Health Care Reform Articles - February 5, 2019

Maine Voices: Medicare uniquely suited to facilitating health care for all Americans

It eliminates the balkanization and fragmentation that make our current, for-profit system inefficient. 

by Philip Caper - Portland Press Herald - February 2, 2019

A commonly held misperception is that Medicare is simply one more type of health insurance. But there are many important differences. Medicare is social insurance, created to facilitate medical care for its beneficiaries. In contrast, commercial insurance is dominated by publicly traded, for-profit companies whose focus, necessarily, is to create wealth for their owners.
Underlying the core business of commercial health insurance companies is a practice known as “medical underwriting.” Underwriting divides insurance beneficiaries into risk pools based on the probability they will use medical services. The practice of denying coverage for pre-existing conditions is but one example of medical underwriting, and is currently outlawed by the Affordable Care Act. But that restriction is now under political attack.
Medical underwriting is a key tool, widely used by insurance companies, to enable them to discriminate against people who are sick or are likely to become sick.
Medical underwriting is complicated and costly. It requires the collection and analysis of detailed and intrusive data.
Using such data, policyholders are segmented into many different risk pools that are priced accordingly. Multiple factors come into play in assessing the likelihood that somebody will need medical care, many completely beyond the policyholder’s control. They include age, gender, occupation, previous medical history, lifestyle, place of residence and access to medical care.
In contrast, social insurance programs such as Medicare use a fundamentally different mechanism to deal with risk. Instead of segmenting and pricing risk, Medicare groups all eligible individuals into a single pool. Instead of charging many different premiums and designing different benefit packages for each, they use public sources to generate a common pool of money and create a common package of benefits that covers most or all eventualities that could face any of the beneficiaries of the program.
By doing this, social insurance eliminates the need to have detailed data, and with it much of the complexity and administrative costs of the commercial insurance system.
In 2012, the National Academy of Medicine (then named the Institute of Medicine) estimated the inefficiencies in our current for-profit health care system to be $190 billion a year nationwide, much of it attributable to medical underwriting and the resulting complexity of our health insurance system. For Maine alone that cost works out to about $800 million a year, money that can and should be used to provide coverage to every Mainer.
Having everybody in a single pool has another benefit – the ability to restrain the now out-of-control overall costs of health care. A single financing pool can be budgeted, something that is impossible in the current multipayer system, leaving us no choice but to attempt to manage costs one service at a time – a very costly, intrusive, contentious and ineffective approach.
There are other advantages to financing health care using a single pool. Our current balkanized and highly fragmented system sets the stage for a great deal of political conflict. Everybody is concerned primarily with making sure their own piece of the system – private insurance, Medicare, Medicaid, the Veterans Affairs system, Obamacare and others – works for them.
A program with just one pool of beneficiaries that serves everybody, such as Medicare, is perceived to be much fairer. Americans sense fairness. Our current balkanized system is perceived to be anything but fair.
That is the key to understanding both Medicare’s efficiency and its broad public appeal. People like it because it’s fair, it works well for everybody and it costs far less than commercial insurance. Public funding also ensures that everybody pays only what they can afford. That’s why such systems work well in most other wealthy countries at a fraction of the cost of ours.
In a universal “Medicare for All” system, we would all have a stake in making sure that system is adequately funded and continues to work well. The public strongly supports universal healthcare for economic, moral, political and practical reasons. It’s time to make the transition to “Improved Medicare for All.”
https://www.pressherald.com/2019/02/02/maine-voices-medicare-uniquely-suited-to-facilitating-health-care-for-all-americans/

Medicare for All Emerges as Early Policy Test for 2020 Democrats

by Jonathan Martin and Abby Goodnough - NYT - February 2, 2019

WASHINGTON — Senator Elizabeth Warren spoke at length this week about her vision for improving the American health care system, like strengthening the Affordable Care Act and making prescription drugs more affordable. Twice, though, she ignored a question posed to her: Would she support eliminating private health insurance in favor of a single-payer system?
“Affordable health care for every American” is her goal, Ms. Warren said on Bloomberg Television, and there are “different ways we can get there.”
To put it another way: I am not walking into that political trap.
Ms. Warren of Massachusetts and three other liberal presidential candidates support a Medicare for All bill, which would create a single-payer health plan run by the government and increase federal spending by at least $2.5 trillion a year, according to several estimates. But Ms. Warren’s determination to sidestep an essential but deeply controversial issue at the heart of the single-payer model — would people lose the choices offered by private insurance? — illustrated one of the thorniest dilemmas for several Democrats as the 2020 primary gets underway.
[Check out the Democratic field with our candidate tracker.]
Their activist base, inspired by Senator Bernie Sanders of Vermont, believes that the party should unabashedly pursue universal health care, ending private insurance entirely. But polls indicate that the broader electorate, particularly the moderate- and high-income voters who propelled the party’s sweeping suburban gains in the midterms, is uneasy about this “Medicare for all” approach in which many would lose their current insurance options and pay higher taxes.

Senator Kamala Harris of California drew immediate attacks from Republicans this week by taking on the issue that Ms. Warren dodged. Ms. Harris breezily acknowledged in a CNN town hall forum that she would “eliminate all of that,” referring to ending private insurance in a country where almost 60 percent of the population receives coverage through an employer.
Her remark triggered an intraparty debate about an issue that until now had been largely theoretical: A decade after Democrats pushed through the most significant expansion of health care since the Great Society, should they build incrementally on the Affordable Care Act or scrap the insurance sector entirely and create a European-style public program?
Four Democratic presidential candidates — Ms. Harris, Ms. Warren, Senator Kirsten Gillibrand of New York and Senator Cory Booker of New Jersey — are among the co-sponsors of Mr. Sanders’s Medicare for All bill, which would replace the Affordable Care Act with a single government health plan for all Americans. Medicare is the federal program providing health coverage to people 65 and older.

The concept of Medicare for all has become popular with Democrats: 81 percent support it, according to a recent Kaiser poll. Yet voter opposition to surrendering the insurance they are used to led to a backlash over President Barack Obama’s repeated promise that “if you like your plan, you can keep your plan” after it proved false for several million people under his health law. Many Democrats are keenly aware of that backlash, and the 2020 presidential race will be the first where many of the party’s leading candidates will have to explain and defend the meaning of Medicare for all.
For now, as Ms. Warren demonstrated, many candidates do not want to wrestle publicly with the details. After Ms. Harris’s comment, her aides hastened to add that she would also support less sweeping changes to health care; like most other candidates, Ms. Harris declined an interview request. And by Friday, Mr. Booker, hours after announcing his presidential bid, sought to curtail the matter by offering a brisk “no” when asked if he supported eliminating private coverage.

