Are Americans just too different to ever finally adopt publicly-funded
universal healthcare?
By Henry Broeska, July 12, 2019
Over the past few years I’ve frequently been asked by some of my American colleagues whether or not I believe single payer healthcare — the way Canada came to adopt it — has a chance of success in the United States. Just as the Medicare-for-All movement is gaining momentum, there remains substantial public opposition to it in many quarters. My friends point out that if it was ever to happen, it would have happened by now — that Canadians have been socialized differently and therefore are more approving of a public universal healthcare system. After all, Canadians enthusiastically accepted their form of Medicare without any of the political wrangling that has characterized American attempts to achieve it over the past 75 years. All good points.
I think most people assume that Canadians are just a sub-group of Americans with the same core beliefs anyway. Because I’ve lived and worked in both countries, I’m acutely aware of the significant social divide that exists between Canada and the US. But there’s nothing to prevent Americans from passing Canadian-style healthcare reform legislation if that’s what they want, right? Nevertheless, the question still nagged at me — “What if my friends are right,” I thought. “What if universal, publicly-funded healthcare can’t be achieved because of an important way Americans are different than people in other countries?”
I concluded that I was probably too biased to answer that question without developing a thesis. I needed to spend some time examining the crucial differences between Canadians and Americans that may expose an inconvenient truth: that any broad-based national consensus on a publicly-funded, single payer healthcare program may not be possible. And even if by the collective will of voters, the greatest policy change in American history occurs, there is sure to be intense and continuing opposition to it. In our divided country, laws that can be made in one political cycle can be abolished in the next by the opposing party or ideologically-motivated courts. So in looking at this question, I decided to start with the documents that gave each country its laws.
Merciless Indian Savages
A nation’s fundamental beliefs are the values and sentiments it formally articulates in its constitution. And it’s also where we find the first major difference between Canada and the US.
In 1984, the new Canadian Constitution identified “peace, order, and good government,” (this was language lifted directly from the antecedent British North America Act of 1867) 1 as the three guiding principles held to be the nation’s highest ideals. Two hundred years earlier, the United States framed “Life, Liberty and the pursuit of Happiness” as “unalienable rights” held to be “sacred and undeniable.”
Canadians more or less live up to the three less dramatic and achievable precepts written into their Constitution. In contrast, the American ideal is both aspirational and
By Henry Broeska, July 12, 2019
Over the past few years I’ve frequently been asked by some of my American colleagues whether or not I believe single payer healthcare — the way Canada came to adopt it — has a chance of success in the United States. Just as the Medicare-for-All movement is gaining momentum, there remains substantial public opposition to it in many quarters. My friends point out that if it was ever to happen, it would have happened by now — that Canadians have been socialized differently and therefore are more approving of a public universal healthcare system. After all, Canadians enthusiastically accepted their form of Medicare without any of the political wrangling that has characterized American attempts to achieve it over the past 75 years. All good points.
I think most people assume that Canadians are just a sub-group of Americans with the same core beliefs anyway. Because I’ve lived and worked in both countries, I’m acutely aware of the significant social divide that exists between Canada and the US. But there’s nothing to prevent Americans from passing Canadian-style healthcare reform legislation if that’s what they want, right? Nevertheless, the question still nagged at me — “What if my friends are right,” I thought. “What if universal, publicly-funded healthcare can’t be achieved because of an important way Americans are different than people in other countries?”
I concluded that I was probably too biased to answer that question without developing a thesis. I needed to spend some time examining the crucial differences between Canadians and Americans that may expose an inconvenient truth: that any broad-based national consensus on a publicly-funded, single payer healthcare program may not be possible. And even if by the collective will of voters, the greatest policy change in American history occurs, there is sure to be intense and continuing opposition to it. In our divided country, laws that can be made in one political cycle can be abolished in the next by the opposing party or ideologically-motivated courts. So in looking at this question, I decided to start with the documents that gave each country its laws.
Merciless Indian Savages
A nation’s fundamental beliefs are the values and sentiments it formally articulates in its constitution. And it’s also where we find the first major difference between Canada and the US.
In 1984, the new Canadian Constitution identified “peace, order, and good government,” (this was language lifted directly from the antecedent British North America Act of 1867) 1 as the three guiding principles held to be the nation’s highest ideals. Two hundred years earlier, the United States framed “Life, Liberty and the pursuit of Happiness” as “unalienable rights” held to be “sacred and undeniable.”
Canadians more or less live up to the three less dramatic and achievable precepts written into their Constitution. In contrast, the American ideal is both aspirational and
hypocritical. To begin with, slavery was legal in all 13 colonies that formed the union
around the time those words were written and didn’t disappear in the southern states
until after the Civil War.
I have some questions of the men who wrote those words because I don’t know what they mean. Were black slaves considered in the “liberty” and “happiness” directives? That is, were they considered to be “human?” Did the concept of “unalienable rights” apply to the “merciless Indian savages” — also a three-word term, there for all to see forever in the language of the Declaration of Independence? While it took a bloody civil war to erase slavery, racial injustice has never disappeared. Jim Crow laws 2 were encoded in the law for a century after the American Civil War. And almost two and a half centuries later, the average black family in America is still ten times poorer 3 than the average white family.
Meanwhile, north of the border, Canada wasn’t challenged by the need to invent a constitution by way of revolution as was the US. Neither did the country build its economy on the backs of slaves. After 1783, British North America remained steadfastly British with close societal and legal ties to England right up through the mid-twentieth century. The English class system very much dominated the Canadian social structure with political roles for the elites. Its laws remained faithful to the continuation of British colonial culture. Peace and order through respectful, dignified, and reserved behavior were prized above all other traits. Canadian separation from Britain occurred gradually through negotiations, and without the need for a violent ‘Revolution.’
I have some questions of the men who wrote those words because I don’t know what they mean. Were black slaves considered in the “liberty” and “happiness” directives? That is, were they considered to be “human?” Did the concept of “unalienable rights” apply to the “merciless Indian savages” — also a three-word term, there for all to see forever in the language of the Declaration of Independence? While it took a bloody civil war to erase slavery, racial injustice has never disappeared. Jim Crow laws 2 were encoded in the law for a century after the American Civil War. And almost two and a half centuries later, the average black family in America is still ten times poorer 3 than the average white family.
Meanwhile, north of the border, Canada wasn’t challenged by the need to invent a constitution by way of revolution as was the US. Neither did the country build its economy on the backs of slaves. After 1783, British North America remained steadfastly British with close societal and legal ties to England right up through the mid-twentieth century. The English class system very much dominated the Canadian social structure with political roles for the elites. Its laws remained faithful to the continuation of British colonial culture. Peace and order through respectful, dignified, and reserved behavior were prized above all other traits. Canadian separation from Britain occurred gradually through negotiations, and without the need for a violent ‘Revolution.’
Already we see a large gap opening on our Canada/US cultural variation scale.
“Canada is the only country in the world that has learned to live without an identity.” ― Marshall McLuhan
Early Canadians, mostly of North England and Scottish heritage, were religious, hard- working, stoic and rigidly conformist. Despite all efforts, from the 1600s right through the late 1800s, it was by no means a safe bet that Canada as a country would endure. For example, new public infrastructure had to be built over wild, vast, and unpopulated landscapes. Canada wouldn’t have been able to maintain its country status without nearly impossible engineering feats. Survival in an inhospitable northern climate meant that people had to cooperate in every area of society — for the common good.
While Canadians were practicing their English sensibilities and cooperating as a social survival strategy, Americans were behaving much differently. Colonial brutality towards other cultures seems to be historically forgotten, or ‘reframed’ as justifiable while never recognizing the hypocrisy of labelling Native Americans “merciless Indian savages.” 4 Harvard Professor Bernard Bailyn has devoted an entire book to historical violence visited upon other cultures going back to America’s earliest days. He believes that the “peaceful Pilgrims” set the tone for all future American behaviors. In recalling accounts of the Pilgrim’s systematic extermination and enslavement of the Pequot Tribe of Native Americans in Connecticut, he says: “a legacy of brutality in intercultural relations developed through this period of which, of course, the overwhelming legacy was slavery.” He went on to add, that with these early acts of savagery, “The rules for chattel slavery were set.” 5
The American perspective: owning a gun is a right; access to healthcare is a privilege
Perhaps the most factious constitutional issue that survives today is the uniquely American right that allow individuals to own firearms. Constitutionally protected ‘gun rights’ are representative of the important way Americans are different than any other people on the planet. There was a time when guns were a necessity for rural-based people. Historically, Canadians as much as Americans used guns as readily as plows or pitchforks as tools to settle their expanding frontiers. But that need for guns ended for urbanized Canadians in a way it didn’t end in the US. So what do guns have to do with healthcare?
‘Healthcare’ too is an important right written into many modern constitutions after the passage of the United Nations’ Universal Declaration of Human Rights (UDHR) in 1948. Modern medicine had advanced to the point that after 1948, many countries’ constitutions were either written anew or updated to reflect healthcare as a human right. But the US Constitution wasn’t amended even though ‘healthcare’ as it is practiced today didn’t exist in 1776. Two centuries ago, primitive medical practices couldn’t be relied upon to cure diseases or save lives. The founders couldn’t have known of the future importance of ‘healthcare.’ On the other hand, gun rights today remain
“Canada is the only country in the world that has learned to live without an identity.” ― Marshall McLuhan
Early Canadians, mostly of North England and Scottish heritage, were religious, hard- working, stoic and rigidly conformist. Despite all efforts, from the 1600s right through the late 1800s, it was by no means a safe bet that Canada as a country would endure. For example, new public infrastructure had to be built over wild, vast, and unpopulated landscapes. Canada wouldn’t have been able to maintain its country status without nearly impossible engineering feats. Survival in an inhospitable northern climate meant that people had to cooperate in every area of society — for the common good.
While Canadians were practicing their English sensibilities and cooperating as a social survival strategy, Americans were behaving much differently. Colonial brutality towards other cultures seems to be historically forgotten, or ‘reframed’ as justifiable while never recognizing the hypocrisy of labelling Native Americans “merciless Indian savages.” 4 Harvard Professor Bernard Bailyn has devoted an entire book to historical violence visited upon other cultures going back to America’s earliest days. He believes that the “peaceful Pilgrims” set the tone for all future American behaviors. In recalling accounts of the Pilgrim’s systematic extermination and enslavement of the Pequot Tribe of Native Americans in Connecticut, he says: “a legacy of brutality in intercultural relations developed through this period of which, of course, the overwhelming legacy was slavery.” He went on to add, that with these early acts of savagery, “The rules for chattel slavery were set.” 5
The American perspective: owning a gun is a right; access to healthcare is a privilege
Perhaps the most factious constitutional issue that survives today is the uniquely American right that allow individuals to own firearms. Constitutionally protected ‘gun rights’ are representative of the important way Americans are different than any other people on the planet. There was a time when guns were a necessity for rural-based people. Historically, Canadians as much as Americans used guns as readily as plows or pitchforks as tools to settle their expanding frontiers. But that need for guns ended for urbanized Canadians in a way it didn’t end in the US. So what do guns have to do with healthcare?
‘Healthcare’ too is an important right written into many modern constitutions after the passage of the United Nations’ Universal Declaration of Human Rights (UDHR) in 1948. Modern medicine had advanced to the point that after 1948, many countries’ constitutions were either written anew or updated to reflect healthcare as a human right. But the US Constitution wasn’t amended even though ‘healthcare’ as it is practiced today didn’t exist in 1776. Two centuries ago, primitive medical practices couldn’t be relied upon to cure diseases or save lives. The founders couldn’t have known of the future importance of ‘healthcare.’ On the other hand, gun rights today remain
constitutionally entrenched just as if they are still essential to arm a civilian militia
made up of shopkeepers and farmers to protect a fragile nation.
