Thursday, August 03, 2017

ANS -- Medicare-for-All Isn’t the Solution for Universal Health Care

This one is long because I have included all the comments. The title is a bit misleading.   It's a good discussion, that we need to have, and many more are needed to get this done.  But the only way we are going to get Universal Health Care is to vote the Republicans out and get Progressives in.  How are we gonna do that?

Medicare-for-All Isn't the Solution for Universal Health Care

The health-care debate is moving to the left. But if progressives don't start sweating the details, we're going to fail yet again.



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  1. Manuel Fiadeiro says:

    I think we should start with the principle that making money out of the people's health (or lack of thereof) is immoral. Taking profit out of the equation is the first step. The second principle should be that nobody should go bankrupt because of a medical condition. Once the basic right to a decent medical coverage is established for all, there can be room for private profiting for the upper 1 or 2% of the population that want face lifts and nose shaping, as long as they pay well the nurses and janitor hands that man their private clinics. No problem with that! 

    Controlling costs, mostly on drugs, is imperative. This habit of increasing the price of a drug by 500% when someone buys a company, must end. Drug companies justify their absurd profits by saying they need the money to develop new drugs. That is a scam. Most research on new drugs goes on universities and laboratories financed by the tax payer. They just pay to taking them to market. Giving them 20 years of exclusive profit is absurd. Our VA system is an example how one can give excellent service and control costs. Medicare coverage is complicated (e.g. option D) because it was made to be, so private companies can get their hands on the honey pot of public financing. 

    The problems of universal coverage are not structural, they are political.

  2. Barry Samuels says:

    Dems continue to frame and discuss this issue incorrectly and it will cost them (us) in the long run. Stop using the term "single payer" when in the end it is about "universal coverage." Stop calling it a "right," a concept that is not absolute and open to vast interpretation and manipulation. Instead, find the language and argument that accurately describes good health insurance as a necessity so basic that our society cannot properly function and thrive if all do not have it, maybe like roads to drive on. Imagine a world without them. Make the argument that universal coverage is the acutal "freedom" that cons keep harping on, as a guarantee to decent health care no matter what will surely liberate millions of Americans from the largely undiscussed scourge of health care insecurity. Lastly, find the language to discuss the issue in more practical terms, how when millions have good health insurance who don't have it now, they will become empowered consumers, better workers, better students, better and more productive citizens benefitting each and every American.

  3. Jeffrey Harrison says:

    Well, it's good to know that we can't get there from here. Lord knows, if we didn't know that, we might be tempted to try to get there from here and meet with ego crushing failure. A prime case of letting your pre-conceived notions limit your range of action....

  4. Gary Kendall says:

    The author says there may be other solutions that haven't even been proposed yet. Here's one for consideration...

    When the public sector steps in to help pay for any good or service, the cost of those goods/services rises. Home prices increased rapidly after the home mortgage tax deduction was enacted. Similarly, the cost of a college education increased rapidly when Pell grants and low-interest loans became available.

    Instead of figuring out how to pay for health care, perhaps we should focus on controlling costs. Put reasonable price caps on every medical procedure, office visit, hospital stay, etc. This method works for the public utility industry. The cost of delivering electricity to a house 100 miles from the power plant is orders of magnitude higher then the cost of delivering electricity to a house across the road from the power plant - yet everyone pays the same low rate and no one complains (I know this because I'm a retired engineer and spent 3+ decades working in the energy sector). Health care is categorically the same as a public utility - both are non-optional services. 

    If the (water/sewer/gas/electric) utility industries can figure out how to stay in business - and even remain profitable - with price caps, the health care industry can also.

    I'm thinking $10,000 for heart bypass surgery is generous. The hospital can cover its costs and the doctor(s) can earn a decent living. Profit? Looks like the consensus in these comments is that profit has no place in health care.

  5. Randall S Andrews says:

    This is the second article in the Nation in just over two weeks, by liberals, for liberals, that spends a lot of ink talking about why healthcare is virtually impossible and quibbling over what we should call it. I am tired of all the negative bickering and the mindless open loop arguments about how we can do better. I'm tired of the mindset that all it will take to enact a liberal agenda is a few more millennia of omphaloskepsis.

    Jeez. This inability to take a can-do attitude doesn't just block the way to healthcare. It's a large part of why so many people voted against their own interests in electing Trump, or why there are so many statehouses controlled by Republicans that hate both the people who elected them and the Republic to boot. If the left could come up with a few more concrete plans to actually make America work again for average Americans it would get a lot further (and get a lot more votes, too.)

