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Health care prices are terrible, but we can control them

Health care prices are terrible, but we can control them

In the U.S., an Angioplasty Costs $32,000. Elsewhere? Maybe $6,400.

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…

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?

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Insurers and hospitals fight while patients suffer

Looming Anthem/Cottage termination could have negative impact on patient access in Santa Barbara area

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…

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.

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William Greider’s message for us

William Greider, August 6, 1936 - December 25, 2019

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.

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…

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.

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Forget moral hazard; let’s achieve health care justice for all

Medicaid Expansion and the Unemployed; NBER Working Paper No. 26553

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…

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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‘Centrist bias’ smothers much needed reform

One Big Thing the Dems Get Wrong About Warren

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…

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…

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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Jim Hightower knocks fraidy-cat Democrats

WHO’S AFRAID OF MEDICARE FOR ALL?

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…

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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CBO report on the distribution of household income

Projected Changes in the Distribution of Household Income, 2016 to 2021

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…

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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Unions fight for better health plans, but…

Not everyone has eye-popping deductibles: How one union kept medical bills in check

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…

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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Wendell Potter pulls Choice of Care out of ‘My Care, My Choice’

By Wendell Potter
Twitter, December 16, 2019

Lately I’ve noticed some Democratic politicians defending the current healthcare system by saying it preserves “choice” for Americans. As a former health insurance exec who helped draft this talking point, I need to come clean on its back story, and why it’s wrong and a trap. 1/11

When I worked in the insurance industry, we were instructed to talk about “choice,” based on focus groups and people like Frank Luntz (who wrote the book on how the GOP should communicate with Americans). I used it all the time as an industry flack. But there was a problem. 2/11

As a health insurance PR guy, we knew one of the huge “vulnerabilities” of the current system was LACK of choice. In the current system, you can’t pick your own doc, specialist, or hospital without huge “out of network” bills. So we set out to muddy the issue of “choice.” 3/11

As industry insiders, we also knew most Americans have very little choice of their plan. Your company chooses an insurance provider and you get to pick from a few different plans offered by that one insurer, usually either a high deductible plan or a higher deductible plan. 4/11

Another problem insurers like mine had on the “choice” issue: people with employer-based plans have very little choice to keep it. You can lose it if your company changes it, or you change jobs, or turn 26 or many other ways. This is a problem for defenders of the status quo. 5/11

Knowing we were losing the “choice” argument, my pals in the insurance industry spent millions on lobbying, ads and spin doctors — all designed to gaslight Americans into thinking that reforming the status quo would somehow give them “less choice.” 6/11

An industry front group launched a campaign to achieve this very purpose. Its name: “My Care, My Choice.” Its job: Trick Americans into thinking they currently can choose any plan they want, and that their plan allows them to see any doctor. They’ve spent big in Iowa. 7/11

This isn’t the only time the industry made “choice” a big talking point in its scheme to fight health reform. Soon after Obamacare was passed, it created a front group called the Choice and Competition Coalition, to scare states away from creating exchanges with better plans. 8/11

The difference is, this time *Democrats* are the ones parroting the misleading “choice” talking point. And they’re even using it as a weapon against each other. Back in my insurance PR days, this would have stunned me. I bet my old colleagues are thrilled, and celebrating. 9/11

The truth, of course, is you have little “choice” in healthcare now. Most can’t keep their plan as long as they want, or visit any doctor or hospital. Some reforms, like Medicare For All, *would* let you. In other words, M4A actually offers more choice than the status quo. 10/11

So if a politician tells you they oppose reforming the current healthcare system because they want to preserve “choice,” either they don’t know what they’re talking about – or they’re willfully ignoring the truth. I assure you, the insurance industry is delighted either way. 11/11

https://threadreaderapp.com…

Comment:

By Don McCanne, M.D.

With the help of the media, the political community opposed to single payer Medicare for All has convinced us that we do not want an undesirable “one-size-fits-all” model of health care reform that takes away our choices. They have countered with an advertising campaign touting “My Care, My Choice” which supposedly protects “patient choice in health care.” In his Twitter thread, former health insurance executive and current health justice advocate Wendell Potter exposes the fraud behind this framing.

Though the private insurance industry claims they are protecting choice in health care, they are not. They are protecting their market of private health plans in which you can choose what health care you are willing to give up by being restricted to networks that limit your choices of physicians and hospitals, limit your affordability of care through high deductibles and other cost sharing, or limit your choice to a plan offered by your employer.

The irony is that the one-size-fits-all plan – single payer Medicare for All – is the plan that does give you your choices of physicians, hospitals and other health care services and products. It is the plan that works for all whereas the My-Care-My-Choice private plans take away many of your choices in health care.

