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.

Republicans Show Contempt For Ethics; Trump Plays The Press

Among the first actions by the House Republicans were rules changes to reduce the power of the Office of Congressional Ethics, and then reversing course. The bad news is that it highlighted their priorities. The good news is that it did show that Republican House members are susceptible to pressure. The media does tend to concentrate more on ethics than policy. An action such as this was bound to receive more scrutiny than actions such as destroying Medicare as we know it, or reducing health coverage for those who have received coverage under the Affordable Care Act.

The impact of the adverse media coverage was helped by many voters taking this seriously. Google searches for “who is my representative” surged. Republican members of Congress were flooded with phone calls.

Donald Trump also played this well when he tweeted on the subject. If you look at the headlines alone, it appears that Donald Trump protested and the Republicans backed down. He called the Office of Congressional Ethics “unfair,” and protested more on the timing of the action than the actual rules changing. It doesn’t appear that he would object to reversing course on the principle of “draining the swamp” as long as they acted to (in his view) making America great first. Of course this doesn’t make very much sense as setting the rules for the upcoming Congress is among the first matters handled.

Donald Trump Is Least Popular President-Elect In Modern History

A Pew Research Center survey shows what was expected after a campaign with the two most unpopular candidates in memory. Donald Trump is the least popular president-elect in modern history. Even George W. Bush, who like Trump failed to win the popular vote, received a 50 percent approval rating in a country which was divided 50:50. Trump is well below this with an approval of only 41 percent.

A majority also disapprove of his cabinet choices and appointments by a 51 percent to 40 percent margin. This is hardly surprising in light of appointments including Steve Bannon, Michael Flynn at NSA, Ben Carson at HUD, and Betsy DeVos at Education. It says something when one of his least objectionable choices is someone known as Mad Dog (James Mattis at Defense).

The poll found many of the same negatives which came out during the campaign:

…many of the same doubts and concerns that voters expressed about Trump’s qualifications and temperament during the campaign are evident as he prepares to take office. Just 37% of the public views Trump as well-qualified; 32% of registered voters described Trump as well-qualified in October. Majorities continue to say Trump is reckless (65%) and has poor judgment (62%), while 68% describe him as “hard to like.”

In addition, more than half of the public (54%) says that Trump has done too little to distance himself from “white nationalist groups” who support him, while 31% say he has done the right amount to distance himself from such groups; 6% say he has done too much in this regard.

And despite all this, the Democrats managed to come up with a candidate who still managed to lose to Trump. There are many reasons why Clinton was such a terrible candidate, all of which were predictable. It also came as little surprise that Clinton ran such an awful campaign, concentrating on personal attacks and avoiding discussion of issues. As people saw Clinton as being as terrible a person as Trump, and were supplied with plenty of confirmation of this with her behavior during the campaign, personal attacks on Trump were not enough to win the election. Perhaps Clinton should have discussed major issues such as Medicare, which the voters had little knowledge of. Pew found:

Overall, only about half of the public (51%) has heard a lot (12%) or a little (39%) about a proposal to change Medicare to a program that would give future participants a credit toward purchasing private health insurance. About as many either have heard nothing (48%) or don’t know (1%).

Instead Clinton gave no reason to vote for her beyond her gender and it being her turn. This left the race as an unpopularity contest among two incredibly unpopular candidates.

Washington Post Editorial Board Spreading Fictions About Bernie Sanders

Washington Post Logo

The Washington Post has carried op-eds both in support of Bernie Sanders and in opposition to him. I looked at a couple of them yesterday. The  Post followed this up with an editorial full of right wing attacks on Sanders which were out of touch with reality. Bernie Sanders has responded:

At a breakfast with reporters here Thursday that was hosted by Bloomberg Politics, Sanders fired back — again and again and again.

