Pretending Single Payer Health Care Is Easy to Pass Doesn’t Make It Easy
by Jonathan Chait - Daily Intelligencer - August 2018
The American health care system developed, like a deformed tree, around employer-sponsored insurance as its core feature. This has made it extremely hard to build a single, simple universal system, because it would require moving people out of health care they have into something new, and require turning their premium contributions into taxes.
If you could sit down face to face with every American and calmly talk them through the numbers step by step, you could probably convince them to feeling comfortable giving up employer-sponsored insurance. Since you can’t do that, the only option is passing a bill in a hysterical atmosphere where the insurance industry and conservatives bombard the public with warnings of massive middle-class tax hikes and tens of millions of Americans losing their current insurance to get moved onto a government plan.
If we didn’t have an employer-based system already, it might be politically feasible to build a single-payer system. But the politics of uprooting that deformed tree are extremely imposing. You can read a history of the struggle for universal health care, like Jonathan Cohn’s Sick, or Paul Starr’s Remedy and Reaction, to understand why most liberals (and Democratic elites) believe the growth of the employer system has tragically blocked the political path to single payer.
Those conclusions, built up over decades of experience and polling data, inform the mainstream liberal view of health care. Since it’s just too hard to convince people they’ll be better off paying taxes instead of premiums, and exchanging their current insurance for a government health care plan, the path to universal coverages lies in working around the existing system. Paul Krugman made this case last year, and so did I.
Ryan Cooper, like many leftists, dismisses the conclusion. Cooper argues that Krugman and I are merely parroting insurance industry propaganda:
But this argument is garbage. Medicare-for-all would mean vastly more people enjoying good health care, and dramatically fewer people getting kicked off their insurance overall.
Their main argument is pretty clearly going to be centered around loss-aversion. “Most Americans support commonsense, pragmatic solutions that don’t interrupt the coverage they rely upon for themselves and their families,” PAHCF spokesman Erik Smith told The Hill. (Jonathan Chait and Paul Krugman have made similar points.)
Well, yes. A well-designed single-payer system would lead to fewer people losing their insurance. I don’t deny that. Neither does Krugman. Both of us disagree with Cooper that it will be easy to convince most Americans to believe this.
To quote the column of mine Cooper links: “Yes, in an imaginary, rational world, people could be reassured that Medicare will be as good as what they have, and the taxes will merely replace the premiums they’re already paying. In reality, people are deeply loss-averse and distrustful of politicians.” Krugman doesn’t deny that either. “You’d have to convince most of these people both that they would save more in premiums than they pay in additional taxes, and that their new coverage would be just as good as the old,” he writes in the other column Cooper links. “This might in fact be true, but it would be one heck of a hard sell.”
It’s possible, of course, that this political analysis is wrong, or that it will change one day. I kept reading through Cooper’s column looking for the part where Cooper either acknowledged that Krugman and I would like single payer in an ideal world, or that we are wrong about the political hurdles. That passage does not exist. The number of words in Cooper’s column devoted to rebutting our actual case about the politics of single payer is zero. Cooper simply concludes “the medical lobby’s argument [is] mistaken,” and driven by “nothing more than greed.” Either Cooper has not bothered to read the columns he is claiming to rebut (they’re short!), or he cannot understand them (they’re quite simple!), or he is intentionally dishonest.
If single-payer advocates can come up with a way to get around the political obstacles in the way of single payer, they should say what they are. (I have seen many such efforts, though none have struck me as persuasive.) More to the point, you’re never going to enact single payer unless you can address the political obstacles. Simply ignoring the obstacles, and pretending the people who are aware of the obstacles are lying shills who hate single payer, isn’t going to get you closer to enacting the policy.
My previous column notes Bernie Sanders’s regrettable habit of avoiding the political obstacles, and pretending the only barrier to enacting single payer is the greed of the insurance industry, and presumably the politicians who are bought up by them. His fans among the intelligentsia have mimicked this unfortunate habit.
Editor's Note:
Here is Don McCanne's commentary on the above article by Jonathan Chait -
-SPC
Comment by Don McCanne
Jonathan Chait is correct. The benefits of a well designed, single payer, improved Medicare for all are not in dispute. It is not the policies that are a problem, but rather it is the political obstacles that have prevented us from enacting and implementing such a system.
We are moving again into a debate on the left - the progressives supporting a bona fide single payer Medicare for all system, and the centrists expropriating the Medicare for all rhetoric to support a public option with a Medicare label. The ideologues on the right don't have to do anything. The left will self-destruct thereby confirming that Chait's point is correct - the political obstacles are great.
An important point here is that the policy message must remain intact. You do not discard essential policy positions as you sit down to negotiate a compromise, such as supporting the incremental step of enacting a public option with a Medicare label. We did that before.
Although the single payer purists were ejected from the process, the center-left supported a public option, but then in negotiations allowed it to be transformed from a strong public model, as described by Jacob Hacker, into a very weak model even stripped of some of the beneficial features of private commercial insurance just to be sure that it would not be a competitive threat in the private market. Even that was too much, and so the emasculated public option was abandoned. That's what happens when you compromise on policy.
Incremental steps merely tweak our dysfunctional, inequitable, unaffordable, administratively overburdened system - perpetuating most of the defects that cry out for reform. We basically have the single payer policy right. We do not want to negotiate that away as the center-left did last time.
Although the barriers are political, it is a mistake to make them partisan. That's obvious when you look at the obstructionism of the Republicans who for years demanded that we replace the Affordable Care Act with their own model that it turns out never really existed. It definitely would be a mistake, as mentioned above, for the Democrats to move forward now with this intra-party divide on single payer Medicare for all versus a Medicare public option for some.
The right understands the well designed single payer model. The recent Mercatus report is an example, even if the single payer concept was modified to try to discredit the concept. They still showed that everyone would be covered with a $2 trillion savings over a decade (though the results would be much more impressive had they accurately analyzed a model such as PNHP's). Also, in a recent Quote of the Day, two libertarians in separate reports indicated that they too understand the benefits of the single payer model. So we don't want to change policy, and, on the politics, we want to end partisanship and start communicating better.
But to the really important point in Chait's article, he says that we are not persuasive in our suggestions on how to get around the political obstacles in the way of single payer. He has a point since we currently do not have a single payer system in spite of a quarter of a century of trying. But what we don't want to do is to walk away because the political barriers are too great, thereby making that a self-fulfilling prophecy (Chait and Krugman, take note). So how do we get around those barriers?
First, as Chait indicates, is eduction. We must be unrelenting in getting out the word on just what an improved Medicare is all about. As the understanding of the concept increases, coalition and grassroots organizing must be utilized to help spread the word. Polling indicates that these efforts have been effective, but the process is very slow and laborious.
Chait, Krugman and others have acknowledged the clear benefits of the single payer model while they have become somewhat dismissive because of the political challenges. Rather than an expression of pessimism on their part, it seems to me that they are expressing realism with their understanding of how difficult the process is. We certainly understand that as well, as we have lived with this all these years.
Education. Coalitions. Activism. Grassroots organizing. These activities in all of their permutations. Be there and do it. Maybe Chait doesn't think this is persuasive, but it is what we have, and it can work as those in the civil rights movement have shown us (and Social Security, and Medicare, and the end of the Vietnam war, and so on). We must keep on. As FDR said, "make me do it."
The Truth About Social Security: Setting the Record Straight
Eighty-three years later, Social Security addresses universal economic risks that have always been with us and always will be
by Nancy Altman - Common Dreams - August 14, 2018
President Franklin Roosevelt signed our Social Security system into law eighty-three years ago today, on August 14, 1935. It has stood the test of time.
Social Security protects us against the economic consequences of risks to which all of us are vulnerable. Rich or poor, any of us can suffer a devastating, disabling accident or illness. Rich or poor, any of us can die prematurely, leaving young children behind. Rich or poor, all of us hope to grow old. When we do, if we are to have a dignified and independent retirement, we need a guaranteed steady income which we cannot and will not outlive.
