The Commonwealth Fund, The New York Times, Harvard T.H. Chan School of Public Health, October 2019

Reforming the U.S. health insurance system has become a major issue in the upcoming presidential election, both in primaries and likely in the general election. There are a number of different health care reform proposals that have been put forth by candidates and parties, but prior studies show that voters in the general public are often not aware of the details of these plans. This suggests that the differentiation voters make between one plan and another is likely based on underlying values, beliefs, and life experiences. This report addresses specifically adults’ views in these three areas, as they relate to health insurance reform proposals supported by the public.

One of the issues that has emerged in recent polling on health insurance reform is that people often report they support more than one type of plan, even though these plans are often very different from each other from a policy perspective. This poll seeks to examine this issue by asking people who are interviewed to choose the plan that they most favor among the three major plans that are being debated currently: (1) Medicare-for-all, (2) improving the existing Affordable Care Act (Obamacare), or (3) replacing the Affordable Care Act with a new law that would give taxpayer funding to states to design their own health insurance systems with fewer federal rules.

Conclusions

This report examines Americans’ current beliefs, values, and experiences, according to their preferences on three major proposals for national health reform. The results point to significant conclusions, which are timely given the importance of health care as an upcoming issue in the Democratic primaries and the 2020 presidential election.

We polled Americans’ values and beliefs across seven different areas: the preferred role of government generally, the preferred role of government in health care, attitudes toward the current U.S. health care system, views on equal treatment in health care, personal experiences with health care, views on the future desired direction of health insurance reform, and public trust in groups trying to improve the U.S. health care system.

Notably, none of the three policies received a majority of Americans’ support as their most-favored plan, suggesting major divisions in preferences on the future of health insurance reform. We found the greatest differences in public opinion are the preferred role of government in health care, attitudes toward the current U.S. health care system, and views on increasing taxes so everyone can have health insurance. Proponents of all three plans showed the greatest similarities in shared values for equality in health care and trust in similar groups trying to improve health care, as well as their personal experiences.

Overall, Americans who prefer Medicare-for-all and those who prefer improving the existing ACA share similar views in several areas that lie in contrast to the views of those who favor replacing the ACA with state health plans. However, proponents of Medicare- for-all and improving the existing ACA also differ in important ways. They are split in their views of the economy, where a slight majority of adults who favor improving the existing ACA have a positive image of capitalism, while a majority of adults who favor Medicare-for-all have a positive image of socialism. Meanwhile, two-thirds of Medicare- for-all proponents prefer more federal government involvement in health care, compared to only a slight majority of proponents of improving the existing ACA. In addition, about two-thirds of adults who favor improving the existing ACA hold favorable opinions about private health insurance provided by employers, compared to only about half of adults favoring Medicare-for-all who share this view.

Among all three groups, there are dramatic differences in views on the preferred role of government involvement in health care. While more than eight in ten adults who favor Medicare-for-all and more than seven in ten adults who favor improving the existing ACA say they think it is the responsibility of the government to make sure all Americans have health insurance coverage, only one in five adults who favor replacing the ACA with state health plans say this. More than seven in ten adults who favor Medicare-for-all and a majority of adults who favor improving the existing ACA prefer a health insurance system run mostly by the government, while only about one in seven adults who favor replacing the ACA with state health plans prefer this approach.

Americans are also divided in their attitudes toward the current U.S. health care system, by their preferences for health reform. While large majorities of adults who are proponents of improving the existing ACA and Medicare-for-all hold favorable opinions of the Affordable Care Act, three-quarters of adults who are proponents of replacing the ACA with state health plans hold unfavorable opinions about it. This suggests major divisions in public opinion, both in how the U.S. health care system is currently operating, as well as the path forward.

Americans also hold opposing views according to their preferences for health reform about increasing taxes so everyone can have health insurance. While large majorities of adults who favor Medicare-for-all and improving the existing ACA favor increasing taxes so everyone can have health insurance, seven in ten adults who favor replacing the ACA with state health plans oppose tax increases.

When it comes to equal treatment in U.S. health care, large majorities of adults favoring all three approaches to health reform share views that while equal treatment is not a current reality, it is an important goal. Americans generally share views on the importance of equal treatment, regardless of income or race.

When it comes to public trust in various groups trying to improve the U.S. health care system, Americans favoring all three plans generally do not trust any interest major groups, with the exception of nurses. This suggests that if outside groups are to play an important role in shaping the future of health reform, they will need to coalesce around a shared vision of what it should look like.

