OP-ED

Nixon Went to China. Can Trump Go to Single Payer?

There is an old Vulcan proverb saying that only Nixon could go to China. Only a man who used to work for Joseph McCarthy could set America on a path to better relations with a virulently Communist country. A few years after Nixon went to China, Menachem Begin, the Israeli Prime Minister who represented people believing that the state of Israel should start at the Nile and end at the Euphrates, gave Egypt back all the lands conquered in a recent war and made a lasting peace with Israel’s largest enemy. They said back then that only Begin could make peace with the Arabs.

Today, I want to submit to you that only Trump can make single-payer health care happen in this country. Only a billionaire, surrounded by a cabinet of billionaires, representing a party partial to billionaires, can make that hazardous 180 degrees political turn and better the lives of the American people, and perhaps the entire world as a result. Oh, I know it’s too soon to make this observation, but note that both Mr. Nixon and Mr. Begin were deeply resented (to put it mildly) in their times, by the same type of people who find Mr. Trump distasteful today. The liberal intelligentsia back then did not have the bona fides required to cross the political chasm between one nation and its ideological enemies, or as real as death immediate foes. The liberal intelligentsia today lost all credibility in this country when it comes to providing a universal solution to our health care woes.

Free health care (and free college) are not solutions. These are rabble rousing slogans to gin up the vote, slogans that end up in overflowing trashcans left in ballrooms littered with red white and blue balloons after everybody goes home to get some sleep before the next round of calls to solicit funds from wealthy donors for the next campaign. Providing proper medical care to the American people is a monumental enterprise that engages tens of millions of workers from all walks of life, every second of every day, in every square mile of habitable land, littered with the hopes and fears of hundreds of millions of invisible men, women and children who call this great country their home. This is not something that can be made free. Nothing is free in our times, not even sunshine and fresh air.

For the jaded, the cynically inclined, and those who are simply too afraid to jump off this cliff, and therefore argue that single-payer is not politically feasible, I have a simple question. Did you all think a couple of years ago, that a President Trump is politically feasible? Okay then. Here is what I believe could be a relatively plausible scenario enabling this one-of-a-kind administration to use its unconventional political capital (if you can even call it that) to get us on the road to making health care great again, greater than ever before.

Step 1: Disaster

The current system, held together with string and duct tape must undergo a seismic shock, preferably a moderate shock and one that does not involve war and famine. The way things look now, the most likely implosion will be the Obamacare individual market. If the Trump administration holds back ransom money from insurance companies (a.k.a. CSRs), or engages in other mischievous behavior, and the individual mandate is not enforced, we may very well have a minor disaster on our hands. In addition, the President’s Commission on Combating Drug Addiction and the Opioid Crisis is requesting that the President declare the opioid epidemic a national public health emergency. Put these two together and you see how lots of people are, or will shortly be, in dire need of medical services not currently available to them via existing “insurance” channels.

Step 2: Relief

The opioid crisis will need much more than providing care for its current victims, but we will need a coordinated effort to provide all necessary medical services to people addicted to opioids who are uninsured, or whose insurer is refusing to pay for the extensive programs needed for recovery. People who were able to afford insurance under Obamacare without, or with minimal, subsidies and are now left hanging to dry will also need a solution, and if they are sick, they will need immediate relief. This would be the perfect time to cut through the red tape and institute the Disaster Relief and Emergency Access to Medicare (DREAM) program. The DREAM will open Medicare to the victims of Obamacare and the victims of the opioid epidemic. This will be put in place as a temporary disaster response program, subject to extension of course, until a more permanent solution can be found. I doubt too many people in Congress could vote against such measure.

Step 3: The DREAM

No matter how short lived, all government programs including temporary ones need rules and regulations to execute now, and to be replicated in future emergencies as needed. Besides, any respectable bill needs more than just a title. How do we define opioid addiction? How do we define Obamacare victim? How do they sign up? What do they get? How much will it cost?

