Office of Governor Gavin Newsom, January 7, 2019

In his first act as California’s 40th Governor, Governor Gavin Newsom announced a series of major, first-in-the-nation executive actions and budget proposals to lower prescription drug and health care costs for all California families and move California closer to the goal of health care for all.

(The Governor) Calls on the federal government to empower California to truly innovate: Governor Newsom has long said California should be the national leader in health care innovation. However, instead of cultivating and rewarding good ideas, current federal law hinders truly transformative innovation, such as a single-payer health care system. Governor Newsom sent a letter today to President Trump and Congressional leaders calling on the federal government to lift these limitations and, instead, empower states like California to enact transformative change that would allow California to develop a single-payer health system to achieve universal coverage, contain costs, and promote quality and affordability.

https://www.gov.ca.gov…

Office of the Governor, Letter, January 7, 2019

The Honorable Donald J. Trump
The Honorable Mitch McConnell
The Honorable Charles E. Schumer
The Honorable Nancy Pelosi
The Honorable Kevin McCarthy

(Brief excerpts from a 6 page letter)

Existing law permits only limited, piecemeal innovation – not the comprehensive reform necessary to address the myriad challenges that Californians face when navigating today’s health care system.

However, to address this ongoing cost crisis in health care in the most effective way, we must have the federal tools to support California’s ability to provide quality healthcare for everyone, financed through a single-payer model like Medicare. We must have the tools to innovate and expand the Affordable Care Act. even as we build towards a more comprehensive, universal system that works for patients, providers, and taxpayers alike.

A comprehensive solution to affordable health care will require both wisdom and courage, with States and the federal government working together as partners. First and foremost, I ask that you amend federal law to enable States to apply for Transformational Cost and Universal Coverage Waivers, empowering California to pursue transformative health care reform, such as a single-payer system. Further, I ask that you build on the progress of the Affordable Care Act, especially by bolstering the affordability provisions of the law.

Sincerely,

Gavin Newsom, Governor of California

https://www.gov.ca.gov…

Comment:

By Don McCanne, M.D.

Various federal policies and programs have prevented states from accomplishing transition into a state-level single payer system. In his first action, moments after his inauguration, Governor Gavin Newsom signed an executive order to create the largest single purchaser for prescription drugs and allow private employers to join the state in negotiating drug prices. Immediately after that, he signed a letter to the President and Congress asking that federal law be amended to permit a single payer financing system, like Medicare, in California. The letter also requested numerous innovations that would build on the progress of the Affordable Care Act.

There should be no confusion about priorities here. The political climate has improved for enactment of a national Medicare for All program, though not until after the next elections. Every effort should be made to set the stage for such an outcome. Because of the uncertainties of being able to accomplish that goal, willing states like California should move ahead with efforts to establish their own single payer systems, such as Saskatchewan did in Canada before the Canada Health Act was enacted. Since there are also uncertainties about the politics of establishing state single payer programs, it is appropriate to move forward with efforts to strengthen the benefits of the Affordable Care Act on a transitional basis. The primary caveat is that that we cannot allow lesser efforts to diminish in the least our resolve to establish a national Single Payer Medicare for All program. If the politics are not aligned, we need to change them.

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By Mark Moore
New York Post, January 6, 2019

Rookie Rep. Alexandria Ocasio-Cortez shot back at critics who say her progressive agenda is too radical and expensive, saying there’s nothing revolutionary about providing people with good jobs, health care and an education.

“When you can’t provide for your kids working a full-time job, working two full-time jobs. When you can’t have health care. That is not dignified,” Ocasio-Cortez told CBS’ “60 Minutes” in an interview that aired Sunday.

The 29-year-old newly minted House member is entering office with an ambitious agenda — including Medicare for all, tuition-free public college, and sweeping environmental protections.

“How are you going to pay for all that?” CBS’ Anderson Cooper asked her.

“No one asks how we’re going to pay for this Space Force. No one asked how we paid for a $2 trillion tax cut,” she said. “We only ask how we pay for it on issues of housing, health care and education. How do we pay for it? With the same exact mechanisms that we pay for military increases for this Space Force.”

https://nypost.com…

Selected prior analyses of single payer financing proposals:
https://pnhp.org…

Comment:

By Don McCanne, M.D.

