"Medicare for All" means ALL -- Accept no substitutes!

Let’s start with the good news. “Medicare for All” is definitely trending. It is the central domestic issue for the Democratic primary. This is because of the absolute crisis in the health system. It is also, let us remember, because of Bernie Sanders, who has supported a single-payer universal health system for decades and made it a central part of his 2016 presidential campaign. He didn’t win the nomination, but he won the battle of ideas, which is why it is so important in this campaign.

People love the idea of being covered for their healthcare needs, and having that coverage untethered from where they work (assuming that where they work provides health insurance), whether they can work if they have been laid off, can’t find a job, or are disabled, or whether they are quite old enough to qualify for Medicare, whether they are quite poor enough to qualify for Medicaid (and let’s be straight, you have to be REALLY poor, even in the most generous states, and in some states it is just ridiculous). This is because the current healthcare system in the US really stinks. A huge percentage of those who are insured have terrible coverage, those who have reasonable coverage pay (often along with their employer) an extremely high amount for that coverage in premiums, deductibles and co-pays, and an unconscionable number of Americans are completely uninsured. The health outcomes in the US are terrible, trailing all other developed countries (discussed here many times). The only thing we lead in is the cost of the system, and of course the amount of profit made by the predatory components of it such as insurance companies, drug companies and some providers – which is of course totally related to why it costs so much.

An excellent example of the insanity of our current profit-driven system is provided by the Kaiser Health Network and covered by CBS Morning News and the medical news site “Medscape”, detailing how a dialysis patient received a half-million dollar bill because the dialysis center he went to, which was closest to his home (70 miles) was “out of network” for him. This particular patient will probably have his bill written off because of the extensive national coverage, but it happens all the time; it is the norm, not the exception. No wonder people are fed up!

The less good news is that, although most of the Democratic presidential candidates (notably excluding front-runner Joe Biden) have endorsed the words “Medicare for All”, their proposals are all over the place. Most of them do NOT guarantee universal coverage, not to mention the necessary expansion of benefits (“Improved and Expanded Medicare for All”) needed to ensure that the American people get ALL the health care that they need (including mental health, vision, hearing, long-term care, substance abuse treatment, etc.) The New York Times, which has made a crusade of limiting coverage of Bernie Sanders and trying to minimize or denigrate him when they do cover him, and is also an opponent of truly, universal, comprehensive single-payer health care, does have a very useful graphic in an article originally from the “Upshot” in February but in the print edition of August 13. It portrays the characteristics of many of the health plans proposed currently, and makes clear that only two, those sponsored by Sanders in the Senate and the bill in the House with Pramila Jayapal (D-WA) as the primary sponsor and over a hundred co-sponsors, actually would provide what we need.  

A clear exposition of many issues, including facts misrepresented about universal single payer, is summarized in an elegant piece in the Washington Post by Rep. Jayapal. It is an excellent point-by-point response to various criticisms and concerns that have been raised, and is well worth the time to read, even if you don’t have time to read the whole bill (Medicare for All Act of 2019).

Two of the most important criticisms to which she responds are particularly telling, since they are deeply tied. One is that people want to be able to keep their private insurance (presumably those who have, or possibly mistakenly think they have – good insurance). The “evidence” provided for this claim is that the percent of people who say that they support “Medicare for All” goes down if the question “even if you have to give up your current insurance” is added. Of course, the question is misleading; when people are told that they would be fully covered for everything, with no co-pays or deductibles or co-insurance, and that they will have completely free choice of providers, this objection goes away. Let’s be honest; no one cares about having a choice of which insurance company will deny them what they need; this is a nonsense concern. And, yet, this is driving the proposals of some presidential candidates and members of Congress to do a less-than-universal solution, some version of Medicare-for-More, or “buy-ins” or expansion of Obamacare.

The other objection, “how will we pay for it”, is also frequently heard, even from those who know how but just don’t want to accept it. The answer is very closely tied to the answer to the question above, because the cost only becomes impractically expensive if insurance companies – and their overhead and profit – are built back into the equation. A comprehensive Medicare-for-All program, when fully implemented, will be funded by the money that Americans and their employers pay for health insurance currently, including all the money spent by the federal government and states on Medicare and Medicaid, supplemented by additional taxes on corporations that do not already provide comprehensive insurance and on the wealthiest Americans. Yes, most people’s taxes would increase, but for the vast majority, the increase would be far less than they pay now in insurance premiums, co-pays, and deductibles, and would “buy” them comprehensive care for all medical problems with no limited ‘panels’ of providers. Those who would pay more can well afford it. But the key here is not having insurance company profit and overhead built into the system; this is one big reason that the US health care system is so expensive, and leaving it in makes it much less affordable. To suggest such solutions is like saying “the cost of business is so high, especially including payoffs we make to gangsters for protection -- but of course it is really important that any new system we develop include those gangster payoffs!”

Why would many pundits and “liberal” media outlets like the NY Times, CNN, etc. want to create such confusion and undermine efforts to create a truly universal, comprehensive single-payer system? I can’t know. I do know that they are all in the upper tiers of income, have good insurance, and are surrounded at work and in their neighborhoods by those in similar situations. Maybe this makes them blind to the needs of most people; maybe they believe that the top 10% of income of which they are a part is in fact typical. Or maybe they realize their privilege and want to keep it, and don’t want everyone else diluting their access.

But including everyone is key, not only for the financial reasons, but for quality reasons. When the upper income and well-educated are in the same system as the poorer and less empowered, they can be depended upon to ensure that the system is of quality, and this benefit then applies to everyone. It is why we cannot let them opt out.

Out health care system is a mess, delivering poor outcomes for lots of money, and is a maze of different programs and eligibility. We don’t need more of that; we need to simplify it and have one outstanding system that covers everyone.