Yet there is one likely 2020 contender who is thrilled to discuss Medicare for all.
Mr. Sanders, in an interview, did not mince words: The only role for private insurance in the system he envisioned would be “cosmetic surgery, you want to get your nose fixed.”
“Every candidate will make his or her own decisions,” Mr. Sanders said, but “if I look at polling and 70 percent of the people support Medicare for All, if a very significant percentage of people think the rich, the very rich, should start paying their fair share of taxes, I think I’d be pretty dumb not to develop policies that capture what the American people want.”
But Michael R. Bloomberg, the former New York City mayor who is considering a 2020 bid on a centrist Democratic platform, said it would be folly to even consider a single-payer system. “To replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time,” Mr. Bloomberg told reporters in New Hampshire on Tuesday.
The Congressional Budget Office has not scored Mr. Sanders’s Medicare for All bill, but a study last year by the Mercatus Center of George Mason University predicted it would increase federal spending by at least $32.6 trillion over the first decade. The cost could be even greater, the study says, if the bill overestimated the projected savings on administrative and drug costs, as well as payments to health care providers.
The divide between Mr. Sanders, a democratic socialist, and Mr. Bloomberg, a Republican-turned-independent-turned-Democrat, reflects the large chasm in a party that has been reshaped by President Trump.
The president’s hard-line nationalism has simultaneously nudged Democrats to the left, emboldening them to pursue unambiguously liberal policies, and drawn independents and moderate Republicans to the party because they cannot abide his incendiary conduct and demagogy on race. These dueling forces have created a growing but ungainly coalition that shares contempt for Mr. Trump but is less unified on policy matters like health care.

And these divisions extend to what is wisest politically.
Liberals argue that the only way to drive up turnout among unlikely voters or win back some of the voters uneasy with Hillary Clinton’s ties to corporate interests is to pursue a bold agenda and elevate issues like Medicare for all.

Representative Pramila Jayapal of Washington will soon become the main sponsor of a Medicare for All bill similar to the one led by Senator Bernie Sanders of Vermont.

“Those who run on incremental changes are not the ones who are going to get people excited and get people to turn out,” said Representative Pramila Jayapal of Washington, the co-chair of the Congressional Progressive Caucus.
And by preserving their options, Democrats risk alienating liberal primary voters, some of whom consider support for Medicare for all a litmus test.
“The center is not a good place to be on these policies anymore,” said Mary O’Connor, 61, a substitute teacher and horse farmer in Middleburg, Va., who wants a single-payer system. “I’ll be watching extremely closely, and I will most likely jump on board and volunteer for whoever it is that’s going to be the most forceful for this.”
But moderates believe that most Democratic primary voters are more fixated on defeating Mr. Trump than applying litmus tests — and that terminating employer-sponsored insurance would only frighten the sort of general election voters who are eager to cast out Mr. Trump but do not want to wholly remake the country’s health care system.
“Most of the freshmen who helped take back the House got elected on: ‘We’re going to protect your health insurance even if you have a pre-existing condition,’ not ‘We’re going to take this whole system and throw it out the window,’” said Kenneth Baer, a Democratic strategist.
While polling does show that Medicare for all — a buzz phrase that has lately been applied to everything from single-payer health care to programs that would allow some or all Americans to buy into Medicare or Medicaid — has broad public support, attitudes swing significantly depending on not just the details, but respondents’ age and income.
On the House side, a bill similar in scope to Mr. Sanders’s is under revision and will soon be reintroduced with Ms. Jayapal as the main sponsor. Other Democrats have introduced less expansive “Medicare buy-in” bills, which would preserve the current system but would give certain Americans under 65 the option of paying for Medicare or a new “public option” plan. Another bill would give every state the option of letting residents buy into Medicaid, the government health program for poor Americans.

The buy-in programs would generally cover between 60 and 80 percent of people’s medical costs and would require much less federal spending because enrollees would still pay premiums and not everyone would be eligible. Some proponents, like Senator Jeff Merkley, Democrat of Oregon, have described them as a steppingstone on the way to a full single-payer system; some of the Democrats running for president are co-sponsoring these “Medicare for more” bills as well as Mr. Sanders’s.
Mr. Sanders has suggested options to raise the money needed for his plan, such as a new 7.5 percent payroll tax and a wealth tax on the top 0.1 percent of earners. He has also predicted several trillion dollars in savings over 10 years from eliminating the tax exclusion that employers get on what they pay toward their workers’ insurance premiums, and other tax breaks.
But Robert Blendon, a health policy professor at Harvard who studies public opinion, said it would be wise not to delve into financing details for now.
“The reason it failed in Vermont and Colorado was taxes,” Professor Blendon said, referring to recent efforts to move to a near-universal health care system in those states, which flopped resoundingly because they would have required major tax increases. “But Democratic primary voters will not go deep into asking how these plans will work. What they will say is, ‘Show me you have a principle that health care is a human right.’”
The general election will be a different story, Professor Blendon added. If Ms. Harris were to become the Democratic nominee and keep embracing the idea of ending private coverage, he argued, “she’s going to have terrible problems.”
The difficulty for Democrats, added Ezekiel Emanuel, a former Obama health care adviser, is that many voters look at the health care system the same way they view politics. “They say Congress is terrible but I like my congressman,” as Mr. Emanuel put it.
According to the Gallup poll, 70 percent of Americans with private insurance rate their coverage as “excellent” or “good;” 85 percent say the same about the medical care they receive. The Kaiser poll found that the percentage of Americans who support a national health plan drops by 19 percentage points when people hear that it would eliminate insurance companies or that it would require Americans to pay more in taxes.

