By Jaimy Lee
MarketWatch, December 28, 2019

A handful of companies like Humana Inc. and Walgreens Boots Alliance Inc. that are better known for operating pharmacy counters and managing health plans are now turning into primary care providers.

CVS Health Corp., Humana HUM, Walgreens, Walmart Inc., and UnitedHealth Group Inc. now operate hundreds of clinics that directly market themselves as primary care providers or provide a majority of primary care services. And they all plan to open more clinics in 2020.

“There is an emerging consensus that the best way to control medical costs in America is to have patients have an old fashioned-style primary care relationship with someone in the health system,” said Dr. Bob Kocher, a partner at venture-capital firm Venrock. “There is a belief that the pendulum is swinging to the next-generation version of managed care.”

“Although maybe only 5% of health care cost is incurred in the primary [care] environment, a good or bad decision determines what the next 95% looks like,” Andrew Witty, CEO of UnitedHealth Group’s Optum business, said during an investor day in early December, according to a FactSet transcript. Optum currently operates 47 primary care clinics, a number that has doubled over the past two years, Witty noted during the investor day.

A Walgreens spokeswoman said the pharmacy giant operates nine primary care clinics, in partnership with several organizations, including primary care-provider Village Medical.

Humana had 230 primary care centers that it owns or that are part of joint ventures, according to comments made during its annual meeting by Humana president and CO Bruce Broussard in April. “We’re not convinced that the primary care model is completely figured out,” Broussard had said in mid-2018, before adding: “I would say that the intensity of it will increase and our commitment of putting more and more in a faster way and scalable way will increase over the next 24 months or so.”

CVS Health, which has opened 50 of its HealthHubs in Atlanta, Houston, Philadelphia and Tampa, Fla., and Walmart, which opened its first health center in Georgia this year, don’t expressly say that they operate primary care clinics. However, spokespersons for each company separately said the majority of the visits to their clinics are for primary-care services.

Startups like Iora Health and One Medical have pulled in hundreds of millions of dollars in private funding. One Medical, which is now the largest independent primary-care practice in the U.S., is reportedly considering an initial public offering early next year, according to CNBC.

“Given all the new market entrants, there is an emerging fight for the front door that can dramatically affect the overall business of health care systems and help the move to drive care out of hospitals,” said Lisa Suennen, a longtime health care investor and leader of Manatt’s venture capital practice.

How that has played out so far is a steady stream of announcements in 2019 about medical practices being opened in or adjacent to drugstores. CVS has plans to open an estimated 1,500 HealthHubs in its stores over the next two years; CEO Larry Merlo told investors in November to expect a material impact from the hubs in 2021. In the case of CVS, the pharmacy retailer also operates the Aetna health plan so its investment in building clinics touches on both retail and health care cost-reduction trends.

Walgreens, on the other hand, this year decided to focus on a partnership model. Its first primary care clinic with VillageMD opened its doors in November in Houston, next door to a Walgreens drugstore. The goal is foot traffic.

“If there’s a primary care—that is why we’re testing these pilots—we’re trying to see the uplifts on both retail and on scripts,” Walgreens CFO James Kehoe said on an earnings call in October. “So you’ve got three sources of income in most cases.”

https://www.marketwatch.com…

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Comment:

By Don McCanne, M.D.

So now we are going to have pre-packaged for us health insurers, retail pharmacies and primary care. Walgreens CFO James Kehoe says, “So you’ve got three sources of income,” certainly suggesting what it’s really all about. And Dr. Bob Kocher, a partner at venture-capital firm Venrock, “There is a belief that the pendulum is swinging to the next-generation version of managed care.”

While there is considerable foot-dragging on the shift to single payer Medicare for All, the medical-industrial complex is rushing in to change the health care delivery system to position itself for optimal entrepreneurial advantage. Maybe the political hucksters who claim that we’ll have “Medicare for None” have some insight as to where we’re headed. At any rate, a system designed primarily to enrich passive investors does not sound good from the standpoint of the patients.

With the previous iterations of managed care (network model health maintenance organizations, managed competition, accountable care organizations, horizontal and vertical mergers, etc.), those of us advocating for a universal, equitable system of financing health care for everyone seemed to be considered irrelevant in the national dialogue on reform.

What attitude will the industry have toward us when they have rearranged the health care delivery system to meet their business objectives? Will we be left outside while we merely demonstrate with our “Medicare for All” placards? Or are we ready for a real (though bloodless) revolution? We’re starting a new decade; what will we do with it?

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Robert Weissman
Port Charlotte Sun, December 29, 2019

By almost every relevant metric, we do the worst or nearly the worst among all rich countries. We are the only country to permit tens of millions to go uninsured, far more people in the United States report skipping care because of cost issues than other countries, our infant mortality rate is atrocious and our life expectancy trails other nations and is actually dropping.

There’s no excuse for any of this in such a rich nation. We can solve all of these problems — by expanding coverage, eliminating underinsurance and co-pays and improving health care and health outcomes — with “Medicare for All.”

Medicare for All would cover everyone, and end the outrage of a system that permits 27 million Americans to go uninsured.

Medicare for All would solve the problem of underinsurance, which affects three in 10 adults. It would eliminate high deductibles that lead many to skip care.

And here’s the most overlooked fact about Medicare for All: It would improve coverage not just for the uninsured or underinsured, but for everyone, even those with the best health insurance plans now available. Medicare for All would eliminate co-pays and deductibles, provide for dental and vision care, and cover long-term care, including care in homes and nursing homes. With Medicare for All, every doctor would be “in network,” and you could use a doctor of your choice. That’s far better even than existing “Cadillac” plans.

Can we afford a system that would improve care for every single person?

Yes.

We can expand and improve Medicare at no additional cost compared to what we currently spend.

Leaving aside the very significant economic benefits — not just human health, but economic gains — that will come from improving the national health system, we can eliminate upward of $500 billion annually in spending wasted on bureaucracy, inefficiency and excessive corporate profits.

Thanks to price-gouging exploitation of patent monopolies and other government-granted market exclusivities, the United States spends outrageous sums on prescription drugs. By negotiating drug prices and ending Big Pharma rip-offs and price gouging by middlemen, we could conservatively save $200 billion every year.

