The following essay is one I wrote as an op-ed or (long) LTE for the Bangor Daily News in response to an article they wrote in December. They have chosen not to publish it, citing a plethora of submissions and limited space. I think the article is self-explanatory.
- SPC
The ACA’s Family Glitch Can Be Fixed- and Mainers Could Save over a Billion Dollars a year on Healthcare
by Philip Caper, M.D. - Maine AllCare
On December 22 the BDN published an article titled “This Maine man lost his ACA insurance because he got married. He’s not alone.” The man, Owen Marshall, unwittingly lost his ACA subsidy when he got married. That was due to the well known “family glitch” in the Affordable Care Act. It’s unclear whether the family glitch was inserted into the ACA by Congress to save money, or was simply an unintentional error.
It doesn’t really matter. If the glitch was intentionally inserted into the law it’s unlikely the current Congress would have any interest in changing it. If it was an error, as many believe, it would have been routinely corrected by Congress long ago through the passage of non-controversial technical and conforming amendments. But in today’s hyper-polarized political climate Congress has been unreceptive to re-opening”ObamaCare” to any amendments, no matter how harmless they may seem.
Quoting Kate Ende of Consumers for Affordable Health Care, the article concluded that Owen’s only quick and “practical” solution to his dilemma would be to divorce his wife! Ende also opined that “there’s currently no good solution to the problem, no workaround and no national legislation in the works to fix it.”
That opinion is not accurate. There are at least two bills in Congress and one now under consideration in the Maine Legislature that would definitely fix the family glitch, and many other of the deficiencies in the ACA - for good. What Ende should have said is that there is no bill aimed solely and specifically at fixing the family glitch. That is true. But that’s not what was reported.
Advocates of fundamental reform of our badly broken healthcare system, (such as me) have become accustomed to being routinely ignored, discounted or marginalized by politicians, the media and “practical" experts on both sides of the aisle for being unrealistically radical. We truly are the skunks at the healthcare lawn party.
Many of those who are so dismissive of our “radical” proposals are the same political savants who not so long ago predicted that Donald Trump and Bernie Sanders could never be serious candidates for the US presidency. As late as October of 2016 they were also confidently predicting that Hillary Clinton was going to be POTUS starting in 2017.
It’s never too late to learn. Anybody who believes they can predict the course of today’s politics in the US simply hasn’t been paying attention.
In fact, there are at least two serious “Medicare for All” style bills in Congress: the Sanders bill in the Senate and the Jayapal bill in the House. But there is no reason to have to wait for action by the Congress. A bill pending in the Maine legislature - LD 1611, introduced by Representative Heidi Brooks, would provide the people of Maine many of the benefits of those federal bills.
At a pubic hearing On December 16, a study by the Maine Center for Economic Policy, funded by Maine AllCare, was presented to the Health Care, Insurance and Financial Services Committee of the legislature. In it MECEP presented an economic model that could be created under a bill such as LD 1611. They concluded that universal heath care for the people of Maine was not only feasible, but would be a vast improvement over Maine’s current system.
By adopting the MECEP model, healthcare total spending overall in Maine would be reduced by about $1.5 billion and 80% of Mainers would pay less for healthcare than they do now. Expanded coverage would be paid for by eliminating some of the tremendous waste in our present healthcare system. Under the MECEP model, Every Mainer would be covered. Co-pays and deductibles would be greatly reduced or eliminated and the scope of benefits expanded for all Mainers including those covered by Medicare, Medicaid and private insurance.
The focus of healthcare providers would return to treating patients, not fighting over medical bills. Health coverage would be permanent for everybody, and could not be taken away. No major changes in federal law would be necessary as existing federal programs would be retained pretty much intact, and supplemented by the new Maine program.
The MECEP study has demonstrated that there are plenty of excuses, but no insurmountable economic or technical barriers to moving ahead with such a transformation - only politics.
Now it’s up to the legislature and the people of Maine.
Trump’s Plot Against Health Care Continues
by Paul Krugman - NYT - January 13, 2020
Make no mistake: Health care will be on the ballot this November. But not in the way ardent progressives imagine.
Democrats
running for president have spent a lot of time debating so-called
Medicare for all, with some supporters of Bernie Sanders claiming that
any politician who doesn’t demand immediate implementation of
single-payer health care is a corporate tool, or something. But the
reality is that whatever its merits, universal, government-provided
health insurance isn’t going to happen anytime soon.
I say this
because even if Democrats take the Senate in addition to the White
House, the votes for eliminating private health insurance won’t be
there; nor will the kind of overwhelming public support that might
change that calculus. In practice, any of the Democratic candidates —
even Sanders — will, if victorious, end up building on and improving Obamacare.
On
the other hand, if Donald Trump wins, he will probably find a way to
kill Obamacare, and tens of millions of Americans will lose health
coverage.
Let’s talk for a minute about
Obamacare. There’s a sort of perverse alliance between Republicans and
some progressives, both of whom are determined, albeit for different
reasons, to see the Affordable Care Act as a failure.
Paul Krugman’s Newsletter
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These
downbeat assessments are made easier by the fact that the A.C.A. left
much of its implementation up to the states, and that national
performance has been held down by states that have done their best to
sabotage health reform.
But look at states that have tried to make
the law work, and what you see is a huge if incomplete policy success.
Take the case of California. In 2010, before the A.C.A. went into
effect, 21 percent
of nonelderly Californians were uninsured, above the national average.
By 2016 the uninsurance rate had dropped to 8 percent. And Californians
with pre-existing medical conditions saw an enormous improvement in
their health and financial security.
Now, 8 percent uninsured is
still too many, and even those with insurance often face high
out-of-pocket costs. But relatively minor improvements in the law,
especially a modest increase in the generosity of insurance subsidies, could substantially improve both the quality and the quantity of coverage.
Does
pointing out the possibility of incremental progress mean giving up on a
truly universal system? No. By all means let’s make something more
ambitious, such as Medicare for all, a long-term goal. But this goal
shouldn’t stand in the way of policies that would immediately benefit
millions of Americans, and save thousands of lives.
And while we
debate the ideal health system, we mustn’t forget that Trump and his
allies are as determined as ever to undo the progress we’ve made.
It’s
true that so far repeated Republican attempts to destroy the Affordable
Care Act have failed. In 2012 the Supreme Court rejected claims that
the whole law was unconstitutional. In 2017 a Republican-controlled
Congress narrowly failed to repeal Obamacare. And a variety of narrower
efforts to undermine health reform and send insurance markets into a
“death spiral” have fallen short: Markets seem to have stabilized, and one by one, states that initially rejected Medicaid expansion have been relenting.
But the people who want to take away your health care haven’t given up.
The latest attempt is a lawsuit
claiming that the 2017 tax cut, which reduced the penalty for not
having insurance to $0, somehow made the entire Affordable Care Act
unconstitutional. It’s a ludicrous claim, both in terms of substance —
would the law suddenly become constitutional if the penalty were a
penny? — and because it’s clear that this was not legislators’
intention.
But the Trump administration has joined the suit and a
partisan Republican judge has indeed ruled that the A.C.A. as a whole
should be struck down.
Clearly, this case is headed for the Supreme Court. But Trump doesn’t want it heard until after the election.
Why
does Trump want to leave this court case hanging? Partly because his
side would probably lose. As I said, the lawsuit is ludicrous, although,
given the partisanship of Republican-appointed judges, it might prevail
anyway.
Beyond that, however, Trump’s
political health care strategy is to flat-out lie about what he has done
and is trying to do. On Monday he made the breathtakingly dishonest claim
that he is “the person who saved pre-existing conditions” —
breathtaking because he has tried at every stage to remove the
protections for Americans with pre-existing conditions created by the
Affordable Care Act.
And while Trump, who lies constantly, often
seems to pay little penalty for those lies, this one — which touches the
lives of millions of voters — would be thrown into sharp relief if the
case were heard by the Supreme Court. He wants to take away your health
care, but he doesn’t want you to see him doing it until the election is
behind him.
So that’s the real health care issue this year. Will
it be expanded coverage under a Democrat — it probably doesn’t matter
much which one — or will it be tens of millions of newly uninsured
Americans under Trump? https://www.nytimes.com/2020/01/13/opinion/obamacare-medicare-for-all.html?action=click&module=Opinion&pgtype=Homepage
Labor
Take My Benefits—Please!
Employment-based Health Care Has Become an Anchor Around the Neck of the U.S. Working Class
by Mark Dudzic -
At
the June 2019 House Ways and Means Committee Hearing on Medicare for
All, Texas Republican Kevin Murphy lamented, “That great health care
plan that your union negotiated for you? It’s gone. Banned under
Medicare for All.”1
A right-wing congressman with a 7 percent lifetime voting score from
the AFL-CIO crying crocodile tears for great union health care plans can
be easily dismissed as just another absurdity of the increasingly
dysfunctional American political system. But when Joe “the workingman’s
friend” Biden repeats the charge almost word for word and when AFL-CIO
President Rich Trumka insists—on Fox News no less!—that “if
there isn’t some way to have our plans integrated into the system, then
we would not support [Medicare for All],”2 something is
certainly happening out there. Talking points, after all, don’t just
come out of thin air. They are carefully crafted and disseminated by a
coterie of lobbyists and publicists often working on behalf of shadowy
corporate and political interests.
