How Much Will Americans Sacrifice for Good Health Care?
A battle is looming over universal health care. Politicians and voters will have to decide whether the trade-offs are worth it.
by The Editorial Board - NYT - February 17, 2018
It’s been nearly 10 years since the passage of the
Affordable Care Act — one of the most sweeping health care overhauls in
the nation’s history. The law has brought the number of uninsured people
in America to an all-time low, secured protections for people with pre-existing conditions and advanced the notion that health care is a human right.
But the system was never perfect, and its fractures and stress points have become too great to ignore. The number of people who are uninsured or underinsured is rising again, after two years of sabotage to the current law by the Trump administration. A Republican-led lawsuit that once seemed like a lark is threatening Obamacare’s protections for pre-existing conditions. And high out-of-pocket costs, absurd hospital billing practices and ever-rising prescription drug prices have forced too many people to skip crucial treatments, avoid emergency rooms and ration life-sustaining medications.
America may be a country rich in medical innovation — a place where robots perform surgery — but it’s also one where tens of thousands of people die every year because they can’t afford basic care.
Both parties seem certain to make health care a significant election issue over the next two years. There are no fewer than six Democratic bills floating through Congress that would address these problems. And “Medicare for all” — a concept that describes only some of those proposals — has become both a rallying cry and a test of progressive credentials.
But the system was never perfect, and its fractures and stress points have become too great to ignore. The number of people who are uninsured or underinsured is rising again, after two years of sabotage to the current law by the Trump administration. A Republican-led lawsuit that once seemed like a lark is threatening Obamacare’s protections for pre-existing conditions. And high out-of-pocket costs, absurd hospital billing practices and ever-rising prescription drug prices have forced too many people to skip crucial treatments, avoid emergency rooms and ration life-sustaining medications.
America may be a country rich in medical innovation — a place where robots perform surgery — but it’s also one where tens of thousands of people die every year because they can’t afford basic care.
Both parties seem certain to make health care a significant election issue over the next two years. There are no fewer than six Democratic bills floating through Congress that would address these problems. And “Medicare for all” — a concept that describes only some of those proposals — has become both a rallying cry and a test of progressive credentials.
Voters, however, appear more ambivalent. Though health care has long topped the electorate’s list of concerns, including in the 2018 midterms,
surveys suggest that most Democrats want their party to focus on fixing
the Affordable Care Act rather than on starting a long-shot bid for a
single-payer health care system. In a recent Kaiser Family Foundation
poll, some 56 percent of Americans, including nearly a quarter of
Republicans, supported the idea of a new federal program; but when
trade-offs like higher taxes or the loss of private insurance options
were factored in, that support evaporated.
As the 2020 race heats up, here’s a primer to help citizens sort out where they stand.
The proposals fall into two broad categories: universal and incremental. On the universal side, Medicare for all would largely eliminate the need for private insurance and for other public programs like Medicaid and the Children’s Health Insurance Program. Its coverage would also be more expansive than current Medicare: It would include eye and dental care as well as prescription drugs, and it would eliminate premiums, deductibles, copays and surprise medical bills.
A single federal payer — as such proposals envision — may well eliminate the waste, inefficiency and corruption that make the current system so expensive and inaccessible; the experience of countries like Canada and Britain that rely heavily on one government payer suggests as much. But such a system would require dramatic changes from the status quo and would be a tough political sell. What’s more, single-payer is not the only way to achieve universal coverage.
On the incremental side, several different proposals would allow certain people to buy into existing public plans. Some would enable older Americans who are not yet eligible for Medicare to buy into that program — at age 50 or 55 or 60. One would let people who don’t have other insurance coverage buy into Medicaid (as long as their state opted into the program).
As the 2020 race heats up, here’s a primer to help citizens sort out where they stand.
What are the options?
The plans currently in play differ in their particulars: Senator Bernie Sanders’s Medicare for All Act would scrap private insurance and create a new federal system to cover everyone; a plan from the Center for American Progress, a think tank, would create an optional public program that anyone could buy into; and a plan from Senator Debbie Stabenow would give all Americans the option to buy into Medicare when they turn 50. But these plans would extend coverage to more people and would increase the federal government’s role in providing and policing health insurance.The proposals fall into two broad categories: universal and incremental. On the universal side, Medicare for all would largely eliminate the need for private insurance and for other public programs like Medicaid and the Children’s Health Insurance Program. Its coverage would also be more expansive than current Medicare: It would include eye and dental care as well as prescription drugs, and it would eliminate premiums, deductibles, copays and surprise medical bills.
A single federal payer — as such proposals envision — may well eliminate the waste, inefficiency and corruption that make the current system so expensive and inaccessible; the experience of countries like Canada and Britain that rely heavily on one government payer suggests as much. But such a system would require dramatic changes from the status quo and would be a tough political sell. What’s more, single-payer is not the only way to achieve universal coverage.
On the incremental side, several different proposals would allow certain people to buy into existing public plans. Some would enable older Americans who are not yet eligible for Medicare to buy into that program — at age 50 or 55 or 60. One would let people who don’t have other insurance coverage buy into Medicaid (as long as their state opted into the program).
Because
these programs don’t rely on a single payer, they would not do as much
to clean up the existing system. But they have a better chance of being
adopted by Congress, and some could bring the country very close to
achieving universal coverage.
That’s too bad. The idea of forcing more than half the country off existing programs might sound scary, but the majority of those people are at constant risk of losing their health coverage — for instance, if they lose or leave their jobs, if their employers change plans or if their insurers change their terms in ways that increase out-of-pocket costs.
Still, the choice between universal health care and private insurance will very likely prove to be a false one. Most of the six plans leave ample room for private options to play a role, and the ones that don’t — the true Medicare for all proposals — will almost certainly change as they are negotiated. As Vox points out, no other country has managed to achieve universal health care without including some form of private insurance.
A single-payer system would mean fewer administrative costs. Eliminating other government programs would free up billions of dollars for the new plan. And eliminating private insurers would bring billions more dollars worth of profits and employer taxes back into the health care system. (Businesses currently enjoy a tax break on the money they spend covering their employees.)
But there would also be new taxes. Proponents say that, to the extent those taxes fell on consumers, they would be offset by the elimination of premiums, deductibles and copays. But that may not be enough to assuage voters. In Vermont and Colorado, legislators dropped bids for a state-run single-payer system when it became clear that people would not support the tax increases needed to sustain such a program.