Even bigger savings would come from eliminating the wasteful spending by the health care sector on administrative costs. The key would be to move away from per-treatment billing and instead rely on global budgets. Hospitals and other medical providers would receive an overall payment based on the patients they serve and the treatments they provide, and then they could get on with the business of providing care. The arrangement would be no different than the ways police stations or public libraries are funded; libraries don’t send a bill to the city treasurer each time a person checks out a book. The potential available savings are tremendous:

• Administrative costs consume an astounding 25% of U.S. hospital spending, far above most comparable countries, due largely to the costs of billing. If hospital administrative spending were brought in line with more efficient countries, the United States could save more than $150 billion each year on hospital spending alone.
• Researchers have found that American medical practices spent almost four times more money than Canadian doctors on dealing with payment issues — $82,000 per physician annually compared to $20,000.
• Processing bills, coupled with expenses for collection of unpaid bills, accounts for half or more of medical practice’s administrative costs — between 50% and 60%, according to a 2005 study published in Health Affairs.

A Medicare for All system would also be able to rationalize spending on expensive renovations and health care technology. By requiring separate budgets for the purchases of expensive medical equipment and other expansions, Medicare for All would ensure that such purchases are warranted by a community’s needs and would thus reduce unnecessary spending, both on the capital expenses themselves as well as on spending for related services.

Critics of Medicare for All have it wrong. They suggest that Medicare for All would bring rationing. But it’s the current system that imposes rationing as a shocking one in three Americans skip care because of costs. The critics say doctors or hospitals won’t be paid enough, ignoring that their costs will plummet because they won’t have to waste so much money on billing and administration. And they scream that quality of care will decline _ even though the evidence is plain that, under the current system, we have the worst health indicators among rich countries, by far.

We absolutely can afford Medicare for All. What we can’t afford is to continue with our current failed system. The time is now for Medicare for All.

Robert Weissman is president of Public Citizen.

https://www.yoursun.com…

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Comment:

By Don McCanne, M.D.

It seems appropriate to end this year and begin the next with a clear statement of what our cause is all about. Public Citizen’s Robert Weissman provides that statement for us. It’s up to us to bring his words to fruition. As he says, “The time is now for Medicare for All.”

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Margot Sanger-Katz
The New York Times, December 27, 2019

Why does health care cost so much more in the United States than in other countries? As health economists love to say: “It’s the prices, stupid.”

The International Federation of Health Plans, a group representing the C.E.O.s of health insurers worldwide, publishes a guide every few years on the international cost for common medical services. Its newest report, on 2017 prices, came out this month. Every time, the upshot is vivid and similar: For almost everything on the list, there is a large divergence between the United States and everyone else.

Patients and insurance companies in the United States pay higher prices for medications, imaging tests, basic health visits and common operations. Those high prices make health care in the U.S. extremely expensive, and they also finance a robust and politically powerful health care industry, which means lowering prices will always be hard.

For a typical angioplasty, a procedure that opens a blocked blood vessel to the heart, the average U.S. price is $32,200, compared with $6,400 in the Netherlands, or $7,400 in Switzerland, the survey finds. A typical M.R.I. scan costs $1,420 in the United States, but around $450 in Britain. An injection of Herceptin, an important breast cancer treatment, costs $211 in the United States, compared with $44 in South Africa. These examples aren’t outliers.

The international survey focuses on prices paid by private insurance companies; in many countries, public health programs pay less, meaning the gap in prices for many countries may be even larger if it took account of every patient. The survey doesn’t have information from every country, nor detailed prices for every medical procedure. Drug prices do not include rebates. But the report’s overall message is clear. Prices in the United States are higher for nearly everything — by a lot.

The single-payer plans Senators Bernie Sanders and Elizabeth Warren have proposed would use a large government insurer to set prices for all medical services. Both campaigns assume substantial savings would result as that government system lowered prices across the board: for doctors, hospitals, medical devices and drugs.

Even plans considered more moderate, like those from Pete Buttigieg, the South Bend, Ind., mayor, and Michael Bloomberg, the media executive and former mayor of New York, would impose some controls on health care prices, by limiting the amount that doctors and hospitals could charge in the situations where they typically charge the most.

Higher prices are not new for the United States, but they have become newly salient, as more health insurance comes with high deductibles and other forms of cost sharing that require patients to pay a larger part of the bill or even the full cost of their care. The overall upward creep of prices has also led insurance premiums to rise, taking a bite out of tax revenue, wages and corporate profits, too.

Any successful effort to tamp down American prices, of course, will mean reducing someone’s paycheck. The uniquely high prices for drugs in the United States help make pharmaceutical companies profitable. The high prices paid for hospital care help keep large research hospitals and small rural providers afloat. The high prices help doctors pay off extensive education debt — but also help place them among the highest-paid professions in our economy. None of those groups particularly want a pay cut.

https://www.nytimes.com…

International Federation of Health Plans Comparative Price Report:
http://www.ifhp.com…

Health Care Cost Institute: iFHP Survey
https://healthcostinstitute.org…

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Comment:

By Don McCanne, M.D.

Yes, this report confirms once again that in the United States it’s the prices that account for much of our higher health care spending. But it is important to be clear what can be done that would make health care more affordable without creating barriers to care, that is, assuring adequate volume without excessive prices.

A well designed single payer model of Medicare for All would use economic tools such as rate negotiation and global budgeting to reduce excessive prices while ensuring adequate capacity in the system through separate budgeting of capital improvements. In contrast, a Medicare for those who want it would only add one more player to our fragmented, dysfunctional health care financing system and thus would have very little impact on overall prices.

Those who suggest that physicians and hospital administrators will be unhappy with the price reductions are failing to consider one of the greatest contributors to high prices in the United States: our egregiously wasteful administrative excesses due largely to the private insurers and the administrative burden they place on the delivery system.

Recovering this administrative waste by enacting and implementing single payer Medicare for All would reduce cumulative prices at our current volume of utilization by close to 500 billion dollars without reducing net income of physicians or hospitals. That does not mean that total spending would be reduced because much of the savings would be used to pay for care currently forgone by the uninsured and underinsured. Also capacity limitations would prevent an excessive volume of services of little value.

So prices would be lowered, total spending would not change much, adequate net incomes for physicians and hospitals would be assured, and capacity would be adequate for essential services. What more could we ask for?

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

California Medical Association, December 23, 2019

Cottage Hospital System has initiated a contract termination with Anthem Blue Cross that affects three hospitals in the central Santa Barbara area. If the two parties fail to come to an agreement by the end of the year, the contract will terminate effective January 1, 2020.