In addition, we found that people’s personal experiences, though important to individuals, do not generally drive opinions about preferences for health reform. While a greater share of adults who favor Medicare-for-all express concerns about health care costs and health care access compared to those who favor improving the existing ACA and those who favor replacing the ACA with state health plans, large majorities of adults preferring all three plans say they are satisfied with their current health insurance coverage.

As we look ahead to the debate over national health insurance reform, it is clear that Americans’ viewpoints on health care issues are heavily driven by their basic beliefs and values. Medicare-for-all is a powerful issue in the Democratic primary, but for Americans who are Republicans or Independents, this approach to health insurance reform does not resonate the same way. These Americans are split in preferences between improving the existing ACA and developing other alternatives.

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The following responses are grouped based on the plan most preferred by individual respondents:

• Plan A: Medicare for All
• Plan B: Improving the Affordable Care Act
• Plan C: Give taxpayer funding to states to design their own health insurance systems

Q12. In the future, how involved do you think the federal government should be in health care? Should it be (more involved), (less involved), or about as involved as it is now?

• Plan A: 67% MORE involved
• Plan B: 54% MORE involved
• Plan C: 65% LESS involved

Q13. Do you think it is the responsibility of the government to make sure all Americans have health insurance coverage, or is that not the responsibility of the government?

• Plan A: 85% Responsibility
• Plan B: 73% Responsibility
• Plan C: 76% NOT responsibility

Q14. Do you favor or oppose increasing taxes on higher income people so everyone can have health insurance?

• Plan A: 84% Favor
• Plan B: 76% Favor
• Plan C: 70% OPPOSE

Q15. Would you personally be willing or unwilling to pay more in taxes so that everyone can have health insurance in the U.S.?

• Plan A: 79% Willing
• Plan B: 67% Willing
• Plan C: 74% UNWILLING

Q16. Which of the following approaches for providing health insurance in the United States would you prefer–a health insurance system (run mostly by the government), or a system (based mostly on private health insurance)?

• Plan A: 73% Run mostly by the government
• Plan B: 55% Run mostly by the government
• Plan C: 84% Mostly PRIVATE HEALTH INSURANCE

Q27. Do you think all Americans should have a right to health care regardless of ability to pay, or not?

• Plan A: 94% Should have right
• Plan B: 91% Should have right
• Plan C: 60% Should have right

Q29. How important is it to you that all Americans be treated equally in terms of the health care they receive? Very important, somewhat important, not too important, not important at all?

• Plan A: 97% Very or somewhat important
• Plan B: 98% Very or somewhat important
• Plan C: 88% Very or somewhat important

Q30. How important do you think it is that poor American families receive the same quality of health care as rich American families? Is it very important, somewhat important, not too important, or not at all important?

• Plan A: 98% Very or somewhat important
• Plan B: 98% Very or somewhat important
• Plan C: 90% Very or somewhat important

Q31. How important do you think it is that African Americans receive the same quality of health care as white Americans? Is it very important, somewhat important, not too important, or not at all important?

• Plan A: 99% Very or somewhat important
• Plan B: 99% Very or somewhat important
• Plan C: 92% Very or somewhat important

Q32. How much do you trust each of the following groups when it comes to trying to improve the U.S. health care system? How about (INSERT ITEM)? Do you trust them a great deal, a fair amount, not very much, or not at all?

• g. Pharmaceutical companies
• • Plan A: 70% Not very much or not at all
  • Plan B: 72% Not very much or not at all
  • Plan C: 78% Not very much or not at all
• h. Health insurance companies
• • Plan A: 67% Not very much or not at all
  • Plan B: 64% Not very much or not at all
  • Plan C: 53% Not very much or not at all
• i. The federal government
• • Plan A: 48% Not very much or not at all
  • Plan B: 47% Not very much or not at all
  • Plan C: 70% Not very much or not at all

https://cdn1.sph.harvard.edu…

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Comment:

By Don McCanne, M.D.

This survey confirms, once again, that Americans are divided over the role that government should play in financing our health care system. Those favoring a greater role for government are divided between improving the Affordable Care Act or replacing it with Medicare for All. Those opposing government involvement would prefer that states design their own systems, and they are unwilling to pay more taxes to fund health care.

What is interesting is that those opposed to a greater government role nevertheless do support health care justice in that they agree that health care should be a right regardless of ability to pay, that all Americans be treated equally in terms of the health care that they receive, that poor American families receive the same quality of health care as rich American families, and that African Americans receive the same quality of health care as white Americans.

The report confirms that Democrats are split between the two options of Medicare for All or expanding the Affordable Care Act, Republicans favor turning health care over to the states, and Independents are divided between the three options.

