Biden: Not Medicare for All, but leadership on COVID

The defeat of Donald Trump in the 2020 election was a wonderful thing, despite the less-good news: that the “blue wave” did not appear, that the Senate (barring two unlikely upsets in Georgia) will continue to be controlled by Mitch McConnell, that the GOP gained seats in the House, and especially that 70 million Americans voted to re-elect the worst president in American history, thus supporting racist, misogynist, anti-environment, anti-union, pro-corporate and pro-billionaire policies, and bellicose macho authoritarian bluster. The election of a Black (and Asian) woman as Vice-President is historic and great. While it is possible that Biden’s uninspiring “centrist” (read “center-right”) positions gained him votes, the division in America has never been more dramatic. Cities like, most highly featured in the days following the election, Philadelphia and Atlanta (as well as New York, Los Angeles, Chicago, etc.) went 70-80%+ for Biden, while rural counties went for Trump by the same margins.

My purpose here is not to be a political commentator, but to discuss what this might mean for health care under a Biden administration. Certainly not a supporter of any kind of single payer universal health insurance, including Medicare for All, Biden further has to contend with a (probably) Republican Senate and a newly strengthened rightist Supreme Court that even as this is being written is hearing another challenge to the ACA, President Obama’s signature domestic achievement, and the scaffold on which Biden hoped to build his own health care plan by adding a “public option”.

Assuming that, despite Senate and possible SCOTUS opposition, the ACA survives and even that the “public option” becomes law, it would be a great advance in the number of Americans who had access to decent health insurance (which, in itself, may doom its chances in those two “august” bodies!) Indeed, the arguments that many, including myself, have made for the savings that could be achieved by government single-payer program (extension of an improved Medicare to everyone) would likely be somewhat achieved by a well-designed public option, since better coverage would cost less money than it does under the private, for-profit, insurance sector. Not nearly as much as would be achieved by single-payer, but enough to have a good chance of eroding the base of those who hang on to excessively costly, poor-quality private insurance.

And yet, ”Medicare for All” continues to enjoy wide public support, certainly in those “blue” cities and counties, but also within the US as a whole, including some of the “reddest” areas. People know that their health insurance is costly and that the coverage is inadequate, and that not only their lives and health are at great risk, but so (to the extent that they have any) is their “treasure”. Democrats who supported M4A were all re-elected, while many opponents were defeated. Indeed, this illustrates the difference between those in power, members of the Senate and the House (and SCOTUS) who serve the wealthy and are mostly wealthy themselves, for whom tax cuts for their patrons and corporations (under the umbrella of the scandalous SCOTUS decision in Citizens United that declared money to be speech and corporations to be people!) are the main agenda, and their constituents. The latter have poor and costly health insurance, benefit little if at all from tax cuts, and are losing their jobs right and left as US companies push more and more money to the top. For the former, Medicare for All is a bugbear; for the latter it may be a lifeline.

The most important healthcare issue in which the election of Joe Biden is likely to make a big difference, however, is the most important healthcare issue currently facing America, and the world – the COVID-19 pandemic. This second (or maybe third) wave is breaking all kinds of records for new cases, new hospitalizations, and new deaths. In my state, Arizona, we have the highest rates since July. The nation has had well over 100,000 new cases a day recently, in some of the “reddest’ counties, with rates over 200/100,000 residents in some. The reason is that the virus does not care about what you want, and apparently what we have wanted is greater opening, an end to social isolation and not going out to restaurants and bars, not having parties and funerals and visits with our relatives. We want businesses to open, we want our jobs back, we want our personal economy (not just the stock market) to improve. We bristle at the “discomfort” of masks (like the “discomfort” of seatbelts). We want to rush, en masse, onto the football field to celebrate a huge victory for Notre Dame over Clemson (oh, wait, we did that!)

The problem, of course, is that each of those things spreads the virus, and the spread of the virus means more people will die. I have often said REOPENING=DEATH and it remains true, however much we want it not to be; there is nearly a linear relationship between the degree of reopening in any city or state and the increase in the rate of cases of “the rona”. Now, as we look toward all those college students, including those from Notre Dame, returning home for the holidays, we hold our breaths as we worry about how many of their parents and grandparents will become infected and die, putting a damper on the celebrations.