Trumka was shortly joined by American Federation of Teachers
President Randi Weingarten, who just six months earlier had delivered a
full-throated endorsement of the Medicare for All Act at a rally
celebrating its introduction.3 In her September 23, 2019, Politico article,
Weingarten walked back that support in favor of a fictitious system in
which “employer-based insurance would be allowed to exist to the extent that
plans met or exceeded the standards set by the Medicare plan.” Such a
system “would allow people who like their current employer-based
plan—which seven in ten Americans claim to (although it’s likely they
like their doctor, not the plan itself)—to keep it, allow for a gradual
transition from one plan to another when necessary, and effectively
improve on the model originally created by the Affordable Care Act.”4
The spectacle of national labor leaders defending a system that is
the biggest cause of strikes, lockouts, and concession bargaining is
mind-boggling. For an entire generation now, unions in the United States
have traded wages and other benefits for shrinking coverage by
employer-provided health insurance (or for the ever-increasing employer
contributions required to maintain similarly shrinking benefits from
union-sponsored health and welfare funds). An Accident of History
The U.S. health care system’s linkage to employment is unique among
industrialized countries. It emerged as an accident of history in the
years just following World War II when Roosevelt’s promise to enact a
“Second Bill of Rights” in the postwar period was stopped dead in its
tracks by resurgent capital. In 1946, the American Medical Association
led the fight to defeat the Wagner-Murray-Dingell Bill that would have
created a publicly funded national health insurance program. The
following year saw the passage of the Taft-Hartley Act, which, combined
with an orgy of anti-communism and race baiting, set the powerful
postwar labor movement into a long retreat.
Unable to expand the social wage by treating public goods such as
health care as a basic right available to all, labor helped craft a
“second-best solution” of making access to health care a benefit linked
to employment. Corporate America piled on and offered elaborate benefits
to recruit and retain employees and to keep unions out. This system was
flawed from the beginning. It created tiers of coverage that reinforced
employment-based racial and gender disparities and massive amounts of
“churn” that disrupted continuity of care for even the best insured.
Particularly after the expansion of for-profit health insurance and
health care providers beginning in the 1970s, more and more
administrative inefficiency was built into the system to facilitate
profit taking, until, by the early twenty-first century, the U.S. health
care system was twice as expensive as the OECD average.5
Nonetheless, in the post-World War II period of high union density
and employment stability, many unions were able to negotiate a robust
“private welfare state” that provided health care security for tens of
millions of working-class Americans. These benefits were almost never
handed to workers. Unions had to wage long and unremitting fights to
expand and defend employer-based health care. By the 1980s, almost every
contract negotiation was faced with employer demands for reductions in
coverage and transfer of costs from the employer to the worker. Nonunion
workers fared even worse as they were forced to accept whatever the
employer offered. And, unlike attempts to cut social insurance benefits
like Social Security or Medicare that almost always fail due to massive
popular opposition, cuts to employment-based health care benefits take
place company by company under cover of night and arouse little or no
popular opposition. Today, even those few union members who have been
able to preserve good benefits find themselves as islands in a sea of
inadequate and precarious health care coverage. A System in Crisis
Like it or not, employment-based health care is simply unsustainable. The Milliman Medical Index6 reports
that the 2018 total health care costs for a family of four with decent
employment-based coverage exceed $28,000 per year. That is $14 per hour
worked for a full-time employee—almost twice the federal minimum wage.
The employer pays $15,000 of that, and $13,000 is paid by the worker
through co-insurance, out-of-pocket charges, co-pays, deductibles, and
all of the other myriad ways that the medical industrial complex
extracts money from our pockets. These amounts already exceed the
average hourly wage in food services and retail occupations and are
increasing two times faster than the rate of wage increases for all
workers, putting them on track to exceed average wages in manufacturing
and other core industries within the next decade. The percentage of
total health care costs paid by the worker has gone up nearly every year
since it was first tracked in the 1990s. Employment-based health care
is coming up upon the limits of Stein’s Law, formulated by economist
Herbert Stein in 1985: “If something can’t go on forever, it will stop.”
Employment-based health care is also a major driver of wage
stagnation. Every worker trades wages for health care. A recent Gallup
poll found that 61 percent of Americans would be willing to trade 10
percent of future wage increases for a guarantee that their health care
costs would not go up for five years.7 This puts workers and
their unions at a huge bargaining disadvantage and goes a long way
toward explaining why wages continue to stagnate at a time of low
unemployment and growing corporate profits.
And even the best employment-based health care is not there when we
need it the most: when we lose our jobs, change jobs, go on strike, or
struggle with long-term illness.
What was once a source of pride in the “union advantage” has become
an anchor around the necks of the U.S. working class. No union leader in
their right mind can conjure a scenario where the system of
employment-based health care could be stabilized in ways that could
provide sustainable health care security for workers and their families.
That is why unions representing a majority of organized workers now
support HR 1384 – The Medicare for All Act of 20198 and why
the AFL-CIO at its 2017 convention unanimously voted to support policies
to “move expeditiously to a single-payer Medicare for All system.”9 The Medicare for All Solution
Medicare for All would take health care off the bargaining table and
increase union bargaining leverage in nearly every negotiation. It would
allow union-sponsored health and welfare funds the opportunity to
reallocate revenues currently sunk into the world’s most expensive and
inefficient health care system. Savings could be applied to new “union
advantage” programs such as enhanced disability benefits, supplemental
unemployment benefits, tuition and training programs, legal services,
child- and eldercare, and others. Some revenues could also potentially
be reallocated to shore up endangered pension plans.10
Medicare for All would also provide better coverage than any
employment-based plan in existence today. Opponents of Medicare for All
often conflate the constricted benefits offered under today’s Medicare
program after more than 50 years of underfunding and privatization
attempts with the greatly expanded and improved benefits proposed under
Medicare for All. HR 1384—Rep. Pramila Jayapal’s Medicare for All Bill
with 119 cosponsors—proposes to cover the following benefits without a
single co-pay, deductible, or other out-of-pocket cost:
Hospital services, including inpatient and outpatient hospital care,
including 24-hour-a-day emergency services and inpatient prescription
drugs. (2) Ambulatory patient services. (3) Primary and preventive
services, including chronic disease management. (4) Prescription drugs
and medical devices, including outpatient prescription drugs, medical
devices, and biological products. (5) Mental health and substance abuse
treatment services, including inpatient care. (6) Laboratory and
diagnostic services. (7) Comprehensive reproductive, maternity, and
newborn care. (8) Pediatrics. (9) Oral health, audiology, and vision
services. (10) Rehabilitative and habilitative services and devices.
(11) Emergency services and transportation. (12) Early and periodic
screening, diagnostic, and treatment services, as described in sections
1902(a)(10)(A), 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A); 1396a(a)(43); 1396d(a)(4)(B);
1396d(r)). (13) Necessary transportation to receive health care services
for persons with disabilities or low-income individuals (as determined
by the Secretary). (14) Long-term care services and support (as
described in section 204).11
By comparison, the highly touted federal employees’ health benefit
plan merely offers the choice of a number of fairly comprehensive
private insurance products with the typical array of co-pays,
deductibles, and narrow networks. For all of this, federal employees
must kick in 28 percent of the weighted average premium for all plans.
Arguably, union employees working for the City of New York might have
some of the best coverage of any working-class American. They can get
fully employer-paid coverage in the default Emblem Health/HIP plan12
which has almost no co-pays or deductibles (workers may also choose
other private insurance plans that do require employee contributions).
They also receive generous dental, optical, and prescription coverage.
But even here, workers must use a narrow provider network or face
substantial co-pays, and the plan falls far short of HR 1384 in its
coverage of long-term care, disability services, and community and
home-based care. Moreover, every contract negotiation is held hostage to
the imperative to hold on to these extraordinary benefits at almost any
cost. I challenge any advocate of employment-based coverage to show
me a plan that matches the level of comprehensive services, freedom of
choice, and absence of out-of-pocket costs proposed by HR 1384.