Thus there is a conflict between concepts of health care justice which are supported by all and the three options for reforming health care. Only a single payer Medicare for All program would accomplish the listed goals of social justice. The Republicans have been stumbling around with proposals that would actually further suppress health care justice, while Independents and moderate Democrats support the model we already have that still falls far short of health care justice for all.

Which really is more important? Health care justice for all? Or holding fort in your ideological camp? We are accomplishing the latter but not the former. Shouldn’t we reverse our priorities?

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Committee for a Responsible Federal Budget, October 28, 2019

In the coming months, the Committee for a Responsible Federal Budget will publish a detailed analysis describing numerous ways to finance Medicare for All and the consequences and trade-offs associated with each choice. This paper provides our preliminary estimates of the magnitude of each potential change and a brief discussion of the types of trade-offs policymakers will need to consider.

We find that Medicare for All could be financed with:

• A 32 percent payroll tax
• A 25 percent income surtax
• A 42 percent value-added tax (VAT)
• A mandatory public premium averaging $7,500 per capita – the equivalent of $12,000 per individual not otherwise on public insurance
• More than doubling all individual and corporate income tax rates
• An 80 percent reduction in non-health federal spending
• A 108 percent of Gross Domestic Product (GDP) increase in the national debt
• Impossibly high taxes on high earners, corporations, and the financial sector
• A combination of approaches

Each of these choices would have consequences for the distribution of income, growth in the economy, and ability to raise new revenue. Some of these consequences could be balanced against each other by adopting a combination approach that includes smaller versions of several of the options as well as additional policies.

Consequences could also be mitigated through aggressive efforts to lower per-person health care costs and/or by substantially scaling back the generosity or comprehensiveness of Medicare for All.

While the financing options above are quite large in magnitude, they could be reduced significantly by reducing the cost of Medicare for All itself.

These cost reductions could be achieved in part by reforming or reducing provider payments, improving care coordination, and identifying policies to reduce excessive utilization of care.

From the Conclusion

In deciding how to finance Medicare for All, policymakers must consider the distributional, economic, and policy consequences of replacing premiums and cost sharing with various alternatives. Most of the options we put forward are more progressive on average than current law but would shrink economic output and bring the top tax rate up to its revenue-maximizing level – leaving little capacity for further taxes.

http://www.crfb.org…

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Comment:

By Don McCanne, M.D.

The Committee for a Responsible Federal Budget is an influential organization that professes to advance bipartisan concepts that would place controls on the federal budget, but if you check the list of Directors (on the first page of their report) you will see that those on the left are predominantly neoliberals, with a stark absence of authorities with more progressive views – at best some may be classified as neutral academics. Understanding this is important because it seems to explain why they selected for this report their unusual framing of the options for financing Medicare for All.

They list eight different options plus a ninth option of combining various approaches. Most of the analysis is an evaluation each option isolated separately with the assumption that it would finance the entire health care system – nearly one-fifth of our economy. On the face of it, these assumptions are ridiculous. Opponents of single payer Medicare for All can take any one of them and hold the concept of trying to finance our entire health care system up to ridicule. As an example, they say that the concept of paying for health care by taxing the rich – high earners, corporations, and the financial sector – is an impossibility because at 100% tax rates there is not enough money there to pay for health care for all. They seem to ignore the fact that nobody has suggested paying for all health care in this manner nor through any of the other financing methods listed when used as the sole source of health care revenues. They end the list with a consideration of enacting a combination of approaches, almost as if it were an afterthought.

In discussing the trade-offs, they caution that most of the options “would shrink the economy,” with the potential of even greater damage to the economy should a decision be made to use deficit-financing for Medicare for All. Also they caution that there is risk that each of these options would bring the top rate close to the “revenue-maximizing rate” beyond which there is not much tax capacity left, reducing the ability of government policymakers to raise revenue in the future.

In spite of the distinguished officers and directors of this organization, this appears to be a hit piece designed to extinguish the flames of the passionate supporters of single payer Medicare for All. This is a preliminary report, and they say that in the coming months they will be publishing more detailed analyses, obviously timed to coincide with the election season. Unfortunately these reports will be suited only for the electronic trash heap, though we must keep our guard up so that they do not gain traction amongst the public at large.