Opioid Crisis

  • Congress will appropriate $45 billion for this program for a period of five years to cover administrative costs, medical costs and program analysis costs.
  • Emergency funding will be provided to Federally Qualified Community Centers (FQHCs) to set up a process for opioid addiction screening. FQHCs are non-profit clinics, funded by the Federal government to serve low income populations regardless of ability to pay. All physicians and staff are salaried. The funding will be administered by the Health Resources and Services Administration (HRSA) and defined by the Secretary of Health and Human Services (HHS).
  • Any American citizen or lawful permanent resident will be eligible to access any FQHC and undergo opioid screening as specified by the Secretary at no cost. Individuals eligible for relief, based solely on clinical criteria, will need to provide information about their insurance status. Upon receipt of consent from the individual or legal guardian if the screened individual is a minor, eligibility results and insurance information will be sent from the FQHC to CMS for enrollment in the DREAM program.
  • If the eligible person (EP) is currently covered by commercial insurance, CMS will contact the EP’s insurance plan and require that the plan contacts the EP or legal guardian and obtains proper consent to transfer the EP’s coverage to the DREAM program. Following EP consent, Medicare will become the primary payer for the EP. Medicare at its sole discretion may discontinue eligibility for the EP and the commercial plan must reinstate coverage for the EP at that time. All subsidies paid by the Federal government to the insurance plan, if any, will be paid into the Medicare trust fund for the duration of DREAM participation.
  • The EP will pay to Medicare premiums equal to the last monthly amount the EP paid to the commercial plan. Medicare will cover all opioid related services with zero deductible and zero copay. For other services the EP deductible and copays will be equal to those of traditional Medicare beneficiaries (parts A, B and D). Medicare will end DREAM eligibility for an EP who missed 3 consecutive monthly payments.
  • If the EP is insured, or eligible to be insured, through Medicaid or any other public program, Medicaid or any other public program, will transfer into the Medicare trust fund estimated monthly premiums as calculated by the Secretary for the duration of DREAM participation. Medicaid will become the secondary payer for EPs previously enrolled, or eligible to be enrolled, in Medicaid.
  • If the EP is uninsured and not eligible for public insurance, the EP will be enrolled in Medicare (parts A, B and D), under the same terms as beneficiaries 65 years or older for the duration of DREAM eligibility, except that all opioid related services will be covered with zero deductible and zero copay.

Obamacare Crisis

  • Congress will appropriate $45 million for this program for a period of five years to cover program administration, evaluation and analysis. All other program costs, if any, will be absorbed by CMS budgets.
  • Any American citizen or lawful permanent resident who is not offered employer sponsored insurance, and is not eligible for Medicaid or another public insurance plan, and is not eligible for Federal subsidies on the Obamacare exchanges equal to at least 50% of total costs of the current benchmark plan, or resides in a county where no Obamacare plans are available on the exchange on the first day of the open enrollment period, will be eligible to enroll in Medicare parts A, B and D, at an annual rate of average Medicare spending per beneficiary (MSPB), adjusted for EP age.
  • The Secretary shall publish a list of DREAM premiums for three age bands, 0-21, 22-45, 46-64, no later than one month before the first day of open enrollment for the Obamacare exchanges. All DREAM rates will be assessed and billed for each individual EP. No family rates will be available and no Federal subsidies will be given to DREAM enrollees.
  • The EP, or a legal guardian if the EP is a minor, is responsible for premium payments to Medicare. EP deductible and copays will be equal to those of traditional Medicare beneficiaries (parts A, B and D). Medicare will end DREAM eligibility for an EP who missed 3 consecutive monthly payments.
  • For each program year the Secretary shall conduct and publish comparative analyses of Federal spending on Obamacare exchange enrollees and DREAM program enrollees to inform Congress and the public on the merits of each program.

Step 4: Consequences

See? Wasn’t that bad now, was it? Defining the program is relatively easy and the above is just an abbreviated example. Other details will need to be added, removed or changed, but the main idea here is to open Medicare in the short term to people who are hurting and are underserved by the commercial health insurance markets. There will of course be consequences. First, the Obamacare exchanges will most likely go bust, and we will have to expand the DREAM to allow enrollment of people who will bring their subsidies with them. Second, employers may decide to fund Medicare premiums instead of dealing with health insurance in house. Third, the folks who don’t qualify for the DREAM program may start chomping at the bit, seeing how DREAMers get to choose pretty much everything without breaking the bank.

