Since Saturday’s Nevada primaries, confusion seems to be reigning about how Bernie Sanders seems to be winning. Time (and not a lot more of it) will tell who actually ends up as the Democratic nominee. But the progressive side (Bernie + Warren) is doing much better than the moderate side (Biden/Butt-edge-edge/Klobuchar) expected, while we wait to see how the Republican side of the Democratic primary (Bloomberg) does in an actual vote. The key here is the main policy differential between the two sides, Medicare For All.
Don’t get too hung up in the details of the individual plans, especially as revealing said details may have hurt Elizabeth Warren. But do remember that there is one big difference between Sanders/Warren and the moderates. It comes down to whether everyone is in the same state-run single payer system (a modified and expanded version of Medicare) or whether the private employer system is left as it is, with expanded access to something that looks like Medicare (the public option) for everyone else. Note that no Democrat wants to stand pat on Obamacare “as is”. Everyone is way to the left of what Obama ran on in 2008 (or at least what he settled for in early 2009).
We’ve been spending a
lot of time these past few years debating healthcare reform. First the
Affordable Care Act was debated, passed, implemented, and almost continuously
litigated since. Lately the concept of Medicare For All, or variations on
it, has been the hot policy debate. Other smaller but still important
issues like high prescription drug prices or surprise billing have also
received significant attention.
As worthy as these all
are, a new study suggests that focusing on them may be missing the
point. If we’re not addressing wealth disparities, we’re unlikely to
address health disparities.
It has been well
documented that there are considerable health disparities in the U.S.,
attributable to socioeconomic status, race/ethnicity, gender, even geography, among other
factors. Few would deny that they exist. Many policy experts and
politicians seem to believe that if we could simply increase health insurance
coverage, we could go a long way to addressing these disparities, since coverage
should reduce financial burdens that may be serving as barriers to care that
may be contributing to them.
Universal coverage may
well be a good goal for many reasons, but we should temper our expectations
about what it might achieve in terms of leveling the health playing field.
A seasoned health policy expert, his article cross-references the opinions and work of a range of health commentators including Atul Gawande, Steven Brill, Sarah Kliff, Elizabeth Rosenthal, Zack Cooper, and Canadian health economist Robert Evans. But his major companion is Princeton health economist, Uwe Reinhardt, whose posthumous book, Priced Out: The Economic and Ethical Costs of American Health Care, was recently published by Princeton University Press.
Gaffney’s affection for Reinhardt is evident as he recounts his desperate upbringing in post-war Germany, challenged by poor living conditions, but made whole by access to health care. Quoting a 1992 JAMA interview, Reinhardt states, “When we needed medical care, we got it at the local hospital, no questions asked. When you were sick, society was there for you.”
That acknowledgment is not only personal but historically significant, as I outline in my recent book, Code Blue: Inside the Medical Industrial Complex. The services Reinhardt received were part of a new national health care system funded fully by American taxpayers as part of the Marshall Plan. At the very same time, American citizens were denied a national health plan of their own as Truman was effectively branded a supporter of “socialized medicine” by the AMA and a cabal of corporate partners.
The Cure for healthcare isn’t Medicare for All, it’s establishing organizations with complete responsibility for the total care, costs, quality and outcomes for a person.
Discussions of Medicare for All substitute structure for substance. They engender a debate about the trappings of care delivery, administration, and cost, but don’t address the fundamental issue, which is how to provide genuinely better care for people of all ages and economic circumstances.
The premise of Medicare for All is that a single payer will provide better and more cost effective care. But what is really needed is single entity accountability. Whether there are one or many, whether they are public or private, is not as important as that one organization and its people become responsible for the total health and care of an individual and the costs associated with that care. With incentives for doing it well, and penalties for doing it poorly. And an ease of transition for people to move from an entity that doesn’t serve them well to one that does, to maintain the benefits of competition and varied approaches based on differing conditions.
Focusing on Medicare for All promulgate a systemic flaw baked into our health insurance and provider systems. High costs and lower quality can’t just be fixed by a single payer negotiating lower drug prices, nor would providing fewer services mean better care at lower costs. The core problem is exemplified by the invidious arbitrary split in public health insurance between Medicaid and Medicare, with each providing different services spread out among many providers, none of whom have sole responsibility for the complete health of the person.
BetterCare for All need not be a win-lose proposition, of Medicare for All or nothing. The feasibility near term of a one payer system is low, whereas the feasibility of building on existing systems and frameworks to create single system accountability is much higher.
It is not wise for Democrats to spend all their energy
debating Single Payer health care solutions.
None of their single player
plans has much chance to pass in 2020, especially under the limited
reconciliation process. In the words of Ezra Klein, “If Democrats don’t have a
plan for the filibuster, they don’t really have a plan for ambitious health
Yet while we debate Single Payer – or, even if it somehow
passed, wait for it to be installed — millions of persons are still hurting
under our current system.
We can help these people now!
Here are six practical programs to create a better ACA.
Taken all together they should not cost more than $50
billion a year. This is a tiny fraction of the new taxes that would be needed
for full single payer. This is at least negotiable, especially if Democrats can
take the White House and the Senate.
The impending closure of
Hahnemann University Hospital is a local tragedy. Eliminating a 170-year
old institution is certain to exaggerate the daily travails of the economically
disadvantaged inner-city population that Hahnemann serves as a safety-net
hospital. The closure is also a national tragedy. Hospitals are the
towering, visible monuments of our healthcare system, and closings imply that
something insidious ails that very system—that all is not well.
