How ‘Medicare for All’ Went Mainstream
by Robert Draper - NYT - August 27, 2019
On
June 17, 2016, 15 prominent Democratic Party activists and elected
officials gathered in a hotel conference room in downtown Phoenix. Their
job was to formulate language for the party platform, which would be
adopted at the following month’s national convention in Philadelphia.
But the platform-drafting committee also had an unspoken mission: to
defuse the lingering intraparty tension in the wake of Bernie Sanders’s
spirited but unsuccessful primary battle against Hillary Clinton.
The Democrats hadn’t faced convention infighting since 1980, when Senator Edward M. Kennedy challenged the incumbent president, Jimmy Carter, and party leaders hoped to use the process of drafting the platform — the compendium of official positions on policies and issues that the party faithful formally approve at the convention — to head off a similar situation. Sanders, the Vermont senator, had been awarded five of the committee’s 15 seats in order to come up with platform language that would be as unifying and unoffensive as possible.
The fifth session was devoted to health care, and it began innocently enough. “The Democratic Party believes accessible, affordable and high-quality health care is part of the American promise,” the committee’s chairman, the Maryland congressman Elijah Cummings, intoned. Several minutes’ worth of earnest self-congratulation about the Affordable Care Act, the legislative centerpiece of Obama’s presidency, followed. The Republican presidential nominee, Donald Trump, had vowed to eliminate “the disaster known as Obamacare,” which mandated that private insurers offer health-insurance plans to those who otherwise didn’t have access to insurance, and mandated that most uncovered Americans enroll in them. The Democrats in the Phoenix conference room were unanimous in their desire to preserve the A.C.A. and to draft platform language assuring the American public that their nominee, Hillary Clinton, would do just that.
A half-hour into the session, Cummings directed the attendees’ attention to a guest on their computer screen. It was RoseAnn DeMoro, the executive director of National Nurses United, the labor group that for years had been the dominant advocate for a government-run national health care system, also known as “single payer” or “Medicare for All.” DeMoro was Skyping in from Chicago, where she was due to speak that evening at the People’s Summit, a gathering of thousands of Sanders supporters. Sanders had requested that DeMoro be given one of his five seats on the platform-drafting committee but had been overruled by Clinton’s loyalists, most likely because DeMoro’s union had loudly supported Sanders over Clinton.
The Democrats hadn’t faced convention infighting since 1980, when Senator Edward M. Kennedy challenged the incumbent president, Jimmy Carter, and party leaders hoped to use the process of drafting the platform — the compendium of official positions on policies and issues that the party faithful formally approve at the convention — to head off a similar situation. Sanders, the Vermont senator, had been awarded five of the committee’s 15 seats in order to come up with platform language that would be as unifying and unoffensive as possible.
The fifth session was devoted to health care, and it began innocently enough. “The Democratic Party believes accessible, affordable and high-quality health care is part of the American promise,” the committee’s chairman, the Maryland congressman Elijah Cummings, intoned. Several minutes’ worth of earnest self-congratulation about the Affordable Care Act, the legislative centerpiece of Obama’s presidency, followed. The Republican presidential nominee, Donald Trump, had vowed to eliminate “the disaster known as Obamacare,” which mandated that private insurers offer health-insurance plans to those who otherwise didn’t have access to insurance, and mandated that most uncovered Americans enroll in them. The Democrats in the Phoenix conference room were unanimous in their desire to preserve the A.C.A. and to draft platform language assuring the American public that their nominee, Hillary Clinton, would do just that.
A half-hour into the session, Cummings directed the attendees’ attention to a guest on their computer screen. It was RoseAnn DeMoro, the executive director of National Nurses United, the labor group that for years had been the dominant advocate for a government-run national health care system, also known as “single payer” or “Medicare for All.” DeMoro was Skyping in from Chicago, where she was due to speak that evening at the People’s Summit, a gathering of thousands of Sanders supporters. Sanders had requested that DeMoro be given one of his five seats on the platform-drafting committee but had been overruled by Clinton’s loyalists, most likely because DeMoro’s union had loudly supported Sanders over Clinton.
DeMoro, now
70, tends to wear an intent expression that alternates between amusement
and withering skepticism. She dispensed with the pleasantries. Obama’s
health care program in many ways, she told the attendees, “has fallen
short.” Costs were continuing to go up. Sick people continued to be
denied coverage. The legislation’s biggest winners were the insurance
and pharmaceutical industries. “We’re urging the Democratic Party to put
patients before profits,” DeMoro said, “and to make health care for
everyone basically a right.”
The Sanders delegates in the conference room applauded enthusiastically. Later the Clinton adviser Neera Tanden reminded DeMoro that the convention intended to feature stories of people whose lives had been saved by Obamacare. Representative Barbara Lee of California insisted that she and other House Democrats had “fought very hard” for single payer. Their goal now should be to “build upon the Affordable Care Act,” Lee argued.
DeMoro was not having it. Building upon a for-profit plan would only serve to entrench the profiteers, she insisted. For every Obamacare success story Tanden might wish to promote, she told the committee, the nurses could recite a multitude of tragedies. “You are not ever going to corner the nurses into saying it’s adequate,” DeMoro said. “I see the dynamic that’s happening here,” she added, her eyes narrowing. “You think that I’m criticizing the Democratic Party for not fighting hard enough for a single-payer health care system. And I think that’s probably accurate.”
Onstage that evening at the People’s Summit, DeMoro gleefully recounted the rancorous exchange. “They wanted me to say that the Democratic Party fought hard enough,” she told the audience. “But in reality, they didn’t.” Then, to thunderous applause, DeMoro said, “When I appeared by Skype before the committee, I could feel the Bernie movement’s power. I could feel the 58 percent of the American people who support single-payer health care.”
That power was not enough to sway the platform committee, which by a margin of one vote elected not to include any mention of a single-payer system in its 45-page official document. A little more than a month later at the Democratic convention, DeMoro remembers running into Lee. Lee, a liberal from DeMoro’s state, was still stung by her criticism. “Man, you went after me hard!” DeMoro recalls Lee saying. As a state senator in 1998, Lee reminded her, she had co-written a single-payer bill that died in committee. And Lee had, in fact, joined Sanders’s five drafting-committee members in voting to include single-payer language in the party platform.
The Sanders delegates in the conference room applauded enthusiastically. Later the Clinton adviser Neera Tanden reminded DeMoro that the convention intended to feature stories of people whose lives had been saved by Obamacare. Representative Barbara Lee of California insisted that she and other House Democrats had “fought very hard” for single payer. Their goal now should be to “build upon the Affordable Care Act,” Lee argued.
DeMoro was not having it. Building upon a for-profit plan would only serve to entrench the profiteers, she insisted. For every Obamacare success story Tanden might wish to promote, she told the committee, the nurses could recite a multitude of tragedies. “You are not ever going to corner the nurses into saying it’s adequate,” DeMoro said. “I see the dynamic that’s happening here,” she added, her eyes narrowing. “You think that I’m criticizing the Democratic Party for not fighting hard enough for a single-payer health care system. And I think that’s probably accurate.”
