Bernie Sanders Brings Us One Step Closer To A Single-Payer Health Plan

Bernie Sanders has introduced legislation to establish a single-payer health care plan, as he promised during his run for the Democratic nomination. In an op-ed in The New York Times he wrote Why We Need Medicare for All beginning with describing the problem we face:

This is a pivotal moment in American history. Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive health care to every person as a human right? Or do we maintain a system that is enormously expensive, wasteful and bureaucratic, and is designed to maximize profits for big insurance companies, the pharmaceutical industry, Wall Street and medical equipment suppliers?

We remain the only major country on earth that allows chief executives and stockholders in the health care industry to get incredibly rich, while tens of millions of people suffer because they can’t get the health care they need. This is not what the United States should be about.

All over this country, I have heard from Americans who have shared heartbreaking stories about our dysfunctional system. Doctors have told me about patients who died because they put off their medical visits until it was too late. These were people who had no insurance or could not afford out-of-pocket costs imposed by their insurance plans.

I have heard from older people who have been forced to split their pills in half because they couldn’t pay the outrageously high price of prescription drugs. Oncologists have told me about cancer patients who have been unable to acquire lifesaving treatments because they could not afford them. This should not be happening in the world’s wealthiest country…

This has divided the Democratic Party. Hillary Clinton ran a dishonest campaign against Medicare for All during the primaries, and remains opposed. Much of the Democratic leadership, which badly needs to be replaced, is also opposed. Several of those being mentioned as candidates in 2020 are supporting the plan, showing that they realize this is where a leader of the party must be.

Al Franken has blown apart Hillary Clinton’s arguments against Sanders, showing that supporting Medicare for All is not an attack on Obamacare or Medicare as Clinton falsely claimed. Politico reported:

Sen. Al Franken (D-Minn.), who has been mentioned as a possible 2020 candidate, also expects to sign on to the single-payer bill, a spokesman said Tuesday. Franken noted that his cosponsorship reflects the bill’s status as a long-term goal while the party continues short-term work on Obamacare.

“This bill is aspirational, and I’m hopeful that it can serve as a starting point for where we need to go as a country,” Franken said in a statement. “In the short term, however, I strongly believe we must pursue bipartisan policies that improve our current health care system for all Americans — and that’s exactly what we’re doing right now in the Senate Health Committee, on which both Senator Sanders and I sit.”

Yes, we can defend Obamacare and support improvements, including a Medicare buy-in and a robust public option if that is something more quickly obtainable, while also understanding that a single-payer plan must be the ultimate goal.

Many centrists, both within and outside of the Democratic Party, remain opposed. Jonathan Chait misses the point when he argues that Bernie Sanders’s Bill Gets America Zero Percent Closer to Single Payer. This is not the first time Sanders has introduced legislation to promote a single-payer plan. This is also not the bill which will ultimately establish it. What Sanders has done has made single-payer the goal of the left and many on the center-left. This is analogous to making support for same-sex marriage the expected position of a Democratic leader to the degree that even Hillary Clinton had to alter her position prior to running in 2016, no matter how much this conflicted with her socially conservative beliefs.

The Affordable Care Act was a tremendous improvement over the system we had before, for the first time providing access to coverage which could not be taken away based upon one’s medical condition. However it did very little to change the reality that coverage on the individual market is expensive. Ironically, Republicans are pushing the inevitability of a single-payer plan without realizing it. This includes Republicans in state governments who have denied access to the expanded Medicaid plan to those in several states, and Donald Trump who is trying to destabilize the marketplace plans.

With the limitations of Obamacare, a single-payer plan is the only idea which makes long term economic sense. A majority of doctors have come around to realizing this. Bernie Sanders is now making the Democratic Party acknowledge this. When Obamacare was first being considered, discussion of single-payer plans was blocked. Bernie Sanders has made single-payer part of any discussion of further health care policy.

Vox, A Voice Of The Democratic Establishment, Now Realizes That Bernie Sanders Is The Democrats’ Real 2020 Frontrunner

During the 2016 campaign, Matthew Yglesias and Vox were often seen as a voice for Hillary Clinton and “Neoliberal Corporatism.” It is with this background that I find it significant that Yglesias now proclaims that Bernie Sanders is the Democrats’ real 2020 frontrunner. While many establishment Democrats continue to resist Sanders and his supporters to various degrees, there are signs such as this that others are acknowledging this reality.

The post by Yglesias makes some points which I have made in the past, leaves out some things of significance, and does have some interesting material which Sanders supporters might not be aware of.

Yglesias does repeat a point I have made previously, both in the context of one reason why Sanders lost, along with an explanation for why Sanders went on to back Clinton and try to work with the establishment. It is important to understand how things looked before Sanders entered the race. Clinton’s nomination appeared inevitable and nobody (including Sanders) thought he had a chance. Sanders two main goals were to force Democrats to consider his economic views, and to strengthen his position in the party in order to push his priorities in the future. As Vox put it:

By the time it was clear the Sanders 2016 campaign had legs, it was already fatally hobbled. Almost no one believed in the summer and fall of 2015 that he stood any chance of beating Hillary Clinton — and that included Sanders himself. As Patrick Healy and Yamiche Alcindor reported last April, he “was originally skeptical that he could beat Mrs. Clinton, and his mission in 2015 was to spread his political message about a rigged America rather than do whatever it took to win the nomination” and only began to really focus on trying to win when his poll numbers unexpectedly soared in early 2016.

Consequently, labor leaders who sympathized with Sanders’s critique of Clinton didn’t give any serious thought to actually endorsing him. Instead, they used his presence in the race as leverage to extract concessions on issues like the Trans-Pacific Partnership and the Cadillac tax on high-value health insurance plans from Clinton.

And since Sanders was running to raise the profile of his issues rather than to win, he didn’t bother to develop much in the way of answers to foreign policy questions, even though Clinton’s record of support for the 2003 invasion of Iraq and her hawkish instincts were some of her biggest vulnerabilities with the Democratic Party base.

