Jared Bernstein is offering what he terms to be a compelling idea for offense. It is Medicare for All.
we should also aim higher, building off the compelling fact that other countries already provide universal or near-universal coverage to their citizens while spending about half of what we do as a share of GDP. Their approaches vary, but a common thread unites them: an increased role for the public sector, either as regulator, price-setter, insurer, provider, or some combination thereof….
How to get from where we are to Medicare for All is a huge challenge. Paul Starr recently suggested a smart, incremental step in the Prospect: “Midlife Medicare,” which extends the system to 50- to 64-year-olds without employer coverage. Demos strategist Vijay Das recommends expanding Medicare first to kids.
Here is what I’m struggling with as I read through this argument. Is Medicare for All a means to an end or an end in and of itself?
Medicare is a funky insurance product. It offers roughly 84% actuarial value for the elderly with a very bizarre and idiosyncratic benefit design. It has no catastrophic cap on exposure so a person with a million dollar claim will be at bankruptcy risk. It is disjointed and strange as it is currently built out. It also (mostly) works with the creation of a wrap-around supplemental buy-up market and Medicare Advantage.
The one great advantage Medicare has over most private insurance is that it uses its great buying power to drive down provider rates.
So here is my question that I struggle with. Medicare for All would be system transforming. It would provide near universal coverage for all while blowing up the current healthcare finance system as it is. That means provoking very powerful interests that have a current stake in holding the line with the ACA exchanges and Medicaid expansion. For a Democrat to do this is too invite the SEIU to go to war against the party. It is to invite every provider group to either be neutral or actively opposed. It is to invite mass failure or massive inefficiencies in the newly designed and highly disruptive system to buy out pre-existing stakeholders.
Now if the desired end in and of itself is merely universal coverage with Medicare for All as a plausible means to an end, that is a different story. We have demonstration cases already that near universal coverage can be achieved with stakeholder buy-in from Massachusetts, DC, Iowa and Hawaii. They all go about that near universal coverage in different ways but they work. Tweaks can be made to improve those experiences and increase coverage to 98% or 99% instead of 96% with a safety net of Medicaid presumptive eligibility for everyone who falls through the cracks. But we have local examples of templates that work with local stakeholder buy in already.
Yes, we will need to solve the fundamental Texas problem of their elites not giving a damn, but that problem is a constant for an evolutionary pathway and a disruptive pathway. Is Medicare for All an end in and of itself or merely a means to an end? For me, it is a means to an end. For others, it is an end in and of itself.
Baud
I think at bottom Medicare for All is a catchy and understandable label for people to latch onto.
Sab
I don’t understand this stuff, being a normal human being with an average brain not so great with numbers, but what about lowering the Medicare age so that 50 or 55 year olds could buy in, and let the youngsters fend for themselves in the Obamacare sort of free market. It seems to me that all us slightly below medicare age folks are seriously screwing up the market hence insurance rates.
rikyrah
I would like to see Medicare for All begin with the lowering of the age to 50. I think that could be transformative in itself.
Turn 50 – get that AARP card and enroll in Medicare.
Is there a reason that SCHIP doesn’t cover all kids? Is that why Das wants it expanded to children? Which children are left out of SCHIP?
Cermet
The system is a mess – i.e. exactly how the elite want it – money for them and confusion, fear and very high costs for us. Except for no insurance coverage, the next best thing …
Baud
@rikyrah: Good question.
Sab
@rikyrah: Wow. I am not following this stuff at all. Why are there kids not covered by SCHIP? I thought that was the whole point of it, to cover all kids?
Baud
Today just reported that the Freedom Caucus and the Administration have been negotiating on a new health care bill and there could be a bill in the next day or so.
jacy
I’m not sure the best way to frame it, or if it should be an end or a means to an end. I do know that the argument needs to ultimately shift to the belief that healthcare is a right and not a privilege. And healthcare needs to be unyoked from employment.
But I really think that’s where the crux of everything is. Most Republicans believe you have to do something to “deserve” healthcare, and usually that’s make enough money to purchase it. We need to shift to the idea that absolutely everyone has a right to a basic level of healthcare, and it’s just fundamental. The ACA shifted that needle a bit. Expanding Medicare (and Medicaid) shift the needle more. Then as it’s more and more accepted that everybody should have healthcare, we can improve the systems to deliver it. So I guess I just answered my own question — I think it’s a means to an end.
rikyrah
@jacy:
That is the fundamental difference between Dems and Republicans.
Democrats believe that healthcare is a right. And, we need to say it over and over and over. The only GOPer that has said it -is that Cassidy person. We should put the GOP on the defensive. Everytime on a panel with a Republican and healthcare comes up..
” I believe that healthcare is a right. Do you?” – put THEM on the defensive.
Kay
@rikyrah:
SCHIP was meant to cover kids whose parents made too much for Medicaid but didn’t have private health insurance.
Kids are maybe a good example of putting together single payer and private. Medicaid, SCHIP and private health insurance. It’s a big success over the last 20 years. Many, many more kids are covered.
I don’t know why it isn’t talked about more as a big success- why Democrats don’t promote it more. They’re almost solely responsible for it.
Kay
Why don’t we use kids coverage as an example, David? It was quieter and more gradual but eventually most of them got covered.
Xantar
@rikyrah:
SCHIP has an income limit. It’s pretty generous by Medicaid standards, but it’s still not universal.
rikyrah
@Kay:
So, Kay, who are the 7%?