“That’s not a new argument. We’ve been hearing that months and months, and that’s in a sense what this campaign is about,” Sanders said in response to a request for his reaction to the editorial. “People are telling us, whether it’s the Washington Post editorial board or anybody else, our ideas are too ambitious — can’t happen. Too bold — really? Well, here’s something which is really bold. In the last 30 years, there has been a massive transfer of wealth from the middle class and working families of this country. The middle class has become poorer and trillions of dollars have been transferred to the top one-tenth of 1 percent.”

“That’s pretty radical, isn’t it?” Sanders said. “Where was The Washington Post to express concern that the middle class was shrinking?”

…When he was asked about foreign policy, Sanders detoured: “Getting back to The Washington Post — check out where all the geniuses on the editorial page were with regard to the invasion of Iraq.” (They supported it.)

At another point: “I know The Washington Post may think I’m radical, but I’m not.”

More on Sanders’ response at Common Dreams.

Just as The Washington Post was wrong on the facts when they supported the Iraq war and in ignoring the economic meltdown, they totally botched the health care issue:

He admits that he would have to raise taxes on the middle class in order to pay for his universal, Medicare-for-all health-care plan, and he promises massive savings on health-care costs that would translate into generous benefits for ordinary people, putting them well ahead, on net. But he does not adequately explain where those massive savings would come from. Getting rid of corporate advertising and overhead would only yield so much. Savings would also have to come from slashing payments to doctors and hospitals and denying benefits that people want.

He would be a braver truth-teller if he explained how he would go about rationing health care like European countries do. His program would be more grounded in reality if he addressed the fact of chronic slow growth in Europe and explained how he would update the 20th-century model of social democracy to accomplish its goals more efficiently. Instead, he promises large benefits and few drawbacks.

Medicare for All is not a program which Sanders has pulled out of the air. Supporters of health care reform have discussed this for years. It is not difficult to see where the savings would come from. To begin with, Medicare is much more efficient in the use of health care dollars than the private insurance industry. This isn’t just about getting rid of corporate advertising and some overhead costs. This is about eliminating the vast amount of money spent on the health insurance industry and the huge profits they make. This is all money which would be better spent on health care for Americans.

Rationing? These days all health care payers have restrictions on what they will pay for. We already have rationing, and often it is the private payers which are more restrictive than the government Medicare program.

Some of the savings will come from the fact that Medicare often pays less than private insurance. Despite this, there is good reason why many of us doctors support the plan. The secret is that we believe we will come out ahead financially with Medicare for All. Here’s why–

Back in the old days, a medical practice would typically have one biller. Now things are much more complicated. Many practices need to pay additional people to handle the billing because of the complexity of handling different rules from each payer–and the billers are very likely the highest paid non-medical employee in any medical practice you step foot in. It gets even worse. We also have to have employees to handle getting prior authorizations from different payers for tests, procedures, and prescriptions, again dealing with multiple sets of rules. On top of all this, a growing amount of payment to physicians comes from incentive payments which come from not only practicing medicine as required, but having somebody enter all the data into the insurance company computer systems. Again, each payer has their own set of rules, often requiring more than one employee to handle them. Plus it is a headache to try to keep track of all the rules from each payer.

Just compare this to the overhead of a medical practice in Canada, which has a single payer plan similar to Medicare for All.

Plus if we have Medicare for All, we will no longer have to worry about bad debts from uninsured patients, and receiving payments significantly lower than from Medicare on patients with Medicaid. It is a win financially for many physicians, as well as for most Americans who will no longer have the large insurance premiums and out of pocket expenses they now face.

The Washington Post also questions whether Sanders  can pass his agenda. Whether or not he can is a fallacious reason not to support him. Sanders’ supporters see what Sanders speaks about as being a description of his long-term goals, not a set of promises to be completed his first hundred days in office. With our current grid lock in Washington, no candidate will be able to quickly get their goals through Congress, but I see Sanders has having a far better chance of bringing in members of Congress who will support him than Clinton. If Clinton is the nominee, my bet is that many people will split their ticket, wanting members of the other party to keep an eye on a president they know is untrustworthy.