Elected officials were almost uniformly afraid to endorse him, even if their policy views were closer to his than to Clinton’s, and left-of-center think tanks — including ones that are deliberately positioned to the left of mainstream Democrats ideologically — shied away from working with Sanders on policy development, for fear that Clinton’s wrath would destroy them if they did.

I would also add that the view that he could not win also affected Sanders’ early strategy. He continued to work in the Senate and initially only campaigned part time. If he realized how close the campaign would be he might have campaigned more in 2015, including going to the Super Tuesday states and work earlier to increase minority support. He might also have protested more about the lack of early debates, and made an issue out of Clinton’s scandals.

The lack of early debates also brings up another point which Yglesias ignored–the degree to which the nomination was rigged for Clinton from the start. There was undoubtedly pressure to clear the field for her, and Wikileaks made it clear that the DNC was not following their own rules about neutrality. This has further been confirmed in the class action lawsuit against the DNC.

Rules since McGovern, including Super Delegates and front loading the process with southern states, were specifically written to get a more conservative nominee. The irony is that they failed to change with the times, and these rules gave the Democrats a nominee who could not even beat Donald Trump, while harming a strong general election candidate such as Sanders when he did arise.

Rather than reverse the outdated rules, the Democrats instead altered the rules even further in 2016 to help Clinton. This included limiting debates, changing fund raising rules, and refraining from announcing the popular vote in Iowa, which Sanders probably won, as was done in 2008. Harry Reid’s actions in Nevada, at a time when he claimed to be neutral, also helped tilt the race towards Clinton. Despite the primary process, Hillary Clinton was chosen in back rooms by the Democratic establishment in 2016 in a manner which was little different than how parties picked their nominees in the proverbial smoke filled rooms in the past, ultimately costing the Democrats the election.

Things will be different in 2020. Yglesias also points to how Sanders is building a team to expand upon the issues he raised in 2008. As I noted again yesterday, among the major reasons I supported Sanders were his opposition to the Iraq war and the Patriot Act, as opposed to the major issues he campaigned on. A future campaign will hopefully include these issues. Yglesias wrote:

Earlier this year, Sanders — who doesn’t sit on the Foreign Relations, Armed Services, or Intelligence Committees — quietly added to his team Matt Duss, a veteran Middle East analyst known for looking askance at America’s tendency toward uncritical alliance with Saudi Arabia and Israel. It’s a clear sign that Sanders, who had a keen interest in left-wing foreign policy as mayor of Burlington but hasn’t had much of a profile on the issue in Congress, is serious about being able to play competently on the full spectrum of issues.

Sanders also picked up Ari Rabin-Havt, best known in recent years for his Sirius XM radio show but previously an adviser for Harry Reid in his early years as Democrats’ Senate leader.

While Sanders is deepening his team in Washington, his national political organization Our Revolution is diligently working to get Sanders supporters elected to state and local offices. Critically, the list of Our Revolution winners — a group that includes House members, state legislators, state party chairs, and even city council members — is quite ethnically diverse. His camp is aware that 2016’s African-American outreach strategy was flawed in both concept and execution, and he’s setting himself up to be able to count on black and Latino elected officials from all regions of the country as surrogates while also courting national leaders like the NAACP’s William Barber.

Yglesias also says that Sanders is moderating his views, but if true he does remain well to the left of Hillary Clinton. While Clinton campaigned against single payer health care, Sanders continues to push for Medicare-for-all. I cannot disagree with Yglesias when he points out that Sanders’ age could be a problem in 2020. We will have to wait and see if he is still up to running. The post did look at other possible candidates should Sanders not run, concluding by saying that “Among the Bernie faithful the most frequently named fallback candidate isn’t the well-known Warren or labor-liberal warhorse Sherrod Brown. It’s Nina Turner…”

Yglesias ended with a strong argument that “It’s time to take Bernie Sanders seriously”

The Democratic Party establishment is, in many respects, in worse shape than it realizes.

Sanders’s insurgent campaign revealed a Democratic Party electorate that is fairly eager to embrace an ideological champion as a progressive counterpoint to the decidedly conservative GOP. The notion of pragmatism continues to carry weight, but having lost control of all three branches of the federal government and blundered to a point where Democrats don’t control the state Senate in New York or the governor’s mansion in Illinois, party leaders’ credentials as strategic masterminds are in question.

Last but by no means least, relying on African-American voters as a bulwark against left-wingery, as Clinton did, is tenuous as black views on economic policy are generally quite left-wing. Democrats now rely heavily for votes on the large — and very Democratic-leaning — millennial generation that lacks clear political memories of the Cold War or the booming neoliberal economy of the 1990s, so “socialism” isn’t a scare word for them, even as it remains unpopular nationally.

Sanders became their champion over the course of 2016 and continues to hold that status now. But while in 2016 he faced a unified — and intimidating — opponent and launched with a ramshackle campaign, today he has a strong national political organization, a proven fundraising track record, and is moving decisively to address his weak points on international affairs, policy development, and minority outreach. Everyone agrees that in a perfect world he’d also wave a magic wand and scrape 10 or 15 years off his age, but that’s not possible. The movement he’s created lacks an obviously more compelling successor, and he continues to be broadly popular with the public.

Predicting the future is a mug’s game. But if Bernie Sanders runs again, he’ll be hard to beat. And as far as one can tell, he’s doing everything you would do to set yourself up to run again.

While I often disagreed with Yglesias during the 2016 campaign, this is a far more realistic viewpoint than he expressed previously, and far more realistic than the delusional account of the race which Peter Daou posted on Facebook today.