We tend to try to provide an overly detailed answer when people ask how we would pay for health care for everyone through a single payer Medicare for All program. The appropriate answer in most circumstances is that we would pay for it like we do for all other publicly-financed programs – through equitable tax policies which would be affordable for each of us, less than most of us are paying now.

For more specific details, over the past three decades many single payer financing proposals have been analyzed (see link above). The recent Pollin PERI study is another example. They all show that the single payer model covers everyone while making health care affordable for each of us. That is what people need to know. Inevitably, opponents ferret out isolated details, which vary in each proposal, that are used to claim that the system is unaffordable while they fail to mention details of the fundamental design that, in fact, show that health care actually would be affordable for all.

Regardless, we should avoid dead end arguments over the specific details of these reports. We should hold firm on the general position that the efficiencies of a single payer system would offset the additional costs of covering everyone, and that it would be affordable for each of us through equitable public financing. Like Alexandria Ocasio-Cortez says, “we pay for it with the same exact mechanisms that we pay for (any other government program).”

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By Peter Sullivan
The Hill, January 3, 2019

Speaker Nancy Pelosi (D-Calif.) supports holding hearings on “Medicare for all,” her spokesman said Thursday, marking a major step forward for supporters of a single-payer health system.

Some Democrats have been talking about holding hearings on the issue, but Pelosi’s backing is seen as a boost for those efforts.

Pelosi had said last year only that Medicare for all would “have to be evaluated” and is “on the table.”

Rep. Pramila Jayapal (D-Wash.), the main sponsor of Medicare for all in the House, said Thursday that hearings would likely start in the Rules and Budget committees.

That would leave out the main committees with jurisdiction over the issue: Energy and Commerce and Ways and Means. The chairmen of those committees have not given their backing to Medicare for all, while the chairmen of Rules and Budget have.

Jayapal has been working to update the Medicare for all legislation and said Thursday she hopes to have draft text available “in the next week or two.”

She said she is hoping to eventually have hearings in the Energy and Commerce Committee, and has spoken to its chairman, Rep. Frank Pallone Jr. (D-N.J.), but that he has yet to give a commitment to hold hearings.

“He hasn’t committed that to me but I have the Speaker’s commitment that she will help me to do this,” Jayapal said. “And I spoke to Pallone and Pallone is not opposed, he just hasn’t said yes yet.”

Pallone threw cold water on the idea in November, but that was before Pelosi’s support for hearings.

“I’ve always been an advocate for Medicare for all or single-payer, but I just don’t think that the votes would be there for that, so I think our priority has to be stabilizing the Affordable Care Act, preventing the sabotage that the Trump administration has initiated,” Pallone said in November.

Jayapal said that the bill she is working on will not spell out how the measure would be paid for or which taxes will increase.

“This is really going to be a bill on what the system looks like,” she said.

Some lawmakers are awaiting the details of the new version.

Rep. Joe Kennedy III (D-Mass.) told The Hill in November that he was “hopeful” he could support the new version if issues with last year’s bill were worked out.

(In an 11/30/18 article in The Hill, Kennedy said that the bill needs more vetting and detail, but that he “absolutely” supports the idea of single-payer health insurance, which has the government provide health insurance for everyone. “There’s no doubt that our country needs to continue this progress towards making sure that everybody gets access to health care that you need, when you need it, at a price you can afford,” he said. “That has been something that’s one of the big driving motivators for me in my work here, it’s been something that obviously members of my family have been working on for a very long time.”)

Rep. John Yarmuth (D-Ky.), the chairman of the Budget Committee, said last year that he planned to hold hearings on Medicare for all.

“Chairman Yarmuth plans to hold a hearing this Congress on the various approaches to expanding coverage and making health care more affordable, which would include different Medicare for All options,” spokesman Sam Lau said Thursday.