I don’t like to call someone a liar, but when the insurance industry tells you that they are “fighting to protect patient choice in health care,” they are flat out lying. Insurers do not provide health care, and they sharply restrict what health care they will pay for, thus taking away choices in health care.

The Lie of the Year award just went to President Trump for his 80 false statements about the whistle-blower. But I would have voted to grant the award to the private insurers for their claim that they are fighting to protect patient choice in health care when their products are quite specifically designed to take health care choices away from patients.

Let’s renew our fight for single payer Medicare for All – the inclusive size that really does fit all – perfectly.

How about that for a sound bite: “Medicare for All – the inclusive size that really does fit all – perfectly.”

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Newsom’s flip is wrong, Single Payer is the answer to Democrats’ health care fights

By John Marty

Response to the November 19, 2019 POLITICO article, “Does Gavin Newsom have the answer to Democrats’ health care fights?”

California Governor Gavin Newsom’s shifting position on single payer shows why voters become cynical. His switch shows why progressives are still waiting for universal healthcare almost ninety years after Frances Perkins first called for it.

The November 19 POLITICO article says that in two years, Newsom went from: “it’s about time” for single payer to: “these things take time” and now to: “[it] continues to be a guiding beacon for where we’re trying to go.” That might not sound like a big transformation, but it’s huge. Newsom’s vision of universal healthcare is now so far away that one cannot even see it – you need a beacon to help steer in the general direction. In other words, California is not going to get there in the foreseeable future.

I don’t know Governor Newsom and don’t know California politics, but it appears that he has become one of the “can’t do Democrats” he railed against in his primary campaign. As he said in the campaign, “If these can’t-do Democrats were in charge, we would have never had Medicare and Social Security.” He was right about that, and as Newsom morphs into a can’t do Democrat, California clearly won’t get universal healthcare.

Democrats opposing single payer claim there are “less disruptive” ways of achieving universal healthcare. Look at the Democratic presidential candidates’ positions. All of them, including those who don’t support single payer, say they support “universal” healthcare.  That means everyone is covered.

All the Democratic candidates’ plans, like Newsom’s proposal, brag about covering more people. They hype the progress they are making. The POLITICO article says California reduced its uninsured rate down to about 7 percent, from much higher numbers before Obamacare. If they keep working, perhaps they’ll lower it to where Massachusetts is, only about 3 percent uninsured.

That would be a wonderful goal, except for two things:

  1. The three percent who don’t have any health coverage. That’s a lot of people, often very sick folks.
  2. The other 97 percent. Many of them cannot afford care despite their insurance. Check out the number of desperate families creating “Go Fund Me” pages to pay for care. Look at the bankruptcies caused by medical debt.

Does anyone think it would be acceptable if “only three percent” of young children were not able to go to elementary school because they couldn’t afford it? Would it be OK if some of the kids in school couldn’t afford the reading or math classes? No. We want every child to get an education. No exceptions.

But with healthcare, many candidate appeals to universal healthcare are cynical appeals to voters who believe everybody needs healthcare, just as every child needs an education.

I describe those political appeals as cynical, because many are. “Democratic and Republican strategists told POLITICO that the way single-payer played out in the Newsom-Villaraigosa contest is exactly how they see the fight” in the presidential race. “First, promise Medicare for All. Win the primary. Then move to the middle to pick up more middle-of-the-road voters and start explaining how you were misunderstood all along.” No wonder voters distrust politicians.

Returning to the claim of “less disruptive” ways to achieve universal healthcare, in California even Newsom’s staff recognizes that his alternative plan won’t get there: “The governor continues to insist that we move forward towards [emphasis added] a system that will cover everyone.” Effectively, we don’t really expect to get there, but don’t worry, we’ll push in that direction.

If there are alternatives to single payer that will deliver universal healthcare, why hasn’t anyone proposed an alternative that covers everyone? Democratic candidates who don’t support Medicare for All recognize the popularity of a universal system, so they offer similar-sounding plans like “Medicare for All Who Want It,” but those plans would not cover everyone and would not save money. They continue the bureaucratic insurance system, simply adding one more plan to the mix. It might save money for some of the people on it, but it doesn’t bring down costs or fix the fundamental problems.

While some countries deliver universal health care through private insurers, those insurers are selling the same plan, with the same coverage, with the same providers, and they are tightly regulated. In the U.S., it doesn’t work that way. Here, insurance companies effectively set the rules: The Senate author of the Affordable Care Act singled out a former insurance company VP as the designer of the ACA. Not surprisingly, insurance company profits have been sharply up since Obamacare’s passage.

