Health Care Reform Articles - April 19, 2019

I agree with Angus King on health care — sort of

by Philip Caper - Bangor Daily News -  April 17, 2019

I agree with Sen. Angus King’s frustration, expressed in his March 31 BDN OpEd, with the seemingly endless debate about how best to provide access to health care to all Americans. I have known King for more than 40 years, dating back to the time we were both on the staff of the U.S. Senate. In general, I agree with King’s politics, and admire his skills as a politician. But in the case of the debate about health care, I disagree with his analysis.

In his OpEd, King decries the Groundhog Day nature of our national health care debate, yet advocates putting yet another patch on the Affordable Care Act rather than replacing it with something better.

He writes, “The ACA isn’t perfect, but it’s made people’s lives better, and that’s worth building on by making simple fixes around the edges rather than tearing it apart or repealing it entirely.” His sentiment is a noble one. But, as Albert Einstein once put it, “The definition of insanity is doing the same thing over and over again and expecting different results.” There have been many attempts to patch up our insurance-and-market-based system. All have failed.

In Maine, Dirigo Healthcare is a prime example. It was launched in 2003 by then-Gov. John Baldacci but never achieved its coverage goals and was allowed to sunset in 2014 by Baldacci’s successor, Gov. Paul Le Page — with hardly a whimper from the public.

In Massachusetts, Romneycare achieved better coverage than did Dirigo, but it has failed to reign in out-of-control health care costs. As a result single-payer health care bills have once again been introduced in the Massachusetts Legislature.

Patching our fundamentally flawed insurance-based system will not solve our health care problems. The problem is not one of designing better insurance, because insurance itself is the problem.

Medical underwriting, the fundamental business of commercial insurance, is all about finding ways to discriminate against sick people or those who are likely to become sick, in order to increase shareholders’ profits. Do we really want a health care financing system that discriminates against sick people? We need to create a system better than insurance.

The ACA lacks adequate cost controls when we’re already spending too much and getting poor results for our money. Furthermore, patches to the ACA will do nothing to fix the extreme fragmentation of our current health care system. That would only contribute to the ongoing confusion and polarization about health care reform that have created our current political gridlock.

Improved Medicare for all would introduce sorely lacking budgets into every level of the system, going a long way toward controlling out-of-control health care costs. And a gradual transition to a new and better system can limit the disruption that is inevitable with any change of this magnitude.

King is a very smart and thoughtful politician with a sophisticated understanding of the complexities of American health care. But on this issue he’s a bit too cautious. He has yet to endorse improved Medicare for all, the one solution that would put an end to his Groundhog Day.

Winston Churchill once said, “Americans will always do the right thing, once they’ve exhausted all alternatives.” Now is the time.

Philip Caper of Brooklin is an internist and founding board member of Maine AllCare.

https://bangordailynews.com/2019/04/17/opinion/contributors/i-agree-with-angus-king-on-health-care-sort-of/ 

Bernie Sanders Has an Important Lesson for Republicans

by Peter Suderman - NYT - April 10, 2019

Last week, Bernie Sanders released the latest version of his “Medicare for all” plan, which would establish a federally run single-payer system to finance care for everyone in the United States. The plan has changed little from its previous iterations, but there is one crucial difference: This version is backed by several of Mr. Sanders’s rivals for the Democratic presidential nomination.
Republicans are, by most appearances, thrilled — or at least relieved — to be running against Mr. Sanders and his plan, which would wipe out most private health insurance coverage, with prominent Republican politicians from President Trump on down taking repeated swipes at the idea.
But rather than simply mocking him, Republicans should take a minute to learn from what he has accomplished, and how. You don’t have to support single payer — I certainly don’t — to see that Mr. Sanders has been remarkably successful as a policy entrepreneur.
Working as an outsider over the course of a long political career, he has moved a sweeping and radical idea into the mainstream of Democratic policymaking. In doing so, he has modeled a certain kind of tenacious political salesmanship, using the Senate and his presidential campaigns as platforms to advance a major policy idea without initial backing from party leadership.