    Let us begin by assuming that whatever problems arise, be they actual, or just stumbling blocks thrown out there by the profiteers who might have to give up their sixth, seventh and eighth vacation homes if they're not allowed to gouge the American public, can be solved.

    Let's keep our eyes on the prize. In the end healthcare has to be a right for all Americans. Let us figure how to get there while we are on the road, not spend endless decades mapping out the perfect route and deciding just how we will describe it.

    1. Mary Baine Campbell says:

      Randall Andrews I sort of agree--I like your spirit!--but sort of don't. What Holland says about health care systems we carelessly call "single-payer" is true--I've lived in several of those countries, including France. And read a lot about the history of public health-care systems, all set up a long time ago when costs were lower. The big "fear of loss" problem I've worried about since I experienced the terrific French system is that French doctors (I have French doctor friends) just don't have 2 or 3 homes and yachts and live like royalty as so many US doctors too. They make the kind of living non-Ivy League profs and architects and engineers do. Decent but not luxurious. I worry: will enough US doctors be willing to give up being rich? Because if they're not (and people generally do freak out at the prospect of cutting their income in half!), well...they have a lot of collective influence and power.

    2. Philip Gerard says:

      I agree. One thing is for certain it will never become a reality if we do not try.

  6. Philip Gerard says:

    I would not argue that the transition would be difficult or that it should be rushed into or even that there might be a more nuanced system that might be better. However whatever is done it must include a concerted effort to eliminate the for profit system that we are currently burdened with. This is what every other developed country has done. Healthcare should be a right sold at cost not a commodity sold for profit.

  7. Chris Darling says:

    You make a lot of good points. However, when you say, 
    "At a minimum, it's time to get past the idea that anyone who doesn't embrace Medicare-for-All, as it's currently defined, must be some kind of neoliberal hack."
    I challenge you to find one politician on the national level who is not for Medicare-For-All who is not a neoliberal hack.

    Rose Ann DeMoro, head of both the California Nurses Association and National Nurses United, has been taunting the California Democratic Party Establishment about how they are "for" universal health care as a concept, but not for SB 562, the now killed single payer bill that made it through the California Senate. None of the people who oppose SB 562 are genuine in wanting universal healthcare because they are too afraid of going up against insurance, drug companies, etc. While there is a need for discussion about how to transition to universal coverage, and also perhaps what form it should take, the reality is that all those opposed to single-payer are also taking money from the insurance companies, the drug companies, and other health industry special interests. We need to beat the corporate Democrats, who are universally phony shills for the wealthy, before we get into the details of how to transition.

  8. Wesley Decker says:

    Your arguments might make some sense had I not lived through both Medicaid Expansion and the ACA, both of which are administrative nightmares working in theory only. Sure it's not going to be dead simple getting to single payer, but compare the current system to Social Security and Medicare. The Social Security application takes less than fifteen minutes and once you're in that system, a letter shows up one day saying you're already enrolled in Medicare parts A and B, with instructions on how to opt out of default coverage if you choose to do so. Anything that actually works would be a nearly one-hundred percent improvement over the status quo.

  9. Ivan Sipos says:

    Health care is a human right. Many of our insurance plans are a sham with huge deductibles, large co pays and questionable coverage. Let's say it straight the goal of a corporation is to increase its profit. Leaving a human right like health care in the hands of private corporations is resulting in high prices questionable care and a lot of profits. Everybody from cradle to grave should be enrolled in one plan that covers everything with no opt out. Anybody who knows elementary mat can see that as a way to assure the lowest prices, human decency and an element necessary to a functioning human society. The well being of an individual should be not left to an employer-that was in slavery when owner were interested to keep a slave working. A human right like health care should be managed by elected officials.
    If we agree on those principles working out the payment-tax-system will fall in place. We are the richest country, we have the highest productivity of labor and our health care for our citizens is by far not on par with the modern times. Finally our elected officials should be on the same plans the citizens that they supposedly are representing and serving are