What would happen to private insurance?
A recent Kaiser poll found that the potential loss of private insurance was what turned most people off the concept of Medicare for all. That’s not surprising. About half of all Americans — some 156 million people — get their health insurance through employer-based plans, and another 30 million rely on other forms of private coverage, including the A.C.A. marketplace and Medicare Advantage plans. The vast majority of those people say that they like their coverage. And so far, the majority of Americans seem loath to give up what they have, no matter how good the alternative is made to sound.That’s too bad. The idea of forcing more than half the country off existing programs might sound scary, but the majority of those people are at constant risk of losing their health coverage — for instance, if they lose or leave their jobs, if their employers change plans or if their insurers change their terms in ways that increase out-of-pocket costs.
Still, the choice between universal health care and private insurance will very likely prove to be a false one. Most of the six plans leave ample room for private options to play a role, and the ones that don’t — the true Medicare for all proposals — will almost certainly change as they are negotiated. As Vox points out, no other country has managed to achieve universal health care without including some form of private insurance.
Who pays?
Proponents of Medicare for all say that total health care spending would remain roughly the same, but that more of that spending would be shouldered by the federal government and less of it would be wasted.A single-payer system would mean fewer administrative costs. Eliminating other government programs would free up billions of dollars for the new plan. And eliminating private insurers would bring billions more dollars worth of profits and employer taxes back into the health care system. (Businesses currently enjoy a tax break on the money they spend covering their employees.)
But there would also be new taxes. Proponents say that, to the extent those taxes fell on consumers, they would be offset by the elimination of premiums, deductibles and copays. But that may not be enough to assuage voters. In Vermont and Colorado, legislators dropped bids for a state-run single-payer system when it became clear that people would not support the tax increases needed to sustain such a program.
Taxes are not the
only trade-off. Increased efficiency and less profiteering should mean
that more people would be covered and could afford the care they needed.
But a single-payer system could also mean the elimination of many
thousands of health care jobs and lower pay for providers, both of which
could impede access to, and the quality of, care. Those impediments
could be small — slightly longer wait times, for example. Or they could
be substantial — much longer wait times and far fewer doctors.
Medicare for all would forgo the first option, meaning that it would cover everything. But it would use the massive bargaining power of so many users — the entire United States population — to negotiate far better deals on prescription drugs, hospital stays and more. The different incremental programs would use both levers: Most would not cover vision or dental, for example. But all of them would also direct the secretary of health and human services to negotiate costs with providers.
Most other countries use negotiating power to control health care costs; that’s why prescription drugs cost so much less elsewhere than they do in the United States. But those countries accept a trade-off, inherent in this approach, that the United States has so far resisted: They forgo access to certain innovations, like pricey new drugs and medical devices whose benefits are found to be minimal.
A plan that results in higher taxes but skimps on cutting-edge medicine may seem unfair — and may well be unpopular. But many Americans are already being denied essential services every day. It may make sense to forgo innovations that a growing number of people can’t benefit from anyway in exchange for a program that sets fair prices at the outset and doesn’t leave people rationing low-tech essentials or begging for donations to cover basic costs.
The fight to once again remake American health care will almost certainly be brutal. Before voters can decide if they want to have that fight, candidates will need to clarify what they are selling. Only then can the nation have an honest dialogue about the risks, benefits and trade-offs ahead.
https://www.nytimes.com/2019/02/16/opinion/sunday/medicare-for-all-universal-health-care.html
Editor's Note -
The following is a letter I submitted to the NYT in response to their February 17 editorial. Not yet published:
"Your February 17 editorial does a nice job of discussing the trade-offs inherent in fundamental reform of our sick American healthcare system.
As a physician I like to understand the underlying pathology that leads to many of the symptoms you describe.
The fundamental mission of tax-supported social-insurance programs such as Medicare and Medicaid is to facilitate the provision of medical care to their beneficiaries.
The fundamental mission of tax-subsidized commercial health insurance companies is to create wealth for their owners by impairing access to medical care. They use tools such as restrictive networks of doctors and hospitals, restricted pharmaceutical formularies and other techniques that discourage patients with expensive conditions from enrolling, out of pocket payments from patients and medical underwriting (pricing policies to risk) that has the net effect of discriminating against those who are sick or are likely to become sick.
Only in America do we countenance a health care system that discriminates against sick people."
-SPC
Editor's Note:
The following journal article, by Professor Ted Marmor, is a bit of a departure from my usual practice of publishing mainly articles from lay publications in this blog. I encountered a few formatting problems transcribing his essay into the blog. So any spelling or formatting errors I may have missed are my responsibility, not Professor Marmor's.
-SPC
What would be covered?
There are two basic ways for insurance programs to curb costs. One is to cover fewer things; the other is to negotiate on prices.Medicare for all would forgo the first option, meaning that it would cover everything. But it would use the massive bargaining power of so many users — the entire United States population — to negotiate far better deals on prescription drugs, hospital stays and more. The different incremental programs would use both levers: Most would not cover vision or dental, for example. But all of them would also direct the secretary of health and human services to negotiate costs with providers.
Most other countries use negotiating power to control health care costs; that’s why prescription drugs cost so much less elsewhere than they do in the United States. But those countries accept a trade-off, inherent in this approach, that the United States has so far resisted: They forgo access to certain innovations, like pricey new drugs and medical devices whose benefits are found to be minimal.
A plan that results in higher taxes but skimps on cutting-edge medicine may seem unfair — and may well be unpopular. But many Americans are already being denied essential services every day. It may make sense to forgo innovations that a growing number of people can’t benefit from anyway in exchange for a program that sets fair prices at the outset and doesn’t leave people rationing low-tech essentials or begging for donations to cover basic costs.
The fight to once again remake American health care will almost certainly be brutal. Before voters can decide if they want to have that fight, candidates will need to clarify what they are selling. Only then can the nation have an honest dialogue about the risks, benefits and trade-offs ahead.
https://www.nytimes.com/2019/02/16/opinion/sunday/medicare-for-all-universal-health-care.html
Editor's Note -
The following is a letter I submitted to the NYT in response to their February 17 editorial. Not yet published:
"Your February 17 editorial does a nice job of discussing the trade-offs inherent in fundamental reform of our sick American healthcare system.
As a physician I like to understand the underlying pathology that leads to many of the symptoms you describe.
The fundamental mission of tax-supported social-insurance programs such as Medicare and Medicaid is to facilitate the provision of medical care to their beneficiaries.