The California Medical Association (CMA) is very concerned that if the termination becomes effective, Anthem may not be meeting geographic access standards and patients will be forced to travel long distances to receive services at in-network facilities. CMA has asked the Department of Managed Health Care (DMHC) to closely monitor the situation, given the potential disruption to patient care.

As a result of the pending termination, Anthem is requiring its contracted physicians who only have privileges at Cottage hospitals to obtain privileges other in-network facilities. Physicians who do not do so will have their Anthem contracts terminated, which will further impact access to care in the Santa Barbara area.

Based on the list of alternative hospitals Anthem listed in its notice to physicians, it appears that most patients will not have access to an in-network Anthem facility within DMHC’s geographic access standards… There is a high probability that many of Anthem’s contracted physicians will not be able to travel the distance to treat Anthem patients.

CMA is also concerned that this termination is happening after the Covered California enrollment period just closed. Unless Anthem was proactively disclosing to prospective enrollees that these three facilities would not be in-network, patients who enrolled with the plan expecting the Cottage Hospital System to be available in their network will be blindsided.

It remains to be seen whether the two parties will come to terms before the contract termination becomes effective. CMA will provide additional information on this situation as it becomes available.

https://www.cmadocs.org…

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Comment:

By Don McCanne, M.D.

The Partnership for America’s Health Care Future was formed to oppose Medicare for All. Amongst its members are America’s Health Insurance Plans, representing the insurers, and the American Hospital Association, representing the hospitals. The American Medical Association was a member but dropped out after its own members demonstrated shifting support towards Medicare for All. Patients are not represented.

Not surprising, this dispute is between insurers and hospitals, both opposed to Medicare for All. The dispute places at risk care of the patients and the ability of physicians to provide that care.

The conclusion is obvious: Let’s dump our current system that allows insurers and hospitals to negatively impact patient care because of a dispute over money, and replace it with a system that ensures care will always be there when needed: a single payer model of Medicare for All. Above all, that benefits patients; the physicians are becoming ever more supportive; the hospitals will do fine after they replace their administrators who may not be dedicated to public service; and the insurers… we’ll find them jobs that will benefit society instead of harming us.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The End of New Deal Liberalism

By William Greider
The Nation, January 5, 2011

We have reached a pivotal moment in government and politics, and it feels like the last, groaning spasms of New Deal liberalism. When the party of activist government, faced with an epic crisis, will not use government’s extensive powers to reverse the economic disorders and heal deepening social deterioration, then it must be the end of the line for the governing ideology inherited from Roosevelt, Truman and Johnson.

Political events of the past two years have delivered a more profound and devastating message: American democracy has been conclusively conquered by American capitalism. Government has been disabled or captured by the formidable powers of private enterprise and concentrated wealth. Self-governing rights that representative democracy conferred on citizens are now usurped by the overbearing demands of corporate and financial interests. Collectively, the corporate sector has its arms around both political parties, the financing of political careers, the production of the policy agendas and propaganda of influential think tanks, and control of most major media.

What the capitalist system wants is more—more wealth, more freedom to do whatever it wishes. This has always been its instinct, unless government intervened to stop it. The objective now is to destroy any remaining forms of government interference, except of course for business subsidies and protections. Many elected representatives are implicitly enlisted in the cause.

A lot of Americans seem to know this; at least they sense that the structural reality of government and politics is not on their side. When the choice comes down to society or capitalism, society regularly loses. First attention is devoted to the economic priorities of the largest, most powerful institutions of business and finance. The bias comes naturally to Republicans, the party of money and private enterprise, but on the big structural questions business-first also defines Democrats, formerly the party of working people. Despite partisan rhetoric, the two parties are more alike than they acknowledge.

In these terms, the administration of Barack Obama has been a crushing disappointment for those of us who hoped he would be different. It turns out Obama is a more conventional and limited politician than advertised, more right-of-center than his soaring rhetoric suggested. Most Congressional Democrats, likewise, proved weak and incoherent, unreliable defenders of their supposed values or most loyal constituencies. They call it pragmatism. I call it surrender.

Obama’s maladroit tax compromise with Republicans was more destructive than creative. He acceded to the trickle-down doctrine of regressive taxation and skipped lightly over the fact that he was contributing further to stark injustices. Ordinary Americans will again be made to pay, one way or another, for the damage others did to society. Obama agrees that this is offensive but argues, This is politics, get over it. His brand of realism teaches people to disregard what he says. Look instead at what he does.

With overwhelming majorities in Congress and economic crisis tearing up the country in 2009, incumbent Democrats opted for self-protection first, party principles later. Their Senate leaders allowed naysayers to determine the lowest common denominator for reform—halfway measures designed not to overly disturb powerful corporate-financial interests, and therefore not able to repair the social destruction those interests had wrought. Senate Democrats say they didn’t have the votes. Imagine what Mitch McConnell would have done if he were their leader: Take no prisoners. Force party dissenters to get in line and punish those who don’t. Block even the most pedestrian opposition proposals.

Democrats are not used to governing aggressively. They haven’t done so for decades, and they may no longer believe in it. For many years, incumbent Democrats survived by managing a precarious straddle between the forces of organized money and the disorganized people they claim to represent. The split was usually lopsided in favor of the money guys, but one could believe that the reform spirit would come alive once they were back in power with a Democratic president. That wishful assumption is now defunct.

Obama’s timid economic strategy can be described as successful only if the standard of success is robust corporate profits, rising stock prices and the notorious year-end bonuses of Wall Street. Again and again, Obama hesitated to take the bolder steps that would have made differences in social conditions. Now it is clear that the bleeding afflictions experienced by the overwhelming majority of citizens will not be substantively addressed because Democrats, both president and Congress, have chosen to collaborate in the conservative cause of deficit reduction: cut spending, shrink government, block any healing initiatives that cost real money.

Republicans, armed with strong conviction, are resurgent with what amounts to ideological nihilism. Leave aside their obvious hypocrisies on fiscal rectitude and free markets. Their single-minded objective is to destroy what remains of government’s capacity to intervene in or restrain the private sector on behalf of the common welfare. Many of government’s old tools and programs are already gone, gutted by deregulation, crippled by corporate capture of the regulatory agencies originally intended to curb private-sector abuses and starved by inadequate funding. The right wants smaller government for the people, but not for corporate capitalism. It will fight to preserve the protections, privileges and subsidies that flow to the private sector.

