Some smaht guy who writes here makes a good point on healthcare:
Amen. Universal coverage is the core goal. Doctrinaire folks can imagine the blank page on which we’d write the perfect system. In the real world, we have to confront-and reform-a system w. stakeholders, rent-seekers, and tons of sub-optimal equilibria. Eyes on the prize. https://t.co/6xGdVgkkSw
— Thomas Levenson (@TomLevenson) December 24, 2018
I am in full agreement with Tom. My priority on a personal and political level is universal coverage without too much concern for the actual mechanics of that coverage as long as those mechanics produce an outcome that creates affordable care at both the point of service and for society, some justice in the distribution of care and health, and continues to produce reasonably strong innovation incentives.
And all of those goals will require dealing with current stakeholders, rent-seekers, political roadblocks and non-optimal (locally or universally) equilibrium. It is going to be messy as an overtired and caffeinated toddler at a birthparty which has a build your own sundae as the main sweet.
To achieve that goal, a political coalition will need to cater to the marginal votes. To achieve that goal, a political coalition will need to make hard trade-offs. To achieve that goal, a political coalition will need to smooth off pain points at the cost of optimality (however that may be defined).
It will be messy politics as it is a core political question of who holds and how does power over life and the future function.
LibraryGuy
In one of these online debates in 2016 I mentioned that moving to something like the NHS might throw 100’s of thousands of people out of current jobs and threaten people invested in the health care field, and I was told “so what? they shouldn’t be working for the corrupt insurance companies”
Real political skills, there.
01jack
Not bad, but really difficult.
schrodingers_cat
I think the sage of Vt has moved onto greener pastures. Medicare for all is so yesterday.
dr. bloor
Your lips to the Star Child’s ears, but I fear that Pontin has precisely identified what the debate will be re: health care, at least through the primaries. M4A is an emotionally-fraught, easily demagogue-able issue, and will be a centerpiece issue for more than a few in the seemingly large field of primary contestants in 2020. It’s easy to see how the party can set itself up to fail and take a huge bloodbath no later than 2022.
kindness
Spent some time Christmas Eve with a buddy I don’t see too much any more. He announced he’s all in on Bernie for 2020. Mind you this is a very liberal guy who buys Bernie’s shit. In 2016, this guy was the face of Democrats who did everything they could so Republicans could win by trashing Democrats because Bernie (not an actual Democrat) didn’t win. I had no words for the guy. I asked him not to lose the race for us this time. He didn’t understand. You see, he really does think it was all us squishy Democrats who lost the race. The fact that Hillary got 3 million more votes doesn’t count. It’s tough to love some people,
LibraryGuy
Navigating different demands, recognizing core needs, building coalitions, bringing facts to the debate while looking out for the people affected by policy – it’s depressing to look at Congress and at the state legislatures and realize that there are few, if any, Republicans who know or care about _any_ of these things.
Dems will accomplish more if they are clear-eyed on this point.
different-church-lady
Unable to afford care? Birthparty?
Matt
We tried incrementalism back in 2008. The health insurers responded by helping get Trump elected.
The only thing we should be offering them is NOTHING.
If you’ve got a vampire squid attached to your face, you don’t spend your time worrying about how the squid will survive if you remove it or entertaining alternative plans that label having a squid-free face a “pony”.
dr. bloor
@Matt: The vampire squid in question is about 17% of the economy. Care to give us the specifics of your plan to rip it off our faces without taking our vital organs and gray matter with it?
dmsilev
@Matt: Putting aside the policy question and looking purely at politics, the big problem with trying to push a plan that blows up the private insurance industry is that lots and lots and lots of people get health insurance through their employers and while they may or may not be happy with that coverage, it is a known quantity to them and pushing a plan that requires taking a swan dive into the unknown will not be popular. Even if the endpoint is better coverage at lower cost, convincing people that they should take that risk is not trivial.
tobie
@kindness: Sorry to hear about your friend. Bernie divided the party. There’s no getting around that. How he did it and continues to do it is of some interest, though not particularly encouraging. Like all demagogues–and this includes Ronaldus Magnus and Trump–he hates the process of governing and thus treats every issue as one that can be fixed with a wave of the magic wand. We are a nation with the attention span of a fly, which makes us perfect bait for tweets and policy-as-mere-tweet: M4All!, Green New Deal!, Abolish ICE!, Free College! etc. Finally he’s a populist who claims to speak for the people and must continue to whip up rage at the enemies of the people (the elite, the establishment, the bankers, millionaires and billionaires, etc.). Let’s hope that 4 years of Trump makes most Americans tired of this strategy.
schrodingers_cat
@tobie: I haven’t heard a word from the Green mountain man about immigration. Have you?
Gin & Tonic
@dmsilev: I think Matt is far too pure to worry about trivial things like that.
FlipYrWhig
I lose track of whose jobs we are and aren’t supposed to be upset about disappearing. Where are we supposed to be on coal companies and steel companies these days?
I still feel like Sanders gets a special benefit from representing a state that has so few business interests and thus not having ever had to navigate the distinction between the prosperity of an industry and the prosperity of that industry’s workers.
tobie
@schrodingers_cat: You follow this issue more closely than I do, so I trust that if Sanders had said something about immigration you would have heard about it. You’re right that he has a lousy record on the subject. He’s cast some horrible votes in his time in the House and the Senate, and the opposition to the comprehensive immigration reform bill in 2007 is a big one.
LibraryGuy
@Matt: That’s a hilariously bad take.
The insurance industry isn’t some dark lord on his dark throne taking in the wealth of the US and denying all claims while it jacks up prescription prices and laughs maniacally.
It’s people – administrators, data-entry workers, agents, etc., and their families, and the communities that depend and support those people and their families.
You make it sound like you would be ok with a law outlawing private insurance and mandating a national health program, effective immediately, which is just a way of saying “I don’t give a shit about actual people, just about my abstract policy preferences.”
Emma
@Matt: i have private employer insurance. Since my employer is a large university with teaching hospitals and nationally-known clinics attached, my cancer treatments — six years spread out over two decades — didn’t make a dent in my savings. Now, since my only “dependent” is an 85 year old father and I have no children, I might be willing to give it a whirl. But there are about 2,500 (plus or minus) women working at non-professorial levels that trade relatively low wages for benefits, primarily family health insurance that does not break the family bank and put them into bankruptcy. It ain’t perfect but it works for them. Unless you explain to those women why your system will be better than what they now have, they will rise en masse and commit serious mayhem.
Lymie
When folks talk about the costs of healthcare they never seem to consider how much employers are already paying as part of the equation. The improvements in mobility of people if they can go anywhere or go independent are important. Getting rid of the number of bankruptcies due to health costs will keep thousand Out of poverty.
Barbara
Most people who are for Medicare for all don’t have Medicare and don’t understand how it works. Sanders understands how it works, I will give him that, and his demand that there be zero cost sharing was no doubt informed by the knowledge that 90% of seniors either have retiree supplemental benefits or purchase supplemental insurance from — wait for it — private insurance companies. Currently, close to 40% of seniors get Medicare benefits through a Medicare Advantage plan run by — wait for it — private insurance companies. But the really annoying thing is not to understand that as it is currently Medicare fee for service reflects the status of health care operations of — wait for it — private insurance companies circa 1965. Because Medicare was always intended to be and always has been administered by — wait for it — private insurance companies, from day 1, but it has never really been fundamentally updated to reflect the potential for more efficient and more holistic care as time has gone by. It is, literally, at least 40 years out of date.
sdhays
I agree that universal coverage is priority 1, but a close priority 2 should be transforming the system as a whole into something less completely awful and downright fraudulent to deal with. Every encounter with the system leaves me stunned at how it runs on essentially practically outright fraud kabuki dances with no one ever really being able to give a straight answer about what something costs until a check has been cashed. It’s really awful, and a system for dealing with people who are already feeling awful should not add to the pain.
schrodingers_cat
@tobie:BS has been one of the closest allies of Chuck Grassley on immigration issues. Many of the USCIS and ICE administrators are Grasseley aides including the USCIS head Cissna. Grasseley is probably the most hardline anti-immigrant R in senate today and he was like this long before T came on the scene.