That said, it is imperative that we understand how we can finance Medicare for All so that it works for everyone. Yesterday’s message was on the new book, “The Triumph of Injustice” by Emmanuel Saez and Gabriel Zucman. They describe tax policies that would make health care affordable for absolutely everyone while actually increasing the incomes of those who have been stuck in wage stagnation for the last several decades. If you did not followup on this yesterday, please do so now; health care justice depends on it:

https://pnhp.org…

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By Emmanuel Saez and Gabriel Zucman
From Chapter 9: A World of Possibility

Private Health Insurance: A Huge Poll Tax

The other specificity of the United States compared to other advanced economies is that public health insurance is far from universal in America. About half of all health care spending (10% out of 20% of national income) is publicly funded. A large fraction of the population must purchase private insurance. The system of private insurance excludes millions of Americans and imposes a mammoth burden on workers.

As we saw in Chapter 5, private insurance premiums are akin to a huge private tax. Although most workers get insurance through their employers – and thus employers nominally foot the bill – the premiums are a labor cost as much as payroll taxes are. Just like payroll taxes, premiums are ultimately borne by employees. The only difference is they are even more regressive than payroll taxes, because the premiums are unrelated to earnings. They are equal to a fixed amount per employee (and only depend on age and family coverage), just like a poll tax. The secretary literally pays the same dollar amount as an executive.

(Historically, in American colonies and in some US states before 1964, voting registration was conditioned on the payment of “poll” taxes. In this book, we use the classic definition of a poll tax, namely a tax levied on every adult without reference to income or resources.)

Poll taxes, unsurprisingly, are not popular. When Margaret Thatcher imposed a poll tax in 1988 to replace real estate property taxes, she faced an unprecedented revolt and was ousted from office in 1990. No government would out of the blue impose a poll tax to fund health care; it would be a crushing burden on moderate-income families. And yet in essence that’s what the United States does today: employers are administering a huge poll tax on behalf of the government. Since the passage of the Affordable Care Act in 2010, employers with fifty or more employees are legally required to provide health insurance to their workers or pay a penalty of $2,500 per employee in 2019. Given how big the average annual health insurance premium has become ($13,000 per covered worker), this system is unsustainable.

To illustrate the magnitude of this poll tax, let’s look at the distribution of US tax payments once we include mandatory private health insurance premiums. As we saw in the first chapter, considering regular taxes only the US tax system looks like a giant flat tax that becomes regressive at the top. But with the health care poll tax added, it is in fact frankly regressive: once private health insurance is factored in, the average tax rate rises from a bit less than 30% at the bottom of the income distribution to reach close to 40% for the middle class, before collapsing to 23% for billionaires.

The poll tax hammers the working and the middle class. At the bottom of the distribution, it’s not as onerous as sales and payroll taxes. But that’s because many working-class Americans do not get health insurance from their employers. They either face the burden of obtaining coverage themselves, rely on a family member to cover them, enroll into Medicaid, or go uninsured. The Affordable Care Act increased the pool of Americans eligible for Medicaid and subsidized the purchase of private insurance for low-income people who weren’t otherwise covered, but the law still left about 14% of the adult population uninsured in 2019. And it provided no relief for workers who fund their health care through a poll tax whose cost for the middle-class far outweighed that of the income tax.

https://wwnorton.com…

Tax Justice Now: Use the following link to access an interactive website where you can see the current tax system, Triumph of Injustice’s Tax Plan, Joe Biden’s Tax Plan, Bernie Sanders’ Tax Plan, Elizabeth Warren’s Tax Plan, or make your own tax plan.

https://taxjusticenow.org…

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Comment:

By Don McCanne, M.D.

The Quote of the Day for Friday, October 25 was from an article in The Guardian by Emmanuel Saez and Gabriel Zucman which was adapted from their book, “The Triumph of Injustice.” In that article they explained how single payer Medicare for All would make health care affordable for everyone while also providing a pay raise for most of us.

If you expect to be able to explain to others how we can make health care affordable for everyone through Medicare for All, then it is imperative that you have a clear understanding of the tax policies that would make that possible. The policies are not that complex, but they are not simply intuitive either. So this is why you should read “The Triumph of Injustice.”

The excerpt selected today explains how private health insurance premiums act like a huge poll tax – one of the least fair forms of taxation since it is not based on ability to pay, that is, it is not based on income nor personal resources. Because health care is now close to one-fifth of our economy, that places a very large financial burden on middle-income Americans who are not eligible for government subsidized programs such as Medicaid or ACA subsidies.

Think about what that means for Medicare as a public option. Presumably those eligible for government assistance will be enrolled in Medicaid or a subsidized plan in the ACA exchanges whereas those with middle incomes who do not qualify for subsidization will be paying high premiums for the Medicare public option just like they would with private insurance plans. Once again, this would be like a huge poll tax – very unfair.