Free speech, religious belief, and facts: how does it affect health?

The massacre at the French magazine Charlie Hebdo was shocking and horrible, as are the massacres and atrocities that occur regularly with less immediacy to those in the West, such as those committed by Boko Haram in Nigeria. The most positive result was the massive outpouring of support for free speech, for being able to say and print what you want even if it offends people. And, I would add, particularly if it offends the powerful, which Charlie Hebdo also did. More than a million in the streets of Paris saying “Je suis Charlie” (“I am Charlie”), with more than 40 heads of state in attendance, even if they didn’t actually lead the march, but were photographed together on a protected side street. And even if many of them sponsor severe repression of free speech in their home countries. 

The inclusion of Israeli Prime Minister Benjamin Netanyahu was particularly problematic given the violently repressive policies of his government, but given that the companion attack was on a kosher supermarket where four Jews were killed, the symbolism was important even if a lightning rod for (largely just) criticism of Israeli government policy. Less appreciated was the message from Netanyahu that French Jews should all come to Israel, and more appreciated were the sentiments of French Prime Minister Manuel Valls that ‘France Without Jews Is Not France’, and the demonstrators, most of whom were not, who carried signs that said “Je suis juif” (“I am Jewish”).

But the necessary condemnation of terror, and moves to avert it, along with the necessary condemnation of anti-Semitism and the conflation of Jews with the actions of the government of Israel (or the conflation of Islam with the actions of Islamic terrorists) does not solve the problem of communication, that people see “truth” so differently. I don’t know that I can offer much more insight into the conflict of seeing truth through the lens of religious doctrine (and of course some people and groups’ interpretation of religious doctrine) and a “liberal” concept of the value of free speech. I was interested in the perspective of Maajid Nawaz, a British Muslim who became a radical Islamist at 16, served 4 years in an Egyptian jail where his readings changed his perspective and later founded Quilliam, an anti-jihadist think tank in London, expressed on NPR’s Fresh Air. Asked by host Terry Gross how he saw himself as the same person, given his loss of relationships including family and friends since his “conversion”, Nawaz spoke about commitment to justice. He said it was the blatantly unjust treatment of Muslims that motivated him to fight as an Islamist, and the same commitment to justice that makes him oppose terrorism. Ideologically, I think that this is a good start.

 Most countries, including France and the US, have a mixed relationship with free speech. In the US (which I know much better), many people not only support free speech for positions that they agree with but also positions that they can tolerate listening to. Of course, however, true support for free speech means support for speech you abhor, hate, despise, think dangerous. Not, of course, the same as action (“your free speech stops just short of my nose”), but certainly includes free assembly and demonstrations to express views. If one’s religious views include opposing anyone’s right to criticize your religion (or, even more, as illustrated by the Inquisition or ISIL’s massacres of Yazidis, not adopt your religion), you are clearly endorsing a society antithetical to free speech. And, of course, with the grossly immoral series of US Supreme Court decisions that money is speech and that corporations are people who can exercise that “speech”, the entire concept of free speech in our country is perverted.

Closer to home, and closer to the usual themes of this blog, health and social justice, we see again how beliefs not only threaten free speech but threaten our ability to act as an honorable and just society because groups of people see things so differently. The reasons given are many: our social isolation from groups of people unlike us (residential segregation by race and class and age and educational level), our ability to receive “customized” news, where what we watch on TV or find on the Internet is that which agrees with what we already believe. When people hold views based on their faith, it may be difficult or even unreasonable to expect to change it; this is what “faith” is. However, when people hold views that are not religious and are demonstrably wrong in the face of the facts, and those beliefs are held as firmly as those that are religious, and those beliefs threaten the core well-being of other parts of our society, we would hope that they could change.

I have often written about the Social Determinants of Health. These are the conditions of people’s lives that make them more vulnerable to illness, less likely to be able to prevent it through both health screening and living in places and circumstances in which prevention is possible. For example, not near areas of high pollution, not in poor quality cold housing, not in no housing. To have shelter, and decent food, and the opportunity for education for themselves and their children. All the things that characterize their lives and come before their access, or lack of access, to the health system comes into play. If we are to improve the health of the American people, we must not only provide equitable access to health care geographically, financially, and socially (with language access and caring and actual interest in people’s health) but also address those social determinants that disadvantage so many in the pursuit of their health.

 

And then I read the results of a survey by the Pew Research Center that says a majority of well-to-do Americans think that poor people “have it easy”. Widely reported, including by the Washington Post which leads with “There is little empathy at the top”, and CNN, which reports “54% of those with the greatest financial security believe that ‘poor people today have it easy because they can get government benefits without doing anything in return’…Only 36% of the wealthiest say ‘poor people have hard lives because government benefits don't go far enough to help them live decently.’" I want to say this is unbelievable, but I have to believe it is true that they think this. I am, nonetheless, aghast that they could think this. What world do they live in? Is it really true that their only contact with poor people is on TV news, Fox News at that? Have it easy?

Would they want to test that? Live like poor people for a while? Even knowing that – unlike real poor people – they could return to their comfort in a month or a week, would they be able to tolerate it? Not being able to pay their bills, not have heat, not have decent or sufficient food, not be able to afford the doctor, not be able to take off work without losing pay to go to one even if they had health insurance? I think – I know – that if they did they would feel differently about it being easy to be poor. But while there is great value to “walking a mile in someone else’s shoes”, there is a way to know what is going on without even doing that. It is called opening your eyes, looking at the facts.

Even when they are uncomfortable, even when they challenge your beliefs, or more importantly your sense of self-entitled comfort. To not do so is part of no one’s religion. This is the responsibility of free people.