Yes, yes, I know. I’m being too clever by half, but surely someone who professes to be the voice of the forgotten men and women, could see his way clear to make this happen. It will, after all, lead to a complete repeal and replace of Obamacare. And for all timid liberals enamored with the poetry inscribed at the feet of Lady Liberty, let’s help the President erect a statue of liberty at the gates to Medicare.

 

 

 

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Steven FindlaySaurabh JhaRoss KoppellBarry CarolPeter Recent comment authors
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Steven Findlay
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Steven Findlay

I’m way late to this dialogue…but what good fun to ponder and debate single payer. Another great provocative blog by Margalit. No time to read all the comments so I’m jumping off of Palmer’s point just below: why not amend/loosen up Sec 1332 of ACA to allow states to experiment with single payer more easily with fed support, with the trade off being that Republican governors get a smoother path to try their stuff out—-like shifting costs to consumers. That permits state experimentation that could help inform the national debate down the road when there might actually be a chance… Read more »

William Palmer MD
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William Palmer MD

I would say that if we are going to try a single payer that we try it in a small jurisdiction like a county or a hospital district first, We have to sharply define what we are trying to do medically. We have to get the money somehow and this needs realistic planning. Its leaders have to lose something if it fails; at least their identities have to be known to the voters…so that we have accountability. We have to decide who we are going to declare as beneficiaries. Are we going to allow illegal Dream kids or not, e.g.… Read more »

Steve2
Member
Steve2
Margalit Gur-Arie
Member

Yes, when Bain Capital deals in your health care, you now it’s pretty much over. Also venture capital from the saintly Silicon Valley is investing in “innovative” primary care “organizations”, some of which already went belly up.
Either way if single-payer, or something like single payer, set prices their joy ride is over..

William Palmer MD
Member
William Palmer MD

Margalit, Your intuitive desires seem to be monopsony purchasing (single payer) vs monopoly providers (physicians’ union). This is 180 degrees away from a free market, which has many buyers and many sellers. This is like the government vs GM and Chrysler during the 2008 recession. I’m not sure why you feel this remarkably heavy hand needs to be taken.

Margalit Gur-Arie
Member

It’s really not. I actually think that this is the only way to have a semblance of free market. What we have now is most certainly not a free market, and as more and more physicians become employed by larger and larger health systems, negotiating prices in secret with even bigger insurers, we are moving away further and further from a market where either doctors or patients have anything to say about what they sell or what they buy. If systems were smaller and physicians were small businesses and government role was to regulate, and guarantee payment of, a base… Read more »

Allan
Member
Allan

Margalit, it sounds like you are trying to create a system from top down believing that it would then grow organically into a free market system. Somewhere along the line I am losing your train of thought. We agree that what we have today is not a free market system and I believe no free market existed since WW2 when wage and price freezes led to the creation of employer sponsored healthcare. Admittedly government interference in this method of insurance at the onset was low, but gradually increased demonstrating that what might appears to be benign government involvement can suddenly… Read more »

Margalit Gur-Arie
Member

Alan, there are two major influences in our health care system that make it untenable. One is indeed government and its massive regulatory power, which can be good, but it is misapplied in so many ways that it has become a burden to all, including the government itself. The second is unbridled profit taking. This has no place in health care. It has no place in any other health care system that works relatively well anywhere in the world. It has got to go, or we will not be able to fix anything. We live in a capitalist society and… Read more »

Allan
Member
Allan

“unbridled profit taking”

Off the top of my head unbridled profit taking occurs basically under three conditions.

1) Government laws and regulations which I think you recognize.
2) Monopoly which incentivizes others to enter the market.
3) Unconscionable contracts which can be voided by a judge.

The solution is a freer marketplace with a lot less government intervention and subsidies to those that absolutely need them.

Margalit Gur-Arie
Member

Would have been a long time ago. It’s too late now. The players are too big and too few. If you remove whatever restraints government has on them at this point, we’ll end up with a “single-payer” that cannot be voted out office and 40% GDP on health care.

Allan
Member
Allan

I believe that as a rule government and the largest entities are working more in concert than against one another. Throughout history the regulators all too frequently were protecting their own interests. Look at the history of railroad long haul vs short haul.