Like global warming, the case for replacing our dysfunctional,
multipayer, for-profit health care system with a publicly funded,
universal system with a single standard of care for all is so compelling
that it has reached the level of scientific fact. Nonetheless, too many
national labor leaders continue to sing the praises of employment-based
health care benefits, while too many others give merely rhetorical
support for Medicare for All—passing resolutions at conferences and
conventions to please union activists while continuing to devote the
bulk of their union’s mobilizing and legislative efforts to support for
incremental and defensive policy fixes. Only a few national unions have
begun to commit the kind of resources and organizing capacity that will
be needed to defeat the concentrated political and economic power of the
medical-industrial complex. Union Backpedaling
As momentum for Medicare for All builds, we are witnessing more
backpedaling within the labor movement. And not all of it is confined to
national labor leaders (though it certainly is more pronounced at that
level). In New York, a single-payer-style state bill—NY Health—has twice
passed the State Assembly and is edging toward passage in the State
Senate backed by a growing popular movement. While the bill does have
considerable labor support, including from the state’s powerful hospital
workers and nurses unions, a significant section of the labor movement
has gone into open opposition. In June of 2018, James Cahill, the
president of the New York State Building and Construction Trades
Council, joined the CEO of the Business Council pf New York State in
co-authoring an op-ed in Crain’s New York Business opposing the bill and “government-run health care.”13
Taken by itself, this expression might be dismissed as another sign
of the class collaborationism and conservatism than infects significant
sections of the building trades. But they were joined by a number of
other unions, including the 380,000-member Municipal Labor Council—whose
affiliates include a number of “progressive unions”—which told Politico that they “dread the impact of the single-payer proposal in Albany.”14 It
is true that, unlike national proposals, state-level single-payer-style
plans are notoriously complex to design and difficult to fund. But this
hostility goes beyond having legitimate questions about implementation.
The fact that major sectors of the labor movement refuse to engage in
an effort to make health care a birthright in a state with near-Canadian
levels of union density is profoundly unsettling for those of us who
believe that, in order to succeed, labor must be in the forefront of the
fight to win Medicare for All.
So what is driving this opposition? Perversely, in New York some of
it derives from precisely these high levels of union density. Unions
still think they have a seat at the table and may sincerely believe that
they can bargain better and more secure benefits that would not be
subject to the precariousness of annual state budget debates. This
parochial perspective ignores the reality that New York unions are only
one election or economic downturn away from catastrophe. They only need
to look across the Hudson to see what anti-union Governor Chris Christie
did to New Jersey public sector workers’ ability to bargain for health
care during his administration (aided and abetted, I would add, by
Democratic political elements associated with some of the most
politically influential building trades locals).
Putting aside the idiosyncrasies of New York labor politics, many
union leaders may also believe that “the members aren’t ready” to
support Medicare for All. Loss aversion plays a central part in shaping
that belief. Behavioral scientists have observed that people are much
more likely to be motivated by the fear of losing something they have
than by the prospect of gaining something they want. Fear of loss of
health insurance is a major driver of working-class insecurity in the
United States. It is no surprise, then, that the lobbyists and
publicists working on behalf of the medical-industrial complex would
focus on this theme in their effort to scare the American people away
from a just health care system. Some of that fear has infected union
members. The failure to confront such fears, of course, is a classic
mistake that anyone who’s ever been through an organizing campaign would
know to avoid. The real problem here is union leaders who fail to
articulate a vision of working-class politics that will inspire and
unify union members.
These concerns are compounded in the wake of the Janus decision,
which has made public sector union membership completely voluntary.
Many public sector union leaders are convinced that the best way to
persuade workers to maintain their union membership is to show how the
union adds value in their workplace. Negotiating health insurance
benefits that are much better than those enjoyed by most other
working-class Americans is one way to do that without necessarily having
to engage in risky internal organizing and mobilizing activities that
may end up undermining existing union leadership.
Some unions have raised the specter of job loss as a reason to oppose
Medicare for All. This is a legitimate concern. Studies have shown that
close to two million workers will be displaced due to the
administrative efficiencies of Medicare for All.15 While both
the House and Senate bills provide funding for transition benefits for
these workers, decades of working-class experience with bearing the cost
of environmental-, trade-, and automation-related job losses have made
workers rightly skeptical of any promises of economic security. The
Labor Campaign for Single Payer has called for centering these worker
concerns in the political and legislative battles to come and has warned
that a failure to do so will give our opponents the opportunity to
divide workers against each other.
Unions have also expressed concern that employers would reap the
benefit of all of the sunken wages that unions have agreed to divert to
maintain decent private insurance coverage. This would assume that, in
the transition to Medicare for All, unions would be so weak and/or
incompetent that they would be unable to recapture those already
bargained monies. Even assuming a worst-case scenario, this objection is
tantamount to someone opposing student loan forgiveness because they’ve
already paid off a chunk of their loan.
There are also a number of institutional factors that can work to
discourage union support for Medicare for All. Union health and welfare
funds often have substantial brick-and-mortar investments in union
facilities and provide a range of member services that often strengthen
members’ union identification. A vast web of relationships also exists
between union officials and health care vendors, brokers,
intermediaries, attorneys, and various hangers on. Some are outright
corrupt. Others are more benign, such as the insurance company that
subsidizes their stewards training or the broker that they can call to
get a member rapid placement in a substance abuse treatment program.
Nonetheless, all of these relationships are ultimately corrupting
because of the entailments of obligation that they engender with players
who have a vested interest in maintaining the status quo.
However, the biggest factor by far that drives union opposition to
Medicare for All is many union leaders’ fear of disrupting their
political relationships. Unions are multi-issue organizations, and many
of their bargaining and organizing goals are impacted by local and
national political concerns. The ascendancy of a right-wing, anti-labor
political regime is an existential threat to the institutional labor
movement as well as to a wide range of working-class concerns. Unions
routinely pull their punches in the interest of maintaining these
relationships. For example, with a few notable exceptions, unions were
nowhere to be seen in the 2016 Democratic Party platform fight around
Medicare for All and other issues of central concern to the working
class led by Bernie Sanders supporters. Enmeshed in the two-party system
and with diminishing leverage, unions often see no alternative. Every
election cycle is the most important one in the history of the nation,
and, whatever the outcome, unions nearly always emerge weaker from each
round.
This political practice engenders cynicism and apathy among union
members and provides the space for right-wing populism to take root
within some sections of the working class. The past decade has seen the
reemergence of a refreshing political independence in some of the most
dynamic sections of the labor movement. By challenging the status quo,
they have inspired their members to take risks and have forced important
concessions from the political establishment. Medicare for All, because
it seeks to reclaim a public good on behalf of the entire working
class, can be an important wedge issue in building out an independent
working-class politics. The Path Forward
Our experience in the Labor Campaign for Single Payer has shown that
support for our cause is greatest at the front lines of the labor
movement, where leaders and staffers have to deal on a daily basis with
the consequences of private, for-profit health care. Our goal has been
to work with those activists as they find ways to constructively engage
with national labor leadership. After AFL-CIO President Trumka’s Labor
Day appearance on Fox News, for example, we asked unionists to
write him to remind him that support for Medicare for All is the
official policy of America’s largest labor federation. Over 2,500 people
answered the call. These are the leaders who will drive change in our
movement and ultimately bring the formidable political and mobilization
resources of institutional labor into the battle to make health care a
right for everyone in America. When that happens, we will win.
As Washington State Labor Council President Larry Brown stated,
“Unions do not serve their members well by trying to circle the wagons
around an unsustainable model of employment-based health care.”16 Our labor movement will thrive when we express the aspirations of all workers and speak on behalf of the entire working class.
Union members should be justly proud of the long battle that unions
have waged to protect their right to access affordable, quality health
care, and the Labor Campaign for Single Payer stands in solidarity with
all workers everywhere who fight to protect these hard-won gains. But
our movement is at an historic juncture. Now is not the time to muddy
the waters or bargain against ourselves. We need labor to lead as we
work to make this a key issue in the 2020 elections and to hold
politicians accountable in 2021 and beyond. And we have the right to
expect that the union leaders who represent us and the politicians that
we support will do more than just parrot the talking points crafted by
health care industry lobbyists. Notes
Robert Pollin, James Heintz, Peter Arno, Jeannette Wicks-Lam, and Michael Ash, Economic Analysis of Medicare for All, Political Economy Research Institute, 108-12.
About Author
Mark Dudzic is a longtime union activist and former national
organizer of the Labor Party. He currently serves as national
coordinator of the Labor Campaign for Single Payer Healthcare.
‘I Honestly Don’t Trust Many People at Boeing’: A Broken Culture Exposed
A trove of internal employee communications shows that the aviation giant’s troubles go beyond one poorly designed plane.
by David Gelles - NYT - January 10, 2020
Boeing’s troubles run deep. The 737 Max, its newest and
most important jet, has been grounded since March after two deadly
crashes killed 346 people. The cascading crisis has disrupted the global
aviation industry, cost the company billions of dollars and led to the ouster of its chief executive.
Yet the steady drip of bad news and embarrassing revelations — culminating in Thursday’s release
of 117 pages of damning internal communications — has revealed
something more disturbing than one poorly designed plane. The very
culture at Boeing appears to be broken, with some senior employees
having little regard for regulators, customers and even co-workers.