Few if any legislators on the right are attempting anything comparable. And yet they could. The strategies Mr. Sanders employed would be available to any Republican or independent right-of-center politician inclined to use them.
First, and most important, he had a clear vision, and he has tirelessly made the case for that vision and the benefits he believes it will provide: coverage for everyone, no premiums or co-payments, no maze of insurance paperwork to navigate. When Mr. Sanders talks about Medicare for All, he doesn’t treat it as a bureaucratic system, a complex piece of legislation to be explained. Instead, he is relentlessly focused on why he believes his ideas would improve the lives of ordinary voters.
That persistence is another of Mr. Sanders’s strengths. The latest version of his Medicare for All legislation is the fifth iteration, a sign of his long-term commitment not only to the broad strokes of the idea but also to legislation that gives it shape and form. Building on the democratic socialist politics of his youth, he has been pushing for government-run universal coverage for years, even in the face of considerable resistance from the Democrats he has caucused with.
That, too, accounts for some of his success: Mr. Sanders, probably the nation’s most successful independent politician, has not been afraid to oppose Democratic Party leadership or work outside of traditional partisan power structures. Instead, over the years, he has built his own base of political power, including the Congressional Progressive Caucus, a group for liberal legislators that he helped found and led in the 1990s. In the process, he has helped promote others who share his ideas and can echo and amplify his message — lawmakers like the co-chairwoman of the Progressive Caucus, Representative Pramila Jayapal, who recently introduced a single-payer plan that is, if anything, more far-reaching than Mr. Sanders’s.
The radicalism of single payer has long been seen as a drawback, but Mr. Sanders has arguably used it to his advantage. Instead of pushing for incremental tweaks, he has forced a broad discussion about upending the nation’s entire health care system in one fell swoop. In fact, he has recently rejected some of the more incrementalist tweaks to Obamacare favored by party leadership.

Mr. Sanders has paired his radicalism with transparency and a willingness, at least up to a point, to talk about some of the trade-offs his plan would require. He has been blunt about the fact that his plan would largely eliminate private insurance and has argued that this is both necessary and good.
At the same time, he has left some of the most difficult policy questions open for discussion — in particular the problem of how to finance the significant increase in government spending that Medicare for all would entail. Here, his strategy seems to be to open the floor for discussion, allowing third parties to present various ideas, and then see which ones, if any, take hold.
In the end, it may still not be enough. A full-fledged Sanders-style single payer system is almost certainly too disruptive, too fiscally burdensome, too big a political lift, at least for the foreseeable future. And Mr. Sanders’s brand of cantankerous democratic socialism would pose real risks if he was installed in the presidency, where he would be expected to manage and govern rather than simply campaign.
Yet even in defeat, he is likely to come out ahead. Over the past several years, he has pushed Democrats in Congress and the progressive policy apparatus — think tanks, activist organizations, academic influencers — to think seriously about ways to move closer to his goal, laying the groundwork for a big health care push at the next opportunity. Democrats may not follow his exact plans, but the party is now chasing his vision.
Mr. Sanders doesn’t deserve all the credit for Democrats’ leftward turn, but he was ready and waiting when it happened. And he has thus provided Republicans and others on the right with a model — not of policy design, but of legislative advocacy, of using the power of the Senate and a presidential campaign to build support for a major substantive idea.
Republicans have, on occasion, pressed similarly to bring issues to the fore — think of Rand Paul’s opposition to federal surveillance policy. But there’s no Republican who has played a similar role on health care, and none who appears poised to do so. And any Republican lawmaker who wanted to do so would need to have a big idea, like, say, the conservative health analyst Avik Roy’s plan to restructure Medicare, or the Cato Institute health policy scholar Michael Cannon’s idea for large, tax-free health savings accounts.
Instead, Republicans tend to work within the system, defer to leadership and duck difficult questions about trade-offs. Needless to say, there’s hardly a policy vision to guide them.
But if Republicans want to become, as President Trump says, the “party of health care,” Mr. Sanders has demonstrated the sort of long-term, dogged effort it is likely to take. His single-payer plan may thus prove to be a gift to Republicans in more ways than one.
Peter Suderman is the features editor at Reason.
https://www.nytimes.com/2019/04/15/opinion/bernie-sanders-republicans.html?smid=nytcore-ios-share