  10. John Murphy says:

    I am physician and working in a for profit walk-in clinic. 
    A couple years ago, I saw a 64 year old lady who had clearly had a ministroke a couple days before. 
    I sent to the ER for a carotid ultrasound. 
    I was paid 65$ an hour at this clinic and saw at least two more patients that hour. 
    The patient went to the ER, got the ultrasound, a CT AND and MRI only the first of which she needed. 
    The was started on plavix to which she had an allergic reaction, and was sent home, after one night in the hospital on aspirin. 
    She saw me again a couple weeks later and showed me her bill for $88,000!!!! 
    She had seen 3 doctors, the ER doc, an internist and a neurologist plus and ultrasound tech and radologist interpretation. I guarantee you that none of them got more the $200 for their services. (The ultrasound tech probably was paid more than me for that case) 
    The author makes the same critical error as every other theoritical bureaucrat, ie Doctor (OK, 'provider') salaries are the big problem. I STRONGLY challenge the notion that all physicians are in the top 2%, Many pediatricians and primary care docs make less than welders. 
    Until we get control of the increasingly vertically integrated, for profit system, which includes the repacious pharmaceutical companies it does not matter who pays the bill. 
    I also do occupational medicine which is a separate medical system for people injured at work. My work there is 99% legal and administrative, ie, trying to get a brick layer with a ruptured disc and MRI which his insurance carrier has denied. The administrative costs, including lawyers, advocates, 
    special consultants etc etc etc are MASSIVE and would simply disappear with a single payer system. 
    You get hurt , you go see your doctor who treats your problem like anybody else. 
    We will never have a workable medical care system in the US until we convert to a non-profit system where hospital CEO's do NOT make $2.000,000 a year and up. 
    See the post below, he has it right, except we need MORE doctors in order to reduce the value producing scarcity that we now have.

  11. Aaron Sobel says:

    Eye opening. This article should somehow find its way onto the desk of each senator and congressman. If only that can be done, and further, be actually read.

  12. Charles Pack says:

    We have an unsustainable number of people employed in the healthcare business. The number of people delivering care is probably OK. But, add in all the insurance company people, the people in the doctor's office supporting insurance and appeals and the marketing and lobbying and no wonder it is so expensive. Single payer (medicare or medicaid for all) would greatly simplify the system and its overheads. It would also eliminate a lot of the costly profit (perhaps keeping some in supplementals). Start with medicare for older people and move the age down gradually. This should reduce costs to insurance companies and maybe reduce premiums for the rest. Stop making excuses and get on with it!

  13. Ira Dember says:

    Like many people, I feel it's urgent to fix our grotesque system right now — and for good reason. Millions of families are suffering. 

    I think the author makes a good point, asking what a massive systemic transition might look like. This thinking helps take the healthcare issue out of theory and rhetoric, and makes it more concrete. 

    Despite the urgency, I propose that we think if it in two ways simultaneously: (a) benefiting the most people in the short term, and (b) gradually building out a long-term solution, as we did with the interstate highway system. 

    Remember too that, rightly or wrongly, the highway system was sold to policymakers partly on the basis of a military rationale, a national security rationale. 

    I propose that we could lubricate the healthcare issue by framing it as benefiting the military and national security. 

    If managed skillfully, perhaps a fraction of our bloated military budget might then be redirected for a few years into building out our awesome new public healthcare system, whatever that may look like. 

    To benefit national security. Of course. Just like the interstate highway system.

  14. J R Ranney says:

    Without even reading this attuale I pretty much know what it says from my own experience. I'm a retiree with Medicare and employer-provided insurance (Aetna) and I always still have to pay quite a lot extra. An insider let slip the info that it's standard practice with providers to max out all insurance and bill for about another 15%.

    1. John Murphy says:

      There are now a number of for profit hospital systems who have demanded, and strong armed their doctors to agreeing to allow professional billing specialists to review their discharge summaries and revise them to increase the "billable" bullet points.
      This is technically illegal, except that the hospitals give the physician 24 hours to make changes. After that, the chart is automatically adopted over the physician's signature. 
      Professional Medical organizations have strongly objected to this practice but the hospitals intimidate and threaten them into submission. 
      As a society we are so conditioned to the idea of doctors as fat cats who control the system, that we have NO IDEA that MD's have largely become tools for the profit making machine. 
      The entire US "Health Care" System is a gigantic extractive scam, run by thugs. 
      This sounds crazy and paranoid, but, it is anything but

  15. Robert Andrews says:

    Who provided this information to the OECD? I hope this article isn't based on information provided by the healthcare industry.

  16. Carolyn Herz says:

    What would be really helpful to the discussion itself would be for the news media and pundits to stop referring to proposals as "progressive" or "Conservative" or "left" or "centrist," because it injects unnecessary emotional reactions into the discussion. Focus on the policy goals and the best way to get there.

  17. Ira Dember says:

    Look at the collective impacts described in my previous comment: no more coding game, no payment-denial battles, no exorbitant private liability insurance, and no ruinous medical-school debt. It would substantially reduce the doctor's costs and, I'll bet, substantially boost the quality of his or her professional life. 

    For some burdened doctors, it could mean a return to actually enjoying the practice of medicine! 

    Further, these doctors might not make as much money, but they wouldn't need as much money. 