David ?Canadian Anchor Baby? Koch
@Kay:
I remember when this happened – pretty big fucking deal. $60 FUCKING BILLION within 14 days of office. 4 million new enrollees!
But “liberals” didn’t want to talk about it cuz Barry sold us old by not arresting Bush and Cheney.
Baud
@Kay:
@Kay:
Wasn’t the decline in the overall adult uninsured rate even faster under Obamacare? And you see how difficult it has been to get people to appreciate it.
jacy
@rikyrah:
Cassidy is one my state senators. I think one of the things that has informed him is dealing with the healthcare problems in Louisiana. We had Jindal, who screwed everybody in every way he could, and held up Medicaid expansion, which hurt a ton of people. Then there was at least on state insurer that came in with the ACA and tried to cover people with catastrophic plans — but there were so many people who had been so sick for so long without any insurance who could now at least afford to buy in that they went belly-up pretty quickly, because there was a rush to get medical care for a lot of expensive and chronic conditions. Now you have John Bel Edwards, the Democratic governor, who immediately expanded Medicare, and covers thousands upon thousands of people. It has been quite a shock to the system here, and has changed a lot of people’s attitudes about healthcare, and specifically about poor and rural medicine. I don’t know what’s in Cassidy’s heart — but I do know that he’s what you get when you give a vast, poor, Southern electorate access to something they didn’t know they could have. They suddenly don’t want it to go away again……
Kay
@Baud:
Right, but kids are an emotional issue. Take the stories you heard about uninsured adults and apply them to children and it’s a much different narrative. That’s why Pelosi was able to hammer Bush and Republicans so effectively over blocking SCHIP expansion.
It’s weird how successful government programs don’t get talked about. It’s huge for public health that kids are covered! It affects their whole adult lives.
Democrats need a public programs PR team :)
Baud
@Kay:
Hatred of Democrats > Love for children.
germy
New York Magazine
OzarkHillbilly
@Cermet: I have a permanent rotating account with our local small hospital. Every time I think I’m just about to pay it off, I get hit with another charge and I have no idea what it’s for. I always owe it, it’s just from a procedure I had months or even as much as year before and have all but forgotten about. Happened again yesterday, for something that was done last June.
AnonPhenom
Medicare expansion must be introduced as an adjunct to our current ‘system’.
– as a public option in regions where there are only x (1?, 2?..) commercial plans to choose from
– as a public option for individual over 50 (55?)
– for young adults without other options
etc..
Once it’s been expanded, keep finding more excuses to expand it and reduce subsidies to the commercial plans. Cause them to whither on the vine.
What?
It’s how Republicans do things (see; USPS)
Revrick
I have fought this battle a number of times on Facebook, particularly with those of the more Bernieish persuasion, who are adamant that Medicare for All is an end in itself. They seem to refuse to accept the fact that there are other, less disruptive, means to the end of universal coverage. They seem absolutely sure that every other nation with universal coverage does so with government funding, period, end of discussion. Then,too, many seem invested in the idea that insurance companies and their employees are, by definition, evil.
Rational discussion becomes difficult, to say the least. It has become an article of faith. Blindingly so.
jacy
@Kay:
Democrats need to stop apologizing for having better ideas. We all need to flatly state what we believe in and not back down. I think the window for compromise on ideas is currently closed, because the other side are monsters. You can’t compromise with monsters. Healthcare is a right. Democratic ideas help people, while Republican ideas hurt people. People need to keep telling their stories as loudly as they can and as often as they can.
Hal
Anyone know the best way to find health insurance for a mother and 11 month old in South Carolina? Family friend is currently looking.
germy
@OzarkHillbilly:
Baud
@germy: Oddly enough, Bernie doesn’t support the Conyers bill.
germy
@Baud: Has he given a reason why not? I’m curious.
Does he call it a neoliberal giveaway to Big Medicare?
Kay
@Baud:
That might be a good way to go after Trumpcare. If the Medicaid cuts threaten children’s health coverage, focus there.
“A huge step backward. Millions of children newly uninsured”. You know they didn’t read the fucking thing and don’t understand downstream consequences. I’m sure it threatens children’s health care in some manner. Pelosi was one of the leaders on children’s health care and she’s still there. Kennedy was the other.
The lower/middle income parents I see never care if they’re covered- they’re young- they care a lot if their children are covered. Trump has no idea how these elaborate layered programs work. Make him defend Trumpcare – just throw every possible scenario at him and watch him try to bullshit his way through it.
rikyrah
Um…where’s the Morning Thread?
OzarkHillbilly
@Hal: Move to Massachusetts.
(sorry, just couldn’t pass it up)
David ?Canadian Anchor Baby? Koch
@Baud: it’s not single payah!
Another Scott
@Hal: I would assume starting here is a good place:
http://www.doi.sc.gov/798/Affordable-Care-Act
Good luck!
Cheers,
Scott.
rikyrah
@Baud:
I’m curious too. How come?
Cermet
@jacy: LOL; sorry but the bedrock belief of all so-called conservatives is
with a big period afterwards.
As for the elite,
Revrick
@jacy: I think you have touched on one of the difficulties in this discussion when you say we need to use the language that health care is a right.
For me, rights language is often weak tea. I much prefer the more substantive language of justice which incorporates both equality and freedom.
OzarkHillbilly
@germy: Amen to that.
