By Alvin Powell
The Harvard Gazette, January 14, 2020
Health care, climate change, and political reality collided this week, when experts discussing national single-payer health insurance clashed over the question of whether Democrats should make it their top priority if the party manages to retake both the White House and Congress this year.
John McDonough, a professor of the practice of public health who played a role in the design and passage of the Affordable Care Act, shook his head, arguing that recent history suggests health-care overhaul debates tend to crowd out all other issues and to exact a high political price.
“Health care is vitally important, but so is climate change, so is voting rights, so is gun control,” he said. “When health reform is on the agenda, it sucks up all the political oxygen in the room, and there’s very little room or space for anything.”
Adam Gaffney, an instructor in medicine at Harvard Medical School and president of Physicians for a National Health Program, disagreed, citing Franklin D. Roosevelt’s New Deal and Lyndon B. Johnson’s Great Society as examples of packages of progressive initiatives that passed despite multiple controversial parts.
“If you look at American history, many times many important reforms can be sought and achieved at the same time and that’s what we’re hoping for,” Gaffney said.
The exchange came during The Forum at Harvard T.H. Chan School of Public Health. The webcast, “The Future of National Health Insurance: Debates During a U.S. Presidential Election Year,” also featured Robert Blendon, professor of health policy and political analysis at the Chan School; Sara Collins, vice president of health care coverage and access for The Commonwealth Fund; and Phil Ellis, president of Ellis Health Policy Inc. and former analyst, adviser, and deputy assistant director at the Congressional Budget Office.
McDonough reminded the panel what happened to Democrats the last two times they took on health care. The party has won the coveted “trifecta” of the House, Senate, and White House just twice in the last 40 years. The first was during the first two years of the Clinton presidency and the second was during the first two years of the Obama presidency. Both times, he said, health-care restructuring topped the agenda — unsuccessfully for Clinton and successfully for Obama. And both times Democrats lost control of Congress in the midterm election.
“Each of them made heath reform their signal, main issue, and very little else happened,” McDonough said. “I think we have to be pragmatic … because the consequences are severe, not just for health but for everything else we care about.”
He also said that even under Democrats’ most favorable election scenario, mustering the votes for Medicare for All or another single-payer national health plan is unlikely, because a Democratic Senate majority, if achieved, is unlikely to approach the 60 votes needed to forestall a Republican filibuster.
National polls show that voters care deeply about health care and Democratic presidential candidates have made the issue central to their campaigns. But Blendon cautioned that a closer look at polling responses shows that Democrats and the general public aren’t necessarily talking about the same thing. While Democrats are dedicated to making the health-care system more efficient overall, the public is more narrowly focused on personal costs, such as co-pays and other out-of-pocket expenses. They’re skeptical that they’ll see savings from any plan aimed at system-wide efficiencies.
Polls show Americans clearly split between keeping and tweaking the Affordable Care Act, scrapping the current system in favor of Medicare for All or other similar national health insurance, or Republican-sponsored changes that would reduce federal mandates and devolve more power to the states.
That split, Blendon said, shows that despite years of debate so far, the discussion about health care isn’t close to finished.
“This is what polarized looks like,” Blendon said.
Demographically, Blendon said, some changes are likely over the next 10 years. The wing of the Democratic Party that is most disaffected with today’s institutions and most willing to scrap the current health-care system is also its youngest, which means that support for fundamental change is likely to grow over the next decade.
Despite differing outlooks, panelists agreed that further action on health care is needed. Currently 27 million to 30 million Americans are uninsured, and another 44 million are underinsured, with high co-pays and out-of-pocket expenses. Though the ACA brought the nation’s uninsured below 9 percent for the first time, other developed countries have rates between 0 and 1 percent.
“That’s not nearly good enough. That’s important to keep in mind,” McDonough said of U. S. progress.
Recent studies show that Medicare for All may save money, Gaffney said. The U.S. spends $812 billion annually just for administration of its health-care system, twice what Canada pays. That indicates that even if the cost of care itself doesn’t change under Medicare for All, there may be administrative savings.
Panelists said it is difficult to predict the impact of a Trump reelection on health care, but the general trend of Republican action has been to make health insurance cheaper by reducing coverage and relaxing mandates that insurers cover preexisting conditions. If insurers are again allowed to refuse those with preexisting conditions, Ellis said it’s likely that markets would be split between healthy people paying lower premiums and the sick, who may be forced into high-risk pools with higher premiums. McDonough said it’s also likely we’d see a continued rise in the number of uninsured, whose ranks have risen by 2 million in recent years.
Forum – Harvard T.H. Chan School of Public Health, “The Future of National Health Insurance” – 1 hour video:
By Don McCanne, M.D.
Clearly the single payer model of Medicare for All is vastly superior to other models of reform under consideration. It would provide all essential health care services to everyone at a cost close to that of our current highly dysfunctional financing system, while ensuring affordability for each individual by implementing equitable tax policies.
But the public is more concerned about their individual costs. They are concerned about the high cost of drugs, about high deductibles, about surprise medical bills, and about high insurance premiums if they are not covered by employer-sponsored plans. They want to see these issues addressed directly, though they are divided between whether the best way would be through expansion of the Affordable Care Act perhaps with a Medicare for All public option added, or if they would prefer more flexibility in private insurance products and in the health care marketplace.
Polls currently show that the nation is fairly evenly split in support of these three options. The neoliberals have apparently decided that we should improve ACA by adding a public option, and then try to bring the single payer supporters into their camp. The conservatives are still floundering with their efforts to patch together market solutions that simply won’t work for most individuals.
The polls are partly responsible for this effort to perpetuate ACA with a public option added. Opponents of single payer have been trying to convince the public that they should have the right to keep their private plans. Since most of those plans are employer-sponsored, beneficiaries believe that their personal costs will be less since they generally do not see the portion of the premium paid by the employer and they are quite unaware of tax expenditures for the deductibility of the plans for which we taxpayers are responsible. They contrast that with the prospect of paying for Medicare for everyone through a massive increase in their Medicare payroll taxes, or the equivalent in income taxes, or whatever, not considering that they would be equitable, progressive taxes
Since we really can’t improve on the single payer Medicare for All model, we should not use the poll results to compromise the single payer policies just to preserve choice of private plans. Instead we should use the poll results to show how single payer much more effectively addresses the individual concerns that the public actually has – controlling drug costs, eliminating surprise bills, eliminating insurance premiums and deductibles, eliminating provider networks that take away their choices of physicians and hospitals, and ensuring that they would be covered for life. Right now the opponents of single payer Medicare for All are using the polls as a deterrence by threatening loss of choice of private health plans.
Polling expert Robert Blendon: “For the average voter, they want to vote for someone who will deal with medical bills… This is a meat and potatoes issue for the average person not voting in the Democratic primary – ‘I want to see something done about these insulin costs, etc., etc.’.. And that’s what scares them about Medicare for All. If you could just talk about – ‘I’ll pay less next year’… But when you get into the trillions, people can’t deal with it – People say ‘I don’t know what a trillion is, but at the end of the day I’m going to be paying more.’ In reality if you can say your fees will go down, your delivery costs will go down, your drug costs will go down, that would be a debate the others would like to have, but that is lost in the aggregate numbers.”
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