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It continues to develop that the insurrection is largely, if not exclusively, a war upon the first principle of popular government–the rights of the people. Conclusive evidence of this is found in the most grave and maturely considered public documents, as well as in the general tone of the insurgents. In those documents we find the abridgment of the existing right of suffrage and the denial to the people of all right to participate in the selection of public officers except the legislative boldly advocated, with labored arguments to prove that large control of the people in government is the source of all political evil. Monarchy itself is sometimes hinted at as a possible refuge from the power of the people.

In my present position I could scarcely be justified were I to omit raising a warning voice against this approach of returning despotism.

It is not needed nor fitting here that a general argument should be made in favor of popular institutions, but there is one point, with its connections, not so hackneyed as most others, to which I ask a brief attention. It is the effort to place capital on an equal footing with, if not above, labor in the structure of government. It is assumed that labor is available only in connection with capital; that nobody labors unless somebody else, owning capital, somehow by the use of it induces him to labor. This assumed, it is next considered whether it is best that capital shall hire laborers, and thus induce them to work by their own consent, or buy them and drive them to it without their consent. Having proceeded so far, it is naturally concluded that all laborers are either hired laborers or what we call slaves. And further, it is assumed that whoever is once a hired laborer is fixed in that condition for life.

Now there is no such relation between capital and labor as assumed, nor is there any such thing as a free man being fixed for life in the condition of a hired laborer. Both these assumptions are false, and all inferences from them are groundless.

Labor is prior to and independent of capital. Capital is only the fruit of labor, and could never have existed if labor had not first existed. Labor is the superior of capital, and deserves much the higher consideration. Capital has its rights, which are as worthy of protection as any other rights. Nor is it denied that there is, and probably always will be, a relation between labor and capital producing mutual benefits. The error is in assuming that the whole labor of community exists within that relation. A few men own capital, and that few avoid labor themselves, and with their capital hire or buy another few to labor for them. A large majority belong to neither class–neither work for others nor have others working for them. In most of the Southern States a majority of the whole people of all colors are neither slaves nor masters, while in the Northern a large majority are neither hirers nor hired. Men, with their families–wives, sons, and daughters–work for themselves on their farms, in their houses, and in their shops, taking the whole product to themselves, and asking no favors of capital on the one hand nor of hired laborers or slaves on the other. It is not forgotten that a considerable number of persons mingle their own labor with capital; that is, they labor with their own hands and also buy or hire others to labor for them; but this is only a mixed and not a distinct class. No principle stated is disturbed by the existence of this mixed class.

Again, as has already been said, there is not of necessity any such thing as the free hired laborer being fixed to that condition for life. Many independent men everywhere in these States a few years back in their lives were hired laborers. The prudent, penniless beginner in the world labors for wages awhile, saves a surplus with which to buy tools or land for himself, then labors on his own account another while, and at length hires another new beginner to help him. This is the just and generous and prosperous system which opens the way to all, gives hope to all, and consequent energy and progress and improvement of condition to all. No men living are more worthy to be trusted than those who toil up from poverty; none less inclined to take or touch aught which they have not honestly earned. Let them beware of surrendering a political power which they already possess, and which if surrendered will surely be used to close the door of advancement against such as they and to fix new disabilities and burdens upon them till all of liberty shall be lost.

http://www.presidency.ucsb.edu…

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Comment:

By Don McCanne, M.D.

There is a reason why we celebrate Labor Day rather than Capitalism Day. Although there was no Labor Day in 1861, President Lincoln’s astute and prescient words remind us why it is natural for our nation to celebrate labor.

And, yes, this message is very directly related to the issue of health care justice for all, even if unspoken.

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For many years, Kaiser Family Foundation has been tracking public opinion on the idea of national health plan. Since the 2016 presidential primary and Bernie Sanders’ rallying cry for “Medicare-for-all,” our polls have shown a modest increase in support for the idea of a national health plan (Figure 1), and broad support for proposals that expand Medicare (Figure 2). Overall, about six in ten adults favor a national health plan or Medicare-for-all plan (Figure 3). There is robust support among Democrats, and even somewhat among Republicans, for expansions of the Medicare program through a Medicare buy-in (Figure 6) or an “optional” Medicare-for-all proposal (Figure 7). Yet, it is unclear how much staying power this support has once people become aware of the details of any plan. Public support quickly erodes when people hear further explanation about potential tax increases or increased government control (Figure 8) and recent polling also shows many people falsely assume they would be able to keep their current health insurance under a single-payer plan (Figure 10), suggesting another potential area for decreased support.