The fundamental mission of tax-subsidized commercial health insurance companies is to create wealth for their owners by impairing access to medical care. They use tools such as restrictive networks of doctors and hospitals, restricted pharmaceutical formularies and other techniques that discourage patients with expensive conditions from enrolling, out of pocket payments from patients and medical underwriting (pricing policies to risk) that has the net effect of discriminating against those who are sick or are likely to become sick.
Only in America do we countenance a health care system that discriminates against sick people."
-SPC
Editor's Note:
The following journal article, by Professor Ted Marmor, is a bit of a departure from my usual practice of publishing mainly articles from lay publications in this blog. I encountered a few formatting problems transcribing his essay into the blog. So any spelling or formatting errors I may have missed are my responsibility, not Professor Marmor's.
-SPC
OUR LOST VOCABULARY OF SOCIAL INSURANCE
by Theodore R. Marmor - Niskanen Center - December 10, 2018
Social insurance programs are at the center of American politics. In scal terms, Medicare and the Social
Security Administration’s programs for retirement, disability, worker’s compensation, and worker’s life
insurance amount to roughly 41 percent of the federal budget. This scal centrality, however, does not rest
on anything like a broader, public understanding of what makes social insurance social — and thus why
such programs are so important in American political life. On the contrary, over the years our vocabulary of
social insurance has become increasingly replaced with a vocabulary of welfare and redistribution, creating
a fundamentally misleading impression about most of what the federal government does.
In the mid-1930s, when the retirement and survivors insurance programs had their legislative start, university-educated Americans had every reason to be clear about what distinguished social insurance from its commercial counterpart. Indeed, most undergraduate programs in the social sciences took up social insurance’s rationale and history. But note the data measuring the historical use of the expression in three of America’s most important daily newspapers. The changes recorded are startling. By the end of the 20th century, the category of social insurance had seemingly lost its place in the vocabulary of American politics.
In the mid-1930s, when the retirement and survivors insurance programs had their legislative start, university-educated Americans had every reason to be clear about what distinguished social insurance from its commercial counterpart. Indeed, most undergraduate programs in the social sciences took up social insurance’s rationale and history. But note the data measuring the historical use of the expression in three of America’s most important daily newspapers. The changes recorded are startling. By the end of the 20th century, the category of social insurance had seemingly lost its place in the vocabulary of American politics.
By the 1970s, social insurance programs had become major components of the federal government, but also the targets of ideological and budgetary attack. Social Security retirement, Medicare, disability, and unemployment insurance were increasingly labeled as simply “entitlements,” and charged with contributing to out of control spending via unaffordable benefits. This allowed critics to advocate for a much smaller social policy commitment, urging a less costly “safety net” for the deserving among America’s poor citizens. The semantic bait-and-switch can be seen with Google’s Ngram viewer, which tracks word frequencies across the American English corpus.
So, What is Social about Social Insurance?
Social insurance, like commercial insurance, is about protection against nancial risk. It is “insurance” in the sense that people contribute to a fund to protect themselves against unpredictable nancial risks. These include outliving one’s savings in old age, the early death of a breadwinner, the onset of a disability that makes work difficult if not impossible, the high costs of acute illness, involuntary unemployment, and work- related injury. Yet unlike with commercial insurance, contributions are not prices in a market and thus do not depend on the contributor’s risk prole (unless commercial regulations say otherwise, in essence creating “social” insurance through the backdoor). Instead of a contract between an enrollee and an insurer, social insurance is a system of shared protection among the insured, most comparable to mutual insurance in the commercial realm, with contributions made in proportion to one’s market income. In social insurance, the “insurer”—whether a government agency or a corporate body with a joint labor-management board—is the agent of the contributing enrollees. And unlike commercial insurance, the social insurance “contract” mandates participation by law, since otherwise adverse selection would cause its unraveling.
Social insurance spreads the costs of coverage according to a different logic than that of commercial insurers. The same risk in commercial insurance carries the same premium price. The greater the risk, the higher the price of coverage. Social insurance, by contrast, operates on the premise that contributions are calculated according to one’s income and benefits according to one’s needs. But the central political feature of social insurance is that the contributors are also beneficiaries. This is not the case with social assistance programs with means-tested eligibility standards. As important as such programs are for those who experience poverty, taxpayers do not in general identify with welfare beneficiaries.
How much difference does it make that most contemporary reporting on social insurance programs, and much social science scholarship, ignores their conceptual underpinning and distinctive operational features? Should popular voices in American social policy be criticized for using proper names to describe programs
I would not be writing this
essay if I did not believe, as one of three co-authors, that the title of our 2014 book — Social Insurance:
America’s Neglected Heritage and Contested Future —
“Entitlement”-talk
identified an important problem.
Words make a difference to all thinking about public policy, but this is especially the case where conflicts are over fundamental values. Consider, for example, the common use of “safety net” as a collective description of programs as diverse as Medicare and Medicaid, old age Social Security, food stamps, disability insurance, and homeless shelters. This expression collapses the distinction between means-tested welfare and social insurance programs into a metaphor suggesting that recipients have to “fall” into poverty to warrant help. This is the opposite of social insurance, which represents a platform on which one can stand before economic risks arise. The term “safety net” is even more ambiguous, particularly when modified by terms like high or low, porous or tightly knit, threadbare or generous, or applied in situations when one’s financial resources are largely “spent.”
The use of public finance terms like “income transfers” further blurs the differences between cash benefits that one receives only after income and asset tests are applied and insurance payments that kick in without such tests. Then there is the term “entitlement,” which was meant to refer to the non discretionary nature of the spending, but now connotes an adolescent sense of entitlement among the beneficiaries. Neither term helps us understand the robust public approval of our major social insurance programs, and indeed, are often employed by opponents of social insurance in order to obfuscate an otherwise popular concept.
The negative connotation of “entitlements” is especially misleading. When one legitimately claims some social insurance benefit, the implication is that there is a corresponding duty to provide that benefit. That is the basis of the common sentiment among recipients of retirement income Social Security that they have earned their pensions. That widely shared sentiment largely explains the political fear that any substantial reduction in those benefits is a “third rail.” Few if any critics of the program criticize the appropriateness — or desirability — of OASI, the old age retirement and survivors insurance programs, on its own terms. Instead, they concentrate on claims that the programs are unaffordable. As a result, a large proportion of the public fears for their future despite the obvious political vulnerability of such critiques.