Onstage that evening at the People’s Summit, DeMoro gleefully recounted the rancorous exchange. “They wanted me to say that the Democratic Party fought hard enough,” she told the audience. “But in reality, they didn’t.” Then, to thunderous applause, DeMoro said, “When I appeared by Skype before the committee, I could feel the Bernie movement’s power. I could feel the 58 percent of the American people who support single-payer health care.”
That power was not enough to sway the platform committee, which by a margin of one vote elected not to include any mention of a single-payer system in its 45-page official document. A little more than a month later at the Democratic convention, DeMoro remembers running into Lee. Lee, a liberal from DeMoro’s state, was still stung by her criticism. “Man, you went after me hard!” DeMoro recalls Lee saying. As a state senator in 1998, Lee reminded her, she had co-written a single-payer bill that died in committee. And Lee had, in fact, joined Sanders’s five drafting-committee members in voting to include single-payer language in the party platform.
DeMoro
regarded Lee’s efforts as insufficient. The Sanders campaign’s success
in making Medicare for All a defining progressive issue, she told me
recently, “was a time in history when you knew change had come and the
movement was moving past the standard-bearers of the left. It was one of
those lead-or-get-out-of-the-way moments. And Barbara was playing an
insider game and wasn’t willing to fight.”
Like many progressive activists, DeMoro — who retired from National Nurses United last year but remains an influential voice on the left — views her movement’s proximate adversary as the Democratic establishment rather than Trump’s Republicans. Of late, she has devoted much of her social-media energy to deriding Senator Kamala Harris, whom she has called “Chameleon Harris” on Twitter. A longtime resident of the Bay Area, DeMoro viewed Harris more or less favorably when she was California’s attorney general. But as Sanders’s presidential opponent, she had, to DeMoro’s thinking, revealed herself to be a transparently calculating triangulator: “There’s no there there.”
The day before the second round of Democratic presidential debates in Detroit, Harris’s campaign announced her new health care plan, which would guarantee universal coverage but also keep private insurers. Even though the plan was not a single-payer system, Harris had nonetheless felt compelled to call it Medicare for All. Three weeks later, however, she would tell her donors, “I’ve not been comfortable with Bernie’s plan, the Medicare for All plan.”
The contortions suggested how much the politics of health care among Democrats had changed — and how much Sanders and DeMoro had changed them. In a party that three short years ago kept single-payer advocates at Skyping distance, Medicare for All now sits at the head of the table, pulling the Democrats decisively leftward. Sanders’s Medicare for All bill in the Senate has 16 co-sponsors. In the House of Representatives, Pramila Jayapal, who is the co-chairwoman of the Progressive Caucus, has introduced a health care bill with 117 Democratic co-sponsors that is even more lavish in its benefits (and thus probably costlier) than the plan Sanders has put forward in the Senate; it, too, is called Medicare for All. In addition to Harris, two other presidential candidates have offered health care plans that pilfer from Sanders in name if not in substance: Pete Buttigieg, with Medicare for All Who Want It; and Beto O’Rourke, with Medicare for America — the latter borrowing from a proposal developed by Neera Tanden’s Center for American Progress, itself called Medicare Extra for All. The idea’s original advocates, like DeMoro and Sanders, after years of struggling to get into the mainstream Democratic policy debate, suddenly have an embarrassment of allies — or at least people who claim as much. “Medicare for All shouldn’t mean all things to all people,” Warren Gunnels, Sanders’s senior campaign adviser, told me. “It’s single payer. Everybody else’s program is Medicare for Some.”
Like many progressive activists, DeMoro — who retired from National Nurses United last year but remains an influential voice on the left — views her movement’s proximate adversary as the Democratic establishment rather than Trump’s Republicans. Of late, she has devoted much of her social-media energy to deriding Senator Kamala Harris, whom she has called “Chameleon Harris” on Twitter. A longtime resident of the Bay Area, DeMoro viewed Harris more or less favorably when she was California’s attorney general. But as Sanders’s presidential opponent, she had, to DeMoro’s thinking, revealed herself to be a transparently calculating triangulator: “There’s no there there.”
The day before the second round of Democratic presidential debates in Detroit, Harris’s campaign announced her new health care plan, which would guarantee universal coverage but also keep private insurers. Even though the plan was not a single-payer system, Harris had nonetheless felt compelled to call it Medicare for All. Three weeks later, however, she would tell her donors, “I’ve not been comfortable with Bernie’s plan, the Medicare for All plan.”
The contortions suggested how much the politics of health care among Democrats had changed — and how much Sanders and DeMoro had changed them. In a party that three short years ago kept single-payer advocates at Skyping distance, Medicare for All now sits at the head of the table, pulling the Democrats decisively leftward. Sanders’s Medicare for All bill in the Senate has 16 co-sponsors. In the House of Representatives, Pramila Jayapal, who is the co-chairwoman of the Progressive Caucus, has introduced a health care bill with 117 Democratic co-sponsors that is even more lavish in its benefits (and thus probably costlier) than the plan Sanders has put forward in the Senate; it, too, is called Medicare for All. In addition to Harris, two other presidential candidates have offered health care plans that pilfer from Sanders in name if not in substance: Pete Buttigieg, with Medicare for All Who Want It; and Beto O’Rourke, with Medicare for America — the latter borrowing from a proposal developed by Neera Tanden’s Center for American Progress, itself called Medicare Extra for All. The idea’s original advocates, like DeMoro and Sanders, after years of struggling to get into the mainstream Democratic policy debate, suddenly have an embarrassment of allies — or at least people who claim as much. “Medicare for All shouldn’t mean all things to all people,” Warren Gunnels, Sanders’s senior campaign adviser, told me. “It’s single payer. Everybody else’s program is Medicare for Some.”
Medicare for All,
as envisioned by Sanders in a 2017 Senate bill, would expand coverage
in phases over a four-year period. Drug co-payments would not exceed
$200 a year. The overall cost of the plan would be roughly $30 trillion
over a decade. According to an analysis
by the University of Massachusetts Amherst’s Political Economy Research
Institute, that amount would be largely offset through savings in areas
such as administrative overhead, pharmaceutical costs and physician
salaries. A combination of payroll, sales, capital gains and income
taxes could pay for the remainder. The result would be a government-run
health care system in which Americans of all ages are covered, are able
to select whichever doctor they choose and incur almost no out-of-pocket
expenses.
Not since the Great Society era has so ambitious a social program been so actively promoted by influential Democrats. Whether this is a good thing, both as a matter of policy and for a party longing to defeat Trump next year, is currently at issue. On the one hand, the predominance of health care as a voting concern typically favors Democrats; as Sanders’s pollster Ben Tulchin put it to me, “When the conversation is about health care, we’re already winning.”
Not since the Great Society era has so ambitious a social program been so actively promoted by influential Democrats. Whether this is a good thing, both as a matter of policy and for a party longing to defeat Trump next year, is currently at issue. On the one hand, the predominance of health care as a voting concern typically favors Democrats; as Sanders’s pollster Ben Tulchin put it to me, “When the conversation is about health care, we’re already winning.”
Single-payer
advocates achieved a victory of a sort in the July 30 Democratic
presidential debate in Detroit, when the CNN moderator Jake Tapper said,
“Let’s start the debate with the No. 1 issue for Democratic voters,
health care — and Senator Sanders, let’s start with you.” The 10
candidates onstage discussed Medicare for All for the next 20 minutes —
longer than any other issue.