Barry Carol
Member
Barry Carol

I’m wondering how much drug and alcohol treatment costs these days in a decent well run facility and how long does the typical treatment program last? My perception is that it can easily cost $30K for 30 days in the equivalent of a three star facility and far more in the types of places the celebrities typically go to when they need treatment. How much does Medicare and commercial insurers pay now and what is the maximum number of treatment days they will pay for? An NP tells me that residential drug treatment is only successful about 10% of the… Read more »

Margalit Gur-Arie
Member

No, it doesn’t. This is a national emergency Barry. We can’t afford to draw lines. We can’t afford to be penny wise and pound foolish. We need to throw the kitchen sink at this one.

And the idiotic arguments some are making (not you) that because we mishandled other issues in the past, we should also mishandle this one to avoid the appearance of discrimination, is just that, idiotic.

Allan
Member
Allan

“Nobody on the Right gives a [bleep] about opioid victims” Bobby G, I’d say people on the right are taking action. The Trump administration is stopping Opiods from enterring in from Mexico something Obama was very lax about. Drug Cartels Fuming at New U.S. Policy Screening 100% of Mexican Cargo Trucks AUGUST 01, 2017 In a major shift from lax Obama-era regulations, the Trump administration is finally allowing customs officers to screen all cargo trucks entering the U.S. from Mexico and sources on both sides of the border tell Judicial Watch Mexican drug cartels are fuming. U.S. Customs and Border… Read more »

Peter
Member
Peter

“In a major shift from lax Obama-era regulations, the Trump administration is finally allowing customs officers to screen all cargo trucks entering the U.S. from Mexico”

“Drug Cartels Fuming”

Right wing Judial watch claim that has been cut and pasted by every other right wing nut job publication – mostly false.

http://www.politifact.com/texas/statements/2016/dec/05/roger-williams/mostly-false-roger-williams-claim-lot-trucks-not-i/

Steve2
Member
Steve2

We have been working with our county officials since Vivitrol is being aggressively pushed in our area. At least in our area we have seen no change in the availability or cost of narcotics. Really, this is just a continuation of the War On Drugs. If there is any war that has failed, this is the one. Since you are a Trump fanboy you are convinced that it will work this time. It won’t. There are a lot of other things that might help. One of those is the lack of mental health and addiction services. In our research we… Read more »

Margalit Gur-Arie
Member

Maybe if we enroll them all in the flagship of health insurance and pour in everything we’ve got, we could make a difference….
This is a national problem. It needs a national solution.

Allan
Member
Allan

“If there is any war that has failed, this is the one.”

Our approach to drugs isn’t realistic and our leaders are protecting their own interests. Recidivism and thievery runs ramplant.

Allan
Member
Allan

Peter, the difference between you and Judicial Watch is they document everything they say. You probably hate them because they said things your probably disagreed with only to find out later that what they said was in black and white or in emails all obtained with FOIA requests.

Peter
Member
Peter
Allan
Member
Allan

Peter, what in your article demonstrates that “In a major shift from lax Obama-era regulations, the Trump administration is finally allowing customs officers to screen all cargo trucks entering the U.S. from Mexico … is using X-ray technology and other non-intrusive tools to screen 100% of cargo trucks crossing the southern border after eight years of sporadic or random screening permitted under the Obama administration.” What in your http tells us that the above isn’t true? Nothing. Why did you post it? You like the spin CNN provides even if what they say is blatantly untrue. Why don’t you tell… Read more »

Peter
Member
Peter

Your contention was that Trump cares about opioid addition because he told the border to inspect all trucks – mostly false. Not sure how you stop and inspect all trucks without massive congestion. Why not inspect all cars going across the border as well. The CNN report tells a much different story about his purported caring about the issue. He doesn’t back any of his tweet concerns with the funds and action necessary to actually do anything. The issue is more than a Tweet, although I doubt the Trump “brain” can get any deeper than tweet thoughts. He likes to… Read more »