Stone tablets
Fearing a breakdown of the political deals that aggregated the new states into a fledgling country, the founders made it effectively impossible to amend the US Constitution to reflect changes in society, even ones that demand a break with the past. The President recently justified continuing private ownership of assault weapons by saying that Americans need them for “entertainment” — a frivolous use that the founders never envisioned, and never would have endorsed. 6
Would the founders have added ‘healthcare’ had they been able to recognize its importance to a burgeoning nation? Did they mean for the constitution to remain unchanged for all time?
Without a need to defend against foreign threats, hunt food, or snipe varmints from the front porches of our urban homes, the country's historic need for guns has morphed into something else, something that exposes a darker side of American values today. My neighbor across the street in California recently confided that he owns dozens of handguns and assault weapons, and keeps them on his premises. He told me that he isn’t a collector, and he doesn’t feel threatened; in his words, “I just like guns.”
“The guns and the bombs, the rockets and the warships, are all symbols of human failure.” — Lyndon Johnson
In my observations I have come to believe that many Americans enjoy owning guns, not for reasons of need, principle, or self-defence, but because it is a kind of self- actualization. From an American perspective, “gun ownership is normative, not deviant behavior across vast swaths of the social landscape.” 7
I point out this difference because Canadians consider that using personal firearms outside of their limited, modern-day purpose is the ultimate aberrant behavior. In Canada, the number and type of guns owned by my neighbor would be a criminal matter. The police are the ones who are supposed to be armed to protect the country’s citizens. This belief makes for a rather orderly society with the capacity and prerogative to argue for constitutional rights that are more practical and socially useful — like healthcare.
“Polarizing people is a good way to win an election, and also a good way to wreck a country.” ― Molly Ivins
Americans have historically demonstrated a cycle of polarized opinions that results in catastrophic outcomes; a civil war, baseless foreign wars, assassinations of political figures, unstoppable domestic mass shootings, a continuation of racist policies, and complete gridlock in the political process. Most times the US Constitution is invoked as justification for one deviant action or another. Today, the United States is at the height
Stone tablets
Fearing a breakdown of the political deals that aggregated the new states into a fledgling country, the founders made it effectively impossible to amend the US Constitution to reflect changes in society, even ones that demand a break with the past. The President recently justified continuing private ownership of assault weapons by saying that Americans need them for “entertainment” — a frivolous use that the founders never envisioned, and never would have endorsed. 6
Would the founders have added ‘healthcare’ had they been able to recognize its importance to a burgeoning nation? Did they mean for the constitution to remain unchanged for all time?
Without a need to defend against foreign threats, hunt food, or snipe varmints from the front porches of our urban homes, the country's historic need for guns has morphed into something else, something that exposes a darker side of American values today. My neighbor across the street in California recently confided that he owns dozens of handguns and assault weapons, and keeps them on his premises. He told me that he isn’t a collector, and he doesn’t feel threatened; in his words, “I just like guns.”
“The guns and the bombs, the rockets and the warships, are all symbols of human failure.” — Lyndon Johnson
In my observations I have come to believe that many Americans enjoy owning guns, not for reasons of need, principle, or self-defence, but because it is a kind of self- actualization. From an American perspective, “gun ownership is normative, not deviant behavior across vast swaths of the social landscape.” 7
I point out this difference because Canadians consider that using personal firearms outside of their limited, modern-day purpose is the ultimate aberrant behavior. In Canada, the number and type of guns owned by my neighbor would be a criminal matter. The police are the ones who are supposed to be armed to protect the country’s citizens. This belief makes for a rather orderly society with the capacity and prerogative to argue for constitutional rights that are more practical and socially useful — like healthcare.
“Polarizing people is a good way to win an election, and also a good way to wreck a country.” ― Molly Ivins
Americans have historically demonstrated a cycle of polarized opinions that results in catastrophic outcomes; a civil war, baseless foreign wars, assassinations of political figures, unstoppable domestic mass shootings, a continuation of racist policies, and complete gridlock in the political process. Most times the US Constitution is invoked as justification for one deviant action or another. Today, the United States is at the height
of one of those cycles of polarized opinions that’s revealing the cruelty inherent in our
national personality.
Yet lawmakers continue to venerate the US Constitution as if it was Divine Law handed down by God on stone tablets. The divinity bestowed upon the US Constitution, the national values of violence and racism it maintains, the elite dominance of a minority over a majority, and the difficulty in ever changing it now reveals a much wider cultural gap between Canada and the US.
But wait. There’s more...
Canada’s great social experiment
Canadians have no history of clinging to constitutional ideals so tightly that it results in breakdowns of law and order or violence. But I believe it was the three constitutional principles of “peace, order, and good government” that might have predicted how universal healthcare came to happen.
Western Canada became a kind of Petri dish for Canada’s version of nation-building, and particularly, universal healthcare. By the time the transcontinental railroad had pushed west in the 1880s, Canada needed an immigration boom to populate the country and grow the economy. Fleeing the tyranny of communism and famine, western Canada was filled by non-English-speaking eastern and northern Europeans, mostly farmers. They found safe harbor on the rich agricultural soils of Manitoba, Saskatchewan and Alberta (collectively, the Prairie Provinces).
New Canadians were freely encouraged to practice their religions and cultures, but in terms of social order, it was decidedly British. The centuries-old colonialization practices of Britain were useful for achieving the civilizing mission in a domestic quasi- colonial setting — albeit with a Canadian flavor. The settlers learned English and British customs — while a photograph of the Queen beamed down on their children in every school classroom. No longer under despotic rule, the new equality they claimed allowed them to welcome the authority of Canada’s British version of government and Common Law, along with respect for its customs and social order.
The political power behind this Canadian experiment was always a self-proclaimed group of elites of mostly English and Scottish origin. There were well-heeled French- Canadian families in the mix. They bestowed upon themselves control of key Canadian industries; banking, grain, forestry, mining, oil and gas, transportation, and manufacturing. To this day, some have kept their hereditary peerage titles, a vestige of their British heritage. In future generations their sons, grandsons and great-grandsons still run the political bureaucracies as well as some of the academic institutions (the Trudeau family is an example Americans would recognize).
The social policies they brought forward tended to be for the common good, not themselves. This ‘common good’ focus took precedence over the ‘individual rights’ angle preferred in the United States and embraced in their constitution. Lest there be temptation to pass laws that benefitted the elite class over another, a new, highly-
Yet lawmakers continue to venerate the US Constitution as if it was Divine Law handed down by God on stone tablets. The divinity bestowed upon the US Constitution, the national values of violence and racism it maintains, the elite dominance of a minority over a majority, and the difficulty in ever changing it now reveals a much wider cultural gap between Canada and the US.
But wait. There’s more...
Canada’s great social experiment
Canadians have no history of clinging to constitutional ideals so tightly that it results in breakdowns of law and order or violence. But I believe it was the three constitutional principles of “peace, order, and good government” that might have predicted how universal healthcare came to happen.
Western Canada became a kind of Petri dish for Canada’s version of nation-building, and particularly, universal healthcare. By the time the transcontinental railroad had pushed west in the 1880s, Canada needed an immigration boom to populate the country and grow the economy. Fleeing the tyranny of communism and famine, western Canada was filled by non-English-speaking eastern and northern Europeans, mostly farmers. They found safe harbor on the rich agricultural soils of Manitoba, Saskatchewan and Alberta (collectively, the Prairie Provinces).
New Canadians were freely encouraged to practice their religions and cultures, but in terms of social order, it was decidedly British. The centuries-old colonialization practices of Britain were useful for achieving the civilizing mission in a domestic quasi- colonial setting — albeit with a Canadian flavor. The settlers learned English and British customs — while a photograph of the Queen beamed down on their children in every school classroom. No longer under despotic rule, the new equality they claimed allowed them to welcome the authority of Canada’s British version of government and Common Law, along with respect for its customs and social order.
The political power behind this Canadian experiment was always a self-proclaimed group of elites of mostly English and Scottish origin. There were well-heeled French- Canadian families in the mix. They bestowed upon themselves control of key Canadian industries; banking, grain, forestry, mining, oil and gas, transportation, and manufacturing. To this day, some have kept their hereditary peerage titles, a vestige of their British heritage. In future generations their sons, grandsons and great-grandsons still run the political bureaucracies as well as some of the academic institutions (the Trudeau family is an example Americans would recognize).
The social policies they brought forward tended to be for the common good, not themselves. This ‘common good’ focus took precedence over the ‘individual rights’ angle preferred in the United States and embraced in their constitution. Lest there be temptation to pass laws that benefitted the elite class over another, a new, highly-
motivated democratic socialist political Party led by Tommy Douglas, an immigrant Scot
himself, kept them honest.
The concept of public universal healthcare was proven on the wheat fields of Saskatchewan using this cultural mixture of new Canadian immigrants. And it was Tommy Douglas, founder and first leader of the New Democratic Party (the NDP), who pioneered the first universal healthcare legislation in North America. There is little doubt that this is legislation that wouldn’t have been enacted without a democratic socialist perspective. Like the US, Canada had primarily a two-party system up until the formation of the NDP in the early 1960s. This third social democratic party, often called “Canada’s conscience,” 8 has no equivalent in the United States. The socially progressive policies that came out of the western Prairie Provinces allowed the Tommy Douglas-led federal New Democratic Party to force the national adoption of publicly- funded healthcare and many other social programs.
Progressive Canadian governments recognized that vulnerable people, through no fault of their own, cannot fully participate or progress if they cannot overcome their health problems. Not only was public universal healthcare the right thing to do, it was economically valuable for the country. An economic benefit/cost analysis demonstrated that universal healthcare saves money because healthy workers are happy and productive taxpayers, not a social burden. As a service to a grateful nation, there was really no argument that could be made against it.
Once universal healthcare was proven to work in Saskatchewan, the leaders of the three federal parties with opposite ideological beliefs saw that they had no choice but to work together to make it happen nationally. Medicare became so popular with Canadians that anything less than a ringing endorsement would have seen the dissenting party wiped off the political map.
Here in the US, the Progressive wing of the Democratic Party is just now starting to represent some of the policies of the Canadian NDP of 50 years ago. If Medicare-for-All is to happen, it will be this group of progressives who leads the way. They’ve got their work cut out for them. They are stuck inside a middle-of-the-road party that will prevent their most progressive ideas from ever becoming party policy. So how on earth will it be possible to convince an entire country to vote for radical health policy reform if they can’t get their party’s full backing?
This is the point at which the cultural gap between Canada and the United States really turns into a chasm. To complete the picture, I need to finally demonstrate that Canadian commitment to justice, fairness and equity go a lot further than health policy. What most Americans don’t understand about Canada would make their heads spin.
Pierre Trudeau’s “Just Society”
For Canadians, progressive policies didn’t end at universal healthcare. The Liberal government of the 1960s instituted some remarkable changes in the social order. The move to the left was not forced upon the country by disgruntled youth protesting a foreign war or marching against racial injustice. It was started by a new generation of
The concept of public universal healthcare was proven on the wheat fields of Saskatchewan using this cultural mixture of new Canadian immigrants. And it was Tommy Douglas, founder and first leader of the New Democratic Party (the NDP), who pioneered the first universal healthcare legislation in North America. There is little doubt that this is legislation that wouldn’t have been enacted without a democratic socialist perspective. Like the US, Canada had primarily a two-party system up until the formation of the NDP in the early 1960s. This third social democratic party, often called “Canada’s conscience,” 8 has no equivalent in the United States. The socially progressive policies that came out of the western Prairie Provinces allowed the Tommy Douglas-led federal New Democratic Party to force the national adoption of publicly- funded healthcare and many other social programs.