If you go to the Tax Justice Now website (link above) and click on “Tax Breakdown” you can see how the revenue sources would vary by income groups under various tax plans, including that of the authors. It would be difficult to see how we could have a more equitable method of funding health care than that devised by the authors, with two of the three presidential candidates’ plans coming close. Compare theirs with the current tax system to see how unfair the status quo would be (private insurance premiums and out-of-pocket cost sharing would fall in the pink “health” section).

As stated in the last message, let’s make America affordable again.

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Not only would universal healthcare reduce taxes for most people, it would also lead to the biggest take-home pay raise in a generation for most workers

By Emmanuel Saez and Gabriel Zucman
The Guardian, October 25, 2019

The debate about healthcare has been at the center of the Democratic primaries, yet it is hard to make sense of the conversation. For some, public universal health insurance – such as Bernie Sanders’s Medicare for All bill – would involve massive tax increases for the middle class. For others, it’s the opposite: Medicare for All would cut costs for most Americans. Who is right?

The starting point of any intelligent conversation about health in America must be that it’s a cost for all of us – and a massive one. The United States spends close to 20% of its national income on health. Elderly Americans and low-income families are covered by public insurance programs (Medicare and Medicaid, respectively), funded by tax dollars (payroll taxes and general government revenue). The rest of the population must obtain coverage by a private company, which they typically get via their employers. Insurance, in that case, is funded by non-tax payments: health insurance premiums.

Although they are not officially called taxes, insurance premiums paid by employers are just like taxes – but taxes paid to private insurers instead of paid to the government. Like payroll taxes, they reduce your wage. Like taxes, they are mandatory, or quasi-mandatory. Since the passage of the Affordable Care Act in 2010, it has become compulsory to be insured, and employers with more than 50 full-time workers are required to enroll their workers in a health insurance plan.

A frequent objection to calling health insurance premiums a tax is that people have some choice. Can’t the poor, the argument goes, enroll in cheap health plans? If you start calling health insurance premiums a tax, then shouldn’t we also call spending on food and clothes a tax?

This argument, however, is wrong, because cheap healthcare does not exist. There are cheap meals, there are cheap clothes, but there is no cheap way to treat your heart attack, to cure your cancer, or to give birth. Cheap health insurance means no healthcare when you need it. All wealthy nations, even those that try hard to control costs, spend 10% of their national income on health – the equivalent of $7,500 a year per adult in the United States. The view that healthcare services are like haircuts or restaurant meals – services for which there is a product tailored to any budget – is a myth. Healthcare is like education: everybody needs it, regardless of their budget, but it’s expensive. That’s why all advanced economies, except the United States, fund it through taxation.

The main difference between the insurance premiums currently paid by American workers and the taxes paid by workers in other countries is that taxes are based on ability to pay. The income tax has a rate that rises with income. Payroll taxes are proportional to income, at least up to a limit. Insurance premiums, by contrast, are not based on ability to pay. They are a fixed amount per covered worker and only depend on age and the number of family members covered. Insurance premiums are the most regressive possible type of tax: a poll tax. The secretary pays the same amount as the executive.

Many people believe that the United States has a progressive tax system: you pay more, as a fraction of your income, as you earn more. In fact, if you allocate the total official tax take of the United States across the population, the US tax system looks like a giant flat tax that becomes regressive at the very top. And if you add mandatory private health insurance premiums to the official tax take, the US tax system turns out to be highly regressive. Once private health insurance is factored in, the average tax rate rises from a bit less than 30% at the bottom of the income distribution to reach close to 40% for the middle class, before collapsing to 23% for billionaires.

The health insurance poll tax hammers the working class and the middle class. At the bottom of the distribution, it’s not as onerous as sales and payroll taxes. But that’s because many low-income Americans rely on a family member to cover them, enroll into Medicaid, or go uninsured. For the middle-class, the burden is enormous. Take a secretary earning $50,000 a year, who has employer-sponsored health insurance at a total cost of $15,000. In reality her labor compensation is $65,000 (that’s what her employer pays in exchange of her work), but the secretary only gets $50,000. The executive earning $1,000,000 also pays the same $15,000 for his healthcare. This is a terrible funding mechanism.

Funding healthcare via insurance premiums would be acceptable if this private poll tax was small. When the system of private health insurance developed initially, the cost of employer-sponsored health insurance was moderate, the equivalent of 0.5% of national income in the 1950s. Today, however, it is huge: 6% of national income, almost as much as payroll Social Security taxes. The Affordable Care Act increased the pool of Americans eligible for Medicaid and subsidized the purchase of private insurance for low-income people not covered by their employer. But it provided no relief for workers who fund their healthcare through a huge and growing poll tax.