Another Scott
Richard and all,
I agree that too many people think that everything is simple with Medicare for All. They either don’t know anyone on Medicare and don’t know the issues, or they’re simply overcome with wanting a simple solution.
Medicare doesn’t cover everything that people need. Lots of physicians don’t take Medicare. And there are the issues of potentially blowing up the existing insurance and healthcare system and making new enemies as well.
Incremental progress is the way to fix complicated systems. Yes, expand Medicare access, and yes expand Medicare coverage. But do it incrementally and cover the most important problems first. Don’t let bumper sticker slogans determine policy and the way forward. (Similarly with SCHIP, mental health access and coverage, drug treatment access and coverage, public health access and coverage, and all the rest.)
Cheers,
Scott.
Kay
@rikyrah:
Half of the 7% are people who are eligible but don’t know they’re eligible. Interestingly, child support plays a huge role in this. If you enroll in child support they conduct a health insurance review because states added “medical support” to child support under Bush. If you’re under 150% of poverty you automatically qualify in Ohio and are enrolled. It was a huge deal at the time and people predicted all kinds of dire consequences – “chaos!” “people will be OUTRAGED at this heavy-handed government role!” but… nothing happened. It started and no one paid any attention and now it’s a given.
Baud
@rikyrah: I’m going to go with, because it’s the Conyers bill and not the Sanders bill. But that’s just a guess.
Cermet
@OzarkHillbilly: Insane; this is just using a system to bleed people like you. I once paid a large hospital bill and they, rejected it because …never did understand why. Six months later, they billed me again. I wrote them that I paid it but that they had declined the payment so I was no longer responsible for the bill. Never heard from them again nor did it appear in a collection or on my credit rating. Really was strange (frankly, I did expect to pay them but thought my letter was fair turn about – never dreamed they’s agree …just too weird. Always felt guilty that I was unfairly allowed to avoid payment …sick how we are trained to feel this way while rich people do it all the time with no remorse; guess that is why they are rich!)
Taylor
@Kay:
Maybe it has something to do with the crucial role played by a woman in getting the original legislation passed.
A woman whose last name is
RodhamClinton.germy
@Another Scott:
That needs to be against the law. That should be illegal.
TriassicSands
@Baud:
It is, but it carries the implication that Medicare is a good model for providing universal coverage. It’s not. Anyone on Medicare who can afford it has a supplemental policy to make up for the fact that Medicare is an 80/20 policy that leaves people liable for potentially crippling financial charges. No universal system should make it possible for patients to face medical bankruptcy.
Medicare for All is only a starting point. Its other huge failing is that Medicare allows for-profit insurance companies to offer policies — something that is definitely not part of a workable universal health care system.
I’m on Medicare and I don’t want Medicare for All to be the system we adopt for universal coverage. Other countries have moved to universal coverage in a relatively abrupt change without causing major problems. Our problem is the same problem that elected Trump — we have way too many stupid people. They’re going to be swayed by every bogus argument the Right can raise — OMG a mandate!!! Panic. Riots in the streets. So, Democrats, if we ever want to have a worthwhile universal health care system are going to have to design it in advance, work out as many of the kinks as possible through modeling (or any other means that would help), and prepare a carefully thought out PR program that will be ready to go. It will need to have effective slogans as well as simple explanations for how the system will work and responses to every conceivable complaint or criticism. Only in the US is this an almost impossible task, and that’s because we are neck deep in bogus ideological theories and objections, stupid voters, and we have a major political party that will oppose even a perfect system if it involves the government.
Oh, and Medicare’s Part D prescription medication plan is even worse that Medicare parts A and B.
Chyron HR
@rikyrah:
The charitable explanation is that he doesn’t want to be part of any revolution that he isn’t leading.
The uncharitable explanation is racism.
Kay
I don’t care if it’s Medicare for all but Obamacare has problems on affordability and that has to be fixed. I know a guy who is a loyal Democrat, an “Obamabot” and he has Ocare and it’s just too expensive for him. I feel like 9% of income as the peg was too high. I know it came from conservative Democrats in the Senate but it’s too high. Ohio’s child support number for % of income to health insurance is 5%. 5% is more reasonable and seems to work.
Baud
@Taylor: good point.
Baud
@Kay:
Neoliberal
We lost the battle when the message that Obamacare had to be perfect at its inception or it’s a failure became conventional wisdom. No major program has ever met that test.
gene108
@AnonPhenom:
This is why stuff like SCHIP does not get celebrated more. The goal of many on the Left is the destruction of the health insurance industry.
Only that which can destroy Cigna, BCBS, Aetna, etc is worthy of praise.
Everything else is a sell out.
Plus, how is eliminating subsidies going to impact the employer based group market, wherein most folks, not on Medicare, get their insurance? Hint, employers don’t get subsidies for providing insurance. The impact would be minimal there.
If you really want to kill the health insurance industry, you need to decouple insurance from employment.
OzarkHillbilly
@Cermet: In truth, this particular medical group has forgiven a # of bills of mine, that I had set up payment plans for, without my ever asking for any kind of financial assistance. Just “Poof!” gone. I actually complained about it. I felt like I have the ability to pay, I just need time. Give the aid to somebody who really does need it.
The issue I am having is due to the fact that they don’t bill me until the insurance company pays their end and that seems to take forever. It’s just really frustrating for someone like me who has multiple issues. I am always waiting for the other shoe to drop, I know it’s coming but I have no idea when or where from.
gene108
@Kay:
I think the affordability issue comes down to paying for more subsidies. I am not sure Democrats were able to get buy ins for the higher taxes needed to fund more generous benefits.
gene108
@Revrick:
We can always try to modify FDR’s Four Freedoms. Take the word Freedom back. The Right abuses it.