ETA: Together CG and BS have tanked even small measures that would give some relief to immigrants and those on long term visas.
Barbara
@Lymie: Employers consider it a lot, but their employees — sometimes known as voters — don’t and don’t want to be told that they have to give up something they know for something they don’t know. Please learn the cardinal lesson from 1994 health reform debacle: You can only piss off and scare one interest group at a time. You must divide and conquer in order to make progress on health care. Thank Dog Obama understood that in 2010. Sanders, who has never actually passed anything important, appears not to care. What is great about the potential of the marketplace and exchange plans is that it could pave the way for gradual transition to more portable plans without waging a frontal assault on employer provided benefits.
tobie
@Emma: I think you could add that unless M4All-diehards can tell the diabetic who needs regular dialysis, or the cancer patient who needs regular chemotherapy, or any other person dependent on regular, life-saving care that their treatment will not be disrupted one bit as the country magically switches from employer-provided to government-provided healthcare overnight, the proposal is dead in the water, as is the party responsible for pushing the switch.
ETA: Americans don’t like revolutionary changes. As Barbara said above there are other ways to approach M4All incrementally that have a much better chance of success.
Jim, Foolish Literalist
It’s becoming a hardened CW among the Wilmerites that the Obama presidency was a failure, and from there they move on to the double fantasy that their Idol can A) win a general election B) once in office, can pass all his massively disruptive programs through righteous bellowing
In the feverish last days of the primary when there was some notion among them that St Bernie would wrest his due back from the Evil Ones through… something… Jon Fugelsang (who is not stupid by often blinded by a near-delusional self-righteousness) explained that Bernie would be a one term president because he would pass all his programs by executive order. Which while insane at least addresses the powers of the Oval Office more realistically than most in the Cult ever do.
Barbara
@sdhays: What needs to happen, in my view, is for a transition of everyone in the same system, with the possible exception of current Medicare beneficiaries who seem to exemplify IGMFY as a political position on health care. That will allow a much more united and coordinated effort to make things better for everyone, unlike what happens now, making them better for some only by making them worse for others.
sdhays
@tobie: To add to your point: we’re the country that chickened out of moving to the metric system because too many people were freaking out about that disruption. Think of how trivial that is compared to the system that actually saves lives.
Villago Delenda Est
The problem of rent seekers has a known solution. Euthanize them. That’s Galbraith’s solution, anyways.
tobie
@schrodingers_cat: Grassley is awful — he’s not only conservative but also miserably dumb. I had hoped the Butina case might bring him down. He was one of the attendees at the National Prayer Breakfast and sat next to a Russian representative that, I believe, Butina got invited to the event.
sdhays
@Barbara: Yes, the system needs a reduction in moving parts and almost certainly more regulation. But it needs to be gradual to minimize disruption and maximize incremental benefit.
Raven Onthill
So it gets even more confusing, even more difficult to sign up, and even more expensive?
What more complexly about is buying off various profiteers in the system so they don’t fight the system in Congress. It’s not about delivering more health care or better health care. If it were about that we’d be making the system simpler.
As if that were not enough, many of the businesses in the system did not even stay bought. They did not defend the system that was bringing them windfall profits. That was left to us.
Maybe this expensive mess is the best we can do. Maybe we need to defend it for a generation, just so there can be a system. But it doesn’t speak well of our country but that is so.
Baud
Remember, only Baud!Care! covers your pets. Everyone else kowtows to rent-seeking vets.
Bemused senior
@Barbara: This. I am now on Medicare, and I ended up choosing Kaiser Medicare Advantage. I was afraid I would not be able to spot the fine print in the Medicare supplement plans that would leave my family with some huge uncovered expense when I eventually have some major medical problem. People touting M4A seem unaware that Medicare has caps and you must have additional coverage. Another thing about Medicare in the context of employer- provided insurance… I work full-time for a tech start-up and I can’t use my medical benefits to cover the costs of Medicare. Another agist assumption, that Medicare eligible people are retired.
Betty Cracker
There’s some truth to the notion that Americans don’t like revolutionary solutions — ironic since we were founded via the Revolutionary War. But we also have a history of tolerating intolerable things until we snap and go with the “burn it down and start over” strategy. We may be approaching such an inflection point with healthcare.
I’m glad the ACA passed and has survived attempts to completely gut it. I realize it has helped millions, including people in my family’s situation, at least on the margins, by bending the cost curve so that the premiums for our shitty employer-provided coverage aren’t rising as fast as they did pre-ACA.
But the heathcare access delivery system in this country still sucks giant green gators. If the M4A people are too pie in the sky, some of the committed incrementalists are too sanguine about the current crisis, IMO. Compromise will be required of both camps.
Emma
One thing I’d like someone to work on is basic paperwork reduction. Before my dad moved into a geriatric clinic setting, he had a wonderful primary. Over the years the poor woman — independent provider taking all sorts of insurance — had to shift staff just to handle paperwork. She ended up having to close the office every Friday while everyone, including herself, handled insurance paperwork.
Paul T
“The Perfect is the Enemy of The Good.”
Baud
@Betty Cracker:
Seems like the two big questions with the next legislation will be (1) will private insurance be allowed and (2) will people have any premium/co-pays or will it be entirely publicly financed.
Gvg
I was healthy until I turned 49 when I found out I had a rather serious cancer. I had chosen a highly rated insurance provided by my employer, where we had a choice of 6 ompanies every year. I never had any way of knowing if they were really good till I got sick. Then I found out they were great. My total costs including surgery, copays and chemo was around $1600 in small amounts, mostly 20 and 40, but the surgery was 200. The doctors offices employ experts who help you apply for assistance to pay which most people even with insurance need for something like this. I didn’t need it. Avmed if anybody is interested.
4 years later my employer choices changed and now I have a new company with a similar rating and reputation but I would have preferred to stay with the known quantity. I also feel Avmed was entitled to keep getting my premiums but that isn’t the way things work. Avmed only questioned one test cost, and they did cover it without my making any calls. I can’t really explain how sick and tired I was and how I kept going by not thinking about things too much. I did not need to be calling either an insurance company nor a government agency to get approvals or whatnot and fortunately I didn’t have to. I don’t feel that the insurance industry should be burnt to the ground. It’s half of Congress I could roast.
And the family leave medical act also was a big help to me. I was able to work irraticaly as able until I recovered. Bill Clinton got that through. I was also lucky to have ethical employers who didn’t try to beat the rules. In my job, I see proof that happens a lot.
I thought the whole year how lucky I was and so many aren’t. Everyone needs my benefits.
Jim, Foolish Literalist
I agree the incrementalists– I count Pelosi and Schumer and a lot of the new crop of Congress among them– need to keep on talking about health care, and start talking now about clear steps they want to take, as clear as such a complicated issue can be.
Vox has this layout of different proposals. I think Schatz would be a good media face for this. He’s smart and witty and actually doesn’t seem to be running for president in 2020, and I don’t think he’d get caught up in purity wars
Citizen Alan
@Jim, Foolish Literalist:
One thing that both astonished and horrified me when I forced myself to watch the Green Party “debate” in 2016 was when all of the debaters (including Stein, who, believe it or not, was the most sane of them) continually claimed that the most sweeping and outrageous policies — Nationalize all the insurance companies! Confiscate every gun! — could be achieved simply by executive order. That was when I finally realized that the ultra liberals and the ultra conservatives both agree we should be living in a dictatorship but simply disagree on what policies they want the dictator to force upon us at gunpoint.
tobie
@Baud: If those are the two questions, we will be outliers in the world. France and England–both single payer models–have private insurance companies. France even has copays, as do the Bismarck model countries (Germany and Switzerland). Japan has an entirely different system than Europe that I should read up on. Healthcare financing and delivery is a complicated subject. I’m with Tom and David on this — messy isn’t necessarily a bad thing given facts on the ground.
kindness
@Baud: Private insurance will have to be allowed because so many people work in the industry. Senior Advantage covers a lot of people. The way it is set up now, there is no possibility to enact a plan that doesn’t include the Insurance Industry that exists now. Acting like one could work up an industry without the current private parts to start on a given day isn’t possible.