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Once again, Republicans are mounting an assault on liberalism’s crown jewel, Social Security, only this time they might succeed, because the Democratic president is collaborating with them. The deficit hysteria aimed at Social Security is fraudulent (as Obama’s own experts acknowledge), but the president has already gravely weakened the program’s solvency with his payroll-tax holiday, which undercuts financing for future benefits. Obama promises the gimmick won’t be repeated, but if employment is still weak a year from now, he may well cave. The GOP will accuse him of damaging the economy by approving a “tax increase” on all workers. Senate Democrats are preparing their own proposal to cut Social Security as a counter to the GOP’s extreme version. In the end, they can split the difference and celebrate another great compromise.

This is capitulation posing as moderation. Obama has set himself up to make many more “compromises” in the coming months; each time, he will doubtless use the left as a convenient foil. Disparaging “purist” liberals is his way of assuring so-called independents that he stood up to the allegedly far-out demands of his own electoral base. This is a ludicrous ploy, given the weakness of the left. It cynically assumes ordinary people not engaged in politics are too dim to grasp what he’s doing. I suspect Obama is mistaken. I asked an old friend what she makes of the current mess in Washington. “Whatever the issue, the rich guys win,” she responded. Lots of people understand this—it is the essence of the country’s historic predicament.

To get a rough glimpse of what the corporate state looks like, study the Federal Reserve’s list of banking, finance and business firms that received the $3.3 trillion the central bank dispensed in low-interest loans during the financial crisis (this valuable information is revealed only because reform legislators like Senator Bernie Sanders fought for disclosure). If you were not on the list of recipients, you know your place in this new order.

The power shift did not start with Obama, but his tenure confirms and completes it. The corporates began their systematic drive to dismantle liberal governance back in the 1970s, and the Democratic Party was soon trying to appease them, its retreat whipped along by Ronald Reagan’s popular appeal and top-down tax cutting. So long as Democrats were out of power, they could continue to stand up for liberal objectives and assail the destructive behavior of business and finance (though their rhetoric was more consistent than their voting record). Once back in control of government, they lowered their voices and sued for peace. Beholden to corporate America for campaign contributions, the Democrats cut deals with banks and businesses and usually gave them what they demanded, so corporate interests would not veto progressive legislation.

Obama has been distinctively candid about this. He admires the “savvy businessmen” atop the pinnacle of corporate power. He seeks “partnership” with them. The old economic conflicts, like labor versus capital, are regarded as passé by the “new Democrats” now governing. The business of America is business. Government should act as steward and servant, not master.

This deferential attitude is reflected in all of Obama’s major reform legislation, not to mention in the people he brought into government. In the financial rescue, Obama, like George W. Bush before him, funneled billions to the troubled bankers without demanding any public obligations in return. On healthcare, he cut deals with insurance and drug companies and played cute by allowing the public option, which would have provided real competition to healthcare monopolists, to be killed. On financial reform, Obama’s Treasury lieutenants and a majority of the Congressional Dems killed off the most important measures, which would have cut Wall Street megabanks down to tolerable size.

Society faces dreadful prospects and profound transformation. When both parties are aligned with corporate power, who will stand up for the people? Who will protect them from the insatiable appetites of capitalist enterprise and help them get through the hard passage ahead? One thing we know for sure from history: there is no natural limit to what capitalism will seek in terms of power and profit. If government does not stand up and apply the brakes, society is defenseless.

Strangely enough, this new reality brings us back to the future, posing fundamental questions about the relationship between capitalism and democracy that citizens and reformers asked 100 years ago. Only this time, the nation is no longer an ascendant economic power. It faces hard adjustments as general prosperity recedes and the broad middle class that labor and liberalism helped create is breaking apart.

My bleak analysis is not the end of the story. Change is hard to visualize now, given the awesome power of the status quo and the collapse of once-trusted political institutions. But change will come, for better or worse. One key dynamic of the twentieth century was the long-running contest for dominance between democracy and capitalism. The balance of power shifted back and forth several times, driven by two basic forces that neither corporate lobbyists nor timid politicians could control: the calamitous events that disrupted the social order, such as war and depression, and the power of citizens mobilized in reaction to those events. In those terms, both political parties are still highly vulnerable—as twentieth-century history repeatedly demonstrated, society cannot survive the burdens of an unfettered corporate order.

People are given different ideological labels, but Americans are not as opposed to “big government” as facile generalizations suggest. On many issues, there is overwhelming consensus that media and pundits ignore (check the polls, if you doubt this). Americans of all ages will fight to defend social protections—Social Security, Medicare and Medicaid, among others. People are skeptical to hostile about the excessive power of corporations. People want government to be more aggressive in many areas—like sending some of the financial malefactors to prison.

One vivid example was the angry citizen at a town hall meeting who shouted at his Congressman: “Keep your government hands off my Medicare!” I heard a grassroots leader on the radio explain that basically the Tea Party people “want government that works for them.” Don’t we all? In the next few years, both parties will try to define this sentiment. If they adhere to the corporate agenda, they are bound to get in trouble, and the ranks of insurgent citizens will grow. Nobody can know where popular rebellion might lead, right or left, but my own stubborn optimism hangs by that thread.

Whatever people on the left may call themselves, they have a special burden in this situation because they are deeply committed to the idea that government should be the trustworthy agent of the many, not the powerful few. Many of us believe further (as the socialists taught) that the economy should serve the people, not the other way around.

The current crisis requires people to go back to their roots and re-examine their convictions—now that they can no longer count automatically on the helping hand of government or the Democratic Party. Obama’s unfortunate “hostage” metaphor led Saturday Night Live to joke that the president was himself experiencing the “Stockholm syndrome”—identifying with his conservative captors. Many progressive groups, including organized labor, suffer a similar dependency. They will not be able to think clearly about the future of the country until they get greater distance from the Democratic Party.

I suggest three steps for progressives to recover an influential role in politics. First, develop a guerrilla sensibility that recognizes the weakness of the left. There’s no need to resign from electoral politics, but dedicated lefties should stake out a role of principled resistance. In the 1960s uncompromising right-wingers became known as “ankle biters” in Republican ranks, insisting on what were considered impossible goals and opposing moderate and liberal party leaders, sometimes with hopeless candidates. They spent twenty years in the wilderness but built a cadre of activists whose convictions eventually gained power.