Political consultants, pundits, and cynical politicians tell us that these incremental steps will lead to single payer. The article mentions health “experts” who suggest that Newsom’s numerous incremental steps and tinkering with the Affordable Care Act, “can put him on the doorstep” of universal healthcare. The best they can offer is that some year, far in the future, we’ll be on the doorstep, begging to be let in.

We ought to be ashamed at the mere tinkering our political system has done on healthcare. A single health plan that covers all Americans has been a goal of progressives since the 1930s, yet political consultants say we are moving too fast.

Minnesota has been trying other approaches to deliver universal healthcare for over thirty years. I’ve been involved in some of those efforts. We made some improvements, but they were marginal at best.

Many alternatives to single payer have tried to cut costs and make sure nobody gets unnecessary treatment. The most common result from those reforms is an increasingly complex and bureaucratic system – listen to doctors and nurses who burn out from paperwork. And, with this convoluted system, where you need to “qualify” for care, there will always be people with mental health or other physical or intellectual challenges that prevent them from successfully enrolling and re-enrolling every year.

Unfortunately, our current, insurance-based model is unable to deliver universal healthcare. And we cannot afford additional decades of tinkering.

Democrats who oppose single payer claim it isn’t feasible.

Neither was Social Security. The concept of providing “social security” to the elderly and people with disabilities, was a nice dream, but in the 1930’s, in the middle of a depression, that just wasn’t realistic – there is no chance it could pass. But it did.

Ten years ago, gay marriage wasn’t going to happen in our lifetimes. But then it did.

I share the concerns of Newsom and others about the strength of the political opposition, but that does not justify inaction when lives are at stake.

And lives are at stake. Occasionally these tragedies catch the public eye.  But week-in and week-out, people die from a lack of access to care with virtually no public awareness. Preventing those senseless tragedies and making sure everyone has access to health care should be our first concern.

Dismissing universal healthcare, or any other proposal, as “politically unrealistic” is a self-fulfilling prophecy. If even people who (pretend to) support the policy say it’s unrealistic, then it must be unrealistic, so why fight for it?

Democratic opponents say we can’t afford single payer       

But the reality is quite different. Not only is our current insurance-based model unable to deliver universal health care, but we will never control spending without a universal single-payer system. Why? Only a Medicare for All single-payer approach allows for real price negotiations and only it eliminates the bureaucratic and extraordinarily wasteful financing system.

POLITICO quotes a Democratic strategist dismissing single payer saying, “the deeper you go, the harder it is to explain how you’re going to pay for it.” Perhaps it would be difficult to explain if we weren’t already paying for it.

We currently spend over one sixth of all the dollars in our economy on healthcare – twice what most industrialized nations spend, yet we have worse health outcomes. That astronomical spending is driven by our complicated insurance and billing system and the lack of rational price negotiations. When some hospitals charge 16 times as much as other hospitals for the same procedure, the need for fair price negotiations is obvious. The same is true when comparing prescription drugs. Other countries negotiate drug prices, but we don’t have a real system for doing so. Only in the United States do we allow price gouging by Big Pharma.

There are also enormous savings to be gained with a logical, efficient financing system that gets rid of sad reality where most hospitals have more billing clerks than hospital beds.

With these efficiencies, the universal system would be less expensive than the current system, despite covering everyone. Since we already pay more than enough for universal healthcare; we simply need to change how we collect the money and where it goes.

A good start would be changing from premiums based on age, to premiums based on ability to pay. Everybody pays, but it’s affordable to all.

Businesses would be freed from the time consuming, expensive, and challenging responsibility of shopping for health insurance, replaced by reasonable healthcare taxes.

The biggest source of funds for healthcare, by far, would continue to be the federal and state governments. Well over half of all healthcare dollars are already paid for by government.

These are significant, but manageable changes in the financing of care. More of the dollars would be collected by government, not insurance companies. Instead of paying premiums to Aetna or United Healthcare, we would pay them to Medicare (or whatever state plan is created.)

Just as the dollars we pay into Social Security are not co-mingled with other public funds, we can ensure that these dollars go directly to Medicare where they are used for healthcare and cannot be diverted for other purposes.

To paraphrase that Democratic strategist quoted earlier, “the deeper you go, the harder it is to explain how you’re going to pay for the current dysfunctional health care financing model have while covering more people.”

