Zack Buck at the Harvard Petrie Flom Center’s blog raises an interesting argument about the Biden Administration’s health care plans:
Though health policy debates during the 2020 presidential primaries centered around expanding access to public health insurance programs (e.g., “Medicare-for-All”), the focus of the nascent Biden administration has been on making private health insurance more durable, not deconstructing it.
While these changes are likely to make private insurance plans more affordable and attainable, choosing to reinforce private insurance plans puts global systemic reform, the goal of many advocates, further out of reach.
But changing tax subsidy formulae and income cliffs is highly specific, individualized, and detail-oriented. While the changes are welcome, they may fail to address the deep, structural causes of America’s health care cost crisis, like hospital and prescription drug prices, saturated marketplaces, and inefficient and fragmented payment structures. Those challenges remain.
In some ways, I completely agree with his argument. The Biden Administration’s current accomplishments and ongoing priorities are “individualized, and detail-oriented” and do not “address the deep structural causes of America’s health care cost crisis….” And at the same time, I am completely underwhelmed by the argument for several reasons.
Most importantly, the most critical number in implementing big change is 218-51-1-5.
Democrats on the best of days can assemble that coalition. They were able to assemble that coalition for the American Rescue Plan. They can assemble that coalition for a “Puppies are adorable and Ice Cream is yummy” bills.
They currently can’t assemble that coalition on prescription drug pricing bills. They can’t assemble that coalition on Medicare for all. They can’t assemble that coalition for a national public option with prices linked to Medicare. The possibility space is constrained by the plausible coalitions that can be assembled especially if we assume that anything that has long term structural changes to the provision of health insurance coverage to any one under the age of 65 is likely to be a Democrats only bill.
Secondarily, as I wrote in January 2019, prioritization was a key:
Prioritization will be a key differentiator of Democratic Presidential and Senate primary candidates. I believe that most Democrats will share significant elements of what is on their top-10 list of areas that need federal government attention in a government that could theoretically have a narrow Democratic trifecta. But the key will be prioritization….
Senate floor time is a key constraint. A very productive Senate might have slots for two big bills, three or four medium actions (such as SCOTUS nominees) and a lot of housekeeping. A productive Senate is most likely positively correlated with the size of the effective majority.
Right now, there are numerous agenda items that could qualify as a “big” thing from the Democratic/liberal perspective….
Candidates are likely to share the same items on a top-10 list but the rank ordering and asset allocation will matter a lot. One candidate might want to spend six months on healthcare again at the cost of doing not much if anything on immigration and naturalization. Another candidate could want to spend a little time on a minimal “fix-it” healthcare bill while spending more time on global warming policy. Those are all defensible choices.
Biden during the campaign never focused on making healthcare reform one of his two big priorities. He was pretty clear that he wanted to build on pre-existing structures and improve known problems and extend on successes. That was a major point of contrast to several of his opponents including Senators Sanders and Warren. Agree with that prioritization or not, it was a clearly communicated priority. And it has been accomplished for at least the next two years.
I think that there is a difference in opinion on the value of optimization versus improvement. Is there value in pocketing a few rolls versus holding out for the full loaf of bread? That is a moral question, that is a risk tolerance question and that is technocratic question all at once. Given very narrow Democratic majorities with a clear blocking coalition that is unlikely to want to go big in the direction of Medicare for All and given a clear history of healthcare being an important but not the most important priority of the Biden campaign nor Biden administration, I’m more than happy to pocket a few rolls and getting back to work on improving the current system as is instead of hoping for a complete reconstruction of a kludged up system with a fairly high probability of failure of the reconstruction project. But that is a personal judgement…
Jim Bales
My answer to almost any complaint about what Biden is/is not doing is,
“218-51-1-5”
I cannot comprehend how people don’t get this
Best
Jim
Another Scott
+1
Progress is Incremental. It sucks, but that’s the way life is.
We can change the slope to be a little more positive, but we’re not going to see Heaviside step function applied to progress very often.
Thanks.
Cheers,
Scott.
lowtechcyclist
Biden has it right, of course. Do as much as you can, as SOON as you can, to make people’s lives better.