Social Security addresses universal economic risks that have always been with us and always will be. That explains why more than 170 countries today have some form of social security. It also explains Social Security’s deep and longstanding popularity in our country. In a survey conducted in 1936—one year after the enactment of Social Security, before a penny of benefits was expended—68 percent of those surveyed expressed approval for the new and untested program. By 1944, that percentage was a nearly unanimous 96 percent. That high level of support has been consistent throughout the last eighty years.
Despite Social Security’s more than eighty-year history, some elites either do not understand Social Security or willfully refuse to understand it. They talk about providing benefits to those who need them, as if the program were government largesse, which it is not. Rather, Social Security is insurance that is earned through work and paid for with premiums regularly deducted from workers’ pay.
In addition, elites often speak as if the trust funds were some kind of gimmick, somehow less real than private pension trust funds. Perhaps most absurd are those who claim that what the creators of Social Security intended is not the program we now have.
Indeed, today’s discussions of Social Security are replete with revisionist history—statements made today about what was or was not intended by its original creators and champions. Some of today’s revisionist statements are zombie lies: Claims made and refuted again and again over the last eighty years; claims that refuse to die.
Former Senator Alan Simpson (R-WY), for example, has stated that Social Security “was never intended as a retirement program. It was set up in ’37 and ’38 to take care of people who were in distress—ditch diggers, wage earners….” Nationally syndicated columnist George Will claims, “People forget Social Security was advocated ... in the 1930s, as a way of getting people to quit working, because they thought we were confined to a permanent scarcity of jobs in this country.”
Syndicated columnist Robert Samuelson in a column entitled, “Would Roosevelt recognize today’s Social Security?” even claims, “Social Security has evolved into something he never intended and actively opposed.” Samuelson, Will, Simpson, and the other revisionist historians are wrong. Indeed, to state it bluntly, those modern-day statements are all nonsense.
Roosevelt’s and the other founders’ words and actions make clear that they envisioned Social Security to be a permanent part of the economy, once the Great Depression was history. They knew that the nation would return to full employment. When we did, the goal was to have in place Social Security and other programs that improved the economic security of all Americans and prevented, as much as possible, the human cost imposed by the ups and downs of all modern economies. In particular, Social Security was not designed to alleviate the suffering of people caught in the immediate distress of the Great Depression, nor to get people to quit their jobs. Rather, it was set up as wage insurance that people earned.
This should be obvious to anyone with even a superficial knowledge of Social Security’s history. Because the architects knew that it would take time and work to earn Social Security’s benefits, the Social Security Act of 1935 was written so that not a single penny of those earned monthly retirement benefits was payable for seven years!
But the absurdity of those revisionist historians goes much further than simply being wrong on the facts. They seek to expunge the far-sighted and noble vision of Social Security’s founders. President Roosevelt and those around him had a sweeping vision that still has yet to be fully realized.
Medicare is consistent with a first step toward the vision of universal health insurance.
When Roosevelt signed the Social Security Act of 1935 into law, he described it as “a cornerstone in a structure which is being built but is by no means complete.” He and his colleagues were anything but short-sighted. They were not simply and solely focused on the immediate distress caused by the Great Depression, as the revisionists would have us believe. Rather, they saw Social Security as a “cornerstone,” a beginning on which to build.
Despite today’s revisionists, the structure and size of today’s Social Security program is completely consistent and harmonious with what Roosevelt began. Medicare is consistent with a first step toward the vision of universal health insurance. The revisionists are wrong when they claim that Roosevelt would not recognize today’s Social Security and Medicare.
He would be surprised that more progress hadn’t been made, but he would absolutely recognize how those who came later built on what he envisioned and began. Now it is our turn. It is time to expand Social Security and enact an improved Medicare for All.
Editor's Note:
The following article may seem a little off-point for a health care reform blog - but keep reading.
-SPC
Eighty-three years later, Social Security addresses universal economic risks that have always been with us and always will be
by Nancy Altman - Common Dreams - August 14, 2018
President Franklin Roosevelt signed our Social Security system into law eighty-three years ago today, on August 14, 1935. It has stood the test of time.
Social Security protects us against the economic consequences of risks to which all of us are vulnerable. Rich or poor, any of us can suffer a devastating, disabling accident or illness. Rich or poor, any of us can die prematurely, leaving young children behind. Rich or poor, all of us hope to grow old. When we do, if we are to have a dignified and independent retirement, we need a guaranteed steady income which we cannot and will not outlive.
Social Security addresses universal economic risks that have always been with us and always will be. That explains why more than 170 countries today have some form of social security. It also explains Social Security’s deep and longstanding popularity in our country. In a survey conducted in 1936—one year after the enactment of Social Security, before a penny of benefits was expended—68 percent of those surveyed expressed approval for the new and untested program. By 1944, that percentage was a nearly unanimous 96 percent. That high level of support has been consistent throughout the last eighty years.
Despite Social Security’s more than eighty-year history, some elites either do not understand Social Security or willfully refuse to understand it. They talk about providing benefits to those who need them, as if the program were government largesse, which it is not. Rather, Social Security is insurance that is earned through work and paid for with premiums regularly deducted from workers’ pay.
In addition, elites often speak as if the trust funds were some kind of gimmick, somehow less real than private pension trust funds. Perhaps most absurd are those who claim that what the creators of Social Security intended is not the program we now have.
Indeed, today’s discussions of Social Security are replete with revisionist history—statements made today about what was or was not intended by its original creators and champions. Some of today’s revisionist statements are zombie lies: Claims made and refuted again and again over the last eighty years; claims that refuse to die.
Former Senator Alan Simpson (R-WY), for example, has stated that Social Security “was never intended as a retirement program. It was set up in ’37 and ’38 to take care of people who were in distress—ditch diggers, wage earners….” Nationally syndicated columnist George Will claims, “People forget Social Security was advocated ... in the 1930s, as a way of getting people to quit working, because they thought we were confined to a permanent scarcity of jobs in this country.”
Syndicated columnist Robert Samuelson in a column entitled, “Would Roosevelt recognize today’s Social Security?” even claims, “Social Security has evolved into something he never intended and actively opposed.” Samuelson, Will, Simpson, and the other revisionist historians are wrong. Indeed, to state it bluntly, those modern-day statements are all nonsense.
Roosevelt’s and the other founders’ words and actions make clear that they envisioned Social Security to be a permanent part of the economy, once the Great Depression was history. They knew that the nation would return to full employment. When we did, the goal was to have in place Social Security and other programs that improved the economic security of all Americans and prevented, as much as possible, the human cost imposed by the ups and downs of all modern economies. In particular, Social Security was not designed to alleviate the suffering of people caught in the immediate distress of the Great Depression, nor to get people to quit their jobs. Rather, it was set up as wage insurance that people earned.
This should be obvious to anyone with even a superficial knowledge of Social Security’s history. Because the architects knew that it would take time and work to earn Social Security’s benefits, the Social Security Act of 1935 was written so that not a single penny of those earned monthly retirement benefits was payable for seven years!
But the absurdity of those revisionist historians goes much further than simply being wrong on the facts. They seek to expunge the far-sighted and noble vision of Social Security’s founders. President Roosevelt and those around him had a sweeping vision that still has yet to be fully realized.
Medicare is consistent with a first step toward the vision of universal health insurance.
When Roosevelt signed the Social Security Act of 1935 into law, he described it as “a cornerstone in a structure which is being built but is by no means complete.” He and his colleagues were anything but short-sighted. They were not simply and solely focused on the immediate distress caused by the Great Depression, as the revisionists would have us believe. Rather, they saw Social Security as a “cornerstone,” a beginning on which to build.
Despite today’s revisionists, the structure and size of today’s Social Security program is completely consistent and harmonious with what Roosevelt began. Medicare is consistent with a first step toward the vision of universal health insurance. The revisionists are wrong when they claim that Roosevelt would not recognize today’s Social Security and Medicare.