Understood as a technical budgetary category, entitlements in American social policy are simply those programs whose benefits and beneficiaries cannot be adjusted without statutory changes. Administrations cannot simply reduce a program’s benefits or change its eligibility rules on their own. That entails constraints on administrative flexibility, redirecting the idea of stable governmental commitment to social insurance protections over long periods.
Using the entitlement category in two senses is confusing and in that respect harmful. What citizens believe about the appropriateness of a program is a distinct concept from the budgetary rules about changing its provisions. Both are important, but when was the last time you, the reader, saw this distinction explained when the entitlement term was used? Instead, “entitlement” is used like a four-letter word in diatribes about the supposedly troubled future of social insurance programs.
“Solvency”-talk
Still another source of linguistic confusion is what I will call solvency talk. When policy discussion turns to the social projections of social insurance programs, critics and defenders alike turn to the trust fund. If the old- age retirement actuaries forecast a revenue projection of X in 25 years and the projected outlays of Y equal more than X, the “trust fund” is, according to this logic, in trouble. It will no longer have enough to meet its “bills at that date to continue, the necessary result would, in this framing, be programs like Social Security given fairly modest reforms, nor the political catastrophe of allowing the trust fund to run dry. In this sense, solvency talk is a lot like the threat of government shutdown created by the Federal debt ceiling — a crisis manufactured from the intransigence of elements on both sides of the aisle rather than anything fundamental.
Words make a difference to all thinking about public policy, but this is especially the case where conflicts are over fundamental values. Consider, for example, the common use of “safety net” as a collective description of programs as diverse as Medicare and Medicaid, old age Social Security, food stamps, disability insurance, and homeless shelters. This expression collapses the distinction between means-tested welfare and social insurance programs into a metaphor suggesting that recipients have to “fall” into poverty to warrant help. This is the opposite of social insurance, which represents a platform on which one can stand before economic risks arise. The term “safety net” is even more ambiguous, particularly when modified by terms like high or low, porous or tightly knit, threadbare or generous, or applied in situations when one’s financial resources are largely “spent.”
The use of public finance terms like “income transfers” further blurs the differences between cash benefits that one receives only after income and asset tests are applied and insurance payments that kick in without such tests. Then there is the term “entitlement,” which was meant to refer to the non discretionary nature of the spending, but now connotes an adolescent sense of entitlement among the beneficiaries. Neither term helps us understand the robust public approval of our major social insurance programs, and indeed, are often employed by opponents of social insurance in order to obfuscate an otherwise popular concept.
The negative connotation of “entitlements” is especially misleading. When one legitimately claims some social insurance benefit, the implication is that there is a corresponding duty to provide that benefit. That is the basis of the common sentiment among recipients of retirement income Social Security that they have earned their pensions. That widely shared sentiment largely explains the political fear that any substantial reduction in those benefits is a “third rail.” Few if any critics of the program criticize the appropriateness — or desirability — of OASI, the old age retirement and survivors insurance programs, on its own terms. Instead, they concentrate on claims that the programs are unaffordable. As a result, a large proportion of the public fears for their future despite the obvious political vulnerability of such critiques.
Understood as a technical budgetary category, entitlements in American social policy are simply those programs whose benefits and beneficiaries cannot be adjusted without statutory changes. Administrations cannot simply reduce a program’s benefits or change its eligibility rules on their own. That entails constraints on administrative flexibility, redirecting the idea of stable governmental commitment to social insurance protections over long periods.
Using the entitlement category in two senses is confusing and in that respect harmful. What citizens believe about the appropriateness of a program is a distinct concept from the budgetary rules about changing its provisions. Both are important, but when was the last time you, the reader, saw this distinction explained when the entitlement term was used? Instead, “entitlement” is used like a four-letter word in diatribes about the supposedly troubled future of social insurance programs.
“Solvency”-talk
Still another source of linguistic confusion is what I will call solvency talk. When policy discussion turns to the social projections of social insurance programs, critics and defenders alike turn to the trust fund. If the old- age retirement actuaries forecast a revenue projection of X in 25 years and the projected outlays of Y equal more than X, the “trust fund” is, according to this logic, in trouble. It will no longer have enough to meet its “bills at that date to continue, the necessary result would, in this framing, be programs like Social Security given fairly modest reforms, nor the political catastrophe of allowing the trust fund to run dry. In this sense, solvency talk is a lot like the threat of government shutdown created by the Federal debt ceiling — a crisis manufactured from the intransigence of elements on both sides of the aisle rather than anything fundamental.
Reflect for a moment about budget forecasts of Department of Defense outlays. Nobody writes about the military department going “broke” or becoming “insolvent” no matter how fast the growth in the budget. Indeed, no sensible analyst would make 20, 30, or 40-year forecasts for defense expenditures. Some analysts, in discussions of the future of Social Security make conditional forecasts long into the future. These are said to be useful exercises, reminding the public that commitments now have long-term effects. But the very preoccupation with solvency generates unnecessary anxiety. Since DOD does not have a “trust fund” budgetary categorization, its future outlays are presumed to be ones over which future governments have some control.
The same legal control is available to the Social Security Administration and the Congress. The confusion is even worse in programs that combined different funding mechanisms. For instance, funding for Part A of Medicare comes from the social health insurance trust fund (HI) while Part B is funded from general revenues and beneficiary premiums; it cannot go broke, but it can be reduced. That prompts solvency talk about Medicare’s future without clarification of how the program differs in two of its component parts.
The background of most solvency questions is the widely reported growth of the future retiree population. The Census Bureau projects that the over-65 population will soon make up 20 percent of the population. Such projections, unaccompanied by estimates of what increases in funding social insurance programs will require, prompt concern. Dire predictions of “insolvency” or cuts in retirement benefits get reported in the media without much scrutiny. As a public speaker, I face such questions regularly. I urge my questioners to dwell for a moment on how a growing proportion of senior citizens can be politically compatible with large reductions in future Social Security benefits. Put another way, how could the “sacred cow” of Social Security — in the language of its critics — face such a fate under conditions that, if anything, only cement its political sanctity?