Make no mistake. It’s important to work for incremental improvements, but it’s not an excuse to avoid bolder change. In the Minnesota Senate, I advocate for universal healthcare and simultaneously work on smaller changes. Advocating for a solution to access and affordability problems does not excuse one from ignoring incremental changes to make the system better in the interim. I’ve been fighting for an end to pharmaceutical price gouging, less insurance company interference in treatment, and have passed numerous bills to improve the system. I supported the passage of our MinnesotaCare plan many years ago and pushed for implementation of the Affordable Care Act and expansion of Medicaid more recently.

But when we as a nation fail to treat people with serious mental illness, housing them in jails instead, when young adults die because they cannot afford insulin, when workers with “good” health insurance plans face bankruptcy from medical bills, incremental changes are not enough.

John Marty is a senior member of the Minnesota Senate and author of a proposed single payer universal healthcare plan.

It’s the private insurers, stupid

Private insurance's costs are skyrocketing

By Drew Altman, Kaiser Family Foundation
Axios, December 16, 2019

The cost of private health insurance is out of control, compared to Medicare and Medicaid. You see that clearly if you take a long-term view of recently released federal data on health spending.

Why it matters: This is why the health care industry — not just insurers, but also hospitals and drug companies — is so opposed to proposals that would expand the government’s purchasing power. And it’s why some progressives are so determined to curb, or even eliminate, private coverage.

By the numbers: Per capita spending for private insurance has grown by 52.6% over the last 10 years.

  • Per-capita spending for Medicare grew by 21.5% over the same period, and Medicaid 12.5%.

Private insurance generally pays higher prices for care than Medicare, which generally pays more than Medicaid.

  • There’s a long-running debate about whether public programs deliver efficiency because of their purchasing power, or simply underpay.
  • Democrats have proposed a variety of steps to curb health care costs, including cutting payments for out-of-network care, competition from a public insurance plan, and steep payment cuts through Medicare for All.
  • Industry opposes most of them.

The bottom line: The industry knows cutting government spending can only go so far. Any effort to rein in health care costs will have to confront the growth in the cost of private insurance.

https://www.axios.com…

Comment:

By Don McCanne, M.D.

Other studies have shown that the higher level of health care spending in the United States compared to other nations is due to higher prices and not due to higher utilization. Yet our higher prices are not bringing us better outcomes, on average.

The decade of 2008 to 2018 shows us that the private insurance industry has been far less effective in controlling spending increases than have our government programs – Medicare and Medicaid – in spite of the implementation of the Affordable Care Act. But the issues are different for each of these programs.

Medicaid, being a welfare program for low-income individuals and families, has been chronically underfunded primarily because of the lack of a strong political voice for those served by the program. Under a single payer Medicare for All program, this problem of underfunding would be eliminated since Medicaid beneficiaries would be moved into an equitable, universal program that covered everyone.

Although the rate of spending increases per Medicare enrollee over the past decade has been almost twice that of the Medicaid program, it has been less than half the rate for private health insurance. Considering that our national per capita health expenditures are about twice the average of other wealthy nations, it would seem illogical to push Medicare rates up to those of the private insurance sector. We do not have a pressing need to use public funds to pad private profits. Nevertheless, in some instances Medicare payments have been inadequate to ensure the viability of institutions such as rural hospitals, especially those with low volumes or a high percentage of uninsured, indigent patients.

Because Medicare payments often tend to be more modest than those of the private insurers some opponents of single payer are making outrageous claims such as fees for the health care delivery system would have to be cut by 40 percent. First of all, the method of determining payments would not be the same as with the current Medicare program. Hospitals would be paid through global budgets, much as fire departments are. Fee-for-service or capitation rates would be negotiated at a level that would ensure that the capacity of the system is adequate. That is, rather than being compensated at current Medicare rates, the system would be funded under an improved financing infrastructure at rates that would meet legitimate expenses and provide fair margins while avoiding gouging the taxpayers. Besides, reduction in payments that are made possible by reducing administrative overhead waste may be able to be achieved without any reduction in net income.

In looking at the graph you can see that the greatest source of our excessive health care spending is through the private insurers. When you think of what the insurance industry does, you can understand why that might be the case. Their primary business product is administrative services. The more they can sell to us, the more successful is their enterprise. The funds that they hold to pay medical claims are our funds, not theirs, whether they receive them through premiums or through government taxpayer subsidies. The greater the volume, the more administrative services they can sell us. Also, though they distribute about 85 percent of their revenues as medical benefits (medical loss ratio) they keep the other 15 percent or so for the administrative services they are selling us and for profits (or margins for the non-profits). So it is to their advantage to contract with hospitals and physician groups for higher rates since they keep a percentage of the total spent. It is no wonder that the spending curve for private insurers is so much higher than the public insurers who continue to strive for administrative efficiency and are not looking for profits (i.e., no need to shift our taxes from one column (revenues) to another (profits) on our federal budgetary balance sheets).