It was an establishing shot that lingered even when the night’s camera frame panned over to immigration and climate change. A couple days after the debate, an ABC News/Ipsos poll showed that when Democratic voters watched both a video of Sanders explaining the virtues of Medicare for All and a video of the front-runner Joe Biden arguing for simply improving Obamacare, 31 percent found the Sanders plan “very convincing,” while only 18 percent said the same of Biden’s position.
A few days later, however, a Monmouth University poll of likely Democratic caucusgoers in Iowa found that 56 percent preferred the option to receive Medicare, as opposed to a mere 21 percent favoring a government-run plan that abolished private insurance. It underscored the fears of Democrats on the center-left that the issue will boomerang on them in 2020 — that campaigning on an entirely government-run health care system, the creation of which would remove about 156 million Americans from their employer-based plans, according to a Kaiser Family Foundation analysis, will invite an electoral backlash. “It’s been the case of health care policy for decades,” Tanden told me. “If a health care plan is perceived to be about protecting something, it’s usually good. If it’s about losing something, it’s usually toxic.”
Eighteen percent of the United States economy, or $3.5 trillion, is tied to health care, up from 5 percent in 1960. The United States spends at least double per capita what other industrialized nations spend on health care. The health sector is among America’s most profitable industries. And despite the vast profits and expenditures, the United States has comparatively worse health outcomes than other advanced nations that spend far less on health care: higher overall mortality rates, higher premature deaths and higher preventable deaths — all on top of the fact that two-thirds of all bankruptcies and nearly half of all foreclosures in America today are related to medical costs.
In spite of these dismal returns, the health care system has proved extraordinarily resistant to disruption — no doubt in part because of the uniquely palpable stakes. “Health care is unlike any other issue,” Tanden says. “People feel an expertise about it, because they’ve lived it. It’s very personal to them: They think of the care of their child, of their aging parents, of their own vulnerability.”
Though highly attuned to the health care system’s deficiencies, the public has also been fretful that their political leaders will only succeed in making a flawed system worse. For a quarter century, Gallup polls have found that almost without exception, 65 to 73 percent of Americans believe the health care system to be in a state of crisis or having major problems. The same polls observed Republicans feeling especially dire starting in 2010, while conservatives were condemning Obamacare; and Democratic fears spiked in 2018, after Obamacare narrowly escaped repeal by congressional Republicans.
Those sentiments might suggest that Americans would prefer the government to leave well enough alone. But at a moment when a reconsideration of the party’s staid politics is already brewing, they might just as easily be interpreted as a call to arms: a rationale for burning down the system and starting anew.
It was an establishing shot that lingered even when the night’s camera frame panned over to immigration and climate change. A couple days after the debate, an ABC News/Ipsos poll showed that when Democratic voters watched both a video of Sanders explaining the virtues of Medicare for All and a video of the front-runner Joe Biden arguing for simply improving Obamacare, 31 percent found the Sanders plan “very convincing,” while only 18 percent said the same of Biden’s position.
A few days later, however, a Monmouth University poll of likely Democratic caucusgoers in Iowa found that 56 percent preferred the option to receive Medicare, as opposed to a mere 21 percent favoring a government-run plan that abolished private insurance. It underscored the fears of Democrats on the center-left that the issue will boomerang on them in 2020 — that campaigning on an entirely government-run health care system, the creation of which would remove about 156 million Americans from their employer-based plans, according to a Kaiser Family Foundation analysis, will invite an electoral backlash. “It’s been the case of health care policy for decades,” Tanden told me. “If a health care plan is perceived to be about protecting something, it’s usually good. If it’s about losing something, it’s usually toxic.”
Eighteen percent of the United States economy, or $3.5 trillion, is tied to health care, up from 5 percent in 1960. The United States spends at least double per capita what other industrialized nations spend on health care. The health sector is among America’s most profitable industries. And despite the vast profits and expenditures, the United States has comparatively worse health outcomes than other advanced nations that spend far less on health care: higher overall mortality rates, higher premature deaths and higher preventable deaths — all on top of the fact that two-thirds of all bankruptcies and nearly half of all foreclosures in America today are related to medical costs.
In spite of these dismal returns, the health care system has proved extraordinarily resistant to disruption — no doubt in part because of the uniquely palpable stakes. “Health care is unlike any other issue,” Tanden says. “People feel an expertise about it, because they’ve lived it. It’s very personal to them: They think of the care of their child, of their aging parents, of their own vulnerability.”
Though highly attuned to the health care system’s deficiencies, the public has also been fretful that their political leaders will only succeed in making a flawed system worse. For a quarter century, Gallup polls have found that almost without exception, 65 to 73 percent of Americans believe the health care system to be in a state of crisis or having major problems. The same polls observed Republicans feeling especially dire starting in 2010, while conservatives were condemning Obamacare; and Democratic fears spiked in 2018, after Obamacare narrowly escaped repeal by congressional Republicans.
Those sentiments might suggest that Americans would prefer the government to leave well enough alone. But at a moment when a reconsideration of the party’s staid politics is already brewing, they might just as easily be interpreted as a call to arms: a rationale for burning down the system and starting anew.
“I’m not an incrementalist,” DeMoro
told me one afternoon at a pizza restaurant in Napa, where she now
lives in retirement. “I firmly believe that change happens through
rupturing. Trump’s a prime example of that. And the Democrats have used
Trump as an excuse not to have a platform of their own. Well, Bernie’s
running for systemic change.”
DeMoro became the executive director of the California Nurses Association in 1993. The daughter of the owners of a pizza parlor and a beauty salon in St. Louis, she had never worked in the medical profession. She was fluent in political theory as well as in blue-collar issues and had become close with two of the most tenacious grass-roots activists in postwar American history: the labor organizer Tony Mazzocchi, who successfully agitated for passage of the Occupational Safety and Health Act of 1970; and Ralph Nader, who prodded Congress to pass the Consumer Product Safety Act into law in 1972. “She was steeped in the history of the labor movement, had a critical mind and locked horns with everybody,” Nader recalls. “She would trash the A.F.L.-C.I.O. for lacking substance and courage. But she also really understood the issues. I thought she was the greatest labor leader out there.”
DeMoro took her post shortly after Bill Clinton was elected president, at a moment when rupture seemed imminent in the American health care system. The number of uninsured Americans under 65 had risen steadily from 33.4 million in 1989 to 37.1 million in 1992. (It would be 41.6 million in 2004.) This troubled a Washington State congressman and former child psychiatrist named Jim McDermott. As a medical-school student in the early 1960s, McDermott watched with interest as Canada built its single-payer system while, he recalled, “the American Medical Association leadership predicted that this was the end of the profession, socialized medicine, blah blah blah. Then they said the same about Medicare, until it became a goddamned cash cow for doctors.”