Hospitals are complex
entities with varied financial drivers, and the solution is never simple.
And the moment is too rich for politicians who see Hahnemann’s failure as the
culmination of their dystopian predictions. Bernie Sanders, most
prominently, stood on the hospital’s doorstep and pitched his deceptively
simple solution—Medicare for All. Medicare for All, Sanders said, would
ensure that every patient carries the same coverage, hospitals are paid a predictable
rate, and voila, no hospitals need to close. Private insurance would
disappear, and no one would be without coverage.
Even physicians have jumped on the Medicare for All bandwagon. Some
doctors insist that once profit is removed as a motive for hospital bottom
lines, and government bodies decide which hospitals can buy a surgical robot,
build a new wing or offer proton beam treatment cancer treatment centers, then
all hospitals will do better.
But these arguments miss
a fundamental point: why pitch government insurance for all, like Medicare and
Medicaid (a federal and state insurance plan to cover low income adult and
children) as a remedy, when it is precisely government-run insurance that is
killing Hahnemann and other hospitals in distress?
Americans spend about $3 trillion
per year on healthcare, or about $10,000 per person per year. Despite these
expenditures, Americans are worse off than their international counterparts
with respect to infant mortality, life expectancy and the prevalence of chronic
In policy debates, Republicans
mostly prefer to let the marketplace devise the appropriate outcomes, but this
approach ignores the market failures that plague the industry.
On the other hand, Democrats propose
a variety of solutions such as “Medicare for All” which nationalizes all
healthcare insurance or, as a variant, “Medicare as an Option for All” which further
extends the federal government into the provision of healthcare insurance. Such
approaches could actually result in a less efficient outcome, or worse yet, create
a market beset by political ping pong when Administrations change.
This paper proposes a new
standards-based approach for fixing the inefficiencies plaguing the healthcare
industry in the United States. As described herein, a non-profit standards body
would be established by Congress to bring a coordinated approach to healthcare
for each of the top ten chronic diseases.
Such an approach would establish consistent
priorities and practices across all of the components of the healthcare
industry affecting these chronic diseases, including standards of care, areas
of research emphasis and insurance guidelines.
Under such an industry structure,
patient care would improve and the overall costs for the provision of
healthcare would drop significantly.
I could’ve been Kamala Harris, Joe Biden and Marianne Williamson all rolled into one. That’s how I might have handled my first, only, and not-so-great presidential debate.
No, I wasn’t actually running for president. But I was involved in the campaign of someone who was: Barack Obama. In September, 2008, the campaign asked me to serve as a surrogate in a debate with John McCain’s health care adviser when one of Obama’s close advisers – as opposed to me, who’d met the candidate once at a campaign event – couldn’t make it.
As a policy wonk and politics junkie, I was ecstatic. Entering the debate, I was confident. Afterwards, metaphorically dusting the dirt off my clothing and checking for cuts and bruises, I was chastened.
Getting off the couch and onto the stage, even a small one, is tougher than it looks. Watching the cluster of Democratic presidential candidates go at it on health care, I scoffed and sneered along with other experts at their obfuscations and oversimplifications. (More on that in a moment.) But I also sympathized.
Amazon has quietly put together a syndicate including Berkshire Hathaway and JP Morgan to provide better and more affordable health care for their combined 1.2 million workers.
The joint effort, called Haven, makes sense because many companies of size today are self-insured to provide health care at lower costs. But this is different. Jeff Bezos, Jamie Dimon and Warren Buffett seem to be personally involved in the development of Haven. So, what could they possibility have up their sleeves?
At the same time, many Democrats running for president are promising single payer health care (Medicare For All) as the solution to controlling costs and providing quality health care for everyone. Republicans argue that this is socialism and will result in unacceptable increases in taxes that will ruin our economy.
While politicians debate, Amazon’s real objective may be to create a health care payer to rival all payers with tens of millions of Amazon Prime Members as health plan members.
With Amazon’s buying power, scale and capabilities, the ecommerce giant could create a health payer offering that could render the need for a single payer system moot.
In the 2nd night of the Democratic Primary debate on June 27, 2019, Pete Buttigieg was asked whether he supported Medicare-For-All. He responded, “I support Medicare for all who want it.”
In doing so, he side-stepped the controversial debate over shifts of power from states to the federal government, and trusted that logic would eventually prevail over a collusive Medical-Industrial Complex with an iron lock grip on a system that deals everyone imaginable in on the sickness profitability curve – except the patient.
On July 30, 1965, President Lyndon B. Johnson signed into law “Medicare,” a national insurance plan for all Americans over 65. He did so in front of former President Truman, who 20 years earlier had proposed a national health plan for all Americans, and for his trouble was labeled by the AMA as the future father of “socialized medicine.”
For Truman, there was a double irony that day in 1965. First of all, the signing was occurring at around the same time as our neighbor to the north was signing their own national health plan, also called “Medicare”, but their’s covered all Canadian citizens, not just the elderly.
The second incongruity was that Truman was fully aware that in 1945, as he was being tarred and feathered as unpatriotic by taxpayers for having the gall to suggest that health care was a human right, those very same citizens were unknowingly funding the creation of national health plans as democracy stabilizers in our two primary vanquished enemies – Germany and Japan – as part of the US taxpayer funded Marshall Plan.