Allan
Member
Allan

The problem is that CNN didn’t address a true fact nor anything else that Judicial Watch mentioned. CNN has barely mentioned Debbie Wasserman Schultz’s problems with her Pakistani computer whiz who was arrested while leaving the country. CNN leaves out a lot of things and doesn’t deal with facts unless those facts agree with their spin. Therefore, what you say is blatantly misleading unless you can show that CNN took into account what is actually being done and proves its case. I think many people realize that CNN is a joke, even those that are not on the right. Perhaps… Read more »

Steve2
Member
Steve2

“but surely someone who professes to be the voice of the forgotten men and women” That was just to get their votes. By his actions, there is no evidence that he actually cares about those people, and in particular it is pretty evident he has little interest in health care. My prediction, the last time you said Trump was going to fix things, was that he would defer to GOP leaders and the only thing we could be sure about was big cuts to Medicaid. At this point we either get some version of the existing House or Senate bill… Read more »

Margalit Gur-Arie
Member

I guess it depends on how you frame it. That’s where the opioid crisis comes in. Maybe we start with just that. I can’t see how people vote against helping with this and win any election after that. My guess is that the narcotics problem is only at its beginnings and it will get much worse in a year or two. This may very well be one of the defining issues of 2020 (all other things being equal). If every disaster is an opportunity, then that’s a pretty big disaster, so the opportunity should be equally huge. Democrats as a… Read more »

BobbyGvegas
Member

Nobody on the Right gives a [bleep] about opioid victims, with the exception of AG Jefferson Beauregard Sessions III, for whom they’d make nice customers for his newly authorized private prisons.

Peter
Member
Peter

Why are we calling them “opioid victims” and wanting to spend billions on care? What did Sessions call crack cocaine users?

William Palmer MD
Member
William Palmer MD

Do you really want the CMS to be controlling the financing of all health care? LTC? Disabled? Autism and developmental disorders? Capital investments in hc infrastructure? Does this control need to reach back into the medical schools and nursing schools? …after all, these are the input factors of production of the hc sector. .

All this would be a needless upheaval and I don’t think you really mean a single payer for the whole shebang.

Talk about your real boundaries.

Margalit Gur-Arie
Member

Well, I do understand the concern, but I don’t want CMS to control much more than they are already controlling between Medicare and Medicaid. Medicaid is controlling pretty much all of those things you mentioned at the start, although I am not sure that “control” is the right term to use. They pay for these things. The fact that states pay for some of it doesn’t make me feel warm and fuzzy, seeing how positively mean some states have been, and not just red states…I also don’t quite see how CMS can reach into infrastructure and medical schools (and residencies)… Read more »

Steve2
Member
Steve2

Medicaid covers a lot of the disabled. Fridays are my disabled and mentally challenged kids day. Have a fair number of challenged adults now on the other days. Almost all on Medicaid. Not sure I see a lot of difference in having Medicare covering these people with disabilities rathe than Medicaid, except maybe we get paid more. Good luck with getting insurers to compete. They work pretty hard at avoiding that. However, in the states with lots of insurers, you then face the possibility of providers having excessive market power. Left to the markets, this has not spontaneously resolved itself… Read more »

Margalit Gur-Arie
Member

I think getting paid more is paramount. It’s hard to get referrals for Medicaid kids, especially psych. Oh they’ll compete like crazy for the crumbs. If there is a Medicare option in town, they will be forced to play by those rules. How do you sell a stupid narrow network, when people can cross the street and get no networks and no restrictions for the same price? How do you restrict doctor practice or charges if the big gorilla doesn’t? That’s why they don’t want a public option. They can’t compete in a free market. They are only good at… Read more »

Steve2
Member
Steve2

Suppliers give discounts to large networks. Networks are able to concentrate sicker patients in their tertiary centers. Concentrate pediatric care in one facility. We are not a huge network, only about $3.5 billion in revenue, but I can tell you based on our stats that patient care suffers absent the resources of the larger central hospitals. If doctors are going to get paid a lot more, I assume this will apply to other providers. Hospitals will get paid more. How is this all getting paid for? Talk with young docs. I think it pretty safe to say at least half… Read more »