Plus the important thing in voting for a president is over matters more directly under the control of the president. Sanders is far less likely to get us involved in unnecessary wars than Clinton or the Republican candidates. Sanders is more likely to reform the surveillance state and back away from the drug war. A Sanders Justice Department will treat those who violate the law on Wall Street far different than I would expect a Clinton Justice Department to respond.

It is The Washington Post, not Bernie Sanders, which is spreading fictions.

Ben Carson Doesn’t Know Any More About Health Care Policy Than He Knows About The Constitution Or Foreign Policy

Ben Carson Health Plan

You might know Ben Carson as the ignorant theocratic who does not understand the Constitution of the United States or understand separation of church and state. Or you might know him as the Republican who had been challenging Donald Trump for leadership in the GOP race until it became apparent that he didn’t know a thing about foreign policy. Today we were introduced to a new Ben Carson–a doctor who doesn’t have any idea how to formulate a health care plan.

Carson tried to distract from his ignorance about other matters by introducing his health care plan (copy here). There are far more pictures than detailed policy in the pdf. There is a lot of talk about hating Obamacare and of providing a market solution–two lines which Republicans love but which don’t hold up too well if you think about them. The whole reason for Obamacare was that the market was not able to handle providing health care coverage. We wound up with perverse profit motives which led insurance companies to try to profit by denying care and eliminating coverage from those who were sicker.

Carson’s plan relies on “health empowerment accounts,” which are essentially another name for health savings accounts–which people can already purchase with high deductible plans under Obamacare (which is exactly what I have done). Except if you get rid of Obamacare, you also get rid of the preventative care covered without out of pocket expenses, the subsidies to help people afford it, coverage for young adults on their parents’ plans, and the guarantee that nobody can be denied coverage.

The biggest folly in Carson’s plan is to gradually increase the eligibility age for Medicare from 65 to 70. We should be doing the reverse–gradually lowering the eligibility age. (Or better yet, go with Bernie Sanders’ plan and offer Medicare for All right now). Our traditional private health care insurance has generally worked for the young (unless they got really sick and became as expensive to care for as the elderly). The problem has been with covering people as they get into their 40’s and 50’s and start developing more medical problems which private insurance companies would rather not deal with.

Medicare handles the chronically ill much better. Originally this problem might have been dealt with under the Affordable Care Act with either a public option modeled on Medicare or a buy in for Medicare. For the benefit of those who have forgotten the details surrounding the fight to enact the Affordable Care Act, the two most conservative Senators voting with the Democrats, Joe Lieberman and Ben Nelson, would only vote for Obamacare if these ideas were dropped, and there were no votes to spare with the Republicans one hundred percent united in voting against it.

Carson’s idea to increase the eligibility age of Medicare to 70 is awful, although that might not be the worst part of the plan. Carson also wants to replace the government Medicare plan with private insurance companies. Everyone would get a fixed contribution from the government towards purchasing a plan. Presumably if the fixed contribution is not enough to purchase an adequate plan they would be on their own (with their health empowerment plan, if there is enough there), but to conservatives that’s freedom. Medicare patient’s already have the option of a private plan instead of the government plan. We have found that it costs fourteen percent more to care for patients under the private plans than under the government plans–so much for greater efficiency in the private sector.

Brain surgery, along with rocket science, was once considered among the most difficult of intellectual pursuits. Now that America has become familiar with neurosurgeon Ben Carson, we will have to reconsider that idea.

Nation’s Largest Organization of Nurses Joins Liberal Writers In Protesting Hillary Clinton’s Attacks On Bernie Sanders

National Nurses Union Medicare For All

Hillary Clinton’s sharp move towards the right has many liberals questioning how much further right she will move in the general election, and if elected president. Her recent attacks on Bernie Sanders for his advocacy of a single payer health plan, which as I have noted she once supported, has resulted in considerable criticism from the left and a major nurses organization.