There is another irony here that warrants discussion. The original use of trust fund language in social insurance had more to do with trust than with funds. President Roosevelt rightly felt in the 1930s that the contributory ethos of social insurance would come to be central to its secure political status. A population believing that each contributing worker had earned their social insurance benefit would not tolerate substantial budgetary cutbacks. The idea of a trust fund, then, was to emphasize the special status of a program whose benefits would be decades after a contributor’s payments. Its design is to enforce time- consistency, and its language is meant to highlight reliability. Yet sadly this language has since been turned upside down, bringing needless fear of “running out” of funds and thus uncertainty about the future. Roosevelt’s protective rhetoric backfired as the original understandings of social insurance weakened, even while the popularity of the programs remained substantial.
Social Insurance, Our Neglected Heritage
There are at least two plausible criticisms of this essay’s argument about the importance of relearning the appeal of social insurance principles. One is that the world has changed dramatically since the birth of social insurance in the late 19th century, let alone since the 1934-35 Committee on Economic Security provided a blueprint for expanding social insurance in American public life. The other is that changes in long-standing European social insurance programs show that major adjustments in the American programs are required
as well.
The claim that the world has changed does not necessarily mean that the economic risks against which
social insurance programs offer protection have been fundamentally altered. Consider every one of the
risks noted in this essay — outliving one’s savings, involuntary unemployment, medical costs, and disability.
Not one has disappeared, and social insurance programs for each have been implemented in wealthy
democracies. I doubt, in other words, whether social insurance is in any conceptual trouble.
But that does not mean social insurance programs don’t need to adapt to contemporary circumstances. The spread of contract employment has been particularly challenging for European countries where social insurance is a function of trade unions and other sector-level organizations. It is equally obvious in the US that employer-provided health insurance puts a damper on labor market flexibility. Reduced employment in regular jobs with health coverage will demand the search for other sources of provision. These and other realities of our changing economy will only bring to the fore the central claim of this essay: Social insurance programs dominate American social policy but what that means for our politics is too little understood or explained. And that criticism extends not only to harried reporters but to a signicant amount of the public policy community, as well.
Theodore (Ted) Marmor is a Niskanen Center adjunct fellow and Professor Emeritus at The Yale School of Management.
https://niskanencenter.org/blog/lost-vocabulary-of-social-insurance/ 1/6
Medicare For All or Bust? — State and National Democrats test the political winds for support for single-payer health care system
by Francis Fliciuk - Portland Phoenix - February 17, 2019
Within the next couple weeks, Rep. Pramila Jayapal (D-WA) and Sen. Bernie Sanders (D-VT) will introduce Medicare-For All proposals in the U.S. House and Senate, and some Democrats are already walking back their commitment for the initiative.Last Monday, 2020 presidential hopeful Sen. Cory Booker (D-NJ) — who often champions the phrase “health care is a human right” — did not fully embrace Sen. Sanders bill when asked about it by CBS News. “A lot of people use that term and there’s differentiation about what they actually believe,” Sen. Booker said.
Six other Democratic bills relating to Medicare are currently under revision, but only Jayapal’s and Sanders’ can truly be categorized as “Medicare For All.” Theirs are the only bills which call to phase out private health insurance altogether in favor of government-backed system that extends premium free health care coverage to all U.S. residents.
“Enough is enough,” Sen. Sanders tweeted on January 14. “We are going to end the disgrace of health care being a privilege for the wealthy. We must pass Medicare for all and make healthcare a right.”
In contrast, other Democratic politicians who have touted the “health care is a human right” line often rely on vague market-driven qualifiers like “affordability” and “accessibility” when pressed for details on their health care platform.
Take Booker for example. He’s sponsored Sanders’ bill, but he’s also sponsored all six of the other lighter alternatives and hasn’t publicly prioritized one over the other. Those bills range in scope from Sen. Debbie Stabenow’s (D-MI) plan of expanding Medicare to people aged 55 and older, to Sen. Brian Schatz’s (D-HI) plan of a hybrid system where people can choose to “buy-in” to Medicare or keep their private or employer-provided insurance. Democrats like Sens. Sherrod Brown (D-Ohio) and Amy Klobuchar (D-Minn.) are supporting these less inclusive proposals over Sanders’ single-payer model.
Sen. Elizabeth Warren (D-Mass), another presidential hopeful who has put health care reform at the top of her agenda, also supports single-payer, but hasn’t ruled out backing the watered-down alternatives. “There are different ways we can get there. But the key has to be always keep the center of the bulls-eye in mind. And that is affordable health care for every American,” Warren told a Bloomberg reporter on Jan. 30.
And then there’s Democratic Speaker of the House Nancy Pelosi, who has aspirationally backed the idea of Medicare For All in the past, but hasn’t joined Jayapal’s Medicare-For-All Congressional Caucus or backed her proposal. Instead, she has reportedly been meeting with executives from private insurance company Blue Cross Blue Shield, reassuring them that Democrats were not focused on single-payer health care and were more determined to lower the cost of prescription drugs, according to a Feb 5 report in The Intercept. (Last month, Pelosi announced that Democrats in the House would consider Jayapal’s far-reaching bill in a series of special hearings in the Rules and Budget committee, so hey, baby steps.)
HOLDING DEMS' FEET TO THE FIRE
Progressive supporters of a single-payer system worry that Democrats using the Medicare-For-All slogan while simultaneously backing bills that require people to “buy in” to Medicare are muddying the initiatives original intent.
“There is a major scramble and counter-offensive happening among the Democratic Party establishment to ensure that leading 2020 candidates back off from single-payer, Medicare for All,” tweeted Waleed Shahid, a communications director for Justice Democrats. “They will try to redefine it as a buy-in. Don’t let them.”
Dr. Phillip Caper, the founder of the Maine chapter of the nonprofit Physicians for a National Health Program, told the Phoenix that his group does not support “incremental proposals that just kick the can down the road once again,” like Sen. Schatz’s bill for a buy-in plan, because it doesn’t fulfill their principles of public financing, inclusivity for all U.S. residents, and rigorous cost containment.
“We believe the current system is fundamentally flawed, as a result of over 40 years of free-market ideology inappropriately applied to healthcare in Maine and throughout the nation,” Dr. Caper said. “The system must be fundamentally reformed and patches to it have not and will not result in an economically or politically sustainable system.”
Bonnie Castillo, a nurse and executive director of the National Nurses Union, an advocacy group which represents 150,000 nurses nationwide, agrees. She said that the some of the Democrats' “Medicare-lite” plans will only “exacerbate the ongoing health care crisis for tens of millions of Americans.”