Gex
@LibraryGuy: Building coalitions is so bad for the purity factor though, so unfortunately some of our most energetic and enthusiastic voters on the left are actively engaged in making sure that can’t happen by making M4A or single payer an ideological litmus test.
Jim, Foolish Literalist
and speaking of Schatz and M4A
Gex
@Gin & Tonic: Listen, there’s no sacrifice he isn’t willing to impose on others to get this problem fixed!
Lapassionara
Medicare has the power to negotiate lower costs from providers. I have an expensive infusion once a month or so. The hospital says i should pay $7000, but Medicare tells it what to charge, much less than $7000, then pays 80% of that, my supplemental policy pays the rest. I pay nothing, but my premiums. There is a huge healthcare industry in our economy that would also take a big hit if Medicare were to cover everyone.
Betty Cracker
@Jim, Foolish Literalist: You’re exactly right — they need to keep talking about healthcare because it really is an ongoing disaster for a lot of people and a odious burden for tens of millions more, even “lucky duckies” who have employer-provided coverage and don’t require subsidies. There’s danger in insisting that the current system be completely overturned, and there’s danger in proclaiming reform a fait accompli thanks to the ACA. Given the recent movement of the party, most of the danger is from the former rather than the latter, but I think to some extent the poles reinforce one another and are thus ripe for exploitation in the coming Troll Wars.
Brachiator
@tobie:
That’s really funny. Really.
OK, back to the health care debate.
schrodingers_cat
As long as people in the red states continue voting for the likes of open racists and cheaters like Kemp and DeSantis at the state level and T at the national level, railing against the Ds for not being pure enough achieves less than nothing. It aids the R propaganda.
ETA: By the way I love the idea of M4All. I voted for it on the referendum here in the Commonwealth. I just don’t see it happening at the national level given the politics we have. And making it a litmus test aids BS personally, his Russian allies and the Republicans in undermining Ds.
Ted Doolittle
@Gvg:
GVG: Glad you got through a major illness without too much fighting with your insurance company. Be aware that at least for those who live in Connecticut, there is a state agency called the Office of the Healthcare Advocate that can help consumers who are fighting with their health insurance. We have a staff of nurses, attorneys, paralegals and others who can represent you for free against your insurance carrier.
https://www.ct.gov/oha/site/default.asp
Villago Delenda Est
@Citizen Alan: This always seems to be the case. JUST DO SOMETHING without consideration for the unintended consequences. Sometimes you get so desperate to move forward that you inadvertently create more problems and worse outcomes. See the French in 1789, the Russians in 1917.
Suzanne
@tobie: T. R. Reid’s book “The Healing of America” was really informative about the healthcare systems of other countries to a non-policy-wonk like me.
Brachiator
@Betty Cracker:
I guess I don’t understand why we cannot just expand and improve the Affordable Care Act.
And Medicare for All is just an empty slogan, as meaningless as Bernie Sanders honking for “single payer, just like they have in Europe.”
Mandalay
@Villago Delenda Est:
I think that came from Keynes, though Galbraith may have been in agreement.
tobie
@Brachiator: I’m aware of the US’s revolutionary history. In context it’s clear I’m talking about seismic shifts in public policy that are supposed to happen with the stroke of a pen.
Regarding medical bankruptcy: did Trump remove the out-of-pocket cap? I can’t recall. The places that do need fixing are lowering premiums, deductibles, and drug prices. And upping the subsidy for those on the exchanges who make less than a certain income. We’re talking about a very small group here. I think only 5% of Americans purchase insurance on the private market. How much of that 5% earns less than 400 x the poverty level is likely small. Medicaid expansion and a mandate are of course critical for the ACA to work optimally.
Baud
@tobie: I don’t know how they do it there, but single payer can’t survive if it’s competing with private insurance for both patients and providers.
tobie
@Suzanne: Thanks for the reference! I’ve lived in Germany and had German insurance where I had copays and where some doctors wouldn’t see me because the fee for service offered by my public insurance policy was lower than the fee for service offered by private insurance. Interestingly public insurance actually costs more in Germany than private insurance because you’re subsidizing those who can’t pay. These are not complaints. I liked my insurance there a lot and thought it was easy to use. I’ve also had some exposure to healthcare in France. But that’s not a huge sample. I’ll check out the book you recommend.
Brachiator
@Suzanne:
I will check this out. Thanks for bringing it to our attention.
I’m also look at the Vox story another poster linked. Good stuff, but all Democrat plans. I think that HSAs and whatever else Republicans are offering should be shown, as well.
Betty Cracker
@Brachiator: Expand and improve it how, specifically?
zhena gogolia
Wow, you guys are so smart and clear-headed. I need a pet thread.
tobie
@Baud: I was referring to private supplemental insurance in France. Granted that is not the same as baseline insurance.
jeffreyw
@zhena gogolia:
You just need moar Homer!
laura
I’d be thrilled if a first step to overhauling the healthcare industry was lowering the age of medicare to 60, or 55. As a Union thug representing blue collar workers in northern and central California, I see broken men. The Case Deakins economic study is a real time report regarding repair and death. The toll that working in refuse collection, and disposal, road maintenance, park maintenance and water distribution and wastewater treatment, long and short truck hauling would surprise many -the vibration alone seriously damages the body. I see lots of spine, muscle, and organ damage, and self treatment to try and stay on the job until 65 is skin to climbing Everest.
If these old, but not old enough, and broken workers given half a chance to afford healthcare earlier, youd see a rush to the exits, more job opportunities for younger workers. Hell, I could consider retirement in the next few years too. Right now, spouse and I could not afford the full 24large per year that our insurance costs and my employer pays for.
Jim, Foolish Literalist
@Jim, Foolish Literalist: Hoo-Ray for ambitious pragmatism!
Brachiator
@Baud:
I’m not sure that many countries have anything like pure single payer. This seems to be an American fantasy.
Ken
@Brachiator: As long as there’s a FAQ for each of the plans, e.g.
HSA. You can put up to $10,000 of pre-tax income each year into an HSA to pay for your medical expenses.
Q. What if I don’t have a spare $10,000 to set aside?
A. Sucks to be you.
Q.What if I have a major medical issue for which the hospital bills more than $10,000, like, say, a two-hour visit to an emergency room?
A. The $10,000 will cover your deductibles. Your employer-sponsored health care will pick up the rest.
Q.What if I don’t have employer-sponsored health care?
A. Sucks to be you.
And so on.
Miss Bianca
@kindness: People like this make me so mad my hair hurts. It’s hard for me to engage them with even a modicum of civility.
Brachiator
@Betty Cracker:
Isn’t this what we have a Congress for?
But an obvious first step would be to remove the impediments created by Trump.
Can something be done to make the Individual Mandate smaller or more palatable? Do other subsidies need to be increased?
If I recall, Massachusetts created a universal health plan some years ago, and tinkered with it. I don’t know if it is a success story or still needs major overhaul. But I have not read any stories where people want to throw it out and replace it with Medicare for All.
In California, I see that more people have insurance coverage, but still have trouble finding a primary care physician. And more people are going to urgent care facilities or to emergency rooms. Other states may have other issues.
??? Goku (aka Amerikan Baka) ??