Perhaps
most tellingly, the documents show Boeing employees repeatedly
questioning the competence of their own colleagues, and the quality of
the company’s engineering.
“This is a joke,” a Boeing employee, referring to the 737 Max, said to a colleague in 2016. “This airplane is ridiculous.”
Another employee wrote: “I honestly don’t trust many people at Boeing.”
Boeing is the largest manufacturing exporter in the United
States, and its fate can sway the national economy. It employs more than
130,000 people, in all 50 states, and supports a network of thousands of suppliers.
And the dysfunction at the heart of one of America’s most important
companies, as illustrated by the new messages, still has the power to
shock.
“We’ve all seen this movie before, in places like Enron,” Chesley B. Sullenberger III,
the pilot who safely landed a plane on the Hudson River in 2009, said
in an interview. “It’s not surprising that before a crisis, there are
indications of real deep problems that have their roots in leadership.”
Sara
Nelson, the president of the Association of Flight Attendants union,
said the messages revealed a “sick” culture at Boeing, noting that “the
trust level was already in the toilet.”
The
internal communications, which were provided to congressional
investigators and cover a five-year period before the crashes in late 2018 and early 2019, show Boeing employees cavalierly dismissing the Federal Aviation Administration, which certified the Max
as safe to fly. Ahead of a 2016 meeting to discuss training
requirements for the plane, a Boeing employee described regulators as
“dogs watching TV.” Another time, a Boeing employee wrote: “There is no
confidence that the F.A.A. is understanding what they are accepting (or
rejecting).”
117 pages, 23.73 MB
Airlines, which pay about $100 million
apiece for the Max, were derided as incompetent, their questions
unreasonable. When discussing whether pilots at an Indonesian airline
connected to Lion Air, which operated the first Max that crashed, might
need simulator training before flying the Max, a Boeing employee said it
was “because of their own stupidity” and called the airline “idiots.”
“This
is confirmation that the problems go beyond Muilenburg,” said Michael
Stumo, whose daughter Samya was killed in the second Max crash,
referring to Dennis A. Muilenburg, the chief executive who was dismissed last month. “This is deeply flawed, long-term cultural erosion.”
On
Friday morning, Greg Smith, Boeing’s interim chief executive, wrote an
email to employees expressing contrition for the messages and imploring
the company to change.
“These documents do not represent the best
of Boeing,” Mr. Smith said in the email, which was obtained by The New
York Times. “The tone and language of the messages are inappropriate,
particularly when used in discussion of such important matters, and they
do not reflect who we are as a company or the culture we’ve created.”
Mr.
Smith noted that the messages involved a relatively small number of
employees, and said the company had confidence in the Max. The company
declined to comment on Friday beyond Mr. Smith’s email.
For
generations, Boeing represented the pinnacle of American engineering. It
helped win World War II, land men on the moon, build Air Force One and
make commercial air travel ubiquitous, even glamorous. But the newly
released messages portray a company that appears to have lost its way.
Once
relentlessly focused on safety and engineering, Boeing employees are
shown obsessing over the bottom line. Though Boeing is one of the
American government’s biggest contractors, the F.A.A. was viewed as a
roadblock to commercial goals that would “impede progress” when it tried
to “get in the way.”
At times, Boeing employees expressed reservations about the safety of their planes.
“Would
you put your family on a Max simulator trained aircraft? I wouldn’t,”
one said to a colleague in 2018, before the first crash.
While the most insensitive comments appear to have been
made by a few employees, the messages reveal a coordinated effort among
Boeing employees to persuade the F.A.A. that the Max did not need
simulator training, a significant financial boon for the company.
Boeing
employees congratulated one another for using “Jedi mind tricks” to
convince regulators that minimal training was needed on the Max. In an
email from 2016 celebrating the agency’s preliminary decision not to
require simulator training on the Max, the plane’s chief technical
pilot, Mark Forkner, said the news “culminates more than three years of
tireless and collaborative efforts across many business units.” Last
year, other damaging internal communications involving Mr. Forkner were released.
In
an exchange with Mr. Forkner in 2014, an employee who was developing
the computer-based training for the Max suggested providing more
guidance in the pilot manual for how to handle certain emergencies. (The
plane featured a new software system later found to have played a role
in both crashes.)
Mr. Forkner told the employee that the company
couldn’t add that information because it might lead regulators to
require more extensive training for pilots. “We need to sell this as a
very intuitive basic pilot skill,” Mr. Forkner wrote.
“I
fear that skill is not very intuitive any more with the younger pilots
and those who have become too reliant on automation,” the employee
responded.
“Probably true, but it’s the box we’re painted into,”
Mr. Forkner said, citing the desire to keep training to a minimum. “A
bad excuse, but what I’m being pressured into complying with.”
After fighting so hard to avoid simulator training, Boeing reversed itself
this week and recommended that all pilots have the training before
flying the Max. Bloomberg Intelligence estimated that it would cost the
company $5 billion, though Boeing said it was too soon to know the true
figure.
“Had they done the right thing upfront, they might have
had slightly higher costs upfront, but they would have saved billions in
the long term,” Mr. Sullenberger said. “But that’s hard to do in this
world run by Wall Street.”
Stan Sorscher, a former Boeing engineer
who then worked with a union representing company engineers, said
priorities had shifted over the past two decades, with profits mattering
more than quality.
“Engineers normally just don’t talk that way,” Mr. Sorscher said of the messages. “It’s not the company I knew.”
Boeing and the F.A.A. said on Thursday that the new messages, damning
as they are, did not reveal any new safety concerns about the Max.
Regulators may approve the Max to return to service in the coming
months, and the plane could be flying commercially by the summer.
Yet
Boeing’s problems are hardly over. The messages are likely to further
undermine public confidence in the company and the Max. Today, according
to Boeing’s own research,
40 percent of travelers are unwilling to fly on the plane. There is no
timetable for the return of the Max, costs are mounting, and shares in
the company have fallen 22 percent since the second crash, including a 2
percent drop on Friday.
After last month’s announcement that Boeing would temporarily shut down production of the Max, suppliers are hurting, too. On Friday, Spirit AeroSystems, which makes the fuselage for the plane, said it would lay off around 2,800 employees.
With
a new chief executive, David Calhoun, taking over on Monday, Boeing is
trying to turn a corner. The company promoted its transparency in
releasing the messages and its decision to recommend simulator training
as examples of a new culture. On Friday, Boeing said Mr. Calhoun would
receive a $7 million bonus if he got the Max safely flying again. (Mr.
Muilenburg is leaving with $62.2 million in stock and pension awards.)
But
in the words of Boeing’s own employees, the culture is entrenched. As
recently as mid-2018, colleagues were lamenting the state of their
company in pained emails to one another.
“I don’t know how to fix
these things … it’s systemic,” one employee wrote to another in an email
about the 737 Max. “Sometimes you have to let big things fail so that
everyone can identify a problem … maybe that’s what needs to happen
rather than continuing to scrape by.” https://www.nytimes.com/2020/01/10/business/boeing-737-employees-messages.html?action=click&module=Well&pgtype=Homepage§ion=Business
The View From Here: A moderate case for Bernie Sanders
The Vermont left-winger might be best positioned to deliver the policies that moderates say they prefer.
by Greg Kesich - Portland Press Herald - January 12, 2020
Let’s say that you’re a moderate Democrat trying to decide who to vote for in the 2020 presidential primary.
Your top concern is picking a candidate who can beat Donald
Trump in November. You also want a humane immigration policy, health
care that’s affordable to everyone and action on climate change.
It’s not asking a lot, but you’re a moderate and have moderate dreams.
Your candidate should be Sen. Bernie Sanders.
I know. He’s the most radical member of the 12-candidate field.
But you may have to learn to love a 77-year-old, Sandinista-supporting,
democratic socialist from the electorally irrelevant state of Vermont.
That’s because Joe Biden, the logical safe choice for risk-averse voters, is not seeming like a very safe bet right now.
The former vice president is still leading in most polls, but
not by much. His debate performances have been unsteady, and that’s
being generous. If you wonder how he’ll hold up to six months of
questions about what his son Hunter was doing in a Ukrainian corporate
boardroom while his dad was vice president, check out Biden’s answer to
a retired farmer in Iowa last month. Biden called the guy a liar and
challenged him to a pushup contest.
This could go very badly.
But there are so many other candidates in the race – why Sanders?
It has to do with your top concern: beating Trump. Sanders’ advantage is that he talks to people who don’t always vote.
If you had been watching the Democratic debates last year, you
would see candidates struggling to boil their 12-point plans into
digestible sound bites.
Sanders doesn’t get dragged down into the details. He makes his
case with a few blunt assertions illustrated with hand gestures, which
you don’t need a college diploma and a subscription to The Atlantic to
understand.