Masks and reasonable social distancing will not prevent this entirely, but will help a lot; masks really decrease transmission. Having a President who wears a mask, who encourages safer behaviors, who does not encourage total irresponsibility as has the current incumbent, is likely to make a big difference. Something has to, and certainly it needs to happen soon. Most encouraging, Biden is not only willing to, but enthusiastic about accepting science as the guiding principle of the response to the epidemic. He has already named members to his COVID “panel”. It could use some more epidemiologists, some nurses, but the intent and direction are good. The increase possibility of a vaccine, especially the recent news from Pfizer, is very encouraging. With a new administration committed to making a difference by using strategies that might actually make a difference, the trajectory of the virus might be turned around.

There are, and will continue to be, great obstacles. The most vulnerable populations will continue to be the most vulnerable – including people in prison, and those immigrants in federal detention, whose rates of infection are staggering. The Pfizer vaccine requires shipping and storing at temperatures of -80 degrees, which is very difficult in many places, particularly in less developed countries where the pandemic is raging.

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But leadership from the US President can go a long way. Whatever else we might wish from him that we are unlikely to get, we can hope that Biden will provide this.

The Trump Election, the ACA and health care in America: Not with a bang but a whimper

As you may have already heard, Donald J. Trump won the election and will be the next President. “The media”, from the mainstream to the left, have moved from excoriating him as a candidate with outrageous personal characteristics and terrifying policy proposals, to excoriating him as President-elect, with less emphasis on his personal characteristics and more on what future policy is likely to be. There is special and valid emphasis on the people who are his main advisors, right wing zealots like Steve Bannon, and the hawkish, sometimes completely out of touch with reality, group. 

There are many  post-hoc analyses of why Clinton lost – I recommend Naomi Klein’s discussion of neoliberalism -- and what the most scary aspects of a Trump presidency are. Regarding the latter the always-terrific Noam Chomsky’s interview on Truthout, firmly identifies global warming and climate change as the greatest threat to the continuation of the world. He emphasizes this threat by noting that 40% of Americans are not concerned about the long-term impact of global warming because they believe that Christ will return and the rapture will occur in the next several decades.

There will, certainly be many other major threats, some of which, like nuclear war, could end the world. After the election, I was reminded that T.S. Eliot wrote in The Hollow Men, “this is the way the world ends, not with a bang but a whimper,” and yet the bang is not out of the question. In less apocalyptic, but just as serious terms, many people in America, whole populations, have real reason to be fearful. Obviously Muslims and “illegal immigrants” have been the victims of the most direct attacks by the President-elect and his advisors, and have a great deal to fear, but the list goes on to include Latinos who are here legally, citizens, members of other groups based on race/ethnicity (African-Americans) or other characteristics (LGBT). It includes women who may seek not only abortions but effective and available contraceptive care – and their partners. It affects all of us who value justice, diversity, peace, civil rights and civil liberties, opportunity, and freedom. We may see some irony in the last two, as they were clarion calls by many Trump supporters, but it has always been clear that for much of this group “freedom” was the freedom to do what they want (carry guns, practice their religion, etc.) and not any concept that would apply to everyone (be safe, have reproductive rights, practice their religion). Opportunity was always about the opportunity of some people to get ahead and not lose ground.

Many Trump supporters, but of course not those who are or will be in leadership in his administration, will be among those who suffer, because income and wealth will be major drivers of suffering, as they always have been. This is not to minimize the impact of race; as Dr. Camara Jones analyzes in her discussions of the “social determinants of equity”, class may be the final mediator of social, and especially health, disadvantage, but it does not explain why there are so many Black and other minority people in the lower class. Yes, surveys have shown that the bulk of Trump voters were white people in the “middle class” ($50,000-$90,000) range, but there were also many lower income whites. Indeed, while conservative ideologues in the Republican party railed against the ACA because it actually provided benefits to people in a “socialist” way, most voters who were hostile to it were motivated by (in addition to racism; it was after all “Obamacare”, named for our African-American President) the fact that premiums were going up to unaffordable levels, and the coverage that they received, when they got sick, was inadequate.

Of course, to be concerned about your premiums and deductibles and co-pays going up under the health insurance exchanges, you have to be covered by them. And, if we didn’t have “Obamacare”, you wouldn’t be covered at all, especially if you have a “pre-existing condition” or have to be paying a lot more if you could. Trump recently seem to be recognizing this, noting that there are popular as well as unpopular aspects of the ACA, and that junking the whole thing, as Republicans have voted to do dozens of times, might be a bad move. The things people like about ACA are that they can get coverage, that they can’t be denied coverage for a pre-existing condition, that there is “community rating” which means that they can’t be charged an especially high premium because they are sick, and that children can stay on their parents’ policies until 26. What they don’t like is high and increasing premiums, high deductibles, high co-pays, discovering the insurance that they could afford is lousy and doesn’t cover what they need and, in many cases, community rating, which means that if you are young and healthy you pay more.