He would be surprised that more progress hadn’t been made, but he would absolutely recognize how those who came later built on what he envisioned and began. Now it is our turn. It is time to expand Social Security and enact an improved Medicare for All.
Editor's Note:
The following article may seem a little off-point for a health care reform blog - but keep reading.
-SPC
Liberal Blind Spots Are Hiding the Truth About ‘Trump Country’
by Sarah Smarsh - NYT - July 19, 2918
WICHITA, Kan. — Is the white working class an angry, backward monolith — some 90 million white Americans without college degrees, all standing around in factories and fields thumping their dirty hands with baseball bats? You might think so after two years of media fixation on this version of the aggrieved laborer: male, Caucasian, conservative, racist, sexist.
This account does white supremacy a great service in several ways: It ignores workers of color, along with humane, even progressive white workers. It allows college-educated white liberals to signal superior virtue while denying the sins of their own place and class. And it conceals well-informed, formally educated white conservatives — from middle-class suburbia to the highest ranks of influence — who voted for Donald Trump in legions.
The trouble begins with language: Elite pundits regularly misuse “working class” as shorthand for right-wing white guys wearing tool belts. My father, a white man and lifelong construction worker who labors alongside immigrants and people of color on job sites across the Midwest and South working for a Kansas-based general contractor owned by a woman, would never make such an error.
Most struggling whites I know live lives of quiet desperation mad at their white bosses, not resentment of their co-workers or neighbors of color. My dad’s previous three bosses were all white men he loathed for abuses of privilege and people.
It is unfair power that my father despises. The last rant I heard him on was not about race or immigration but about the recent royal wedding, the spectacle of which made him sick.
“What’s so special about the royals?” he told me over the phone from a cheap motel after work. “But they’ll get the best health care, the best education, the best food. Meanwhile I’m in Marion, Arkansas. All I want is some chickens and a garden and place to go fishing once in a while.”
What my father seeks is not a return to times that were worse for women and people of color but progress toward a society in which everyone can get by, including his white, college-educated son who graduated into the Great Recession and for 10 years sold his own plasma for gas money. After being laid off during that recession in 2008, my dad had to cash in his retirement to make ends meet while looking for another job. He has labored nearly every day of his life and has no savings beyond Social Security.
Yes, my father is angry at someone. But it is not his co-worker Gem, a Filipino immigrant with whom he has split a room to pocket some of the per diem from their employer, or Francisco, a Hispanic crew member with whom he recently built a Wendy’s north of Memphis. His anger, rather, is directed at bosses who exploit labor and governments that punish the working poor — two sides of a capitalist democracy that bleeds people like him dry.
“Corporations,” Dad said. “That’s it. That’s the point of the sword that’s killing us.”
Among white workers, this negative energy has been manipulated to great political effect by a conservative trifecta in media, private interest and celebrity that we might call Fox, Koch and Trump.
As my dad told me, “There’s jackasses on every level of the food chain — but those jackasses are the ones that play all these other jackasses.”
Still, millions of white working-class people have refused to be played. They have resisted the traps of racism, sexism, homophobia, xenophobia and nationalism and voted the other way — or, in too many cases, not voted at all. I am far less interested in calls for empathy toward struggling white Americans who spout or abide hatred than I am in tapping into the political power of those who don’t.
Like many Midwestern workers I know, my dad has more in common ideologically with New York’s Democratic Socialist congressional candidate Alexandria Ocasio-Cortez than with the white Republicans who run our state. Having spent most of his life doing dangerous, underpaid work without health insurance, he supports the ideas of single-payer health care and a universal basic income.
Much has been made of the white working class’s political shift to the right. But Mr. Trump won among white college graduates, too. According to those same exit polls trotted out to blame the “uneducated,” 49 percent of whites with degrees picked Mr. Trump, while 45 percent picked Hillary Clinton (among them, support for Mr. Trump was stronger among men). Such Americans hardly “vote against their own best interest.” Media coverage suggests that economically distressed whiteness elected Mr. Trump, when in fact it was just plain whiteness.
Stories dispelling the persistent notion that bigotry is the sole province of “uneducated” people in derided “flyover” states are right before our eyes: A white man caught on camera assaulting a black man at a white-supremacist rally last August in Charlottesville, Va., was recently identified as a California engineer. This year, a white male lawyer berated restaurant workers for speaking Spanish in New York City. A white, female, Stanford-educated chemical engineer called the Oakland, Calif., police on a family for, it would appear, barbecuing while black.
Among the 30 states tidily declared “red” after the 2016 election, in two-thirds of them Mrs. Clinton received 35 to 48 percent of the vote. My white working-class family was part of that large minority, rendered invisible by the Electoral College and graphics that paint each state red or blue.
In the meantime, critical stories here in “red states” go underdiscussed and underreported, including:
Barriers to voting. Forces more influential than the political leanings of a white factory worker decide election outcomes: gerrymandering, super PACs, corrupt officials. In Kansas, Secretary of State Kris Kobach blocked 30,000 would-be voters from casting ballots (and was recently held in contempt of federal court for doing so).
Different information sources. Some of my political views shifted when my location, peer group and news sources changed during my college years. Many Americans today have a glut of information but poor media literacy — hard to rectify if you work on your feet all day, don’t own a computer and didn’t get a chance to learn the vocabulary of national discourse.
Populism on the left. Today, “populism” is often used interchangeably with “far right.” But the American left is experiencing a populist boom. According to its national director, Democratic Socialists of America nearly quadrupled in size from 2016 to 2017 — and saw its biggest one-day boost the day after Ms. Ocasio-Cortez’s recent primary upset. Progressive congressional candidates with working-class backgrounds and platforms have major support heading into the midterms here in Kansas, including the white civil rights attorney James Thompson, who grew up in poverty, and Sharice Davids, a Native American lawyer who would be the first openly lesbian representative from Kansas.
To find a more accurate vision of these United States, we must resist pat narratives about any group — including the working class on whom our current political situation is most often pinned. The greatest con of 2016 was not persuading a white laborer to vote for a nasty billionaire with soft hands. Rather, it was persuading a watchdog press to cast every working-class American in the same mold. The resulting national conversation, which seeks to rename my home “Trump Country,” elevates a white supremacist agenda by undermining resistance and solidarity where it is most urgent and brave.
Single Payer Is Actually a Huge Bargain
Single Payer Is Actually a Huge Bargain
by Steffie Woolhandler, David Himmelstein and Adam Gaffney - August 10, 2018
Last week, Charles Blahous at the Koch-funded Mercatus Center at George Mason University published a study suggesting that Bernie Sanders’s single-payer health-care plan would break the bank. But almost immediately, various observers—including Sanders himself—noted that according to Blahous’s own estimates, single payer would actually save Americans more than $2 trillion over a decade. Blahous doubled down on his argument in The Wall Street Journal, and on Tuesday, The Washington Post’s fact-checker accused Democrats of seizing “on one cherry-picked fact” in Blahous’s report to make it seem like a bargain.
The Post is wrong to call this a “cherry-picked fact”—it’s a central finding of the analysis—but it is probably right that single-payer supporters shouldn’t make toomuch of Blahous’s findings. After all, his analysis is riddled with errors that actually inflate the cost of single payer for taxpayers.
First, Blahous grossly underestimates the main source of savings from single payer: administrative efficiency. Health economist Austin Frakt aptly demonstrated the “bewildering complexity of health care financing in the United States” in The New York Times last month, citing evidence that billing costs primary-care doctors $100,000 apiece and consumes 25 percent of emergency-room revenues; that billing and administration accounts for one-quarter of US hospital expenditures, twice the level in single-payer nations; and that nearly one-third of all US health spending is eaten up by bureaucracy.
Overall, as two of us documented recently in the Annals of Internal Medicine, a single-payer system could cut administration by $500 billion annually, and redirect that money to care. Blahous, in contrasts, credits single payer with a measly fraction of that—or $70 billion—in administrative savings.