@Matt:
Anarcho-Syndicalism or bust, squish. Democratic socialism and Sanders are for neoliberals
jl
I think a huge problem of US health care is the very high prices, on average much nigher than other comparable countries. No matter whether we stick with Obamacare (‘Obamacare done right’, Go Swiss!) or Medicare for All (Go Australia!), tackling this problem is a blank page.
The hard choices should not be first and foremost for the average US resident. They have enough hard choices as it is. We need my version of the three legged stool:
Universal coverage and guaranteed issue (actually automatic issue)
Community rating based on age bands (no underwriting for preexisting conditions,or family history)
Subsidies for poor, and risk adjustment for providers stuck with expensive populations.
And I would add a fourth: a method to stop price gouging by insurers and providers with market power.
Those have to be solved, regardless of how we finance the insurance. Otherwise we’ll have a system that is too expensive for many people, or too expensive for the government.
Ella in New Mexico
@sdhays:
This is probably one of the biggest issues (aside from out-of-pocket/deductible/cost-sharing creep that’s killing even good employer provided insurance plans) I have lately with how our “Insurance” system works. For far too many people, we’ve slipped back to the days where even though you pay $800 bucks a month in premiums, and your insurance company pays a provider what it thinks is reasonable and customary, and you pay whatever your insurer and you agreed was your cost-share, it’s not the end of the story financially.
That’s because that provider–and a ton more lately– has decided no, we want all the $$$ we can get, period, like in the good old days. So they’re back to sending out “remainder” bills to folks, attempting to recoup the difference between what ridiculous, non-transparent charges they think they’re owed and what your insurance and/or Medicare will pay them. Or bills from providers working for their system from their private practices even though they should be contracted into the bigger bill (anesthesiologists in ambulatory surgery centers, for example). And about half the time, some poor frightened or overwhelmed by the complexity of it all Senior Citizen pays these bills they don’t owe.
They’ve ruined what Obamacare could have been by exploiting it’s flaws and weaknesses. If we don’t move to a highly consumer-protective, less complex, not-for-profit healthcare system then we’re in for more of this.
StringOnAStick
I suspect the only people who don’t think about health insurance are those that have yet to have an encounter with the system by getting sick or hurt, and then it’s a steep learning curve. That covers every young committed BS cultist I’ve met or worked with. Try explaining to them that Medicare has a 67% actuarial value, a word they don’t understand but translate as “I’m talking to a corporatist shill, ignore all further discussion”. Health care is going to be huge in the 2020 election, and so will the number of bots and useful idiots enforcing ideological purity tests.
I have arthritis in one knee and I get those hyaluron (Synvisc, etc; there’s lots of versions) injections to keep the pain down because I am trying to put off a knee replacement for as long as I can. The last ortho doc I saw only wanted to use one kind and my pharmacy benefit manager didn’t carry that one so his office would approach other pharmacies and I’d pay the difference. His office barely got it done in the 60 day pre-approval window I had one time, and totally dropped the ball on the next so I moved on to a different doctor (plus that doctor was a complete asshole, telling an audience of seniors that Medicare needs to be eliminated, period, the country can’t afford it). Since doctors try to cut costs by having MA’s handle stuff like ordering meds, the kid who was handling mine suddenly quit so it got lost in the fallout. Then I found out my PBM is carrying a different selection now, so I called them and the rep told me oh yes, that’s in the specialty pharma group, here, talk to them. That rep told me no pre-authorization was needed, so I waited another week, called my insurance company and they told me no, a pre-authorization is needed and we haven’t received any request for one, so I passed that on to the doctor’s office and of course they are closed this week. I feel like insurance companies do a lot of this crap on purpose to slow down care, or as in the last time I tried to get an injection, totally avoid paying for it because the patient gives up out of frustration. Also, look at all the points where this fell apart because of the various providers having to do the proper set of dance moves to get the insurance company and PBM to agree to do something. Oh, and once it is authorized, the PBM has to call me IN PERSON to get my approval to ship the injection to the doctor’s office so he can use it on me. I can’t pre-approve that shipment and I have a job where I can’t answer the phone when I’m working; luckily I work part time so we might end up talking without too much phone tag though they don’t leave any message at all because of privacy regulations. Nice catch 22 there in so many places.
Betty Cracker
@Brachiator: In other words, you don’t have specifics on how to expand or improve the ACA, but M4A is a “meaningless slogan.” Thanks for demonstrating the validity of the concerns I expressed at #33. :)
Brachiator
@Ken:
Did we have this conversation before, where you thought a $0 cost Bronze plan was a bad deal?
You also falsely assume here that a person must always spend $10,000 in deductibles.
Miss Bianca
@schrodingers_cat:
This. I am stealing this quote lock, stock, and smoking barrel next time I feel compelled to engage a Berniebro/sis.
zhena gogolia
@jeffreyw:
Haha, thanks. He too looks very smart and clear-headed. Got any hungover cats?
Kelly
@Betty Cracker: 1) Give everyone cheated out of medicaid free coverage in the Marketplace or federalize Medicaid.
2) Remove income cap from subsidies.
3) Include monthly payments in the total out of pocket limits. No one pays more than 10% of MAGI for healthcare.
4) Vision and Dental. Weird that these have been separated.
jl
There are more than 25 ways to do better. WHO site below covers Europe, and other countries such as Australia, Israel, Japan and New Zealand. From those > 25 ways, I think there has to be models that can be adapted to US. For the US, it’s a political and a legal problem, not an economic problems.
WHO European Health Observatory
http://www.euro.who.int/en/about-us/partners/observatory/publications/health-system-reviews-hits
LibraryGuy
@Gex: “Building coalitions is so bad for the purity factor though, so unfortunately some of our most energetic and enthusiastic voters on the left are actively engaged in making sure that can’t happen by making M4A or single payer an ideological litmus test.”
I know, I’m getting that from leftist purist on Twitter all the time.
Go to war with conservatism with the coalition you have, I guess.
jl
Commonwealth fund is easier reading. Maybe we could have a BJ contest where commenters describe their favorite system and we vote on it. Cole breaks ties.
Commonwealth Fund
International Health Policy Center
https://www.commonwealthfund.org/international-health-policy-center
Mayken
@schrodingers_cat: Nope, it’s still being used by the Real True Lefties as a cudgel against the Once and Future Speaker and “corporate” Dems (who are Just As Bad as Republicans.” Bernie may (or may not) have moved on but the Bros have not!
Just Chuck
@Villago Delenda Est: Is there anything for which murder isn’t a solution in your world? Another browser, another pie filter.
jl
Personally, I don’t see a problem with Congress working on plans to lower age of Medicare eligibility and making expansion of Medicaid more attractive to state governments. Those plans would almost certainly only pass in House over next two years. But if political support grows, whether the US eventually goes that route (that would be in direction of ‘Go Australia!), would perhaps nudge Congress in direction of legislating significant improvements in Obamacare.
Obamacare was a historic first step in health care reform. But it required so many corporate-friendly compromises that it was unstable, and too susceptible to gaming, and swings in affordability for average person. Emphasizing the need to protect Obamacare is necessary over next two years, but I am doubtful that simply preserving Obamacare will, over long run, be compelling enough to voters for that to be the whole policy. Politicians need to explain a vision for continued improvement in health care policy.
So, when a politician has nothing other to say than ‘Protect Obamacare’ and has no additional ideas, I am suspicious that they don’t want to step on corporate toes that will eventually have to be stepped on to make further progress. ‘Protect Obamacare’ is a necessary foundation and rallying cry for short term, but it cannot be the complete vision. IMHO.
Edit: If Baud 2020! movement gets going, we can debate the idea of staying just drunk and stoned enough to not care too much about it right now.
Juice Box
@Lapassionara: insurance companies also negotiate prices with providers. Generally prices are expressed as a percentage of Medicare, in the 105-110% range, so slightly higher prices with less certain, slower payment.