Margalit Gur-Arie
Member

Suppliers will have to price stuff as their market can bear. Besides hospitals have a long history of banding together for purchasing purposes. No need to merge just for that. I’m not sure I understand why would large hospitals not be there…. There will be central ones and less central ones, like we had before they bought each other. Perhaps I’m missing something here? Doctors will get paid more than Medicaid and perhaps less than commercial payers pay. All in all, they’ll probably be paid the same, except I hope they find a way to pay primary care a lot… Read more »

Steve2
Member
Steve2

Since you don’t work in a hospital would take longer to explain than I have time right now, but let me give a brief example. Most of those smaller, rural hospitals or the less well off urban ones have limited staff resources. They typically have docs who trained at tier 2 and 3 residencies. Then, it is more difficult to keep up on latest developments and have access to the latest tools. In some ideal world they do, but in reality it just doesn’t happen. Within a network, where the docs will belong in the same group, you can rotate… Read more »

Margalit Gur-Arie
Member

I understand that. We have a few systems here that own rural hospitals in addition to the big city ones, and I assume they do similar stuff (used to work for one years ago). But how big do you need to be? Is it really necessary to own dozens of hospitals in dozens of states? I understand the benefits of being affiliated with a large hospital that attracts the best, but surely there is some limit after which, it’s just too much, no?

Barry Carol
Member
Barry Carol

Margalit, since you’re from the St. Louis area, I assume you’re referring to Ascension Health though they’re certainly not the only healthcare system (network) that owns hospitals and clinics in more than one or two states. Dignity Health, formerly Catholic Healthcare West, in CA is another. Both are non-profit so there is no shareholder value that has to be maximized. Why is it so terrible for these hospital systems to be big but if government controls 100% of the market in terms of what’s covered and prices paid, it’s a great thing? I like the sorts of innovation that can… Read more »

Margalit Gur-Arie
Member

In Switzerland Barry, insurance companies are nothing more than TPAs for the very generous basic benefits. They are not allowed to profit from that. They are not allowed to restrict access to “networks”. They are not allowed to “negotiate” (collude on) prices with humongous health systems. They are not allowed to collude with PBMs to keep drug prices high and volumes through the roof. And they are not allowed to deny care or ration care under the guise of “managed care”. We tend to ignore those differences for some peculiar reason. Same is true in Germany. If you superimpose a… Read more »

Barry Carol
Member
Barry Carol

Swiss insurers are much more than TPA firms because they absorb actuarial risk. They must cover their expenses with revenue from insurance premiums. U.S. insurers who process claims, negotiate reimbursement rates and provide a network for self-funded employer health plans are more like TPA firms as they simply charge the employer a per member per month (PMPM) fee for their services. The employer absorbs all of the actuarial risk unless it separately purchases reinsurance. While you’re correct that Swiss insurers can’t make a profit from selling the government mandated benefits package, roughly 35%-40% of the U.S. non-Medicare and non-Medicaid health… Read more »

Margalit Gur-Arie
Member

Barry, whether for-profit or for-revenue makes no difference to me. I personally think that no business that makes over 1 million in revenue should be exempt from taxation. Insurers have zero interest in keeping prices down because they get to keep a fixed percent of revenues. The higher the prices, the higher the revenues, the higher the stated profit and the higher the not-stated profits and executive compensations. You could argue that lowering prices and premiums is necessary because the market can only bear so much, but that is not how things work. If the market can’t bear their prices,… Read more »

Steve2
Member
Steve2

I think you make a good point about how big systems need to be to accomplish the good things that networks can accomplish. I don’t know wha the cutoff is, but I would agree that at some point there is no social utility in the increased size of networks.

Steve

Margalit Gur-Arie
Member

I wish someone would d a study about this… It would be very useful to know, just in case they really try to fix something… 🙂

Barry Carol
Member
Barry Carol

Margalit, I strongly disagree with your premise that insurers have no interest in mitigating healthcare cost growth because they make more profit from higher healthcare prices and higher healthcare utilization. For our largest health insurer, UnitedHealth Group, their public business already exceeds their private commercial business. Their average margin on Medicare business is 5% pretax and on Medicaid, it’s 3% pretax. Healthcare prices are basically dictated in both cases. On the commercial side, 73% of members are in self-funded plans now where United assumes no actuarial risk but just provides administrative services including claims processing, providing a network and negotiating… Read more »