This situation is not sustainable. Most countries have understood this a long time ago. Health and retirement benefits started, like in the United States, as negotiated arrangements between employees (represented by their unions) and employers. But the task of funding health and retirement was then gradually entrusted to the government. Private premiums morphed into regular taxes, based on ability to pay. In the United States, this transformation has not happened yet for healthcare – leading to the crises we are in now.

This is the context needed to understand the current debate at the heart of the presidential elections. Proposals such as Medicare for All would replace the current privatized poll tax by taxes based on ability to pay. Some believe that it would result in a big tax increase for America’s middle class. But the data show that it would, in fact, lead to large income gains for the vast majority of workers.

Take again the case of a secretary earning $50,000 in wage and currently contributing $15,000 through her employer to an insurance company. With universal health insurance, her wage would rise to $65,000 – her full labor compensation. With an income tax of 6% – which, if applied to a base large enough, would be enough to fund universal health insurance – she would have to pay about $4,000 more in tax. But the net gain would be enormous: $11,000. Instead of taking home $50,000, the secretary would take home $61,000.

On TaxJusticeNow.org, any interested reader can simulate the effect of replacing private health insurance premiums by taxes – progressive income taxes, wealth taxes, consumption taxes, or broad taxes on consumption or all of national income. This simulator that we developed is open-source, user-friendly, and based on a systematic exploitation of all available statistics about who earns what and pays what in taxes and health insurance in America.

As one illustration, it’s possible to see how the tax plans of the leading Democratic primary candidates would affect tax rates for each group of the population. For instance, Bernie Sanders’s tax proposals would be enough to replace all existing private insurance premiums, while leaving 2.6% of national income to cover the uninsured and spend on other programs. Under such a plan, the 9 bottom deciles of the income distribution would gain income on average, as would the bottom of the top 10%. With smart new taxes—such as broad income taxes exempting low wages and retirees—it is possible to make the vast majority of the population win from a transition to universal health insurance.

Supporters of Medicare for All are right. Funding universal health insurance through taxes would lead to a large tax cut for the vast majority of workers. It would abolish the huge poll tax they currently shoulder, and the data show that for most workers, it would lead to the biggest take-home pay raise in a generation.

Emmanuel Saez and Gabriel Zucman are economics professors at the University of California, Berkeley, and the authors of The Triumph of Injustice: How the Rich Dodge Taxes and How to Make Them Pay, from which this essay is adapted.

https://www.theguardian.com…

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Comment:

By Don McCanne, M.D.

We have two major socioeconomic problems that cry out for resolution. Decades of income inequality have resulted in income stagnation for low- and middle-income workers while the benefits of their gains in productivity have flowed upward, with massive wealth accumulation at the top. Also, health care spending is approaching one-fifth of our economy, placing a great economic burden on those whose incomes have not kept pace with health care inflation.

As difficult as these two problems are we should recognize the opportunity we have to address both problems with one straightforward solution, improving significantly the lot of the typical American. Emmanuel Saez and Gabriel Zucman show us that by enacting and implementing a well designed single payer model of Medicare for All we can not only make health care affordable for everyone, but we can also use equitable tax policies to improve incomes for most of the nation’s workers and their families (and we can do that without disrupting the lifestyles of the wealthy).

Let’s make America affordable again!

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A decade ago, Harvard surgeon Atul Gawande helped popularize the idea that U.S. health care spending is high because we use too much medicine. He was wrong: it’s the prices, and who pays them.

By Adam Gaffney, M.D., M.P.H.
Boston Review, October 17, 2019

Priced Out: The Economic and Ethical Costs of American Health Care
By Uwe Reinhardt
Princeton University Press, $27.95 (cloth)

Reinhardt helped reorient the health care reform discussion from quantity to price, which was a step in the right direction. Yet high prices should be seen less as the underlying disease than a symptom of the true malady, our uniquely privatized and fragmented financing system.

That system leaves millions uninsured and underinsured—by current counts upwards of 87 million are inadequately insured. It is premised on the notion that private insurers can control costs by forming restrictive provider networks—increasing their market leverage but reducing patients’ choice of providers—but this scheme invariably results in out-of-network bills of the ruinous sort Kliff and others describe.