AnonPhenom
@gene108:
You saying that like it’s a ‘bad’ thing?
My own background includes employment (Director Pharmacy Services) with an Insurance provider. I’m confident I’m on solid ground here.
gene108
@AnonPhenom:
How have Germany, Switzerland, France, etc achieved universal coverage through private insurance providers?
There are ways to get universal coverage, with private insurance.
The draw back is everyone involved in the healthcare sector will have to take a pay cut, as drugs, services, insurance premiums, etc get more tightly regulated and prices more controlled.
Edit: The drawback is it will be disruptive to the economy, if we follow the tightly regulated European model.
Central Planning
@OzarkHillbilly: My insurance company (UHC) says that you don’t have to pay anything if it takes them >6 months to bill you.
ObDisclaimer: IANAL, check with your lawyer, not valid in Ozarks, etc.
Ohio Mom
@germy: Same is true of Medicaid, it can be hard to find a doc who will take it — I’m under the impression that some practices have a limit on how many Medicaid patients they want on their rolls.
On another note, one little corner of single-payer that escapes notice is dialysis. I’ve always been curious about the history of this. I’m told that no insurance company would take on this group so the federal government stepped in. But I can’t help wondering if the start of this wasn’t that there wasn’t a specific Republican congressperson with a relative worh kidney disease.
El Caganer
@Baud: Wouldn’t Sanders have kind of a tough time introducing a bill into the House? I mean, considering that he’s a Senator and all.
OzarkHillbilly
@Central Planning: My insurance company says they don’t have to pay anything if it takes the provider >6 months to bill them. My provider says I am on the gig for the entire amount then. Hasn’t happened yet, when it does there will be a fight, don’t know if I will win it.
Thoroughly Pizzled
Weird that nobody on the left talks about single-provider, which would go much further than single-payer. It’s flat out impossible to pull off here, but that hasn’t stopped people before.
liberal
@Thoroughly Pizzled: amen.
A rational health care system would involve both single payer and single provider, like the British NHS.
satby
@Ohio Mom: the optometrist I work for applied to be a provider under the Indiana Medicaid system months ago. Still waiting. I think a lot more doctors would take Medicaid if they could get approved as providers, the bottleneck seems to be in that approval process.
gvg
People do think insurance companies are evil. There is some validity to this view and I hear this from former insurance employees with lots of examples. Of course I think it was worse in a life or death sense before health insurance existed but the results haven’t really been what we want. The thing that always gets me is if you have a serious illness, you are not energetic nor are you mentally agile, especially if you are also older or taking drugs which dull pain but affect your mind. At that point, you cannot be spending hours on the phone over and over dealing with rules you don’t understand because you haven’t been trained in it. People want to pay regular fees and go to doctors and have no mysterious bills and denials of treatment. their are quack treatments that should be denied for that reason but basically they just want to feel better without being tortured and mentally if may be impossible for them to jump through too many hoops. single payer or provider, whatever, people don’t care what it’s called, I think that is what they want. We shouldn’t need a degree in health insurance to get it.
Sam Dobermann
Medicare fot all is dumb and unworkable. It’s a single person policy so couple would pay 2 premiums.plus they wiuld need separate coverage for prescriptions and to cover the 20% copay.
People who want this show they don’t understand the systems.
Best way is to expand Medicaid gradually — to 200% poverty level to start then ease up. And increase the pay to most important primary care providers and rest as in ACA.
I will explain more later including reducing cost of HC.
By the way Medicare covers 95% of seniors after many years.Under the ACA about 90% are covered ( all though it would be higher If Medicaid expansion in all states). Pretty good going for new program with much opposition and denigration.
Thoroughly Pizzled
@liberal: I suppose we could reinstate the draft and put everyone on the V.A. Might be the simplest way.
Ruckus
As an old, I’ve looked at Medicare pretty closely. What it is, is better than what olds had, which was effectively nothing. It costs monthly out of your SS payment, it has normally a 20ish% copay, and if you have any issues at all you will most likely have to pay full pop for at least part of the year for medication. So you are still at the mercy of the HCI industry and have to have a Medicare Advantage policy to have any hope. If you are fully vested in SS and have a decent pension or savings to live off of it isn’t horrible. If you lost everything in the recession or never had a lot, it sucks. Once again, not near as bad as nothing but it still actually sucks.
@Thoroughly Pizzled:
The VA is overloaded as it is, given the budget that congress gives it. The only way the VA could possibly work is if every non VA hospital and doctor and nurse was nationalized and became providers, universal care IOW. And congress would still under fund it.
Ohio Mom
@satby: Medicaid varies a lot state by state since each state administers it a little differently. I wonder if some states make it more appealing for doctors and some less appealing?
At any rate, good on your boss for wanting to serve Medicaid patients.
It’s always on the back of my mind that while right now my kid is on my husband’s insurance with his Medicaid Waiver as the secondary insurer, one day it will probably be Medicaid only (unless he gets a job that comes with health insurance).
I’ve heard from other special needs parents that finding medical providers can be a challenge. Especially since our adult children have, um, special needs in additional to being under Medicaid with its skimpy payments.