Where are the left-wing ankle biters who might change the Democratic Party? It takes a bit of arrogance to imagine that your activities can change the country, but, paradoxically, it also requires a sense of humility. Above all, it forces people to ask themselves what they truly believe the country needs—and then stand up for those convictions any way they can. Concretely, that may lead someone to run for city council or US senator. Or field principled opponents to challenge feckless Democrats in primaries (that’s what the Tea Party did to Republicans, with impressive results). Or activist agitators may simply reach out to young people and recruit kindred spirits for righteous work that requires long-term commitment.

Second, people of liberal persuasion should “go back to school” and learn the new economic realities. In my experience, many on the left do not really understand the internal dynamics of capitalism—why it is productive, why it does so much damage (many assumed government and politicians would do the hard thinking for them). We need a fundamental re-examination of capitalism and the relationship between the state and the private sphere. This will not be done by business-financed think tanks. We have to do it for ourselves.

A century ago the populist rebellion organized farmer cooperatives, started dozens of newspapers and sent out lecturers to spread the word. Socialists and the labor movement did much the same. Modern Americans cannot depend on the Democratic Party or philanthropy to sponsor small-d democracy. We have to do it. But we have resources and modern tools—including the Internet—those earlier insurgents lacked.

The New Deal order broke down for good reasons—the economic system changed, and government did not adjust to new realities or challenge the counterattack from the right in the 1970s. The structure of economic life has changed again—most dramatically by globalization—yet the government and political parties are largely clueless about how to deal with the destruction of manufacturing and the loss of millions of jobs. Government itself has been weakened in the process, but politicians are too intimidated to talk about restoring its powers. The public expresses another broad consensus on the need to confront “free trade” and change it in the national interest—another instance of public opinion not seeming to count, since it opposes the corporate agenda.

Reformers today face conditions similar to what the Populists and Progressives faced: monopoly capitalism, a labor movement suppressed with government’s direct assistance, Wall Street’s “money trust” on top, the corporate state feeding off government while ignoring immoral social conditions. The working class, meanwhile, is regaining its identity, as millions are being dispossessed of middle-class status while millions of others struggle at the bottom. Working people are poised to become the new center of a reinvigorated democracy, though it is not clear at this stage whether they will side with the left or the right. Understanding all these forces can lead to the new governing agenda society desperately needs.

Finally, left-liberals need to start listening and learning—talking up close to ordinary Americans, including people who are not obvious allies. We should look for viable connections with those who are alienated and unorganized, maybe even ideologically hostile. The Tea Party crowd got one big thing right: the political divide is not Republicans against Democrats but governing elites against the people. A similar division exists within business and banking, where the real hostages are the smaller, community-scale firms imperiled by the big boys getting the gravy from Washington. We have more in common with small-business owners and Tea Party insurgents than the top-down commentary suggests.

Somewhere in all these activities, people can find fulfilling purpose again and gradually build a new politics. Don’t wait for Barack Obama to send instructions. And don’t count on necessarily making much difference, at least not right away. The music in democracy starts with people who take themselves seriously. They first discover they have changed themselves, then decide they can change others.

https://www.thenation.com…

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Comment:

By Don McCanne, M.D.

A decade after William Greider wrote this article, it becomes more obvious that his lesson for us is not so much about the political personalities and their respective political affiliations, rather it is about the need for the people to put the music in democracy.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Thomas C. Buchmueller, Helen G. Levy, Robert G. Valletta
National Bureau of Economic Research, December 2019

Abstract

We examine how a key provision of the Affordable Care Act–the expansion of Medicaid eligibility–affected health insurance coverage, access to care, and labor market transitions of unemployed workers. Comparing trends in states that implemented the Medicaid expansion to those that did not, we find that the ACA Medicaid expansion substantially increased insurance coverage and improved access to health care among unemployed workers. We then test whether this strengthening of the safety net affected transitions from unemployment to employment or out of the labor force. We find no meaningful statistical evidence in support of moral hazard effects that reduce job finding or labor force attachment.

https://www.nber.org…

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Comment:

By Don McCanne, M.D.

It seems that a positive bit of news, however seemingly mundane, would be appropriate for the Holiday Season.

One argument often made by opponents of health financing reform is that insurance function creates moral hazard – individuals are willing to accept greater risks when other parties bear the costs.

One example is that low-income individuals who receive health care coverage under Medicaid supposedly are less compelled to seek or maintain gainful employment. This study shows that the strengthening of the Medicaid safety net under the Affordable Care Act in states that implemented Medicaid expansion did not produce moral hazard effects that reduce job finding or labor force attachment.

A lesson here is that it is a mistake to advance policy solutions strictly designed to avoid moral hazard when the task at hand should be to ensure that everyone has affordable access to essential health care services.

It would be nice if we could return from the Holidays in a spirit where we are ready to all work together to achieve such a goal. Even Scrooge could be swayed.

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The political establishment loves the center. But it’s the radicals who end up writing history.

By John F. Harris
Politico Magazine, November 7, 2019

Washington journalists these days are having many conversations with Democratic operatives and veterans of previous administrations that go something like this:

This is insane. Our party has a death wish. We are going to blow this election and give the country four more years of Donald Trump.

These downbeat Democrats are talking generally about what they regard as their party’s dangerous lurch to the left in the 2020 campaign. Most often these days they are talking specifically about Elizabeth Warren.

The right has been fulminating for decades about liberal bias in the media. More recently the left, including Bernie Sanders, has inveighed against capitalist bias caused by corporate ownership of news organizations.

Meanwhile, a quarter-century covering national politics has convinced me that the more pervasive force shaping coverage of Washington and elections is what might be thought of as centrist bias, flowing from reporters and sources alike.

I am not terribly self-conscious about my predispositions to see politics and governance a certain way. These wouldn’t be my predispositions if I didn’t think they had something going for them. But the recognition of bias imposes an obligation to push against default thinking and explore the possibility that it is wrong.

Here’s the main reason it might be wrong: The most consequential history is usually not driven by the center.

It is clear that Warren, who has so far run the most disruptive and effective campaign of the Democratic race, is ready to divide the country and her party over the proposition that a much more aggressive role for government is needed to bring business to heel and protect individuals and the global climate from the predations of a free market. Sanders has won a corps of devoted backers animated by the same disdain for centrism.