By 1993, McDermott was single payer’s leading champion in Congress. That same year, he put forward a single-payer bill in the House. (Among its 90 co-sponsors was an obscure Vermont freshman named Bernie Sanders.) “Then Clinton came into office,” McDermott told me recently. “Mrs. Clinton needed my 90 votes for their health care plan. She didn’t want to have anything that looked like socialism. She said, ‘Jim, you want to take out the insurance industry, but it’s deeply embedded in our society.’ ”
McDermott gamely offered his support. But Hillary Clinton’s determination to preserve the private insurance system was not enough to assuage Republicans or health care industry lobbyists. The 1,342-page Clinton plan known as “Hillarycare,” which required employers to either provide insurance or pay a penalty that would finance insurance exchanges, was demonized by the health-insurance industry’s “Harry and Louise” TV ads as a wallet-busting bureaucracy that would eliminate Americans’ right to choose their doctors.
DeMoro became the executive director of the California Nurses Association in 1993. The daughter of the owners of a pizza parlor and a beauty salon in St. Louis, she had never worked in the medical profession. She was fluent in political theory as well as in blue-collar issues and had become close with two of the most tenacious grass-roots activists in postwar American history: the labor organizer Tony Mazzocchi, who successfully agitated for passage of the Occupational Safety and Health Act of 1970; and Ralph Nader, who prodded Congress to pass the Consumer Product Safety Act into law in 1972. “She was steeped in the history of the labor movement, had a critical mind and locked horns with everybody,” Nader recalls. “She would trash the A.F.L.-C.I.O. for lacking substance and courage. But she also really understood the issues. I thought she was the greatest labor leader out there.”
DeMoro took her post shortly after Bill Clinton was elected president, at a moment when rupture seemed imminent in the American health care system. The number of uninsured Americans under 65 had risen steadily from 33.4 million in 1989 to 37.1 million in 1992. (It would be 41.6 million in 2004.) This troubled a Washington State congressman and former child psychiatrist named Jim McDermott. As a medical-school student in the early 1960s, McDermott watched with interest as Canada built its single-payer system while, he recalled, “the American Medical Association leadership predicted that this was the end of the profession, socialized medicine, blah blah blah. Then they said the same about Medicare, until it became a goddamned cash cow for doctors.”
By 1993, McDermott was single payer’s leading champion in Congress. That same year, he put forward a single-payer bill in the House. (Among its 90 co-sponsors was an obscure Vermont freshman named Bernie Sanders.) “Then Clinton came into office,” McDermott told me recently. “Mrs. Clinton needed my 90 votes for their health care plan. She didn’t want to have anything that looked like socialism. She said, ‘Jim, you want to take out the insurance industry, but it’s deeply embedded in our society.’ ”
McDermott gamely offered his support. But Hillary Clinton’s determination to preserve the private insurance system was not enough to assuage Republicans or health care industry lobbyists. The 1,342-page Clinton plan known as “Hillarycare,” which required employers to either provide insurance or pay a penalty that would finance insurance exchanges, was demonized by the health-insurance industry’s “Harry and Louise” TV ads as a wallet-busting bureaucracy that would eliminate Americans’ right to choose their doctors.
The
Democrats abandoned their efforts six weeks before the 1994 midterm
elections so as to minimize the political damage. In the years that
followed, health care costs rose and coverage rates fell. In 1999,
medical expenses consumed 14 percent, on average, of American’s
take-home pay. By 2017, that figure would more than double, to 31
percent.
These costs ballooned despite the health
care industry’s efforts to maximize efficiency through a “managed care”
approach, restructuring hospitals and clinics as health maintenance
organizations, or H.M.O.s. Under the H.M.O. model, nurses found
themselves losing status, leverage and in some cases their jobs. Those
who remained employed often found their jobs transformed. “We as nurses
were expected to get ’em out fast and move on,” Elizabeth Pataki, a
former nurse and labor activist (and cousin of New York’s former
governor George Pataki), recalls. “It was heartbreaking to see how
little care they were getting and how so many of them couldn’t pay their
deductibles, how their premiums were becoming ruinous, how they would
ration their medicine by breaking it in half.”
That was the landscape DeMoro encountered as she led the undersize 17,000-member California Nurses Association into the fight against what she would term “the commodification of health.” She spent hours on picket lines with the nurses and absorbed their eyewitness grievances. In the male-dominated world of union leadership, the C.N.A. president stood out. “Nurses of a certain age like me didn’t have role models back then, except perhaps nuns and teachers,” Pataki says. “But RoseAnn, for many of us, showed what it meant to be a woman of commitment, to be warm and funny but also dedicated and direct. I could see where we could go with her.”
They did not go very far at first. In 1994, DeMoro’s California-based union pushed the State Legislature to adopt a single-payer bill, to no avail. Two years later, DeMoro’s union promoted Proposition 216, which aimed to curb the ability of hospitals and H.M.O.s to restrict coverage, only to be bombarded by TV ads (paid for by a coalition of H.M.O.s and business affiliates) conceived by the same political consultants whose “Harry and Louise” ads were used to defeat Clinton’s health care initiative.
The 2008 presidential campaign offered fleeting hopes for single-payer advocates. As a state senator in 2003, Barack Obama proclaimed himself to be “a proponent of a single-payer universal health care program.” Late in the summer of 2007, DeMoro remembers receiving a call from an Obama campaign staff member. The candidate was coming to the Bay Area, the staff member said. Would she like to spend the day driving around with him and discussing health care?
DeMoro agreed. But in typical fashion, she commissioned radio advertisements on the eve of Obama’s arrival, urging the candidate to openly advocate for a single-payer system. “I got a call from one of his people, asking, ‘Did you guys do this ad?’ ” she recalled. “And when I said it was us, they canceled the visit.”
Her union, which by 2008 had grown to around 100,000 members, nonetheless held events around the country for Obama. But in office, DeMoro told me, Obama “proved that he had learned exactly the wrong lesson from Hillarycare.” Insurance and pharmaceutical companies who viewed single payer as an apocalyptic proposition were awarded seats at the table, as were Republican senators.
“Barack said, ‘I don’t want to just message this issue, I want to get something done,’ ” Tom Daschle, Obama’s early pick for Health and Human Services secretary, told me. “The view was that if we started more moderately and reached out to Republicans with something they supported in the past, we’d have something we could accomplish. There were some who believed that Medicare was a good brand that we could expand on. But he didn’t believe Republicans were likely to join that effort.”
That was the landscape DeMoro encountered as she led the undersize 17,000-member California Nurses Association into the fight against what she would term “the commodification of health.” She spent hours on picket lines with the nurses and absorbed their eyewitness grievances. In the male-dominated world of union leadership, the C.N.A. president stood out. “Nurses of a certain age like me didn’t have role models back then, except perhaps nuns and teachers,” Pataki says. “But RoseAnn, for many of us, showed what it meant to be a woman of commitment, to be warm and funny but also dedicated and direct. I could see where we could go with her.”
They did not go very far at first. In 1994, DeMoro’s California-based union pushed the State Legislature to adopt a single-payer bill, to no avail. Two years later, DeMoro’s union promoted Proposition 216, which aimed to curb the ability of hospitals and H.M.O.s to restrict coverage, only to be bombarded by TV ads (paid for by a coalition of H.M.O.s and business affiliates) conceived by the same political consultants whose “Harry and Louise” ads were used to defeat Clinton’s health care initiative.