Jonathan Cohn, Senior National Correspondent at The Huffington Post asked, Why is she talking like a Republican? He also pointed out, “This is why Hillary Clinton makes so many progressives queasy.” Jim Newell at Slate wrote, Hillary Is Already Triangulating Against Liberals: Her new attack on Bernie Sanders’ single-payer health care plan shows her indifference to progressive voters. He pointed out that “she is a Clinton, and this is what they do.”

National Nurses United, which previously endorsed Bernie Sanders for president, has issued a press release to respond to Clinton’s attacks on Sanders over his support for a single payer plan:

National Nurses United, the largest U.S. organization of nurses, condemned the Hillary Clinton campaign today for its attack on Sen. Bernie Sanders’ proposal for healthcare for all, including its slanted use of data on the economics of Medicare for all.

“Any politician that refuses to finance guaranteed health care has abandoned my patients, and I will never abandon my patients. That’s why we support improved Medicare for all, and that’s why I support Bernie Sanders,” said NNU Co-President Jean Ross, RN.

“While the Affordable Care Act corrected some of the worst injustices in our insurance, profit-based healthcare system, the work of healthcare reform is far from done,” said Ross. “Today, 33 million Americans remain uninsured. Tens of millions more remain underinsured, facing bankruptcy due to unpayable medical bills or the choice of getting the care they need or paying for food or housing for their families.”

“The only fix for our broken system once and for all is the prescription Bernie Sanders has so eloquently presented – joining the rest of the world by expanding and updating Medicare to cover everyone,” Ross said.

NNU also criticized Clinton for citing a rightwing report first published in the Wall Street Journal on the inflated cost of $15 trillion to implement a Medicare for all system. The Journal report claimed as its source research by University of Massachusetts Amherst economics professor Gerald Friedman.

But Friedman himself has criticized the Journal report, noting in a Huffington Post column that the “economic benefits from Senator Sanders’ proposal would create dynamic gains by freeing American businesses to compete without the burden of an inefficient and wasteful health insurance system.”

Those include a “productivity boost coming from a more efficient health care system and a healthier population, [that] would raise economic output and provide billions of dollars in additional tax revenues to offset some of the additional federal spending,” said Friedman.

Friedman estimates nearly $10 trillion in savings while still reducing national health care spending by over $5 trillion. “With these net savings, the additional $14.7 trillion in federal spending brings savings to the private sector (and state and local governments) of over $19.7 trillion,” Friedman wrote.

Clinton is “ignoring the enormous savings that would come by assuring people could get proper care where and when they need it,” Ross added.

For example, a report out just last week noted $6.4 billion in lost wages and productivity in low income communities through premature deaths due to colon cancer, according to researchers at the Centers for Disease Control and Prevention.

“Dismissing the yearning of millions of Americans for a more humane healthcare system not based on ability to pay, and relying on a disputed data is disgraceful,” said Ross. “It’s a reminder again why nurses across the U.S. have been rallying and campaigning for a candidate who will never stop fighting for guaranteed healthcare for all.”

I further discussed Clinton’s fallacious attacks on Sanders here.

By attacking Sanders from the right on health care and economic policy, along with reminding the left how hawkish she is in her recent speech at the Council on Foreign Relations, Clinton risks seeing progressive voters refuse to vote for her.

Conor Lynch at Salon warns that Hillary Clinton is playing a dangerous game: How her anti-Bernie talking points could cost her — and America — big time. He began, “Hillary Clinton is starting to remind progressives why the name Clinton brings up such a mixed bag of emotions, and why it’s so hard to believe Clinton’s pivot to the left this campaign season.”He concluded:

But Clinton is making it harder for progressives to support her. With a history of hawkish foreign policy and Wall Street backing, she truly is the lesser to two evils. (A neoliberal is better than a fascist, after all [referring to Donald Trump]) But many on the left tend to vote with their conscience, and going after single-payer healthcare and hurling dishonest attacks on Sanders will only alienate progressives further.