Then we might actually go into November 2022 with an electorate that, by and large, is thankful as hell that the Dems are running things. That gives us our best chance to hold our ground in the House and pick up a couple of Senate seats, so not everything will be dependent on the whims of Manchin and Sinema.
Systemic reform, much as I think it’s desperately needed, will have to wait for a Congressional majority that will support it. We don’t have one now. End of story.
IOW, gimme them pocket rolls!
WaterGirl
@lowtechcyclist: Agree. Do what you can NOW, and make sure it’s clear that this is a downpayment with more to come, so voters need to make sure we keep the house and the senate in 2022.
Ruckus
I’d like to know what it is that people mean when they say Medicare for All. There is so many things floating around out in political space called this and they vary wildly and widely. And because Medicare, while far better than nothing, really isn’t all that great.
rikyrah
@Jim Bales:
It is that simple. And, something that I always remember.
Dan B
Thanks for a clear reminder of how the mechanics of politics, and of change, actually works. Too much of the discussion in society is on the perfect and so much less is on what’s good enough for now.
To summarize: I’d love to try the coffee that’s been through the innards of a Civet, but maybe I should replace the cracked French Press for now. Or maybe I should have friends over for coffee brewed in a cone filter and talk about Civets? (Or whatever animal it is…(
Ruckus
@Jim Bales:
How many people want what they want and/but have no idea how to get there? A safe bet is most.
Dan B
@Ruckus: Medicare isn’t that great. Truer words. My monthly rate just went up. Apparently I missed signing up for Part D in 2019. I’m sure I did but maybe I didn’t get the right box checked, and there’s no appeal. That’s a minor quibble compared to 2017 when I was broke and couldn’t make the payment on time and forgot the bill in a big stack of late bills. Zero insurance for six months – the longest I’ve held my breath since the AIDS crisis.
stinger
Great post and great comments!
stinger
@Dan B: I’m not on any medications and apparently I didn’t sign up for Part D when I first became eligible, either. The next year I realized I should, as who knows what may happen — and now my premiums are $2 higher each month for the rest of my life, than they’d have been had I signed up in the first place.
I had an advisor, and I can’t see how she let that (me) slip through the cracks that way.
Cameron
Much as I’d like to see some sort of universal system (doesn’t have to be single-payer), it really isn’t doable with the current numbers. Right now, lowering the Medicare age to 60 and/or some sort of dental/eye provision would have to be considered a smashing victory.
Dan B
@WaterGirl: Plus with the number of anti-Trans bills and voters suppression bills we need some inroads in statehouses.
Transparency in the COC and exposure of ALEC &/or a progressive alternative would also be nice.
WaterGirl
@Dan B: I was listening to Jen Psaki’s daily briefing from Tuesday (2 days behind!) and some knucklehead said “Capito wants this amount and Joe wants that amount, is he willing to meet in the middle?”
As if Biden pulled a random number out of the fucking air and said “hey, this seems like a good amount!”
These people do not understand that the numbers on the Dem side come from hard work and research and knowing what is needed.
You know, cars would be cheaper if they went with 2 wheels instead of 4, one side mirror instead of 2, and hey, let’s go with just one windshield because glass is expensive!
WaterGirl
@Dan B:
COC?
Dan B
@stinger: Mine went up $7 per month for life. I’ve worked with a lot of people for whom this would mean Medicare if they could get it.
It’s seems the only revenge is to avoid paying by dying.
Maybe we should recommend this to anti-government anti-taxers. With a smile, of course.
Dan B
@WaterGirl: Sorry, CoC. Chamber of Commerce. I guess I was in the mood for an acronym since I’m guessing at the 281-51-1-5 reference. House / Senate / President / Supremes?
Betty
@Dan B: This is what non-Medicare people don’t understand. Reform will need to include Medicare and Medicaid. The whole system is broken. Maybe the way forward is to tackle certain aspects to get uniformity, such as one payment schedule. It is complicated, but big change is needed sooner rather than much later.