Progressive Canadian governments recognized that vulnerable people, through no fault of their own, cannot fully participate or progress if they cannot overcome their health problems. Not only was public universal healthcare the right thing to do, it was economically valuable for the country. An economic benefit/cost analysis demonstrated that universal healthcare saves money because healthy workers are happy and productive taxpayers, not a social burden. As a service to a grateful nation, there was really no argument that could be made against it.
Once universal healthcare was proven to work in Saskatchewan, the leaders of the three federal parties with opposite ideological beliefs saw that they had no choice but to work together to make it happen nationally. Medicare became so popular with Canadians that anything less than a ringing endorsement would have seen the dissenting party wiped off the political map.
Here in the US, the Progressive wing of the Democratic Party is just now starting to represent some of the policies of the Canadian NDP of 50 years ago. If Medicare-for-All is to happen, it will be this group of progressives who leads the way. They’ve got their work cut out for them. They are stuck inside a middle-of-the-road party that will prevent their most progressive ideas from ever becoming party policy. So how on earth will it be possible to convince an entire country to vote for radical health policy reform if they can’t get their party’s full backing?
This is the point at which the cultural gap between Canada and the United States really turns into a chasm. To complete the picture, I need to finally demonstrate that Canadian commitment to justice, fairness and equity go a lot further than health policy. What most Americans don’t understand about Canada would make their heads spin.
Pierre Trudeau’s “Just Society”
For Canadians, progressive policies didn’t end at universal healthcare. The Liberal government of the 1960s instituted some remarkable changes in the social order. The move to the left was not forced upon the country by disgruntled youth protesting a foreign war or marching against racial injustice. It was started by a new generation of
political intellectuals led by young Prime Minister Pierre Trudeau (father of current PM,
Justin). Trudeau had a vision for Canada, which he called a “Just Society.” 9 Upon
assuming the role of Prime Minister, his speech began with the words: “No one in the
society should be entitled to superfluous or luxury goods until the essentials of life are
made available to everyone.” It would be hard to imagine any American politician,
much less their nation’s leader ever making the same public commitment to equity.
Trudeau’s “Just Society” expression was not simply an opportune catch-phrase. Canada’s 60s shift toward liberalism engendered policies and practices that fundamentally changed Canada forever. As Americans struggled with their internal race relations, Trudeau’s government deliberately began welcoming more brown skinned people from around the world as it tried to secure the country’s economic future. As a first step to avoid the possibility of racial discrimination, the government formalized the policy of multiculturalism. 10 Trudeau’s government also redefined capitalism to mean social democracy, which is capitalism with an ambitious set of rules and social programs that safeguard the rights of subordinate social groups.
“The past is to be respected and acknowledged, but not to be worshipped. It is our future in which we will find our greatness.” — Pierre Trudeau
Other progressive Trudeau government programs were: subsidized secondary education and vocational training to stream young workers into the workplace; college and university tuition costs are a fraction of what they are in the US. Once graduates got into the workplace they were protected by strict anti-harassment and anti-discrimination laws with severe penalties for hate-speech and hate-crimes. Unemployment insurance benefits were expanded to match workers with a living wage for as long as they remained unemployed. Paid vacations became law, and sick days could be banked. For raising kids, there were a number of programs including a child tax credit, which is paid directly to parents to help defray the cost of raising each child. In addition, the government created federally-mandated paid maternal and paternal leave of 12-months. 11 Today there are many more health-related and social programs outside of the healthcare system itself. As long as I can remember, Canada has added, not subtracted social programs. Trudeau’s government or not, social equality has always been in Canada’s DNA.
Canadians understand that social prosperity isn’t simply a monetary measure of wealth or income. True prosperity in society is a collection of fair resolutions to the challenges that everyone faces from time to time. The aggregate wealth of the country must be applied to circumstances of need — and by the mid-twentieth century Canada had become one of the wealthiest countries in the world thanks to its hard-working people. All of these social programs are rewards for the people’s contributions to their country’s prosperity. They were designed to help all Canadians achieve full potential or catch them if they stumble — a kind of social contract.
The outcome of the Canadian experience has been a relatively un-stressed, compassionate and non-agitated national population. It highlights perhaps the most important difference between Canada and the US: Canadians are predisposed to trust
Trudeau’s “Just Society” expression was not simply an opportune catch-phrase. Canada’s 60s shift toward liberalism engendered policies and practices that fundamentally changed Canada forever. As Americans struggled with their internal race relations, Trudeau’s government deliberately began welcoming more brown skinned people from around the world as it tried to secure the country’s economic future. As a first step to avoid the possibility of racial discrimination, the government formalized the policy of multiculturalism. 10 Trudeau’s government also redefined capitalism to mean social democracy, which is capitalism with an ambitious set of rules and social programs that safeguard the rights of subordinate social groups.
“The past is to be respected and acknowledged, but not to be worshipped. It is our future in which we will find our greatness.” — Pierre Trudeau
Other progressive Trudeau government programs were: subsidized secondary education and vocational training to stream young workers into the workplace; college and university tuition costs are a fraction of what they are in the US. Once graduates got into the workplace they were protected by strict anti-harassment and anti-discrimination laws with severe penalties for hate-speech and hate-crimes. Unemployment insurance benefits were expanded to match workers with a living wage for as long as they remained unemployed. Paid vacations became law, and sick days could be banked. For raising kids, there were a number of programs including a child tax credit, which is paid directly to parents to help defray the cost of raising each child. In addition, the government created federally-mandated paid maternal and paternal leave of 12-months. 11 Today there are many more health-related and social programs outside of the healthcare system itself. As long as I can remember, Canada has added, not subtracted social programs. Trudeau’s government or not, social equality has always been in Canada’s DNA.
Canadians understand that social prosperity isn’t simply a monetary measure of wealth or income. True prosperity in society is a collection of fair resolutions to the challenges that everyone faces from time to time. The aggregate wealth of the country must be applied to circumstances of need — and by the mid-twentieth century Canada had become one of the wealthiest countries in the world thanks to its hard-working people. All of these social programs are rewards for the people’s contributions to their country’s prosperity. They were designed to help all Canadians achieve full potential or catch them if they stumble — a kind of social contract.
The outcome of the Canadian experience has been a relatively un-stressed, compassionate and non-agitated national population. It highlights perhaps the most important difference between Canada and the US: Canadians are predisposed to trust
authority and see government as a good thing, while Americans are suspicious of their
government and see it as a necessary evil.
Canada mirrors most other countries in the developed world. It’s the United States that is really quite different from the rest, and many of those differences end up producing negative and even life-threatening consequences for a growing number of people. While Canada is still broadening its social safety net, the United States is tearing theirs apart. Social welfare programs have been cut back and re-investment in education and infrastructure have been curtailed. Instead of keeping progressive taxation, the government has lowered taxes for the elite class. And while the US government promotes free market policies as a benefit to all, deregulation, de-unionization, and a declining manufacturing base have resulted in both wage decline and wage inequality. The current Administration’s disengagement of regulations, actions and policy changes will have negative social consequences for years, if not decades.
“Sadly, the American dream is dead.” — Donald Trump
Anger with a paralyzed American political system elected a demagogic President who successfully reflected that anger back upon a resentful white electorate as if it was consecration of their feelings. In doing so, for many, he turned himself into an untouchable folk hero who no can longer be judged on his corruption, his lies, his racism, or his immoral lifestyle of excess. Americans used to be famous around the world for their pragmatism and good old American ‘know-how.’ As social and political norms are shattered daily, the global perception of Americans is that they have become a highly agitated people with extreme views given to lunatic conspiracy theories.
Americans have been told that the biggest threat to the country is brown-skinned mothers and their children fleeing poverty and domestic terrorism and claiming asylum in the United States. While our attentions are being misdirected to the southern border, tens of millions of Americans struggle with paying their medical bills and getting timely access to treatments. Through it all we are warned daily that a public health insurance plan covering everyone will destroy our American way of life. (and that would be a bad thing, why?)
So misplaced is our anger towards new, protective social services, that it’s inevitable there will more venting and lashing out at attempts to create a national public health insurance scheme. It’s incredible to think that in a healthcare system as dysfunctional as this, many believe that a public plan will be worse. Unfortunately Americans conflate ‘social programming’ with ‘socialism.’ They don’t realize that invoking the term ‘socialism’ is a tried and true way for corporations and their political surrogates to keep the social order and maintain a particularly ugly brand of capitalism.
I hope this short discussion gives the reader a sense of how far out of touch the US is with the rest of the world. In times of prosperity, governments of most other developed nations work earnestly to provide more rights and protections for their citizens. A universal healthcare plan is the ultimate protection that developing countries strive to achieve for their citizens. But despite this time of unprecedented economic growth, that
Canada mirrors most other countries in the developed world. It’s the United States that is really quite different from the rest, and many of those differences end up producing negative and even life-threatening consequences for a growing number of people. While Canada is still broadening its social safety net, the United States is tearing theirs apart. Social welfare programs have been cut back and re-investment in education and infrastructure have been curtailed. Instead of keeping progressive taxation, the government has lowered taxes for the elite class. And while the US government promotes free market policies as a benefit to all, deregulation, de-unionization, and a declining manufacturing base have resulted in both wage decline and wage inequality. The current Administration’s disengagement of regulations, actions and policy changes will have negative social consequences for years, if not decades.
“Sadly, the American dream is dead.” — Donald Trump
Anger with a paralyzed American political system elected a demagogic President who successfully reflected that anger back upon a resentful white electorate as if it was consecration of their feelings. In doing so, for many, he turned himself into an untouchable folk hero who no can longer be judged on his corruption, his lies, his racism, or his immoral lifestyle of excess. Americans used to be famous around the world for their pragmatism and good old American ‘know-how.’ As social and political norms are shattered daily, the global perception of Americans is that they have become a highly agitated people with extreme views given to lunatic conspiracy theories.
Americans have been told that the biggest threat to the country is brown-skinned mothers and their children fleeing poverty and domestic terrorism and claiming asylum in the United States. While our attentions are being misdirected to the southern border, tens of millions of Americans struggle with paying their medical bills and getting timely access to treatments. Through it all we are warned daily that a public health insurance plan covering everyone will destroy our American way of life. (and that would be a bad thing, why?)
So misplaced is our anger towards new, protective social services, that it’s inevitable there will more venting and lashing out at attempts to create a national public health insurance scheme. It’s incredible to think that in a healthcare system as dysfunctional as this, many believe that a public plan will be worse. Unfortunately Americans conflate ‘social programming’ with ‘socialism.’ They don’t realize that invoking the term ‘socialism’ is a tried and true way for corporations and their political surrogates to keep the social order and maintain a particularly ugly brand of capitalism.
I hope this short discussion gives the reader a sense of how far out of touch the US is with the rest of the world. In times of prosperity, governments of most other developed nations work earnestly to provide more rights and protections for their citizens. A universal healthcare plan is the ultimate protection that developing countries strive to achieve for their citizens. But despite this time of unprecedented economic growth, that
is not happening in the United States. While offering no new programs or benefits, and
in fact, removing protections for the most vulnerable in our society, the current
leadership instead blames every past and future shortcoming in our country on
displaced people of color.
In such a collective confused, depleted and unresourceful state of being, the question remains whether Americans could ever agree to adopt a healthcare system like Canada’s, even if we know it saves lives, money, and a lot of needless pain. If we do, it will come to Americans in a much different way than it came to Canadians.