I used to be a single-payer person, but then I learned more about it. A lot of people simply confuse single-payer with universal coverage (and flat tax with simplified tax forms). Real single payer like the VA or the NHS frequently often wind up being a political football when “conservatives” are in power. That’s a lot harder to do when the system is more distributed. In a perfect world….
Some years ago there was a big lawsuit decided against Kaiser for refusing to pay for bone marrow transplant for advanced breast cancer because it was an unproven treatment. Various states got involved and passed legislation requiring coverage. Better data proved that BMT was useless against BC. The insurance company push back was correct.
Brachiator
@Betty Cracker:
What are you going on about? Barbara at #19 had a great point in noting that most people don’t even understand Medicare and how it is tied to private insurance. Hell, when we got Medicare for our mother, my sister and I had to wade through all kinds of stuff about Medicare Part A, B, D (still not sure if there is a part C) and how supplemental coverage was needed for medications, eyeglasses,etc.
I also don’t understand why you would pull the tired rhetorical gambit of demanding that anyone posting comments must offer a detailed plan on improving ACA. Dave Anderson is a freaking expert on the insurance industry, and I have yet to see him bite off on “This is exactly what must be done to solve the health care problem in America.”
But I repeat. When an elected politician says “we must have Medicare for All” it is as empty as that same politician saying “We need single payer, just like in Europe.” If that politician says, “We need Medicare for All, This is what it will cover. This is what it will cost. This is how we will pay for it.” Then you and I have something to respond to and possibly support.
Can you tell me where the ACA has specifically failed and why it must be replaced, if that is your belief?
Can you offer specifics on how Medicare For All will be a radical improvement on what we have now? Do we really have a health care crisis (a word you used in your comment). Has nothing significantly improved since the ACA was implemented?
You seem to want to pick a fight where none is needed.
Roger Moore
@jl:
I think this was one of the big hopes for the public option and a big reason so many people were disappointed when we didn’t get one.
jl
@Roger Moore: There are many ways to take care of it. I agree that the public option was one way. I’d be happy if a politician put ‘Protect Obamacare’ front and center for now, and also say we need to reconsider public option. I think that would give voters hope enough for better to voice support.
One problem with ‘Go Swiss!’ is that their method of containing prices would present big legal and constitutional problems for US system. Lot’s of court cases. Merely threatening a public option or expanding Medicare eligibility might send a signal to corporate hospital chains and some of the corrupt self-dealing in large medical groups, big pharma, and medical equipment supply chains that if they continue to be so greedy, they might not get anything at all. Then they might be willing to make more substantial deals on next edition of Obamacare.
I don’t see a problem in simultaneously pursuing multiple ways forward to a better system.
Kelly
@Betty Cracker: 5) Federal pharmaceutical formulary all plans must use with negotiated, published prices.
6) Financial aid to non profit community hospitals to keep rural hospitals open and check consolidation by corporate and Catholic hospital chains. Also anti-trust laws to break up existing hospital monopolies.
Kelly
@Betty Cracker: 7) Require all providers to post their prices on an accessible public database.
jl
If the BJ ‘build your own health reform’ contest creates too many vicious fights among comments, then I suggest a concurrent contest that will lighten things up. I’d like to see contest where commenters estimate what percent of Trump different foreign countries have bought.
It would be a fun March Madness bracket type of thing. Lot’s of yuks.
Ideally would be settled by a table, or pie chart, in the upcoming Mueller report. But, if not, AS and CR can judge.
different-church-lady
@Matt:
jl
@jl: Trump has probably oversold the shares in his presidency, so no reason to require that things add up to 100 percent.
jeffreyw
@zhena gogolia:
They are all butt-hurt because Mrs is severely curtailing their bird feeder stalking
Sab
@Brachiator: Yay you.
I have been trying to post all day and comments keep being eated.
TR Reid’s book should be read.
USA fucked up system v UK HSA are not the only two options. See TRReid.
I am really sick of people coasting on their (or spouses) employer provided insurance lecturing the rest of us on insurance. Obamacare sucks in many ways, but the actual insurance it provides is pretty good. I paid a lot for insurance in the private market for years, only to discover that I didn’t actually have insurance because of some alleged preexisting condition that I didn’t know I had.
Roger Moore
@Juice Box:
You’re also confusing single payer with sole provider systems. Universal coverage simply means that everyone gets health insurance, which could be public (with a mandate, subsidies, etc.) or private. Single payer means the government functions as the only insurance company and pays the premiums from taxes, like with traditional Medicare, but the health care is provided by private and/or non-profit care providers. Programs like VA and NHS take it a step further by having the government run the care providers and well as covering the cost from taxes.
Sab
@Kelly: A lot of providers don’t even know their prices. They ‘charge’ whatever insurance will pay, and they don’t take the uninsured. Have you been out in the healthcare marketplace lately?
Kelly
@Sab: ” A lot of providers don’t even know their prices.”
One of the things a publishing requirement would fix.
I have always been lucky enough to always have good insurance. I’d like to take luck out of the equation.
Mnemosyne
@Kelly:
This is tricky, because pricing depends on the contract that your insurance company has negotiated with that provider. They often can’t quote a price because there IS no fixed price.
When I was uninsured, I was able to negotiate one-on-one with providers for non-urgent care (like dermatology) and get lower prices than the “list” price they gave insurers.
We’re probably better off adapting the Medicaid/Medicare price list and telling providers, “If you bill for X procedure, you will be reimbursed Y.”
Sab
@Kelly: I see your point. My insurance often sucked. I am trying to avoid battling you (available target) when I should be battling elsewhere.
Mnemosyne
The horrible job that G was laid off from in 2015 was in the healthcare realm where they provided compounded in-home medication to patients.
They would occasionally have a patient want to pay out of pocket for something that their insurance wouldn’t provide, and there was LITERALLY no way to provide that price, because there was no actual list price. Every insurer paid something a little different and their “list price” was the agreed-upon amount that was blown up to reflect the “discount” in the contract.
People don’t realize that the huge patchwork of thousands of different contracts within EACH insurance company is an enormous issue when it comes to trying to even simplify our current system before we can improve it.
jl
@Kelly: Large providers, clinics and hospitals, do publish list prices for services, but they are rarely used. They are like sticker prices on cars on a dealers lot. They get referred to when some uninsured person is unlucky enough to get charged. No one else pays them. The transaction prices for anyone with insurance, or contracted coverage with a medical group differ substantially. I heard a news report of research that found many providers have no clue what the average prices of their services are. and have a hard time matching up their list prices to descriptions of procedures. Most countries don’t allow such confusion. Some states have systems that prevent such completely opaque pricing, I think Maryland had a system for in-patient acute care hospitals.
Sab
@Mnemosyne: @Mnemosyne: When I was uninsured my dermatologist told me to take a hike until I got insurance.
Betty Cracker
@Brachiator: I don’t think it’s belligerent to ask for specifics, particularly when responding to someone whose main point is that other people’s ideas lack specificity.
Yes. We spend far more than other developed countries, provide less access to care and get worse outcomes. Life expectancy is falling, infant mortality rates are a national disgrace, etc.
As I said at #33, the ACA is an improvement. But we can’t rest on our laurels, as jl at #82 argues convincingly (IMO).
Also IMO, there’s often a knee-jerk dismissiveness around here about people who aren’t satisfied with the progress we’ve made on healthcare — a tone, as if they’re great pampered babies who want everything for free or don’t understand how healthcare works or don’t appreciate PBO’s or the Democrats’ efforts to reform healthcare, blah blah blah.
No doubt there are ignorant, unappreciative babies out there making stupid M4A arguments, but there are also people who are really struggling in our improved but still deeply shitty system, and we dismiss their concerns at our peril.
Mnemosyne
@Betty Cracker:
Here’s the thing, though: ACA was never meant to be the be-all and end-all. It was meant to be slowly implemented over 5 years and then evaluated and improved.
However, since Republicans decided to bring lawsuit after lawsuit against it, the Obama administration had to spend all of its time preventing the original legislation from being totally gutted.