“Medicare for some plans still leave us tethered to a market-driven model of health and are a placebo that will only prolong the pain and delay the care we need,” said Castillo in a written statement. “What we should have learned from other industrialized nations is that it is possible to achieve genuine universal, guaranteed care for all their residents at lower cost and with equal or better health outcomes that in our broken and dysfunction, profit focused system.”
Throughout February, Medicare-for-All activists plan to gather in 130 “barnstorms” across the country, to put pressure on their representatives in Congress to back a single-payer plan and not settle for less.
University of Southern Maine social work student Phoebe Shields organized one of these events in coordination with the Maine People’s Alliance last Tuesday in an attempt convince Maine Rep. Jared Golden to back Jayapal’s bill.
“The bottom line is that there should be a single-payer national health plan where no one is left out. That should be the goal,” said Shields. “Terms like 'affordability' and 'increasing access' do not necessarily address the issue at hand, and actually continues to give the power to insurance companies. That is why it is so important to maintain this vision of a single-payer system, to keep power with the people.”
The Phoenix couldn’t reach Rep. Jared Golden or Sen. Susan Collins for comment, and both have been publicly silent on the issue of single-payer so far. We did reach a spokesperson for Sen. Angus King, but he declined to comment on Jayapal’s bill because it hasn’t been formally introduced — that spokesperson also “didn’t want to get into particulars” when asked whether or not Sen. King believes that health care is a matter of consumer choice in the free market or a public good the government should guarantee.
Rep. Chellie Pingree is the only one of Maine’s congressional delegates to back Medicare For All — as she’s consistently done in the past — and is a co-sponsor of Jayapal’s bill. Pingree remains confident that the upcoming hearings and debate within the Democratic party on what the size and scope of Medicare will be productive.
"It’s clear that exorbitant out-of-pocket costs, confusing red tape, and the Trump administration’s attacks on consumer protections have driven unprecedented grassroots support for a universal health care program,” said Rep. Pingree in a statement to the Phoenix. “As with any major legislative initiative, members of Congress will bring their own perspectives, questions, and concerns. That’s what the hearings process is for — ironing out differences and building consensus. With Democrats now in the House majority, I’m eager to see the process finally move forward and to ensure that Mainers are part of the conversation."
Despite some Democratic apprehension to back a single-payer plan and affirm that health care should be a human right, support for Medicare-For-All is popular — 85 percent of Democrats and 52 percent of Republicans back it, according to a Reuters survey conducted last summer.
https://www.portlandphoenix.me/news/this_just_in/medicare-for-all-or-bust-state-and-national-democrats-test/article_813ca3f2-2e42-11e9-ba58-cb025030e983.html
The Only Guide to 'Medicare for All' That You Will Ever Need
by Timothy Faust - February 14, 2019
Healthcare has claimed its prime spot in the great zodiac of policy issues in the 2020 Democratic presidential primary. As it should: Tens of thousands of Americans die a year from lack of health insurance, and in total, nearly half of American adults under 65 are either uninsured or underinsured, meaning they have insurance plans which don’t cover what they need at prices they can afford.In the coming weeks, Rep. Pramila Jayapal (D-WA) is set to release a new “Medicare for All” bill. I’m generally inclined to distrust the policy gestures of elected officials, but I’ve read a detailed overview of the bill from Jayapal’s office and I’m happy to say that this bill is astonishingly strong, and should become the baseline for federal legislation toward single-payer healthcare. (I’ll discuss why in a minute.)
The problem of American health finance—not care, but finance—can be expressed in two complementary points:
- It is extremely profitable to charge a sick person as much as possible, so long as someone is footing the bill.
- It is not profitable to insure people who are sick or who are likely to become sick.
Staring down these problems are the corporate dorks and the feckless policy dweebs whose policy prescriptions, whose wildest visions, continually place corporations in charge of our healthcare, and ensure that American public money subsidizes them for failing at it. If you hear 2020 candidates talk about the rot of American healthcare, look out if they float a “pragmatic policy solution” or talk about plans named something like “Medicare Extra As A Service... For You!” (If they’re polite, perhaps they will at least say they support “Medicare for All” before announcing they’d be open to keeping the feet of private insurance companies on our throats).
These pathetic programs, which usually revolve around a “public option,” are what happens when politicians understand the need for a massive change but lack the moral imagination to do anything but genuflect to existing structures. They are, in reality, corporate bailout packages which do very little for you, but quite a bit for the Aetnas and the Sacklers and the Joe Manchins.
On the other hand, you have federal single-payer, often called “Medicare for All.” Healthcare plans in the single-payer mold pool all the money currently spent on healthcare to insure every person in America. By pooling this buying power into one giant public insurer (the single payer), “Medicare for All” has much more leverage to determine prices through negotiation. It can say, “oh, we’re only going to pay $200 for an MRI instead of $1,000; or, “our data shows that a knee replacement costs $15,000 to perform even though you bill five times that amount; take it or leave it,” and since it’s the only insurer in town, the hospital has to take it. This isn’t radical — virtually every other country with universal coverage has a form of aggressive rate-setting. (And it lets the hospital spend a lot less money on massive towers of billing staff.)
It’s cheaper, it’s nicer, it’s better, and it lets you go to the doctor without paying anything. Yet a lot of inadequate policies are attempting to crib the name—including, paradoxically, the one advanced by Bernie Sanders.
“Medicare for All” is a misnomer. If anything, true single-payer would be a significant improvement and expansion of Medicare, which has all kinds of loopholes, exclusions, and out-of-pocket costs.
Here is what a health policy must have to truly be a “single-payer” or “Medicare for All” program.
A single, mandatory risk pool
At the core of single-payer is the promise to cover all care, for all people. This means that all are included—but nobody can take their contributions and go play ball elsewhere. This is what’s known as the “universal risk pool.”
A “risk pool” is the pooling together of many peoples’ insurance money. Not many people need very expensive healthcare at once—50% of healthcare spending comes from 5% of the population. Many people who need expensive healthcare will only need it for a short period of time (e.g. a car accident or hip surgery). As a result, the larger the risk pool grows, the more able it is to sustain itself (at a significant discount relative to our fragmented private-insurance model). If rich people or people who are currently not in need of healthcare are permitted to, say, take their contributions out of the risk pool and spend it on a private option, the risk pool weakens (and, in turn, becomes less able to negotiate lower prices).