Medicare for All: Accept no substitutes

by Richard Eskow - Nation of Change - April 15, 2019

Last week, Sen. Bernie Sanders (I-VT) introduced the Medicare for All Act of 2019. A companion bill of the same name has already been introduced in the House by Rep. Pramila Jayapal (D-WA). That’s good news for the country. Unfortunately, these bills are facing opposition from what, for some people, will be an unexpected direction.
I don’t mean Republicans. They’ve already lost the health care debate, in one sense, now that large majorities of voters support Medicare for All. The real threat may well come from its friends. They’re the people who say they support Medicare for All’s “goals,” but claim to have found a better way to achieve them.
Intentionally or not, Medicare for All’s “frenemies” are sowing confusion about it. Among them is Ezekiel Emmanuel, who argues, “At least four different approaches to health reform could truthfully carry the Medicare for all label.”
Why would that be so? The term was crafted by Sanders, Jayapal, and their allies to describe a single-payer system, administered by the government, with no co-payments or deductibles, and without the participation of private insurers.
To be sure, the idea’s frenemies have added to the chaos. A variety of watered-down alternatives to Medicare for All have been proposed, most with names that sound like “Medicare for All”: “Medicare X,” “Medicare Extra for All,” “Medicare for America” … (I’m still waiting for a proposal called “I Can’t Believe It’s Not Medicare for All!”)
These plans are Medicare for All decoys. They claim to resemble Medicare for All, at least in their outcomes, but they’re not. Each depends on some naive combination of employer cooperation, insurance company goodwill, “smart shopping,” and Rube Goldberg-like fiscal contraptions. Each would continue to force working Americans to spend thousands of dollars on premiums, copays, and deductibles, at a time when most families say they’d have trouble finding $1,000 to cover an emergency.
Worst of all, each would allow insurance company cheating, preventable suffering, bankruptcies, and needless deaths to go on year after year.
“It turns out that most people don’t really know what Medicare for all means,” write Austin Frakt and Aaron E. Carroll. They’re speaking, in large part, about health policy types. But health policy experts, of all people, should be able to distinguish between these proposals and the Sanders/Jayapal plan.
The Urban Institute’s Linda Blumberg even goes so far as to argue that the “Medicare for All” label is a “misnomer.” Speaking to Fierce Healthcare, an industry publication, Blumberg argues that the Sanders/Jayapal program would require a massive new administrative structure, adding: “The idea behind these bills is to eliminate the current Medicare program and put them in something new.”
Unfortunately, neither statement is defensible. Medicare’s administrative systems are, for the most part, already in place. And it’s misleading to argue that Medicare for All would “eliminate” the current Medicare system. It would keep and enhance its positive features, while eliminating the out-of-pocket costs and administrative challenges that bedevil so many of its current recipients. Worse, the word “eliminate” is likely to sow unfounded panic among fearful elders.
Medicare for All would eliminate private insurers from the current Medicare system, which is presumably part of Blumberg’s expressed concern. But that isn’t likely to be disruptive for enrollees, since the benefits they’ll receive under the new plan will be much better than those they currently receive through private insurers – without the complicated paperwork – eliminating the need for private add-ons.
Medicare for All’s Democratic opponents also attack it on political grounds. They argue that public support for Medicare for All is illusory. That argument largely relies on a survey by the Kaiser Family Foundation (KFF), which found that support for the idea dropped when people learned more about how it would work.
But that poll was highly flawed, for reasons I discussed at length here, and inadvertently misled interviewees about the proposal. (To its credit, KFF has indicated to me and others that it intends to ask better and more detailed questions in the future.)
To many of Medicare for All’s frenemies, however, these flawed findings have taken on the quality of holy writ. Why? Confirmation bias, perhaps, or to win an argument?
The “frenemies” argue that people don’t picture the Sanders/Jayapal plan when they tell pollsters they support Medicare for All. But it seems unlikely that voters are picturing a system that still includes complicated forms, a “marketplace” of incomprehensible choices, supplemental insurance plans at extra cost, gaps in pharmaceutical coverage, high out-of-pocket costs, or the other encumbrances Medicare for All would eliminate.
Most of these concessions to the private sector are invisible to people until they enter the thicket of Medicare enrollment. What most people hear when they hear the word “Medicare” – its essential “Medicare-ness,” if you like – is almost certainly a government-run program that provides health care to everyone, with access to the providers of their choice.
When opponents like Emmanuel argue that Medicare for All is “the most politically impractical” of all the proposals on the table, it’s important to remember two things: First, they have no expertise in politics. They’re out of their lane. Secondly, their political track record isn’t very impressive. They misread the depth of opposition to the ACA, for example, and failed to predict the surge in support for Medicare for All.
Neither Medicare for All nor its alternatives will pass the current Senate, so we need a plan that will help shift political power. Medicare for All is compelling enough to do that in a way that the weaker alternatives aren’t. More importantly, it’s better policy.
There’s only one Medicare for All plan, and it deserves widespread support – from its friends, its current enemies, and all the people in between.
https://www.nationofchange.org/2019/04/15/medicare-for-all-accept-no-substitutes/

Maine Democrats are fighting to lower prescription drug costs

 by Troy Jackson - Bangor Daily News - April 16, 2019

A prescription is more than just a piece of paper. For some, it’s a pathway to living a better life. For others, it’s a pathway to stay alive. But that piece of paper is worthless if you can’t afford your medication and for too many Mainers the cost of prescription drugs is out of reach.