Rep. Richard Neal (D-Mass.), the Ways and Means chairman, has been more open to the idea, saying in December that Medicare for all deserved “a conversation.”

Democrats, however, face pressure from their left wing on the issue, not only from Jayapal but from a class of new members including incoming Rep. Alexandria Ocasio-Cortez (D-N.Y.).

https://thehill.com…

Comment:

By Don McCanne, M.D.

The political process is evolving as it should. Every seat in the House was open for the midterm election, and the voters placed control of the House in the hands of a majority that supports comprehensive health reform, with many supporting specifically Medicare for All. It is entirely appropriate for the House to now initiate hearings on Medicare for All. Many voters and certainly several members of Congress would like to have more details on what Single Payer Medicare for All would look like and how it would work. The hearings thus can serve an important role in educating Congress and the public at large.

Since President Trump and the majority in the Senate state that they oppose Medicare for All, it is unrealistic to expect that such a program could be enacted in this session of Congress. But the next election is less than two years away and that is a very short time to inform and mobilize the political forces that would be essential for enabling enactment of Medicare for All.

The hearings will be part of the process, but it is important that we continue with our other advocacy activities as well. Special targets should include politicians who do not yet seem to understand why single payer is an imperative, and politicians who profess to be advocates but who could be swayed to support detrimental reform policies in a perversion of the process of political compromise. We need to continue to work with politicians who are already fully on board, but we should also continue our efforts to educate those who say they are opposed, if, for no other reason, they might accept defeat more readily were they to understand the clear social benefit of Medicare for All. Also we cannot let up in the least in our efforts to educate the public at large. Grassroots efforts will continue to be an essential component of the reform effort.

As a 501(c)(3) organization, PNHP does not support any individual politician or political party. We encourage all politicians, regardless of political affiliation, to learn about and support a single payer national health program, an improved Medicare for all, that would ensure comprehensive, affordable health care for everyone.

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By Chad Terhune
Kaiser Health News, January 3, 2019

Marcela Villa isn’t a big name in health care — but she played a crucial role in the lives of thousands of Medicaid patients in California. Her official title: denial nurse.

Each week, dozens of requests for treatment landed on her desk after preliminary rejections. Her job, with the assistance of a part-time medical director, was to conclusively determine whether the care — from doctor visits to cancer treatment — should be covered under the nation’s health insurance program for low-income Americans.

She was drowning in requests, she said, and felt pressed to uphold most of the denials she saw. “If it was a high-dollar case, they tried to deny it,” Villa said. “I told them you can’t deny it just because it’s going to cost $20,000.”

Villa, 32, did not work for the government. She did not even work for an insurer under contract with the government. She worked for a company now called Agilon Health. Owned by a private equity firm, it’s among the legion of private subcontractors looking to profit from Medicaid patients.

California’s Medicaid program, known as Medi-Cal, has determined that the Long Beach company, which was paid to coordinate care for about 400,000 patients, improperly denied or delayed care for at least 1,400 of them, state officials confirmed. The state Department of Managed Health Care is investigating further.

The state findings, along with internal company documents and a whistleblower complaint obtained by Kaiser Health News, shine a light on the potential dangers of outsourcing care for poor people. Government oversight, not rigorous to begin with, fades as taxpayer money filters down through layers of companies eager to seize on Medicaid’s substantial growth under the Affordable Care Act. Medicaid officials say they have authority only over the health plans, not their subcontractors.

Skimping On Services?

Nearly three-quarters of the 73 million low-income Americans on Medicaid are now in managed care, in which states pay health insurers fixed monthly amounts for each enrollee to cover the range of services they need.

Under this system, keeping patients as healthy as possible is one way to make money. Another is to deny or skimp on services.

Increasingly, Medicaid plans outsource the work of managing patients’ health and medical treatment to subcontractors like Agilon — passing along a share of the government money coupled with the financial risk posed by a fixed budget.

These firms can be powerful gatekeepers. They run physician groups, bear responsibility for forming doctor networks and judge whether a request for care is necessary.

Agilon is a big player in California — doing business with insurers such as Molina Healthcare and Blue Shield of California.