Health care for all would be
funded by taxes, like they do in every other country in the developed
world. The same goes for free tuition in public colleges and
universities. Workers deserve a minimum wage that you could live on.
Simple.
Sanders isn’t the only candidate who is talking about major
changes that would help millions of people stuck in an economy that
works best for the wealthy. But he does it without apology, leaving
little room to wonder what he’s really up to.
But you’re a moderate. You are comfortable with nuance.
You may have to leave your comfort zone if you want to beat Trump.
Biden has strong support from older voters, the kind of people
you can count on to show up on Election Day, but that’s the point. Those
people will be showing up anyway. It’s the less-reliable voters you
need on board, and they may not turn out for Joe.
Biden also has strong support from African-American voters, according to the polls. But so did Hillary Clinton.
Sanders is especially strong with
young voters (of all races), exactly the kind of people who stay home or
vote for a third-party candidate when they don’t like the nominee. The
danger of going too safe would be alienating them.
Is Sanders’ program too radical for moderates? Not if they are paying attention.
You have to remember that the legislative process is basically
broken. A President Sanders would not be able to pass his “Medicare for
All” bill as written, even if the Democrats retook the Senate this year.
Sanders can say he wants to tear the system down, but the only kind of
change that we are likely to see in the near term is the incremental
kind that moderates say they want. The political revolution Sanders says
would be needed to achieve his ultimate goals would take a series of
election victories, not just one.
In the meantime, a president committed to humane immigration policy,
universal health care and an adequate response to climate change could
achieve a lot. He could also keep us out of a war.
The theory of Sanders’ electability will be put to the test soon. If
infrequent voters don’t show up to support him in the early state
primaries, he can’t claim he has the ability to motivate them.
But if they do turn out for Sanders, center-left Democrats may
have to do what they told progressives to do four years ago: Swallow
hard and fall in behind a candidate well outside their comfort zone. https://www.pressherald.com/2020/01/12/the-view-from-here-a-moderate-case-for-bernie/
The health-care industry is letting surgeons behave like muggers
By Cynthia Weber Cascio - Washington Post - January 13, 2019
We’ve been hearing a lot about surprising medical bills
lately — horrible stories about wages being garnished because of large
unpaid bills, people losing their homes, even people taking their own lives because of medical debt.
Yet
the public still seems largely unaware that such horrendous situations
could happen to anyone — even those with great health-care plans. That’s
because our health-care system is ripe for bad actors to abuse patients
in emergency situations. I should know; it happened to me.
About a
year ago, I began to have stomach discomfort and thought I had overdone
it at Starbucks. The pain got worse overnight. Antacids didn’t help.
Then came the nausea, 102-degree fever and pain that had moved to my
lower right side, making it difficult to lift my leg. By dawn, I knew it
was appendicitis and told my husband we had to go to the hospital.
There
were several options, but I felt so sick that we chose a nearby
hospital, which we have long trusted for our family’s health. A CT scan
and bloodwork quickly confirmed acute appendicitis. I would need surgery
immediately. Not to worry, the ER doctor told me. They had a good
surgeon on call. Things were moving efficiently and smoothly. We were
impressed.
Then we met the surgeon as I was being prepared to be
taken into the operating room. He explained that if he didn’t operate
right away, I might get sepsis and die. He also said he didn’t take my
insurance but assured us I was in capable hands, as he was very
experienced. After asking about our occupations, he announced his fee
for my laparoscopic appendectomy would be $15,000. We were stunned by
the timing and the amount. Was this supposed to be a negotiation?
But
there was no time for discussion. I was wheeled off for a
straightforward surgery that took about 35 minutes — not much longer
than a colonoscopy. The procedure went well.
Eventually, the
surgeon’s bill arrived: $17,000 including charges for an ER consult
neither my husband nor I recall. I called the insurance company (for
which we’re paying more than $25,000 in annual premiums). Sorry, he’s
not one of ours. No contract with us.
Fortunately, my insurance
covered all other related hospital costs — the ER doctors and tests, the
operating room, medications, the anesthesiologist’s fee — but that
still left us with the $17,000 charge from the surgeon. That’s more than
seven times the out-of-network, uninsured rate for the hospital’s
locale, according to FAIRHealth Consumer.
I appealed to the Maryland Insurance Administration,
which regulates the state’s insurance industry. MIA was sympathetic,
but there was nothing to be done because the surgeon didn’t have a
contract with the insurance company.
I wrote to the head of the
hospital and patient relations. Surely the surgeon mistakenly added an
extra zero? Was the hospital aware business affairs were taking place in
pre-op? Can an out-of-network surgeon simply make up any fee on the
spot? I felt violated.
Three months later, I got what appeared to
be a computer-generated email survey asking if I had any complications.
It also said the surgeon who performed my procedure was part of a
quality control panel. I have heard from the hospital subsequently — in
the form of more general emails, asking me to donate money.
Meanwhile,
we appealed our insurance company’s refusal to cover the surgery, and
as we waited for its final determination, the surgeon kept asking the
status of the claim. In an email exchange, he offered to reduce his fee
by 30 percent if it would help.
Finally, I went to the Maryland
attorney general’s office, which wrote a letter to the hospital. With
that, we came to a resolution: I agreed to pay the surgeon what I felt
reasonable — $3,000 — generously above the customary rate for an
uncomplicated laparoscopic appendectomy in our area ($2,330).
I
asked a relative, an esteemed big-city surgeon, why this happened. Many
doctors and hospitals are squeezed, he said. Some doctors work in public
hospitals by day, privately at night. Care for an uninsured burn
victim, for example, can cost millions. Everything is a balance —
judgment, ethics, conscious, subconscious. Which is why massive overhaul
is needed.
But reform appears in no one’s best interest,
especially given the current political climate. Insurance companies,
hospitals and doctors are businesses. Lawmakers, even at the local
level, often serve on hospital boards and in some cases are major
donors.
Telling a patient to negotiate a bill directly with the
provider, as my insurance company suggested, is akin to telling the
victim of a mugging to ask the thief for their purse back. It’s
uncomfortable and intimidating. And in an emergency, patients don’t have
the luxury of time for research. Without any kind of regulation or
oversight, it’s fertile ground for the opportunistic and unscrupulous.
What if we had told the surgeon, as I was about to be wheeled off, we thought his fee was too high? What would have happened?
Commentary: Cancer isn’t the only thing that’s killing Americans
Big drops in cancer mortality rates are worth celebrating, but they
stand in sharp contrast with many persistent and worrisome health
trends.
By Max Nisen - Bloomberg Opinion - January 14, 2020
Americans got some fantastic health news last week: Based on the latest data, U.S. cancer deaths are plunging at the fastest rate ever.
The finding came in a report
released Wednesday by the American Cancer Society, which attributed the
decline to a reduction in smoking, which has lowered lung-cancer
mortality rates, as well as advances in surgery and diagnosis and the
arrival of new and effective medicines. Even better, those numbers come
from 2017 and should improve with expanded use of the latest drugs and
technology.
Our knowledge of and ability to combat cancers has grown
substantially in recent decades, and the resulting decline in deaths is
something to cheer. But as much as I’d like to savor this victory, I
have to point out that these scientific advances and improved outcomes
in oncology stand in sharp contrast with other trends. Chief among them,
American life expectancy trails other developed nations and outright
declined in recent years, even as the country spent more than any other
on health care. This disconnect shows how much more needs doing.
One big reason drug companies have flocked toward cancer
and gotten a record number of oncology drugs approved in recent years
is related to the payoff, which is a function of how our health care
system works. Cancer drugs face limited reimbursement pressure relative
to medicines that target larger populations and chronic conditions. That
continues to be true even as list prices at launch routinely exceed $100,000
for a course of treatment. Spending on the category more than doubled
between 2013 and 2018 from $27.3 billion to $56.7 billion. So you can
see why drug companies might favor pumping money into cancer R&D
over remedies for other conditions.
New drug development for mental health and addiction, for example,
has been glacial in comparison to cancer, even as suicides and overdoses
contribute to declining U.S. life expectancy. Nearly 73,000 Americans
died from liver disease and other alcohol-related illnesses in 2017,
which is more than double the number
in 1999. Alzheimer’s disease will only become a more prominent cause of
death and financial burden as the population ages, and yet there’s been
minimal progress toward a treatment. And while we’re great at
compensating companies for the development of multiple cancer medicines
in the same category, developers of antibiotics – medications we’ll
probably need to ensure the survival of the species – keep going
bankrupt. Unless the government ponies up significant cash
to support researchers that take on big challenges or changes
incentives to better target areas of unmet need, that may not change.
Finances are only a part of the equation. For sure, new technology
and medicines to treat cancer have helped tame the disease, but public
health efforts arguably deserve even more credit
for cutting mortality rates. The nearly 30 percent drop in the adult
smoking since the 1960s has led to a considerable reduction in deaths
from lung and other cancers. Given the high cost of treatment in
American hospitals and the price and limited efficacy of many medicines, prevention is always a better deal.