Perhaps we will have an age of enlightenment after the darkness of these past years, which will inspire a sea-change in thinking. But we can’t depend on that. Unfortunately, I believe that healthcare reform will only happen when enough Americans feel more pain. How many more and how much pain is the question. Far more educational work must be done before a national publicly-funded healthcare system will seriously be considered by either the American electorate or lawmakers.
Ultimately, it may come down to individual progressive states trying to save themselves if local lawmakers can loose themselves of their corporate masters. What the constitution takes away by allowing elite minority dominance, it also attempts to give back through states’ rights, a kind of local counter-balance to federal authority. This route hasn’t been tested before for such a major policy piece but because of the mighty corporate forces against the national Medicare-for-All movement, the only path to healthcare reform may well be through the states, just like it was through the provinces in Canada. But there the similarity ends. In the meantime it will take advocacy, activism, and eventually, mass civil disobedience to force healthcare reform. This does not preclude the possibility of violence. In America, ‘twas ever thus.
References
In such a collective confused, depleted and unresourceful state of being, the question remains whether Americans could ever agree to adopt a healthcare system like Canada’s, even if we know it saves lives, money, and a lot of needless pain. If we do, it will come to Americans in a much different way than it came to Canadians.
Perhaps we will have an age of enlightenment after the darkness of these past years, which will inspire a sea-change in thinking. But we can’t depend on that. Unfortunately, I believe that healthcare reform will only happen when enough Americans feel more pain. How many more and how much pain is the question. Far more educational work must be done before a national publicly-funded healthcare system will seriously be considered by either the American electorate or lawmakers.
Ultimately, it may come down to individual progressive states trying to save themselves if local lawmakers can loose themselves of their corporate masters. What the constitution takes away by allowing elite minority dominance, it also attempts to give back through states’ rights, a kind of local counter-balance to federal authority. This route hasn’t been tested before for such a major policy piece but because of the mighty corporate forces against the national Medicare-for-All movement, the only path to healthcare reform may well be through the states, just like it was through the provinces in Canada. But there the similarity ends. In the meantime it will take advocacy, activism, and eventually, mass civil disobedience to force healthcare reform. This does not preclude the possibility of violence. In America, ‘twas ever thus.
References
-
Gall, Gerald L. and A. Anne McLellan. "Peace, Order and Good Government". The
Canadian Encyclopedia, 26 October 2017, Historica Canada.
https://www.thecanadianencyclopedia.ca/en/article/peace-order-and-good-
government. Accessed 11 July 2019.
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Wikipedia contributors. (2019, July 8). Jim Crow laws. In Wikipedia, The Free
Encyclopedia. Retrieved 22:26, July 11, 2019, from
https://en.wikipedia.org/w/index.php?title=Jim_Crow_laws&oldid=905283086
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Jan, T. Black and Hispanic Families are making more money but they still lag far
behind whites. Washington Post 28 October 2017
https://www.washingtonpost.com/news/wonk/wp/2017/09/28/black-and-
hispanic-families-are-making-more-money-but-they-still-lag-far-behind-
whites/?noredirect=on&utm_term=.bc84bd8435ab
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Carocci, Max. “Written Out of History: Contemporary Native American
Narratives of Enslavement.” Anthropology Today 25, no. 2 (April 2009): 15–20.
Link.
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Rosenbaum R., The Shocking Savagery of America’s Early History. Smithsonian
Magazine. March 2013. https://www.smithsonianmag.com/history/the-
shocking-savagery-of-americas-early-history-22739301/?no-
ist=&=&page=3&webSyncID=ea1db281-38d6-4873-5437-20c4932ea9a7
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Christopher, T. Trump Says People Need Assault Weapons Used in Mass
Shootings for ‘Entertainment.’ Media ITE Jun 5th, 2019,
https://www.mediaite.com/news/trump-says-people-need-assault-weapons-
used-in-mass-shootings-for-entertainment/
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Wright, J. D. (1995). Ten essential observations on guns in America. Society,
32(3), 63–68.
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Bell, D. And now a word from our NDP conscience. The Globe and Mail.
Published April 12, 2011, updated May 3, 2018
https://www.theglobeandmail.com/news/politics/second-reading/and-now-a-
word-from-our-ndp-conscience/article613379/
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Wikipedia contributors. (2019, July 8). Just society. In Wikipedia, The Free
Encyclopedia. Retrieved 17:32, July 12, 2019, from
https://en.wikipedia.org/w/index.php?title=Just_society&oldid=905414153
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Wikipedia contributors. (2019, June 12). Multiculturalism in Canada. In
Wikipedia, The Free Encyclopedia. Retrieved 22:45, July 11, 2019, from
https://en.wikipedia.org/w/index.php?title=Multiculturalism_in_Canada&oldid
=901565586
- Government of Canada website. EI maternity and parental benefits: What these benefits offer. Retrieved July 11, 2019 https://www.canada.ca/en/services/benefits/ei/ei-maternity-parental.html
Erasing Obamacare Could Undermine Trump’s Own Health Initiatives
by Margot Sanger-Katz - NYT - July 11, 2019
In court, the Trump administration is trying to get all of Obamacare erased. But at the White House, President Trump and his health officials are busily using the law to pursue key proposals.
Last week, the president highlighted a policy in the works meant to narrow the gaps between what drugs cost in the United States and overseas. On Wednesday, he signed an executive order to transform care for patients with kidney disease.
Both measures were made possible by a provision in the Affordable Care Act, and both would be effectively gutted if the administration’s position prevailed in court.
In between, administration lawyers told a receptive panel of judges in New Orleans that the entire Affordable Care Act should be overturned.
Last week, the president highlighted a policy in the works meant to narrow the gaps between what drugs cost in the United States and overseas. On Wednesday, he signed an executive order to transform care for patients with kidney disease.
Both measures were made possible by a provision in the Affordable Care Act, and both would be effectively gutted if the administration’s position prevailed in court.
In between, administration lawyers told a receptive panel of judges in New Orleans that the entire Affordable Care Act should be overturned.
“What
they’re doing now is tolerating this ambiguity between the flat-out
rhetoric of ‘repeal Obamacare’ and the reality that they love many
aspects of what was enacted in the Affordable Care Act,” said Dan
Mendelson, the founder of the health care consulting firm Avalere
Health.
The crucial provision is known as the innovation authority. It allows Medicare and Medicaid to test strategies for paying for medical care in pursuit of ways to lower costs and improve the quality of care.
It is a very broad authority. Before Obamacare, most changes to Medicare required special legislation from Congress. Congress can move slowly, and medical industries tend to oppose provisions that would result in less spending on treatment. With the innovation authority, the Department of Health and Human Services can introduce various experiments, and it has the power to take successful pilot programs national, without involving Congress.
That’s a power that has been welcomed in an administration that has embraced broad executive power. Obama administration officials liked the innovation center power, too. But the Trump administration has gone further, experts said, in pursuing a variety of interesting ideas about how to reform health care delivery.
Alex Azar, the secretary of Health and Human Services, has pointed enthusiastically to this authority at times, telling reporters last year that his “pen has a lot of power.”
The crucial provision is known as the innovation authority. It allows Medicare and Medicaid to test strategies for paying for medical care in pursuit of ways to lower costs and improve the quality of care.
It is a very broad authority. Before Obamacare, most changes to Medicare required special legislation from Congress. Congress can move slowly, and medical industries tend to oppose provisions that would result in less spending on treatment. With the innovation authority, the Department of Health and Human Services can introduce various experiments, and it has the power to take successful pilot programs national, without involving Congress.
That’s a power that has been welcomed in an administration that has embraced broad executive power. Obama administration officials liked the innovation center power, too. But the Trump administration has gone further, experts said, in pursuing a variety of interesting ideas about how to reform health care delivery.
Alex Azar, the secretary of Health and Human Services, has pointed enthusiastically to this authority at times, telling reporters last year that his “pen has a lot of power.”
When asked about the court case Wednesday, Seema Verma, a top deputy in the department, told Anna Edney at Bloomberg News
that the department had a “plan in place” to preserve some parts of the
health law even if the court overturned it. She mentioned the
innovation authority specifically but did not give details on the plan.
Wednesday’s announcement on changes in kidney care featured an executive order and a speech from the president. But the meat of the proposal was four demonstration projects begun under the innovation authority. One was devised to reshape how kidney care providers are paid and would affect around half of all patients with renal disease, a sweeping change.
The president talked about another top health care priority last week: his desire to lower the cost of prescription drug prices. He mentioned a policy under review that would make some of the prices charged by drug companies more aligned with those in other developed nations. That proposal, too, was authorized under the Affordable Care Act’s innovation authority and would otherwise require a new law.
Other areas of experimentation include surgery, primary care and cancer treatment. Ashish Jha, a Harvard professor who studies changes in the health care delivery system, said the Trump administration had been ambitious and creative in trying new ways to use payment experiments to nudge medical providers toward higher-quality care.
But the administration’s position in court could jeopardize all those initiatives. If the Affordable Care Act is overturned, as government lawyers have pushed for, the innovation authority will go with it.
That outcome would undermine large parts of the administration’s health care agenda, Dr. Jha said: “I think the administration is going to be very hobbled in terms of their efforts to really improve the delivery system.”
https://www.nytimes.com/2019/07/11/upshot/trump-repeal-obamacare-innovation-authority.html?
At one point, the meaning of “Medicare For All” was quite
clear. Under Medicare For All, every American, instead of having to
navigate the tangled and inefficient marketplace of for-profit health
insurance corporations, would simply be enrolled in Medicare. Instead of
people paying premiums and copays to an insurance company, they would
pay taxes, and those taxes would be used to pay providers. As Dr. Abdul
El-Sayed wrote in this magazine, Medicare For All is “single-payer healthcare that would provide cradle-to-grave government-supported healthcare for all Americans.”
But as Democrats have realized how well the phrase “Medicare For All” polls with voters, its meaning has been deliberately muddied. Most of the Democratic presidential candidates now support something they call “Medicare For All,” but it’s often not clear what they mean by it. Some, when they clarify specifics, make it clear that what they actually want is a “public option,” i.e. a new kind of government insurance plan that you can buy within the structure of the existing healthcare marketplace. Pete Buttigieg says that he believes in “Medicare For All Who Want It.” Presumably, what this would mean in practice is that when you go to healthcare.gov to select your insurance plan, one option would be a thing called “Medicare For All,” and you could buy it, through premiums, if you chose it. This is, as Dr. El-Sayed points out, a “rebranding” of the concept, an attempt to present Bernie Sanders’ single payer proposal and Barack Obama’s old abandoned “public option” idea as roughly the same.
But how do proponents of (actual) Medicare For All respond to the basic arguments made by those proposing “Medicare For All Who Want It”? What Pete Buttigieg and other moderates say is this: Why force people into a government program? Most people are satisfied with their healthcare (though note the huge difference between the 70 percent of Medicare enrollees who say they are satisfied with the cost, and the 51 percent of people with private insurance who are satisfied with cost). Why abolish private insurance? Why not just have insurance companies compete against a government plan in an open marketplace where people can choose? That way, everyone who wants Medicare gets it, while people who are satisfied with their current insurance can keep it. Everyone wins. The implication here is that anyone who supports a full single-payer plan, in which everyone would just be insured under a government program, must be rigidly ideological, wanting to shutter the private insurance industry for no good reason. Why would we do that instead of just providing a new option?