Agilon’s June report depicts an operation that was often stretched thin: Nurses were handling 120 to 200 requests for care per day, on average, with no full-time medical director to review the findings.

From 2014 until May, the company relied on a family physician who was working 10 to 12 hours a day running his own medical practice, according to the report.

Ultimately, Agilon’s internal investigation found that patient care may have been denied 439 times since 2014 without a physician’s review of the medical records — a potential violation of state law. Under California law, only a licensed physician or health care professional who is “competent to evaluate the specific clinical issues involved” can determine medical necessity.

“These private entities get very little oversight,” said Linda Nguy, a policy advocate at the Western Center on Law & Poverty in Sacramento, “and there’s real harm being done to patients.”

https://khn.org…

Comment:

By Don McCanne, M.D.

Private Medicaid managed care companies using private subcontractors to appropriate to themselves our public funds by denying health care – need we say more?

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By Doug Henwood
Jacobin, December 26, 2018

How much will universal health coverage cost? The Mercatus Institute, a Koch-funded free-market think tank at George Mason University, recently put it at $32 trillion over the next decade. That sounds like a lot, but is it?

Well, the study also estimated that the cost was $2 trillion less than it would cost to do just the same thing as we are now — which is surprising considering the source, but much less interesting to mainstream reporters.

But the Political Economy Research Institute at the University of Massachusetts has its own estimates. Its long and rigorous study shows we could cover everyone in the United States with no copays and cut overall health spending by almost a fifth. Lead author Robert Pollin, professor of economics at the University of Massachusetts and co-director of PERI, recently spoke with Doug Henwood for his Jacobin podcast Behind the News.

Doug Henwood: You’re projecting over the long-term that US health care expenditure would stabilize around 15 percent or 16 percent of GDP. Which is still well above what we see in Canada and Britain, and quite above also Germany and France, who spend more than Canada and Britain.

We’re talking about a difference of a trillion or more dollars, which is enough to save the climate and have enough left over for dessert. Why can’t we get down to those levels?

Robert Pollin: Very good question. We really wanted this study to be really heavily peer reviewed. One reviewer was Jeffrey Sachs, who was extremely active and very helpful, and was quite critical in some points. This was his main question. “If we’re going to do all of this, we end up with a system that is going to cost 16 percent of GDP. Why can’t we do better, if Canada and the others are 11 percent, 10 percent, 9 percent?”

Some of the other reviewers I have were pushing on the other side, saying, “You can’t make these cuts. It’s unrealistic to think you’re going to get this level of savings.” On balance, this is where I think is realistically we can get to.

Henwood: We have this coalition now developing in Congress of Democrats opposed to any idea of single-payer, so not obvious at this point.

Pollin: Well, not obvious. But 70 percent of the population says they’re for it.

The argument was for a long time, “Yeah, you may be for it, but you don’t know what the hell it is and you can’t pay for it.” I hope that my study and other people’s studies have demonstrated that that simply isn’t true. It was obvious all along that it wasn’t true — other countries are paying a lot less, and they have some equivalent to Medicare for All.

But in the US case, now we have these various studies, including ours, that make it blindingly clear that this is completely practical, and the financing works. It works way better for almost everybody in society. It relieves people of all the anxieties they have about how they cover themselves when they have health problems. It’s a much better way to run a health care system.

On the other side, you have people making tons of money off of a bad health care system. That’s what we are going to struggle over.

https://www.jacobinmag.com…

U MASS PERI Analysis:
https://www.peri.umass.edu…

Reviewer Assessments, including that of PNHP’s Woolhandler, Himmelstein, and Gaffney:
https://www.peri.umass.edu…

Comment:

By Don McCanne, M.D.

Those passionate about single payer have been energized by the expanding public support for Medicare for All and by recent policy studies such as that by U MASS-Amherst Professor Robert Pollin and his colleagues, and also particularly by the fact that legislative models are in development on both the state and federal levels. But there are disputes about both policy and process.