Betty Cracker
@WaterGirl:
If the admin has a problem on this issue (too early to know that, IMO) it lies in messaging about the bolded part above.
Barbara
@Dan B: Medicare shares no small part of the blame for why American health care is so fragmented and focused on piecemeal interventions. People love it because it is always there, but if we paid as much loving attention and resources to Medicaid it would be better. Basic problem with Medicare is that benefit structure is frozen in time to reflect what Blue Cross plans were like circa 1965, with an ill-fitting Rx add on.
Jim, Foolish Literalist
I doubt there’s an issue more infected with Green Lanternism– which is altogether too widespread– than “Medicare For All”. A sizable minority of the left has made it an article of faith that M4A/Berniecare is, as the phrase was a couple of months ago, “incredibly popular”. That latest wave was caused by a Kaiser (IIRC) poll that described a version of “Medicare For All” as something a lot more like a vague public option than the Rose Twitter dream of the CEO of Anthem roaming the streets barefoot with a tattered blanket and a begging bowl. Something I’d be okay with– my premiums may mean I will have to seriously rearrange my life in my mid-fifties. I do not want to do that. But Susan Collins was re-elected by seven points, and voters in Iowa care more about abortion than the social safety net, and in Florida… fuckin’ Florida, man.
Redshift
I’ll go further than the political argument and say this entire argument is bullshit. It’s a “heighten the contradictions” argument, and those always just assume that the results will be more support for their favored position, without providing any evidence.
The most convincing argument for universal government-provided healthcare (the best-case version of what the “Medicare for All” marketing slogan means) is that, like Medicare, it will make it so you don’t have to worry about a lot of stuff that you have to deal with now, and you don’t have to deal with companies whose free-market incentive is to try to deny care. Second is that if it’s paid for through taxes, it doesn’t become unaffordable for people with less money. How does making the current system suck somewhat less makes those arguments significantly less compelling?
Dan B
@Barbara: Makes sense to look at the history. I was surprised that the decision to raise my rate was based on an audit I was not informed of until after it was done. I spent three hours on the phone trying to figure out why. If a private company was this opaque it would be in trouble. $7 extra per month I can afford at the moment but if the Social Security Administration decides – very unlikely to impossible – to cut my payments it would have devastating consequences or at least undermine my future plans.
Redshift
@Betty:
This is why I like Medicare for All as a slogan, but not actually expanding Medicare to everyone. Base it on Medicaid (probably, mostly), but call it Medicare because people have a much more positive opinion of Medicare than Medicaid.
OldDave
I didn’t sign up for Part D when I first became eligible some three years ago. I still haven’t, but then, I’m still working.
Barbara
@OldDave: Right. It’s okay if you have employer provided drug coverage. Same for Medicare Part B, if you are enrolled in an employee benefit plan. But once you cease active employment, you have to take advantage of a special enrollment period or else your premiums for both will be permanently higher. People get confused when they have retiree coverage, and think that counts as employer provided coverage but it doesn’t.
Barbara
@Dan B: It’s better not to get me started on this path, but Medicare is built on platforms that silo inpatient care from outpatient care from outpatient drug coverage, and spends ungodly amounts of civil servant brain power trying to figure out how to incentivize the separate players receiving different revenue streams to coordinate between themselves. In so doing it creates all kinds of perverse incentives, especially for hospital utilization. This is one reason why CMS likes Medicare Advantage — you have one entity that gets a lump sum payment and it has to figure out how to integrate things, but without all the payment regulations that create barriers to coordination. It’s not that they love private insurers per se, it’s that the benefit structure becomes so much more rational when it is delivered that way, although plans too are somewhat hamstrung when it comes to integrating drug coverage, and of course, have their own negative incentives.
prostratedragon
“218-51-1-5”
The big phrase in academic econ is “subject to constraint.” There is our constraint, for now. Can’t beat improving up to its limits and leaving the rest for when it gets relaxed.
Darkrose
@Ruckus:
My wife is on Medicare. She often says that people who push Medicare for All have never actually had to deal with the Medicare system.