Her problem is also not likely to be limited to progressive voters. When Clinton campaigns as a Republican-lite, many potential Democratic voters are not going to see very much reason to turn out to vote, risking the same fate for Democrats as they suffered in 2014.

Clinton Attacks Sanders On Progressive Agenda Including Single Payer Health Care

BernieSanders-Healthcare2

Hillary Clinton distorted the meaning of single payer health plans in the second Democratic debate and is continuing to attack Sanders’ progressive agenda on the campaign trail. Politico reports, “Three days after the fairly cordial second Democratic debate, Clinton’s campaign is mounting an attack against Sen. Bernie Sanders for proposals to raise taxes on the middle class that were part of the national single-payer health care bills he introduced in Congress.”

As Jonathan Cohn, Senior National Correspondent at The Huffington Post asks, Why is she talking like a Republican? He also points out, “This is why Hillary Clinton makes so many progressives queasy.”

Sanders’ campaign responded:

“On Medicare for all, the middle class would be far better off because it would save taxpayers money,” Sanders spokesman Michael Briggs said in response to Clinton’s latest line of attack. “More people would get better care at less cost. Didn’t she used to be for that? We wouldn’t throw money away on costly premiums for profit-making private insurance companies. Pharmaceutical companies would no longer be able to rip off Americans with the most expensive prescription drugs in the world. Didn’t she used to be for that?”

“Secretary Clinton has singled out Senator Gillibrand and praised her [family leave] legislation which, it turns out, Secretary Clinton now refuses to support because of the way it’s paid for,” Briggs added, noting it requires a small tax hike on the middle class. “No wonder people have their doubts about her.”

His campaign web site has further information:

What’s the Truth About the Clinton Campaign False Attacks?

The truth is that a single-payer plan will save American families money and provide universal health care.

Under the legislation offered by Sen. Sanders in 2013, families with taxable income under $250,000 a year (individuals under $200,000) would pay a tax of 2.2 percent of taxable income.

That means a family with a taxable income of $100,000 a year would pay $2,200 a year – but would be relieved of paying any private health insurance premiums and any copayments or deductibles.

A family making $50,000 would pay $1,100 a year.

The page also notes that, “The Clinton campaign received more contributions from the pharmaceutical industry than any other – Republican or Democrat – through the first six months of the campaign.”

Clinton’s attack sounds like a  repetition of attacks on Sanders in The Wall Street Journal in September. Physicians For A National Health Program responded:

In a front-page Wall Street Journal article a few days ago, the projection was made that a single-payer national health insurance program (NHI), as part of the presidential campaign of Senator Bernie Sanders (I-VT), would cost $15 trillion over ten years. Accurate though that figure is, this under-researched article conveys disingenuous misinformation to a broad readership that might be inclined to dismiss such a program as too expensive to even consider.

This article is irresponsible in what it doesn’t say— what the savings would be of reining in our current wasteful, overly bureaucratic profit-driven medical industrial complex, and the benefits that NHI would bring to our entire population compared to what we have now or have ever had.

Thanks to a landmark study in 2013 by Gerald Friedman, Professor and Chairman of the Department of Economics at the University of Massachusetts, we have a solid financial analysis of the costs and benefits of a single-payer national health plan. With NHI, $592 billion would be saved annually by cutting the administrative waste of some 1,300 private health insurers ($476 billion) and reducing pharmaceutical prices to European levels ($116 billion). These savings would be enough to cover all of the 44 million uninsured (at the time of his study) and upgrade benefits for all other Americans, even including dental and long-term care. A single-payer public financing system would be established, similar to traditional (not privatized) Medicare, coupled with a private delivery system. Instead of having to pay the increasing costs of private health insurance, so often with unaffordable deductibles and other cost-sharing, patients would present their NHI cards at the point of service without cost-sharing or other out-of-pocket costs. Care would be based on medical need, not ability to pay…

There is far more on this in the full post. Common Dreams adds:

Sanders’ embrace of a single-payer system—also widely backed by the American public—earned him the endorsement of the National Nurses United (NNU), the nation’s largest organization of nurses. NNU Executive Director RoseAnn DeMoro said in August that his ” issues align with nurses from top to bottom,” including his “insist[ance] that healthcare for everyone is a right not a privilege.”