Once you exclude those who oppose a government role in ensuring health care for all, the primary disagreement on policy is whether we want to build on our current dysfunctional model of financing health care or if we want to move forward with Single Payer Medicare for All. There is really no contest since the single payer model wins out based on effectiveness, efficiency, accessibility in a system that is both affordable and equitable. Building on the current system by measures such as adding a public option or Medicare buy-in doesn’t come close; lack of insurance, underinsurance, impaired access, and financial hardship would be perpetuated. There are still some differences of opinion regarding details of the single payer model, but this can be worked out cooperatively. What is clear is that expanding the current system is not adequate.

What about process? Above all we need to work with legislators and their staffs and others in the policy community who will be providing input into the legislative process. But in our passion it is essential that we not forget about the importance of civility.

Before Pollin’s team released their analysis, they had it reviewed by several other noted individuals from the policy community (link above). Although not all differences were resolved, the various opinions were advanced for consideration by the community at large. This process includes the crucial ingredient of civility. Without it, the process breaks down, as our highly polarized members of Congress demonstrate repeatedly.

When the legislation needs to be protected against flawed or harmful policies, working together with our colleagues to educate the legislative staffs will get us much further than bombarding them with what appears to them to be the product of uncooperative dissidents. Again, when we are clearly in the right, civility will pave the way.

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By Robert Pear
The New York Times, December 29, 2018

More and more Democrats, fed up with private health insurance companies, are endorsing the goal of a government-run, single-payer system like Medicare for all Americans. But they have discovered a problem. More than one-third of Medicare beneficiaries are in Medicare Advantage plans, run not by the government but by private insurers.

Whether to allow younger Americans to enroll in such private Medicare plans has become a hotly debated political question as Democrats look to 2020.

When liberal Democrats started advocating “Medicare for all” more than 25 years ago, Medicare was the original fee-for-service program run by the government. Since then, it has changed in big ways. More than 20 million of the 60 million beneficiaries are in comprehensive Medicare Advantage plans sold by private insurers like UnitedHealth, Humana, Kaiser Permanente and Blue Cross and Blue Shield.

“Medicare for all” has become a rallying cry for progressive Democrats, though it means different things to different people. Supporters generally agree that it is a way to achieve universal coverage with a system of national health insurance in which a single public program would pay most of the bills, but care would still be delivered by private doctors and hospitals.

Billy Wynne, a health care lobbyist who used to work for Senate Democrats, said: “The literal meaning of ‘Medicare for all’ would include Medicare Advantage. But that is not what most supporters of Medicare for all have in mind.”

The champions of Medicare for all generally see insurance companies as part of the problem, not the solution.

“There are a lot of insurance companies and medical companies that are advocating for their own best interests, and those best interests are usually money, and not people’s health,” Representative-elect Deb Haaland, Democrat of New Mexico and a supporter of Medicare for all, said in an interview.

President Trump and other Republicans have mocked the idea of Medicare for all, saying it could ruin the program for older Americans and generate huge costs for the federal government. It would “come at a staggering cost to taxpayers,” said Alex M. Azar II, the secretary of health and human services.

Asked if his vision of Medicare for all included private Medicare Advantage plans, Adam Green, a founder of the Progressive Change Campaign Committee, an advocacy group, said: “No, absolutely not. Why would it? Medicare for all, in the end, means fundamental systemic change. People would no longer be at the mercy of for-profit insurers that make money by denying people care.”

Mr. Sanders and Representative Pramila Jayapal, Democrat of Washington and a chairwoman of the Medicare for All Caucus in Congress, see no need for private Medicare Advantage plans.

Vedant Patel, a spokesman for Ms. Jayapal, said her vision of Medicare for all was the traditional Medicare program, not private plans. “The purpose of Medicare for all is defeated if there are other plans people can buy into,” he said.

Josh Miller Lewis, a spokesman for Mr. Sanders, said: “We would get rid of duplicative health insurance. Our version of Medicare would cover most procedures. There would be no need for a Medicare Advantage program.”

Other lawmakers support expanding Medicare, but do not want to disrupt coverage for consumers who like the insurance they have.