There are plenty of important intervention initiatives that deserve
greater funding, including efforts to reduce obesity and lower infection
rates of hepatitis C and HPV. Unfortunately, thinking ahead is rarely
what the U.S. system prioritizes or where it excels. Money that could
flow to those efforts or to what might be the most significant public
health issue of all – ensuring that basic care is accessible and
affordable – instead gets vacuumed up by high prices and wasteful spending.
The drop in cancer mortality is worth celebrating, but not without acknowledging the context and the costs.
Taiwan’s single-payer success story — and its lessons for America
Dylan Scott - Vox - January 14, 2020
HUALIEN COUNTY, Taiwan — Thirty years ago, before she
dyed her hair pink to cover up the white, Dr. Huei-wen Tien came to
Xiulin, a township on the east coast of Taiwan severed from the island’s
urban centers by a formidable mountain range.
She had agreed to serve for 10 years in an aboriginal
community in exchange for her medical education. Unconventional by
nature — her motorcycle helmet says “Punk” — Tien says she wanted a
challenge. She found one here, where about 15,000 people, mostly of the
Taroko tribe, live near the lush gorges of a national park that shares
their name.
Diabetes, alcoholism, and heart disease are common
problems among the Taroko. The indigenous people have endured
displacement, forced assimilation, and discrimination over the
centuries. They are also poorer than the ethnically Han Chinese who make
up most of Taiwan’s population.
But they never have to worry about one thing: their
health care. In Taiwan, everybody is covered. The Taiwanese health care
system is built on the belief that everyone deserves health care, in
Xiulin just as much as anywhere else. The costs to patients are minimal.
And the government has set up special programs to deliver care to the
people in Xiulin and their neighbors in Hualien County.
On a warm October afternoon, in a government health
clinic in the foothills of the Zhongyang (Central) Mountain Range, Tien
saw an older Taroko woman she’s treated for decades. They have a
comfortable rapport. The doctor teased the patient for her high blood
sugar, asked what she had for breakfast, and insisted the woman take her
diabetes medication that she skipped that morning. (The woman said she
was busy.)
Tien then inserted the woman’s national health insurance
card into a chip reader to pull up her medical record on the computer.
The cards are ubiquitous in Taiwan, the signature of its single-payer
health care system, carried by everyone from the woman in Xiulin to a
venture biotech executive I met in Taipei.
In the 1990s, Taiwan
did what has long been considered impossible in the US: The island of
24 million people took a fractured and inequitable health care system
and transformed it into something as close to Sen. Bernie Sanders’s vision of Medicare-for-all as anything in the world.
I came here last October to learn what it takes to set up
and sustain such a system. It’s one of several stops around the globe
that Vox made this past fall, in an effort to learn how other countries
tried to achieve universal and affordable health care. Our project, Everybody Covered, was made possible by a grant from The Commonwealth Fund.
There’s clearly a need for lessons. Compared to the rest
of the developed world, America spends more money on health care and
produces worse outcomes. By one advanced metric
— mortality for causes that should be avoidable with accessible,
high-quality health care — the United States ranked last among the G7
countries in 2016. America’s infant mortality rate is almost double that of some of its peers. Nearly one in 10 Americans lack insurance. People go bankrupt over medical bills. Yet Americans still spend about twice as much money on health care per capita as the average comparable country.
No health care system is perfect. But most of America’s
economic peers have figured out a way to deliver truly universal
coverage and quality care. The United States has not.
“Canada and virtually all European and Asian developed
nations have reached, decades ago, a political consensus to treat health
care as a social good,” health care economist Uwe Reinhardt wrote in
his book Priced Out shortly before his death in 2017. “By
contrast, we in the United States have never reached a politically
dominant consensus on the issue.”
Taiwan made its choice in the 1990s and embraced
single-payer. It has required sacrifice: by doctors who believe they’re
forced to see too many patients every day; by patients with complex and
costly conditions who can’t always access the latest treatments; by
citizens who have been asked from time to time, and will be asked again,
to pay more for their health care than they did before.
The vast majority of Taiwan’s citizens today approve of
their health care system. They know it isn’t a utopia. The country has
made hard choices to keep this program sustainable, and it will need to
do so again. That is what it takes to realize the single-payer dream.
Taiwan took a broken system and built a new national health insurance program
Extraordinary circumstances paved the road to Taiwan’s single-payer system.
In the 1980s, Taiwan wasn’t yet a democracy, but the
stirrings of popular rule could be felt. At the time, about 40 percent
of Taiwanese people lacked health insurance — some people lost
everything, even their house, if they had a medical crisis. Desperate to
outflank reformers, the ruling government convened high-profile
meetings to fix its health care system.
One guest at a 1989 conference was the German-born
Reinhardt, a Princeton economist who was married to Taiwan-born scholar
Tsung-Mei (May) Cheng.
Reinhardt, who later co-wrote the seminal paper “It’s The Prices, Stupid”
about American health care and helped define the health policy debate
in the US in the 2000s, was asked what system he thought Taiwan should
adopt. He thought it over and talked about it with his wife for a couple
of nights in their hotel room.
He finally delivered his answer: single-payer. One national health insurance plan, run by the government, covering everybody.
In Reinhardt’s view, single-payer would be the most
equitable and efficient program. It was similar to systems already in
place in Canada and the United Kingdom. He came up with the metaphor of
the “single pipe” — through which all the money for health care would
flow — to convey the concept to public officials.
It was a convincing presentation. As Cheng and her
husband left to return to the United States, they didn’t know what would
happen next. “We went back to Princeton,” Cheng recalls, “and six
months later, we were told the government would accept your
recommendation to go single-payer.”
The national government would eventually fast-track the
implementation of the new system to 1995, hoping to get the chaotic
transition period over before the first popular elections in 1996. There
was plenty of skepticism leading up to it. Industry, experts, and the
public alike doubted the program would succeed. Labor protesters threw
paper money traditionally used in a funerary rite when the legislature
passed the single-payer bill in 1994. A majority of people in Taiwan
disapproved of the single-payer plan when it took effect.
But the program’s reputation quickly improved once people
started to enjoy its benefits. Approval has dipped (when premiums were
hiked in the 2000s) and risen (when the rural health care program that
employs Tien in Xiulin was implemented) over the years, but there has
always been a solid baseline of support. Today, approval of the national
health insurance program hovers near its all-time high, over 80
percent. The system endures 25 years after it was established.
Part of its appeal is its simplicity. Everybody in Taiwan
is insured through the National Health Insurance Administration (NHIA).
They receive an ID card as proof of coverage, which also stores their
medical records. The Taiwanese program runs with extraordinary
efficiency: About 1 percent of its funding is spent on administration,
according to a 2015 review by Cheng. (Compare that to the US, where researchers have estimated that private insurers spend around 12 percent of overhead, and hospitals spend around 25 percent on administrative work.) Experts say Taiwan’s advanced IT infrastructure deserves a good share of the credit.
The benefits are quite comprehensive: hospital care,
primary care, prescription drugs, traditional Chinese medicine. Patients
must make copays when they visit the doctor or fill a prescription or
go to the ER, but they are generally low, 360 NTD (about $12) or less.
Lower-income patients are given an additional break on their
cost-sharing obligations. Higher-income patients can take out private
insurance for certain things not covered by the single-payer program.
The system is mostly funded by payroll-based premiums,
with contributions from workers and their employers, supplemented by
more progressive income taxes and tobacco and lottery levies. Premiums
have been raised twice in the past 18 years to cover the growing cost of
the program. The most recent rate increase in 2010 moved the payroll income tax rate from 4.55 percent to 5.17, a 14 percent increase.
In the early 2000s, again at Reinhardt’s recommendation,
Taiwan converted to global budgets to pay for health care as another
cost-control measure. This means that every year, government officials
and private providers sit across a table and negotiate rates for
services, with an annual cap set on the total payments to hospitals and
doctors that the government will make. Health spending has stayed flat in recent years as a percentage of GDP, and it is growing at a slower rate in Taiwan than in the United States.
Taiwanese patients use a lot of health care, and it puts a strain on providers
What it all adds up to is a system that patients seem
broadly happy with — maybe too happy, according to doctors and
economists I met.
“I believe we are too kind to our patient[s],” says
Shou-Hsia Cheng, a health economics professor at National Taiwan
University (NTU) who has worked at NHIA on and off over the years,
“which is not a good thing, actually.”
Taiwanese people take advantage of their cheap, accessible health care. The average number of physician visits per year (12.1) is nearly twice that of other developed economies. There was a dramatic spike in use after single-payer was passed: A 1997 JAMA research paper
led by Shou-Hsia Cheng found that physician visits among the newly
insured doubled in the first year of the program compared to the year
before.