    On balance, many might find this scenario quite attractive. I think Physicians for a National Health Plan (PNHP) could structure a questionnaire around just such a vision. See how average docs would feel about savoring unburdened freedom to practice their profession.

    1. John Murphy says:

      I saw my orthopedic surgeon for a cortisone shot. 
      Medicare was billed about $300 for the 3 minute procedure. 
      The reimbursment was around $50. 
      Furthermore, this orthopedist is now de facto employee of a large, profit making group, who may well get over half of the reimbursement paid. 
      So, I think you are right. 
      I was an ER doc for over 30 years, never had a lawsuit and IMHO provided superb care. 
      I quit because I could not keep up with the paperwork, which could easily run 3 hours after a 12 hour shift. PLUS, the increasing use of the ER for routine care, resulting in a 12 hour night shift with NO break except to jam a half stale tuna sandwich in my mouth and see the next patient.

  18. Ira Dember says:

    1. Simplicity works on the provider side, too. It eliminates most of the staff now devoted to battling insurers and gaming the system with medical-procedure "codes". 

    2. Along with single-payer care, offer single-payer medical liability insurance. Today's liability coverage is ruinously expensive, driving up costs. In some specialties like ob-gyn, it is almost unaffordable. 

    3. Public-funded liability coverage would also help reduce costly defensive medicine. ("I'm going to order these tests, not because they're needed but so no one can sue me later.") 

    4. Another cost burden: medical-school debt. The government could wipe out all or most of it.

  19. Ira Dember says:

    Complexity is one of the worst features of many healthcare systems. Ours seems to be the worst of the worst. From a user perspective, the ideal is this: you show up, show your ID, and get treated. Period. 

    I'm on Medicare. Each year I receive over 300 pages of printed information — just so I can decide how to purchase and use various coverages. It is a freaking nightmare. Simplicity would bring enormous cost benefits and quality-of-life benefits which I believe may be overlooked or under-appreciated.

  20. Ira Dember says:

    I wish this article had explored structural changes such as the Thai system, which (I read recently) achieves efficiencies through a national network of health maintenance and basic-care clinics feeding into the hospital system.

  21. Hunter Van Valkenburgh says:

    One thing the author omits is that to a certain extent, the cost containment of a single-payer system is automatic, as providers will be forced to accept what is offered. Are doctors getting extremely rich going to leave the field because they are only getting very rich? They will be expendable.

  22. Barbara Pentony says:

    I've read many studies from health experts and economists that "completely disagree" with your conclusions Mr. Holland. Here is just one article from 2014/15 that concludes otherwise, as follows:

    Economist says Canadian-style, single-payer health plan would reap huge savings from reduced paperwork and from negotiated drug prices, enough to pay for quality coverage for all – at less cost to families and businesses.

    Upgrading the nation's Medicare program and expanding it to cover people of all ages would yield more than a half-trillion dollars in efficiency savings in its first year of operation, enough to pay for high-quality, comprehensive health benefits for all residents of the United States at a lower cost to most individuals, families and businesses.

    That's the chief finding of a new fiscal study by Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst. There would even be money left over to help pay down the national debt, he said.

    Friedman says his analysis shows that a nonprofit single-payer system based on the principles of the Expanded and Improved Medicare for All Act, H.R. 676, introduced by Rep. John Conyers Jr., D-Mich., and co-sponsored by 45 other lawmakers, would save an estimated $592 billion in 2014. That would be more than enough to cover all 44 million people the government estimates will be uninsured in that year and to upgrade benefits for everyone else.

    "No other plan can achieve this magnitude of savings on health care," Friedman said.

    His findings were released this morning [Wednesday, July 31] at a congressional briefing in the Cannon House Office Building hosted by Public Citizen and Physicians for a National Health Program, followed by a 1 p.m. news conference with Rep. Conyers, Sen. Bernie Sanders (I-Vt.) and others in observance of Medicare's 48th anniversary at the House Triangle near the Capitol steps. A copy of Friedman's full report, with tables and charts, is available here.

    Friedman said the savings would come from slashing the administrative waste associated with today's private health insurance industry ($476 billion) and using the new, public system's bargaining muscle to negotiate pharmaceutical drug prices down to European levels ($116 billion).

    "These savings would be more than enough to fund $343 billion in improvements to our health system, including the achievement of truly universal coverage, improved benefits, and the elimination of premiums, co-payments and deductibles, which are major barriers to people seeking care," he said.

    Friedman said the savings would also fund $51 billion in transition costs such as retraining displaced workers from the insurance industry and phasing out investor-owned, for-profit delivery systems.