Josh Miller Lewis, a spokesman for Mr. Sanders, said: “We would get rid of duplicative health insurance. Our version of Medicare would cover most procedures. There would be no need for a Medicare Advantage program.”

Other lawmakers support expanding Medicare, but do not want to disrupt coverage for consumers who like the insurance they have.

“Millions of Americans who rely on employer-sponsored insurance and Medicare Advantage are satisfied with their coverage,” said Representative Rosa DeLauro, Democrat of Connecticut.

Some health policy experts have suggested building a national health insurance program on Medicare Advantage rather than on the traditional fee-for-service Medicare program.

“Medicare Advantage for all — that would be a much more politically feasible and a uniquely American spin on single payer,” said John K. Gorman, a former Medicare official who is a consultant to many insurers. “It would be Medicare paying all the bills, but it would be privately administered by heavily regulated plans that would effectively serve as utilities.”

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

As we move into the next year, we should be celebrating the fact that “Medicare for All” has gained traction and now has widespread support throughout the United States. But can we? Any celebration has to be tempered by the fact that a multitude of very powerful forces are hijacking the “Medicare for All” label and using it to advance their own agendas based on ideology and especially greed.

What has crept into the national dialogue more recently is an emphasis that Medicare is not just the traditional public program but it also includes the private Medicare Advantage plans. The latter are being promoted by those in the insurance industry camp as the ideal model for expanding the Medicare program, whether by reducing the eligibility age, or by offering Medicare Advantage as a ready-to-go “public option” (that is actually private), or by opening up the ACA exchanges to include private Medicare Advantage plans (as a devious route to premium support – using ACA subsidies to support privatized Medicare).

Whatever, it is clear that the private insurance industry is going to continue to do all it can to capture the present and future versions of the Medicare program, and they are doing it with the help not only of the conservatives but also the neoliberals who have infiltrated the progressive camp. We will likely be hearing much more about Medicare Advantage for All.

It is going to be a rough year.

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By Theodore R. Marmor
Journal of Health Politics, Policy and Law, December 2018

Abstract

Social insurance, like commercial insurance, is about protection against financial risk. In the United States, Medicare and the Social Security Administration’s programs for retirement, disability, worker’s compensation, and worker’s life insurance have become dominant features of American public policy, amounting to more than 41 percent of the federal budget. Yet their fiscal centrality does not rest on anything like an understanding of what makes social insurance social—or why that is so important to American political life. This essay seeks to clarify the crucial differences between social and commercial insurance and elaborates on the conceptual justifications and distinctive operational features of America’s social insurance programs.

What Is Social about Social Insurance?

Social insurance, like commercial insurance, is about protection against financial risk. It is “insurance” in the sense that people contribute to a fund to protect themselves against unpredictable financial risks. These include outliving one’s savings in old age, the early death of a breadwinner, the onset of disability that makes work difficult if not impossible, the high costs of illness, involuntary unemployment, and work-related injury. Contributions are not prices in a market and so, unlike commercial insurance, are not higher or lower depending on the customer’s risk profile. Instead of a commercial insurance contract between enrollee and insurer, social insurance is for shared protection among participants in which they agree that each should pay for that protection according to their work income. The “insurer”—a government agency or, originally in Europe, a corporate body with a joint labor/management board—is the agent of the contributing enrollees. The social insurance contract, once created, cannot be voluntary and survive long. By law contributions are required, because otherwise adverse selection would be financially disabling.

Social insurance, then, spreads the costs of coverage according to a different logic than that of commercial insurers. In commercial insurance, price must reflect risk. Social insurance, by contrast, operates on the premise that contributions are calculated according to one’s income and benefits are related to one’s needs. But the central political feature of social insurance is that the contributors are also beneficiaries. This is not the case with social assistance programs with means-tested eligibility standards. As important as such programs are for those who experience poverty, taxpayers do not in general identify with welfare beneficiaries. And, finally, private insurers, unlike governments, cannot tax citizens to make up for losses. But private insurers do routinely try to select customers with an eye to signing up those least likely to experience the risk the insurance policy is to mitigate. That’s why fire insurance is more expensive in poorer neighborhoods, not because insurance firms are racist.