That has had predictable downsides: Hospitals get crowded
in Taiwan. The capacity of health care providers to attend to everyone
in need can be stretched pretty thin.
I visited the National Taiwan University Hospital, a
red-brick building in the heart of Taipei from the Japanese colonial
period, one weekday afternoon. All of the clinic lobbies were full. The
registration desk, run take-a-number style, was bustling, beeps
constantly pinging over the PA system as patients’ numbers were called.
On another morning, inside a north-central Taipei primary
care clinic, several patients were already sitting along the walls,
hooked up to machines receiving infrared therapy for chronic pain, just a
few minutes after the doors opened. The one doctor on site looked a bit
frazzled as he showed me around before his clinic filled up any
further.
The scenes bring to mind something I heard from trauma
surgeon Li-Jian Chien, a member of the Taiwanese doctors union that
formed in 2012 out of the frustrations felt in the medical profession.
In Taiwan, he says, “the patient [is] in heaven” — but “the doctor is in hell.”
It’s the opposite of the United States, he elaborates,
where high cost sharing leads people to skip necessary care for serious
conditions.
Chien says national health insurance with negligible cost
sharing has pushed doctors to the brink. His friend and fellow
physician Bing-Hong Lin exclaimed at one point during our interview: “We
are not the Avengers!”
Surveys conducted by the government show health care
providers have rather mixed opinions on the single-payer system — a
significant plurality, 43 percent, said they were “neutral” in 2018 — a
sharp contrast to the public’s sky-high favorability.
Chien says he sometimes sees the same patient dozens of
times every year in the emergency department where he works, often for
problems that aren’t emergencies. The low costs mean patients have
little incentive to avoid the ER.
“Everyone wants to live forever, but it’s impossible,” Chien says. “Some people abuse emergency, abuse health care.”
At the same time, because Taipei has a lot of traffic
accidents, injured drivers and pedestrians come through his emergency
department’s doors all the time. His attention is divided when it
shouldn’t be.
Lin has started doing cosmetic medicine for adults on the
side because he has become so frustrated by his pediatric practice.
It’s a more lucrative field, paid for privately by patients, with a less
demanding workload. His is not an uncommon choice, according to
experts. Lin still bitterly remembers being called back early from leave
he had taken in 2005 to attend his father’s funeral, because there was a
staffing shortage at the hospital where he was doing his residency.
Taiwanese hospitals and clinics are understaffed compared to the rest of the world: There are about 1.7 doctors
in Taiwan for every 1,000 patients, which is well below the average of
3.3 in other developed countries. There are especially shortages of
specialists in less urbanized parts of the country.
“Taiwan’s low ratios would be considered inadequate by OECD standards,” Tsung-Mei Cheng wrote in 2015, “especially in view of the high utilization of health care services in Taiwan.”
The country does excel at keeping wait times short for services like cataract and hip replacement surgeries. But providers are feeling the strain.
Taiwanese doctors work about 10 more hours a week on average than those in the United States. A 2016 survey
of hospital physicians found that working overtime was prevalent, and
doctors who worked a lot of overtime were more likely to say they might
leave the hospital where they worked.
Crowded facilities, like the NTU Hospital, are the norm. Hospitals supplement their medical payments with high-margin non-health care services — food courts, parking, and so on — to keep themselves solvent.
The worry is that Taiwan’s national health insurance has
given patients such a good deal on medical care that they are
overwhelming the system.
Patients must make sacrifices, too, like when a drug is too expensive to cover
The patients have their own grievances. They’ve seen
their premiums hiked and more taxes introduced over the past two
decades, and they will probably be asked again soon to chip in more
money.
And though the benefits are comprehensive for most
people, Taiwan still doesn’t cover everything. Costly treatments for
rare conditions are sometimes excluded.
A new drug for spinal muscular atrophy — a genetic
disorder that progressively breaks down the patient’s muscle tissue,
resulting in early death — came on the market in the US in 2017. The
first year of treatment costs $750,000. Yi Jie Li, a 25-year-old woman
with spinal atrophy and an outspoken advocate who wrote the 2017 book 7,300 Days: The Most Ordinary Luxury, penned a letter to the NHIA pleading with it to cover the drug for the patients it could help.
The department replied in a letter, and the president of
Taiwan called her on the phone. They said they would do their best. But
the drug still isn’t covered.
New medicines sometimes debut in Taiwan a full five years after they came on the market in the United States. For patients who need those medications, every day of waiting is a trial.
“Now the medicine is there,” Li says, “but you cannot use” it.
In some rural parts of the country, medical understaffing
means less access to specialists and pediatricians. High use has
frustrated doctors in the cities, but it’s patients who suffer if it’s
hard for them to see a doctor or nurse.
Even though Taiwanese patients get a good deal on health
care, they don’t come across as entitled. Some of the patients I met,
including those who have faced the gravest diagnoses, seem acutely aware
of the trade-offs demanded of them to keep a single-payer system
sustainable.
Gloria Lin was diagnosed with breast cancer shortly
before national health insurance took effect; today she is president of
the Taiwanese Cancer Patient Association. Her group plays a part in
talks between government and providers about what will be covered (and
for how much).
She told me that of course she wants to see every new
cancer drug covered by the government plan. But she also understands why
that’s impossible: The system would become too expensive.
“We don’t want it [to go] bankrupt,” she says. “We have
to work hand to hand together to solve the problem. … We have to be
sensible for each other.”
Sustaining a single-payer system requires hard choices for patients, providers, and taxpayers
National health insurance achieved what the Taiwanese
government hoped it would. Everybody can afford health care. People are
living longer, healthier lives.But the ever-growing
cost of providing health care to everybody makes it challenging for the
program to remain financially sustainable.
The government keeps having to ask doctors, hospitals,
and patients to make sacrifices to keep single-payer running. That’s not
usually a political winner. No elected official is running on a
campaign of higher premiums and higher copays.
But it helps that national health insurance has proven so
popular. People want to make it work because single-payer has clearly
improved Taiwanese lives.
One metric
tells the tale: a rating based on medically amenable mortality, which
gives a sense of how often people die of causes for which medical
interventions should be available. In 1990, before Taiwan’s single-payer
program was implemented, the country held a rating around 60, far
behind the United States’ rating of 80. In 2016, Taiwan had nearly
caught up with the US, topping 85; the US sat at 88, trailing its
socioeconomic peers in Europe.
There is no doubt that medical care in Taiwan is better
under single-payer, though it improved from a much worse status quo than
the American system.
Today, Americans die prematurely
of heart disease and lung cancer at higher rates than the Taiwanese.
People in Taiwan live a little longer in general, though there are
populations that encounter early deaths from alcohol use and stroke,
just as some disadvantaged groups do in the United States. Yet overall,
Taiwan spends 6 percent of its GDP on health care, about a third of what the United States does.
There is no comparison between the Taiwanese system of
yesteryear — a 40 percent uninsured rate and the risk of financial
catastrophe — and the one that exists today.
But hard choices still loom.
In the early 2000s, with health spending growing too
quickly, the national health insurance office decided to institute the
global budgets, a set pool of money that would cover all the medical
services in a given year. Hong-Jen Chang, then the NHIA director,
remembers seeing his effigy being decapitated in protests by hospital
supporters. The opposition was overwhelming, and he had to resign over
that decision in 2004. That was also shortly after the first premium
increase was approved.
NHIA Director-General Dr. Po-Chang Lee told me that,
after the presidential election this month, he would pitch the new
government on increasing copayments so patients pay more out of pocket
if they visit the doctor or hospital.
It may take more than that. Shou-Hsia Cheng, the NTU
professor, predicted Taiwan would soon have to reevaluate its payments
for end-of-life care. The country is currently debating how to expand
long-term care for an aging population; it’s not covered by the national
health plan.
The financial crunch is coming. The NHIA, which ran
surpluses for a while after the last round of rate increases, is now
about to see its reserves run out.
“Either we should increase the premium rate or increase
the copayment, or we have to delete some coverage items,” Chang, the
former NHIA director, says. “That will happen — not in two years,
perhaps in 10 years. It will happen.”
But in Taiwan, the need for premium increases or hospital
budget caps isn’t considered an indictment of national health
insurance, at least if approval ratings for the system are anything to
go by. It’s part of the evolution of the system they have built. And
because the underlying program is so popular, Taiwanese leaders are
confident patients will be willing to do what’s needed to keep
single-payer viable.
“They will adjust,” Cheng, the professor, says. “I believe so.”
Taiwan is realizing the dream of “health care as a human right”
Since the beginning, the debate in Taiwan has been about
balancing the imperatives of equity and access that underpinned the
national health insurance program. Perhaps there’s been no greater
demonstration of that than seeing the health care system at work in the
mountain township of Xiulin, where Tien was making her rounds.
