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.

The Supremes and ACA: Is opposing coverage for the poor really just mean?

In the context of the historic and momentous Supreme Court decision legalizing gay marriage across the US, and its affirmation of the Fair Housing Act, the third of the “trifecta” of progressive decisions announced this week, the ruling against those who argued that the ACA forbid federal financial support of federally-sponsored rather than state-sponsored insurance exchanges, seems rather pedestrian. After all, it just decided that the intent of the ACA was to achieve what its intent was – greater insurance coverage for the American people – and this would not be invalidated by 4 poorly-chosen words in a 1,000 page bill. What is more worthy of note is that there were three Supreme Court Justices who voted against it, when it was clearly not a real issue of law but an end-run to get it invalidated on a technicality. The low point of the dissent was Justice Scalia’s juvenile characterization of the majority decision as “jiggery-pokery”, an archaic expression most recently used in the public domain in a Harry Potter movie. Of course, Scalia could make a fair Harry Potter villain; not the potent evil of Lord Voldemort, but more of a scowling, snarling Severus Snape.

But the decision has real meaning. It means that millions of Americans in the 34 states that elected to not establish state-based exchanges and thus depend upon federal ones will not lose their health insurance. That is a good thing for those people, and it is a good thing for America. It does nothing for those people who were excluded by the SCOTUS decision 3 years ago (also written by Chief Justice Roberts) that, while validating ACA, precluded requiring states to expand Medicaid. This left millions more in the states that have not done so (like mine, Kansas) without insurance.  It certainly does nothing for the millions of those without legal documentation who live here, or the many others who fall between the cracks of the law. It still leaves us without the moral, medical, social, and economic advantages that come from a truly universal health system such as any of those adopted by every other wealthy nation, which achieve better health for less cost (see graphic). But it does make us seem slightly less cruel and benighted.

Not that this will end the discussion. A small article in the New York Times of June 27, 2015 notes that “Legal challenges remain for health law”.  These include a lawsuit by House Republicans led by Speaker John Boehner maintaining ACA is invalid because it spends money not appropriated by Congress, and a series of suits by religious organizations about the law’s requirement that they cover contraception. Indeed, the whole opposition to the law has becoming akin to a religion itself; according to its opponents (obviously also including all the Republican candidates for President) it is bad as a matter of faith, even though it does so much good. Yes, it does good in costly ways, ensuring that insurance companies make their profit; it does it in arcane ways; it does it in ways which in fact cost some people more than they might have otherwise paid. But it provides several million people the opportunity to not be the Donna Atkins or Tommy Davis of the future (see Dead Man Walking: People still die from lack of health insurance, November 17, 2013).

In response to a blog in which I posted a map that shows that the vast majority of those remaining uninsured are in the states of the former Confederacy and suggested that while Southern people might not be meaner than others, the impact of their policies was (Medicaid expansion and uncovered lives: are people meaner in the South?, February 8, 2015), Bobby Cohen wrote in a comment “If meanness doesn't explain the rejection of Medicaid expansion by Southern states, what does?” Well, for many people, I suppose, it is ignorance, of the sort demonstrated by “Keep the government’s hands off my Medicare!” or what I have called the “Craig T. Nelson fallacy” (“I've been on food stamps and welfare. Anybody help me out? No. No.”!!). Or the beliefs of some of the people in southeast Kansas interviewed for Kai Wright’s excellent article “Life and Death in Brownback’s Kansas”, published in the June 22/29 issue of The Nation where it seems that “Everyone is convinced that someone else is getting a better deal, that somewhere a horde of Kansans are gaming the system and preventing the truly needy from getting help.” In a true “What’s the Matter with Kansas”[1] illustration, even the doctor at the community health clinic who is fighting hard to get care for her impoverished patients who would have otherwise had Medicaid is conflicted; Brownback, after all, is a strong anti-abortion advocate, as is she.

All of these may explain some of the position of the leaders of this movement, but a better explanation can be found in the answer to one of the questions in “Steven Pinker’s Mind Games”, a psychology quiz on the NY Times website: “the best liar is the one who believes his own lies”. But it is hard to look at, not to mention listen to or read, the hard-core right-wing justices on the Supreme Court (who, unlike the GOP’s many presidential candidates are not even running for office) without thinking that they are, essentially, mean. They are not only against helping people when it will cost them, not altruists (another Pinker question), but even when it will save them money (again, see graphic).

I do not claim to be a legal scholar of the status of any of the Supreme Court Justices, or indeed the President. I gained some understanding from “The elusive right to health care under US law”, by Prah Ruger, Ruger, and Annas in the June 25, 2015 issue of the New England Journal of Medicine, published before any of these SCOTUS decisions were announced.[2] It’s a good and readable article which helps medical people like me understand some of the logic of court decisions. One line I found of particular interest was “American constitutionalism has championed negative liberties more than positive rights.” The idea is that the Constitution says government should not be allowed to take away our individual liberties (e.g., our guns) but not so much that we have a right to things (e.g., health care).

And yet, as pointed out by Gail Collins in “Supremes hit a high note”, this Court has “…destroyed the nation’s campaign finance laws, limited workers’ rights to challenge wage discrimination and women’s rights to control their bodies. And basically disemboweled a 50-year-old Voting Rights Act that Congress had renewed by increasingly large margins on four different occasions.” These decisions, almost all of which came out differently from those of the last 2 days only by the “swing vote” of Justice Kennedy (Chief Justice Roberts did join the majority in the decision on ACA), do not always follow this logic. It is quite an extension of the idea of liberty to say that corporations are people (the founders certainly didn’t think so) or money is speech. It is quite opposite protecting individual liberty to have laws limiting the ability of women to obtain contraception or abortion (although they can sure have guns!). Whether put forward by ignorant bigots, self-serving politicians, or sanctimonious Supreme Court Justices, the concept is most consistently “people should be allowed to do whatever they want, as long as they want the same things I do, but not what I disapprove of”. Sometimes, particularly when describing the actions of the powerful, this is described as political. But I think Dr. Cohen is right; it is essentially mean.

A phrase we commonly hear is that “mean people suck”. They do, but more important, when they have positions of power, they can do a lot of damage to others.

  

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[1] Thomas Frank. “What’s the matter with Kansas?”. Henry Holt. 2004 [interestingly, published in the UK and Australia under the title “What’s the matter with America?”!] ISBN 0-8050-7339-6.

[2] Jennifer Prah Ruger, Ph.D., M.S.L., Theodore W. Ruger, J.D., and George J. Annas, J.D., M.P.H., The Elusive Right to Health Care under U.S. Law, N Engl J Med 2015; 372:2558-2563June 25, 2015DOI: 10.1056/NEJMhle1412262