Among those who make over $90,000 a year — the sort of voters in the House districts that several Democrats captured in the midterms — those surveyed in the Kaiser poll were particularly wary of an all-government system: 64 percent in this income group said they would oppose a Medicare for all plan that terminated private insurance.
“My constituents are tired of bumper sticker debates about complex issues,” said Representative Lizzie Pannill Fletcher of Texas, a freshman from an affluent Houston district. “We don’t want ideologues in charge.”
In Vermont, where former Gov. Peter Shumlin shelved his ambitious plan for a single-payer system in 2014 after conceding it would require “enormous” new taxes, advocates for universal health care are now resigned to a more incremental approach.
Dr. Deb Richter, a primary care doctor who helped lead the state’s single-payer movement, said that while the Democratic field is “going to have to face the T word,” being upfront about the required tax increases, she now thinks phasing in a government-run system is a better approach.
“There’s ways of doing this that don’t have to happen all at once,” she said, pointing to a push in Vermont to start with universal government coverage for primary care only. “But you need to talk about the end goal: We are aiming for Medicare for all, and this is a way of getting it done.”
https://www.nytimes.com/2019/02/02/us/politics/medicare-for-all-2020.html

Kamala Harris and Michael Bloomberg Clash on Medicare for All

by Maggie Aston - NYT - January 29, 2019

A day after Senator Kamala Harris of California endorsed ending private health insurance in favor of a “Medicare for all” government plan, Michael R. Bloomberg, a possible rival of hers for the Democratic presidential nomination, said the proposal would “bankrupt us for a very long time.”
Mr. Bloomberg, the former New York City mayor who is considering a 2020 bid on a centrist Democratic platform, rejected the idea of “Medicare for all,” which has been gaining traction among Democrats.
“I think you could never afford that. You’re talking about trillions of dollars,” Mr. Bloomberg said during a political swing in New Hampshire, which holds the nation’s first primary in 2020.
“I think you can have ‘Medicare for all’ for people that are uncovered,” he added, “but to replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time.”

Mr. Bloomberg did not mention any of his would-be competitors by name. But his wording — particularly the distinction he drew between providing Medicare to everyone and providing it only to those currently uninsured — positioned him clearly against Senator Harris.
Few Democrats have explicitly suggested ending private insurance, even though many have endorsed “Medicare for all.” Ms. Harris initially stopped short of it, too, saying at a CNN town-hall event on Monday that she supported “Medicare for all” and adding, “We have to appreciate and understand that access to health care, it should not be thought of as a privilege. It should be understood to be a right.”
But when the CNN anchor Jake Tapper pressed her on what that meant for private insurance, Ms. Harris responded, “Let’s eliminate all of that.”
Lily Adams, a spokeswoman for Ms. Harris, responded to Mr. Bloomberg on Twitter, noting that he is a billionaire.

On Tuesday night, a campaign spokesman for Ms. Harris said she still supports and prefers the elimination of private insurers, but also noted that she had previously backed other bills that are alternates to “Medicare for all” that would preserve some role for the insurance industry. A Harris spokeswoman also emphasized on Twitter that this comment did not mean Ms. Harris was bending on “Medicare for all.”

But the campaign’s move to modify Ms. Harris’s comments on such a major issue illustrated the difficulty the 2020 hopefuls could face attempting to appeal to their progressive base while not turning off general election voters.
The disagreement between Mr. Bloomberg and Ms. Harris reflects a basic divide within the Democratic Party. On one side are liberals who have proposed ambitious left-wing policies, from “Medicare for all” to a wealth tax on the richest Americans. On the other side are centrist and fiscally conservative Democrats, along with liberals who support such policies in theory but argue that voters would reject them.
https://www.nytimes.com/2019/01/29/us/politics/medicare-for-all-harris-bloomberg.html

The Next Big Thing in Health Reform

by Jeanne Lambrew and Ellen Montz - Century Foundation -  January 3, 2018

The next Democratic candidate for president or Democratic Congress will likely embrace some sort of public plan as part of the “next big thing” in health reform. Numerous congressional Democrats have thrown their weight behind Senator Bernie Sanders’s “Medicare for All” bill. Support is also growing for various kinds of “public options”—opportunities to expand the role of public programs through Medicare, Medicaid, or the health insurance marketplaces.
These ideas are similar in their goal of providing lower-cost, simpler, and more secure health-care coverage for all Americans through insurance plans that are publicly backed and organized. The proposals reflect frustration with private insurers and a belief in a stronger and more direct role for government, but they differ in how they work. Single-payer plans concentrate health-care finance in the federal government, while Medicare and Medicaid buy-in proposals build on existing programs, payment rates, and relationships with health-care providers.
The proposals also differ in where they start. Barack Obama is among the many who have said that if we could start from scratch, a single-payer system would make the most sense. The U.S. health system, however, is far from a blank slate. It is the largest in the world in spending. Relatedly, it is one of the nation’s largest employers, as well as its most lucrative: Nine of the top ten highest-paid occupations are in health care, and both the industry and its employees are likely to resist changes they see as threatening. More than nine in ten Americans now have coverage thanks to the Affordable Care Act (ACA). Changing this entrenched system incrementally has proved daunting; changing it radically may prove impossible. The cliché “don’t bet against the house” is safely applied in health policy.
In light of those considerations, we focus here on four major approaches to expanding the public role in achieving the goals of health-care reform. These approaches do not necessitate picking one preferred plan over all others, nor do any of them inevitably lead to a predetermined outcome. The expansion of programs often stalls, as is evident in the long lags between past health reforms. Consequently, the next steps we take are as important as the ultimate destinations that we hope to reach.

Start Where Private Insurance Ends

Historically, public coverage has started where private insurance has stopped. The recognition that private insurance would not cover the old, the poor, and people with disabilities contributed to the passage of Medicare and Medicaid in 1965. Nearly five decades later, Democrats designed the ACA to close the remaining gaps, first, by making Medicaid a true safety net for all low-income Americans and, second, by requiring private insurers to cover all people regardless of any pre-existing conditions. The Supreme Court partly undid the first step by making the Medicaid extension optional for the states. Nonetheless, filling the gaps as far as the ACA did led to 20 million more people being covered. The Trump administration’s efforts to undermine the ACA have threatened those gains and led to skyrocketing health insurance premiums for 2018. Additionally, private insurers have balked at offering coverage in the individual market in parts of the country, jeopardizing residents’ access to any plan. The prospect of “bare” counties has been one impetus for bills such as “Medicare X,” which would offer a Medicare-like plan in counties with no or only one other insurer.
Republicans have previously embraced the concept of a public plan as a gap-filler where no private plan is available. The Medicare prescription drug program, enacted under President George W. Bush, has a government-funded fallback plan for areas with fewer than two private plans. Former Maine Senator Olympia Snowe supported a “triggered” public plan for inclusion in the ACA, a proposal blocked by Senator Joe Lieberman. Depending on its design, a fallback public plan could improve affordability in areas where there is low competition and high prices.
This deployment of public plans, however, may not be necessary to address the problems in these areas, since other responses might suffice. For example, federal law could require urban insurers to serve nearby rural areas, or it could extend Medicare’s provider payment rates to private insurance plans in places with no or low competition. A public plan, once it enters an area, may make private insurers less likely to return, potentially replacing private with public plans one county at a time. Most of the areas with few insurers are in red states where governors and legislatures have shown little interest in making their health insurance markets work. While this geographic pattern could make a public option fallback harder to pass through Congress in the first place, it could lessen partisan opposition to public plans in the long run if they succeeded in those areas and built up local support.