Clinton Flip Flop

There is added irony in that this is yet another flip-flop from Hillary Clinton. She has flip-flopped on some selective economic issues to try to attract progressive support, and she has flip-flopped on gun control.  As I recently posted, some of her statements on gun legislation were  like the views from Sanders which she attacks. At other times she has taken a more conservative viewpoint.  As Martin O’Malley pointed out during the second debate, she has held at least three views, portraying herself  “as Annie Oakley and saying we don’t need those regulations.” Clinton has also supported a single payer plan in the past. This is from Clinton in 1994, both supporting single payer and showing no objection to a general tax to fund it (emphasis mine):

..I believe, and I may be to totally off base on this, but I believe that by the year 2000 we will have a single payer system. I don’t think it’s — I don’t even think it’s a close call politically.

I think the momentum for a single payer system will sweep the country. And regardless of the referendum outcome in California, it will be such a huge popular issue in the sense of populist issue that even if it’s not successful the first time, it will eventually be. So for those who think that building on the existing public-private system with an employer mandate is radical, I think they are extremely short-sighted, but that is their choice.

There are many ways to compromise health care reform, and I don’t think that the President could have been clearer in every public statement he has made that he has one bottom line. It is universal coverage by a date certain. And he has basically told the Congress, you know, you’ve got different ways of getting there. Come to us, and let’s look at it. There are only three ways to get to universal coverage. You know, a lot of people stand up and applaud universal coverage, and they sit down, and you say, “Well, how are you going to get there?”, and they don’t want to confront that there are only three ways.

You either have a general tax — the single payer approach that replaces existing private investment — or you have an employer mandate, or you have an individual mandate. And there isn’t any other way to get to universal coverage. The market cannot deliver universal coverage in the foreseeable future, and any compromise that people try to suggest that would permit the market  to have a few years to try to deliver universal coverage without a mandate that would take effect to actually finish the job will guarantee a single payer heath care system.

Or maybe we are just dealing with ignorance of the topic as opposed to flip-flopping.  Physicians For A National Health Program pointed out her confusion on Medicare for All as a model for single payer plans displayed in an interview in The New York Times in 2008:

Q: Last question. You talked earlier in the interview about how your plan maintains the private insurance system. But in October, at the forum of the Kaiser Family Foundation, you were asked whether your plan to make government insurance, a Medicare-type plan, available to all was a backdoor route to a single payer system, and you said, “What are we afraid of? Let’s see where the competition leads us.” So is it okay with you if the market ultimately dictates that the U.S. system sort of morphs into a single-payer system? And if so, doesn’t that arm the Republicans with exactly what you were talking about, this claim that it’s socialized medicine?

MRS. CLINTON: No, because I think what we would be offering would be a Medicare-like system, which is something people are familiar with, and you know whether we would call it Medicare 2.0 or whatever we would call it. And we’d see whether people want that or not. And where it morphs to, I think this whole system will morph. I mean, look at where Medicare started and where it is today. In large measure, some of the problems we have are because of the way it evolved. But I think from my perspective, having this Medicare-like alternative really does answer the desires of people. And there’s a significant minority who want quote a single-payer system. It at least gives them the feeling it’s not for profit, they’re not paying somebody a billion dollars for raising their premiums 200 percent and all the rest of the problems that we face with the for-profit system. You get the costs of overhead and administration down as much as possible. I believe in choice. Let Americans choose and what better way to determine that than letting the market have some competition and you know see where it does lead to.

Q: And if the choice is a single-payer system, that’s fine by you?

MRS. CLINTON: You know, I think that would be highly unlikely. I think that, you know, there’s too many bells and whistles that Americans want that would not be available in kind of a bare-bones Medicare-like system but I think it’s important to have that competition.