Medicaid, Medicare, and Social Insurance

Medicaid’s very structure is ill designed for broad expansion. Its means-tested mode of eligibility creates a fiscal cliff. That is the term for when an additional dollar of a beneficiary’s income means the loss of a program’s benefit.5 No wealthy democracy has found a way to set the cliff at a point where some other arrangement and a means-tested program can combine to create universal health care. The design problems are particularly evident in the supposedly more middle-class part of the program, long-term care. The means testing and asset testing create cliffs and incentives for fraud. Quality problems can be severe, and yet many people go without needed services

There is little to say about Medicare in the context of conflict over the ACA. Democrats did not rely on expanding Medicare, save for a brief dalliance with voluntary coverage for Americans fifty-five to sixty-five years of age. The “public option” relied on Medicare’s ability to limit prices but not on explicit social insurance principles.6 Indeed, there was no serious discussion of how social insurance ideas were relevant, even though they were important in fact. The regulatory innovations of Obamacare represent earnest efforts to regulate commercial health insurance to become more like social insurance. Requiring insurers to guarantee issue at a fixed price regardless of preexisting conditions would reduce risk selection that social insurance eliminates directly. Requiring commercial insurers to offer a basic benefit plan also moves toward the common coverage that social health insurance offers automatically. The partial measures in the ACA appealed to the values underlying social insurance, but almost no connection was made between these measures and a principled vision of social insurance.

https://read.dukeupress.edu…

Our Lost Vocabulary of Social Insurance

By Theodore R. Marmor
Niskanen Center, December 10, 2018

Social Insurance, Our Neglected Heritage

There are at least two plausible criticisms of this essay’s argument about the importance of relearning the appeal of social insurance principles. One is that the world has changed dramatically since the birth of social insurance in the late 19th century, let alone since the 1934-35 Committee on Economic Security provided a blueprint for expanding social insurance in American public life. The other is that changes in long-standing European social insurance programs show that major adjustments in the American programs are required as well.

The claim that the world has changed does not necessarily mean that the economic risks against which social insurance programs offer protection have been fundamentally altered. Consider every one of the risks noted in this essay — outliving one’s savings, involuntary unemployment, medical costs, and disability. Not one has disappeared, and social insurance programs for each have been implemented in wealthy democracies. I doubt, in other words, whether social insurance is in any conceptual trouble.

But that does not mean social insurance programs don’t need to adapt to contemporary circumstances. The spread of contract employment has been particularly challenging for European countries where social insurance is a function of trade unions and other sector-level organizations. It is equally obvious in the US that employer-provided health insurance puts a damper on labor market flexibility. Reduced employment in regular jobs with health coverage will demand the search for other sources of provision. These and other realities of our changing economy will only bring to the fore the central claim of this essay: Social insurance programs dominate American social policy but what that means for our politics is too little understood or explained. And that criticism extends not only to harried reporters but to a significant amount of the public policy community, as well.

https://niskanencenter.org…

Comment:

By Don McCanne, M.D.

From Repeal and Replace to Medicare for All, with heavy doses of health care financing policy such as accountable care organizations, other alternative payment models, and the public option, we are being inundated with messages intended to ignite much needed improvements in our health care financing system. What seems to have slid out of these discussions is the crucial importance of policy design based on a solid foundation of social insurance.

Ted Marmor has provided us with an excellent account of the principles and paradoxes of social insurance as it has played out, or rather failed to play out fully, in the United States. Rather than reading comments here that I might make, it would be more important to download his article from the Journal of Health Politics, Policy and Law. The publisher has kindly removed the paywall, allowing free access to this article, available at the link above. A modified version has also been published by the Niskanen Center. Reading both versions can clarify any points that might not be clear on your first reading.

I believe that this is one of those landmark articles that should be in your health policy library file, whether you are an academic, activist, or simply someone who really cares about our health care system and the people who receive its services. Whatever we do, it is imperative that our future system be imbued with the principles of social insurance. Actually the principles are already there in our model of a universal single-payer improved-Medicare-for-all national health program. But people have to feel it.

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