Central Planning
@OzarkHillbilly: Yeah, I think you’re right. The insurance company might fight on your behalf though. I almost made it 6 months without getting a bill – something like a week before the deadline it showed up :/
Sunny Raines
The great thing about republican climate change denial is pretty soon no one need give a crap about healthcare.
Ohio Mom
@Thoroughly Pizzled: LOL. Except that not every veteran is eligible. That’s all I know, this isn’t my balliwick. Maybe someone else can chime in…
Sam Dobermann
.@Thoroughly Pizzled: k@Thoroughly Pizzled: single providers are what the ACA calls a medical home. A primary care doctor who will refer you to an appropriate specialists if needed. Frequently these primary care docters and CNPs can handle. most thongs themselves.
By the way, full brit style system is what our VA is.
Barbara
I knew this thread would get a lot of comments. People don’t understand Medicare. They don’t understand its weaknesses.
What people like about Medicare is its “thereness.” You have it no matter what. That’s what it’s like in other countries. You just show the card and questions about insurance cease. That is a combination of eligibility plus the government’s ability to impose rules that private payers cannot by themselves. These include limits on balance billing and a significant weighting against providers for performing noncovered services without notice to the beneficiary (called the ABN rules).
What people who are not covered by Medicare don’t see, often enough: fragmentation, unlimited cost sharing, incentives to overutilize care for people who are unlikely to question the need for procedures, the need to get supplemental coverage and a separate prescription drug plan, both at additional cost, what seems like incessant arbitraging of reimbursement rules by providers to extract money from the system regardless of benefit to patient, and, importantly, almost no push back by the payer (Medicare program) to rein in these tactics.
It is my humble opinion that the structure and framework of the Medicare program as a free for all is pretty much directly responsible for runaway health care inflation in the U.S. Yes, the government is a power buyer, but the expectation among beneficiaries that they can get basically unlimited services that now outstrip the amount they paid into the program by a margin of 3 to 1 has inured all of us to the notion of cost benefit when it comes to medical care. And the rest of us that have private insurance are covered by entities that are not power buyers, who are stuck dealing with providers that pretty clearly cost shift whatever they don’t get out of Medicare to the rest of us, and then some.
I think a version of Medicaid for all with added dental and vision coverage at least through age 18 as a default would be better. This is not a popular view.
Rob in CT
RE: destroying insurance industry, bear in mind that Medicare for all is still insurance. You’d still have an insurer, and sometimes that insurer wouldn’t pay. And while that insurer would not have a profit motive, sometimes Republicans would be in charge of it and want to cut it or otherwise screw with it.
Also, note that in order for us to see the cost savings Medicare for All can bring (spending more like 12-14% of GDP on healthcare rather than 18-19% now), we’d have to use it like a hammer to cram down on providers. Doctors. Hospitals. Nursing homes & other outpatient facilities. Medical device manufacturers. Pharma. All of them. Those groups of people are not without political power. They’ll fight.
I’m not opposed to the concept, and I absolutely see the benefit in simplicity (both in political messaging and in terms of how it would function for patients, once we had it up & running). But if you project too much of your own fantasies into something like this, the reality once implemented will disappoint. Like, you know…
satby
@Ohio Mom: as far as I know, my foster son hasn’t been eligible, in spite of being a vet with 5 combat tours in Afghanistan and Iraq. He has PTSD and is mostly deaf in one ear from firing his gun, had some minor discipline problems when he got back that busted him down in rank before he discharged (stuff like getting caught driving on the base where he and his family lived after he was restricted, nothing major). He was discharged with a general, and not eligible for a number of benefits as a result. They did that to a lot of kids that saw combat during Bush the lessor’s years. Helped keep those expenditures down.
Barbara
@Rob in CT: Bear in mind that nearly every Medicare beneficiary purchases private insurance in one form or another: Fully 40% of beneficiaries who are not eligible for Medicaid or employer provided retiree health coverage purchase Medicare Advantage, which is Medicare Part A and B funneled through private payers (who submit bids and are regulated by CMS). Of the remaining beneficiaries, a high percentage that varies by locality purchase private supplemental coverage and Part D coverage (also a contract between private payer and government).
Around 20% of people over 65 still have retiree health coverage, typically provided through private insurers. This area is declining rapidly for private employers, and even for public employers, which now account for the lion’s share of such benefit plans. Think CalPERS.
Medicare FFS is administered by private insurers. The government has always relied on private insurers to administer the Medicare program, from day one of its existence. A lot of people who are not close to it really don’t understand Medicare.
Ohio Mom
@satby: That’s an enraging story about your foster son.
@Barbara: I think you are onto something re: the “Thereness.”
To those of us still too young to know much about how Medicare really works (this thread is giving me a taste, and not a great one), the idea that you don’t have to do anything special to qualify (except live to the eligibility age), and that it can’t be taken away — well, that sounds quite heavenly.
Ruckus
@Ohio Mom:
There are very few vets that aren’t eligible. One needs to have an honorable or general discharge, a minimum time in service, and a few lessor issues. Then your income determines if you have copays and how much they will be. People with purple hearts (wounded) or medal of honor winners, POWs, people who served in a war zone, pay less or no copays no matter their income. I think now everyone pays some copay for meds. A doc can order any relevant testing or treatment, as long as it is VA provided and some that aren’t.