Less Old Next

Another familiar approach is age-based. By far, people under age 18 and over age 65 have the lowest uninsured rates as a result of the programs that America has established for the old and the young. After the passage of Medicare to cover all seniors in 1965, policymakers focused on covering children. Legislation was enacted in 1988 to expand Medicaid to all poor children and in 1997 to create the Children’s Health Insurance Program for near-poor children. In addition to extending these programs, the ACA requires that insurers let young adults stay on their parents’ plans until age 26, one of the law’s most popular provisions.
This year has seen a revival of plans to lower the age of eligibility for Medicare, a proposal first made by President Bill Clinton in 1998 and later debated for inclusion in the ACA. Senator Sanders’s Medicare for All bill includes a version of that idea. The Medicare Buy-In Act and the Midlife Medicare program proposed by Paul Starr would extend Medicare as an option for older adults, variously reducing the eligibility age to 55 or 50.
Proponents of lowering the age of eligibility for Medicare point out that expanding a popular program may be the easiest way to expand government insurance. Starting at age 50 aligns with AARP’s new definition of “older Americans.” This age group tends to have lower average health costs than those already on Medicare yet higher average costs than those in private coverage, so shifting them to Medicare has the potential to lower the average costs both for Medicare and individuals in private insurance. Lowering average premiums in the private market would help attract younger enrollees. And if the goal is to cover all Americans over time in Medicare—literally using it as the foundational health program for people of all ages—this would be the most logical place to start.
The proposals also highlight the differences between Medicare and the ACA marketplace, forcing hard choices. Do these older Americans, for example, get Medicare’s lower deductibles or the ACA’s annual out-of-pocket limit? Do they get Medicare’s social insurance subsidies or the ACA’s income-based ones? And, now that the ACA guarantees access to private plans for this group, is providing different coverage for older Americans the top priority? Older adults are much more likely to be insured and have higher income than younger adults, who may object to being left out. Last but not least, even though lowering Medicare’s age eligibility is the expansion most similar to the current program, it would likely be subject to the scare tactic often used on senior voters—that it would be “messing with Medicare.”

Make it a Choice

Starting about a decade ago, thanks largely to the work of Jacob Hacker, the idea of letting people choose between a public and private insurance plan entered the national debate. Rather than selectively extending public plan eligibility for certain groups, this approach would let people “vote with their feet.” The House-passed version of the ACA included a nationwide public plan (distinct from but resembling Medicare) to be offered alongside private plans to individuals and small businesses. Hacker now proposes that large employers have the choice of a public plan as well. Another option, advocated by Michael Sparer and embodied in a bill introduced by Senator Brian Schatz, would let any eligible individual buy into Medicaid, including those otherwise eligible for individual marketplace or employer coverage.
This approach has appeal in a nation that values the concept of choice. It forces a side-by-side comparison of the different ways to organize coverage, a comparison that proponents believe will dispel myths about public plans. The Congressional Budget Office estimates that proposals such as the one in the 2009 House bill would stimulate competition, improving the value of coverage and reducing its cost. If the public plan “wins” and gets most enrollment, it would be a transition propelled by individuals’ decisions rather than a government decree.
Choice, however, can undermine a system of insurance. People know their health status better than insurers or the government, so it stands to reason that sick people would gravitate to the public plan while healthy people would choose private plans—or vice versa—depending on how the program is designed. That problem can be mitigated behind the scenes through mechanisms such as risk adjustment (compensating health insurers for enrolling a disproportionate percentage of higher-cost enrollees in the market), as is done in Medicare Advantage (although such a system comes at a cost to the federal government). Alternative ways to keep private plans competing alongside a public plan include setting that plan’s provider payment rates closer to private plans’ rates than Medicare’s or requiring Medicare rates for out-of-network providers in private plans, as recently proposed by Zirui Song in The New England Journal of Medicine. Failing to adopt measures such as these could result in private insurers pulling out of the markets, in which case people will be deprived of the choice this model promises. For choice models to work, policymakers would need to make periodic adjustments (as has been done for Medicare Advantage), and that kind of calibration may not be feasible in today’s politically polarized environment.

Go Where the Money is

Another historical point of entry for public programs has been people with serious health needs. Medicaid covers people with certain disabilities, including, in some states, people whose monthly or quarterly medical bills are so high that the bills impoverish them. Medicare covers people with end-stage renal disease and beneficiaries of Social Security Disability Insurance after a two-year waiting period. Proposals to eliminate Medicare’s waiting period have been considered for decades. As Harold Pollack argues, addressing the needs of people with disabilities requires the development of distinctive capacities in public programs, which some states have done. Building up those capacities nationally would not only improve the care of our most vulnerable but also stabilize private insurance markets. The historical impediment to such an approach has been the cost to the federal government.
Now that the ACA has fully integrated people with pre-existing conditions into private plans, policymakers are considering public means of lowering the cost of private insurance. In 2015, private plans paid more than Medicare for the top 1 percent most expensive Americans. Public reinsurance has become a popular, bipartisan idea to lower premiums and improve the functioning of the individual market. By reimbursing health insurers for high costs (for example, for organ transplants or treatment for hemophilia), reinsurance lowers cost uncertainty for insurers and thus the premiums they charge. Alaska and Oregon are implementing such programs in 2018, and legislation sponsored by Senators Susan Collins and Bill Nelson supports additional state programs. The “Invisible Risk-Sharing Program,” a type of reinsurance offered by Republicans in 2017, would pay the costs of people with high-cost conditions like cancer at Medicare provider payment rates. Such a program could, as we have suggested in an article in Health Affairs, extend to employer plans as well, efficiently spreading risk to lower premiums for the 175 million Americans with private coverage.
Public reinsurance has the benefit of lowering premiums and allowing people to “keep their plans.” It builds on a well-established role for government: helping people who face financial hardship, as the federal government does in floods and other natural disasters. Reinsurance was the only proposal in both the Republicans’ 2017 “repeal and replace” bills and Democratic alternatives. And it has the potential of lowering health costs generally depending on its design.
Public reinsurance, however, would primarily replace private reinsurance, and some employers may balk at the strings attached to the money. Because it is a back-end program, employers and insurers rather than the government (and members of Congress who voted for it) would likely get credit for its results. Republicans may reject it as another insurance company bailout, while Democrats may reject it as propping up private insurers rather than expanding “true” public plans. Like other proposals that lower reimbursement, this one could also engender opposition from physicians and hospitals.