Republicans Willing To See Over 200,000 Die In Order To Give Tax Cut To The Wealthy

The Republican efforts to repeal and replace Obamacare have been stalled due to the devastating report from the Congressional Budget Office showing that 22 million people would lose health care coverage. Only 12 percent of Americans back the plan according to a USA TODAY/Suffolk University Poll. They did find considerable consensus that any health care plan include the following:

  • Pre-existing conditions: More than three-fourths, 77%, say it is “very important” that the health care system permit people with pre-existing medical conditions to buy health insurance at the same price as others. Just 6% say that protection isn’t important to them. The Senate bill requires insurers to accept those with pre-existing conditions, but it allows states to seek permission to reduce required benefits. Some patients could face dramatically higher costs or lifetime limits for treatments no longer defined as essential.
  • Medicaid expansion: Nearly two-thirds, 63%, say it is “very important” that lower-income people who became eligible for Medicaid through the Affordable Care Act continued to be covered by Medicaid. Just 10% say that isn’t important to them. The nonpartisan Congressional Budget Office estimates that the Senate plan, which would cut Medicaid spending by $772 billion over the next 10 years, would result in 15 million fewer people being covered.
  • Lower premiums: Close to six in 10, 57%, say it is “very important” that insurance premiums go down in price; 17% say that’s not important. The CBO predicts that premiums would rise for a few years under the Senate plan, then fall by about 30%. But overall health care costs would go up for most people because deductibles would be higher and some states wouldn’t require insurers to provide some benefits that are now mandated.

A growing number of Republican Senators are also opposing the plan, necessitating major changes if there is any chance for passage.

While Republicans claim that repeal of Obamacare is necessary because the program is collapsing, the CBO report on the Republican plan reaffirms statements in previous reports that these Republican claims are false. The current Congressional Budget Office report states:

Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan.

It also needs to be kept in mind that premiums for plans on the individual market typically had double digit increases annually prior to the passage of the Affordable Care Act, and that this is not a new problem created by Obamacare. Unlike insurance plans sold before Obamacare became law, current plans have limits on out of pocket expenses, no lifetime maximums, and cannot be cancelled by insurance companies when people became ill. Of course there also were no subsidies to assist with paying for the plans. It was also commonplace to have limited options and to see insurance companies leave markets prior to Obamacare.

The actual problem with Obamacare is that it did not go far enough. A public option  or Medicare buy-in was necessary to provide more affordable care for those who do not obtain coverage through an employer or government plan. Expansion of Medicare to all would also have provided a more cost effective solution.

Vox looked at the likely effects on mortality should the Senate Republican plan pass, estimating that there will be 208,500 additional deaths over the next decade:

Drawing on that work, we estimate that if the Senate bill becomes law, 22,900 excess deaths will occur in 2020 — and the figure will grow over time. 26,500 extra deaths will take place in 2026. Over the next decade, we estimate that a total of 208,500 unnecessary deaths will occur if the law is passed (see Table 1).

We also calculate anticipated additional deaths, state by state, using state-level coverage losses for the year 2026 (see Table 2). The predicted excess deaths by state range from 30 in North Dakota to 2,992 in California in 2026 alone.

Some commentators have argued that it’s inappropriate — beyond the pale — to suggest that people will die as a result of this legislation. To the contrary, we contend that no debate over a health care policy can ignore evidence that it could have negative effects on health and mortality.

In making these calculations, we draw on the scientific literature demonstrating that expanding health insurance reduces deaths. We specifically apply the results of a particularly robust study of the effects of health care reform in Massachusetts on mortality. Massachusetts’ health care reform — which expanded Medicaid, offered subsidized private insurance, and included an individual mandate — famously served as a model for the ACA. The Massachusetts study looked at county-level mortality data in 2001 to 2005 (pre-reform) and 2007 to 2010 (post-reform), and compared the changes to carefully selected control groups in other states that had not enacted health reform.

Over 200,000 deaths is a high price to pay in order to provide tax cuts for the ultra-wealthy, which appears to be the major goal of the Republican plan.

Republicans Vote To Deny Health Care Coverage To Millions But It Is Far From Certain That Democrats Can Take Advantage Of This

The lie of the week is that the Republican-controlled Congress voted to repeal and replace Obamacare. Repeal yes, but the law they passed is too worthless to seriously be called a replacement. Republicans voted to deny health care coverage to millions, and to open the door for insurance companies to deny coverage for preexisting conditions. Doctors, insurance companies, hospitals, AARP, and many consumers groups are unified in opposing this legislation. Fortunately even some Senate Republicans realize that this is a terrible plan and want to start from scratch.

To summarize the effects of the House plan:

  • Tax cuts for the wealthy–always a Republican priority
  • Defunds Planned Parenthood for one year
  • Allows older Americans to be charged more
  • Cuts benefits to Medicaid recipients
  • Cuts school services for disabled children
  • Could weaken employer sponsored health care along with plans sold on the exchanges, including removing coverage for the essential health benefits now in Obamacare, and removing prohibition on annual limits of coverage

The House plan could return us to the days when insurance companies made their profits by taking in premiums but finding ways to avoid paying out money on claims. Only selling insurance to the healthy very well could result in lower premiums, but this defeats the purpose of having health insurance. Republicans claim to be funding high risk pools to care for those with preexisting conditions, but they are only providing funding to cover five percent of those with preexisting conditions.

Of course, this will depend upon what happens in the states, and how many red states actually do opt out of the current requirements. Scott Walker has already stated he might apply for a waiver for coverage of preexisting conditions in Wisconsin.

Democrats are excited that this will help them politically, with some saying that the GOP just doomed itself. Even those who support many of the GOP goals see this plan as being politically damaging for Republicans.

Health care should dominate politics in upcoming cycles, but Democrats cannot count on this by itself being the key to retaking control of the House. Democrats need to keep up the pressure and do a far better job of making their arguments than they did when the Affordable Care Act was initially passed. It is questionable if anything resembling the House plan will ever pass the Senate and become law. (Presumably Donald Trump will sign whatever the Republicans pass, regardless of how much it violates his campaign promises).