I think that you’re VASTLY underestimating how damaging it was for Medicaid Expansion to be voided by the Supreme Court. That was our road to universal coverage that could be slowly expanded up and out to cover everyone. Once that road was blocked, it made the whole edifice shaky.
The problem is not PPACA as a piece of legislation. The problem is that the Republicans successfully crippled it and people like you said, “See? That proves it was bad legislation all along if the Republicans were able to sabotage it!”
Newsflash: Republicans will sabotage Medicare For All, too, just like they sabotage traditional Medicare, because IT’S WHAT THEY DO.
Jesus, I’m sick of liberals blaming Democrats for Republican sabotage.
Bill Arnold
@LibraryGuy:
The most vociferous Medicare-for-all advocate/Single-payer I know is a far-right-wingnut (QAnon and the full spectrum of right wing conspiracy theories, directly pushed to his phone every few minutes). He flat out assertively asserts that the insurance-based system we have doesn’t work.
I see a potential budding coalition here. Three rights make a left, Three lefts make a right. :-) (Or other political spectrums that have been observed to wrap. :-)
Such a coalition could be built in the US IMO; would take some serious political skills.
Kelly
@jl: @Mnemosyne: @Sab: Chaotic pricing is a problem for cost control. If you don’t know what something costs how do you take any useful action? Many of the systems I worked on at Gigantic Global Tech Corp were to better track and thus control costs. Even there it was a constant struggle. It’s like weeding a garden.
I wouldn’t allow the insurers to keep prices secret. Publish the cash rate, BCBS rate, Aetna rate, etc. I’d like to move health care to a public utility model. Open up your books and apply for rate increases based on documented costs. It’s not perfect.
All of my examples are meant to illustrate a small ball approach to affordable universal health care.
Betty Cracker
@Mnemosyne: For the record, I don’t hold any of the positions you attribute to me in this bullshit comment. You’re spluttering away at strawmen.
Kelly
@Mnemosyne: “ACA was never meant to be the be-all and end-all. It was meant to be slowly implemented over 5 years and then evaluated and improved.”
Yep. The usual Republican break government programs to support their government is the problem bullshit.
Raven Onthill
I wrote a few more remarks on this, and then I turned to practical politics, and realized that there is no path to unity on this issue and yet we direly need to unify on other issues. There is no way I can decently tell sick people that they should just suffer, perhaps die, because we cannot resolve our internal conflicts. At the same time, I see little hope of such a resolution.
I’ll be following this remark with more on-topic commentary, but I wish we would all keep this in mind: above all, the opponents of fascism need to unify.
Raven Onthill
“Medicare for All,” as advocated by the social democrats and democratic socialists, means universal coverage without out-of-pocket expenses. The Sanders proposal can be read at https://live-berniesanders-com.pantheonsite.io/issues/medicare-for-all/. What would be covered and how the system would be funded is spelled out.
“a method to stop price gouging by insurers and providers with market power.” But this is why the insurance companies were brought on board; without guarantees that their profits would be maintained, even increased, they would have made the plan impossible to pass; it barely passed as it was.
As of 2017, the CDC found that 28.9 million Americans had no health plan. Full report: https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201805.pdf.
The ACA has huge coverage gaps (one of the largest is due to the Roberts Court.) Once people have enough income for the system to require insurance, the expenses fall mostly on working poor and lower middle-income people. This could, of course, be changed, but it would require either price regulation or higher taxes, both of which are going to be difficult.
The health insurance companies used to have full-time employees devoted to finding reasons to deny care to cancer patients, and other high-cost insureds. Is this not what most of you would call “evil?” I see no reason beyond expediency to give those businesses anything – they’ve made huge amounts of money.
Brachiator
@Betty Cracker:
Has any of this changed since the ACA was implemented?
We agree on this. Which again, makes me wonder, why the fight?
And again, this is my challenge. A politician (’cause this is why we vote for them to represent us) who says the ACA is a failure and must be scrapped and replaced by Medicare for All has to show me exactly where the ACA failed and exactly how an alternative will be superior.
Also, I will admit here one bias. I presume that anything I hear Bernie Sanders say about healthcare is bullshit. He seems to have spent 25 years admiring what European countries have done, but zero time in understanding it or in crafting a plan or even an outline. By contrast, people like Hillary Clinton or the late Senator Edward Kennedy developed solid proposals for health insurance programs.
And none of this has anything to do with anything that I have ever written, and certainly not with anything that I wrote here today.
I don’t dismiss anyone’s concerns. But as I noted, “Medicare For All” is a slogan, not an argument without details or even an outline.
Mnemosyne
@Kelly:
Okay, here’s one example:
I’m looking at Cigna’s PR “factbook” for 2017 that I found online. One of their bragging points is this:
That means that they have a minimum of 30 separate contracts for primary care with those large providers alone, and probably more like 200+ separate contracts, all with their own pricing, and that’s only for the largest groups.
Let’s take 200 contracts per insurance company as a conservative estimate, though. There are about 850 health insurance companies in the US, most of which will also have individual contracts with different health providers. That means that there are at least 170,000 existing contracts between providers and insurers out there that all have their own individual pricing.
Now add in the number of procedures that would need to be listed in this directory. Are we including lab tests, or just stuff the doctor does in his office? Take a look at your doctor’s coding sheet next time you have an appointment with your general practitioner. Then add in the number of codes for all of the different specialists. We’re getting close to millions of listings, if we’re not already there.
And consumers should be forced to wade through all of that just to figure out what they should be charged for X procedure?
That’s why I think a top-down solution is better than making consumers try to do all of the comparisons themselves.
Kelly
@Mnemosyne: I don’t expect consumers to handle any this individually. I expect advocacy groups, journalists, public agencies and ambitious politicians to attack the slices of the problem. I expect to flatten price differences across insurers and providers.
Mnemosyne
@Betty Cracker:
You’re complaining about people defending the PPACA. I’m pointing out that it’s only broken because the Republicans deliberately broke it.
Saying, Oh, the PPACA is a failure, now we have to do Medicare For All instead ignores the fact that Republicans are going to do their best to break that, too.
We need to face the fact that REPUBLICANS ARE BREAKING OUR SHIT, because they’re going to do their level best to break MfA as well. People need to get their heads out of the sand and accept that MfA is going to get broken before it can be implemented if the Republicans stay in power anywhere.
Medicare For All is not magic. It will get broken unless people are willing to defend it the way they never bothered to defend PPACA. Given how many people run down the PPACA without understanding what happened to it and why, I don’t have a lot of hope that MfA is going to fare much better in the courts. Your pony’s shit will still need shoveling, just like PPACA’s did.
tobie
@Betty Cracker:
I don’t see anyone on this thread defending the status quo. People have named a lot of specific ideas about how to guarantee quality, affordable and accessible healthcare for everyone. Where I think people differ is in the nature of the overhaul they envision. David’s post advocates for ‘messy’ solutions as in ad hoc solutions that can be implemented fairly quickly and easily without disrupting service. I gather you feel like this is like trying to repair a clunker of a car and at the end of the day you’re still left with a clunker.
I’d love to see serious attention paid to price controls for medical care. Private hospitals jack up costs. The privatization of drug testing has also inflated prices. I wonder if the Bayh-Dole Act, which allows people who develop products with NIH and NSF funding to apply for patents, has been such an engine for innovation. Don’t know enough to say but it bothers me that taxpayers pay for the innovation twice–in taxes that support the research and at the drugstore when buying the product. Who should own these patents?
Mnemosyne
@Raven Onthill:
So it will be different than existing traditional Medicare, which does have a monthly fee of $134 and usually has out-of-pocket expenses for the patient because it covers about 60 percent of the bill.
Mnemosyne
@Betty Cracker:
And, yeah, I’m a little annoyed that pointing out that Republicans deliberately sabotaged PPACA is hand-waved away as “knee-jerk dismissiveness.”