By the same token, it is our financing system that has accommodated, and indeed rewarded, hospitals that transform into capitalistic, consolidating, revenue-maximizing behemoths—because those institutions can then extract higher prices from payers through greater leverage of their own. It is the way we pay for health care in the United States that has led to an arms race of administrative bloat, as insurers and providers fight over payments with legions of bureaucrats and billers. And it is our financing system that has allowed some hospital systems to flourish and expand facilities of ever-increasing technological prowess and splendor, but that forces others—the unprofitable ones—to wither, and sometimes die.

And in the end, it is not just empirical questions that are at stake, but ethical ones. “Unfortunately,” Reinhardt notes in the prologue of his book, “we are too shy in this country to debate forthrightly the ethical precepts we would like to see imposed on our health care system.”

But debate them forthrightly we must. For above all, it is our financing system that is increasingly giving way, as Reinhardt recognized, to the rationing of care according to economic class, as policymakers seek to control costs by passing them through to patients instead of doing what high-performing universal systems across the globe have long done: control that spending at its source. The way we pay for health care has produced a curious but deadly mix of deprivation and excess. There is no great mystery behind it. It’s the financing system, stupid.

https://bostonreview.net…

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Comment:

By Don McCanne, M.D.

Although at first glance this is camouflaged as a book review, it is far, far more than that. It is one of the most important treatises ever written on the U.S. health care system.

It is a long article, studded with links to supporting references, so it will take time to read and digest. Graciously, Boston Review does not use a paywall, so the entire article can and should be accessed at the link above (without the necessity of including the entire article in this email).

This is essential reading for the health policy community, politicians, and stakeholders, especially patients. We will need to reduce this message to simple terms in order to inform the large segment of the population that is driven more by memes than by sophisticated discussions of policy science. But the message is fairly straightforward so we should be able to do that.

Your task right now? Select a time that you can read the full article, whether it is now, or perhaps sometime this weekend. Then join with others in communicating this message to the nation. It needs to become the meme that drives health care justice in America.

With thanks to Adam Gaffney and Uwe Reinhardt, we have confirmed that it is the financing system that is the source of the ills of the U.S.health care system, and understanding that fact is not so stupid after all.

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Republican Study Committee, October 22, 2019

Today, the Republican Study Committee released The RSC Health Care Plan: A Framework for Personalized, Affordable Care (click here to download full report). Spearheaded by RSC Chairman Mike Johnson (LA-04), RSC Health Care Task Force Chairman Roger Marshall, M.D. (KS-01), and members of the RSC Health Task Force, the RSC Health Care Plan would protect vulnerable Americans – including those with pre-existing conditions, chronic illness, and serious health issues – while reducing premiums, deductibles, and overall health care costs.

The product of a year of research and stakeholder discussions, the RSC’s approach to achieve more personalized, affordable care is designed to empower patients and doctors rather than bureaucrats and insurance companies.

The RSC Health Care Plan is presented as an alternative to Democrat proposals to double-down on the failing status quo or force all Americans off their current insurance plans – including those with employer-sponsored coverage – and into a one-size-fits-all, government-run health care system.

https://rsc-johnson.house.gov

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The RSC Health Care Plan

Enhanced Portability Protections

First, under the RSC plan, movement into the individual marketplace from the employer marketplace would be facilitated by ensuring that individuals do not need to exhaust COBRA (or other continuation) coverage before entering the individual market with portability protections. Employer-sponsored plans are often far broader and more expensive than people need or can afford on their own.

Second, whether a person is moving from an employer plan into the individual marketplace or switching individual plans, they would receive the same coverage protections afforded to a person enrolling in employer-sponsored coverage under pre-ACA HIPAA law. However, if a person does not have twelve months of continuous coverage,121 the person could be subject to an exclusion period of up to twelve months for an existing condition. Lawmakers could also explore ways in which states could be given flexibly in providing these portability protections in the individual marketplace for those with continuous coverage.

To ensure that ample options exist for Americans to possess continuous coverage, short-term, limited- duration plans would count toward periods of continuous coverage under the RSC plan. Additionally, the RSC plan would codify the Department of Health and Human Services’ new rule allowing short- term, limited-duration plans to last for a term of one year (and renewable for up to 36 months). Health care sharing ministry plans would also count toward continuous coverage. However, in order to combat a potential adverse selection issue where individuals with portability protections attempt to switch to a plan with more substantial benefits, carriers should be given the flexibility to apply the continuous coverage requirements on a benefit-by-benefit basis.

Guaranteed Coverage Pools

The RSC plan would provide federal funding for states to supplement the medical costs of eligible high-risk individuals. The RSC plan refers to this mechanism as a Guaranteed Coverage Pool.