Our profit-driven multi-payer system is the source for this outlandish administrative sprawl. Doctors and hospitals have to negotiate contracts and fight over bills with hundreds of insurance plans with differing payments rates, rules, and requirements. Simplifying the payment system would free up far more money than Blahous estimates to expand and improve coverage.
Next, Blahous lowballs the potential for savings on prescription drugs. He assumes that a single-payer system couldn’t use its negotiating clout to push down drug prices, ignoring the fact that European nations and the US Veterans Affairs system achieve roughly 50 percent discounts relative to the US private sector. (Single payer’s only drug savings, he argues, will come from shifting 15 percent of brand-name prescriptions to generics.) Hence Blahous foresees only $61 billion in drug savings in 2022, even though tough price negotiations would likely achieve threefold highersavings.
Third, Blahous underestimates how much the government is already spending on health care. For instance, he omits the $724 billion that federal agencies are expected to pay for employees’ health benefits over the 10 years covered by his analysis, which would simply be redirected to Medicare for All. He also leaves out the massive savings to state and local governments, which would save nearly $3.6 trillion on employee benefits and another $5.3 trillion on Medicaid and other health programs. Hence, much of the “new money” needed to fund Sanders’s reform is already being collected as taxes.
Yes, there will need to be some new taxes—albeit much less than Blahous estimates. But those new taxes would just replace—not add to—current spending on premiums, co-pays, and deductibles. Additionally, at least some of the new taxes would be virtually invisible. For instance, the $10 trillion that employers would otherwise pay for premiums could instead be collected as payroll taxes. Similarly, Medicare for All would relieve households of the $7.7 trillion they’d pay for premiums and $6.3 trillion in out-of-pocket costs under the current system.
It’s easy to get lost in the weeds here. But at the end of the day, even according to Blahous’s errant projections, Medicare for All would save the average American about $6,000 over a decade. Single payer, in other words, shifts how we pay for health care, but it doesn’t actually increase overall costs—even while providing first-dollar comprehensive coverage to everyone in the nation. The Post’s fact-checker is wrong: Single-payer supporters can and should trumpet this important fact.
Of course, the most important benefits of single payer are altogether invisible in economic analyses like the one performed by Blahous. No matter what injury or illness we faced, we would be forever freed from one great worry: the cost of our care. It’s hard to put a price tag on that kind of freedom. Yet, paradoxically, even the slanted analysis of a libertarian economist provides evidence that it would be fiscally responsible.
Trump’s Sabotage of Obamacare Is Illegal
Last week, Charles Blahous at the Koch-funded Mercatus Center at George Mason University published a study suggesting that Bernie Sanders’s single-payer health-care plan would break the bank. But almost immediately, various observers—including Sanders himself—noted that according to Blahous’s own estimates, single payer would actually save Americans more than $2 trillion over a decade. Blahous doubled down on his argument in The Wall Street Journal, and on Tuesday, The Washington Post’s fact-checker accused Democrats of seizing “on one cherry-picked fact” in Blahous’s report to make it seem like a bargain.
The Post is wrong to call this a “cherry-picked fact”—it’s a central finding of the analysis—but it is probably right that single-payer supporters shouldn’t make toomuch of Blahous’s findings. After all, his analysis is riddled with errors that actually inflate the cost of single payer for taxpayers.
First, Blahous grossly underestimates the main source of savings from single payer: administrative efficiency. Health economist Austin Frakt aptly demonstrated the “bewildering complexity of health care financing in the United States” in The New York Times last month, citing evidence that billing costs primary-care doctors $100,000 apiece and consumes 25 percent of emergency-room revenues; that billing and administration accounts for one-quarter of US hospital expenditures, twice the level in single-payer nations; and that nearly one-third of all US health spending is eaten up by bureaucracy.
Overall, as two of us documented recently in the Annals of Internal Medicine, a single-payer system could cut administration by $500 billion annually, and redirect that money to care. Blahous, in contrasts, credits single payer with a measly fraction of that—or $70 billion—in administrative savings.
Our profit-driven multi-payer system is the source for this outlandish administrative sprawl. Doctors and hospitals have to negotiate contracts and fight over bills with hundreds of insurance plans with differing payments rates, rules, and requirements. Simplifying the payment system would free up far more money than Blahous estimates to expand and improve coverage.
Next, Blahous lowballs the potential for savings on prescription drugs. He assumes that a single-payer system couldn’t use its negotiating clout to push down drug prices, ignoring the fact that European nations and the US Veterans Affairs system achieve roughly 50 percent discounts relative to the US private sector. (Single payer’s only drug savings, he argues, will come from shifting 15 percent of brand-name prescriptions to generics.) Hence Blahous foresees only $61 billion in drug savings in 2022, even though tough price negotiations would likely achieve threefold highersavings.
Third, Blahous underestimates how much the government is already spending on health care. For instance, he omits the $724 billion that federal agencies are expected to pay for employees’ health benefits over the 10 years covered by his analysis, which would simply be redirected to Medicare for All. He also leaves out the massive savings to state and local governments, which would save nearly $3.6 trillion on employee benefits and another $5.3 trillion on Medicaid and other health programs. Hence, much of the “new money” needed to fund Sanders’s reform is already being collected as taxes.
Yes, there will need to be some new taxes—albeit much less than Blahous estimates. But those new taxes would just replace—not add to—current spending on premiums, co-pays, and deductibles. Additionally, at least some of the new taxes would be virtually invisible. For instance, the $10 trillion that employers would otherwise pay for premiums could instead be collected as payroll taxes. Similarly, Medicare for All would relieve households of the $7.7 trillion they’d pay for premiums and $6.3 trillion in out-of-pocket costs under the current system.
It’s easy to get lost in the weeds here. But at the end of the day, even according to Blahous’s errant projections, Medicare for All would save the average American about $6,000 over a decade. Single payer, in other words, shifts how we pay for health care, but it doesn’t actually increase overall costs—even while providing first-dollar comprehensive coverage to everyone in the nation. The Post’s fact-checker is wrong: Single-payer supporters can and should trumpet this important fact.
Of course, the most important benefits of single payer are altogether invisible in economic analyses like the one performed by Blahous. No matter what injury or illness we faced, we would be forever freed from one great worry: the cost of our care. It’s hard to put a price tag on that kind of freedom. Yet, paradoxically, even the slanted analysis of a libertarian economist provides evidence that it would be fiscally responsible.
Trump’s Sabotage of Obamacare Is Illegal
A president doesn’t have the right to dispense with laws he dislikes
by Nicholas Bagley and Abbe Gluck - NYT - August 14, 2018
From the moment he took office, President Trump has used all aspects of his executive power to sabotage the Affordable Care Act. He has issued executive orders, directed agencies to come up with new rules and used the public platform of the presidency in a blatant attempt to undermine the law. Indeed, he has repeatedly bragged about doing so, making statements like, “Essentially, we are getting rid of Obamacare.”
But Mr. Trump isn’t a king; he doesn’t have the power to dispense with laws he dislikes. He swore to preserve, protect and defend the Constitution of the United States. That includes the requirement, set forth in Article II, that the president “take care that the laws be faithfully executed.”
Faithfully executing the laws requires the president to act reasonably and in good faith. It does not countenance the deliberate sabotage of an act of Congress. Put bluntly: Mr. Trump’s assault on Obamacare is illegal.
Among Mr. Trump’s first acts in office was to issue an executive order instructing his agencies “to waive, defer, grant exemptions from, or delay the implementation of” any part of the Affordable Care Act that they could. That order has prompted a series of administrative actions aimed at undermining the law.
To make it harder for people to enroll in Obamacare plans, for example, the administration shortened the open enrollment period on the health care exchanges from three months to six weeks; cut 90 percent of the funding that the exchanges had used to advertise open enrollment; and slashed the funding available to groups that help people navigate the complex enrollment process.
To sow chaos in the insurance markets, Mr. Trump toyed for nine months with the idea of eliminating a crucial funding stream for Obamacare known as cost-sharing payments. After he cut off those funds, he boasted that Obamacare was “being dismantled.”