Trump, in characteristic fashion, promises us we will only get rid of the bad parts, and keep the good parts, so the results will be terrific! Too bad President Obama didn’t think of that. Or me. Or that it isn’t possible within the constraints of the ACA. The ACA was designed to deal in insurance companies and their profits to a more-inclusive national health plan. This was the quid pro quo: we’ll do community rating and insure everyone regardless of pre-existing condition, you have to make everyone buy insurance (the “individual mandate”). But lots of healthy, and especially young, people are not buying insurance, gambling that they will stay healthy. If they get “caught” (and most don’t) the penalty is far less than the cost of the insurance. So they win. Until they lose. Of course, many who buy insurance get the lowest cost policy they can and then they really lose. And if they buy better coverage the insurance companies get mad. Much analysis of the history of ACA and its roots, as well as speculation about its future, is covered by Himmelstein and Woolhandler in this PNHP post.

And it doesn’t come at a good time. The Commonwealth Fund just released a report showing that Americans have more challenges in receiving needed health care than in 10 other rich countries. Well, it hasn’t been a good time for a while. This report just shows, basically, the same thing that Commonwealth and others have been reporting for years.

So what can we expect, as a nation, from a Trump administration? Well, there is odds-on betting that we will get a right-wing, anti-abortion, anti-reproductive rights Supreme Court. And, if not actually a wall, major deportations and harassment of immigrants. And real anti-Muslim activity. Hate crimes are already up, per the Southern Poverty Law Center, with really bad people feeling emboldened by the Trump rhetoric; we can only hope his Justice Department will prosecute these crimes at least as aggressively as they do immigrants. We will probably get more of the same in attacks by police on minorities, and especially on policies that enrich the richest and hurt the poor. We will get little or no action on climate change. And we will not get the jobs that have been lost back, whatever the President-elect promises.

 

Protests will continue, centered as they have been in the small islands of the nation that voted Democratic – and where most of the people in the US live. We need to be sure that the losses I describe above do not come easily, that we do not keep our heads down, that we make waves.

And, in healthcare, we probably will not get single payer, although this would solve the problem and allow Donald Trump to actual give us most of the good without most of the bad. If he would only.

The Trump Election, the ACA and health care in America: Not with a bang but a whimper

As you may have already heard, Donald J. Trump won the election and will be the next President. “The media”, from the mainstream to the left, have moved from excoriating him as a candidate with outrageous personal characteristics and terrifying policy proposals, to excoriating him as President-elect, with less emphasis on his personal characteristics and more on what future policy is likely to be. There is special and valid emphasis on the people who are his main advisors, right wing zealots like Steve Bannon, and the hawkish, sometimes completely out of touch with reality, group. 

There are many  post-hoc analyses of why Clinton lost – I recommend Naomi Klein’s discussion of neoliberalism -- and what the most scary aspects of a Trump presidency are. Regarding the latter the always-terrific Noam Chomsky’s interview on Truthout, firmly identifies global warming and climate change as the greatest threat to the continuation of the world. He emphasizes this threat by noting that 40% of Americans are not concerned about the long-term impact of global warming because they believe that Christ will return and the rapture will occur in the next several decades.

There will, certainly be many other major threats, some of which, like nuclear war, could end the world. After the election, I was reminded that T.S. Eliot wrote in The Hollow Men, “this is the way the world ends, not with a bang but a whimper,” and yet the bang is not out of the question. In less apocalyptic, but just as serious terms, many people in America, whole populations, have real reason to be fearful. Obviously Muslims and “illegal immigrants” have been the victims of the most direct attacks by the President-elect and his advisors, and have a great deal to fear, but the list goes on to include Latinos who are here legally, citizens, members of other groups based on race/ethnicity (African-Americans) or other characteristics (LGBT). It includes women who may seek not only abortions but effective and available contraceptive care – and their partners. It affects all of us who value justice, diversity, peace, civil rights and civil liberties, opportunity, and freedom. We may see some irony in the last two, as they were clarion calls by many Trump supporters, but it has always been clear that for much of this group “freedom” was the freedom to do what they want (carry guns, practice their religion, etc.) and not any concept that would apply to everyone (be safe, have reproductive rights, practice their religion). Opportunity was always about the opportunity of some people to get ahead and not lose ground.