WaterGirl
@Dan B: Yes, yes, yes and yes. :-)
Darkrose
@Redshift: I don’t like Medicare for All as a slogan, because everyone has a different idea of what that means. Too many people who use it seem to think it’s a magic wand that will instantly bring about a single-payer, universal cradle-to-grave coverage utopia and abolish private insurance. There’s never any interest in addressing the issues with implementing such a plan, or how to get stakeholders–including health care workers and patients–to buy into a plan that will radically restructure health care as we know it, just “This will make everything better because we say so; stop whining about fear of losing the coverage you already have.”
Geminid
@Jim, Foolish Literalist: I probably don’t have the knowledge base to correctly evaluate the merits of different healthcare reforms. But looking at the Public Option in political terms, I like it. Many Americans have a basic skepticism about what government can deliver. You could let an average group of citizens hear a presentation about a single payer system by the the most persuasive health care economist out there, with questions and answers, and many would walk away saying, “Well that sounds great. But I’ll believe it when I see it.” A public option seems like it would be a way for people to see “it.” Even if their own employer does not go that route, they will have friends and family who will experience it first hand.
Will the result in ten years be a single payer system? Maybe. But I won’t mind if we end up like Germany, which (I believe) uses a strictly regulated system of private insurance for many of it’s citizens.
But it was a good thing, I think, that the Democrats did not run last year on a platform of Medicare for All. It was hard enough to beat trump as it was. I’m not sure we could have pulled off beating trump and the health insurance industry too.
Jim, Foolish Literalist
@Geminid: It baffles me that a public option/Medicare/aid buy-in isn’t an easier political sell, especially given that the electorate is weighted toward olds like me. But I try to avoid the trap I warn others about, of believing that because I think something/someone should be politically popular, it means it/they are
Geminid
@Jim, Foolish Literalist: I sometimes think of a single-question litmus test to delineate liberals, moderates, and conservatives. It would be, “Do you believe government can solve A) many problems; B) some problems; C) few problems.
Of course, this a crude and simplistic test. I kind of like the way the Wason Center does it when it polls registered Virginia voters. They just let people self-identify as a) strong conservative; b) conservative; c) moderate, lean conservative; d) moderate, lean liberal; e) liberal; f) strong liberal. The results are interesting, and seem more or less consistent from poll to poll. The Wason Center’s demographic information is fairly informative in general.
lowtechcyclist
@Ruckus:
This. I think our goal needs to be a simple UHC system that includes everything an upper middle class family wouldn’t regard as optional.
But even with my vast ignorance of our medical system, I can see that it’s gonna be the devil of a challenge to get there from here.
I’d love to see someone lay out a step-by-step roadmap for that, that doesn’t piss off millions of people at any step. My expectation is that there ain’t no such roadmap, that there’s no path that doesn’t involve pissing off a shit-ton of people at some stage.
Lobo
218-51-1-5. Bingo! That is what frustrates me about some policy proposals and statements like “politician X should do y” without explaining how it would be done. It often hints that the only issue is a lack of will, i.e., green lanterism. Take minimum wage. $15 will not make it through that gauntlet for better or worse. Manchin is right to say why won’t people take $11 as a victory, i.e., as a pocket roll. Is it suboptimal, yes. But is better than the status quo that will help, yes. It is always easier to build on something there. For instance, in the compromise it can be made to become effective earlier than the $15 proposal. And there is nothing to prevent people from coming back and asking it to be raised after that by increments. A $1 increase is less scary than a bigger sum all at once. I don’t like it but the 218-51-1-5 gauntlet still holds.
Ruckus
@Dan B:
I am very lucky, looking back, that I served in the military, and have the VA. At my current income I have to pay copays but it is still cheaper than having to purchase Medicare Advantage, better coverage and when I retire (Next Fucking Month!!!!) those copays will go away.
L85NJGT
Anybody thinking a full on industry overhaul was feasible when the one initiated 12 years ago hasn’t been fully digested by the body politic has shit between the ears.
L85NJGT
@Ruckus:
Make me immortal, and have somebody else pay for it.
