Tag Archives: Single Payer

Something Encouraging For a Change

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In today’s news, Senator Turtle Face (formally known as Addison Mitchell McConnell, Jr., Republican of Kentucky) delayed the vote on the “Less Money for Health Insurance Equals More Money for Rich People” bill. Presumably, he didn’t have enough Yes votes to pass legislation that nobody (except him and a few rich people?) likes.

This will either give the Republicans a few days to find the necessary Yes votes, or it will give opponents of the bill (of which there are many) the chance to create more No votes. Since the Senate Majority Leader had planned a quick vote on a bill he tried to keep as secret as possible, the postponement appears on balance to be a welcome development.

Proving again that he is indeed the Master Negotiator, the President put on a show at the White House today with Republican Senators, at which he announced:

This will be great if we get it done. And if we don’t get it done, it’s just going to be something that we’re not going to like, and that’s OK, and I understand that very well.

As far as we know, the President has not yet demonstrated in a single case whatsoever that he has any understanding at all of the the American healthcare system, the Affordable Care Act, or the Republican effort to repeal or replace it. Clearly, he is a Big Picture guy.

Consistent with the possibility that this is not Hell, some observers think the Republicans’ struggles are a sign of better things to come. Paul Waldman of The Washington Post writes:

The Republican health-care bill is not dead yet, but it’s in rough shape. Whether it passes or not, it has been an utter debacle for the GOP, making the Affordable Care Act they’re trying to undo more popular than ever, energizing the Democratic base, complicating the relationship between President [DT] and Congress and sowing justified distrust of Republican motives among the broader public.

It has also done something else: moved the debate on health care in America to the left and made single payer much more likely.

Even if the Senate bill fails, Republicans give up and move on to tax reform, and the status quo remains in place, this debate will have had profound effects on our politics. While the Democratic Party may have been moving to the left on health care anyway, its momentum in that direction may now be unstoppable. And the entire country will be more receptive than ever to the arguments Democrats will make. This, by the way, will also be the case if the GOP repeal effort succeeds, because it will make so much that people hate about our health-care system a lot worse.

Let me point to one politician as an illustration. For years, Sen. Elizabeth Warren’s position on single payer has essentially been “Maybe someday” — not opposed to it, but focused in the short term on the more urgent priority of defending and enhancing the ACA. But in an article in today’s Wall Street Journal, we learn that she is now ready to take that plunge:

“President Obama tried to move us forward with health-care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” she said during an interview in her Senate office last week. “Now it’s time for the next step. And the next step is single payer.”

Warren is not going to be the last Democrat to take this step. In fact, any Democrat who runs for president in 2020 — and there will be a lot of them — will have a hard time explaining to the primary electorate why they don’t want single payer, and most or all of them will probably say they do.

We can make an analogy with what happened in the GOP after the failure of comprehensive immigration reform [in 2013]…. The situations aren’t exactly the same, but … a dramatic political failure — whether it’s yours or the other party’s — can have profound effects on the choices politicians make about how to approach the electorate. And it’s important to understand that while there are some Democratic politicians who emphatically favor single payer and would be unsatisfied with anything less, most of them would be willing to advocate for a range of policy options, depending on what looks politically achievable and what their base demands at a particular moment.

All the ups and downs of the past eight years, from the beginning of the debate on the ACA to the end of the debate on Republican repeal plans, hold many lessons for Democrats who are still eager to address the problems in the American health-care system. Among other things, we know that voters are risk-averse, that they’re extremely sensitive to out-of-pocket costs, that they want security and that arguments about the glories of the free market aren’t going to be persuasive to them. After seeing how desperately unpopular this Republican plan is, Democrats are going to be much less afraid to defend government health care and advocate its expansion.

And they know that whatever they propose next has to be simple and understandable. We can debate whether the ACA had to be as complex as it was, but next time around, no Democrat is going to believe that you can take on President Trump with a technocratic approach to health care. Saying “Here are the 10 tweaks I’d make to the ACA” isn’t going to cut it.

That isn’t to say that whatever plans they propose won’t be fully fleshed out under the hood, but they’ll have to be presented in a way that is easy for voters to understand. And, yes, Republicans will cry about “Washington bureaucrats making decisions for you,” but Democrats are less likely to be intimidated. Ask your parents or grandparents on Medicare how they feel about their coverage — Medicare is the most popular health insurance program we have, and it’s run by Washington bureaucrats.

It’s important to keep in mind that “single payer” isn’t one thing — if you look around the world at highly developed countries, there is a spectrum of health systems with various levels of public and private involvement. But what they have in common is that they achieve universal coverage while working better and costing less than ours. We could well have 15 Democratic presidential candidates proposing 15 different kinds of single payer. Some may be highly socialized systems — what Bernie Sanders would likely advocate if he runs again — but the ones that are most appealing could be hybrid systems of the kind that have been successful in countries such as France. The way it works is that there’s a government plan that covers everyone’s basic needs, but you can also buy supplemental private insurance to get as many more benefits as you want.

Among the advantages of a hybrid system is that one can actually see a path from where we are now to there. That path runs through Medicaid, which now covers nearly 75 million Americans. What if we auto-enrolled everyone under 65 in Medicaid — it’s there if you need it, but if you have different insurance you’d prefer, go ahead and use that instead. No one would be without coverage. Private insurance would evolve into something you buy to fill in the gaps and get perks that Medicaid wouldn’t provide. Instead of covering all your health care, employers could provide the supplemental private insurance.