The private insurers are responsible for much of the excessive spending in our health care system, primarily in two ways. Besides their own profound administrative excesses, for which we pay, they place a tremendous administrative burden on the health care delivery system, for which we also pay. In addition, they have been far less effective in controlling excessive prices (think drugs, or oligopolistic hospital consolidation) than have been the public insurers. For those who challenge this contention, look again at the graph above. The private insurers have to go.

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New Report: Universal health care in Maine could reduce costs and cover everyone

Maine AllCare, December 16, 2019

A universal, publicly funded health care system that covers every Maine resident could save Maine $1.5 billion in total health care spending, according to a new analysis released today by Maine AllCare.

The analysis, conducted by Maine Center for Economic Policy (MECEP) on behalf of Maine AllCare, was the subject of a hearing today before the Legislature’s Joint Standing Committee on Health Coverage, Insurance, and Financial Services.

Maine AllCare commissioned the report, Assessing the Costs and Impacts of a State-Level Universal Health Care System in Maine, to find out how such a health system could be financed.

This report represents a ‘fiscal plausibility model’ informed by previous analyses of other state-level models. It includes analyses of the costs and economic impact of Maine establishing a universal, publicly funded healthcare system that covers every Maine resident.

The study looked at health care cost scenarios based on seven different families, of varying size and annual incomes ranging from $10,000 to $500,000. All but those with the highest incomes would see savings under the analyzed model. The study shows a state-level plan would provide significant benefits to Maine residents, municipalities and employers and bring fiscal stability to our healthcare providers and hospitals.

“The first question people ask when the subject of universal health care comes up is: ‘How are you going to pay for it?’” said Henk Goorhuis, MD, Board Chair of Maine AllCare. “The truth is America pays more for health care than any other developed nation, all while families continue to skip doctor’s visits or forgo necessary care because they can’t afford it.”

“This feasibility analysis reveals that a better system is possible — one that would guarantee health care that was without charge at the point of service, allow greater choice of providers, and reduce costs in the long run. We just need the political will to create it,” Goorhuis said.

Under the model analyzed by MECEP, federal programs including Medicare, Medicaid, VA, Tricare & Indian Health would remain intact and a state-run program would cover the remaining 652,000 of the population, including roughly 74,000 uninsured Mainers and all those covered (often inadequately) by private insurance. The model fills coverage gaps and eliminates out-of-pocket expenses for those enrolled in federal programs. It also provides dental, vision, and hearing benefits to every Maine resident.

Approximately 80 percent of the cost of a new publicly funded health care system would be paid for in the form of individual and employer taxes that would recapture funds currently being spent on premiums, deductibles, and out-of-pocket costs. The remainder — about $1 billion — would need to be paid for by raising taxes. In this report, MECEP has included several potential revenue sources.

Impacts of the new state-based public healthcare plan include:

  • 80 percent of families and individuals would see a net gain in their household income due to elimination of insurance premiums and out of pocket health costs.
  • Municipalities, counties and school districts would see an annual net savings of $214 million, or 8.4 percent of current property tax, equivalent to a reduction of 1.5 mills.
  • Most employers would pay the same or less than they do today, based on a sliding scale, that spans from 3 percent of payroll for businesses with fewer than 10 employees to 10 percent of payroll for businesses with more than 500 employees. Workers’ Compensation would be cut in half. Employers would eliminate the costs of choosing and managing healthcare coverage plans.
  • Hospitals and providers would be paid promptly and directly at Medicare rates. Uncompensated charity care would be eliminated, and administrative overhead would be reduced. Most providers would see minimal, if any, net financial effects. All hospitals and doctors’ offices would remain private.
  • An estimated 2,931 administrative jobs in healthcare would be lost due to a greatly simplified system. The model presumes wage replacement and retraining costs for those workers as part of the transition.

Broader economic benefits would accrue from a healthier workforce, along with increased entrepreneurship when healthcare coverage is decoupled from employment. However, the report cautions a more detailed analysis would be necessary.

“Informed by this report, Maine AllCare’s board of directors — together with the tens of thousands of Maine AllCare supporters — will continue our advocacy and education to transform today’s broken health care system into a new, fair and cost-effective publicly funded system that serves every Mainer,” Goorhuis said.

Four-page summary of the report:
https://pnhp.org…

Audio presentation of the findings:
http://legislature.maine.gov…

https://maineallcare.org…