When Congress declined to repeal the Affordable Care Act, as Mr. Trump had requested, he said that he was taking on that job himself: “So we’re going a little different route.”
This month, the Trump administration dealt what may be its biggest blow yet to the insurance markets. In a new rule, it announced that insurers will have more latitude to sell “short-term” health plans that are exempt from the Affordable Care Act’s rules. These plans were designed to provide people insurance for small gaps in coverage, like those created when switching jobs. They had previously been limited to three months.
Under Mr. Trump’s new rule, however, such plans can last for 364 days and can be renewed for up to three years. That rule joins an earlier one that allowed businesses to join together to create “association health plans” that also evade the Affordable Care Act’s strictures. In effect, these rules are creating a cheap form of “junk” coverage that does not have to meet the higher standards of Obamacare. This sort of splintering of the insurance markets is not allowed under the Affordable Care Act as Congress drafted it.
The Trump administration’s goal is not only to weaken the Affordable Care Act but also to trick the public into thinking, as opponents of the law like to say, that Obamacare is “collapsing under its own weight.” Let’s be clear: If the Affordable Care Act collapses, it is because the president demolished it.
Never in modern American history has a president so transparently aimed to destroy a piece of major legislation. What makes Mr. Trump’s sabotage especially undemocratic is that Congress has repeatedly considered repealing the law — and repeatedly declined to do so. In addition, the Supreme Court has twice sustained the Affordable Care Act in the face of major legal challenges. Mr. Trump’s attempt to destroy the law any way he can is an unconstitutional usurpation of power.
That is also the message of a lawsuit — the first of its kind — filed this month in federal court in Maryland. Brought by several plaintiffs including the cities of Chicago, Cincinnati and Columbus, the lawsuit recounts the “relentless and unlawful campaign to sabotage and, ultimately, to nullify” the Affordable Care Act. Taken individually, some of the Trump administration’s actions may be defensible. Taken together, they amount to a derogation of his constitutional duties.
The lawsuit asks the court to strike down the administration’s new rules and to enjoin the president from further sabotage. To prevail, the plaintiffs may have to overcome some procedural hurdles, including questions about whether the courts have the authority or the institutional competence to prevent violations of Article II’s requirement that the president “take care that the laws be faithfully executed” — especially given the wide discretion that presidents traditionally have to implement the laws.
But if there is ever going to be a viable claim along these lines, this is it. After all, no court has ever held that the president has the power to consciously aim, in bad faith, to destroy Congress’ handiwork. Yet with his attacks on this law, that is precisely what Mr. Trump has been doing. No matter how you feel about Obamacare, we should all care about that.
The Large Hidden Costs of Medicare’s Prescription Drug Program
by Austin Frakt - NYT - August 13, 2018
At a glance, Medicare’s prescription drug program — also called Medicare Part D — looks like the perfect example of a successful public-private partnership.
Drug benefits are entirely provided by private insurance plans, with generous government subsidies. There are lots of plans to choose from. It’s a wildly popular voluntary program, with 73 percent of Medicare beneficiaries participating. Premiums have exhibited little to no growth since the program’s inception in 2006.
But the stability in the premiums belies much larger growth in the cost for taxpayers. In 2007, Part D cost taxpayers $46 billion. By 2016, the figure reached $79 billion, a 72 percent increase. It’s a surprising statistic for a program that is often praised for establishing a competitive insurance market that keeps costs low, and that is singled out as an example of the good that can come from strong competition in a private market.
Much of this increase is a result of growing enrollment — it has doubled in the past decade to 43 million — and higher drug prices. But there is also a subtle way in which the program’s structure promotes cost growth.
When enrollees’ drug costs are relatively low, plans pay a large share, typically about 75 percent. But when enrollees’ drug spending surpasses a certain catastrophic threshold — set at $5,000 in out-of-pocket spending in 2018 — 80 percent of drug costs shifts to a government program called reinsurance. This gives people in charge of private insurance plans an incentive to find ways to push enrollees into the catastrophic range, shifting the vast majority of drug costs off their books. For example, they could be less motivated to negotiate for lower drug prices for certain types of drugs if doing so would tend to keep more enrollees out of the catastrophic range.
Reinsurance spending, which is not reflected in premiums, has been rising rapidly.
“This harms the very competition that Part D was supposed to establish,” said Roger Feldman, an economist at the University of Minnesota. Consumers are naturally attracted to lower-premium plans, but choosing them increasingly shifts higher costs onto taxpayers if plans achieve those lower premiums in part by shifting more drug expenses onto the government’s books.
Documenting this is a recent study by Mr. Feldman and Jeah Jung of Penn State University that was published in Health Services Research. The study found that the disconnect between premiums and reinsurance costs has increased over time. Additionally, insurance company plans exhibiting less of an effort to manage the use of high-cost drugs had higher reinsurance costs. This is consistent with incentives to encourage enrollees into the catastrophic range of spending.
The Medicare Payment Advisory Commission has been warning about this problem for several years in its annual reports to Congress. According to MedPAC, between 2010 and 2015, the number of enrollees entering the catastrophic drug cost range grew 50 percent, from 2.4 million to 3.6 million, now accounting for 8 percent of enrollees.
“It’s ironic for a program supposedly built on market principles,” said Mark Miller, a former MedPAC director. “You wouldn’t see this kind of thing in the commercial market.” For commercial market insurance products — such as those offered by employers or in the health insurance marketplaces — only about 1 percent of policyholders reach a catastrophic level of expenditures at which reinsurance kicks in. (Mr. Miller and I are co-authors of an editorial about Ms. Jung’s and Mr. Feldman’s study, which also appears in Health Services Research.)
Reinsurance is the fastest-growing component of Medicare’s drug program, expanding at an 18 percent annual rate between 2007 and 2016. In 2007, it accounted for 17 percent of government spending for Part D. In 2016 it was 44 percent.
The Affordable Care Act hastened this growth. The law requires pharmaceutical manufacturers to pay some of the cost of the drug benefit. (The Bipartisan Budget Act of 2018 further increased how much manufacturers must contribute.) For the purposes of reaching the catastrophic threshold and triggering reinsurance, these industry contributions count as out-of-pocket payments for enrollees, even though they are not.
That means enrollees don’t have to spend as much as they otherwise would to trigger the reinsurance program. Although this is of great benefit to enrollees, it also pushes up taxpayer liability for the program.
Changing the extent to which manufacturer’s contributions count as enrollee out-of-pocket spending is one potential reform of the program. Other solutions include increasing the liability of insurance company plans in the catastrophic range and decreasing the liability of taxpayers.
This would have the effect of bringing premiums more in line with program spending. Doing so would “return Part D to the market-based program it was intended to be,” Ms. Jung said. As it stands, there is a substantial divide between what Part D was billed as and what it actually is.
Short-term health plans coming to Maine won’t cover pre-existing conditions, or much else
Authorities say the latest effort to undermine the Affordable Care Act will likely raise costs and generate more medical bankruptcies.
by Joe Lawlor - Portland Press Herald - August 12, 2018
New low-cost, short-term health insurance plans allowed by the Trump administration will be available in Maine this fall, but health care advocates say the plans won’t provide protections for pre-existing conditions and are filled with loopholes to avoid paying claims.
Mitchell Stein, a Maine-based health insurance consultant, said many of the short-term plans, which cost as little as $30 to $50 a month, are “junk insurance.” They don’t have to offer a prescription drug benefit or maternity coverage, for instance.
“The reason they’re cheaper is because they’re cheap,” Stein said. “People will buy these thinking they’re covered, but they’re not.”
The Trump administration unveiled new rules for short-term health insurance plans this month, the latest effort to undermine the Affordable Care Act, and the plans will likely be on the market by October. While the impact on Maine and the nation is unclear, experts worry the short-term plans will weaken the ACA, make health care more costly and cause more medical bankruptcies.
Those most likely to be interested, Stein said, will be the 15 percent of ACA enrollees, about 10,000 Mainers, who do not qualify for subsidies and have borne the brunt of premium increases.