Which Path Forward?

It is hard to work out the details of the next advance for affordable coverage when the specter of “Obamacare repeal and replace” still looms. Preventing dramatic reductions in coverage under a Republican-controlled White House and Congress remains a priority.
What the health system looks like at the end of the Trump era will affect future choices. If today’s major health programs are frayed but structurally intact, a future Congress or president may prefer less-dramatic proposals, especially given what else might be on the national and international agenda. Starting with a back-end public reinsurance program to lower costs would build trust and support among employers for a program that could be expanded by making more costs, and thus more people, eligible. A fallback public plan or a public plan choice may be the natural solution for the marketplace. While lowering the age of eligibility for Medicare may be considered a partial solution to private insurance problems, it could be part of larger Medicare reform. And an “all of the above” approach could be taken.
Alternatively, if the health system is in shambles when the next president takes office, the appetite (although not necessarily the ability) to move more rapidly to some type of public plan may be greater. Widespread problems—from few unsubsidized enrollees in the individual market to a watered-down Medicaid program to a return to large annual premium hikes in Medicare and employer-based health plans—could fuel proposals that give all Americans the promise of more affordable, reliable health coverage.
No matter the state of the system, proponents should consider calibrations of various ways to expand public plans in recognition of Americans’ distrust of change. We tend to look back before looking forward. Fear of change worked against the ACA’s movement of people to reformed private plans; many preferred to “keep their plans,” despite their flaws. That same fear worked against Republicans’ attempt in 2017 to take away the ACA’s Medicaid expansion. A recent survey found that nearly half of Americans do not realize they would have to change plans under a single-payer system. Regardless, ideas across the spectrum we described should be ready since the Trump administration’s health policies will almost certainly necessitate a response.
https://tcf.org/content/report/next-big-thing-health-reform/?

Editor's Note:

The preceding article by Lambrew and Montz, even though it was written a year ago, contains some interesting ideas about we could incrementally advance toward the ultimate goal of a single, publicly financed universal healthcare system in the US.  

Their suggestions should each be carefully considered - but if, and only if - a clear plan for reaching that goal is an integral part of the plan.

Lewis Carroll once said "If you don't know where you're going, any road will take you there". We need to keep our goal firmly in mind.

-SPC

 

Pros and Cons of Different Public Health Insurance Options: A Guide for 2020 Democratic Presidential Candidates

by Sherry Glied and Jeannie Lambrew - The Commonwealth Fund -  November 16, 2018

Options for Expanding Health Care Coverage

It is more than likely that Democratic candidates for the 2020 presidential election will propose some type of public health insurance plan. In one of two Commonwealth Fund–supported articles in Health Affairs discussing potential Democratic and Republican health care plans for the 2020 election, national health policy experts Sherry Glied and Jeanne Lambrew assess the potential impact and trade-offs of three approaches:

• Incorporating public-plan elements into private plans through mechanisms such as limits on profits, additional rules on how insurers operate, or the use of Medicare payment rates.
• Offering a public plan — some version of Medicare or Medicaid, for example — alongside private plans. Such a plan could be offered to specific age groups, like adults 50 to 64 who are not yet eligible for Medicare, to enrollees in the Affordable Care Act’s (ACA) marketplaces, or to everyone under 65, including those working for self-insured employers. It also could be made available in regions of the country where there is little health care competition.
• Replacing the current health care financing system with a “Medicare for all” single-payer system administered by the federal government. Some single-payer proposals would allow consumers to purchase supplementary private insurance to help pay for uncovered services.

Watch archived video of live Health Affairs event held Nov. 16, 2018. (Registration required.)

Top health care concerns among surveyed Americans

#1 High health care costs

#2 Losing access to benefits

Issues for Consideration in 2020

The authors find trade-offs in each type of public plan. First, a single-payer system would significantly increase the federal budget and require new taxes, a politically challenging prospect. On the other hand, federal spending might decrease if a public plan were added to the marketplace or if public elements were added to private plans. In 2013, the Congressional Budget Office estimated that a public plan, following the same rules as private plans, would reduce federal spending by $158 billion over 10 years, while offering premiums 7 percent to 8 percent lower than private plans. A single-payer approach would lower administrative costs and profits, and likely reduce health care prices as well. By assuming control over the financing of health care, the federal government could reduce administrative complexity and fragmentation. On the flip side, the more than 175 million Americans who are privately insured would need to change insurance plans.
A public–private choice model would help ensure that an affordable health plan option is available to Americans. While politically appealing, this option presents implementation challenges: covered benefits, payment rates, and risk-adjustments all need to be carefully managed to ensure a fair but competitive marketplace. A targeted choice option might be adopted by candidates interested in strengthening the ACA marketplaces in specific regions or for specific groups (as with the Medicare at 55 Act). It would benefit Americans whose current access to affordable coverage is limited, but the same technical challenges associated with a more comprehensive choice model would apply.
Finally, to lower prices for privately insured individuals, public plan tools such as deployment of Medicare-based rates could be applied to private insurance, either across the board or specifically for high-cost claims, prescription drugs, or other services. The major challenge here is setting prices that would appropriately compensate providers.

The Big Picture

Under the ACA, the percentage of Americans who had health insurance had reached an all-time high (91 percent) in 2016, an all-time high, and preexisting health conditions ceased to be an obstacle to affordable insurance. But Americans remain concerned about high out-of-pocket spending and access to providers, and fears over losing preexisting-condition protections have grown. While most Democratic presidential candidates will likely defend the ACA and seek to strengthen it, most recognize that fortifying the law will not be enough to cover the remaining uninsured, rein in rising spending, and make health care more affordable.
While the health reform proposals of Democratic candidates in 2020 will likely differ dramatically from those of Republican candidates, recent grassroots support for the ACA’s preexisting condition clause may indicate a willingness by both political parties to support additional government intervention in private insurance markets.
https://www.commonwealthfund.org/publications/journal-article/2018/nov/pros-cons-public-options-2020-democratic

https://www.citizen.org/sites/default/files/the_case_for_medicare-for-all_-_february.pdf