Barbara
@Ohio Mom: The thing is, “thereness” is an important, maybe even a vital, component of security. As a child, knowing that your parents are always there confers a considerable advantage in emotional stability throughout your entire life. Knowing that you are entitled to some level of care is actually a compelling feature of a social entitlement program. But thereness can be achieved through means other than Medicare. I would actually start by looking at Medicaid in a state like California that has commitment to the program, to determine benefit structure. I would also look at how Maryland pays for hospital care (the all payer rate regulation that does not allow hospitals to cost shift between payer types).
Most Medicaid programs also rely on private insurers. What insurers do is bring more management of health care benefits, for ill or for good. But Medicare and Medicaid are seriously fragmented without this approach. I saw this with my mother in law, who had FFS Medicare, whose final deterioration was caused by being discharged from a hospital after minor surgery with instructions that basically overdosed her on insulin, and no one in a position to evaluate what was going on. My mother, who is in an MA plan, had much more effectively coordinated care when she had a hip replacement. So the question is, how do you leverage what insurers do better than the government program, while tamping down their incentive to unreasonably deny care?
Ohio Mom
@Barbara: I also think you are on to something with the idea of expanding Medicaid, especially for kids. And I know from my own family’s history how fragmentation adds stress and decreases overall quality of care.
You do have to wonder what the lack of “thereness” for medical care does to our collective psyche as a nation. There has to be underlying anxiety that most are not aware of (like the proverbial fish does not know it is in water), that distorts all of our thinking and feeling. When you are not thinking straight it is hard to take sensible actions.
amygdala
@germy: In some states, Medicaid reimbursement rates are pennies on the dollar and combined with more than the usual administrative burden. Practices can lose money on every single Medicaid patient seen.
@Ohio Mom: Medicare reimburses fairly well, especially compared to Medicaid. But yeah, there are parts of the country where Medicare patients can have a hard time accessing some kinds of specialty care. A good friend was able to stay with her urologist when his group decided not to take new Medicare patients any more because she was a continuity patient of the group. She has complex problems requiring ongoing care and he’s taken great care of her. And she’s not in some remote or impoverished part of the country; she lives in suburban Denver.
@satby: I’m so sorry to hear about this. It’s outrageous. Anecdata, certainly, but I hear similar stories from several friends who are VA docs. It’s astonishing what isn’t considered service-connected. How is PTSD or the effects of polytrauma, which happened in Iraq or Afghanistan, not service-connected?! Or maybe not so astonishing, since, unlike cutting the VA budget, sharply restricting eligibility easily stays under the radar.
chopper
@germy:
because it isn’t his bill. the only single payer bill he’ll vote for has to have his name all over it.
Ohio Mom
@amygdala: I don’t imagine that too many people go into medicine because they want to be ruthless businesspeople but the overall system often seems to force practitioners in that direction.
David Anderson
@Barbara: @Rob in CT: I am highlighting both of these comments for tomorrow.
amygdala
@Ohio Mom: @Ohio Mom: Some do, and I think they’re the ones who are grumpiest about the ACA. It’s changing, though. Younger physicians increasingly favor salaried positions.
DHD
@Barbara: Perhaps I missed your point, but if the “expectation among beneficiaries that they can get basically unlimited services that now outstrip the amount they paid into the program” in Medicare were really the problem with the cost of healthcare in the USA, then why don’t we see the same explosion of costs in other countries where coverage is truly universal, government-funded, and unlimited (e.g. Denmark, Canada, Taiwan, UK, etc, etc, etc)? The “notion of cost benefit when it comes to medical care” is in my mind a slippery slope that leads to “free market solutions” like HSAs, etc. It’s not the responsibility of the patient to have to make decisions about the cost/benefit trade-off of every given test, procedure, etc. And since Medicare has unlimited cost sharing, it isn’t like people are insulated from costs anyway…
There is definitely a case to be made for introducing limited cost sharing into a universal system (this is illegal in Canada and the UK, but done in Sweden, for instance). But there is no clear evidence from what I’ve seen that it has a major influence in reducing costs or improving accessibility (except insofar as it prevents poor people from going to the doctor…). Australia seems to have an ongoing debate over this which is interesting reading.
Looking outside the USA, it doesn’t seem to me that the “problems” with Medicare are really out of line with what people experience elsewhere. The French system is pretty close to Medicare-for-all (it covers like 75% of costs and people have to get supplemental insurance) and it consistently ranks near the top of the list for quality and accessibility. Canada’s system, which I would not hold up as a model for accessibility, but which provides good quality care to everybody at low cost, is extremely “wacky” in its own way, with 100% coverage of a somewhat arbitrary basket of “medically necessary services” and 0% of everything else, for a total coverage of around 70%.
It also seems that there is really no alternative to “fragmentation” given that the USA is 300 million people living in a huge and wildly diverse country, which, for better or worse, has some kind of cultural allergy to effective government regulation…
low-tech cyclist
I spend a great deal of time under another handle on a message board that will remain nameless here, and one of the people there is a wonk at a health care advocacy nonprofit. When I mentioned Medicare For All a week or so ago, she brought up some of these same issues, as well as saying some of the same things Barbara and Triassic Sands have said upthread. Though I think highly of this person, it’s good to get confirmation from another person who knows this stuff and whose opinion I deeply respect.
NR
@Baud:
Source?
Barbara
@DHD: I know this is a hard thing to convey. There are at least three reasons for the lower health care cost as a percentage of GDP in other countries. The first is simple, that per unit cost of items and services is lower. Health care providers of every kind make less for their services (there are exceptions but overall this is true).