States do have the power to further regulate the short-term plans – New York has banned them outright – but Maine has no plans to do so. The state does have laws on the books predating the ACA that offer some consumer protections, but the protections are not as comprehensive as the ACA.
“The Bureau (of Insurance) has no plans at this time to create any new applicable rules,” said Judith Watters, consumer outreach specialist at the bureau.
About 75,000 Mainers have ACA insurance through the individual marketplace, which is designed primarily for the self-employed or workers who can’t get insurance through their employer.
Short-term plans may become more prevalent after the Trump administration relaxed rules making the policies available to enrollees for up to three years, compared to the Obama-era limit of three months. Maine permits short-term plans for up to 12 months, and a replacement plan for an additional year.
The ACA prohibited short-term plans that lasted more than three months. Hawaii just approved a state law limiting the short-term plans to three months, and a few other states are heavily regulating them, including Massachusetts, Vermont and Rhode Island.
But states that permit the short-term plans to be sold closer to the Trump administration’s vision for them could see the plans cut into ACA enrollment, drive up ACA premiums and leave more people susceptible to medical bankruptcy, experts say.
RISK FOR PRE-EXISTING CONDITIONS
About 20 million Americans have ACA insurance, either through the individual marketplace or Medicaid expansion.
The short-term plans will start to become available to consumers in October, for up to 36 months according to the national rule, instead of the three-month maximum under the ACA. President Trump, who is in favor of repealing the ACA, has touted the short-term plans as an affordable alternative to the ACA marketplace.
But one of the key weaknesses in the short-term plans, experts say, is the plans don’t have to cover pre-existing conditions. About 230,000 Mainers under age 65 have a pre-existing condition, according to the Kaiser Family Foundation.
A pre-existing condition can be any condition that the enrollee knew about prior to signing up for insurance. If the health insurance company discovers the patient had a pre-existing condition before enrolling, the insurer can legally deny claims. A pre-existing condition could be something as serious as cancer or as mild as high blood pressure or a nut allergy.
Before the Affordable Care Act, denials based on pre-existing conditions were one of the more common reasons people would file for medical bankruptcy.
PREMIUMS AND SUBSIDIES
Stein said many of the short-term plans have daily limits on how much they will pay out – so someone who is in an accident and ends up in the hospital for a week or develops a debilitating and costly disease will leave himself vulnerable to taking on massive debts.
In Maine, premiums for higher-income people, those earning more than 400 percent of the federal poverty level, or $83,000 for a family of three, have soared by 70 percent or more since 2014. Depending on age, where you live in Maine and which plan is chosen, ACA premiums for middle-age Mainers who don’t qualify for subsidies have increased from about $300 to $350 per month to $500 to $800 permonth since 2014.
The subsidies have shielded those who stay at 400 percent of the poverty level or lower, meaning their premiums are around $100 to $300 per month, depending on which plan is chosen and other factors. Lower-income people who earn about $27,000 or less can qualify for zero-premium plans that have high deductibles.
Premiums for short-term plans can be as low as $30 to $50 per month, according to the Kaiser Family Foundation, a Washington think tank, but some of the plans that offer more extensive coverage can cost $300 or more.
TURNING ACA INTO ‘HIGH-RISK POOL’
Gary Claxton, vice president of the Kaiser Family Foundation, said in a phone interview that the short-term plans do pose a threat to the ACA marketplace. Healthy people who don’t qualify for subsidies may roll the dice and purchase a short-term plan, but as soon as they become sick they will migrate to ACA plans that have more generous coverage.
“These plans have traditionally been lightly regulated because they were not designed for the long term,” Claxton said. “They could provide a bridge to another job. They weren’t meant to be for anyone to be on them for any period of time.”
Claxton said if healthy people purchase short-term plans and remove themselves from the ACA marketplace, that leaves sicker, older people in the ACA. Because insurers set rates based on how likely people will get sick and make claims, removing healthy people from the marketplace will drive up premiums.
“It could turn the ACA into a high-risk pool,” Claxton said.
Unlike some states, Maine does have protections for consumers who buy short-term plans, under laws that predate the ACA. Short-term plans in Maine must cover mental health care, medical equipment for diabetes, mammograms, clinical trials, AIDS care, breast cancer care and preventive screenings.
“Short-term policies are subject to all of Maine’s individual health insurance mandated benefits,” Watters said.
Letter to the editor: Medicare for All bill makes fiscal sense
The benefits of Bernie Sanders' proposed reform outweigh the problems.
Having seen in the Portland Press Herald no reporting or comment on the recent fiscal analysis of Bernie Sanders’ Medicare for All, or M4A, bill, I wanted to be sure readers knew about it.
In the study, done by Charles Blahous of the Mercatus Center, one can see, among other things and buried in Table 2, that, for the decade 2022 to 2031, the National Health Expenditure (country’s total health spending) under M4A would be $2.054 trillion less than it would be with our current system.
Mr. Blahous highlights two problems, though. First, he projects the cost to the federal government of funding health care this way during that decade would be $32 trillion. But this sum is large because, commercial premiums and cost sharing being eliminated, the (reduced) health care cost would be paid entirely through taxes. Most Americans would end up keeping more of their money while enjoying reduced bureaucracy, reduced job lock, less threat of debt, more freedom of choice. Many would have improved coverage; many coverage for the first time.
Second, $5 trillion of the savings created by the M4A bill would result from setting provider reimbursement at Medicare levels (60 percent of commercial insurance levels because of Medicare’s high-risk population).
Understandably, providers might protest. However, reimbursement decreases could be lessened by using some of the $2 trillion in savings, as well as some of the even greater potential savings highlighted by Woolhandler and Himmelstein in their critique of the study. Provider reimbursement could well be maintained with no increased overall health care cost.
As we have seen in previous health care reform efforts, benefits of reform can bring problems. In the case of M4A, however, many may conclude that the benefits of the reform outweigh the problems, which may not be problems at all.
Daniel Bryant, M.D.
Cape Elizabeth
Fact-Checking the Fact-Checkers on Medicare-for-All
by Matt Breunig - People's Policy Project - August 13, 2018
Two weeks ago, the libertarian Mercatus Center released a report estimating the cost of Bernie Sanders’ Medicare-for-All (M4A) proposal. Like most think tank products, the author and communications team behind the Koch-funded Mercatus report carefully cultivated a certain kind of media coverage in pursuit of their political agenda. In this case, the political goal was to undermine M4A by getting journalists to write that it was impossibly expensive.
The Strategy
You can tell that this was their goal by looking at how the Mercatus paper was written, and specifically how its abstract was written. The first sentence contains the claim that many journalists put as their headline and lede: M4A will “increase federal budget commitments by approximately $32.6 trillion” between 2022 and 2031. The rest of the abstract and indeed the rest of the text of the paper omits the more important fact that their estimate states that overall health expenditures would fall by $2 trillion over that period.
The abstract then says “doubling all currently projected federal individual and corporate income tax collections would be insufficient to finance the added federal costs of the plan.” This claim makes it seem like the author is saying we would have to more than double federal taxes, but this is only because the author curiously excluded payroll taxes from the sentence, despite the fact that payroll taxes are the second-largest federal revenue source and the fact that payroll taxes are the main proposed mechanism for raising the funds.
The abstract closes with the claim that “healthcare providers operating under M4A will be reimbursed at rates more than 40 percent lower than those currently paid by private health insurance.” This is designed to trick journalists into thinking that M4A would cut provider payments by 40 percent overall. Indeed, this phrasing did successfully trick the Washington Post’s Glenn Kessler who wrote as much in his piece and later had to issue a correction. The abstract fails to mention that, although provider payment rates for the privately insured will go down, provider payment rates for the uninsured and those on Medicaid will go up.