While health care appears to be playing a role in the 2018 midterm campaigns (Figure 11) and single-payer has been a hot-button issue in some Democratic primaries, it is unclear that it will play a major role in the general election, with few voters saying a candidate’s position on a national health plan is an important factor in their vote (Figure 12). So while the general idea of a national health plan (whether accomplished through an expansion of Medicare or some other way) may enjoy fairly broad support in the abstract and it can be used as a rallying cry to motivate the liberal base of the Democratic party, it is unlikely to be a determining issue for most 2018 midterm voters.

12 Power Point slides which can be downloaded:
https://www.kff.org…

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Comment:

By Don McCanne, M.D.

Kaiser Family Foundation has summarized in twelve Power Point slides the public opinion on single payer, national health plans, and expanding access to Medicare coverage. Over the last two decades support for “a national health plan in which all Americans would get their insurance from a single government plan” has gradually grown from 40 percent to 53 percent.

Support increases when those initially opposed are told that such a plan would “reduce health insurance administrative costs,” “ensure that all Americans have health insurance as a basic right,” or “reduce the role of all private health insurance companies in health care.”

Support diminishes when those initially in support are told that such a plan would “give the government too much control over health care,” “require many Americans to pay more in taxes,” or “eliminate or replace the Affordable Care Act.”

However the polling suggests that there is considerable support for more incremental approaches. When asked, “Do you favor or oppose letting some people under the age of 65 buy insurance through the Medicare program?”, 63 percent are in favor and 33 percent are opposed. When asked if they would favor “A national Medicare-for-all plan open to anyone who wants it but people whom currently have other coverage could keep what they have,” support is 75 percent as opposed to 59 percent who favor “A national health plan, or Medicare-for-all, in which all Americans would get their insurance from a single government plan.”

Thus it seems that support for a multi-payer system that expands the role of Medicare is greater than support for a single payer version of Medicare for all. This, of course, plays into the hands of those who support expanding the use of private Medicare Advantage plans – a concept that currently is being sold under the false label of “Medicare for All.”

A Medicare Advantage option for all has almost nothing in common with a bona fide single payer improved Medicare for all. The former perpetuates all of the injustices, waste, and excess costs of our current fragmented, dysfunctional method of financing health care, whereas the latter finally brings to us an efficient, effective, equitable method of removing financial barriers to care for absolutely everyone with a system that each of us could afford.

It is going to be very difficult to get this crucial message across when “let those who want to buy into Medicare do it” becomes the reflex response. The polling suggests that it may already be a meme.

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The U.S. health insurance industry’s premium composition is increasingly shifting toward government-sponsored business, which exposes carriers to additional risks as the business is generally low-margin and results in a greater reliance on state and federal funding, according to a new A.M. Best report.

The Best’s Market Segment Report, “Government-Related Health Insurance Business Continues to Grow Despite Risks,” states that the health industry is generating an increasingly large share of premium from Medicare Advantage, Medicaid and individual commercial businesses. Medicaid reported the largest increase in net premiums written growth, to $224.0 billion in 2017 from $43.1 billion in 2007, owing to Medicaid expansion under the Affordable Care Act (ACA), and to more states turning to managed care to run traditional, pre-expansion Medicaid programs. Medicaid’s share of total industry NPW (Net Premiums Written) in that timeframe rose to 27.1% from 10.2%, although much of that growth occurred in 2014-2015. Medicare Advantage also has been a major source of premium growth for health insurers, with NPW increasing to $202.7 billion in 2017, representing 24.5% of overall industry premium, from $69.9 billion in 2007. Like Medicaid, growth in this business has flattened over the past few years.

According to the report, changes in the nature and financing of the individual market under the ACA have effectively turned this portion of the commercial market into government-sponsored business. At the same time, group commercial premium since 2014 has experienced lower growth because of relatively stable medical cost trends, the absence of material membership expansion and the transition to self-funded arrangements. As a result, many commercial carriers have a greater exposure to government-financed business without having increased their participation in Medicaid or Medicare Advantage lines. Increased exposure to the individual exchange business and its financial losses led to a decline in underwriting margins in the commercial segment from 2014 to 2016, but the market recovered in 2017, leading to historically high results for the overall commercial segment.