I’m not saying that familiar Democratic voices like Rahm Emanuel (“Someone needs to say it: Medicare for All is a pipedream”) or Bill Galston (her new plan may be “the longest suicide note in recorded history”) or Steve Rattner (“a Warren presidency is a terrifying prospect”) are wrong. I am asking how they are so sure they are right.

Fundamental societal change comes from people burning with grievances, obsessed with remedies, ready to demolish old power arrangements to achieve their ends.

John Harris was formerly political editor at The Washington Post and then founding editor of Politico.

https://www.politico.com…

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How ‘Centrist Bias’ Hurts Sanders and Warren; The media has a bigger problem than liberal bias.

By David Leonhardt
The New York Times, December 22, 2019

John F. Harris is about as mainstream as the mainstream media gets.

Last month, Harris wrote a column that I can’t get out of my head. In it, he argued that political journalism suffers from “centrist bias.” As he explained, “This bias is marked by an instinctual suspicion of anything suggesting ideological zealotry, an admiration for difference-splitting, a conviction that politics should be a tidier and more rational process than it usually is.”

The bias caused much of the media to underestimate Ronald Reagan in 1980 and Donald Trump in 2016. It also helps explain the negative tone running through a lot of the coverage of Elizabeth Warren and Bernie Sanders this year.

Centrist bias, as I see it, confuses the idea of centrism (which is very much an ideology) with objectivity and fairness. It’s an understandable confusion, because American politics is dominated by the two major parties, one on the left and one on the right. And the overwhelming majority of journalists at so-called mainstream outlets — national magazines, newspapers, public radio, the non-Fox television networks — really are doing their best to treat both parties fairly.

In doing so, however, they often make an honest mistake: They equate balance with the midpoint between the two parties’ ideologies. Over the years, many press critics have pointed out one weakness of this approach: false equivalence, the refusal to consider the possibility that one side of an argument is simply (or mostly) right.

But that’s not the only problem. There’s also the possibility that both political parties have been wrong about something and that the solution, rather than being roughly halfway between their answers, is different from what either has been proposing.

This seemingly radical possibility turns out to be quite common, as the historian Arthur Schlesinger Jr. — author of the classic book, “The Vital Center,” no less — pointed out. The abolition of slavery, women’s suffrage, labor rights, the New Deal, civil rights for black Americans, Reagan’s laissez-faire revolution and same-sex marriage all started outside the boundaries of what either party favored. “The most consequential history,” Harris wrote, “is usually not driven by the center.”

Political and economic journalism too often assumes otherwise and treats the center as inherently sensible. This year’s Democratic presidential campaign has been a good case study. The skeptical questions posed to the more moderate Democrats are frequently about style or tactics: Are you too old? Too young? Too rich? Too far behind in the polls?

The skeptical questions for the more progressive candidates, Sanders and Warren, often challenge the substance of their ideas: Are you too radical? Are you being realistic? And, by golly, how would you pay for it all?

As regular readers know, I’m a moderate on Medicare, immigration and college debt, among other subjects. John Harris, for his part, confesses to “a pretty strong bout” of centrist bias.

But maybe that’s why we recognize it and pine for more objective coverage. Not every policy question posed to Democrats needs to have a conservative assumption, and not every question posed to Republicans needs to have a liberal one. If Warren and Sanders are going to be asked whether their solutions go too far, Joe Biden should be asked whether his solutions are too timid: Mr. Vice President, many economists believe that inequality is bad for an economy, so are you doing enough to attack inequality?

Once you start thinking about centrist bias, you recognize a lot of it. It helps explain why the 2016 presidential debates focused more on the budget deficit, a topic of centrist zealotry, than climate change, almost certainly a bigger threat. (Well-funded deficit advocacy plays a role too.) Centrist bias also helps explain the credulousness of early coverage during the Iraq and Vietnam wars. Both Democrats and Republicans, after all, largely supported each war.

The world is more surprising and complicated than centrist bias imagines it to be. Sometimes, people like Bernie Sanders and Elizabeth Warren are right. Even when they’re not, they deserve the same skepticism that other politicians do — no less, no more.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

With our highly polarized politics there is often a tendency for the mainstream media to try to be fair in covering both sides of the issues, often resulting in a “centrist bias” in the reporting. Health care is a case in point.

One view is to minimize the role of government and rely more heavily on markets to ensure that health care is affordable and accessible for all, placing much of the responsibility on the individual. Another view is to place the role of financing health care in the hands of our government, funding the system through equitable taxes, ensuring affordability and accessibility of health care for all. Since these are often considered to be extreme views, the media seeks to report on centrist solutions that meet in the middle.

So what is the centrist position in health care reform? Use public policies, such as Medicaid and community health centers, for those who cannot pay for their care or the insurance to cover it, and depend on private health plans for those who can. However, there is a dispute between the sides over trying to fill in the voids with Medicare, including private Medicare Advantage plans, with subsidies for private plans offered in the ACA exchanges, and now with whether or not a competing, Medicare-like public option should be offered.

So do we really have two extreme views which require centrist solutions? Many decades ago, Nobel laureate Kenneth Arrow demonstrated to us that markets do not work in health care. So that is an extreme view. What about universal public insurance? That has been shown to work in many nations. So that is not an extreme view. Trying to craft a centrist program by combining a market-based program that does not work with a public insurance program that does work inevitably results in a fragmented, dysfunctional system – precisely what we now have.

Those supporting mere tweaking of the current system have a centrist bias, but, as John Harris states, “The most consequential history is usually not driven by the center.” An extreme position may be bad, as with a nation that supports regime change through war while rejecting diplomacy. But it can be good, as with the many nations that have elected to implement some form or other of a national health program, as opposed to leaving patients at the mercy of the markets.

There may be some disagreement as to the precise model preferred for a national health program, but since we would be starting with an agreement to abandon false centrist solutions we should move forward with the most efficient, effective, and equitable model out there – a single payer model of an improved Medicare that covered everyone. A national health service model would also be an option but would likely be rejected as being too disruptive.

Regardless, we need to remain acutely aware of centrist bias and reject it for what it is – a mechanism of smothering the reform that we desperately need.

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Not ordinary Democrats or independents — just insurance companies, lobbyists, and old-line politicians.