To understand why full “single payer” health insurance is the left’s goal, rather than just “another insurance plan on the marketplace,” it helps first to understand the left’s vision for how healthcare should work. In an ideal world, your healthcare would not be something you have to think about very much. If you got sick, you would choose a doctor’s office and make an appointment. You would go to that appointment and see the doctor. Then you would leave. You would not have to apply for insurance, not have to pay bills. And this would be the case no matter who you were or how much money you made. In Britain, this is what you do already. As U.K. Current Affairs contributor Aisling McCrea has explained, the NHS makes healthcare easy. “Insurance” isn’t a part of it at all: Your relationship is between you and your doctor, not you and your doctor and your doctor’s hospital’s billing department and your insurance company. Leftists dream of making healthcare as easy as possible to receive and universally accessible to all regardless of how much money they have.
Private health insurance is an unnecessary part of the healthcare system. Insurance companies are middlemen, and insurance just exists to make sure that providers get paid. It was our government’s own choice to encourage the proliferation of private insurance, through laws like the Health Maintenance Organization Act of 1973. It was the federal government that subsidized private insurance companies and encouraged employers to use them. Other countries didn’t build this kind of healthcare system, for two reasons:
Not only will a public option fail to cover everyone, it will do nothing to restrain the growth of healthcare costs. Single payer systems control costs by giving the health service a monopoly on access to patients, preventing providers from exploiting desperate patients for profit. If instead there are a large number of insurance companies, providers can play those insurance companies off each other. Right now, we have a two-tier system, in which the best doctors and hospitals refuse to provide coverage unless your insurer offers them exorbitantly high rents. To support that cost while still making a profit, your insurer has to subject you to higher premiums, higher co-pays, and higher deductibles. Poor Americans with poor-quality insurance are stuck with providers who don’t provide high enough quality care to make these demands. The best providers keep charging ever higher rents, and the gap between the care they offer and the care the poor receive just keeps growing. Poor Americans are now seeing a decline in life expectancy, in part because they cannot afford to buy insurance that would give them access to the best doctors and hospitals. Costs balloon for rich Americans while the quality of care stagnates for the poor.
The bloat doesn’t just come from providers. Because insurance works on a profit incentive, the insurance companies must extract rents as well. So the patient is paying to ensure not only that their doctor or hospital is highly-compensated, but that the insurance company generates profit too. Each insurance company has its own managers—its own CEO, its own human resources department, and so on. We have to pay all of these people, and because there are so many private insurance companies, there are so many middle managers to pay. (Barack Obama once bizarrely critiqued single payer by saying it would eliminate millions of jobs in the insurance bureaucracy, implying that we should keep admittedly pointless jobs and gouge patients as a make-work program.)
These duplicate bureaucracies are expensive to maintain and do nothing to improve the quality of care. The providers make them compete to offer higher compensation, and you pay for it. Getting rid of these middle men makes the system far more efficient. We now spend 17 percent of GDP on healthcare. Britain spends 10 percent, and British people can expect to live two years longer. (Though in order to achieve a full cost-effective British system, we’d have to socialize medicine rather than just socializing insurance.) People do not associate government with efficiency, but when it comes to moving money from one place to another—which, after all, is all an insurance company does—it can be quite good, and it makes far more sense to have government handle healthcare payments than to leave it to companies with a direct financial incentive to deny treatment.
Private insurance is inconvenient, inefficient, and continues to leave large numbers of Americans with inadequate insurance or no insurance at all. The Affordable Care Act shored up this system by funnelling more public money into subsidies for private insurance. Now these Democratic candidates are proposing to make a new insurance company, call it “Medicare,” and charge you premiums to use it. That doesn’t get rid of the problem of wasteful duplicative bureaucracies, and will guarantee that some people remain uninsured. It was the federal government’s decision to build this bizarre, burdensome system. Nothing about private health care is natural or inevitable. It doesn’t have to be like this.
And yet: Democratic presidential contenders seem reluctant to call this system what it is, and stand behind a comprehensive replacement. It’s not just Buttigieg. Candidates like Elizabeth Warren and Kamala Harris claim there are “many paths” to Medicare-For-All. In addition to Bernie Sanders’ bill, they’ve quietly signed onto some of the “buy-in” bills circulating through congress. Elizabeth Warren says she has a plan for everything, but there’s no Medicare-For-All plan on her website. (A plan for everything except healthcare, as Tim Higginbotham put it in Jacobin.) When asked at a town hall about it, she said:
When we talk about Medicare for All, there are a lot of different pathways…Some folks are talking about “Let’s start lowering the age. Maybe bring it down to 60, 55, 50″…Some people say “Do it the other way. Let’s bring it up, from, uh, everybody under 30 gets covered by Medicare.” Others say “Let employers be able to buy into the Medicare plans.” Others say “Let’s let employees buy into the Medicare plans.” For me, what’s key is we get everybody at the table on this…I’ve also co-sponsored other bills including expanding Medicaid as another approach that we use.
It’s a waffling answer that tells us little about Warren’s vision for healthcare—beyond her willingness to count the public option “buy-in” bills as “pathways” to Medicare-For-All. Yet Warren also came out at the Democratic debate for getting rid of private insurance. With no actual plan, it’s hard to know quite what she’s advocating. The Harris campaign does something similar. Harris has co-sponsored multiple buy-in bills, including Jeff Merkely’s and even Michael Bennett’s. Asked about Harris’ stance on Medicare-For-All, Harris’ press secretary said:
Medicare-for-all is the plan that she believes will solve the problem and get all Americans covered. Period…She has co-sponsored other pieces of legislation that she sees as a path to getting us there, but this is the plan she is running on.
A single payer system requires a lot of political commitment, because it means going up against the insurance companies and the ritzy providers and telling them they can’t screw us over anymore. They can’t deny us coverage, extract heavy rents, and keep us on the phone forever. If a Democratic candidate doesn’t see a meaningful difference between a public option and single payer, if that candidate sees these things as two different “paths” to the same place, that candidate cannot be trusted to put an end to this madness. They are offering just one more piecemeal reform to prop up a failing system—not a true overhaul.
Single payer healthcare is a tried and tested system, and it isn’t radical. Trying to cobble together “universal” coverage from a patchwork of giant for-profit bureaucracies and government insurance products is senseless. “Eliminating private insurance” rather than “adding choice” may sound unnecessarily sweeping. But private insurance just gets in the way of efficiently paying healthcare providers and covering everybody. Medicare-For-All makes sense, and we shouldn’t let it be watered down.
Wednesday’s announcement on changes in kidney care featured an executive order and a speech from the president. But the meat of the proposal was four demonstration projects begun under the innovation authority. One was devised to reshape how kidney care providers are paid and would affect around half of all patients with renal disease, a sweeping change.
The president talked about another top health care priority last week: his desire to lower the cost of prescription drug prices. He mentioned a policy under review that would make some of the prices charged by drug companies more aligned with those in other developed nations. That proposal, too, was authorized under the Affordable Care Act’s innovation authority and would otherwise require a new law.
Other areas of experimentation include surgery, primary care and cancer treatment. Ashish Jha, a Harvard professor who studies changes in the health care delivery system, said the Trump administration had been ambitious and creative in trying new ways to use payment experiments to nudge medical providers toward higher-quality care.
But the administration’s position in court could jeopardize all those initiatives. If the Affordable Care Act is overturned, as government lawyers have pushed for, the innovation authority will go with it.
That outcome would undermine large parts of the administration’s health care agenda, Dr. Jha said: “I think the administration is going to be very hobbled in terms of their efforts to really improve the delivery system.”
https://www.nytimes.com/2019/07/11/upshot/trump-repeal-obamacare-innovation-authority.html?
Biden unveils health plan, sharpening fight among Democrats
by Sean Sullivan - Washington Post - July 15, 2019
Joe Biden unveiled a proposal Monday to expand the
Affordable Care Act with an optional public health insurance program,
escalating a fierce debate with his Democratic rivals who favor a more
sweeping Medicare-for-all system.
Biden’s plan,
which campaign officials estimate would cost $750 billion over 10 years,
would also expand tax credits to pay for health premiums, and it would
create a new coverage option to help people living in states that have
resisted the ACA’s expansion of Medicaid.
The
plan, which formalized ideas Biden has campaigned on for months,
sharpens one of the biggest dividing lines in the Democratic
presidential primary. One on side are traditional Democrats such as the
former vice president, who warn that scrapping President Barack Obama’s
signature health law could have dire consequences. On the other side are
liberals such as Sen. Bernie Sanders (I-Vt.), who argue that a complete
health-care overhaul is necessary to achieve universal coverage.
“I
understand the appeal of Medicare-for-all, but folks supporting it
should be clear that it means getting rid of Obamacare, and I’m not for
that,” Biden said in a video
released by his campaign. “I was very proud the day I stood there with
Barack Obama, and he signed that legislation. . . . Starting over makes
no sense to me at all.”
The dispute between Biden and Sanders, who in many ways represent the ideological poles of the Democratic field, has ramped up is recent days. Biden said he
had “profound differences” with Sanders and another candidate on health
care and suggested their approach could imperil people’s coverage,
prompting Sanders to forcefully rebut him. And Sanders plans to deliver a
speech Wednesday to confront opponents of the single-payer,
government-run plan he has long championed.
Biden’s team signaled he is ready to embrace the
fight, even if it risks alienating some in the party’s liberal base,
suggesting that a fight over an unattainable goal will only undermine
badly needed improvements in the short term.
“You’ll
see him make a case about the urgency of now, that starting over from
scratch is not the way to ensure that people in this country who need
more affordable coverage are going to be able to get it,” said one of
the senior Biden campaign officials who previewed the plan ahead of its
release.
Disagreements over health care, an
issue that polls show is important to many voters, loom heavily over the
general election as well. Many Democrats are eager to reprise their
successful midterm strategy of pointing to Republican efforts to repeal
and replace the ACA. President Trump and his allies are looking to
counter with attacks casting Medicare-for-all as a scary takeover of the
health-care system that would be detrimental to many Americans, a line
of attack that worries some Democrats.
With
AARP hosting a series of candidate forums this week in Iowa, and the
next Democratic debate coming up at month’s end, other candidates are
also seeking to clarify their positions on health care. Sen. Cory Booker
(D-N.J.) will release a proposal Monday to allow more people to be
eligible for Medicaid services.
Biden, who
leads the crowded pack in state and national polls and is running
heavily on the Obama record, faces particular pressure. Among other
things, he hopes to turn the page on a series of controversies — most
notably his comments praising his past work with segregationists, which
he recently said he regretted.
At
the heart of Biden’s health-care plan, which senior campaign officials
said would cover more than 97 percent of Americans, is a proposal to let
people choose a government-run health system like Medicare if they
aren’t happy with private insurance. Obama initially set out to include
such a public option in the ACA law, but later backed away from the idea amid political resistance.
The
former vice president would bolster other parts of the ACA designed to
help people purchase insurance. It would get rid of the income cap — 400
percent of the federal poverty level — used to determine who qualifies
for tax credits that help Americans pay insurance premiums.
Biden’s plan would also seek to circumvent the resistance by many Republican-led states to accepting the expansion of Medicaid, a program
for low-income and disabled Americans. In the 14 states that have not
expanded Medicaid as allowed by the ACA, Biden’s proposal would let
those who would otherwise qualify for assistance buy into the public
option without premiums.
Abortion rights are
also part of Biden’s plan. He would provide federal funding for Planned
Parenthood and combat the actions of states that have moved to tighten
restrictions on abortions. And the overall plan would be funded by
raising taxes on the investment income earned by wealthy Americans.
After
initially aiming most of his fire at Trump, Biden now appears eager to
contrast his position on health care with his Democratic rivals. Many
centrist Democrats fear that if the party’s nominee embraces Medicare-for-all, including the sidelining of private health insurance, it will scare off many voters and play into Trump’s hands.