South Africa is a good counterexample. There, citizens may withdraw from the public healthcare option and enroll in private insurance instead. As a result, one-sixth of the population—the privately insured—spends just under half of South Africa’s health expenditures. These people are disproportionately wealthy and white. Meanwhile, the public insurer can’t negotiate prices and covers a disproportionate amount of sick people. Private carveouts from the national risk pool has virtually reenacted healthcare apartheid in South Africa.
When people ask about the “future of private insurance alongside public healthcare,” they refer to a combination of three things:
- Duplicative basic insurance, which covers the core functions of healthcare, like primary care, the emergency department, or surgery;
- Supplementary insurance, which covers things not addressed by public insurance, like how pharmaceuticals are treated in some countries; and
- Complementary insurance, which offers bells and whistles on top of the public offering to make money off rich people who want luxury.
Comprehensive coverage
“All care for all people” must also mean “all care.” Whatever care a person needs—medical, dental, mental, vision, reproductive, long-term, and more—must be covered. Playing “catch-up” with other countries is not enough: we are capable of, and should, provide a higher standard of care than any currently-existing single-payer program on the globe. Generally, care eligibility is determined by “medical necessity,” because the health finance world lives in utmost terror of someone who gets recreational heart surgery. I don’t disagree with the rule, though I would add a specific pathway for people seeking trans healthcare, who would otherwise need a clinical diagnosis of some type of disorder to get the healthcare they need—a situation which results in some trans people dropping out of the healthcare system.
Worth special mention is the coverage of all elder care, long-term care (LTC), and home-and community-based services (HCBS). Long-term care affects most families in America: two-thirds of seniors will require some sort of living assistance, while people with disabilities often need help maneuvering around their homes and lives. The American system for dealing with this is utterly broken.
Medicare refuses to cover long-term care, and thus the problem is shunted to either private insurance or Medicaid. Private insurance often refuses to cover people who need long-term care, or covers them only at exorbitant rates—and unlike other preexisting conditions, the need for long-term care was virtually neglected by the Affordable Care Act. This leaves much of the work to savings accounts and Medicaid. But Medicaid isn’t great, either. Stay too long in a long-term care facility, for instance, and Medicaid can put a lien on your house—with interest. So funding long-term care in full lets families stay together and gives elders the care they need without shredding their savings or forcing their children to quit their jobs to take care of them.
Healthcare or assistance given to a person in their home—usually referred to as “home or community based services”—is equally essential. For people with disabilities, life without HCBS can be a dystopia of regulations and misery. If home health isn’t available from a state Medicaid program, people with disabilities are often removed from their homes and families and sent to die in structurally negligent nursing homes under the care of deeply overworked and underpaid caregivers privately contracted out to the state. And even if HCBS is offered, its means-testing restrictions can be brutal and oppressive. Disabled couples with too much money in the bank—$22,000 in New York, plus a max of $1,233 in monthly income—often need to spend down or divorce to qualify. In New Jersey, a person who needs home health is only eligible for the program if they have less than $2000 in the bank—and I’ve spoken with people who have a $2000-a-year income cap. (This also presumes the person receives as many caregiver hours as they need, which is not often the case).
LTC/HCBS are fundamental to healthcare—fundamental to the basic dignity of personhood, even—yet for some reason they have been bandied around as if they were auxiliary “maybe” components of various healthcare bills. This is utterly unacceptable. Meanwhile, the field is becoming increasingly corporatized. There will be 1.2 million home health aides by the year 2020, and in states like Iowa and Arkansas, where some state legislators literally work directly for nursing home companies, we’re seeing private long-term care providers (corporate nursing homes, basically, regardless of whether they’re ostensibly “non-profit”) receive sweetheart deals from state Medicaid programs—then turn around and slash care budgets, underpay staff, neglect and abuse their patients, and pocket the profit.
In America, you can build the most ghoulish, most cynical, most cold-bloodedly evil program imaginable, and get a government contract for it—so long as you only hurt disabled people or people in jail.
Standards, payment, and oversight at the federal level.
This one’s quick. The federal government must set minimum standards for care and guarantee prices and payment. When states can pick and choose what care they offer, their smaller budgets and inability to deficit spend gives them a financial incentive to cut costs and save money, and people die.
Local implementation and flexibility
That said, healthcare is local. Healthcare needs in Brooklyn, Boston, Birmingham, and Butte are all different from each other. Keeping the delivery of single-payer funding as close to the ground as possible lets it be more responsive to both the needs of the people and democratic pressure. Let a San Francisco health agency use funds to put people in homes; let a rural Iowan one spend on transport services to bring people in rural areas to their dialysis appointments.
There are many more things a single payer can do, or should do; or tools it can build for itself. But only a program with these basic principles qualifies as single-payer, or the “Medicare for All” name.
There are at least six bills with confusing names currently floating around Congress. Among them: Rep. Rosa DeLauro (D-CT) and Rep. Jan Schakowsky (D-IL)’s “Medicare for America Act”; Sen. Brian Schatz (D-HI) and Rep. Ben Ray Lujan (D-NM)’s Medicaid buy-in bill; plus policy guidelines from the Urban Institute (“Healthy America”) and the Center for American Progress (“Medicare Extra for All”). Just the other day, 368 members of Congress signed a letter sponsored by lobbyist group America’s Health Insurance Plans (AHIP) praising the Medicare Advantage plan, which opens the door to privatization of the system. Almost all of these plans are a variation on the public option and each one fails to meet the principles I’ve just laid out, since they ultimately they seek to sustain the private insurance market, which is like trying to dig your way out of quicksand with a bucket.
This leaves only two bills worth considering: Bernie Sanders’s “Medicare for All” bill in the Senate and Pramila Jayapal’s upcoming House version, The Medicare for All Act of 2019.
Bernie’s bill comes close, but it isn’t there yet. (I’ve said as much before.) It satisfies three of the four pillars of single-payer. What it lacks is comprehensive coverage. Specifically, Sanders has a lousy plan for elder and long-term care. His bill delegates long-term care to state Medicaid programs—the same process which currently results in the medieval policies causing all this abuse and misery. When insurance companies and other corporations build for-profit nursing homes and then win contracts to administer Medicaid, they just pack their halls with any available body, and reward local lawmakers handsomely for it. Just a few weeks ago, an ex-judge in Arkansas was caught accepting bribes from nursing home companies in a scheme directed by a former state representative. Meanwhile, in Kentucky, the former medical director of a nursing home is passing legislation intended to make it much harder for patients to sue nursing homes for malpractice. It is a perpetuation of barbarism, and it should be a simple fix, but Sanders and the other Senate Democrats haven’t flinched. Until they do, Sanders does not have a “Medicare for All” bill—he has a segregated healthcare bill which inflicts unnecessary and preventable harm on people with disabilities.