By Jim Hightower
Other Words, December 11, 2019

We might expect that corporate billionaires and Koch-funded Republican right-wingers would be howl-at-the-moon opponents of a wealth tax, Medicare-for-All, and other big progressive ideas to help improve the circumstances of America’s workaday majority.

But Democrats, too? Unfortunately, yes. Not grassroots activists, but a gaggle of don’t-rock-the-corporate-boat, fraidy-cat elected Democrats.

These naysayers are the party’s old-line politicians, lobbyists, and other insider elites who are now screeching that Democratic candidates must back off those big proposals.

Why? Because, they squawk, being so bold, so progressive, so — well, so Democratic — will scare voters. As one meekly put it: “When you say Medicare for All, it’s a risk. It makes people afraid.”

Excuse me, but in my speeches and writings I say “Medicare for All” a lot — and far from cowering, people stand up and cheer.

In fact, the New York Times just reported that 81 percent of Democrats (and two-thirds of independents) support Medicare for All. Even apple pie doesn’t score that high! It’s simply a lie that the people are “afraid” of the idea of everyone getting public-financed health care.

So who really fears it? Three special-interest groups: Insurance company profiteers, Big Pharma price gougers, and the political insiders hooked on funding from those corporations.

Not only is it a pusillanimous fabrication to claim that the people oppose any changes stronger than corporate minimalism, it’s also political folly. If the Democratic Party won’t stand up for the transformative structural changes that America’s middle and low-income majority clearly wants and needs, why would those people stand up for Democrats?

As the 2016 presidential election taught us so painfully, a whole lot of the working class Democrats the Party counts on won’t.

https://otherwords.org…

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Comment:

By Don McCanne, M.D.

Many would-be political pundits are now saying that if we support single payer Medicare for All, then Trump will be reelected president. Talk about a non sequitur. Yet the media is promulgating this concept, causing some to react by saying that we need to preserve choice of private health plans – as if plans that take away health care choices through restricted provider networks and cost sharing financial barriers would be preferred over a Medicare for All program that really does provide free choice by eliminating networks and cost sharing barriers.

Jim Hightower has it right. We need to stand up and start shouting, lest these pundits drown out our message.

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Congressional Budget Office, December 2019

Share of Total Income Received by Each Income Group

To assess the direct distributional effects of federal fiscal policies, CBO projected each quintile’s share of total income both before and after means-tested transfers and taxes. Income shares are one measure of income inequality: When the share of income received by the top income group grows, income inequality tends to rise. CBO’s projections reflect such a pattern:

• The highest quintile’s share of income before transfers and taxes is projected to increase by 0.7 percentage points between 2016 and 2021, from 54.4 percent to 55.1 percent (see Figure 3 – at link).
• Within that quintile, the growth of shares of total income before transfers and taxes varies in CBO’s projections. For example, for households in the 81st to 90th percentiles, the share decreases by 0.1 percentage points, from 14.9 percent to 14.8 percent. But for households in the top 1 percent, the share rises by 0.6 percentage points, from 15.8 percent to 16.4 percent.
• By contrast, the share of income before taxes and transfers received by the other four quintiles does not grow. The middle three quintiles’ shares decline over the five-year period in CBO’s projections. The lowest quintile’s share remains roughly unchanged at 3.8 percent.

Because higher-income households receive a smaller share of their income in the form of transfers and pay a larger share of their income in taxes, shares of income after transfers and taxes are more evenly distributed than shares of income before transfers and taxes. Nevertheless, in CBO’s projections, the highest quintile’s share of income after transfers and taxes increases even more over the 2016–2021 period than its share of income before transfers and taxes:

• The highest quintile’s share of income after transfers and taxes rises by 1.2 percentage points, from 47.6 percent in 2016 to 48.8 percent in 2021.
• Most of that increase is attributable to households in the top 1 percent, whose share rises by 0.9 percentage points, from 12.5 percent to 13.4 percent.

By contrast, the share of income after transfers and taxes of each of the other quintiles declines over the period.

Projected Changes in Income Inequality

If the distributions of income, means-tested transfers, and federal taxes follow CBO’s projections, income inequality will be greater in 2021 than it was in 2016.

A standard composite measure of income inequality is the Gini coefficient, which summarizes an entire distribution in a single number that ranges from zero to one. A value of zero indicates complete equality (for example, if each household received the same amount of income), and a value of one indicates complete inequality (for example, if a single household received all the income). Thus, a Gini coefficient that increases over time indicates rising income inequality.

Income inequality as measured by the Gini coefficient increased from 1979 to 2016, and CBO projects that it will be higher in 2021. That increase reflects the accelerated growth of household income that is projected to occur at the top of the distribution. The Gini coefficient for income before taxes and transfers is projected to grow from 0.513 in 2016 to 0.521 in 2021—close to its previous peak, which was recorded in 2012 (see Figure 8 – at link).

The Gini coefficient can also be interpreted as a measure of one-half of the average difference in income between every pair of households in the population, divided by the average income of the total population. For example, the Gini coefficient of 0.513 for 2016 indicates that the average difference in income between pairs of households in that year was equal to 102.6 percent (twice 0.513) of average household income in 2016, or about $70,700 (adjusted to account for differences in household size). Similarly, the Gini coefficient of 0.521 projected for 2021 indicates that the average difference in income between pairs of households would equal 104.2 percent (twice 0.521) of average household income in 2021, or about $77,800 (in 2016 dollars).

In CBO’s projections, inequality increases from 2016 to 2021 even as income grows for all income groups, including those at the bottom of the distribution. That pattern is similar to the one observed during the economic expansion of the mid-1990s, when income grew for households at the bottom of the distribution after a long period of stagnation, while inequality increased because income at the top of the distribution grew more strongly. A similar pattern occurred during the expansion of the mid-2000s.

The Gini coefficient for income after transfers and taxes is lower than the coefficient for income before transfers and taxes because means-tested transfers and federal taxes in the United States are progressive. The degree to which means-tested transfers and federal taxes reduce income equality varies from year to year according to the size and progressivity of the tax and transfer systems. In CBO’s projections, the Gini coefficient for income after transfers and taxes is 0.437 in 2021—0.084 less than the Gini coefficient for income before transfers and taxes (see Figure 9 – at link). That reduction in inequality is smaller than the reduction in 2016, when means-tested transfers and federal taxes reduced the Gini coefficient by 0.090, from 0.513 to 0.423.

https://www.cbo.gov…

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Comment:

By Don McCanne, M.D.