Of
the four Democrats leading in the polls, only Biden wants to build on
the ACA rather than push Medicare-for-all. Sens. Elizabeth Warren
(D-Mass.) and Kamala D. Harris (D-Calif.) are largely following
Sanders’s approach.
Campaigning in New
Hampshire last week, Biden said it “took a long time to get us to where
it is now,” referring to the decades-long battle to pass health-care
restructuring. Too many people are at risk, he warned, to go through
another lengthy debate about overhauling the system.
He
went after proponents of Medicare-for-all both directly and obliquely.
Biden said Sanders has “been very honest” about raising taxes on the
middle class to pay for his plan and ending private insurance,
suggesting those ideas are political poison.
Sanders
acknowledges his proposal would require tax increase on middle-class
Americans, but he argues that they would pay far less in health-care
costs, saving them significant money overall. And while his plan would
bar private insurers from replicating services covered under
Medicare-for-all, he has said they could still finance elective
procedures.
The debate over private insurance
has been complicated. Some candidates have tried to walk a fine line,
endorsing Sanders’s plan while trying to avoid alienating Americans who
want the option of keeping their insurance. Harris, who is co-sponsoring
Sanders’s Medicare-for-all bill in the Senate, recently had to clarify that she does not support abolishing private insurance.
Asked
by a reporter whether Harris has been clear in her position on private
insurance, Biden grinned and said, “I’ll let you guys make that
judgment.”
Sanders’s aides say a core part of
their strategy is emphasizing that the senator from Vermont has spent
decades advocating for ideas that have only recently come into vogue
with other Democrats. In his speech this week, Sanders intends to
“confront the Democratic opponents of Medicare-for-all and directly
challenge the insurance and drug industry,” according to his campaign.
Over the weekend, Sanders was just as eager to single out Biden as Biden was to name him.
“Here
are the facts. Under Medicare-for-all, over a four-year period, we will
transition to a system in which Medicare is expanded to cover every
man, woman, and child in the country,” Sanders said in a Saturday
statement responding to Biden. He added, “It is preposterous to argue
that as we expand Medicare-for-all that people with cancer and other
illnesses will not get the care that they need.”
When
it comes to the Affordable Care Act, 46 percent of the public hold
favorable views of the law while 40 percent hold unfavorable views, a
major improvement from several years ago, according to a recent Kaiser Family Foundation poll.
Joe Biden proposes radical leftist health-care plan
by Paul Waldman - Washington Post - July 15, 2019
The 2020 Democratic presidential primary campaign is
in many ways an argument between liberals and moderates over the path
the Democratic Party should take, and on no issue has that argument been
more intense than health care. Joe Biden has now released his health
care plan, and while he’s presenting it as a rebuke of the more liberal
candidates, in fact it represents a significant move to the left.
That’s not how he’s talking about it. The video
Biden put out with the release of his plan was a direct attack on other
Democrats for their crazy liberal ideas and their betrayal of Barack
Obama. Here’s part of what he said:
“I understand the appeal of Medicare For All. But folks supporting it should be clear that it means getting rid of Obamacare. I’m not for that ... I knew the Republicans would do everything in their power to repeal Obamacare. They still are. But I’m surprised that so many Democrats are running on getting rid of it.”
Now let’s look at what Biden actually proposes. Here are the basics:
- Create a public option “like Medicare” that would be open to anyone, including those who currently have insurance through their employer.
- In Republican states that refused to expand Medicaid, allow all eligible people to get the new public option for free.
- Automatically enroll low-income people in Medicaid or the public option when they interact with the government.
- Increase ACA subsidies to make insurance more affordable.
- Force drug companies to negotiate prices with Medicare.
There’s
more in there on drug prices, abortion coverage, surprise billing and
other topics. But overall, this is not just fixing some problems with
the ACA; it goes far past it. It’s extremely similar to the Medicare For America Act introduced by Reps. Rosa L. DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.).
If
you are an advocate of single-payer, you’ll find this too much of a
compromise. But that shouldn’t obscure the fact that it’s a much more
liberal plan than the ACA, which Biden is talking about as though it’s
sacrosanct.
That’s the important historical
context: In 2009 when the ACA was being debated, a plan like this one
would have been considered almost radically leftist. There were still
some liberals who would have preferred a single-payer plan to the ACA,
but in that moment, what those on the left wanted was to include a
public option, a Medicare- or Medicaid-like program that would be
offered on the exchanges and compete with private insurers.
The history of the rise and fall
of the public option is a bit complicated. But what it came down to is
that support for it among moderate Democrats began to bleed, and the
White House made clear it wasn’t all that important to them. Sen. Joe
Lieberman (I-Conn.), who had become consumed with spite for liberals,
declared that if a public option was included then he would join the
Republican filibuster and kill the entire ACA.
Then
and now, a public option was understood by both liberals and
conservatives as the camel’s nose under the tent that could eventually
lead to single-payer or something like it. And the fact that even
Republicans think that’s what would happen demonstrates that they don’t
really believe what they say about private insurance being superior to
government insurance.
After all, if government
insurance was so miserable, no one would choose the option and it would
wither away. But if liberals are right, then it will be attractive and
affordable, and more and more people will abandon their private plans
for the government plan. Market principles will determine the outcome,
which is exactly what conservatives are afraid of. They see how much
seniors love their Medicare and how popular Medicaid is, and they’re
worried the same thing would happen with a public option.
So
is it possible that a plan like Biden’s could be a step on the road to
single-payer? Not exactly, but over the long term it could wind up being
pretty close. If this new public plan worked well, since it’s open to
anyone you could see millions of people gravitate toward it. Eventually
we’d have three large government insurers (Medicare, Medicaid and
Bidencare or whatever it would be called) and private insurers steadily
shrinking. At some point liberals would say, “Why don’t we just combine
these three into one program that covers everyone, and leave private
insurers offering supplemental coverage?”
Then you’d have a system not too dissimilar from the one in France or the one in Canada,
both of which combine universal government-sponsored plans with private
supplemental plans, and both of which work much better than ours.
I’m
not saying there’s no real difference between single-payer and what
Biden is proposing; there are important distinctions and a case to be
made for the superiority of the former. But Biden, who is presenting
himself as the candidate of moderation and incrementalism, wants to go a
lot further than Barack Obama did a decade ago.
Which is reason for liberals to feel as if they’re winning the argument.
Why A “Public Option” Isn’t Enough
by
But as Democrats have realized how well the phrase “Medicare For All” polls with voters, its meaning has been deliberately muddied. Most of the Democratic presidential candidates now support something they call “Medicare For All,” but it’s often not clear what they mean by it. Some, when they clarify specifics, make it clear that what they actually want is a “public option,” i.e. a new kind of government insurance plan that you can buy within the structure of the existing healthcare marketplace. Pete Buttigieg says that he believes in “Medicare For All Who Want It.” Presumably, what this would mean in practice is that when you go to healthcare.gov to select your insurance plan, one option would be a thing called “Medicare For All,” and you could buy it, through premiums, if you chose it. This is, as Dr. El-Sayed points out, a “rebranding” of the concept, an attempt to present Bernie Sanders’ single payer proposal and Barack Obama’s old abandoned “public option” idea as roughly the same.
But how do proponents of (actual) Medicare For All respond to the basic arguments made by those proposing “Medicare For All Who Want It”? What Pete Buttigieg and other moderates say is this: Why force people into a government program? Most people are satisfied with their healthcare (though note the huge difference between the 70 percent of Medicare enrollees who say they are satisfied with the cost, and the 51 percent of people with private insurance who are satisfied with cost). Why abolish private insurance? Why not just have insurance companies compete against a government plan in an open marketplace where people can choose? That way, everyone who wants Medicare gets it, while people who are satisfied with their current insurance can keep it. Everyone wins. The implication here is that anyone who supports a full single-payer plan, in which everyone would just be insured under a government program, must be rigidly ideological, wanting to shutter the private insurance industry for no good reason. Why would we do that instead of just providing a new option?
To understand why full “single payer” health insurance is the left’s goal, rather than just “another insurance plan on the marketplace,” it helps first to understand the left’s vision for how healthcare should work. In an ideal world, your healthcare would not be something you have to think about very much. If you got sick, you would choose a doctor’s office and make an appointment. You would go to that appointment and see the doctor. Then you would leave. You would not have to apply for insurance, not have to pay bills. And this would be the case no matter who you were or how much money you made. In Britain, this is what you do already. As U.K. Current Affairs contributor Aisling McCrea has explained, the NHS makes healthcare easy. “Insurance” isn’t a part of it at all: Your relationship is between you and your doctor, not you and your doctor and your doctor’s hospital’s billing department and your insurance company. Leftists dream of making healthcare as easy as possible to receive and universally accessible to all regardless of how much money they have.
Private health insurance is an unnecessary part of the healthcare system. Insurance companies are middlemen, and insurance just exists to make sure that providers get paid. It was our government’s own choice to encourage the proliferation of private insurance, through laws like the Health Maintenance Organization Act of 1973. It was the federal government that subsidized private insurance companies and encouraged employers to use them. Other countries didn’t build this kind of healthcare system, for two reasons:
- It doesn’t cover everyone.
- It creates a bloated, inefficient insurance bureaucracy.
Not only will a public option fail to cover everyone, it will do nothing to restrain the growth of healthcare costs. Single payer systems control costs by giving the health service a monopoly on access to patients, preventing providers from exploiting desperate patients for profit. If instead there are a large number of insurance companies, providers can play those insurance companies off each other. Right now, we have a two-tier system, in which the best doctors and hospitals refuse to provide coverage unless your insurer offers them exorbitantly high rents. To support that cost while still making a profit, your insurer has to subject you to higher premiums, higher co-pays, and higher deductibles. Poor Americans with poor-quality insurance are stuck with providers who don’t provide high enough quality care to make these demands. The best providers keep charging ever higher rents, and the gap between the care they offer and the care the poor receive just keeps growing. Poor Americans are now seeing a decline in life expectancy, in part because they cannot afford to buy insurance that would give them access to the best doctors and hospitals. Costs balloon for rich Americans while the quality of care stagnates for the poor.
The bloat doesn’t just come from providers. Because insurance works on a profit incentive, the insurance companies must extract rents as well. So the patient is paying to ensure not only that their doctor or hospital is highly-compensated, but that the insurance company generates profit too. Each insurance company has its own managers—its own CEO, its own human resources department, and so on. We have to pay all of these people, and because there are so many private insurance companies, there are so many middle managers to pay. (Barack Obama once bizarrely critiqued single payer by saying it would eliminate millions of jobs in the insurance bureaucracy, implying that we should keep admittedly pointless jobs and gouge patients as a make-work program.)
These duplicate bureaucracies are expensive to maintain and do nothing to improve the quality of care. The providers make them compete to offer higher compensation, and you pay for it. Getting rid of these middle men makes the system far more efficient. We now spend 17 percent of GDP on healthcare. Britain spends 10 percent, and British people can expect to live two years longer. (Though in order to achieve a full cost-effective British system, we’d have to socialize medicine rather than just socializing insurance.) People do not associate government with efficiency, but when it comes to moving money from one place to another—which, after all, is all an insurance company does—it can be quite good, and it makes far more sense to have government handle healthcare payments than to leave it to companies with a direct financial incentive to deny treatment.
Private insurance is inconvenient, inefficient, and continues to leave large numbers of Americans with inadequate insurance or no insurance at all. The Affordable Care Act shored up this system by funnelling more public money into subsidies for private insurance. Now these Democratic candidates are proposing to make a new insurance company, call it “Medicare,” and charge you premiums to use it. That doesn’t get rid of the problem of wasteful duplicative bureaucracies, and will guarantee that some people remain uninsured. It was the federal government’s decision to build this bizarre, burdensome system. Nothing about private health care is natural or inevitable. It doesn’t have to be like this.