With health care remaining a controversial political issue, the regulatory regime is likely to remain volatile over the near to medium term, especially as it relates to the individual exchange segment.

As industry consolidation continues and as companies build massive operational infrastructures to service these programs, a quick exit, if need be, may be more difficult. However, the larger carriers, as well as some of the midsize ones, have been successful in adjusting to regulatory changes and revising business models to accommodate different population needs under the government programs.

https://news.ambest.com…

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Comment:

By Don McCanne, M.D.

This sterile report from A.M. Best suggests that there are uncertainties for the health insurance industry in its participation in government programs, but the important message is that their government-related health insurance business is growing as they prove capable of accommodating to regulatory volatility.

The clear trend is further privatization of the government health insurance programs. With the strong public support for Medicare for All, the insurance industry realizes that there is a great opportunity to expand their markets though the public option of a private Medicare Advantage for All. If you listen carefully to the political candidates supporting Medicare for All, many of them slip in “through a public option,” simply meaning a private insurance option with a Medicare label. That’s what Medicare Advantage is.

Listen up. As we attempt to insert ourselves into the process again (we failed during the Clinton and the Obama administrations), we are going to be met with, “We got it; now get out of our way.” The incremental step of Medicare Advantage for All will ensure a solid rock foundation shoring up the medical-industrial complex, likely for decades to come.

We’re very good at inertia, and it is going to kill any semblance of a single payer, publicly-administered Medicare for all, as we perceive it. Are you just going to sit there? Are all of us just going to sit here?

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* In the first 3 months of 2018, 28.3 million (8.8%) persons of all ages were uninsured at the time of interview—not significantly different from 2017, but 20.3 million fewer persons than in 2010.

* In the first 3 months of 2018, among adults aged 18–64, 12.5% were uninsured at the time of interview, 19.2% had public coverage, and 70.0% had private health insurance coverage.

* In the first 3 months of 2018, among children aged 0–17 years, 4.6% were uninsured, 41.9% had public coverage, and 54.6% had private health insurance coverage.

* Among adults aged 18–64, 70.0% (138.6 million) were covered by private health insurance plans at the time of interview in the first 3 months of 2018. This includes 4.2% (8.3 million) covered by private health insurance plans obtained through the Health Insurance Marketplace or state-based exchanges.

* The percent age of persons underage 65 with private health insurance enrolled in a high-deductible health plan increased, from 43.7% in 2017 to 47.0% in the first 3 months of 2018.

https://www.cdc.gov…

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Comment:

By Don McCanne, M.D.

This annual NHIS study of the uninsured done by the National Center for Health Statistics gives us the most accurate status of health insurance coverage in the United States. A few observations can show us how our system is functioning, now that the implementation of the Affordable Care Act (ACA) has relatively stabilized:

* 28.3 million individuals (8.8%) remain uninsured, the same as last year, so net enrollment seems to have stabilized for the present, with still far too many remaining uninsured.

* Of adults aged 18-64, 138.6 million were covered by private insurance, though only 8.3 million of them were covered through the ACA exchanges, which makes you think that there must be a better option considering the administrative complexity of the program.

* For children aged 0-17, the increase in public coverage (Medicaid and CHIP) reduced their uninsured rate to 4.6%, but most of that increase was prior to the implementation of ACA. Although many consider an uninsured rate of 4.6% for children to be a policy success, we really should ask why we tolerate leaving 3.4 million children uninsured when a well designed single payer system would cover all of them, and everyone else.

* One statistic that is not stable is that the percentage of individuals under age 65 with private health insurance who are enrolled in high-deductible health plans increased from 43.7% to 47.0% in the last year alone, and is up from 25.3% in 2010. This may be the most shocking result reported this year since it demonstrates that the rate of underinsurance, with its consequential epidemic of financial hardship, is skyrocketing.

Although many in the policy community will celebrate these results as a success of the Affordable Care Act, these are actually terrible results. We could have had everyone covered in a program that we could all afford, but instead our policymakers rejected single payer Medicare for all and have left us with tens of millions uninsured, almost half of the privately insured with worsening underinsurance, and persistent unjust inequities in health care coverage. Are we nuts?

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