Margalit Gur-Arie
Member

Why more taxes? As I said in the previous piece, we don’t need more money in the system. We have $3 trillion. That’s more than enough to cover everybody. We just pay whatever we’re paying now (or not paying now) to a central location, which then distributes the money to contracting utilities to reimburse providers of care.In other words traditional Medicare. We can use the surplus created by this efficiency to care for all the people that are not covered now, or are covered by crappy managed care junk. I am not suggesting we do this tomorrow in one swoop.… Read more »

Barry Carol
Member
Barry Carol

Margalit, I keep having a problem with the notion that the $3.4 trillion we currently spend for healthcare according to the National Health Expenditure data would all be available to finance a single payer alternative to the our current health insurance system. What’s really available, in my opinion, is the sum total of what we currently spend for Medicare (including beneficiary premiums), Medicaid, VA, employer sponsored insurance and individual market insurance. For this year, Medicare and Medicaid will probably spend approximately $1.2 trillion combined including beneficiary premiums which the federal government accounts for as offsetting receipts. That’s to cover roughly… Read more »

Margalit Gur-Arie
Member

First of all, since you mentioned him, Paul Krugman is a hack. I used to read his stuff religiously and then it all became just sheer craziness, but I digress. As to the “transition”, because there will have to be one and it may take many years, if it’s ever completed. I am not proposing to take anything away from anybody and I am not proposing any new taxes. Yes, we do indeed have a system and we will have to work with it. I am suggesting we open Medicare to people who can no longer find insurance in the… Read more »

Barry Carol
Member
Barry Carol

Margalit, it sounds like what you’re suggesting is for Medicare to be an insurer of last resort or, if you like, a high risk pool. People who haven’t been able to buy insurance in the current system either can’t afford it because they don’t qualify for a subsidy or qualify for an inadequate subsidy or are healthy, don’t think they need insurance and don’t want to pay for it. Illegal immigrants are a separate issue. I’m not sure how Medicare would price its policies to people younger than 65 who want to buy into the program. Medicare currently spends an… Read more »

Margalit Gur-Arie
Member

Regarding Krugman, that, and the insane reaction to electing Trump and his barely concealed disdain for people who voted for him, which are after all the people his “magnanimous” policies are supposed to be for. If he hates the people, I don’t trust his much professed good intentions. As to Medicare, yes last resort is a good term, but not necessarily because you are uninsurable. The disabled have Medicaid at this point, so keep that for now (later on we can move them, for the same money we spend now). In the individual market there are people who want to… Read more »

Barry Carol
Member
Barry Carol

Pricing would be a challenge. I wouldn’t have a problem with Medicare doing as you suggest if I could be confident that it would compete on a level playing field with private insurers which means it would have to cover medical claims plus administrative costs solely from premium revenue. I don’t think that model would be sustained even if it started out that way. I don’t want to see deliberate under pricing with unlimited access to federal funds with the specific objective of unfairly driving private insurers out of business. People like choices and government should have to compete too… Read more »

Margalit Gur-Arie
Member

They are not competing with Medicare Advantage. They are contracting with Medicare Advantage and losing their shirts doing that. Not to mention the billions in fraud perpetrated by MA plans…. but again, that’s another subject. I agree with you that the under 65 crowd should not cannibalize the trust fund or the general revenue allocated to 65+ folks. But I don’t want a level playing field. I want Medicare to negotiate with drug companies and use its muscle to make premiums cheaper. Same for physician and hospital fees. I could be wrong, but I don’t think any commercial plan would… Read more »

Barry Carol
Member
Barry Carol

Medicare will not be able to negotiate lower drug prices unless it is prepared to refuse to cover certain drugs deemed too expensive. If politicians require Medicare to cover every drug that won FDA approval, negotiation will be useless. The VA gets relatively low drug prices because it’s a comparatively small and sympathetic group. It also has a highly restrictive formulary which most Americans, especially seniors, won’t accept. Medicare spending for the first 10 months of fiscal 2017 is only up about 3% adjusted for timing differences of certain payments and is roughly in line with the growth of the… Read more »