost anything to keep it, even though it will prevent a change in the current crazy, costly, poor-result non-system that we currently have, that would benefit the health of all the rest of us.

The more subtle attacks, or perhaps “criticisms”, are from other Democrats and ostensibly liberal media, like the Times. Senator Bernie Sanders (I-VT) sponsors a single-payer Medicare for All bill in the Senate, S-1804, and many of the current candidates for the Democratic presidential nomination are co-sponsors, including Sens. Elizabeth Warren (D-MA), Kamala Harris (D-CA), Cory Booker (D-NJ), and Kirsten Gillibrand (D-NY), and Rep. Tulsi Gabbard (D-HI) is a cosponsor of HR-1384. Sen. Amy Klobuchar (D-MN) and Rep. Julian Castro (D-TX) are not. S-1804 is not quite as good or comprehensive as HR-1384 (the even-better successor to the old HR-676), but this is not the reason almost all of them (except, of course, Sen. Sanders) have stepped back a little from, or danced around, their position on a single-payer program in various interviews with the press. They worry it might go too far, and while want support from single-payer fans, they fear alienating others, or believe that Medicare for All cannot happen, and talk about compromise. Several senators have introduced another bill that would allow people over 50 to buy into Medicare ('Medicare for More', but only if they pay). The Times, however, is getting more supportive; in their February 16, 2019 editorial ‘How Much Will Americans Sacrifice for Good Health Care?’, they move to focusing on the cost and practicality, and no longer say single payer or Medicare for All is not a good thing.

Of course, other leaders of the Democratic Party do not even pretend to support Medicare for All, and cling to the falsehood that the Affordable Care Act (ACA) would be enough if the GOP had not let many of its components expire, and GOP governors had not refused to institute expanded Medicaid in so many states. The classic rendition of this song was performed by House Speaker Nancy Pelosi (D-CA), in an interview in a recent Rolling Stone. Dr. Don McCanne, in his great Quote of the Day, correctly says of Pelosi’s comments:
‘Perhaps most disappointing have been the responses of those who would prefer to continue to support the Affordable Care Act and add a public option - a Medicare buy-in for some…."All I want is the goal of every American having access to health care. You don’t get there by dismantling the Affordable Care Act." Further she says, "When they say Medicare for All, people have to understand this: Medicare for All is not as good a benefit as the Affordable Care Act." Has she been practicing composing Trumpisms? The Jayapal Medicare for All Act is vastly superior to ACA - absolutely no contest.’

“Compromise” is often touted as a good thing, and sometimes it is. Maybe it means you and your partner take turns deciding what movie to see or what to have for dinner. But often compromise is, as noted by business guru Stephen Covey, it is a “lose-lose”, where everyone gives up something they want. If we can find something that is “win-win”, it is of course better. Medicare for All might actually be a “win-lose”, a win for the American people (comprehensive health care for less money) but a loss of enormous profit for the big health and insurance corporations (no tears here).

The most obvious flaw in the logic of the mainstream Democrats is harping on the cost. Yes, it will cost a lot, but the average American family will pay less than they are now in premiums, deductibles and co-payments. The big saving would be in the elimination of the money being made by insurance companies, drug companies, and health systems, and apparently Speaker Pelosi is not ready to cut off their access to the trough. Already, the government pays almost 60% of all health costs (Medicare, Medicaid, coverage for government employees, tax breaks for employer contributions to health insurance, etc.) This means that, in our country, the government already pays more per capita than in most countries that cover everyone. Yes, HR-1384 would expand the benefits of Medicare (‘Improved and Expanded Medicare for All’) to be basically everything with no copays or deductibles, and this would be costly, but those of us who can afford it pay for them anyway, and those who cannot currently do without.

But there is another flaw. All of the folks advocating for less-than-universal-coverage, Medicare-for-More, buy-in to Medicaid for folks not poor enough to qualify now, let’s-not-let-the-perfect-be-the-enemy-of-the-good, are missing something. What they are missing is those people who are not covered or covered with poor insurance that won’t meet their needs if they are sick. All the compromise politicians and pundits seem to forget that these are real people, not just numbers (yes, if fully implemented the ACA covers 90%, but is that enough?). As I wrote in my very first blog post (“Universal Health Coverage”, November 28, 2008), ‘When was the last time, even in private but certainly in public, you ever heard someone say “I’m really suffering without health coverage, but don’t worry about including me and my family in your health reform plan. We don’t want to let the perfect be the enemy of the good.”?’ Those advocating for less than universal coverage need to get out there and tell us who it is that they don’t think needs good health coverage, who can be left out. You? Your Uncle George or Aunt Minnie? Your neighbor? Who are the Americans who they are advocating leaving out?

I can tell you one thing. It won’t be them or their families.

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