Comment:

By Don McCanne, MD

Competition between a bare-bones Medicare-like plan versus private bells-and-whistles insurance? What kind of framing is that!?

In her proposal, is she really advocating for a public Medicare-like option that provides only bare-bones coverage? That’s certainly not the model that single payer advocates propose.

Is she suggesting that the private insurance industry will be able to provide us with an insurance product that includes all of the bells and whistles at a premium that is affordable? If such a plan were to be offered it would have a very small market limited to only the wealthiest of us. Insurers typically shun small markets.

On this issue, at least, it looks like Clinton has been moving to the right over the years.

I could understand a politician not pursuing a single payer plan because of the political obstacles in getting it passed. It is a totally different thing when Hillary Clinton repeats right wing talking points to attack Sanders for desiring a single payer plan, especially when she once had a far more liberal view on the subject.

Update: Nation’s Largest Organization of Nurses Joins Liberal Writers In Protesting Hillary Clinton’s Attacks On Bernie Sanders

Donald Trump Continues To Threaten To Run As Third Party Candidate

DONALD-TRUMP

Last week I pointed out that Donald Trump was refusing to rule out running as a third party candidate. Several days later The Hill  received the same response in another interview:

Donald Trump says the chances that he will launch a third-party White House run will “absolutely” increase if the Republican National Committee is unfair to him during the 2016 primary season.

“The RNC has not been supportive. They were always supportive when I was a contributor. I was their fair-haired boy,” the business mogul told The Hill in a 40-minute interview from his Manhattan office at Trump Tower on Wednesday. “The RNC has been, I think, very foolish.”

Pressed on whether he would run as a third-party candidate if he fails to clinch the GOP nomination, Trump said that “so many people want me to, if I don’t win.”

“I’ll have to see how I’m being treated by the Republicans,” Trump said. “Absolutely, if they’re not fair, that would be a factor.”

Typically primary candidates remain in the race until they drop out of money. Donald Trump differs as he will not run out of money, not being dependent upon contributions from others. He has the ability to remain in the race as long as he desires–including after the conventions are over if he should feel that the RNC has been unfair to him.

While polls continue to show Trump with a lead (which might not last much longer after his comments on John McCain) for the Republican nomination, he is also among the weakest Republican candidates in head to head match ups against Hillary Clinton. A Washington Post/ABC News poll gives a clue as to what it would mean if Trump were to run as a third party candidate:

The survey shows that in a hypothetical three-way race, Clinton is at 46 percent, Bush is at 30 percent and Trump is at 20 percent among registered voters.

Trump takes more support away from Bush than Clinton in such a contest. In a head-to-head matchup, Clinton tops Bush by 50 percent to 44 percent among registered voters.

The current polls suggest that the Republicans will lose if they nominate Trump, or if someone else wins and Trump decides to run as a third party candidate. These numbers can change quite a bit by next November, but in this poll the vast majority of the votes taken by Trump come at the expense of the Republican candidate, and I would expect that pattern to continue. Possibly the magnitude of Trump’s vote will decrease by then, but this suggests there is an excellent chance that he could take at least five to ten points from the GOP candidate, which would probably tip the balance towards the Democrats should the race become closer (as other polls suggest it might be).

The same pattern is likely to also hold should Sanders or someone else manage to beat Clinton for the Democratic nomination, or someone other than Bush be the Republican candidate. It is certainly premature to assume Bush will be the Republican nominee. If he is, the Democratic candidate might not need any help from Trump in winning if Bush keeps taking about phasing out Medicare.

Single Payer Coming?

It looks like we might be heading in the direction of a single payer health care system, but note in the way we wanted. Aetna is seeking to buy Humana. While this would not actually be single payer, it would further decrease competition in the insurance industry. There is also speculation that UnitedHealth is interested in purchasing Cigna and Aetna. Instead of a single=payer system modeled on Medicare, we could wind up with a more monopolistic system, which should please Republicans. These purchases would be subject to anti-trust review.