In Maine, a single vial of insulin for someone living with Type 1 diabetes is about $450, which means some Mainers pay thousands of dollars a month for a medicine that helps them stay alive. Across the Saint John River, in Canada, the same vile of insulin costs about $20. That’s outrageous and it’s only part of the problem.

There’s no reason Mainers should have to pay more for prescription medicine than our Canadian neighbors. There’s also no reason families should be stuck choosing between lifesaving medicine and basic essentials such as groceries and heating oil. Solving this crisis is complicated but the core issue isn’t.

The high cost of prescription drugs in this state and country is driven by greed.

With our bold reform package, Democrats in the Maine Legislature are fighting this issue from all angles. We’re working to make prescription drugs more affordable and more accessible while holding corporations and middlemen behind these high prices accountable.

The first set of bills deal with importing prescription drugs from Canada, a country with similar quality and safety standards. I’ve introduced two bills to make it legal to do what many consumers are already doing — ordering the same drug they would get in Maine from a Canadian pharmacy for a fraction of the cost. And who can blame them? Other states are already looking into this.

These bills will provide some relief but importation is only a piece of the puzzle. The more you examine the prescription drug crisis, the more you find corporate interests profiting at the expense of real people.

Take pharmacy benefit managers (PBMs) for example. Ever heard of them? Most people haven’t. And they like it that way.

PBMs are middlemen in the prescription drug world. They’re behind decisions about which drugs are covered by your health insurance and how much you have to pay. But the system is rigged. The higher the price a manufacturer sets for a drug, the more PBMs stand to make. And all the secrecy makes it difficult to determine how much PBMs add to the cost. This is why Sen. Heather Sanborn has introduced legislation to ensure the savings PBMs claim to generate are passed to the consumer.

Another bill from Sen. Eloise Vitelli focuses on drug pricing transparency. Her bill will gather more information from drug companies to understand how much it costs to make the medicine and how companies price medicine.

There will be public hearings on these proposals next week, on April 16 and 17. I hope that you’ll be there – to share your story and testify in favor of these bills. We know that “Big Pharma” will be there fighting to block any major reform.

Make no mistake: “Big Pharma” has a lot to lose and they and other groups aren’t going to go quietly. Drug companies are selling almost half a trillion dollars’ worth of prescription drugs a year — and that means big profits they don’t want to give up. PhRMA — the lobbying group that represents these massive drug companies — has collected hundreds of millions of dollars to fight common-sense reforms.

Judging by their record, they’ll try to scare consumers into thinking any change or reform will result in horrible outcomes. It’s what they did in Vermont, where a drug importation bill passed last year, and it’s what they are doing now in Florida. But the reality is, the biggest danger our reform bills pose is to “Big Pharma,” which might not be able to rake in extreme profits next year.

For years, I’ve watched friends, families and neighbors struggle to pay for their prescription medicine. It’s hard to see, and I’m not someone who can sit by and let it get worse. I’m prepared to fight with everything I’ve got to lower the cost of prescription drugs for Maine people. That’s my commitment to you.

Troy Jackson of Allagash is president of the Maine Senate.

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https://bangordailynews.com/2019/04/10/opinion/contributors/maine-democrats-are-fighting-to-lower-prescription-drug-costs/

Socialist! Capitalist! Economic Systems as Weapons in a War of Words

by Andrew Ross Sorkin - NYT - April 19, 2019

Joseph Stiglitz settled into a booth at his favorite diner on the Upper West Side last week with a curious, almost satisfied smile on his face.
He won a Nobel Prize nearly two decades ago for identifying the inequities and imperfections in market economies and has spent a career warning of the perils of wealth concentration, railing against monopoly power and championing higher taxes.
At last, a lot of people seem to be listening.
“It’s been a long fight,” he said.
The cause has been taken up by the new stars of the left, like Representative Alexandria Ocasio-Cortez, and can trace much of its current momentum to the rumpled rabble-rousing of Senator Bernie Sanders. The policy points Mr. Stiglitz talks about — a higher minimum wage, a public option for health insurance and more — could just as easily come from the mouths of any of those seeking to unseat President Trump in 2020.
And yet they demonstrate how the words we choose to talk about our economic priorities are almost as important as the priorities themselves.