Many Trump supporters, but of course not those who are or will be in leadership in his administration, will be among those who suffer, because income and wealth will be major drivers of suffering, as they always have been. This is not to minimize the impact of race; as Dr. Camara Jones analyzes in her discussions of the “social determinants of equity”, class may be the final mediator of social, and especially health, disadvantage, but it does not explain why there are so many Black and other minority people in the lower class. Yes, surveys have shown that the bulk of Trump voters were white people in the “middle class” ($50,000-$90,000) range, but there were also many lower income whites. Indeed, while conservative ideologues in the Republican party railed against the ACA because it actually provided benefits to people in a “socialist” way, most voters who were hostile to it were motivated by (in addition to racism; it was after all “Obamacare”, named for our African-American President) the fact that premiums were going up to unaffordable levels, and the coverage that they received, when they got sick, was inadequate.

Of course, to be concerned about your premiums and deductibles and co-pays going up under the health insurance exchanges, you have to be covered by them. And, if we didn’t have “Obamacare”, you wouldn’t be covered at all, especially if you have a “pre-existing condition” or have to be paying a lot more if you could. Trump recently seem to be recognizing this, noting that there are popular as well as unpopular aspects of the ACA, and that junking the whole thing, as Republicans have voted to do dozens of times, might be a bad move. The things people like about ACA are that they can get coverage, that they can’t be denied coverage for a pre-existing condition, that there is “community rating” which means that they can’t be charged an especially high premium because they are sick, and that children can stay on their parents’ policies until 26. What they don’t like is high and increasing premiums, high deductibles, high co-pays, discovering the insurance that they could afford is lousy and doesn’t cover what they need and, in many cases, community rating, which means that if you are young and healthy you pay more.

Trump, in characteristic fashion, promises us we will only get rid of the bad parts, and keep the good parts, so the results will be terrific! Too bad President Obama didn’t think of that. Or me. Or that it isn’t possible within the constraints of the ACA. The ACA was designed to deal in insurance companies and their profits to a more-inclusive national health plan. This was the quid pro quo: we’ll do community rating and insure everyone regardless of pre-existing condition, you have to make everyone buy insurance (the “individual mandate”). But lots of healthy, and especially young, people are not buying insurance, gambling that they will stay healthy. If they get “caught” (and most don’t) the penalty is far less than the cost of the insurance. So they win. Until they lose. Of course, many who buy insurance get the lowest cost policy they can and then they really lose. And if they buy better coverage the insurance companies get mad. Much analysis of the history of ACA and its roots, as well as speculation about its future, is covered by Himmelstein and Woolhandler in this PNHP post.

And it doesn’t come at a good time. The Commonwealth Fund just released a report showing that Americans have more challenges in receiving needed health care than in 10 other rich countries. Well, it hasn’t been a good time for a while. This report just shows, basically, the same thing that Commonwealth and others have been reporting for years.

So what can we expect, as a nation, from a Trump administration? Well, there is odds-on betting that we will get a right-wing, anti-abortion, anti-reproductive rights Supreme Court. And, if not actually a wall, major deportations and harassment of immigrants. And real anti-Muslim activity. Hate crimes are already up, per the Southern Poverty Law Center, with really bad people feeling emboldened by the Trump rhetoric; we can only hope his Justice Department will prosecute these crimes at least as aggressively as they do immigrants. We will probably get more of the same in attacks by police on minorities, and especially on policies that enrich the richest and hurt the poor. We will get little or no action on climate change. And we will not get the jobs that have been lost back, whatever the President-elect promises.

 

Protests will continue, centered as they have been in the small islands of the nation that voted Democratic – and where most of the people in the US live. We need to be sure that the losses I describe above do not come easily, that we do not keep our heads down, that we make waves.

And, in healthcare, we probably will not get single payer, although this would solve the problem and allow Donald Trump to actual give us most of the good without most of the bad. If he would only.

The political campaign and the future of health reform

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The headline story in the June 28, 2010 issue of the Kansas City Star, by Dave Helling and Steve Kraske, is “Mailings turn aggressive”. It is about direct mail campaigns by those seeking elective office, how they have become a major part of the campaigning, and how the content is almost entirely negative – and sometimes hard to believe. For example, a state legislator running for Congress has a mailer attacking his primary opponent as a “Nancy Pelosi Democrat”, although the only obvious similarity this “staunch conservative” former legislator has with Ms. Pelosi is that they are both women.