Democrats could have the same problem in capitalizing on this as they did in promoting Obamacare. While some might lose insurance coverage immediately, many others might feel safe, not realizing that developing a medical problem could put them at risk of losing coverage in the future. Some will even be happy as young, healthy people very likely could wind up paying less–as long as they remain young and healthy. The adverse effects of this law won’t be fully apparent in 2018.

The Democrats could also lose due to their political cowardice. During the 2016 presidential campaign, Hillary Clinton opposed Bernie Sanders’ proposal for Medicare for All. Truthout debunked Clinton’s arguments. Now Nancy Pelosi and the Democratic establishment are refusing to take this opportunity to push for a single payer plan. The Observer’s view of Pelosi and mainstream Democrats is quite close to that expressed previously by Truthout:

Their failure to support a proposal that the majority of their base wants illuminates the growing disconnect between elected officials and their constituents and the massive influence of the health insurance and pharmaceutical industries. Americans want single payer health care, and the obstacles blocking them from the system they want are special interests, which are bought and paid for Democrats in office who avoid taking principled stances on issues. Democrats like Pelosi don’t stand for anything because fighting for something like single payer health care would upset the party’s wealthy donors.

Pelosi’s and other Democrats’ arguments excuse themselves from supporting progressive policies and reaffirm the Democratic Party as a corrupt entity tied to the wealthiest 1 percent of Americans. On May 1, the Washington Post reported a poll conducted in January among Trump voters who had previously voted for Obama. When those polled were asked what the Democratic Party stands for they gave responses like, “The 1 percent,” “The status quo” and “They’re for the party. Themselves and the party.” One woman, asked whether the Democratic Party is for people like her, flatly declared, “Nope.”

As Donald Trump has learned, health care is complicated. You cannot reduce costs without reducing coverage, unless you make fundamental changes in the system. The most obvious way would be a single payer plan which both removes the huge profits of the insurance industry and places everyone in the same risk pool. In hiding from this reality, Democrats show why they tend to lose and Republicans have been winning. Republicans did not care that their ideas have been far out of the mainstream. They pushed their ideas until they won over enough people to win, even if it has been on fallacious arguments. The party which stands for something, regardless of what it stands for, has an advantage over a party which stands for nothing. Thus we have seen the Democratic losses in 2010, 2014, and now 2016.

Shattered Shows The Dishonesty & Desperation Of Clinton Campaign In Responding To Bernie Sanders

No matter how much Clinton supporters want to deny the facts, reality keeps intruding. Over the past several months multiple media fact checkers have verified the criticism that I, and many others, have made against Clinton. Government investigations, including the FBI and the State Department Inspector General, have verified Clinton’s violation of the rules and repeated lies to try to cover-up her actions. Wikileaks provided further confirmation of actions by both Clinton and the DNC. The publication of Shattered: Inside Hillary Clinton’s Doomed Campaign, which I have previously posted excerpts from here and here,  provides further journalistic evidence. Also see the excerpt I have posted from Insane Clown President: Dispatches from the 2016 Circus by Matt Taibbi on Hillary Clinton.

Possibly the most conclusive evidence that the criticism of Clinton was valid was how she lost what should have been an easy to win election against a candidate as terrible as Donald Trump. The post-election attempts from the Clinton camp to blame Russian influence, James Comey, Bernie and/or Stein supporters, and others is just further evidence of Clinton’s dishonesty and unwillingness to ever take responsibility for her own mistakes.

Shattered provides considerable background material which shows why it was a mistake for Democrats to nominate Hillary Clinton. I have already posted some additional excerpts such as this one on Facebook, and now plan to post more excerpts as blog posts. This one shows the dishonesty, and desperation, of the Clinton campaign in responding to the challenge from Bernie Sanders:

So on January 12, a day after Joe Biden had praised Sanders’s “authenticity” on the issue of income inequality and said it was “relatively new for Hillary” to talk about it, Chelsea Clinton lit into Sanders as she stumped for her mother in New Hampshire. It was odd for the candidate’s daughter to become the vehicle for an attack, but the Clintons were spoiling for a fight. It was better that a charge come from someone other than the candidate, so that Chelsea’s words could be embraced or rejected by Hillary depending on how they played.

“Senator Sanders wants to dismantle Obamacare, dismantle the CHIP program, dismantle Medicare, and dismantle private insurance,” Chelsea said of Sanders’s Medicare-for-all health care plan. “I don’t want to empower Republican governors to take away Medicaid, to take away health insurance for low-income and middle-income working Americans. And I think very much that’s what Senator Sanders’ plan would do.”

Across the Democratic universe, and particularly in Sanders’s camp, the dusting off of the Clintons’ scorched-earth playbook was taken as a sign of desperation. And accurately so. “I was surprised and thought it was out of character,” Arizona congressman Raúl Grijalva told The Hill newspaper. “It seems the Clinton campaign is going into full destruction mode very early in this process.”

The fact-checking website PolitiFact instantly rated Chelsea’s claim as “mostly false.” The attack previewed an angle Hillary would take—that Sanders was so liberal he rejected Obama’s legacy—but it gave Sanders and his allies a perfect opening to stab Hillary back. When he was asked about it, Sanders smiled and replied, “As much as I admire Chelsea, she didn’t read the plan.”

The episode reinforced the idea that Clinton was running scared. It reminded Democrats that Hillary would go negative and do it dishonestly, and she had turned to her daughter to defend her. The Clinton campaign insisted that it was an unplanned moment. But when Bill Clinton did the same thing a week later, also in New Hampshire, it was pretty clear that the Clinton family still didn’t believe that the risk of a low-approval candidate attacking a well-liked one outweighed the prospective gain of drawing blood.

Further excerpts to come.

Republican Failures On Health Care Raise Calls For Single-Payer Health Plan

The failure of  the Republican attempt to repeal Obamacare is a tremendous defeat for Donald Trump, along with Paul Ryan, which may hinder their ability to pass other parts of the Republican agenda, such as rewriting the tax code. The inability of Republicans to come up with a reasonable solution for our health care problems highlights the inability to solve the problem by relying on the market, and has revived calls for a single-payer health care plan.