Success Slips Away
This careful bit of framing and deception by Mercatus initially worked out as planned. They got the Associated Press to write a story with the lede “Sen. Bernie Sanders’ ‘Medicare for all’ plan would boost government health spending by $32.6 trillion over 10 years.” Because of the way the AP wire service works, that means the story showed up on just about every news website in the country: ABC News, Bloomberg, Washington Post, and so on.
But this initial success slipped away from Mercatus because folks like myself quickly noticed that, buried in the report’s tables, the author had actually found that Sanders’ plan would save $2 trillion. That’s right: the same estimate with the scary $32.6 trillion figure they were promoting to all the journalists in the country also said that the US could insure 30 million more Americans, virtually eliminate out-of-pocket expenses, and cover dental, vision, and hearing care for everyone all while spending $2 trillion less over the next 10 years. After this was pointed out, the coverage of the report changed dramatically and Bernie Sanders put out a video thanking the Koch brothers for their positive study.
Needless to say, Mercatus was not thrilled that its attempt to torpedo M4A had become one of the leading talking points in its favor and so it badly wanted a do-over. The preferred theater for their do-over was gullible and biased fact-checkers who they successfully coached into declaring that Bernie Sanders is lying using their inane truth-o-meter and Pinocchio-based measures.
What the Report Says
To understand why the fact-checker’s various declarations are themselves wrong or deceptive, it is necessary first to briefly slog through the actual Mercatus report to explain how it works and what its important findings really were.
In the report, Charles Blahous initially starts with health expenditure projections produced by the Center for Medicare and Medicaid Services (CMS). Those projections say that, under our current system, Americans as a whole will spend $59.653 trillion on healthcare between 2022 and 2031. From there, Blahous adds the estimated cost of insuring the uninsured, virtually eliminating out-of-pocket expenses, and providing dental, vision, and hearing care to everyone. Then he subtracts the savings from lower administrative costs, lower drug prices, and lower payment rates for healthcare providers. After those additions and subtractions, the number drops to $57.599 trillion, which means there is a savings of $2.054 trillion.
Blahous then proceeds to observe that, although M4A saves $2 trillion overall, it also shifts nearly the entire healthcare bill to the federal government, meaning that federal expenditures will necessarily go up. Under the current system, the federal government is expected to contribute $21.927 trillion of the $59.653 trillion in total healthcare spending. Under M4A, the federal government takes on almost all of the spending currently done by private insurers and state medicaid programs, meaning that federal expenditures go up to $54.571 trillion of the (now lower) $57.599 trillion of total health spending. Thus, total federal spending increases by $32.644 trillion ($54.571 – $21.927).
There are two important things to note about this report for our purposes here. The first is that the claim “M4A will cost $32.6 trillion” and the claim “M4A will save $2 trillion” are two ways of describing the exact same estimate. The former claim refers to how much more Mercatus says the federal government will spend. The latter claim refers to how much less they say America as a whole will spend. If the $32.6 trillion cost figure Mercatus promoted to the entire world is correct, then the $2 trillion savings figure is also correct.
The second is that the $32.6/$2 trillion estimate is the one that is based on Sanders’s plan as written. Blahous says this explicitly on page 12:
In contrast with Thorpe’s and the [Urban Institute] team’s earlier estimates, the estimates in this study are based instead on the language of the M4A bill as subsequently introduced, imposing Medicare payment rates on all providers and thereby substantially reducing national average provider payment rates relative to current law.
Blahous then goes on to say that if Bernie Sanders does not actually follow through with his plan as written and instead implements a different plan with significantly higher provider payment rates, then of course the cost will be higher. Blahous estimates these costs with “alternative scenarios” he constructs and then publishes in the appendix of the report. It is important to be very clear on this point though: these alternative scenarios are not Bernie Sanders’s plan but are instead completely different plans Blahous constructed with higher provider payment rates.
Working the Referees
The Mercatus report created a huge mess that at first glance seemed impossible to fix. Mercatus really did release a report that said that Bernie Sanders’s plan, as written, saves $2 trillion in its first 10 years. They really did promote that report and that specific estimate to the journalist community. So how then do they go back into the journalist community and get them to write pieces declaring that Bernie Sanders and M4A advocates are lying about the content of the report?
Apparently, what you do is approach the various fact-checker journalists and try to sell them on the idea that the real estimate of M4A is the alternative scenario Blahous constructed in the appendix of the report, an alternative scenario which Blahous himself says does not track Bernie Sanders’s plan.
Politifact pointed to the alternative scenario to declare the claim that the Mercatus study says M4A will save $2 trillion “Half True.” The AP, which I didn’t even realize did fact-checking, called the claim “spin.” And the Washington Post gave the claim 3 Pinocchios out of a possible 4 Pinocchios, which apparently means it is a “significant factual error” or contains “obvious contradictions.”
Think for a second about how completely absurd these three suspiciously identical fact-check pieces are. They acknowledge that Sanders and others are right that the Mercatus estimate does say there will be $2 trillion in savings. But then they say Sanders is mostly lying because he does not also talk about alternative scores of totally different plans that are not his plan.
It would be like if Sanders released a plan to raise the top tax rate to 70 percent and then a study came out that said the hike would raise $1 trillion of revenue but that a 60 percent hike would only raise $800 billion. Then Sanders said “good news, my 70 percent tax rate raises $1 trillion in revenue” and the fact-checkers wrote pieces saying he was lying because he failed to mention that a 60 percent tax rate would raise much less. That is how ridiculous the argument of these pieces are.
In addition to the absurdity of this general argument Mercatus coached these journalists to repeat, the specific fact-check pieces are quite funny and riddled with errors.
The Washington Post piece, authored by Glenn Kessler, had three serious factual errors in it that he later had to correct. Although Kessler corrected these errors in his piece, one of the factual errors — that the Sanders plan would cut payments to medical providers by 40 percent — is still being broadcasted by the Post’s video version of Kessler’s story without correction.
The Associated Press fact-check piece was authored by Ricardo Alonso-Zaldivar, which is the same AP journalist who initially reported on the Mercatus study when it released in July. What’s funny about this is that Alonso-Zaldivar’s initial piece uses the $32.6 trillion estimate in both its headline and lede, but then his fact-check piece says that Bernie Sanders is basically being deceptive by using that estimate in his messaging. If the estimate is so deceptive, then perhaps Alonso-Zaldivar should take down his first piece reporting on it.
As noted by Vox’s Dylan Scott, the really important takeaway of the Mercatus report is not whether Sanders’ plan saves precisely $2 trillion, but rather that the report confirms that the general Medicare-for-All idea is clearly doable. If you play around with the utilization rates, the provider rates, the coverage areas, and the actuarial value variables, you can generate estimates that range from modest savings to modest spending increases, meaning that a national health insurer that covers everyone in the country is clearly in reach, if we want it.
https://www.peoplespolicyproject.org/2018/08/13/fact-checking-the-fact-checkers-on-medicare-for-all/
Obamacare forgot about you. But Trump didn’t.
by Alex Azar - The Washington Post - August 16, 2018
For all the discussion of Obamacare since its passage, it is too rarely known that the law effectively split the United States’ individual insurance market in two .
One group of Americans — about 8 million enrollees in 2017 — now pay, on average, less than a quarter of the cost of their health insurance, receiving ever-growing taxpayer subsidies to insulate them from Obamacare’s high premiums. But there is a second group of Americans who have faced the full premium increases driven by the law’s broken regulations. Roughly 5 million Americans, as of 2017, have chosen to pay those premiums without any subsidies, while 28 million other Americans remain uninsured, many priced out of coverage entirely.
The law’s skyrocketing subsidies have kept subsidized insurance enrollment fairly steady — although more than 50 percent below what was once expected. But Americans who make too much to receive subsidies have begun to opt out of the insurance market en masse. An independent analysis found that the entire unsubsidized individual insurance market shrank by more than 40 percent from the first quarter of 2016 to the first quarter of 2018. In other words, Obamacare has forced unsubsidized Americans to choose between unaffordable insurance and no insurance at all.
This is unacceptable. It is one reason the Trump administration recently expanded an affordable insurance option the previous administration had all but discarded, providing new choices for these forgotten men and women.