Because of our very high national health expenditures, low- and middle-income individuals and families are unable to afford their proportionate share of health care spending. Fortunately, because we are a wealthy nation, we should be able to pay for health care for everyone by using progressive financing.

The simplest and most equitable method would be to finance the system through progressive taxes, as would be the case with single payer Medicare for All. Since we don’t have such a system now we have had to rely on transfers through various government programs to help finance care for those cannot afford to pay their proportionate share on their own.

This report from the Congressional Budget Office shows how income is distributed amongst households, and it shows how taxes and transfers redistribute income. Then they project the changes they expect in income inequality.

Some important observations:

• The highest quintile’s share of income after transfers and taxes increases even more over the 2016–2021 period than its share of income before transfers and taxes, with most of that going to households in the top 1 percent.
• By contrast, the share of income after transfers and taxes of each of the other quintiles declines over the period.
• Inequality increases from 2016 to 2021 even as income grows for all income groups, including those at the bottom of the distribution.
• The reduction in the projected inequality in 2021 is smaller than the reduction in 2016.

We keep hearing that you can tax all of the income of the wealthy and still we wouldn’t have enough to pay for health care for everyone. Well, first of all, nobody proposes confiscatory taxes on the wealthy. But more importantly, we are already spending $3.8 trillion on health care, and that has been made possible partly because of taxes and transfers already in existence. The amount of additional funds that we will need under single payer Medicare for All is not that great because we will recover hundreds of billions of dollars currently wasted on our profound administrative excesses and on excessive profit margins, especially for pharmaceuticals. If additional funds are required, today’s report shows that we have plenty of leeway at the upper end of the income scale to tap more funds through progressive tax policies. These would be comparatively small adjustments in our tax system that would not in any way impact the lifestyles of the multi-millionaires and billionaires.

Even if we didn’t enact and implement a single payer Medicare for All program, the CBO report still shows that we need more tax policies to correct the excessive maldistribution of income that persists today. There are plenty of potential public programs that could benefit from those revenues, but single payer, improved Medicare for All should be very high on the list.

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By Noam N. Levey
Los Angeles Times, December 17, 2019

Even as soaring insurance deductibles wreak financial havoc on millions of American families, some workers have managed to dodge the affordability crisis.

In Boston, a labor union representing the city’s hotel workers offers its members health coverage with no deductible and family premiums just a tenth of the U.S. average.

This year, workers pay just $16 a month for a single plan and $48 a month for a family plan.

Workers and their families pay nothing out-of-pocket for doctor visits, tests and hospital stays. Even the most expensive specialty drugs cost just $12 per prescription. Generics are $1.

The push by Unite Here, Local 26, to protect Boston hotel workers highlighted the challenges of protecting patients from medical bills, as workers were forced to make difficult choices. But the union’s success — in one of the most expensive healthcare markets in the country — also suggests that Americans may not have to settle for huge deductibles that have put medical care out of reach for millions.

Delivering that peace of mind wasn’t easy. Starting in 2013, when the new health plan debuted, Local 26, which provides coverage for roughly 9,000 union members and their families, had to confront the biggest cause of soaring insurance premiums and deductibles: the high price of U.S. medical care, particularly at hospitals.

It required union members to make a trade-off that many, at first, found unpalatable — giving up access to some of the city’s best known, and most expensive, hospitals.

Local 26, like many unions, had long offered members a health plan, which was largely funded by the hotels that employed its members. Such Taft-Hartley plans, as they are called, are prized by unions, as they typically offer good benefits and have preserved workers’ health protections, even when wages have stagnated.

But Local 26’s plan had a history of struggling, as rising medical costs sapped the plan’s reserves and jeopardized coverage for workers and their families, many of whom are immigrants from Latin America, Africa and East Asia.

In Boston, the 1994 merger of two of the city’s premier academic medical centers — Massachusetts General Hospital and Brigham and Women’s Hospital — created a powerhouse known as Partners HealthCare with unparalleled ability to demand high prices.

When Local 26 officials began their research, they were stunned to see that the Massachusetts General and Brigham and Women’s charged two or in some cases even three times as much as other academic medical centers in Boston.

So, Local 26 put the question to a vote: Should members get a narrower network of medical providers and guaranteed wage hikes? Or should they keep access to all Boston hospitals, but give up raises for 2 ½ years to keep the health plan from going bankrupt?

In the end, two-thirds of the membership backed the switch to the new, limited network plan.

It rolled out in late 2013. Workers got a raise the next year.

Just 2% of employers have eliminated hospitals or health systems from their insurance networks, as Local 26 did, according to a nationwide employer survey by the Kaiser Family Foundation.

https://www.latimes.com…

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Comment:

By Don McCanne, M.D.

It is common to hear that many union members are opposed to Medicare for All because they do not want to give up their health plans (Taft-Hartley plans) gained through years of tough union negotiations. But these plans have required trade-offs, frequently forgoing wage increases. In this instance, the trade-off for Unite Here was agreeing to a narrower provider network, forgoing care at two of Boston’s premier academic medical centers – Massachusetts General Hospital and Brigham and Women’s Hospital (Partners).

As a result of this trade-off, what the workers do see is how small the premiums are that are deducted from their paychecks and how little their out-of-pocket cost sharing is. The trade-off of losing access to Partners hospitals seemed to be worth it. But what they do not see is the employers’ contributions to the plan premiums which are paid for through forgone wage increases.

The union members are losing in two ways. Their benefits are less comprehensive than the benefits included in the single payer model of Medicare for All, including network restrictions not found in Medicare for All. Also, since single payer is funded through progressive taxes, the modest incomes of Unite Here members would result in lower tax payments than they are now paying in forgone wages. It’s just that the difference is not visible to them so they don’t see that it is a much better deal for them – better benefits at a lower cost.

The keepers of the Taft-Hartley trust funds seem to have a disconnect in logic when they oppose single payer reform. They look at the pot of gold they manage, and they seem to think that it has much greater value than the credit appearing in federal balance sheets. Of course, the federal funds are guaranteed by our government whereas the union trust funds, as this article indicates, can have “a history of struggling,” and may not be as secure as they would be in the U.S. Treasury.

But there are individuals within the union movement who clearly understand the superior benefits of single payer Medicare for All who can explain it to the rest of them. Just ask the National Nurses United.

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