The Week has this argument for Why Democrats should push ‘Medicare for all’ now even before it the Republicans gave up on their plan:

The AHCA is a monstrous bill that would leave at least 24 million more people uninsured by 2026. But whether or not it fails, the Democrats shouldn’t sit idly by and wait for Republicans to slowly bleed ObamaCare to death by other means. They need a counter-offer, one that’s more compelling than the creaky status quo. They need a single-payer, Medicare for all plan. Here’s why.

The first reason is that single-payer is quite clearly the best universal health-care policy option for the United States. As Dr. Adam Gaffney explains, the U.S. model of multi-tiered health insurance has generally lousy and highly unequal outcomes, both here and in European countries with similar structures like the Netherlands. Complicated public-private hybrid systems mean much larger administrative costs, and the fact that markets are extraordinarily ill-suited to deliver health care means tons of difficult regulation.

Indeed, the distance in uninsured people between ObamaCare and single-payer is actually greater than that between ObamaCare and the Republican plan. Complicated, janky programs tend to let people fall through the cracks.

..The AHCA is extraordinarily unpopular because it takes coverage and subsidies away from people, and a majority believe that it should be the government’s responsibility to make sure everyone is covered. Fundamentally, Medicare is very popular, a fact only partially covered up by generations of red-baiting and duplicitous austerian propaganda. If Democrats had simply bulled ahead with a single payer-esque plan in 2009, instead of the complicated and heavily means-tested ObamaCare, they almost certainly would have done better than they actually did in the 2010 election.

And even for people who are skeptical of going full-bore all at once on single-payer, it still makes an excellent opening bid. Start with single-payer for all during the next bite at the health-care apple, and you could end up with a plan of combining Medicare and Medicaid, enrolling all people under 26 and over 55, and putting a Medicare buy-in on the ObamaCare exchanges. (That might begin chipping away at the employer-based system and be a somewhat more gradual route to single-payer.) Just witness the original opening bid for ObamaCare, which was far more generous before it got badly whittled down by conservative Democrats…

It also makes an excellent organizing signpost. Medicare for all is simple, easy to understand, and hard to argue against or distort. Most people know someone on Medicare who can testify to the generally good care, or who is counting the days until they can enroll and have the peace of mind that comes with quality coverage. Fabricated agitprop like the mythical ObamaCare “death panels” will be a much harder sell.

Erica Etelson is one of those writing op-eds promoting a single-payer plan, and taking the Democratic Party to task for failing to do so:

With Trumpcare dead on arrival in Congress, Democrats have an opening to propose what they should have pushed for in the first place: single-payer health care for all. Fifty-eight percent of Americans, including 41 percent of Republicans, favor a federally funded health care system that provides universal coverage. Only 48 percent want to keep Obamacare as is.

Though Democrats are loathe to admit it, Obamacare is far from perfect. Some people pay higher premiums and out-of-pocket costs than they can afford. In some areas of the country, choices of doctors are limited. Compared to nations with single-payer systems, health outcomes are poor. And a small but vocal minority of Americans are troubled by Obamacare’s individual mandate which, they believe, infringes on their liberty…

Bernie Sanders ran with remarkable success on a Medicare for All proposal that generated enormous excitement among the progressive wing of the party and sent shivers down the spine of the Democratic corporate establishment. Hillary Clinton, a one-time champion of single-payer, pounced on Sanders with alarmist, counterfactual claims that Sanders’ proposal would increase costs and make people worse off.

While the GOP is still cringing over the humiliating defeat of its seven-year promise to repeal Obamacare, Democrats should kick them while they’re down by introducing single-payer legislation. Even Trump-collaborator, Sen. Joe Manchin, D-WV, is starting to wise up, thanks to his constituents; at a recent town meeting, Manchin praised Canada’s health care system and said he was taking a look at single-payer as an alternative to Obamacare…

We watched the Democratic National Committee undercut Sanders’ candidacy. And we’ve watched the Democrats disappear the single-payer option by refusing to support Rep. John Conyers’, D-MI, single-payer bill (HR 676). Enough.

The Democrats’ lackluster opposition to Trumpism does not match the fierce and relentless resistance of their base. They can and must stop doubling down on the centrist “pragmatism” that has alienated growing numbers of voters and start acting like a party more committed to the health and well-being of the 99 percent than protecting the power and profits of oligarchs.

This populist moment in American politics is the Democrats’ to seize. With a strong majority supporting single payer, the Democrat have a golden opportunity to give their dwindling base a reason to come home. As Trump said moments after conceding defeat, “Here’s the good news: Health care is now totally the property of the Democrats.” Good news indeed, if the Democrats know what to make of it.

Donald Trump now has the opportunity to work with Democrats, and any Republicans who are willing, to fulfill his campaign promises of giving us a great health care plan which will cover everybody. Of course he will not do so, and will probably continue to work to undermine the Affordable Care Act.

The Republican Health Care Plan Screws Many To Help Very Few

It looks like Republicans think that America has been demanding a new health care plan which will greatly reduce the number of people who are insured, increase costs for poor and older Americans, destabilize the individual insurance market, and cut taxes for the wealthy. While waiting for the CBO scoring, the Brookings Institute has made their calculations as to how terrible the Republican health care bill is, predicting that at least 15 million people will lose health care coverage:

There is significant uncertainty about exactly how CBO will model these provisions and how it will expect the various provisions to interact with one another. Nonetheless, we conclude that CBO’s analysis will likely estimate that at least 15 million people will lose coverage under the American Health Care Act (AHCA) by the end of the ten-year scoring window. Estimates could be higher, but it’s is unlikely they will be significantly lower.

 

Many will suffer from the cuts to Medicaid. Many of those who purchase private coverage on the exchanges will suffer because of how the subsidies are restructured, based on age as opposed to income and the actual costs of insurance. The Kaiser Family Foundation has posted projections regarding this.