Americans will once again be able to buy what is known as short-term, limited-duration insurance for up to a year, assuming their state allows it. These plans are free from most Obamacare regulations, allowing them to cost between 50 and 80 percent less.
Insurers will also be able to sell renewable plans, allowing consumers to stay on their affordable coverage for up to 36 months. Consumers can also buy separate renewability protection, which will allow them to lock in low rates in their renewable plans even if they get sick.
Unsurprisingly, experts believe there will be healthy demand for these affordable options. Up to 2 million Americans, and possibly more, are expected to enroll within the next few years.
Such plans were offered for terms of up to 12 months for decades until, in an effort to push Americans into Obamacare, the previous administration restricted the plans to 90 days and prohibited insurers from renewing them beyond that time period. This eliminated them as an option except for the shortest transitions between other sources of coverage.
But these short-term plans can be a good option for many Americans priced out of Obamacare’s regulations — especially small-business owners, independent contractors in today’s “gig economy” and younger Americans transitioning between school and employment.
The Trump administration has gone to significant lengths to ensure customers know that these plans are not subject to the same regulations as Obamacare plans and that they are not the right choice for everyone. In fact, we require more robust warnings about the limits of these plans than President Barack Obama’s administration did.
Some have raised concerns about the possibility that short-term plans will pull healthy consumers out of the Obamacare exchanges, driving up premiums. But estimates from the Centers for Medicare & Medicaid Services actuary suggest any such premium increases would be minimal and would not affect subsidized consumers. This is, in part, because those without subsidies who were previously enrolled in Obamacare plans have already left those plans in droves because of premium hikes under the law. For these consumers, short-term plans can offer an affordable option. Our decision to allow renewability and separate premium protections could also allow consumers to hold on to their short-term coverage if they get sick, rather than going to the exchanges, which improves the exchange risk pools.
Fundamentally, this administration believes in more options, not fewer, for consumers. Expanding short-term insurance is just part of President Trump’s larger agenda to improve health-care choice and competition for Americans.
The president signed legislation that will end the individual mandate penalty starting in 2019. Repealing the mandate and expanding short-term plans mean that millions of middle-class Americans who couldn’t afford health insurance will now be able to do so. The Labor Department has also made it easier for small businesses and self-employed Americans to band together to purchase more affordable insurance through association health plans. And last year, the Trump administration took rapid, decisive action to help stabilize the Obamacare markets and end ways to game the system. We have also worked closely with states to develop solutions that can bring down premiums and expand choices.
Starting about two months from now, thanks to this president, insurers and states will have more freedom to offer consumers more options. Obamacare remains broken at its core, but this administration isn’t shutting out the law’s forgotten Americans. Instead, we’re finally giving them affordable choices.
NY University offers free tuition for all medical students
by Associated Press - The Boston Globe - August 16, 2018
NEW YORK — New York University is offering free tuition for all of its medical students.
The Wall Street Journal reported Thursday the move is a first among major US medical schools.
Rising tuition and six-figure loans have been pushing new doctors into higher-paying fields and contributing to a shortage of researchers and primary care physicians.
The associate dean for admissions and financial aid, Dr. Rafael Rivera, said there’s a ‘‘moral imperative’’ to reduce debt.
‘‘Our full-tuition scholarships make it possible for aspiring physicians to choose a specialty based on their talent and inclinations to better serve the communities who need it most, and to more easily pursue scientific breakthroughs that improve how we care for patients,’’ the NYU School of Medicine said on its website.
Tuition was Pabout $55,000 for the coming year.
Most medical students will still need to pay about $29,000 for annual room and board and other living expenses.
The university will provide full-tuition scholarships for 93 first-year students — another nine are already covered through an MD/PhD program — as well as 350 students already partly through the MD-only degree program, the Wall Street Journal said.
NYU estimates it will need about $600 million to fund the tuition package in perpetuity. It has raised more than $450 million.
Something Not Rotten in Denmark
by Paul Krugman - NYT - August 16, 2018
To be or not to be a socialist hellhole, that is the question. Sorry, I couldn’t help myself.
Last weekend, Trish Regan, a Fox Business host, created a bit of an international incident by describing Denmark as an example of the horrors of socialism, right along with Venezuela. Denmark’s finance minister suggested that she visit his country and learn some facts.
Indeed, Regan couldn’t have picked a worse example — or, from the point of view of U.S. progressives, a better one.
For Denmark has indeed taken a very different path from the United States over the past few decades, veering (modestly) to the left where we’ve veered right. And it has done just fine.
American politics has been dominated by a crusade against big government; Denmark has embraced an expansive government role, with public spending more than half of G.D.P. American politicians fear talk about redistribution of income from the rich to the less well-off; Denmark engages in such redistribution on a scale unimaginable here. American policy has been increasingly hostile to organized labor, and unions have virtually disappeared from the private sector; two-thirds of Danish workers are unionized.
Conservative ideology says that Denmark’s policy choices should be disastrous, that grass should be growing in the streets of Copenhagen. Regan was, in effect, describing what her employers think must be happening there. But if Denmark is a hellhole, it’s doing a very good job of hiding that fact: I was just there, and it looks awfully prosperous.
And the data agree with that impression. Danes are more likely to have jobs than Americans, and in many cases they earn substantially more. Overall G.D.P. per capita in Denmark is a bit lower than in America, but that’s basically because the Danes take more vacations. Income inequality is much lower, and life expectancy is higher.
The simple fact is that life is better for most Danes than it is for their U.S. counterparts. There’s a reason Denmark consistently ranks well ahead of America in measures of happiness and life satisfaction.
But is Denmark socialist?
The libertarian Cato Institute says no: “Denmark has quite a free-market economy, apart from its welfare state transfers and high government consumption.” That’s some qualification.
It’s true that Denmark doesn’t at all fit the classic definition of socialism, which involves government ownership of the means of production. It is, instead, social-democratic: a market economy where the downsides of capitalism are mitigated by government action, including a very strong social safety net.
But U.S. conservatives — like Fox’s Regan — continually and systematically blur the distinction between social democracy and socialism. In 2008, John McCain accused Barack Obama of wanting socialism, basically because Obama called for an expansion of health coverage. In 2012, Mitt Romney declared that Obama got his ideas from “socialist democrats in Europe.”
In other words, in American political discourse, anyone who wants to make life in a market economy less nasty, brutish and short gets denounced as a socialist.
And this smear campaign has had a predictable effect: Sooner or later, if you call any attempt to improve American lives “socialism,” a lot of people will conclude that socialism is O.K.
A recent Gallup poll found that majorities both of young voters and of self-identified Democrats prefer socialism to capitalism. But this doesn’t mean that tens of millions of Americans want the government to seize the economy’s commanding heights. It just means that many people, told that wanting America to be a bit more like Denmark is socialist, end up believing that socialism isn’t so bad, after all.
The same may be said for some Democratic politicians. Much has been made of Alexandria Ocasio-Cortez, not just because of her upset primary victory, but because she’s a self-proclaimed socialist. Her platform, however, isn’t socialist at all by the traditional definition. It’s just unabashedly social-democratic.
And that puts her in line with the rest of her party. Whenever I read articles questioning what Democrats stand for, I wonder if the writers are paying any attention to what candidates are saying about policy. For today’s Democratic Party is actually impressively unified around social-democratic goals, far more so than in the past.
True, there are differences over both policy and rhetorical strategy. Should the push for universal health coverage involve Medicare for all, or simply the right for everyone to buy into an enhanced Medicare program? Should Democrats simply ignore Republican slander of their social-democratic ideas, or should they try to turn the “socialist” smear into a badge of honor?
But these aren’t very deep divisions, certainly nothing like the divisions between liberals and centrists that wracked the party a couple of decades ago.
The simple fact is that there is far more misery in America than there needs to be. Every other advanced country has universal health care and a much stronger social safety net than we do. And it doesn’t have to be that way.
No comments:
Post a Comment