I feel like I’m jumping up and down on the deck of the sinking Titanic trying to point out to a nearby ship that, hey, that iceberg up ahead just sank our ship, and the MfA crowd is saying, “Full steam ahead — there’s no way that iceberg could damage our ship!”
gene108
Democrats need more than “What do we want? ” “Steady incremental change!!!”
That doesn’t inspire people.
We need something simple people can rally behind, and hopefully the folks proposing it have a clue on how to turn it into a workable law and system that can be implemented.
My concern with the M4A folks is they don’t have a clue (1) how single payer works in the USA or how it works in the rest of the world, and (2) have never actually created a piece of legislation before. I base my part one observation on the fact that Medicare and even the Canadian health system have out of pocket costs, insurance, etc. Canadian payments aren’t as steep as ours, but it isn’t free.
@Mnemosyne:
Medicare Part B covers 80%, with no maximum out of pocket. You get a large medical bill, you are on the hook for 20% of what Medicare will not cover. The one advantage you have is you are only responsible to pay 20% at the Medicare reimbursement rates, and not whatever the hospital bills. But otherwise this is why there are so many other parts to Medicare, as well as supplemental insurances sold to those on Medicare.
Also, Medicare Part B fees are income based. I don’t remember the cut-offs, but $135/month is what you pay below a certain income threshold. If you make more, you pay more, but I don’t remember what the income cut-offs and cost tiers are.
Older
@StringOnAStick: I was in your situation for years, but recently, my arthritis doctor told me that knee surgery had improved immensely since the last time I had considered it, and that it was time for me to consider it again. I looked into it, and it seemed that it was much improved, so I had the operation and it was wonderful! If your insurance will cover it, now is the time to have it.
My insurance situation is kind of odd, and could maybe be improved, at least as far as cost is concerned, but it really covers everything. So I don’t have any perspective on the costs of various treatments. But the operation itself was excellent. They kind of went overboard warning me about slow recovery and high pain levels, but better that way than the reverse.
Sab
@Matt: We tried incrementalism in 2008.
I got real insurance as a result. When my heart went whacko in 2015 we got medical help, which we wouldn’t have without insurance.
Sneer at incrementalism all you like, but in my case it saved my life.
Sab
@Kelly: This makes sense. Also, isn’t that what the French do?
J R in WV
@jl:
I think one good first step would be forcing price equality for everyone in the healthcare marketplace. Right now you can’t ask what something costs for any health care issue past your personal doctor’s services, and that sometimes varies according to what your specific insurer is willing to pay.
I was signed up for total shoulder replacement with no idea what the total costs would be, what my insurance would pay, what I would have to pay. In reality, when I went to the hospital where the surgery was to be performed for a pre-op physical with a very nice PA, I had to write a check for $200-300 or so. That was all I paid. I don’t actually know what the surgeon/anesthetist/hospital stay cost in total. My doctor could NOT tell me how much his recommended therapy was going to cost me!
That’s just wrong.
When wife was in hospital for 60 days, with two ICU stays, a minor surgery and a major surgery, early on in that adventure I realized there could be major costs. The ICU staff, when I asked, got a social worker to come up and see me. She had no way to tell me what our total costs would be, but when I told her wife had Medicare and Supplemental, she told me our costs would be relatively insignificant, and to spend all my effort on taking care of wife, not on worrying about the costs.
We did see a total bill for $350K or so, but our share was as promised a tiny, tiny part of that horror, including the home health care we received for a month or so.
Got to fix that murky no fixed price situation.
germy
Betty Cracker
@Mnemosyne: Man, you just dumped such giant loads of horseshit in this thread that shoveling it all will prove too daunting this close to cocktail hour, but I’ll give it a try.
First, I’m not “complaining about people defending the PPACA” — I’m saying that going into full flying monkey mode any time someone mentions M4A is divisive as fuck and will be exploited to divide the Democratic Party, prevent needed progress and elect Republicans. I’m saying that for every “neoliberal shill” there is an equal and opposite “purity pony,” and if we don’t get past that bullshit, stop making assumptions and start listening to each other in good faith, we’re all screwed.
Fair enough, but I didn’t say the ACA is a failure (contra your smarmy “people like you said” comment at #103) — I’ve repeatedly said it’s an improvement, but we still have a long way to go. I think M4A might be useful as a slogan, but I fully recognize the difficulties in translating a slogan into reality. I also fully understand that Republicans have sabotaged the shit out of the ACA and have never said otherwise, contra the bullshit views you erroneously and repeatedly attributed to me (and self-congratulatory prescience you ascribed to yourself) above.
If you can’t see how dismissive and annoying and counterproductive your approach here is, I can’t help you. And you and I are at least somewhat familiar with one another’s views and probably agree 90% of the time or more! This incredibly dumb conversation makes me even more pessimistic about how 2020 is going to play out.
sambolini
I’m sorry David, the only reasons to include the insurance and\or drug companies in this discussion is if your concerned with their compaign contributions or political attack ads. Neither of which the Dem’s should be.
Mnemosyne
@Betty Cracker:
I clarify more below, but I’m sorry that my blanket use of “you” was coming across as directed at, well, you. It wasn’t meant to be personal to you or to anyone here that I did not nym specifically, and I apologize for not being more clear.
People (not meaning you!) who start the conversation by claiming that the PPACA was a total failure because it was a sell-out to corporate interests will get no hearing from me. Sorry. They’ve already established themselves as someone who has no idea how our current system actually works and how many corporate interests are deeply embedded into Medicare as it exists today.
Then you are one of the very, very few people online who use the phrase that way. 90 percent of the people I talk to online who use it have NO IDEA that people currently on Medicare have to pay for it. They really think that everything is free. And if I try to correct them, they tell me that I’m lying and call me a neoliberal corporatist shill and block me. It gets a little wearing.
I’m happy to listen to people who have ideas for how to fix our broken system, and I’ve proposed a couple myself. I have developed an allergy to the phrase “Medicare For All” because the vast majority of people online who use it as a shibboleth (again, I don’t mean you personally!) don’t understand how Medicare works and think it’s free. See Ravenonahill’s comment above, which is based on a completely false understanding of how Medicare actually works today.
And, yes, we probably will have trouble in 2020, because a whole lot of people (again, I do not mean you personally!) think that the MfA slogan means free healthcare for everyone just like people on Medicare get right now and refuse to listen to anyone who points out actual facts. I honestly don’t know what to do about that.
Mnemosyne
@sambolini:
Before we discuss this, please define what “Medigap” is in relation to our current Medicare system. Thank you.
sambolini
@Mnemosyne: Is this a test? As someone who’s 8 months away from Medicare AND counsels seniors on it, I can assure you I know the system very well.
You’ve must got everyone in this thread calling you an asshole. So I’m not having a discussion with you. One of the serious poster maybe. Request respectfully declined.
sambolini
@gene108: To get surcharged, the limits is pretty high. Married filing jointly it’s about $175,000 annually MAGI. So way into the top 10% of filers. And at that point the increase is about $50 per month. Source: Filing paperwork to have it waived right now, based on a big decrease in income in 2018 dropping us under that limit.
Mnemosyne
@sambolini:
So you know personally how deeply embedded insurance companies are in the current US Medicare system and you still think they can be removed from that system quickly and easily?
All righty then. You do you.
sambolini
@Mnemosyne: God, it’s probably a waste of time to engage you. Who said that? What I said was that they don’t get a say. After all, the government engages them AND subsidizes their profit. Do you thing supplemental and advantage plans run at a loss out of the goodness of the insurance companies heart? We pay. We say.
Mnemosyne
@sambolini:
I’m looking at the Medicare.gov website. They are saying that the majority of Medicare recipients pay the minimum charge per month of $135.50 (for 2019), which is generally deducted automatically from their Social Security check or other government pension. Are you filing a form to not have to pay any monthly fee at all, or to reduce yours to the standard fee?