The 2008 presidential campaign offered fleeting hopes for single-payer advocates. As a state senator in 2003, Barack Obama proclaimed himself to be “a proponent of a single-payer universal health care program.” Late in the summer of 2007, DeMoro remembers receiving a call from an Obama campaign staff member. The candidate was coming to the Bay Area, the staff member said. Would she like to spend the day driving around with him and discussing health care?
DeMoro agreed. But in typical fashion, she commissioned radio advertisements on the eve of Obama’s arrival, urging the candidate to openly advocate for a single-payer system. “I got a call from one of his people, asking, ‘Did you guys do this ad?’ ” she recalled. “And when I said it was us, they canceled the visit.”
Her union, which by 2008 had grown to around 100,000 members, nonetheless held events around the country for Obama. But in office, DeMoro told me, Obama “proved that he had learned exactly the wrong lesson from Hillarycare.” Insurance and pharmaceutical companies who viewed single payer as an apocalyptic proposition were awarded seats at the table, as were Republican senators.
“Barack said, ‘I don’t want to just message this issue, I want to get something done,’ ” Tom Daschle, Obama’s early pick for Health and Human Services secretary, told me. “The view was that if we started more moderately and reached out to Republicans with something they supported in the past, we’d have something we could accomplish. There were some who believed that Medicare was a good brand that we could expand on. But he didn’t believe Republicans were likely to join that effort.”
The question was
whether Republicans were likely to join any effort. The party had been
staunchly opposed to government health care expansions, including
Medicare, for half a century, arguing instead for market-driven
solutions, tax credits and restricting malpractice claims. (An exception
to this was when President George W. Bush successfully pushed to extend
Medicare coverage to include prescription drugs in 2003 — an
industry-friendly initiative that was interpreted by some as a means of
shoring up the president’s support among senior citizens in advance of
the 2004 election.)
In practice, however, Republican lawmakers have struggled to reconcile what Ronald Reagan termed “the magic of the marketplace” with tens of millions of Americans’ inability to pay for adequate health care. Obama forced the issue by proposing a health care reform built on the bones of a 20-year-old market-based proposal from the conservative Heritage Foundation. “My line at the time,” Charlie Dent, a moderate Republican congressman from Pennsylvania who retired last year, told me, “was that every American had a right to have access to affordable health care insurance.”
The more expedient option was for Dent’s party to weaponize the issue. Obama and congressional Democrats spent a year and a half trying to engage Republicans on health care, along the way discarding one preferred policy option after the next in hopes of forging a bipartisan agreement.
Max Baucus, the Montana Democrat who was chairman of the Senate Finance Committee at the time and led the negotiating effort, had visited a Canadian hospital and was an admirer of that country’s health care system. Still, when he began committee meetings on health care in late 2008, “I told them, ‘Let’s find a uniquely American solution,’ ” he recalled. “ ‘And nothing’s off the table.’ The only exception to that I made was single payer. I thought our country was just not ready for it. I assumed that if we worked together in good faith that over time, we’d naturally evolve toward that kind of system.”
A few of the Republican senators on the committee, like Chuck Grassley of Iowa and Olympia Snowe of Maine, were active participants in Baucus’s meetings. Eventually, however, the Senate minority leader Mitch McConnell made clear his desire not to hand the new president any legislative victories.
“The Republicans started calling it Obamacare,” Baucus said, “and it tapped into a significant portion of the electorate’s opposition to the president. It was political in the end: ‘Hey, we can run against this thing.’ Grassley was under immense pressure from McConnell, who threatened to primary him if he stayed with this. He told me that, flat out.” (Spokespeople for Grassley and McConnell adamantly deny that McConnell applied any pressure on Grassley.) The Affordable Care Act passed in March 2010 without a single Republican vote.
In practice, however, Republican lawmakers have struggled to reconcile what Ronald Reagan termed “the magic of the marketplace” with tens of millions of Americans’ inability to pay for adequate health care. Obama forced the issue by proposing a health care reform built on the bones of a 20-year-old market-based proposal from the conservative Heritage Foundation. “My line at the time,” Charlie Dent, a moderate Republican congressman from Pennsylvania who retired last year, told me, “was that every American had a right to have access to affordable health care insurance.”
The more expedient option was for Dent’s party to weaponize the issue. Obama and congressional Democrats spent a year and a half trying to engage Republicans on health care, along the way discarding one preferred policy option after the next in hopes of forging a bipartisan agreement.
Max Baucus, the Montana Democrat who was chairman of the Senate Finance Committee at the time and led the negotiating effort, had visited a Canadian hospital and was an admirer of that country’s health care system. Still, when he began committee meetings on health care in late 2008, “I told them, ‘Let’s find a uniquely American solution,’ ” he recalled. “ ‘And nothing’s off the table.’ The only exception to that I made was single payer. I thought our country was just not ready for it. I assumed that if we worked together in good faith that over time, we’d naturally evolve toward that kind of system.”
A few of the Republican senators on the committee, like Chuck Grassley of Iowa and Olympia Snowe of Maine, were active participants in Baucus’s meetings. Eventually, however, the Senate minority leader Mitch McConnell made clear his desire not to hand the new president any legislative victories.
“The Republicans started calling it Obamacare,” Baucus said, “and it tapped into a significant portion of the electorate’s opposition to the president. It was political in the end: ‘Hey, we can run against this thing.’ Grassley was under immense pressure from McConnell, who threatened to primary him if he stayed with this. He told me that, flat out.” (Spokespeople for Grassley and McConnell adamantly deny that McConnell applied any pressure on Grassley.) The Affordable Care Act passed in March 2010 without a single Republican vote.
In March 2015, Sanders
paid a visit to DeMoro. Their relationship began in 1981 when DeMoro,
then a graduate student at the University of California, Santa Barbara,
contributed $20 to Sanders’s first campaign for mayor of Burlington, Vt.
(Sanders won by 10 votes.) As mayor, Sanders became convinced, through
conversations with physicians in Canada, that a single-payer system was
the only sustainable means of delivering universal health care. Like
DeMoro, he condemned any system that preserved a profit-dominated model,
including what would later be known as the public option, as one that
would inevitably shortchange patient care.
Now he
told DeMoro that he was thinking seriously of running for president as a
Democrat. Knowing that he would be heavily outspent by Hillary Clinton
and her allies, he wanted DeMoro’s opinion as to whether he could count
on grass-roots support. By that point, the California Nurses Association
had joined together with other nursing unions in an umbrella
organization, the more than 150,000-member National Nurses United, with
DeMoro at its helm. Although DeMoro doubted that Sanders had much of a
chance, she saw his candidacy as an opportunity to elevate the
single-payer issue. In August, her organization became the first major
union to endorse Sanders.
Sanders, as a presidential candidate, was an outlier’s outlier, and single payer had been deemed political kryptonite by the Democratic establishment. But DeMoro’s union bankrolled a series of surveys and focus groups by Sanders’s pollster Ben Tulchin. Tulchin was a rueful admirer of the conservative movement’s ability to frame policies in memorable ways: rebranding the estate tax as a “death tax,” for example, or slashing government programs for the poor in the name of promoting “freedom.” Democrats were too equivocal in how they framed their ideology, in Tulchin’s view. He sought to change that by devising a crisper way to sell a government-run health care system to the public.