Medical organizations and those representing the elderly including AARP, the American Medical Association and the American Hospital Association have objected to the Republican plan. AARP issued a statement opposing the “House plan that would make changes to our current health care system, such as shortening the life of Medicare, hiking costs for those who can least afford higher insurance premiums, risking seniors’ ability to live independently, and giving tax breaks to big drug companies and health insurance companies.”

The less affluent voters who backed Trump will be hurt by the changes. Of course some people do benefit. “Nearly everyone in the Top 1%, who earn more than $774,000 a year, would enjoy a hefty tax cut, averaging $33,000, according to the non-partisan Tax Policy Center. Those in the Top 0.1% would get an average tax cut of about $197,000.” Insurance companies also benefit:

Obamacare allowed insurance companies to deduct only $500,000 of their executives’ pay as a business expense. The GOP bill would repeal that limitation, starting in 2018.

Top insurers pay their leaders millions in compensation every year so this provision could mean a nice tax savings for the companies.

One excuse given by Republicans for repealing Obamacare is the increased cost of premiums. However, most people receive health care coverage through either government programs or employer programs, which have not had major increases in premiums. The individual market had frequent jumps in premiums, and that has continued, except under Obamacare most people receive subsidies to help cover this. As a consequence, only about three percent of the country is actually facing the increases in premiums which Republicans are using to justify their plan. In return, we receive more comprehensive coverage which cannot be denied based upon medical problems.

As one of the three percent who purchases health insurance without qualifying for subsidies, I certainly do not see the Republicans as doing me any favors. My premiums will be higher under the Republican plan than they are now, and the even bigger problem is that the plan may “threaten the stability of the individual market” per the Brookings report, possibly making it impossible to obtain coverage.

 

Discussing Obamacare Replacement With A Republican Congressman

House Republicans have finally released their plan to replace Obamacare. I have a lot of concerns about the plan, such as whether the tax credits will be sufficient for low income families to afford health insurance, and their attack on Planned Parenthood.

I am going to wait until I have a chance to look at the details of the plan to discuss it in depth, but for other reasons I have found it a good day to blog about health care. Hours prior to the release of the plan, I met with my conservative Republican Congressman, Bill Huizenga, along with a few colleagues, to discuss health care. I figured it would be futile to change the mindset of a conservative Republican, but when I received the invitation I also thought I should make the attempt to try to explain how health care really works. After all, there is zero chance of changing anyone’s mind if no attempt is made to persuade them. I was also appreciative that he was willing to meet with a group which strongly disagreed with him on the issue, while many Republicans around the country are reportedly hiding from their constituents.

The first time I spoke today I made a point of explaining how I am self-employed and have purchased health care on the individual market for my entire life. Therefore I could definitely state that high premiums and high out of pocket expenses, often cited as a failing of the Affordable Care Act by Republican, have always been a characteristic of the individual market–and are not something created by Obamacare.

Discussion got bogged down for quite a while over philosophical issues, especially when someone referred to health care as a right. Congressman Huizenga disagreed. While I managed to get out most of what I wanted to say today, in a conversation with multiple people present, sometimes the topic changed before I got a chance to speak. I didn’t get a chance until after the meeting while speaking to a colleague that I can understand a Republican’s position in not seeing health care as a Constitutional right in the same way as civil liberties specifically expressed in the First Amendment. After all, the Founding Fathers would have never conceived of health care being as expansive, and expensive, as it is now. However, regardless of whether you want to call it a right, access to affordable health care is both highly desirable, and something which is expected in a modern, advanced, industrialized society such as the United States. We should do it regardless of whether you want to label it a right.

The limited nature of assured coverage in the United States, compared to the rest of the world, was an underlying thought in many of our comments. It did come up that 1) the sick can show up to the Emergency Room and will not be turned away and 2) a significant portion of the Medicare population consists of the disabled. In typical Republican dodging of the issue, the Congressman at one point tried to claim that this does provide some form of basic health care as people can go to the Emergency Room. I pointed out that it is one thing to receive coverage in the Emergency Room, but this does not mean that people will receive necessary follow up medical care, especially for the types of chronic medical conditions I typically treat, such as diabetes, heart failure, and emphysema. Initial stabilization in an Emergency Room is both costly and not adequate health care. Plus an Emergency Room physician present pointed out that being seen does not mean patients do not receive large bills, which could be well beyond their ability to pay.

Congressman Huizenga responded that the disabled can receive coverage on Medicare, but I pointed out that people with chronic medical problems are not necessarily disabled, especially if they receive adequate medical treatment. Someone with diabetes, for example, can live and work for many years with the condition. However, without adequate care, twenty years down the road they are far more likely to develop problems such as heart attacks, strokes, and renal failure.

The Congressman’s philosophy on limited government (which, like most Republicans, is terribly selective, ignoring everything from infringements on reproductive rights to today’s revised anti-Muslim travel ban), also influenced his responses. Before his arrival I had discussed with others how market solutions have not worked well, with insurance companies having developed a business strategy based upon collecting premiums and then finding ways to deny care. Congressman Huizenga brought up irrelevant matters such as restrictions on choice present in Canada and other countries which Americans might not tolerate. The typical Republican scare stories. My response was simply that we do not have to adopt the restrictions which he mentioned, regardless of what other countries have done. One point I did not manage to get in was that in the United States, private insurance plans are often far more restrictive on the choices which patients and physicians can make than the government Medicare program is.

The physicians present generally saw Obamacare as an improvement over the previous system, but not going far enough, with Medicare for All being seen as a preferable solution. As a couple of us discussed afterwards, this is a far easier sell for physicians, who see first hand the amount of time and money wasted in having to deal with multiple different insurance companies, with  multiple different sets of rules. Plus this has the huge advantage of taking the astronomical profits received by the insurance industry, and using that money to actually provide health care. (Medicare for All was promoted by Bernie Sanders in the 2016 nomination battle, leading to politically-based opposition from Hillary Clinton.)