The more interesting aspect is not the attack aspect of the ads, but that most of the non-attack “positive” campaigning, touting the candidates’ strengths and thus implicitly responding to attacks, is (among Republicans) to emphasize their negativity. Jerry Moran, a Republican congressman from Kansas’ “Big First” district is running against Todd Tiahrt, congressman from the 4th district (Wichita), for the Senate seat of Sam Brownback (who is odds-on favorite to be our next governor). Both have essentially the same, straight-down-the-Republican-line voting record, but Tiahrt has accused Moran of being less conservative. A recent Moran ad indicates that he fights for Kansas and then lists all the things he has opposed – which is essentially everything that the Obama administration has done. Moran is a nice, personable man and presumably has some good positive ideas, but apparently in the campaign it is not cost effective to promote them. (Note that the Tiahrt campaign takes the same tack, except when attacking Moran for not being conservative enough.) In the Republican primary proudly embracing charter membership in the “Party of NO” is apparently the name of the game, It is possible that in some parts of the country, candidates in the general election will feel pressure to say what they are for, but only if absolutely necessary. In Kansas, where the Republican nominee is pretty much guaranteed victory in most venues, it probably won’t.

In a recent article in Health Affairs, “The political challenges that may undermine health reform”[1], Theda Skocpol ties some of these trends to the future implementation of health reform. She accepts that there will be Republican gains, but also discusses the ways in which Democrats will likely respond, hoping to blunt those gains and prevent a complete Republican takeover of Congress. In its absence, she notes it is likely that most of the part’s of PPACA will be implemented, slowly and quietly, although some of the parts most likely to engage support (elimination of discrimination against those with pre-existing conditions on the individual market and allowing children to stay on their parents’ policies until 26) are front-loaded, going into effect this year. Among the most interesting things she says (to me, a non-political scientist), is that “Political scientists have long know that Americans are what is called ‘operational liberals’; they like specific government benefits. Yet these same Americans are also ideologically conservative, when arguments about government versus the free marked are posed in general rhetorical terms.”

Actually, this makes it almost sound like Americans are “operationally selfish”. Indeed there are many who are, like the family physician I knew in Texas who would mostly rant against the liberals in Washington and the need to elect more conservative Texans, until, in a cost-saving measure pushed through by those fiscal conservatives, the government delayed sending out Medicare payments to physicians. That was intolerable to him! Dr. Skocpol continues: “That is why we will see Republicans doing all they can to keep the argument at the systemic level through early 2012, when they hope to elect a president who will support repeal or make fundamental changes in the 2010 legislation.” No question that arguing against Big Government is going to win more votes than opposing Medicare, or Social Security. And few of the reliably conservative Republican farmers in Kansas (or elsewhere) are going to be won over by arguments against agricultural subsidies. In Missouri, which has more Democrats than Kansas but has a legislature controlled by Republicans, a statewide referendum is about to take place which would prohibit the federal government from forcing people to purchase health insurance. It is being sold with “freedom” arguments, and might well be unconstitutional, but it will be interesting to see how people vote. When turnout is light, the poor and uninsured are less likely to turn out than those who, like the bill’s legislative sponsors, already have insurance; in particular older voters, already receiving Big Government Socialized Medicine Medicare are likely to vote.

While there is much to criticize in PPACA (done very well by John Geyman, “Hijacked: Stolen health care reform V” in the Huffington Post), there is definitely some good. The insurance companies have backed off their threats to not cover people (or at least children) with pre-existing condition, suggesting that people will begin to see some real benefits. The real issue is seen in Dr. Skocpol’s final sentence, above; the Republicans are running on general conservative principles, but should they gain power they will implement a very anti-regular-people agenda, as was done under the Bush administration. This is not limited to health care; while “everyone” (me, for sure!) hates the bankers who brought on the financial crisis (see Maureen Dowd in the NY Times, July 28, 2010: “Washington gave the Wall Street banks billions, and, in return, they stabbed us in the back, handing out a fortune in bonuses to the grifters who almost wrecked our economy”), the Republican party leadership, far from punishing them or reining them in, has tried to block legislation that would even gently restrict their most outrageous activities.

If we are lucky, maybe voters in Missouri and in other places will show that “operational liberals” who “like specific government benefits” are not all like that Texas doctor, and will also support specific benefits that help others. We have seen many polls showing that a majority of Americans favor universal health care even for all, so the sense of common purpose is not dead. Maybe they won’t, but we can hope.

[1] Health Affairs, July 2010; 29(7):1289-91.
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