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.

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.