If Medicare for All is too hard a sell immediately, I, and others, suggested phasing it in. I also mentioned ideas such as the public option and the Medicare buy-in which were considered when the ACA was being written, but died when the two most conservative Senators voting with the Democrats (Joe Lieberman and Ben Nelson) opposed the ideas. Either would help with the high costs on the individual market.

The  higher cost for caring for older individuals, with some of that cost spread to the premiums of younger purchasers, is a major problem in health care coverage.  I doubt insurance companies even want to cover their older customers, who are responsible for the bulk of their costs. Either outright lower the Medicare age (even if gradually, such as initially to 50 or 55, and ultimately to around 40) or allow a Medicare buy-in.

After the Congressman left, his Legislative Director remained for a brief time and suggested that Americans would not go for expanding a government program such as Medicare. While a typical Republican thought, it does not hold up. I pointed out that we all do wind up on a government program, with most people going on Medicare at age 65. Not only are Americans failing to rebel at the though of going on Medicare at age 65, many look forward to the opportunity. Remember all those tea party protests with signs like “Keep Government Out Of My Medicare.”

My parting comment to Congressman Huizenga before he left was that Republicans must move beyond their anti-Obama rhetoric and actually address the problem. I related how for the past eight years I have often heard patients blame Obama for anything wrong with the health care system, even if it was over matters not even related to the Affordable Care Act. However, in early January, before Donald Trump even took office, I started to hear patients blame Trump for their healthcare problems. Republicans now “own” healthcare and must deliver.

I have my doubts as to whether the plan released today does deliver, but I do want to take a look at the details beyond what is in the initial news stories I have read.

Trump Screws Up Obamacare So He Can Falsely Call It A Failure

The White House has pulled ads to promote signing up for coverage under Obamacare, including ads already paid for. If the goal is to provide more affordable coverage, this is counterproductive. Younger, healthier people tend to put off signing up, and are among the last to enroll each year. Having more healthy people sign up for coverage leads to lower insurance premiums.

Of course if the goal is to call Obamacare a failure, then this was a smart move by Trump. The higher premiums are, the easier it is to criticize the plan.

What Donald Trump might not even understand is that the Affordable Care Act did not bring about insurance with high premiums, along with high deductibles and copays. Insurance on the individual market has always been like this for those of use who purchase our own insurance, as opposed to receiving insurance through employers or government plans. The difference is that, prior to Obamacare, people could purchase expensive, high deductible plans and then lose their coverage if they got sick. If they already had preexisting medical conditions, they would often be denied coverage, or have the reasons they need health care coverage be excluded from the plan. These problems no longer exist under the Affordable Care Act.

Republicans are meeting to discuss health care, with a goal of introducing legislation by late March for an alternative program. While President Trump and Republican Congressional leaders are talking about a quick repeal of Obamacare, The Washington Post reports that, behind closed doors, many Republicans are expressing concerns:

Republican lawmakers aired sharp concerns about their party’s quick push to repeal the Affordable Care Act inside a closed-door meeting Thursday, according to a recording of the session obtained by The Washington Post.

The recording reveals a GOP that appears to be filled with doubts about how to make good on a long-standing promise to get rid of Obamacare without explicit guidance from President Trump or his administration.

Senators and House members expressed a range of concerns about the task ahead: how to prepare a replacement plan that can be ready to launch at the time of repeal; how to avoid deep damage to the health insurance market; how to keep premiums affordable for middle-class families; even how to avoid the political consequences of defunding Planned Parenthood, the women’s health-care organization, as many Republicans hope to do with the repeal of the ACA.

In a survey conducted by The New England Journal of Medicine, most primary care physicians preferred making improvements to the Affordable Care Act and opposed repeal. Improvements supported by physicians included creating a public option similar to Medicare to compete with private plans, providing tax credits to people eligible for Medicaid to purchase private plans, and increasing the use of health savings accounts. There was less support for some good ideas such as expanding Medicare coverage to those 55 to 64 years of age. There was also less support for two of the ideas promoted by Republicans, shifting even more costs to consumers and reducing regulations on insurance companies by allowing them to sell insurance over state lines. (From or dealings with insurance companies, doctors know that they cannot be trusted, and regulation is needed.) From the report:

We found that in response to the question, “What would you like to see the federal policy makers do with the Affordable Care Act?,” 15.1% of PCPs indicated that they wanted the ACA to be repealed in its entirety. Responses varied according to the physicians’ self-reported political party affiliation; no Democrats wanted to see the ACA repealed, whereas 32.4% of Republicans did. Among physicians who reported voting for Trump, only 37.9% wanted the ACA repealed in its entirety. PCPs were less likely than the general public to want the law repealed. A Kaiser Family Foundation poll conducted after the election that used a question and response options similar to those in our survey showed that 26% of the general public wants the law repealed in its entirety

When asked about aspects of the ACA as it currently exists, the physicians we surveyed almost universally supported the insurance-market regulations that prohibit insurance companies from denying coverage or charging higher prices on the basis of preexisting conditions (95.1% stated that the prohibition was “very important” or “somewhat important” for improving the health of the U.S. population). There was also strong support for other key provisions of the law, including allowing young adults to remain on their parents’ insurance plan until 26 years of age (87.6%), providing tax credits to small businesses (90.8%) and tax subsidies to individuals (75.2%), and expanding Medicaid (72.9%). A lower proportion — just under half — favored the tax penalty for individuals who do not purchase insurance (49.5%)…

Although only 15% of PCPs want the ACA repealed, nearly three quarters (73.8%) favor making changes to the law. Physicians responded most favorably to policy proposals that might increase choice for consumers, such as creating a public option resembling Medicare to compete with private plans, providing tax credits to allow people who are eligible for Medicaid to purchase private health insurance, and increasing the use of health savings accounts. PCP Survey Responses Regarding Potential Health Reform.). Physicians responded most negatively to policies that would shift more costs to consumers through high-deductible health plans. Less than half were in favor of proposals to decrease insurance-market regulations (by allowing insurance companies to sell across state lines), require states to expand Medicaid, or expand Medicare to adults 55 to 64 years of age.