    Over the next decade, the system's savings from reduced health inflation ("bending the cost curve"), thanks to cost-control methods such as negotiated fees, lump-sum payments to hospitals, and capital planning, would amount to an estimated $1.8 trillion.

    "Paradoxically, by expanding Medicare to everyone we'd end up saving billions of dollars annually," he said. "We'd be safeguarding Medicare's fiscal integrity while enhancing the nation's health for the long term."

    Friedman said the plan would be funded by maintaining current federal revenues for health care and imposing new, modest tax increases on very high income earners. It would also be funded by a small increase in payroll taxes on employers, who would no longer pay health insurance premiums, and a new, very small tax on stock and bond transactions.

    "Such a financing scheme would vastly simplify how the nation pays for care, restore free choice of physician, guarantee all necessary medical care, improve patient health and, because it would be financed by a program of progressive taxation, result in 95 percent of all U.S. households saving money," Friedman said.

    Friedman's findings are consistent with other research showing large savings from a single-payer plan. Single-payer fiscal studies by other economists, such as Kenneth E. Thorpe (2005), have arrived at similar conclusions, as have studies conducted by the Congressional Budget Office and the General Accountability Office in the early 1990s. Other studies have documented the administrative efficiency and other benefits of Canada's single-payer system in comparison with the current U.S. system.

    Friedman's research was commissioned by Physicians for a National Health Program, a nonprofit research and educational organization of more than 18,000 doctors nationwide, which wanted to find out how much a single-payer system would cost today and how it could be financed.

  23. Hunter Van Valkenburgh says:

    My wife's school district pays out $14K per year in health insurance premiums for pretty good coverage, with nominal co-pays of $5. If the district could pay into Medicare and give some of the savings to its employees, they could choose to buy supplemental insurance if they needed it, or accept the coverage seniors get without it. Alternatively, the coverage of Medicare could be enhanced to make it more comprehensive. Why shouldn't there be a floor coverage for dental, mental, and vision? Like any other medical service, it is more cost efficient to treat problems while small than to wait until they fester. The decision to make Medicare stingy was a political one that can be undone.

  24. William J Mac Bean says:

    Half assed at best
    That's Obamacare as it now exists.
    Medicare for all wouldn't be as good as Universal Health Care, but would be at least as good as Obamacare is compared to the NOTHING we used to have.
    If we have to take little steps, then let's take them.

  25. John Dorch says:

    Let's look at some facts: US doctors are the best paid IN THE WORLD!!! Why does the MD have to stand for "more dough"??? They are huge contributors to Republican campaigns as a group. Big pharma has been fleecing the American public for years, while Republican administrators have a huge smile on their face as campaign contributions come in. Then, of course, there is the banksters how administer the insurance end of it.... exactly what do they contribute besides the huge CEO compensation packages? Sorry, Mr. Holland, I don't find your arguments cogent.

  26. David Morgan says:

    As for the bar graph, it's how you lie out loud while obscuring reality. Although the U.S. looks pretty "okay," its medical costs are sky high compared to other countries, Americans don't get good health coverage - in fact we don't even rank in the top 10 nations in terms of medical outcomes, and our employers are paying way too much for health care coverage for their workers. If we built our roads and public electrical infrastructure like we provide medical care, we'd all be walking home after work to dark hovels. That bar graph is pure bogus in the way it portrays American "hell-th" care.

  27. Sarah Bush says:

    Thank you for this overview. I'm excited to see the thinking in the U.S. shift over this issue, and now it's time to do the hard work of figuring out a solution. I've been digging into the various options and this is a great overview of both the challenges and possibilities.

  28. David Morgan says:

    This article reads like it was written by an association of doctors who are in medicine for the money. Throw up a fog bank between disaster and a too-long-waited-for revolution in health care delivery and "they" win. Don't fall for the very false hand wringing. It will take work and time to end the worst "market driven" strangle-hold in the history of this country. The free market is not the know-all-be-all of life. Some are addicted to that notion, but do you put all your faith in addicts? Universal health care. It's what's for life and healthy living

  29. John Dehoff says:

    One suggestion that has been floated is a Medicare at 55 option, allowing people in the 55-and-over group to enroll in Medicare This seems like the most practical first step, because the 55-to-64 age group is the most expensive group for the insurance companies to cover. Taking them out of the pool would lower the price of insuring everyone else, and in an ideal scenario, would lead to lower premiums and deductibles for the under-55 group. The article does not mention the problem of what to do about the health insurance industry and its thousands of employees. Eliminating this industry would certainly free up vast sums that could be applied to actual care rather than company profits, but imagine the fight to the death this attempt would spur. Relieving them of the most costly group might be welcomed. Then bit by bit, the age limit could be lowered.

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