The rebranding efforts by Tulchin happened to coincide with a gathering of progressive discontent. Throughout the 1990s, the left had more or less abided the Clinton administration’s apologetic view of big government as the cost of staying in power. In 2008, after eight years of Bush’s promoting tax cuts for the wealthy, threatening to constitutionally forbid gay marriage and waging two costly wars, progressives believed their moment had arrived and saw in Obama a new champion. But his legislative efforts proved to fall well short of revolutionary. While admonishing the left to play along and accept one moldy half-loaf after another — on the economic stimulus, on climate change, on gun control, on immigration and on several judicial appointments — the Obama White House’s varied attempts to attract Republican support met only scorn.
To many progressives, Obamacare represented the apotheosis of this strategic folly. The president’s health care initiative played by the private sector’s rules, to the pharmaceutical industry’s conspicuous benefit. And then free-market Republicans rewarded this gesture of conciliation by bashing Democrats as socialists while methodically eviscerating the program on both the state and federal levels. When in 2012 it appeared that the conservative-dominated Supreme Court might declare the A.C.A. to be unconstitutional, DeMoro led the nurses’ union on a bus tour to make the case that the time had arrived for a robust, lawsuit-proof single-payer system. The campaign was premature, however: Chief Justice John Roberts cast the tiebreaking vote in favor of Obamacare, and again progressives were compelled to leave the fight. They watched red-faced in the 2014 midterms as some of the Democratic Party’s most cautious-minded legislators were labeled big-government liberals, enabling the G.O.P. to retake the Senate. By the time the party machinery began clearing the way for Hillary Clinton’s nomination, the left had grown tired of shutting up and was now looking to a dyspeptic 74-year-old Vermont socialist as their avatar.
As Tulchin conducted his public-opinion research to address the question of how Sanders might frame his health care initiative, he hit on an answer that was hiding in plain sight. It came from the legacy of Lyndon B. Johnson, who as president had pushed Medicare and Medicaid through Congress. As Tulchin told me: “The reality is, people know what Medicare is, and it’s very popular and seen as very effective. It’s a true success story for the left. Whereas no one knows what single payer is.”
Tulchin’s findings convinced the Sanders campaign to recast single payer as “Medicare for All” — a name that had previously appeared on a 2006 health care bill written by Senator Edward M. Kennedy that included a role for private insurers. (Kennedy had been an early proponent of single payer but had come to believe that opposition from the insurance industry would doom its chances.) Sanders and DeMoro knew that the word “Medicare” would register favorably among older Americans. They had not anticipated the issue’s overwhelming popularity — close to 70 percent, according to recent polling — among millennial voters. “This had been a gray-haired movement for decades,” DeMoro told me. “It surprised all of us how resonant the issue was with young people.”
Sanders, as a presidential candidate, was an outlier’s outlier, and single payer had been deemed political kryptonite by the Democratic establishment. But DeMoro’s union bankrolled a series of surveys and focus groups by Sanders’s pollster Ben Tulchin. Tulchin was a rueful admirer of the conservative movement’s ability to frame policies in memorable ways: rebranding the estate tax as a “death tax,” for example, or slashing government programs for the poor in the name of promoting “freedom.” Democrats were too equivocal in how they framed their ideology, in Tulchin’s view. He sought to change that by devising a crisper way to sell a government-run health care system to the public.
The rebranding efforts by Tulchin happened to coincide with a gathering of progressive discontent. Throughout the 1990s, the left had more or less abided the Clinton administration’s apologetic view of big government as the cost of staying in power. In 2008, after eight years of Bush’s promoting tax cuts for the wealthy, threatening to constitutionally forbid gay marriage and waging two costly wars, progressives believed their moment had arrived and saw in Obama a new champion. But his legislative efforts proved to fall well short of revolutionary. While admonishing the left to play along and accept one moldy half-loaf after another — on the economic stimulus, on climate change, on gun control, on immigration and on several judicial appointments — the Obama White House’s varied attempts to attract Republican support met only scorn.
To many progressives, Obamacare represented the apotheosis of this strategic folly. The president’s health care initiative played by the private sector’s rules, to the pharmaceutical industry’s conspicuous benefit. And then free-market Republicans rewarded this gesture of conciliation by bashing Democrats as socialists while methodically eviscerating the program on both the state and federal levels. When in 2012 it appeared that the conservative-dominated Supreme Court might declare the A.C.A. to be unconstitutional, DeMoro led the nurses’ union on a bus tour to make the case that the time had arrived for a robust, lawsuit-proof single-payer system. The campaign was premature, however: Chief Justice John Roberts cast the tiebreaking vote in favor of Obamacare, and again progressives were compelled to leave the fight. They watched red-faced in the 2014 midterms as some of the Democratic Party’s most cautious-minded legislators were labeled big-government liberals, enabling the G.O.P. to retake the Senate. By the time the party machinery began clearing the way for Hillary Clinton’s nomination, the left had grown tired of shutting up and was now looking to a dyspeptic 74-year-old Vermont socialist as their avatar.
As Tulchin conducted his public-opinion research to address the question of how Sanders might frame his health care initiative, he hit on an answer that was hiding in plain sight. It came from the legacy of Lyndon B. Johnson, who as president had pushed Medicare and Medicaid through Congress. As Tulchin told me: “The reality is, people know what Medicare is, and it’s very popular and seen as very effective. It’s a true success story for the left. Whereas no one knows what single payer is.”
Tulchin’s findings convinced the Sanders campaign to recast single payer as “Medicare for All” — a name that had previously appeared on a 2006 health care bill written by Senator Edward M. Kennedy that included a role for private insurers. (Kennedy had been an early proponent of single payer but had come to believe that opposition from the insurance industry would doom its chances.) Sanders and DeMoro knew that the word “Medicare” would register favorably among older Americans. They had not anticipated the issue’s overwhelming popularity — close to 70 percent, according to recent polling — among millennial voters. “This had been a gray-haired movement for decades,” DeMoro told me. “It surprised all of us how resonant the issue was with young people.”
Sanders’s
early campaign events were packed, in no small measure because of the
mobilizing efforts of the ubiquitous union members dressed in National
Nurses United’s trademark red hospital scrubs. The union’s
political-action committee purchased more than several million dollars’
worth of print and TV ads. Sanders, meanwhile, occasionally called
DeMoro from the campaign trail to enlist her help in demystifying the
arcane mechanics of the health care industry. “When a single-payer
system is finally enacted in the U.S.,” he told an aide, “RoseAnn DeMoro
and the nurses are going to be the heroes of this fight.”
Although the Democratic platform committee shunted aside Medicare for All in favor of preserving the Affordable Care Act, Trump’s shocking victory in November shifted the ground again. The longstanding efforts by G.O.P. state officeholders and the Republican-controlled Congress to chip away at the A.C.A. now had an eager partner in the White House.
Shortly after the election, Sanders persuaded the Senate minority leader, Chuck Schumer, to borrow a page from Sanders’s 2016 campaign and stage pro-Obamacare rallies across the country. Those health care events — the first of them on Jan. 15, 2017, with Sanders, Schumer and other Democrats speaking before 6,000 people in Warren, Mich. — began a counteroffensive that ultimately thwarted the G.O.P.’s ambitions of repealing Obamacare.