AMA Warns Of Risks Of Gutting Health Care Reform

With Republicans appearing to make abolishing Obamacare a top priority (following their failure to gut ethics oversight of Congress), the American Medical Association has weighed in with this letter (emphasis mine) stressing the importance of making coverage more affordable, providing greater choice, and increasing the number insured:

Dear Majority Leader McConnell, Leader Schumer, Speaker Ryan and Leader Pelosi:

On behalf of the physician and medical student members of the American Medical Association (AMA), I am writing regarding our ongoing commitment to reform of the health care system and potential legislative actions during the first months of the 115th Congress.

The AMA has long advocated for health insurance coverage for all Americans, as well as pluralism, freedom of choice, freedom of practice, and universal access for patients. These policy positions are guided by the actions of the AMA House of Delegates, composed of representatives of more than 190 state and national specialty medical associations, and they form the basis for AMA consideration of reforms to our health care system.

Health system reform is an ongoing quest for improvement. The AMA supported passage of the Affordable Care Act (ACA) because it was a significant improvement on the status quo at that time. We continue to embrace the primary goal of that law—to make high quality, affordable health care coverage accessible to all Americans. We also recognize that the ACA is imperfect and there a number of issues that need to be addressed. As such, we welcome proposals, consistent with the policies of our House of Delegates, to make coverage more affordable, provide greater choice, and increase the number of those insured.

In considering opportunities to make coverage more affordable and accessible to all Americans, it is essential that gains in the number of Americans with health insurance coverage be maintained.

Consistent with this core principle, we believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies. Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.

We stand ready to work with you to continue the process of improving our health care system and ensuring that all Americans have access to high quality, affordable health care coverage.

Sincerely,
James L. Madara, MD

Medical groups and physicians have been conflicted regarding expected health care policy under Donald Trump. There was some early support for Tom Price to head Health and Human Services in the hope that he will work to reduce the regulatory burden, but many doctors have come out in opposition to him out of concern for reductions in coverage for many Americans.

While health care policy could likely a major impact of the all-Republican government, it received very little attention during the presidential campaign. This is partially due to the media’s preference to cover the horse race and scandal, Donald Trump making more noise on matters such as the Wall, and an extraordinarily poor campaign by Hillary Clinton which concentrated on stressing Trump’s negatives and avoiding issues. Democrats are now starting to speak out on health care. Chuck Schumer is trying to turn Trump’s slogan against him, warning that Republicans will “Make America Sick Again.” Hopefully they can provide a resistance beyond coming up with a slogan.

Democrats were successful in blocking George Bush when he attempted to partially privatize Social Security in his second term, and similarly have a chance of receiving public support in opposing Republican attempts to reduce health care coverage, including cuts in Medicare and Medicaid. Republicans are also getting jittery about health care legislation. They could safely please their constituents by voting to abolish Obamacare when Barack Obama was in office and they knew he would veto their efforts if it made it past a filibuster. Many now realize they will be held accountable for what happens, including if people lose coverage, and insurance costs continue to rise rapidly. The Committee For A Responsible Federal Budget, typically conservative on government  spending,  has outline the costs of repealing Obamacare, giving further reasons for Republicans to be cautious.

Donald Trump remains a huge wild care, having both promised to abolish Obamacare and to provide a plan to cover all Americans. So far he has given no meaningful specifics, talking primarily about health savings accounts and allowing insurance companies to sell insurance over state lines. Neither is a real plan. One point to Trump’s credit is that, while his major appointees have been from a very narrow group (primarily wealthy conservatives), he has spoken to a wider range of people. Zeke Emanuel, the architect of the Affordable Care Act, came out of a meeting with Trump expressing optimism, as reported by NPR. He believes Trump might seek to have a bipartisan bill after Republicans have complained about how Obamacare was passed by only Democrats. He also pointed out that some conservatives are pushing for “repeal and replace” as opposed to the currently discussed tactic of “repeal and delay” and discussed how legislation might be handled after an initial resolution (even if along party lines) to abolish the ACA utilizing budget reconciliation:

And so that you really do need to repeal and replace, and you need to do it in one bill. Otherwise, you’re really going to disrupt the individual insurance market in a very bad way, and you’ll be responsible for millions of people losing their coverage but also health insurance premiums going up. And I think that is not a scenario that a lot of Republicans really want…

So one possibility is that they pass a resolution saying that they will then come back and pass a bill that will repeal parts of the Affordable Care Act and at the same time have a replacement for those parts of the Affordable Care Act…

The resolution can be party lines, but the bill would then have to construct both the repeal part but simultaneously the replacement part. And I think if you do it that way, you could begin to negotiate with Democrats. If you just have a repeal and we’ll be back in three years and tell you how we’re going to fix it, then the Democrats are simply going to walk away. Chuck Schumer has made that clear.

And they should walk away because then it’s all – it’s the old pottery barn principle that Colin Powell made famous, which is, you break it; you have to fix it, and you take responsibility. And the Democrats will not want their fingerprints anywhere near the breaking of Obamacare and the disruption of the insurance industry in the United States…

The question is, what is the shape of that bill? Is it just a repeal bill, or is it a repeal with replacement? And that negotiation about that bill could take several months. My own estimate is if both sides come with good faith, they could probably hammer this out in about six months. It’s not a small item. I mean health care reform is big.

The question is, what are the gives and takes? I do think – again, one of the reasons I’m optimistic is that when you look at conservative and liberal health policy experts, there’s about 70 or 80 percent overlap between the two groups about the shape of the future and what you would need. And I think that’s, again, why I’m optimistic – because there aren’t that many ways of doing health care reform. They’re really limited.

Of course counting on the sanity of Republicans is a very risky bet.