The Case for Medicare-for-All

by Public Citizen -  February, 2019

Contrary to the image painted by critics, Medicare-for-All would increase access to care and grow the economy, according to an analysis by Public Citizen. The analysis takes a comprehensive look at the research available on Medicare-for-All and lays out the facts, including that such a policy would reduce administrative waste, reduce profiteering of health care and lead to additional federal revenue. The analysis comes as U.S. Rep. Pramila Jayapal (D-Wash.) prepares to reintroduce Medicare-for-All legislation in the U.S. House of Representatives this month. House Speaker Nancy Pelosi has announced support for hearings on the legislation, which would be the first time a single-payer health care system will be taken seriously by House leadership. Medicare-for-All opponents, including Big Pharma and health insurance companies, already have tried to squash any talk of such the reform because it would threaten their profit margins.
Read the report now.
The report addresses common Medicare-for-All questions by highlighting key facts, including:

• The system would save money by reducing administrative costs by $500 billion per year and allowing the government to negotiate for more affordable medicines;
• Such a system would be paid for using a progressive funding mechanism so that higher-income earners would pay a greater percentage of their income than moderate or low-income earners;
• Medicare-for-All would cost patients less than employer-sponsored insurance and improve access to community-based services, including home health care;
• A just transition to Medicare-for-All would ensure that former private insurance workers receive the training and support necessary to pursue new careers; and
• Medicare-for-All would improve financial stability for rural hospitals and doctors.

Finally, under Medicare-for-All, there would not be increased wait times, in part because improved financial incentives for providers would mean better prioritization of care, leading to improved access and a reduction of unnecessary costs.
https://www.citizen.org/case-for-medicare-for-all

Democrats’ confused, and confusing, Medicare-for-all debate

Medicare-for-all doesn’t mean what it sounds like it means.

 by Ezra Klein - VOX - February 5, 2019

The Democrats’ 2020 primary has kicked off with a confusing and confused debate about the details of Medicare-for-all — one that shows just how much complexity lurks behind a seemingly simple slogan.

Sen. Kamala Harris (D-CA) started things, telling CNN’s Jake Tapper that she’d “eliminate all of that,” where “that” referred to private insurance. Within a few hours, her staff was softening the statement, telling reporters that while pursuing single-payer health care was Harris’s goal, she had also signed on to more incremental bills. (“I want a burrito,” tweeted Harris’s communications director, in an impish clarification. “I’d accept tacos in the meantime, but I want a burrito.”)

Sen. Cory Booker (D-NJ) took another tack after announcing his candidacy. Asked whether he would “do away with private health care,” Booker replied, “even countries that have vast access to publicly offered health care still have private health care, so no.”

Within a few hours, Booker was besieged by angry tweets from liberals reminding him that he was a co-sponsor of Sen. Bernie Sanders’s (I-VT) Medicare for All bill and that the bill abolishes private insurance. (It actually doesn’t — more on that in a moment.) So, they said, he’d just proven himself a fake progressive and a real hypocrite.

Sen. Elizabeth Warren (D-MA) quickly surveyed the wreckage and decided to sidestep the whole mess. “We know where we’re aiming, and that is every American has health care at a price they can afford,” she told Bloomberg. “There are multiple bills on the floor in the United States Senate. I’ve signed on to Medicare for all. I’ve signed on to another one that gives an option for buying into Medicaid.”

Sanders, who deserves credit for making Medicare-for-all the defining policy of the 2020 Democratic primary, took the opportunity to tout his bill. “I look at polling and 70 percent of the people support Medicare for All,” he told the New York Times. “I think I’d be pretty dumb not to develop policies that capture what the American people want.”

Meanwhile, Sen. Sherrod Brown (D-OH), another likely 2020 candidate, decided to stake more moderate ground. “I know most of the Democratic primary candidates are all talking about Medicare-for-All,” he told the Clear Lake Chamber Of Commerce in Iowa. “I think instead we should do Medicare at 55.” Brown, one of the Senate’s most liberal members, framed his position as simple pragmatism. “I’m going to talk about what’s practical and what we can make happen,” he continued. “And if that makes me different from the other candidates, so be it.”

Behind this debate is the fact that Democrats have embraced a politically powerful, but intentionally confusing, slogan to describe their health care goals. “Medicare-for-all” doesn’t mean what it sounds like it means. So what it does mean, or should mean, has become a defining debate within the party.

What does the “Medicare” in Medicare-for-all mean?

In the Democratic imagination, Medicare is a generous single-payer insurance system that can be extended to cover the entire country.

In reality, Medicare is a peculiar health insurance plan specifically designed for seniors and mottled by decades of political tussle. It doesn’t cover a host of conditions — like, say, pregnancy — that younger people face. It doesn’t cover vision or dental. It includes significant copays and no limit on out-of-pocket spending, which is why three-quarters of enrollees use supplemental insurance to help defray costs.

Medicare also makes substantial use of private insurance. All prescription drug coverage is provided by private insurers through Medicare’s Part D program, and about 34 percent of Medicare beneficiaries are enrolled in private Medicare Advantage plans instead of traditional Medicare.

Literally none of the plans being proposed expands Medicare insurance to all Americans, and for good reason. If Medicare-for-all actually meant everyone gets Medicare, the insurance itself wouldn’t cover what young people need covered, and quite a bit of the insurance would be private.

What a lot of people seem to mean by Medicare-for-all is Sanders’s Medicare for All bill. As Sarah Kliff’s excellent explainer details, Sanders’s legislation builds a much more generous system under the Medicare banner and, along the way, bans duplicative private insurance and sunsets the current Medicaid and Medicare programs.

It’s not quite true to say Sanders’s plan abolishes private insurance entirely — you could still buy non-duplicative private insurance — but it would mean that the roughly 180 million Americans who have private insurance would see their plans canceled.

Sanders’s bill boasts Booker, Kirsten Gillibrand, Harris, Jeff Merkley, and Warren as co-sponsors — after the 2016 election, few 2020 hopefuls wanted to let Sanders outflank them on health care — but it’s far from the consensus vision, in part because Sanders’s maximalist approach to Medicare-for-all polls poorly.

What does the “all” in Medicare-for-all mean?

People don’t like health insurers in general, but they tend to like their own health insurance. Sixty-one percent of insured Americans under age 65 say their insurance plan is an “excellent” or “good” value. Perhaps that’s why canceling people’s private plans takes Medicare-for-all from majority support (+14 favorable) to majority opposition (-21 unfavorable). Raising taxes and ending the current Medicare program does even more damage.