Aetna purchasing Humana would also give Aetna a much larger share in the Medicare Advantage market. So much for George Bush’s plan to supposedly increase competition and choice for Medicare patients. The plan has was more designed as a reward to the insurance industry for all the contributions they have made to the Republicans.

In related news, The New York Times repeated misleading information on health care rates which I previously discussed. Only plans desiring rates over ten percent are required to submit their requests. Insurance companies have multiple plans, and are only seeking increases on some plans, leaving less expensive choices for those who take advantage of the exchange to compare plans. Plus the requests for larger rate increases will not necessarily be granted.

However, should private insurance rates still be too high, single payer remains the most cost-effective means of providing health care coverage. This could turn into a major issue in Bernie Sanders’ favor.

Americans Generally Satisfied With Healthcare Costs But Those On Medicare Are Happier Than Those With Private Insurance

A Friday afternoon news dump is not always bad news. Gallup released a poll under this headline on Friday: As ACA Takes Effect, Majority OK With Personal Health Costs. Gallup reported, “Nearly six in 10 Americans (57%) say they are satisfied with the total cost they pay for healthcare, on par with other readings over the last five years. So far, there is little indication that the Affordable Care Act (ACA), also known as ‘Obamacare,’ has affected the way Americans view their healthcare costs, either positively or negatively.”

Gallup Insurance Satisfaction

Note that the graph above shows very little change over time, with the current numbers very close to when Obama took office. Satisfaction did increase slightly in 2014, presumably because of more people having coverage thanks to the Affordable Care Act.

Satisfaction increased by age, essentially correlating with reaching age 65 and having Medicare. The assumption that those who are older are more satisfied because they have Medicare is verified when the results are broken down by type of insurance. Satisfaction with costs  is at 74 percent among those with Medicare or Medicaid, compared to 58 percent with those on private insurance. Note that another recent study did show that overall satisfaction was much closer than this poll on satisfaction with costs. Out of pocket payments for those on Medicare are typically significantly lower than those covered by private insurance, except for those with the most generous employer-paid plans.

Gallup Insurance Satisfaction by Age

Other findings were that people were generally satisfied with the quality of health care but less satisfied with healthcare coverage as a whole in the United States compared to other countries. Gallup concluded:

U.S. adults holding health insurance via a private insurance plan are about as likely to rate their coverage positively (77%) as Americans holding either Medicare or Medicaid (75%), suggesting both groups are about equally happy with their plans. But, as noted earlier, Medicare and Medicaid holders are far more satisfied with the cost of their plan.

As Gallup has found in the past, Americans are far less effusive with their praise for healthcare coverage in the U.S. as a whole. This year is not an exception: Fewer than four in 10 Americans now rate healthcare coverage in the U.S. as excellent or good.

Before passing the ACA, the large majority of Americans who had health insurance were broadly satisfied with their medical care and coverage and their healthcare costs. Thus, a major test of the ACA will be whether it succeeds in expanding affordable healthcare to the previously uninsured while doing “no harm” to the large majority of Americans who are already highly satisfied with their healthcare coverage. So far, the verdict is positive. Gallup finds no decrease in insured Americans’ satisfaction with their healthcare services and their costs. At the same time, the uninsured are as negative as ever, but their numbers have dwindled. Gallup’s annual November updates of these trends will monitor whether this positive outcome persists as implementation of the ACA progresses.

Republicans have backed high deductible plans as a way to restrain health care costs for quite a long time. Now that they got what they want with plans sold on the exchanges (like plans previously sold in the individual market) generally having high deductibles, they have been using this as a line to attack Obamacare. If this is the main objection, rather than cowering in the face of attacks on the ACA, Democrats might be better off taking advantage of this as a reason to push for the type of single payer plan that most liberals supported before Obama compromised and promoted what was previously a Republican health care plan.