Second, they are not as generous and apply utilization controls. These tend to be high level. The NHS is more notorious than most, but the reality is that “extreme care” at all levels is less common. At the beginning and end of life as well as in between.
Third, people are not protected from cost benefit analyses in that they really do pay for care — in higher taxes, for instance. Americans with insurance are usually well-insulated from what their health care actually costs, not just in Medicare but in private plans that have incredibly generous tax treatment and that are mostly subsidized by employers. People who buy COBRA coverage are stunned at how much it costs. Being protected from understanding the real cost forestalls any real debate and reinforces the desire to pretend that it is possible to have everything for less money. On a per unit basis, this might be true. On a utilization basis, it almost certainly is not. Along the same lines, there is a lot of misunderstanding here by single payer proponents of how generous other countries actually are, or how in most of these countries people actually do rely quite a bit on private insurance to supplement the public plan (sort of like Medicare Supplement).
Finally, probably somewhat unique to America, we have come to see medicine as a stand in for health in ways that perhaps does not exist in other countries. People who are overweight or have lifestyle disease look to medicine for answers, but the reality is, what you spent on a doctor’s appointment might have been better spent on a gym membership. At a macro level, amounts now spent on health care probably would get a greater return if they subsidized green space and walkable communities.
Barbara
@NR: He introduced his own and is not a co-sponsor of Conyers.
Singular
@Barbara: It seems to me you really have no clue about the NHS, apart from what you have been told by media trying to talk it down. “more notorious than most” because NICE wont pay £100,000 and a pharma CEO’s retirement for prolonging life for a year?
My mother is 79. She has had oesophageal cancer for nearly five years. I think we are entering the end stages now, but the notorious NHS are continuing to treat her. My mum worked a checkout and my dad was a fireman. Anyone in the states without cast iron coverage, or a lot of money, would be selling their house several times over by now.
I get it. You cover the people who can afford it and let everyone else suffer. Do not think this makes you a level-headed realist. Start providing healthcare for your citizens. Stop furthering wonk bullshit talking points, designed to deny you what should be a universal right.
ruckus
@Barbara:
This is good, as a seemingly large segment of the US doesn’t seem to have any idea that there is more of the world than what they can see from their front porch or that it might be in any way different than what they think they know. And moreover, they don’t care.
Singular
Absolute nonsense. Nobody I know, nobody’s parents I know in the UK, have paid a single fucking penny for anything apart from dental, their whole lives. Including scans, chemo, tailored drugs, month long stays in hospital.
Paula
@jacy: Good response!
NR
@Barbara:
Maybe this is because he’s a Senator and the Conyers bill is a House bill?
Nah, couldn’t be. Never mind. Back to your regularly-scheduled circlejerk about how Bernie Sanders is an egomaniac and a racist.
Barbara
@NR: Okay, then, his bill is materially different from the Conyers bill in a way that does not lend itself to reconciliation between the two. You’re the one who called Sanders and egomaniac and a racist. No one likes words being put into their mouth.
Barbara
@Singular: Well there you go. Your friends obviously define the universe. The reality is that many people in the UK buy private insurance to obtain more benefits or more choices than are provided by the NHS. I actually think that there are many ways to get to universal coverage and the UK has one of them. I think most people in the UK staunchly support the NHS, but it is clear that the NHS makes hard decisions that we are not used to in the United States and that would be an obstacle to introducing an NHS type system here. There is no use in denying reality.
Singular
Well, I don’t think that, but as a 43 year old Scotsman who has had ample contact with the NHS, I think that my opinion on the level of treatment counts for at least as much as yours. Reports from 2014 indicate that 7-11% of the population have some kind of private insurance. Of course, this means that (if we accept those figures) 89-93% of the population are covered via their NI payments.
The number of private policy holders in the UK has been falling continuously for over a decade. I was in the Glasgow Royal Infirmary yesterday (and that’s an old hospital – unlike the new Southern with the robot porters and feng shui). I didn’t see the consequences of any “hard choices”. I saw spotlessly clean rooms, dedicated staff and excellent care. All paid for by tax pounds, the 11% that everyone doesn’t seem to give that much of a shit about paying, apart from you.
Mnemosyne
@Singular:
I think you’re misunderstanding what Barbara is saying — in the US, people are accustomed to paying that much or more for end-of-life care. We are the proverbial “penny wise and pound foolish” society that prefers to pay for dramatic life-preserving surgeries rather than the boring everyday care that might have prevented the surgery in the first place.
NR
@Barbara:
I was referencing this comment here.
As for the differences between the bills, they have the same goal, they only differ in their methods (a national program vs. state programs that are regulated nationally). I don’t see how those are irreconcilable differences. And I don’t see how a substantive policy disagreement is evidence of egomania and racism on Sanders’s part as commenters here have accused him of.
Singular
@Mnemosyne: I know healthcare in the US is such a fucked up thing. But it must be getting to the stage it’s such an obvious grift, people are making fortunes from death and suffering. The richest and most powerful nation in the world, cannot provide healthcare for its citizens, because rich people can’t be arsed paying a few dollars extra? Okay, nobody will voluntarily pay more taxes, but the sheer con in progress, the daylight robbery, the short-term thinking.
limousine liberal
I was always for single-payer because I’m a bleeding heart liberal. Now I’m in my 40s and make a lot of money and I’m pissed off that health care costs so damned much in America. Doctors makes too much money, drugs costs too much, tests costs too much, everything is way overpriced compared to every other rich country. You look up the stats and basically everything costs at least twice as much as it should. Even when you can afford it, it stinks because you’re getting gouged at every level. I want single-payer because it’s the only way to fight back against the medical industry. My family is paying $18,000 a year for insurance that has a $6,000 deductible. Taking a sick baby with a high fever to the emergency room cost me $600 and that’s with insurance. Instead of paying an insane amount for insurance for my family I’d rather pay taxes that could pay for two families.