More specifically, under the RSC plan, the federal government would make funding available for states to design and operate their own Guaranteed Coverage Pools. States would not be locked into a particular Guaranteed Coverage Pool mechanism, but rather would be given the freedom to use the federal funds to implement innovative, state-centric designs that would ensure everyone in the state’s pool has access to better care than under the ACA.

Federal funding for Guaranteed Coverage Pools would be delivered to states in the form of a grant derived from repackaging the ACA’s individual marketplace subsidies and Medicaid expansion.

Though the potential $17 billion annual price tag135 may not seem ideal, it sets up a sustainable path for the individual marketplace and deters our nation from heading toward a government-run, one-size-fits-all health care system that would cost taxpayers more than $30 trillion over the next decade.

Tax Benefit Equality

The most notable flaw in the tax code as it relates to health care is the inequitable treatment between employer-sponsored and individually purchased health insurance. A person choosing to purchase health insurance with income from their paycheck is at a significant tax disadvantage versus a person receiving employer-sponsored insurance.

The RSC plan proposes a more efficient system that would provide equal tax treatment in the employer and individual health insurance markets. Thus, the RSC plan would give individuals the ability to use health savings accounts (HSAs) to pay for premiums in the individual marketplace.

Unleashing Health Savings Accounts

Beyond allowing individuals to use health savings accounts to pay health insurance premiums, the RSC plan would enact a significant amount of reforms to expand the accessibility and effectiveness of health savings accounts. In particular, the RSC plan would eliminate the requirement that health savings accounts be tied to a high-deductible plan, increase health savings accounts’ maximum contributions, and expand the scope of eligible health care expenditures.

Critically, while the RSC plan would unleash health savings accounts, it would ensure that these accounts are pro-life and do not inadvertently allow a back-door method of subsidizing abortion procedures.

Protecting Medicaid’s Vulnerable Populations

The RSC plan calls on lawmakers to right-size the Medicaid program so that it can remain a sustainable health care safety net for vulnerable populations for generations to come.

The first step to right-sizing Medicaid under the RSC plan is an immediate moratorium on future Medicaid expansions and the institution of a phase-out of the expansion’s enhanced FMAP rate.

Expanding Direct Primary Care

Direct Primary Care is an innovative, affordable, and transparent care delivery system that allows patients to pay a monthly service fee—usually about $60 – $70 per month—directly to a health care provider instead of paying a copay or coinsurance for each visit to a doctor. As Avik Roy has said, “It’s like concierge medicine, but for everyone, including the poor.”

Health Care Sharing Ministries

Health care sharing ministries (HSMs) are faith-based nonprofit organizations whose members share a common set of ethical and religious beliefs and share medical expenses among themselves in accordance with those beliefs.

Association Health Plans

The RSC plan urges codification of the reforms promulgated by the Department of Labor that ensure Americans have greater access to Association Health Plans (AHP).

Health Status Insurance

Traditional health insurance covers your risk of medical expenses in the current year, whereas health status insurance covers your risk that your insurance premiums may rise due to an unforeseen circumstance that may occur in the future. This essentially allows an individual to pay for the option to purchase more comprehensive insurance at a later date. Functions as “health insurance-insurance.”

Short-Term, Limited-Duration Plans

Short-term, limited-duration plans are exactly what they sound like: health insurance plans meant to be used for short periods of time in-between jobs or during other short lapses of health coverage.

Telemedicine

The RSC is recommending that states work to remove barriers for telemedicine to be able to innovate and become more prevalent.

Certificate of Need Laws

By restricting new construction of provider facilities, these programs reduce competition, prevent the market from working on its own, and are subject to political influence. For these reasons, the RSC plan urges states to reform or repeal their certificate of need laws.

From the Conclusion

To argue for doubling-down on the status quo is to argue against helping these families and the countless number of other Americans who have fallen through the cracks of the ACA. At the same time, to embrace the Left’s “solution” of a government-run, one-size-fits-all ACA replacement proposal is to ignore the fact that individuals have unique health care needs.

As conservatives, we have joined together to propose another path forward—one that can dramatically improve access to quality, affordability, and choice in the American health care system. We offer a plan that will PROTECT the vulnerable, EMPOWER patients, and PERSONALIZE care. It is a plan that will give Americans, including those with pre-existing conditions, access to coverage options they can actually afford to use, and it will right-size Medicaid so it can remain a sustainable health care safety net for those who truly need it for generations to come.

https://rsc-johnson.house.gov…

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Comment:

By Don McCanne, M.D.

The health care plan of the Republican Study Committee might best be characterized as a plan to empower patients to use their own money to personalize their health care. What could be wrong with that?

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