The rallies, and the crowds they drew, suggested how the politics of health care were changing, and how quickly. Trump and congressional Republicans spent most of his first year in office working relentlessly to repeal Obamacare, an effort that barely fell short in the Senate in August. Republican governors picked up the gauntlet: by December 2018, 20 states had joined a lawsuit seeking to weaken Obamacare.
The imperiling of the Affordable Care Act had unintended consequences. One was that, after years of unpopularity, the law began polling favorably. In the 2018 midterms, it was the Republicans who were on the defensive and stammering that, well, sure, there were a few good things about Obamacare and they could be counted on to protect those things. “I’m taking on both parties and fighting for those with pre-existing conditions,” the California Republican congressman Dana Rohrabacher claimed in a TV ad, despite having voted repeatedly to gut or repeal Obamacare. Voters did not seem to buy the G.O.P.’s protestations. Exit polls following the November 2018 midterm elections, in which Republicans lost 38 seats — including Rohrabacher’s — and control of the House, showed that health care was the top concern.
But the vulnerability of Obamacare also served to underscore the case for a more resilient and comprehensive health care system of the sort that Sanders had been calling for. Medicare for All had become not merely a pet cause among the party’s progressive base but a defining one. It had also become a succinct representation to voters of what Democrats aspired to do for them that Trump’s Republicans would not.
That it had fallen to Sanders to rally Democrats to save what he found an inferior health care policy was a peculiarity not lost on Sanders, who growled to me: “I don’t think anyone will tell you that in any way single payer was seriously considered. In fact, until this year there’s never even been a goddamned hearing on single payer!” The first such hearing took place on April 30, but under the auspices of the House Rules Committee, which has no legislative jurisdiction on health care. A more meaningful second hearing was convened before the powerful House Ways and Means Committee two months later.
Although the Democratic platform committee shunted aside Medicare for All in favor of preserving the Affordable Care Act, Trump’s shocking victory in November shifted the ground again. The longstanding efforts by G.O.P. state officeholders and the Republican-controlled Congress to chip away at the A.C.A. now had an eager partner in the White House.
Shortly after the election, Sanders persuaded the Senate minority leader, Chuck Schumer, to borrow a page from Sanders’s 2016 campaign and stage pro-Obamacare rallies across the country. Those health care events — the first of them on Jan. 15, 2017, with Sanders, Schumer and other Democrats speaking before 6,000 people in Warren, Mich. — began a counteroffensive that ultimately thwarted the G.O.P.’s ambitions of repealing Obamacare.
The rallies, and the crowds they drew, suggested how the politics of health care were changing, and how quickly. Trump and congressional Republicans spent most of his first year in office working relentlessly to repeal Obamacare, an effort that barely fell short in the Senate in August. Republican governors picked up the gauntlet: by December 2018, 20 states had joined a lawsuit seeking to weaken Obamacare.
The imperiling of the Affordable Care Act had unintended consequences. One was that, after years of unpopularity, the law began polling favorably. In the 2018 midterms, it was the Republicans who were on the defensive and stammering that, well, sure, there were a few good things about Obamacare and they could be counted on to protect those things. “I’m taking on both parties and fighting for those with pre-existing conditions,” the California Republican congressman Dana Rohrabacher claimed in a TV ad, despite having voted repeatedly to gut or repeal Obamacare. Voters did not seem to buy the G.O.P.’s protestations. Exit polls following the November 2018 midterm elections, in which Republicans lost 38 seats — including Rohrabacher’s — and control of the House, showed that health care was the top concern.
But the vulnerability of Obamacare also served to underscore the case for a more resilient and comprehensive health care system of the sort that Sanders had been calling for. Medicare for All had become not merely a pet cause among the party’s progressive base but a defining one. It had also become a succinct representation to voters of what Democrats aspired to do for them that Trump’s Republicans would not.
That it had fallen to Sanders to rally Democrats to save what he found an inferior health care policy was a peculiarity not lost on Sanders, who growled to me: “I don’t think anyone will tell you that in any way single payer was seriously considered. In fact, until this year there’s never even been a goddamned hearing on single payer!” The first such hearing took place on April 30, but under the auspices of the House Rules Committee, which has no legislative jurisdiction on health care. A more meaningful second hearing was convened before the powerful House Ways and Means Committee two months later.
The hearings
were in a sense a validation of Medicare for All’s newfound legitimacy
within the mainstream of the party, but they also demonstrated the party
leaders’ wariness of the idea. The Democratic Ways and Means chairman,
Richard Neal — who received nearly $550,000 in the 2018 election cycle
from the health insurance and pharmaceutical industries — had already
stated his preference for “a little more incremental” expansion of
health care. According to The Intercept, Neal urged his fellow
Democratic committee members beforehand to consider using phrases like
“universal health coverage” rather than “Medicare for All.”
On one level, these are academic debates. Unless Democrats can break the Republican lock on the Senate in 2020 — a longer-odds proposition than winning the presidential election — they will have no chance of passing any laws, let alone an overhaul of health care far more sweeping than the A.C.A., which Democrats barely managed to enact with a majority in the Senate.
But on another level, the debate isn’t academic at all. It is in fact at the core of the liberal-versus-pragmatic argument among the Democratic presidential candidates, with the former vice president Biden on one end, flashing his battle scars from the Obamacare fight, and Sanders and Warren on the other, arguing that a populist movement now demands more than minor tweaks to a fundamentally flawed health care system. And indeed, on Aug. 21 Sanders tacitly acknowledged the challenge in passing so drastic a change in policy: His campaign announced that his Medicare for All plan had been modified to ensure that union workers who had already negotiated satisfactory health-insurance plans would be compensated for whatever wage increases they had sacrificed in the process.
Several health care experts with whom I spoke consider the Sanders plan, strictly as a matter of policy, to be an entirely reasonable health care solution for America. “The U.S. is an outlier in the rest of the developed world in not having universal coverage and for having such high-cost health care,” Larry Levitt, the nonpartisan Kaiser Family Foundation’s executive vice president for health policy, told me.
Sanders’s proposal “would be an enormous shift in how we pay for health care, and you have to make a lot of assumptions about how that would work, with a lot of uncertainty,” Levitt continued. “For example, how far down could prices for hospitals, physicians and drugs be pushed? How much more health care would people use if we had universal coverage with no deductibles and co-pays? And how well could the supply of hospitals and doctors adjust to an increase in use of health care? There’s a lot of uncertainty to how all of this would play out. But there’s a fair amount of consensus among economists who’ve looked at it that we could provide universal coverage through a Medicare-for-All-type plan and not pay much more for than we’re currently paying.”
Still, the change would be monumental. “The Sanders proposal would leapfrog every country in the world in creating a more liberal health care system,” Levitt said. “Every other system with universal coverage has at least some out-of-pocket costs for patients. And almost every other country still allows for private insurance.” And insurance companies in Europe, for instance, are often nonprofit, highly regulated and with little to no political power. American insurance companies are a different story, and it seems fair to conjecture that they will not forsake their billions in net earnings without a fight.