Kaiser Family Foundation

Sanders’s plan abolishes most private insurance, raises taxes, and replaces the current Medicare program. Moreover, it’s at least theoretically possible that his legislation, which cuts payment rates to medical providers even as it gives every American free access to all health care services, could lead to supply constraints, which are the most dangerous attack you can levy against the idea.

I wouldn’t take any polling to be prophetic, and Sanders has proven himself a uniquely effective health care messenger. Perhaps his plan would prove more robust to counterarguments with him on the trail defending it. But disrupting existing health care arrangements has been politically disastrous for everyone who has tried it.

The most-aired ad of the 2008 presidential campaign was Barack Obama’s attack on John McCain’s plan to tax employer-provided insurance, and the most-aired ads during the 2010 midterms featured Republicans flaying Democrats for cutting Medicare benefits as part of the Affordable Care Act. The American people are very risk-averse when it comes to their health care.

For that reason, other Democrats and liberal organizations have developed Medicare-for-all plans that allow people to opt in to the new Medicare program, rather than being forced onto it, and that keep total costs down.

Reps. Rosa DeLauro (D-CT) and Jan Schakowsky (D-IL), for instance, just released their Medicare for America bill, which enrolls the uninsured, along with everyone on Obamacare and Medicaid, in an expanded Medicare plan and then lets individuals and employers buy into it if they choose, with sliding-scale subsidies based on income. Yale’s Jacob Hacker, who helped craft the legislation, explained the thinking to Vox:

Health care plans have foundered again and again on the shoals of figuring out where to come up with the money. To me, this is in some ways the biggest argument for a Medicare expansion that isn’t single-payer. Where do you come up with the money if you try to essentially socialize the costs of the most costly medical system in the world? There’s a lot of money going through the employment-based system and other pathways that would suddenly go on the federal ledger.

Bernie Sanders’s own team said their plan would cost about 9 to 10 percent of GDP. I’ve pointed out that the tax increase to fund World War II was about 5 percent. That’s a big number. They’re right that you’re just switching private premiums over into public taxes. But I’m incredulous about the idea that you could actually implement that kind of new tax financing as quickly as would be needed to have a universal Medicare system.

Other ideas are even more incremental. Sens. Chris Murphy (D-CT) and Jeff Merkley’s (D-OR) Choose Medicare Act would basically add an expanded Medicare option to the Obamacare exchanges, and give employers the option of buying into it as well.

Every one of these plans defines the “all” in Medicare-for-all differently. Sanders’s plan says everyone gets Medicare, whether or not they want it. DeLauro and Schakowsky’s plan says that anyone can get Medicare but those with private insurance can keep what they have if they prefer it. Murphy and Merkley’s bill makes it possible for anyone to buy Medicare, so long as they can afford it.

The incrementalists (a strange word to use for plans that are still incredibly ambitious, but bear with me) argue that their proposals are safer “glide paths” to everyone being on Medicare.

The argument goes like this: Medicare’s size lets it negotiate better prices with doctors and hospitals, leading to discounts of about 20 percent over private insurance. If Medicare is cheaper and better than private insurance, then everyone will eventually switch over. What’s the purpose of forcing people onto the program and risking a backlash that could annihilate the entire project? After all, President Obama was raked over the coals for canceling around 3 million plans that were so crummy they didn’t meet the Affordable Care Act’s relatively forgiving standards; is canceling orders of magnitude more insurance plans, and far better ones, really the lesson to take from that debacle?

The counterargument is that hospitals and doctors may decide they don’t want an all-Medicare world, and they could stop taking Medicare in an effort to encourage individuals and employers to keep buying the private insurance plans that pay them higher rates. A world in which there are no private insurance plans makes that basically impossible.

The counter-counterargument is that if doctors and hospitals so fear a world where all insurance is paying Medicare rates, they would kill the plan before it ever passed, or they would force any plan that did pass to pay higher rates. Politicians are far less trusted than medical providers, and it’s unlikely any plan could overcome the entire medical industry’s objections.

Needless to say, I’m not going to settle that argument here, and I’m not even certain who has the better end of it. But it goes to show how much of the Medicare-for-all debate is actually about your theory of politics, not just your theory of policy.

The Medicare-for-all brand is appealing precisely because it’s nonthreatening. People are risk-averse when it comes to their health insurance. They want something they know will work.

Medicare works, and Americans know it. That’s a political boon for Democrats. But it carries an implicit threat: If whatever ends up being Democrats’ Medicare-for-all bill feels risky to people, the same forces buoying the idea’s poll numbers now will sink the policy later. As one concrete example, it’s very hard for me to imagine Democrats taking Medicare Advantage away from seniors under the guise of expanding Medicare. If your bill is based on the idea that people love the current Medicare program, taking away something that people love about it will feel like a profound betrayal.

There can be a tendency, when judging presidential candidates, to let ambition act as a signal of commitment. Under that view, if Harris wants to abolish all private insurance, then she’s more committed to Medicare-for-all than Booker, and both of them are more committed than Brown, who just wants to expand the program to 55-year-olds.

But that’s a flawed way to look at policymaking. The point here is expanding better coverage to more people, so the question has to expand to include political strategy. A Medicare plan that passes into law and successfully extends coverage to 40 million people gets the country a lot closer to Medicare-for-all than a plan that envisions expanding Medicare to everyone but fails in Congress and costs Democrats the House in 2022.

I don’t think DeLauro and Schakowsky are less committed to expanding Medicare than Sanders or Harris. Instead, I think they believe that Sanders’s approach could trigger a backlash that discredits the whole project, and their bill is likelier to pass. Whether that’s true is the real debate Democrats need to have.

Nor is this only about what’s inside the plan. Process matters, too. Literally zero of these plans will pass so long as they’re held to a 60-vote threshold in the Senate. Absent a plan to get rid of the filibuster, or absent a bill that can fit entirely inside the budget reconciliation process, all of this is moot. In that world, Brown’s plan to open Medicare to 55-to-64 set is probably the best you can do.