Jayapal’s bill, though, appears to meet all of the criteria for a proper single-payer plan. It includes long-term care with a preference toward home health. It sets guidelines for care but lets doctors overrule them. It is, by all accounts, the first actual robust single-payer bill of the post-ACA era. If you are looking for a bill to call “Medicare for All,” this is the one. It must not be permitted to be weakened.
The bill is not perfect. Early commentators fretted when they noticed it dropped a requirement for all providers to become not-for-profit companies in order to be eligible for single-payer payment. This is understandable—we want to “remove profit from healthcare,” after all—but less compelling to me, as “non-profit” is merely a tax designation. Non-profits like the $8 billion Cleveland Clinic, the 78-hospital Ascension health system, or the University of Pittsburgh Medical Center are all non-profits with incredible histories of grift and fraud—UPMC, to me, is best known for opening food banks for the employees it underpays.
A strong series of budgetary tools lets Jayapal’s single-payer program keep providers on a tight leash. One tool is global budgeting, or the advance determination of the national healthcare budget, which is used to set baseline budget agreements for the year and pay hospitals in guaranteed blanket sums based on expected activity. By saying, “last year you spent $2 million dollars, and we can pretty reasonably predict that this year you’ll need $2.1 million dollars for all your services,” the single payer can pay hospitals fairly while minimizing the hospital’s ability to rack up line items and gouge the government. Further tools include prohibitions on providers using single-payer payments for profit, union-busting, marketing, or federal campaign contributions. A single payer cannot remove profit from healthcare on its own (nor could an American NHS), but at least we can give it the muscle to spar with its worst monsters on equal footing.
If the program has all this power to determine how money can be used, I think it should go further in determining how funds for long-term care can and cannot be used—perhaps to guarantee a minimum hourly wage for long-term-care caregivers, alongside increased standards and oversight of LTC services.
Jayapal (and Sanders) also currently leave the Indian Health Service (IHS) alone, though the current IHS funding model is disastrous. The amount spent per-capita for Natives is a third of that spent nationally. This isn’t because Native people have three times better health factors and health outcomes: men on the Sioux Rosebud reservation in South Dakota have a life expectancy of 47 years. Several factors drive this inequity:
- IHS funding is dispensed as a fixed amount of money on a predetermined schedule, and is not updated for inflation or cost increases.
- IHS hospitals in rural areas often need to contract with private providers for services outside their capabilities, which come at exorbitant rates and receive inadequate Medicare funding.
But no bill, including Jayapal’s, is enough. No bill, on its own, could be enough.
For the past hundred years, every time the insiders—the well-meaning senators, the well-meaning policy writers, the well-meaning union or nonprofit leaders—have taken on the insurance industry, they’ve written a bill and waved it around and tried to gin up support among the grassroots. And then they were beaten by a reactionary establishment that is capable of outmaneuvering, outfoxing, and outgunning health reform. They lost in the ‘40s, they lost in the ‘60s, they lost in the ‘70s, they lost a few times in the ‘90s, and they lost in the 2000s.
But when these well-meaning people lose, it is not the senators or union leaders or policy thinkers who find their suffering compounded. It is the people in who live Section 8 housing; the people in prison; people whose backyards are dumping grounds for toxic waste; people with disabilities forced out of their homes; poor mothers and poor children; the people who have been denied work, care, or dignity.
The policy wonks maintain a fantasy that they are important. They rub a little lucky charm and believe their big brains and their tools and their toolkits are where laws come from. They are wrong. They have tragically misunderstood the rules of the game. There is nothing in their power which can comprehend an opposition willing to block popular laws and popular decisions; willing to go nuclear in fights over health and well-being; willing to stampede off a cliff to serve the narrow interests of wealth. They are impotent.
And thus the wonks, even the really nice ones, are not enough. Bills, even the really nice ones, are not enough. Even a socialist president is incapable of passing single-payer by him or herself. When Jayapal’s bill—our first, best articulation of single-payer—or anything like it is passed, it will be on the backs of a massive popular movement. Policy people like to say that you pass a bill, and then you hold politicians’ feet to the fire. Sure. But first, you must build the fire.
What is the reason that the Disability Integration Act (DIA), which lets people with disabilities receive long-term care at home, exists? Not the spontaneous kindness of co-sponsor Chuck Schumer. It was the constant work of popular activist groups like ADAPT, who wrote the bill—and whom you might remember for saving Medicaid for the rest of us during the ACA repeal debates—or hero activist Ady Barkan. They pushed, they pulled, they called, they screamed, they showed up with a list of demands, and they got a bill. (Why did it stall in the House and the Senate despite bipartisan support? Because temporarily able-bodied people haven’t shown up yet).
Why is Medicaid expansion going to happen in Maine? The Maine People’s Alliance launched a massive statewide campaign for minimum wage increases, won, then turned its supporters out to expand Medicaid as a ballot measure—and then to crush its ruling GOP party, infamous for its disembowelment of Maine’s welfare programs, when it actively refused to comply. Their example gives hope to the people of Utah, who are watching their own successful Medicaid expansion vote be overruled by craven elected officials pushing a partial and punitive measure.
Why is Medicaid expansion going to happen in Idaho? Because of Reclaim Idaho, a grassroots popular movement which started out winning school financing in its’ founders tiny ski town. It grew by driving all over the state in a big green RV and getting Medicaid expansion on the ballot, which it won in 35 of 44 counties for a final vote of 62% in favor—despite no visible “blue wave” in the state. Every attempt to block the movement has failed, most recently a court case. What will happen in Idaho when Medicaid is expanded? Whatever the people who make up Reclaim Idaho decide they want to win next.
This is how you build the fire. These popular movements which win material gains are the components of a giant, searing flame in which politicians will be incinerated, while new and more fearful ones line up behind them, to fill the void from among us. There will be no singular popular vertical campaign that wins Jayapal’s bill or any other future bill toward single-payer, or for health justice beyond it. When it is won, it will be won by a patchwork of smaller movements: of local efforts to win power, which thread together in a great tapestry.
This is something the wonk envies, fears, and cannot understand. This is power.
https://splinternews.com/the-only-guide-to-medicare-for-all-that-you-will-ever-n-1832594853
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