And yet: Democratic presidential contenders seem reluctant to call this system what it is, and stand behind a comprehensive replacement. It’s not just Buttigieg. Candidates like Elizabeth Warren and Kamala Harris claim there are “many paths” to Medicare-For-All. In addition to Bernie Sanders’ bill, they’ve quietly signed onto some of the “buy-in” bills circulating through congress. Elizabeth Warren says she has a plan for everything, but there’s no Medicare-For-All plan on her website. (A plan for everything except healthcare, as Tim Higginbotham put it in Jacobin.) When asked at a town hall about it, she said:
When we talk about Medicare for All, there are a lot of different pathways…Some folks are talking about “Let’s start lowering the age. Maybe bring it down to 60, 55, 50″…Some people say “Do it the other way. Let’s bring it up, from, uh, everybody under 30 gets covered by Medicare.” Others say “Let employers be able to buy into the Medicare plans.” Others say “Let’s let employees buy into the Medicare plans.” For me, what’s key is we get everybody at the table on this…I’ve also co-sponsored other bills including expanding Medicaid as another approach that we use.
It’s a waffling answer that tells us little about Warren’s vision for healthcare—beyond her willingness to count the public option “buy-in” bills as “pathways” to Medicare-For-All. Yet Warren also came out at the Democratic debate for getting rid of private insurance. With no actual plan, it’s hard to know quite what she’s advocating. The Harris campaign does something similar. Harris has co-sponsored multiple buy-in bills, including Jeff Merkely’s and even Michael Bennett’s. Asked about Harris’ stance on Medicare-For-All, Harris’ press secretary said:
Medicare-for-all is the plan that she believes will solve the problem and get all Americans covered. Period…She has co-sponsored other pieces of legislation that she sees as a path to getting us there, but this is the plan she is running on.
A single payer system requires a lot of political commitment, because it means going up against the insurance companies and the ritzy providers and telling them they can’t screw us over anymore. They can’t deny us coverage, extract heavy rents, and keep us on the phone forever. If a Democratic candidate doesn’t see a meaningful difference between a public option and single payer, if that candidate sees these things as two different “paths” to the same place, that candidate cannot be trusted to put an end to this madness. They are offering just one more piecemeal reform to prop up a failing system—not a true overhaul.
Single payer healthcare is a tried and tested system, and it isn’t radical. Trying to cobble together “universal” coverage from a patchwork of giant for-profit bureaucracies and government insurance products is senseless. “Eliminating private insurance” rather than “adding choice” may sound unnecessarily sweeping. But private insurance just gets in the way of efficiently paying healthcare providers and covering everybody. Medicare-For-All makes sense, and we shouldn’t let it be watered down.
https://www.currentaffairs.org/2019/07/why-a-public-option-isnt-enough
Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their patients are or by charging Medicare for treating serious medical conditions they cannot prove their patients have.
Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed or backed off efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat more than 22 million seniors — more than 1 in 3 people on Medicare.
Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 — just a tenth of what it estimates the plans overcharge the government in a given year.
At the same time, the Department of Health and Human Services Inspector General's Office has launched a separate nationwide round of Medicare Advantage audits.
As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.
America's Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it "fatally flawed."
Insurer Cigna Corp. warned in a May financial filing: "If adopted in its current form, [the audits] could have a detrimental impact" on all Medicare Advantage plans and "affect the ability of plans to deliver high quality care."
But former Sen. Claire McCaskill, a Missouri Democrat who now works as a political analyst, says officials must move past powerful lobbying efforts. The officials must hold health insurers accountable, McCaskill says, and demand refunds for "inappropriate" billings.
"There are a lot of things that could cause Medicare to go broke," she says. "This would be one of the contributing factors. Ten billion dollars a year is real money."
Catching overbilling with a wider net
In the overpayment dispute, health plans want CMS to scale back, if not kill off, an enhanced audit tool that, for the first time, could force insurers to cough up millions in improper payments they've received.
For more than a decade, audits have been little more than an irritant to insurers, because most plans go years without being chosen for review and often pay only a few hundred thousand dollars in refunds as a consequence. When auditors uncover errors in the medical records of patients the insurers were paid to treat, CMS has simply required a rebate for those patients for just the year audited — relatively small sums for plans with thousands of members.
The latest CMS proposal would raise those stakes enormously by extrapolating error rates found in a random sample of 200 patients to the plan's full membership — a technique expected to trigger many multimillion-dollar penalties. Though controversial, extrapolation is common in medical fraud investigations — except for investigations into Medicare Advantage. Since 2007, the industry has successfully challenged the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.
"The public has a substantial interest in the recoupment of millions of dollars of public money improperly paid to health insurers," CMS wrote in a Federal Register notice late last year announcing its renewed attempt at using extrapolation.
Penalties in limbo
In a written response to our questions, CMS officials said the agency has already conducted 90 of those enhanced audits for payments made in 2011, 2012 and 2013 — and expects to collect $650 million in extrapolated penalties as a result.
Though that figure reflects only a minute percentage of actual losses to taxpayers from overpayments, it would be a huge escalation for CMS. Previous Medicare Advantage audits have recouped a total of about $14 million — far less than it cost to conduct them, federal records show.
Though CMS has disclosed the names of the health plans in the crossfire, it has not yet told them how much each owes, officials said. CMS declined to say when, or if, they would make the results public.
This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 plans annually.
This spring, CMS announced it would extend until the end of August the audit proposal's public comment period, which was supposed to end in April. That could be a signal the agency might be looking more closely at industry objections.
Health care industry consultant Jessica Smith says CMS might be taking additional time to make sure the audit protocol can pass muster.
"Once they have their ducks in a row," she says, "CMS will come back hard at the health plans. There is so much money tied to this."
But Sean Creighton, a former senior CMS official who now advises the industry for health care consultant Avalere Health, says payment error rates have been dropping because many health plans "are trying as hard as they can to become compliant."
Still, audits are continuing to find mistakes. The first HHS inspector general audit, released in late April, found that Missouri-based Essence Healthcare Inc. had failed to justify fees for dozens of patients it had treated for strokes or depression. Essence denied any wrongdoing but agreed it should refund $158,904 in overcharges for those patients and ferret out any other errors.
Essence also faces a pending whistleblower suit filed by Charles Rasmussen, a Branson, Mo., doctor who alleges the health plan illegally boosted profits by overstating the severity of patients' medical conditions. Essence has called the allegations "wholly without merit" and "baseless."
Essence started as a St. Louis physician group, then grew into a broader holding company in 2007, backed by prominent Silicon Valley venture capitalist John Doerr, with his brother Thomas Doerr, a St. Louis doctor and software designer. Neither would comment for this story.
How we got here
CMS uses a billing formula called a "risk score" to pay for each Medicare Advantage member. The formula pays higher rates for sicker patients than for people in good health.
Congress approved risk scoring in 2003 to ensure that health plans did not shy away from taking sick patients who could incur higher-than-usual costs from hospitals and other medical facilities. But some insurers quickly found ways to boost risk scores — and their revenues.
In 2007, after several years of running Medicare Advantage as what one CMS official dubbed an "honor system," the agency launched "Risk Adjustment Data Validation" audits. The idea was to cut down on the undeserved payments that cost CMS nearly $30 billion over the past three years.
The audits of 37 health plans revealed that, on average, auditors could confirm just 60% of the more than 20,000 medical conditions CMS had paid the plans to treat.
Extra payments to plans that had claimed some of its diabetic patients had complications, such problems with eyes or kidneys, were reduced or invalidated in nearly half the cases. The overpayments exceeded $10,000 a year for more than 150 patients, though health plans disputed some of the findings.
But CMS kept the findings under wraps until the Center for Public Integrity, an investigative journalism group, sued the agency under the Freedom of Information Act to make those results public.
Despite the alarming findings, CMS conducted no audits for payments made during 2008, 2009 and 2010 as they faced industry backlash over CMS' authority to conduct them, and the threat of extrapolated repayments. Records released through the FOIA lawsuit show some inside the agency also worried that health plans would abandon the Medicare Advantage program if CMS pressed them too hard.
CMS officials resumed the audits for 2011 and expected to finish them and assess penalties by the end of 2016. That has yet to happen, amid the continuing protests from the industry. Insurers want CMS to adjust downward any extrapolated penalties to account for coding errors that exist in standard Medicare. CMS stands behind its method — at least for now.
At a minimum, argues AHIP, the health insurers association, CMS should back off extrapolation for the 90 audits for 2011-13 and apply it for 2014 and onward. Should the agency agree, CMS would write off more than half a billion dollars that could be recovered for the U.S. Treasury.
https://www.mainepublic.org/post/records-show-medicare-advantage-plans-overbill-taxpayers-billions-annually
Records Show Medicare Advantage Plans Overbill Taxpayers By Billions Annually
by Fred Schulte - Kaiser Health News - July 15, 2019
Health insurers that treat millions of seniors have overcharged Medicare by nearly $30 billion over the past three years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.
Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their patients are or by charging Medicare for treating serious medical conditions they cannot prove their patients have.
Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed or backed off efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat more than 22 million seniors — more than 1 in 3 people on Medicare.
Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 — just a tenth of what it estimates the plans overcharge the government in a given year.
At the same time, the Department of Health and Human Services Inspector General's Office has launched a separate nationwide round of Medicare Advantage audits.
As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.
America's Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it "fatally flawed."
Insurer Cigna Corp. warned in a May financial filing: "If adopted in its current form, [the audits] could have a detrimental impact" on all Medicare Advantage plans and "affect the ability of plans to deliver high quality care."
But former Sen. Claire McCaskill, a Missouri Democrat who now works as a political analyst, says officials must move past powerful lobbying efforts. The officials must hold health insurers accountable, McCaskill says, and demand refunds for "inappropriate" billings.
"There are a lot of things that could cause Medicare to go broke," she says. "This would be one of the contributing factors. Ten billion dollars a year is real money."
Catching overbilling with a wider net
In the overpayment dispute, health plans want CMS to scale back, if not kill off, an enhanced audit tool that, for the first time, could force insurers to cough up millions in improper payments they've received.
For more than a decade, audits have been little more than an irritant to insurers, because most plans go years without being chosen for review and often pay only a few hundred thousand dollars in refunds as a consequence. When auditors uncover errors in the medical records of patients the insurers were paid to treat, CMS has simply required a rebate for those patients for just the year audited — relatively small sums for plans with thousands of members.
The latest CMS proposal would raise those stakes enormously by extrapolating error rates found in a random sample of 200 patients to the plan's full membership — a technique expected to trigger many multimillion-dollar penalties. Though controversial, extrapolation is common in medical fraud investigations — except for investigations into Medicare Advantage. Since 2007, the industry has successfully challenged the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.
"The public has a substantial interest in the recoupment of millions of dollars of public money improperly paid to health insurers," CMS wrote in a Federal Register notice late last year announcing its renewed attempt at using extrapolation.
Penalties in limbo
In a written response to our questions, CMS officials said the agency has already conducted 90 of those enhanced audits for payments made in 2011, 2012 and 2013 — and expects to collect $650 million in extrapolated penalties as a result.
Though that figure reflects only a minute percentage of actual losses to taxpayers from overpayments, it would be a huge escalation for CMS. Previous Medicare Advantage audits have recouped a total of about $14 million — far less than it cost to conduct them, federal records show.
Though CMS has disclosed the names of the health plans in the crossfire, it has not yet told them how much each owes, officials said. CMS declined to say when, or if, they would make the results public.