The Democratic Party has become much more ambitious in its policy ideas in recent years, and I think it’s a change for the better. But even so, the history of health care reform is mostly a history of failure and backlash. That’s because America’s political institutions make big bills hard to pass, because moneyed interests fight like hell against its passage, and because people don’t trust the government to mess with their health care. How the various Democrats running for president propose to navigate or defuse those threats should be integral to this debate.

https://www.vox.com/policy-and-politics/2019/2/5/18209945/medicare-for-all-bernie-sanders-kamala-harris-cory-booker-single-payer 

Kate Pickett and Richard Wilkinson: ‘Inequality strikes at our health and happiness’

by Dawn Foster - The Guardian - September 18, 2018

New analysis this week showing that 14 million people live in poverty highlights just how unequal a society the UK has become. Poverty is particularly prevalent among disabled people, single parents, unemployed people or those working irregular or zero-hours jobs.
It follows recent research by the OECD showing that social mobility has stagnated, with a child from a poor family in the UK taking five generations on average to earn the average wage, compared to two generations in Denmark, and three in Finland, Norway and Sweden.
It’s hardly surprising, according to Kate Pickett and Richard Wilkinson. The married academics’ 2009 book, The Spirit Level, on the effects of inequality on societies across the world, sold over 150,000 copies in English alone, and was lauded across the political spectrum.
Nine years on, things have not improved. The Inner Level, their long-awaited follow up published earlier this year, looks at the more personal, individual effects of inequality: how the social effects of the gap between rich and poor impact on people. “We’re talking about how inequality affects our intimate lives, our inner lives; our mental wellbeing, our relationships with friends and family,” Pickett says.
The Inner Level examines a society that has dealt with 10 years of austerity, and seen almost every family impacted by stagnant wages, increased job insecurity, swingeing cuts and changes to the benefits system and public services nationally and locally, as well as a surge in problems with mental health across society. “It takes a whole argument and evidence about the effects of inequality to a deeper and more intimate level. In The Spirit Level we were dealing with things about society ‘out there’ – the size of the prison population, homicide rates, obesity rates and so on. But this takes it into the sphere of our social fears and anxieties,” Wilkinson says. “Worries about self worth: all the things that make social contact sometimes seem rather awkward and stressful. Your fears about self presentation and so on are all exacerbated by inequality.”
The problems scrutinised in the book – self doubt, social anxiety, stress, and fear of how we are seen by others – have an impact on day-to-day emotions for individuals, but also a wider impact on relationships, our ability to build functioning communities, and the health and wellbeing of entire populations. These issues are massively exacerbated by inequality, and a belief in meritocracy means that any failure is deemed a personal failure, the book argues. “The reality is that inequality causes real suffering, regardless of how we choose to label such distress. Greater inequality heightens social threat and status anxiety, evoking feelings of shame which feed into our instincts for withdrawal, submission and subordination: when the social pyramid gets higher and steeper and status insecurity increases, there are widespread psychological costs.”
The stress of poverty also influences the cognitive development of babies and children. Measuring the levels of the stress hormone cortisol in infants found that poverty, and the amount of time spent in poverty, can hamper the mental development of children. Pickett and Wilkinson find that “family income is a more powerful determinant of cognitive development than being brought up by single parents, or maternal depression”, and that if children are enrolled in support services like Sure Start and their equivalents in other countries, some of the effects of poverty are offset, and children’s educational and psychological performance improves.
The social demarcations of class, from what we eat and how we talk, to what culture we consume, are also rigorously upheld in more unequal societies, making discrimination much easier and preventing social mobility. In more unequal societies, the book finds, fewer people marry someone of a different class background, the number of visits to art galleries and museums is lower, the prison population is higher and the age of criminal responsibility for children is lower.
Wilkinson and Pickett cite extensive statistical evidence that unequal societies are responsible for less fulfilling personal lives, and in turn harm public health, scupper educational progress, increase crime and lower life expectancy. “We debunk some of the myths that people use to explain why [society] is willing to tolerate greater levels of inequality, namely that inequality is a natural result of our human nature, that we are competitive, individualistic and out for ourselves – that’s the way we are, it’s just human nature and nothing can be done about it,” Pickett says. “That is not the case. We also provide evidence to counter the argument that actually we’re living in a meritocracy, and that inequality is simply a case of the capable and talented moving up, and those who are less capable, less clever, moving down.”
Many of the problems in our increasingly polarised society are down to social inequity and are not natural, they argue. “Inequality itself creates these differences,” Pickett says. “Increased social anxieties and worries about how we are seen damage social life and lead actually to more violence. The worst affected withdraw from life entirely, and even among the rest of the population who don’t feel it so acutely, we all feel it a bit,” Wilkinson warns. “Thatwhile Wilkinson warns that inequality “diminishes social life. What we value most is laughing, joking, relaxing and spending time with friends and family. That is essential to health and happiness – and yet it’s there that inequality strikes.”
If the pair were given power tomorrow, they already have a few policy priorities. “I’d ban private education to put a brake on intergenerational unfairness, in line with Finland. But I’d also institute an exceptionally large inheritance tax,” Pickett says.
Wilkinson concurs, but adds: “I think we have to extend democracy into the economy, and hugely inflated salaries have to be stopped. We should have employee representation on company boards, and incentives to grow cooperatives and employee-owned companies. That whole sector has to grow.”

Curriculum vitae

Age: Kate is 53, Richard is 75.
Lives: They live together near York.
Family: Richard and Kate have been married for six years; they each have a son and daughter from previous relationships.
Education: Kate: Ecclesbourne school, Derbyshire; University of Cambridge (biological anthropology); Cornell University, USA (nutritional sciences); University of California, Berkeley, USA (epidemiology). Richard: the Quaker school, Leighton Park; LSE (economic history); University of Pennsylvania, USA (regional science); University of Nottingham (epidemiology).
Career: Kate: University of Chicago, 1999-2003; University of York, 2003-present, where she is now university research champion for justice and equality. Richard: Avon Area Health Authority, 1979-81; University of Sussex, 1981-2001; University of Nottingham, 2001-2008. They co-founded The Equality Trust (with Bill Kerry) in 2009.
Interests: Both love walking and the countryside. Kate also loves cooking and ballet (both dancing and watching); Richard pursues his interests in fossils, archaeology and anthropology.

https://www.theguardian.com/inequality/2018/sep/18/kate-pickett-richard-wilkinson-mental-wellbeing-inequality-the-spirit-level?

 Editor's Note:

 

 I've included this book review of "The Inner Level" from The Guardian because it deals with one of the underlying pathologies of our society - the growing inequality of income and wealth and its effects on our physical and mental health. 

One question Pickett and Wilkerson do not deal with (as this book seems to focus on the UK)  is how much the US healthcare system itself is contributing to that inequality by transferring wealth and income from those who buy health care to those selling it. As our healthcare spending in the US approaches 20% of rhe GDP, that contribution must be significant. Perhaps we're reaching the point (if we're not already there) when our healthcare system is creating more illness than it's curing.

-SPC