Last year, for the first time in a decade, a Gallup poll showed that Democrats had a more positive view of socialism than they did of capitalism. Those two words may play a pivotal role in our next election: Some Democrats have embraced the label of socialist, one long attacked by Republicans. And even some of those who have profited most from American-style free markets have worried about their sustainability, with the billionaire investor Ray Dalio going so far as to say that “capitalism is broken.”
Mr. Stiglitz, stabbing his fork into his salad, said he believed there had been a critical misunderstanding of the terms themselves — and the economic theories behind them — that had allowed for their weaponization.
“The meanings of the words have changed over time,” said Mr. Stiglitz, the chairman of the Council of Economic Advisers under President Bill Clinton and a former chief economist of the World Bank. And the words have become the subject of a branding battle crossing political and generational divides.
The professor in Mr. Stiglitz launched into a history lesson that reached back to the early 20th century, about how socialism and communism became linked. And he made the case that Mr. Sanders, a self-described democratic socialist, wasn’t actually a socialist — at least as the identity has long been defined.
Mr. Sanders’s agenda — which drew a fair share of cheers during a Fox News town hall this week — is not focused on “ownership of the means of production” or a statist system, Mr. Stiglitz said. “He’s really concerned about the social contract of health, education,” he added.

It is not surprising that Mr. Sanders’s supporters trend young, a group for which the word “socialism” holds no fears of conflict with the Soviets or baggage associated with the Berlin Wall.
“Some people are trying to attach more emotions to the historical legacy of socialism, which was never the same as communism, but in the United States those distinctions have gotten blurred,” Mr. Stiglitz said.
The attacks from the right have been anything but subtle. Just this month, Mr. Trump declared, “We’re going into the war with some socialists.” And Republicans have posited that Venezuela’s challenged economy is the inevitable result of any movement in the policy directions embraced by the left.
The word leaves a bad taste even in the mouths of many on the left, including Nancy Pelosi, the speaker of the House, who lived through the height of the Cold War. “I do reject socialism as an economic system,” she said on “60 Minutes” last weekend. “If people have that view, that’s their view. That is not the view of the Democratic Party.”
(In Europe, Mr. Stiglitz said, similarly minded politicians might rightly be called social democrats. A simple switch in word order emphasizes the “social” instead of “socialist.”)
It all comes back to semantics, Mr. Stiglitz said. And perception was on his mind when titling his new book, “People, Power and Profits: Progressive Capitalism for an Age of Discontent,” which is to be published next week.
In it, he maps out a plan that he calls a “social contract” to improve jobs, health, education, housing and retirement. In fact, it wouldn’t be surprising if it turned into the economic platform for a presidential candidate.

Mr. Stiglitz proposes using a combination of market forces and government nudges — a higher minimum wage and an expanded earned-income tax credit, for example — to help the poorest among us. He also supports a “public option” to improve competition in the private sector in areas like health care and even retirement savings.
That’s not to say he views government as a panacea. For example, he wants to see the mortgage industry privatized. “In a private-sector economy, to have this huge piece of the economy that’s not run by the private sector is odd,” he said. Still, he also recommends a public option so that the government could support the mortgage market in certain cases.
Mr. Stiglitz said he had chosen “progressive capitalism” for his book’s title because he worried about triggering a visceral reaction to the word “socialism.”
“I’m trying to avoid some of the emotions that are still attached,” he said. “I try in my title to use progressive capitalism to try to say I believe in a market economy, but I also believe in government regulation.”
Even as popular figures on the left have embraced the label of socialist — Ms. Ocasio-Cortez is a member of the Democratic Socialists of America — others have sought, like Mr. Stiglitz, to underscore their capitalist views. Pete Buttigieg, the mayor of South Bend, Ind., who formally announced his candidacy for president this week, calls himself a proponent of “democratic capitalism.”
If the evolving meaning of socialism strikes you as an inventive bit of rebranding, Mr. Stiglitz believes the conservative idea of American capitalism as an unfettered free-market system is itself a myth.
“There is no Darwinian capitalism,” he said. “Everybody would say you need some degree of regulation of banks. I mean, no one is talking about real laissez-faire banking.”

Even the word “capitalist” has evolved, Mr. Stiglitz said. It is only since the late 20th century and the rise of the economist Milton Friedman, he contends, that “capitalist” stopped being a dirty word. It was once used in what he called “a pejorative way.”
Capitalists were “people who were exploiting workers,” he said.
That is an opinion, of course. And it is a view that is not hard to come by in some circles now, either.
Language changes, and as convenient as it can be to use linguistic shorthand, it’s important to remember that beneath the words are ideas — the things we should be talking about.
https://www.nytimes.com/2019/04/19/business/dealbook/socialism-bernie-sanders-joseph-stiglitz.html?smid=nytcore-ios-share