Barbara
@NR: Please point to where I used the term egomaniac. Stop arguing with yourself. It’s silly.
Barbara
@Singular: You know Singular, I don’t know how you could possibly read what I have written and respond with the kind of comments that you have. NHS makes hard choices. It appears that most people in Britain are overall satisfied with those choices. If your take is that anyone who doesn’t advocate adopting NHS style reforms in the U.S. obviously hates and/or misunderstands the NHS, well, that’s a big chip on your shoulder not mine, and it is one that is not worth pursuing as far as I am concerned.
Barbara
@Mnemosyne: I don’t even know that I would say that we prefer this way of doing things. It is just that is how things have evolved and most people don’t have enough interaction with the health care system to know how to extract a different outcome. My in-laws and my father all died at home and it took quite a bit of discipline on the part of our respective families to make sure that was the case, so that they were not subjected to futile and expensive end of life care. But we did it. IMO, the hardest part about end of life decisions is feeling secure that this is in fact the end of life. Once you accept that the downward spiral cannot be reversed in any meaningful way, people can let go.
Barbara
@limousine liberal: I think people have to accept that there is no perfect solution, but it is clear that we pay way too much. As someone who has been working in a related field for a long time, I have come across examples of things that could provide a viable path forward but without consensus there is almost no point in trying. Ugh.
Juice Box
@germy: I don’t remember the exact number, but around 5% of physicians don’t take Medicare. It’s mostly a problem in isolated, wealthy pockets; Santa Barbara, Aspen, Santa Fe, etc. My parents lived in Santa Fe for a few years and had no trouble finding primary care docs who accepted Medicare, but they had to drive to Albuquerque to see a dermatologist who took Medicare.
Most private insurance contracts are written as a percent of Medicare reimbursement, usually 110-115% or so. Medicare compensates by paying promptly and without requiring a lot of expensive bill processing.
quakerinabasement
Lost me right there.
Barbara
@Juice Box: One of the biggest problems with Medicare, with a huge echo effect for private payers, is the way Medicare determines how to pay physicians. I won’t go into it in detail, but the bottom line is that Medicare grossly underpays primary care physicians compared to specialists. That is one reason why PCPs make so many referrals to specialists. This has enormous effects on everything from the percentage of doctors willing to go into primary care (way down), the willingness of doctors to work on behalf of hospitals (way up), the increasing percentage of doctors who are specialists and feel the need to do procedures that are highly priced and valued by the Medicare program, etc.
David Anderson
@quakerinabasement: Medicare Supplemental plans that buy up the actuarial value of a Medicare FFS policy. Those are wicked common and they provide both a catastrophic cap and lower out of pocket limits
Singular
@Barbara:
My point, the same point as I was trying to make several comments ago, is that “there is a lot of misunderstanding here by single payer proponents of how generous other countries actually are”. Yes, there is quite a lot of misunderstanding, and I feel that you are contributing to that. You completely do not understand how generous other countries’ healthcare systems are, and are possibly wilfully exaggerating the role of private supplements.
But yes, this exchange isn’t going anywhere. Peace.
NR
@Barbara: I linked you to the comment where someone called him that. All you have to do is click the link.
Barbara
@NR: Not me.
Barbara
@Singular: It is not magic. They pay less per unit and they consume fewer units and control what I call extreme care. I think most are doing better than we are but there is no point in pretending that if we were to use one of those approaches that it won’t be a change.
Ohio Mom
@amygdala: Wouldn’t it be easier to go into business proper if you wanted to be a ruthless businessperson? You’d get to skip all the grueling parts of medical training for one thing.
Sam Dobermann
@Ohio Mom: People can say yea of nay to a business product or service but have have little chance to refuse to do what the doctor says or take what the doctor says to take. Plus the medical professionals are more protected from their gross negligence than any other profession or business.
stonetools
Here is what I think
1) While there is a consensus for fixing the ACA, I don’t think there is a consensus for Medicare for All, which would be a major retooling of the current system
2) Most leftists pushing Medicare for All seem to see it as puppies & rainbows, with no downside and no disruptions
3) I suspect that the biggest proponent of Medicare for All, Bernie Sanders, has no fricking idea of how to carry it out, just like he had no idea of how to break up the big banks.
4) Any move to Medicare for All is going to bring out huge opposition from folks like the Chamber of Commerce, private insurers, heath care providers, and Big Pharma , who would not oppose or even support fixing the ACA
For those reasons, I think the unified Democratic message going forward should be “We are the party that can fix the ACA”. We should ally that with a simple 5 point plan for fixing the ACA ( there are a few floating around). Keep it simple, keep it unified , and let’s go into the 2018 elections with a mission to kick out the Republicans who have shown that they want to wreck HCR, not fix it or make it better
stonetools
@Barbara:
Yet another problem in talking about single payer and Medicare for All is that a lot of folk assume that there is only one way of doing single payer. As the different Conyer and Sanders bills make clear, that is not the case.
A look at this Wikipedia article shows that there were three different single payer bills introduced in 1970. Note all three failed to move forward.