Whether you are elated, appalled, or just plain amazed that Donald Trump is the Republican primary front runner by a considerable margin, one thing should be clear: he’s not a policy guy.
So far, The Donald’s lack of policy specifics seems not to have hurt him. He’s successfully deflected the more searching debate questions, provided vague generalizations or given incomprehensible responses, and—when all else failed—insulted the debate moderators or his fellow Republican candidates.
So far, so good, for the Trump campaign. But is it time to change tactics?
As the number of competing candidates dwindles(So long, Jeb!),the focus in debates and interviews becomes sharper. With the original crowded field winnowed to just a handful,interviewers and debate moderators have time to probe a lot more deeply.And even if the questioners are relatively gentle, every other surviving candidate will be eager to pour scorn on policy statements that lack either substance or rationality.
Like Donald Trump’s healthcare proposals so far.
He’s said he wants the government to negotiate Medicare drug prices, he likes health savings accounts, he wants to be able to buy insurance across state lines, and he wouldn’t cut Medicare. And that’s pretty much it, except for one very big thing: he would “repeal and replace” Obamacare. But by what? “Something terrific” he says.
It’s easy to mock, but all of us – liberals and conservatives — should worry that we might just find ourselves with an incoming president trying to impose such an incoherent healthcare vision that our present system would look like a paragon of rationality.
For all those Americans faced with higher health insurance premiums or less coverage (that’s most of us), the temptation is to blame the Affordable Care Act. Maybe instead we should be blaming the one thing the ACA didn’t significantly change: employer sponsored insurance—the norm for most working Americans.
Although the ACA imposed some new standards for coverage, ESI employers remain free to dictate most insurance details, the tax-exclusion of ESI benefits is largely unchanged, ESI premiums are still generally independent of income, and small employers can still offer ESI or not.
Unfortunately for millions of workers, it’s a model that’s increasingly neither affordable nor equitable. What seemed a reasonable approach fifty or sixty years ago when healthcare costs were far lower is now one of the most regressive health insurance systems in the industrialized world.
The Kaiser Family Foundation’s most recent employee benefits report demonstrates the problem.
It doesn’t seem likely that Senator Bernie Sanders will be our next president, but the current primary election campaign is throwing some pretty startling curveballs. With substantial popular support for one candidate with a fondness for the bankruptcy courts, and another who believes the pyramids were grain silos, a “democratic socialist” can’t be counted out.
In this world of the politically unexpected, Senator Sanders’ “Medicare for All” proposal for restructuring our healthcare system seems like something we should take seriously.
It’s a great slogan – a lot zippier than “Patient Protection and Affordable Care Act” — although the specifics are a little hazy. Senator Sanders has been promising since July to provide more details, but so far has provided only some tantalizing sound bites, like this one from his spokesman a week ago: “At a time when we are the only major country on earth that does not guarantee health care for all and when we spend far more per person that any other country, the time is long overdue for us to pass a Medicare for All, single-payer program. Medicare for All would save the average family thousands of dollars a year in health care costs…”
Most liberals would agree that one of the disappointments of the Affordable Care Act is its failure to assure universal coverage. We still have millions of uninsured and, with coverage increasingly expensive and deductibles skyrocketing, the number seems more likely to grow than decrease. In comparison, a totally tax-supported (as Senator Sanders has proposed in the past) Medicare for All model would bring the United States into line with other nations and protect millions from healthcare financial crises.
However, the claim that “single-payer… Medicare for All would save the average family thousands of dollars a year” is a lot more questionable.
A new report from the usually sensible Commonwealth Fund got lots of media attention this past week. The report –“Competition Among Medicare’s Private Health Plans: Does It Really Exist?” –quickly led to headlines like “Is private-sector Medicare becoming a monopoly? [PBS]” and “Robust Medicare Advantage competition almost non-existent [Modern Healthcare],” and “Health insurance is staggeringly uncompetitive in America, and is poised to get even worse for everybody [Quartz].”
It sounds like Medicare Advantage is headed for disaster, but is this really the case?
The Commonwealth report’s major findings are summarized in one sentence, likely the one that grabbed media attention: “Using a standard measure of market competition, our analysis finds that 97 percent of markets in U.S. counties are highly concentrated and therefore lacking in significant [Medicare Advantage] plan competition.”
After some frantic last minute political
gyrations and a lot of pressure from the President, House Democrats
have announced details of their draft health care reform bill.
Much as expected, the 852-page bill
emerging from three House committees would impose a mandate on larger
employers to provide insurance, impose a second mandate on individuals
to obtain coverage, prohibit medical underwriting by insurers, establish
a government-administered public plan to compete with insurers’ offerings
through insurance exchanges, offer subsidies to lower-income individuals,
and expand Medicaid. The target ten-year trillion-dollar (or more) price
tag would be funded through a combination of taxes on high income individuals
and reductions in some Medicare and Medicaid payments.
So, is this the answer to the nation’s
health care crisis of sky-rocketing costs and growing millions of uninsured?
In a comment on my previous post on
the Senate Health, Education, Labor, and Pensions reform bill, tcoyote
explained some of the political thinking behind what seem like totally
spurious cost projections. While I can readily accept tcoyote’s explanation
of the pols’ efforts to ignore reality, I’m still politically innocent
enough to want to know what the HELP bill might really cost. So I spent
some time looking at the Congressional Budget Office report on the bill.
Here are a few things I noticed:
- The “ten-year projection”
starts in 2010, although the bill does not require insurance exchanges
to be implemented until 2014. The result is that the projection includes
only six years of reform (plus a lengthy transition period), NOT ten
- The CBO projections
include a $58 billion “credit” for the impact of the HELP bill’s
proposed new long-term care program (the so-called CLASS Act). However,
the “credit” accounts for the difference between premiums and benefits
over the 2010-2019 period on a cash basis only. If conventional accrual
accounting were used, CLASS would show a net cost for the period.
If health care reform legislation is passed, it will almost certainly include provisions for Insurance exchanges. Theoretically, these could be key to controlling costs and expanding access to coverage. In practice (and in addition to assumptions about guaranteed issuance, community rating, and the elimination of medical underwriting) these goals will be achieved only if exchange design adheres to some basic principles:
Putting the political cart firmly before the horse, the Senate Finance Committee heard testimony last week on how to pay for reform—before they had reliable estimates of how much it is likely to cost.
It’s not that there aren’t plenty of estimates to choose from. A recent Associated Press report offered ten-year forecasts ranging from “the president’s $634 billion…is likely to be the majority of the cost” (White House budget director Peter Orszag) to “$125 billion to $150 billion a year” (New America Foundation economist Len Nichols) to “$1.5 trillion to $1.7 trillion would be a credible estimate” (Lewin Group consultant John Sheils). Take your pick.
What’s really the number that Senate Finance members must find a way to fund? Leaving aside mythical savings like the $2 trillion sort-of promised by health care industry bigwigs, and the almost as questionable cost reductions for delivery system tweaks offered at previous Senate Finance sessions, the question becomes: how much new spending will universal coverage add?