As a political matter, you could sell this as something that we could transition to over an extended period, and as a system that satisfies the goals of both liberals and conservatives. Liberals get the universal coverage and security they want, and conservatives get the freedom they want — if you’re rich enough to buy a supplemental plan that includes deliveries of Dom Perignon during any hospitalization, go right ahead.

That isn’t to say that Republicans wouldn’t resist and there won’t be more intense arguments about health care, because they would and there will be. But by handling this debate so terribly and proposing something so monstrous, Republicans have opened up the space for Democrats to go much further than they’ve been willing to before. It’s not impossible to foresee Democrats winning the House in 2018, then taking the presidency and the Senate in 2020 — and then taking the first steps toward making single-payer health care in America a reality. 

End quote.

Finally, the Perfect Healthcare System!

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Breaking news from Washington:

House of Representatives Republican leaders ripped the Affordable Care Act, known as Obamacare, and Majority Whip Kevin McCarthy, R-Calif., urged a “patient-driven health care system, not a government-driven health care system.”

So, House Speaker John Boehner, R-Ohio, was asked at a news conference, what does that mean?

“Well,” he said, “When you look at “Obamacare,” what you see is a government-centered health care delivery system. That’s not what the American people want.

“The American people want to be able to pick their own type of health insurance; they want to be able to pick their own doctor; they want to be able to pick their own hospital. That’s what a patient-centered health care system looks like.”

Asked if that was likely to come to a vote next year, Boehner said, “We’ll see.”

Finally, no more in-network-out-of-network! No more we-don’t-accept-Blue-Cross-Medicare-or-Medicaid! No more United-Healthcare-is-no-longer-offered-by-your-company! No more if-I-get-this-job-I’ll-get-health-insurance! No more reasonable-and-customary-charges!

The American people will be able to choose whatever doctor they want and any kind of health care insurance they want. It won’t matter if you’re homeless, you’ll be able to go to the best doctors on Park Avenue. If you stock shelves at Walmart, you’ll be able to get high-quality care at the Mayo Clinic. If your company offers health insurance plans A, B and C, you’ll be able to choose D.

It won’t make any difference to anyone how much doctors, hospitals or insurance companies charge, because the Republicans now have a plan, the ideal plan that nobody else had the courage or insight to propose. In retrospect, however, it’s clearly the only way to guarantee everyone’s right to whatever health care they want without interfering with the free market: 

Every American citizen will have an unlimited supply of money to spend on healthcare! It’s the MONEY IS NO OBJECT plan! (MINO, for short.)

It’s the perfect “conservative” free-market solution, since everything for sale in the healthcare marketplace will be as good as free for consumers, while providers will retain the right to make as much money as possible.

(Note: Aside from replacing the words “government-centered” with “patient-centered”, details of the plan are, to be polite, “sketchy”.)

Meanwhile, here on Earth, there is an informative article in a recent New York Review of Books called “Obamacare: How It Should Be Fixed”. It’s by Arnold Relman, Professor Emeritus at Harvard Medical School. Unfortunately, you have to pay to read the whole thing (after MINO is in effect, we’ll all be able to afford it). But Dr. Relman concludes that our best hope of getting a high-quality, affordable health care system would be a single-payer system built on Accountable Care Organizations, i.e. private medical groups that would be paid by the government, not for every service performed, but for their patients’ overall care:

The only type of ACO [Affordable Care Organization] that has been proven to satisfy patients and physicians is multispecialty group practice. According to the American Medical Group Association, there are now well over 430 such group practices and their number is increasing rapidly as more physicians seek group employment….

Data from the Medical Group Management Association indicate that average staff earnings in groups are fully competitive with earnings in solo or small partnership practice, particularly if the generous fringe benefits that groups usually offer are also considered (for example, office expenses, malpractice insurance, paid vacation, pension plans). And judging from their low turnover rate, physicians who choose employment in successful, well-managed groups are usually satisfied with their job.

However, only a few medical groups currently avoid the inflationary incentives of fee-for-service by contracting with insurance plans that pay them on a per capita basis for comprehensive care of some or all of their patients; and even fewer pay their medical staff by salary….

… I have described in detail how a single-payer system sponsored by the federal government would function when coupled with a reorganized medical care system based on independent multispecialty group practices with salaried physicians. Replacement of all public and private insurance and elimination of itemized bills with a public tax-funded system that simply paid medical groups per capita for comprehensive care would avoid much of the expense and many of the other problems with the current system. The enormous savings could ensure adequate compensation for all the facilities and physicians needed for universal care.

The loss of jobs in the eliminated private insurance industry would probably be more than compensated by increased employment in a greatly expanded public-payer system, and by the new jobs created by the emerging business opportunities created when employers no longer need to pay the health costs of their employees. Government would be able to contain the rise in total health expenditures by its power to set prices and determine the level of taxation required to fund the system, but it need not micromanage medical care. Medical decisions should remain in the hands of physicians and their patients, where they belong.

Most important, this revolution in our health care system would make universal access to good care affordable. It is a revolution that seems inevitable, even though it is not yet on the political horizon.

I’d say it’s far, far beyond the horizon, but at least it’s on planet Earth. Meanwhile, we’ve got the ACA, which is significantly better than what we’ve had.