A decade into the single-payer experiment, when Hong-Jen
Chang was in charge of NHIA, health care access in places like Xiulin
was still lacking. So he decided to start the rural care delivery
program that covers Tien and her patients.
On the same day she treated the Taroko woman at her
clinic, Tien ventured out to visit a bedridden stroke patient in his
home and showed the same warmth, offering him a cheerful thumbs-up as
she went through her exam. A few doors down, a diabetes patient with
gout welcomed a nurse into his house, parakeets chirping at the front
door, so she could take his blood sugar readings, something she does two
or three times a week. Meanwhile, in the town hall, a pop-up Chinese
medicine clinic was set up, and patients filed in to get acupuncture
treatments.
Chang told me a health care delivery program like this
was the natural endpoint for the single-payer experiment, a necessary
extension of its services to reach a vulnerable population. Without it,
the work of Taiwanese health reform would always be incomplete.
“That’s the essence of universal health coverage,” he
says. “The principle of health [as a] human right is that everybody
regardless of geography, religion, gender, age should have the right to
access.”
The people here seem grateful. Wong Shin-Fa, a
63-year-old Taroko man, stopped me on the side of the road in Xiulin and
asked me what I was doing there. When I said I was an American
reporting on health care, he told me a story.
He had a Taroko friend in Los Angeles who broke his arm,
he told me, with a government health worker interpreting. Rather than
get it fixed in the United States, his friend decided to fly back to
Taiwan and have it mended there because he said it would be cheaper.
Shin-Fa knew Tien and her shock of pink hair. He said
she’s famous around those parts. He told me, “The government takes good
care of the Taroko people.”
Republican Health Care Reform: The Congressional Republicans' Irrational Opposition to Medicaid
by Bob Laszewski - Health Care Policy and Marketplace Review - January 13, 2020
Congressional Republicans have consistently, if not unanimously, opposed Obamacare's expansion of Medicaid.
Their opposition is irrational.
It is also unpopular with voters. In dark red states like Nebraska,
Idaho and Utah voters recently went over the heads of their Republican
legislators and governors by approving referendums to expand the
program. And, Kansas is about to become the 37th state to expand
Medicaid under Obamacare after a bipartisan agreement between the
Democratic governor and Republican leaders in the legislature.
While Obamacare's individual health insurance reforms and subsidies have been a disaster for the middle class (See: Obamacare is "Stable" at an Incredibly Unstable Place),
the Medicaid expansion in the states that have approved it has covered
millions of people that would never have been covered otherwise––at a
cost that could never have been less.
Republican opposition has centered around a number of arguments. Let's take a look at each of them. We can't afford such a massive expansion of the welfare state and the impact that would have on deficit spending.
Our rapidly exploding deficits are a big issue we seem to have recently forgotten about.
But blowing up the deficit over health care didn't bother Congressional
Republicans in 2003 when they created the Medicare Part D drug benefit
and didn't pay for it adding $700 billion to the deficit over the
following ten years (Part D added $140 billion to the deficit alone in 2018). But that unpaid-for entitlement expansion helped a big Republican constituency––seniors.
Blowing up the deficit by more than $1 trillion with the Republican tax
cut bill didn't bother Republicans in 2017 arguing it was all going to
pay for itself with economic growth––something that so far hasn't come
close to panning out. Last November the CBO estimated that the annual
deficit will remain between $1 trillion and $1.2 trillion each year
through 2029.
And, just last month in the year-end spending bill, Congressional
Republicans overwhelmingly voted to repeal the Obamacare medical device
tax, the health insurance tax on insurance companies, and the employer
health insurance "Cadillac" tax on high cost plans––taxes originally
intended to pay for the Medicaid expansion and insurance subsidies in
the first place. Doing so will cost $400 billion over ten years, again
all just added to the deficit. None of that bothered Republicans one bit
when they joined the Democrats to pass the larded up year-end spending
bill at a time both the medical device and health insurance industries
are reporting record profits.
But, money for the Medicaid expansion? Irresponsible.
Any Medicaid expansion should be paid for. Just like the Obamacare
Medicaid expansion was fully paid for before Republicans joined with
Democrats last month to repeal three of the law's key taxes! Consumers should have mainstream private coverage not welfare coverage via Medicaid.
A noble objective but simply unaffordable both for low-income consumers and government.
Medicaid is, by far, the cheapest way for government to expand coverage.
And, unlike individual health insurance, Medicaid doesn't have big
deductibles and copays low-income people would find it hard if not
impossible to pay.
The CBO has estimated that the Medicaid expansion cost $4,916 per
enrollee in 2018––for a program with no consumer deductibles and
co-pays. At the same time the CBO estimated that the average
per-enrollee cost for the Obamacare insurance market subsidies was
$6,300––and remember the Obamacare market plans have big deductibles and
the government doesn't subsidize the entire cost.
The cheapest way, by far, to subsidize the poor into plans with minimal copays is through Medicaid.
And, while there are fewer providers participating in Medicaid than
commercial insurance because of the lower reimbursement rates, rates
of access to care and satisfaction with care among Medicaid enrollees
are comparable to rates for people with private insurance.
Whatever the quality of care challenges in Medicaid, it sure beats being uninsured. Insurance should be provided by the private sector, not government.
Congressional Republicans love to take credit for the Medicare Advantage
program that gives seniors a private insurance option. But, do they
understand that most of the Medicaid program is today under private
insurance company managed care organizations (MCOs) administration and
risk-taking subject to competitive bidding?
In 2018, insurers had more than 49 million Medicaid beneficiaries in their programs––two-thirds of the enrollment. Why don't these people just get a job with health benefits?
Sounds good. But what these Republicans don't seem to understand is that
lots of employers don't offer health insurance benefits.
About 48% of private sector jobs are in small businesses and small business creates two-thirds of net new jobs.
The latest annual Kaiser Family Foundation survey of employer-based
health insurance found that only 47% of employers with three to nine
workers offer health insurance, for those with ten to 99 workers, it's
57%. The welfare state is already too big.
The first Republican president, Abraham Lincoln, famously said, "The
legitimate object of government is to do for a community of people
whatever they need to have done, but cannot do at all, or cannot so well
do for themselves in their separate or individual capacities."
Medicaid eligibility extends up to 138% of the federal poverty level in
the 36 states that have expanded the program under Obamacare. That is an
annual income of $17,236 for a single person and $35,535 for a family
of four.
Back in 2013, before Obamacare became effective, it wasn't uncommon to
find a health insurance plan that would cost a family of four about
$5,000 in premiums with a $1,000 deductible––if they had no pre-existing
conditions and could get insurance.
There is no way a family making $35,000 could afford to pay all of those
2013 premiums and deductibles today without assistance, any more than
they could back in 2013. Even if Republicans take us back to the 2013
health insurance market, just how do they think the Medicaid eligible
would be able to access health insurance without the Medicaid expansion? Republican plans like the failed 2017 health care bill passed by the
Republican controlled House make more sense than the existing Medicaid
expansion.
In 2017, House
Republicans would have repealed the Medicaid expansion and the
individual market subsidies and would have repackaged them into a
program that took some, but not all, of that money and sent it to the
states. Each state legislature would have been expected to take that
money and
craft a health insurance reform plan of their own making––fifty
different states doing what the Congress has been unable to find a way
to do.
Here
is the Congressional Budget Office's (CBO's) July 2017 evaluation of
that plan. The CBO calculated the Republican House plan, assuming the
fifty states would have each found a way to pass a plan, would have
spent
$1.3 trillion less than Obamacare over ten years on Medicaid and
insurance subsidies:
The CBO estimated that these funding cuts would have led to:
Nine
million people being pushed out of Medicaid by 2020 growing to 14 million in
2026––and then having to enter the individual market as their only
option for coverage, unless they found their way to employer coverage.
The individual market shrinking by ten million in 2020, and six million by 2026.
The
CBO therefore concluded that the number of people eligible for the
individual market would increase dramatically as the reduced Medicaid
population was forced to seek private individual coverage–– but in a market where money for the
individual coverage subsidies was also substantially cut.
The
2017 House Republican plan's combination of dumping more people into
the pool by shrinking Medicaid––and therefore increasing the number of
people eligible for individual coverage––and cutting the subsidies in
the private market, could only have had the result of making the
percentage of eligible people buying a private health plan even worse.
That in turn could only lead to even worse individual market
affordability and resulting underwriting anti-selection than what we
have had under Obamacare.
I have been in the health insurance industry for 47 years. I am not an advocate for a government takeover of the system.
But, I have also learned in these years that the private sector on its own is not the answer.
The answer lies in a carefully crafted system that includes
both the private sector and government seamlessly doing "for a community
of people whatever they need to have done, but cannot
do at all, or cannot so well do for themselves in their separate or
individual capacities."
I wish the Congressional Republicans could come to the same conclusion that Lincoln did.