Ruckus
@Betty:
I have looked and a good Medicare Advantage program is a significant step up, but at a significant cost if SS is your retirement program. As a geezer I am one of the millions for whom SS is it. I say that the American people deserve and have earned far better than to work 50-60 years and be thrown away while shitheads have stolen so much and basically done nothing positive for their entire lives.
Ruckus
@Darkrose:
Exactly! It really is crap. It is better crap than nothing at all, but that’s the best that can be said.
I couldn’t retire if I had to live on my SS and pay Medicare Advantage.
Brachiator
@Ruckus:
Social Security was not meant to be the main source of retirement income. But the reality is that many people will depend on it. That’s just reality. So, it is going to be necessary to look at ways to improve it, and to improve Medicare.
Ruckus
@lowtechcyclist:
US healthcare is such a fucking mess, and that’s with ACA, with most everything centered around making big money and NOT the care part. I have been in 5 different MRI machines at the VA. They cost the same as every other MRI but their usage and the structure of the system means they get used far more efficiently and cheaper per usage. It is a tool, not a profit center.
taumaturgo
People forget the most pernicious element in the healthcare debate in the USA, corruption. Both parties talk a good game but when it comes to reign drug prices or any structural reform that would impose regulations and legislation to break up the healthcare cartel or expand coverage the 218-51-1-5 turns into 400-35-90-10. Incrementalism is the excuse for prolonged corruption. It’s a no-brainer that politicians are at the bottom among the least trusted professions.
Jim, Foolish Literalist
@taumaturgo: As ever, your useless and infantile word salad is useless.
And infantile.
Ruckus
@Brachiator:
It wasn’t my intention to use SS as my retirement income. But nature (a major earthquake cost me nearly my life but took a lot of money to fix and then GWBastard cost me the rest what was left. (But I’m not bitter, I knew he was a far worse than useless ass well before I didn’t vote for him) But here we are, once again trying to dig out of a republican clusterfuck of once again epic proportions, all the while they are trying to make it far worse. I don’t have a fucking clue how they think their form of opposite utopia is supposed to work for anyone, let alone the dumbest fuckers on earth.
jnfr
I’m really in agreement with you here. There is a lot of work to be done in our healthcare system, and anything we can fix right now will seem small. But we (Biden, I mean) face a lot of big issues right now and I wouldn’t give top priority to this one. Certainly not while the filibuster still exists.
Ted Doolittle
Given that for better or worse, the stated and now for two years implemented policy is to throw money at the problem without making systemic changes — i.e. to keep and indeed turbocharge the private insurance model by reducing the expenditures of most families while just paying, rather than addressing, the internationally abnormal prices that our health insurance companies have negotiated in the job-based and individual market — then isn’t it time for the reform effort to shift to looking under the hood of how private insurance companies actually operate and actually treat their customers?
Yes the ACA did that to a decent extent through things like outlawing the lifetime and annual caps, guaranteed renewal, and maybe a couple of others that slip my mind right now. But let’s go deeper, and examine and justify other insurance operations practices.
If we are going to double down on private insurance, let’s make it better and fairer.
Things like reversing the burden of proof for medical necessity denials. Your treating physician should be the presumptive default decider of medical necessity, not some random insurance company doctor in Cleveland or Utah who has never seen the patient. Make it so the insurance company, and not the sick or injured patient as now, is the one that has to appeal to a neutral third party for permission to deny your doctor’s claim. After all, if the doctor is in network, isn’t that a statement that the insurance company trusts them? If the company doesn’t trust them, why are they in-network?
Closely associated: move utilization review to the provider level, and away from the individual claim level. Pay claims put in by in-network doctors, but if the insurer sees a pattern of inappropriate claims, educate the provider and if there is no change to the practice patter, suspend or terminate the provider from the network.
And, re high deductibles, why not pro-rate the annual deductible for folks who join a plan mid-year?
I’ve got more ideas to get us started. Basically we’re talking about a Health Insurance Consumer Bill of Rights — a much-needed comprehensive pro-consumer rethink of private insurance company operations.
Here’s a bit more:
https://ted-doolittle.medium.com/re-designing-health-insurance-operations-for-the-people-2bc8bb711542