This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 plans annually.
This spring, CMS announced it would extend until the end of August the audit proposal's public comment period, which was supposed to end in April. That could be a signal the agency might be looking more closely at industry objections.
Health care industry consultant Jessica Smith says CMS might be taking additional time to make sure the audit protocol can pass muster.
"Once they have their ducks in a row," she says, "CMS will come back hard at the health plans. There is so much money tied to this."
But Sean Creighton, a former senior CMS official who now advises the industry for health care consultant Avalere Health, says payment error rates have been dropping because many health plans "are trying as hard as they can to become compliant."
Still, audits are continuing to find mistakes. The first HHS inspector general audit, released in late April, found that Missouri-based Essence Healthcare Inc. had failed to justify fees for dozens of patients it had treated for strokes or depression. Essence denied any wrongdoing but agreed it should refund $158,904 in overcharges for those patients and ferret out any other errors.
Essence also faces a pending whistleblower suit filed by Charles Rasmussen, a Branson, Mo., doctor who alleges the health plan illegally boosted profits by overstating the severity of patients' medical conditions. Essence has called the allegations "wholly without merit" and "baseless."
Essence started as a St. Louis physician group, then grew into a broader holding company in 2007, backed by prominent Silicon Valley venture capitalist John Doerr, with his brother Thomas Doerr, a St. Louis doctor and software designer. Neither would comment for this story.
How we got here
CMS uses a billing formula called a "risk score" to pay for each Medicare Advantage member. The formula pays higher rates for sicker patients than for people in good health.
Congress approved risk scoring in 2003 to ensure that health plans did not shy away from taking sick patients who could incur higher-than-usual costs from hospitals and other medical facilities. But some insurers quickly found ways to boost risk scores — and their revenues.
In 2007, after several years of running Medicare Advantage as what one CMS official dubbed an "honor system," the agency launched "Risk Adjustment Data Validation" audits. The idea was to cut down on the undeserved payments that cost CMS nearly $30 billion over the past three years.
The audits of 37 health plans revealed that, on average, auditors could confirm just 60% of the more than 20,000 medical conditions CMS had paid the plans to treat.
Extra payments to plans that had claimed some of its diabetic patients had complications, such problems with eyes or kidneys, were reduced or invalidated in nearly half the cases. The overpayments exceeded $10,000 a year for more than 150 patients, though health plans disputed some of the findings.
But CMS kept the findings under wraps until the Center for Public Integrity, an investigative journalism group, sued the agency under the Freedom of Information Act to make those results public.
Despite the alarming findings, CMS conducted no audits for payments made during 2008, 2009 and 2010 as they faced industry backlash over CMS' authority to conduct them, and the threat of extrapolated repayments. Records released through the FOIA lawsuit show some inside the agency also worried that health plans would abandon the Medicare Advantage program if CMS pressed them too hard.
CMS officials resumed the audits for 2011 and expected to finish them and assess penalties by the end of 2016. That has yet to happen, amid the continuing protests from the industry. Insurers want CMS to adjust downward any extrapolated penalties to account for coding errors that exist in standard Medicare. CMS stands behind its method — at least for now.
At a minimum, argues AHIP, the health insurers association, CMS should back off extrapolation for the 90 audits for 2011-13 and apply it for 2014 and onward. Should the agency agree, CMS would write off more than half a billion dollars that could be recovered for the U.S. Treasury.
https://www.mainepublic.org/post/records-show-medicare-advantage-plans-overbill-taxpayers-billions-annually
We need to get greed out of the American health care system
by Cathleen London - Bangor Daily News - July 15, 2019
Americans will not see single
payer healthcare (Medicare for All or another iteration) any time soon
due to greed. Too many people profit off the hard labor of clinicians,
particularly of physicians. No, it is not physicians raking in the large
paychecks, for that you will have to look to chief executive officers
of insurance companies, hospitals, pharmaceutical companies, device
manufacturers and healthcare systems. The profiteers. These are not the
people delivering the care.
Physicians gave their power away decades ago, and our
organizations did nothing to protect us. In fact, the larger
organizations helped create the systems we now have. The only people benefitting are the executives and stockholders. Don’t expect it to improve anytime soon.
The way physicians are taught is not conducive to changing
the system. Our focus is the patient, the disease process — we cannot
dirty ourselves with profit and loss, or cost structures. We naively
invited the business people in to do that work for us. They gleefully
took over.
We have not learned. While the rest of the industrialized world enjoys universal healthcare and does not worry about how to pay for care when they are ill, Americans go broke.
Physicians are treated as commodities and squeezed harder and harder as
they break. Physicians are centered on empathy and compassion and
capitalism has taken every advantage.
Fewer independent physician practices now exist, which is detrimental to patients (and costs). Reimbursement rates
continue to decline with no recourse, which puts physicians in
untenable positions: stop taking insurance plans, become an employee,
retire, change careers, or find additional income. This is true
insanity. With at least 11 years training for each physician this is
also an incredible waste of talent and resources.
Now we have mid-level practitioners being churned out by online schools,
which is not a replacement for physicians nor the answer to the
increasing shortage of physicians. Mid-level practitioners, such as
nurse practitioners and physician assistants order more tests, refer to more specialists
clogging the pipeline for necessary care, and increasing costs. Where
midlevels practice without supervision, care is often stunningly
inadequate resulting in complications of chronic medical conditions that
are otherwise preventable.
As long as we continue to elect politicians who are turning
America into an oligarchy, our system will worsen. American medicine is
but a symptom of the greater illness. The founders of the United States
envisioned a Federalist Republic. They put in protections against the
corruption humans are prone to. Despite this, we are witnessing our own
downfall. We are watching as these checks and balances fail.
So yes, I am painting a depressing, realistic picture. Until
we as a nation hold politicians accountable for representing everyone
nothing will change. Unless physicians take medicine back the spiral
continues. There are some small starts: direct primary care (physician
run) is one answer to the catastrophe that has become American medicine,
but the trajectory is worsening before improvement. Despite the fact
that the majority of Americans would favor a single-payer system such as Medicare for All, we do not elect representation that will enact these proposals. Change takes action. Right now we have inertia.
Is this the end of America as we know it? Has capitalism
failed all but a few? Are we witnessing the fall of the Republic? Time
will tell. I do think things will get worse, particularly for our
patients. Treatments will become harder to afford, not because those
delivering the care are being paid better, but because money is diverted
to those that have learned to work the system the best. American
exceptionalism indeed.
Cathleen London of Milbridge is a family medicine physician.
President Trump Withdraws Plan to Eliminate Drug Price Rebates
by Katie Thomas - NYT - July 11, 2019
The
Trump administration has abandoned a centerpiece of its efforts to
address high drug prices, backing away from requiring some discounts to
be passed directly to consumers under Medicare that could have lowered
their out-of-pocket costs.
President Trump had announced the proposal with great fanfare in January as part of the administration’s efforts to deal with the rising costs of prescription drugs, which have fueled public outrage. But the decision to kill the proposal is the second time this week that Mr. Trump’s drug-pricing initiatives have failed. On Monday, a federal judge threw out a rule that would have required pharmaceutical companies to list the price of their drugs in television advertisements.
In a statement Thursday, Judd Deere, a spokesman for the White House, said, “Based on careful analysis and thorough consideration, the president has decided to withdraw the rebate rule.”
The rebate rule had long met resistance from within the White House, where fiscal conservatives had balked at the potential cost. The rule was expected to raise drug-plan premiums for all Medicare beneficiaries, and in May, the nonpartisan Congressional Budget Office concluded that the rule, if adopted, would cost taxpayers $177 billion within 10 years.
President Trump had announced the proposal with great fanfare in January as part of the administration’s efforts to deal with the rising costs of prescription drugs, which have fueled public outrage. But the decision to kill the proposal is the second time this week that Mr. Trump’s drug-pricing initiatives have failed. On Monday, a federal judge threw out a rule that would have required pharmaceutical companies to list the price of their drugs in television advertisements.
In a statement Thursday, Judd Deere, a spokesman for the White House, said, “Based on careful analysis and thorough consideration, the president has decided to withdraw the rebate rule.”
The rebate rule had long met resistance from within the White House, where fiscal conservatives had balked at the potential cost. The rule was expected to raise drug-plan premiums for all Medicare beneficiaries, and in May, the nonpartisan Congressional Budget Office concluded that the rule, if adopted, would cost taxpayers $177 billion within 10 years.
The
administration and leading members of Congress have been discussing
some other legislative proposals, including negotiating directly with
companies to set caps on some drug prices. The president also announced
last week that he would issue an executive order that might somehow
connect prices in the United States to those charged by companies in
overseas markets, but the details remained unclear.
“President Trump will consider using any and all tools to ensure that prescription drug costs will continue to decline,” Mr. Deere added.
The news, reported earlier by the news outlet Axios, also dealt a blow to the drug industry. It had strongly backed the measure and tried to blame pharmacy benefit managers for rising prices.
The rule would have essentially done away with after-the-fact rebates that drug companies pay to the private companies that operate Medicare’s Part D drug plans, and instead required that any discounts be passed to consumers at the pharmacy counter. Medicare beneficiaries with high drug costs often have to pay a drug’s list price, or a percentage of it, during certain phases of their coverage. They were required to do so even though, in many cases, the companies operating the plans were collecting rebates on the same drug.
The rule had been opposed by the insurers and pharmacy benefit managers who operate Medicare’s drug plans because they said they used the rebates to pressure drug companies to keep their prices low, and used the savings to keep premiums low for all Medicare beneficiaries. But the drug industry has been campaigning for years on the idea that it is unfair for insurers to keep the rebates when consumers are paying the list price through high deductibles.
“President Trump will consider using any and all tools to ensure that prescription drug costs will continue to decline,” Mr. Deere added.
The news, reported earlier by the news outlet Axios, also dealt a blow to the drug industry. It had strongly backed the measure and tried to blame pharmacy benefit managers for rising prices.
The rule would have essentially done away with after-the-fact rebates that drug companies pay to the private companies that operate Medicare’s Part D drug plans, and instead required that any discounts be passed to consumers at the pharmacy counter. Medicare beneficiaries with high drug costs often have to pay a drug’s list price, or a percentage of it, during certain phases of their coverage. They were required to do so even though, in many cases, the companies operating the plans were collecting rebates on the same drug.
The rule had been opposed by the insurers and pharmacy benefit managers who operate Medicare’s drug plans because they said they used the rebates to pressure drug companies to keep their prices low, and used the savings to keep premiums low for all Medicare beneficiaries. But the drug industry has been campaigning for years on the idea that it is unfair for insurers to keep the rebates when consumers are paying the list price through high deductibles.
Alex
M. Azar II, the secretary of health and human services, had been a
strong proponent of the proposed rule, which he said addressed one of
the key reasons the market for drugs is broken.
In a statement, Caitlin Oakley, a spokeswoman for Mr. Azar, said he and Mr. Trump were working together on a range of other drug-pricing proposals. “Secretary Azar is fighting alongside President Trump to lower prescription drug costs and protect America’s seniors,” she said.
https://www.nytimes.com/2019/07/11/health/drug-prices-rebate-donald-trump.html?action=click&module=Top%20Stories&pgtype=Homepage
In a statement, Caitlin Oakley, a spokeswoman for Mr. Azar, said he and Mr. Trump were working together on a range of other drug-pricing proposals. “Secretary Azar is fighting alongside President Trump to lower prescription drug costs and protect America’s seniors,” she said.
https://www.nytimes.com/2019/07/11/health/drug-prices-rebate-donald-trump.html?action=click&module=Top%20Stories&pgtype=Homepage
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