I am genuinely confused because I have a lot of people online tell me that current Medicare is zero cost to the recipients, which does not match up with what’s on the Medicare.gov website or what people on Medicare have told me.
sambolini
@sambolini: God, it’s probably a waste of time to engage you. Who said that? Misquoting people to set up your poor arguments again. What I said was that the insurance companies don’t get a say. After all, the government engages them AND subsidizes their profit. Do you thing supplemental and advantage plans run at a loss out of the goodness of the insurance companies heart? We pay. They profit. We say. Of course the goal is to eliminate them. For which, again, we don’t need their permission. Probably your in your mind.
Gex
@Bill Arnold: you think they are going to vote for a party that supports POC and queer equality? Our entire problem is they won’t vote for what they need if they can’t also create a second class citizenship (or humanity) for us.
I remember us queers getting yelled at in 2009 because health care reform was more important than marriage equality. And I don’t disagree. I just notice that there’s ALWAYS higher priorities and the requests for waiting and sacrifice always go one way.
I ask again, trepidatiously, how you get them into this coalition.
Jerry
I don’t see being able to cut out private insurance companies from the system without a million lawsuits popping up to prevent that from happening.
Mnemosyne
@sambolini:
Do they get control? Of course not. But most online people calling for Medicare For All seem to think that we can burn all private insurance companies to the ground because current Medicare pays for everything.
Based on our current system, our next interim step would probably be to offer employers who offer insurance to their employees something like the Swiss system: mandated and closely-regulated basic health insurance coverage is issued by a nonprofit arm of the insurance companies, which are then allowed to sell supplemental policies for things like hospital room upgrades at a profit.
I’ve had Aetna as an insurer. I know insurance companies have no heart. That’s why they need to be heavily regulated and scrutinized by the government at all levels (federal, state, and local). The fact that our government is derelict in its duty doesn’t mean that it’s useless to scrutinize them so we should just shut them down. It’s amazing how well regulation works once companies figure out that they can’t weasel their way out of being regulated.
In my ideal world, for-profit healthcare would cease to exist in ALL segments of our system. It doesn’t do us any good to get rid of for-profit insurers while for-profit hospital systems like Tenet and HCA are bleeding the system dry. Removing for-profit insurance from the equation is an important step, but it doesn’t fix the underlying problem that we have a for-profit system at every level, not just the insurance level.
Mnemosyne
@Gex:
I totally agree with your point to Bill Arnold that the QAnon and other right-wingers are not going to join a coalition where they have to treat Those People (as defined by race, gender/sex, sexual orientation, religion, etc) as their equals. They would rather maintain their superiority than have healthcare for all.
I know that marriage in particular is still a sore spot for you because it came months too late, but we did get both healthcare reform and equal marriage. DADT (which was an important first step to full marriage equality) was repealed the same year that PPACA was passed. I do think that happened when it did in part because Congressional Democrats were aware that they had asked LGBTQ people to wait until PPACA was done and knew that they needed to keep that promise.
jl
@J R in WV: In a Medicare for all system, as in Australia, the government decides what to pay, and negotiations proceed through what industry is willing to offer, and what taxpayers willing to fund. Then providers will pay more attention to careful more or less what is a reasonable uniform price, adjusted for region, metro, etc., I suppose.
in Swiss system, industry provider cartels, and that includes an associations for the physicians, one for pharmacists, nurses, etc., negotiate a price band. IANAL, but I see lots of problems with that legally and constitutionally in US. Seems like a dissatisfied supplier would sue for restraint of trade. So if US decides to ‘Go Swiss!’ will probably have to look at best feasible way to stop price gouging.
Having a mandatory uniform minimum benefit design helps, I think, since everyone will be same boat unless they want to pay more through a supplemental policy.
Bill Arnold
@Gex:
You do have a pretty good point; it is possible that even a narrow right/left coalition focused entirely on a US health care reformation would demand too many compromises to be worth pursuing. Perhaps not though, e.g. perhaps a coalition could be built that does not include the problematic religious right people. (I do not have the political skills(z) to make a convincing plan.)
TBH I haven’t researched the conservative (small c) arguments for single payer health care but here’s a quick start:
http://pnhp.org/take-action/reaching-out-to-conservatives/ (2018)
https://www.theamericanconservative.com/articles/the-conservative-case-for-universal-healthcare/ (2017)
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=A+Conservative+Case+for+Universal+Access+to+Health+Care&btnG= (2006; that link gets me a pdf)
Bill Arnold
@Mnemosyne:
Not entirely sure about this. My sample-size-one right-wingnut for example reserves his dislike for Islamists (He’s Jewish). Democrats are not hated, just considered deluded/confused. (Had some fun recently showing him B. Obama’s list of things he authored while President.)
Bill Arnold
If DJ Trump really cared about borders, he wouldn’t have defunded Homeland Security. Including the Coast Guard.
Despite Government Shutdown, Homeland Security Border Patrol Remains on the Job. And Unpaid
He just cares about a win, a number > 0 that he can brag about. (Pelosi was a little early with the Emperor’s New Wall rhetoric IMO.)
(And people have voiced un-evidenced suspicions about kickbacks from a wall vendor, but that remains to be investigated.)
Bill Arnold
[oops wrong thread]
Bill Arnold
[oops wrong thread for last comment]
rikyrah
@laura:
I couldn’t agree more with you
Lower the age for Medicare to 55.
sambolini
@Mnemosyne:
“Are you filing a form to not have to pay any monthly fee at all, or to reduce yours to the standard fee?” The latter. Not 100 sure but I believe you can not get out of the basic fee.
“I am genuinely confused because I have a lot of people online tell me that current Medicare is zero cost to the recipients,” And those people are misinformed. I’m not. Be like me.
Sab
Great. So Mnemosyne, who has full healthcare at Disney, decides to hijack our thread and entertain a troll because mnem is bored during the holidays. To some of us this is life and death, but that doesnt matter because Mnem is bored.
sambolini
@Bill Arnold:
Damn you, I’m not supposed to laugh this much so close to bedtime.
Chris Johnson
Thank you. See, I can go along with this. I’m one of the poster children for ‘graaah burn it all’ but this, I can completely get along with.
My concern is simply that there is NOT regulation, the weaseling is all, and it’s getting worse under Republican administrations. On top of that, I think that really serious regulation risks hurting the profits of the insurance companies because that’s what it’s for and they’re not supposed to be such an enormous profit center of the economy holding us all hostage in the first place! I have absolutely no trust that I’ll be free of getting billed like a retired Baby Boomer with two pensions and cadillac coverage. Everything in my whole life adds up to about one-and-a-half serious medical crises, and then I’m bankrupt and can’t protect myself in myriad ways.
I like to hear about this determined regulation. But I also like that Betty is patiently and firmly advocating, because I get too upset. My life means shit to these people, and I just don’t make enough money to suit their tastes and budgets… and the system isn’t great at making allowances for this.
David ??Merry Christmas?? Koch
How is it Wilmer failed to pass single-payer in Vermont?
If he can’t pass there, then how can it pass anywhere else.
Matt
Your post is exactly why the Democrats lose once they are in power. Half the party wants the start debates at the 50 yard line. “That lefty plan is too crazy, it will scare the people!” I disagree. FDR was successful because he threatened the rich and the conservatives with far left ideas, and then settled for something in the middle. Politics is about fighting for as far left a proposal as you can, and then when that scares the crap out of the rent seekers and entitled rich, they realize they may lose something and accede to something that works better for the poor. Bernie is the perfect candidate, because he scares the crap out of the capitalists and pushes things that are popular among voters. His proposals may be pie in the sky, but at least they may cause the powerful to compromise for something better for the common man, in place of something that would hurt their bottom line. It’s possible that there are other candidates who can do the same, but Obama and most Senate Dems are not amongst that group. I think Beto might understand the politics of power, so he might be another candidate I support.