On one level, these are academic debates. Unless Democrats can break the Republican lock on the Senate in 2020 — a longer-odds proposition than winning the presidential election — they will have no chance of passing any laws, let alone an overhaul of health care far more sweeping than the A.C.A., which Democrats barely managed to enact with a majority in the Senate.
But on another level, the debate isn’t academic at all. It is in fact at the core of the liberal-versus-pragmatic argument among the Democratic presidential candidates, with the former vice president Biden on one end, flashing his battle scars from the Obamacare fight, and Sanders and Warren on the other, arguing that a populist movement now demands more than minor tweaks to a fundamentally flawed health care system. And indeed, on Aug. 21 Sanders tacitly acknowledged the challenge in passing so drastic a change in policy: His campaign announced that his Medicare for All plan had been modified to ensure that union workers who had already negotiated satisfactory health-insurance plans would be compensated for whatever wage increases they had sacrificed in the process.
Several health care experts with whom I spoke consider the Sanders plan, strictly as a matter of policy, to be an entirely reasonable health care solution for America. “The U.S. is an outlier in the rest of the developed world in not having universal coverage and for having such high-cost health care,” Larry Levitt, the nonpartisan Kaiser Family Foundation’s executive vice president for health policy, told me.
Sanders’s proposal “would be an enormous shift in how we pay for health care, and you have to make a lot of assumptions about how that would work, with a lot of uncertainty,” Levitt continued. “For example, how far down could prices for hospitals, physicians and drugs be pushed? How much more health care would people use if we had universal coverage with no deductibles and co-pays? And how well could the supply of hospitals and doctors adjust to an increase in use of health care? There’s a lot of uncertainty to how all of this would play out. But there’s a fair amount of consensus among economists who’ve looked at it that we could provide universal coverage through a Medicare-for-All-type plan and not pay much more for than we’re currently paying.”
Still, the change would be monumental. “The Sanders proposal would leapfrog every country in the world in creating a more liberal health care system,” Levitt said. “Every other system with universal coverage has at least some out-of-pocket costs for patients. And almost every other country still allows for private insurance.” And insurance companies in Europe, for instance, are often nonprofit, highly regulated and with little to no political power. American insurance companies are a different story, and it seems fair to conjecture that they will not forsake their billions in net earnings without a fight.
Though
polling does not reflect an outpouring of love for private insurance, it
is the devil Americans know. “There’s fear of change and comfort with
what’s known, a bias toward the status quo, and it’s hard to quantify
that,” says Topher Spiro, the Center for American Progress’s vice
president for health policy. “There’s a real psychological issue that’s
appropriate for policymakers to consider. I don’t think the people like
us who are putting forth multipayer universal systems are doing so
because we think insurers have some sort of superior efficiency or can
improve the quality of care. It’s really a concern about how we get
there the quickest in terms of political viability and with a minimum of
disruption.”
Single-payer advocates play down the difficulty of transitioning into a government-run health care system. As Sanders puts it: “You have Medicare, a popular system that millions of people are already in. It seems to me the easiest way forward to get to universal care is to expand what’s already a popular system. I find it really amazing that people think this isn’t doable when back in 1965 they did Medicare without the technology we have today, and they were able to sign up 19 million people. So of course we can do it.”
But while the Republican efforts to gut Obamacare have bolstered support for a more ambitious health care policy, they have also clearly illustrated one potential downside of such a policy. “Medicare cuts are in Trump’s budget,” Tanden says. “If you’re worried about a Trump administration now, just imagine if the government has control of everyone’s health care. And I say that as a big-government liberal.”
The day before Sanders took to the debate stage in Detroit to defend Medicare for All, I met with him in a conference room at the Doubletree Suites hotel where he was staying. He was seated alone, wearing his customary off-the-rack navy suit and tieless white shirt, flanked by a Starbucks breakfast of coffee, granola and yogurt.
“We’ve got a health care crisis in this country,” he told me as he struggled with the plastic granola container, finally gouging it open with his car keys. Sanders has a reputation for being as beatific as a snapping turtle, but today he was happy(ish) to be discussing the topic that he and DeMoro had succeeded in crowbarring into the national debate. “You’ve heard me talk about F.D.R. in 1944 talking about economic rights as a human right,” he said. “That’s what we’re doing here, and I think with some success: changing consciousness in this country. Now everybody agrees health care is a human right. How you get there is subject to discussion. But that’s where we are.”
Recently Sanders had been campaigning in Las Vegas. While driving through the city, he marveled at the billboards advertising marijuana for sale. “Five years ago, corporations marketing marijuana would have been out of the question,” he said to the aides in his car. “Now they’re not only doing it, but it’s not even remarkable that they’re doing it. Politics change very quickly.”
A not-so-minor refinement to that thought would be: Politics change quickly as long as nothing is standing in the way. Nearly three decades have passed since Sanders and DeMoro began doing battle with the health industry and the political system. “What they do have is, they lie and they have an enormous amount of money — I get that,” Sanders conceded. “But I do think we’re at a moment in history where the American people are sick and tired of the insurance companies and drug companies. And I do believe we can beat them.”
For any movement, the answer to the question of how is not really legislative. The Rev. Martin Luther King Jr. had his dream. RoseAnn DeMoro told me hers recently. “I think it’s time now,” she said, smirking a bit as she studied her glass of white wine. “I think America needs to say to these C.E.O.s: ‘You’ve had your day. You’ve bought your 50 frigging yachts. But it’s over. Now let’s have health care in this country.’ ”/•/
https://www.nytimes.com/2019/08/27/magazine/medicare-for-all-democrats.html?
Single-payer advocates play down the difficulty of transitioning into a government-run health care system. As Sanders puts it: “You have Medicare, a popular system that millions of people are already in. It seems to me the easiest way forward to get to universal care is to expand what’s already a popular system. I find it really amazing that people think this isn’t doable when back in 1965 they did Medicare without the technology we have today, and they were able to sign up 19 million people. So of course we can do it.”
But while the Republican efforts to gut Obamacare have bolstered support for a more ambitious health care policy, they have also clearly illustrated one potential downside of such a policy. “Medicare cuts are in Trump’s budget,” Tanden says. “If you’re worried about a Trump administration now, just imagine if the government has control of everyone’s health care. And I say that as a big-government liberal.”
The day before Sanders took to the debate stage in Detroit to defend Medicare for All, I met with him in a conference room at the Doubletree Suites hotel where he was staying. He was seated alone, wearing his customary off-the-rack navy suit and tieless white shirt, flanked by a Starbucks breakfast of coffee, granola and yogurt.
“We’ve got a health care crisis in this country,” he told me as he struggled with the plastic granola container, finally gouging it open with his car keys. Sanders has a reputation for being as beatific as a snapping turtle, but today he was happy(ish) to be discussing the topic that he and DeMoro had succeeded in crowbarring into the national debate. “You’ve heard me talk about F.D.R. in 1944 talking about economic rights as a human right,” he said. “That’s what we’re doing here, and I think with some success: changing consciousness in this country. Now everybody agrees health care is a human right. How you get there is subject to discussion. But that’s where we are.”
Recently Sanders had been campaigning in Las Vegas. While driving through the city, he marveled at the billboards advertising marijuana for sale. “Five years ago, corporations marketing marijuana would have been out of the question,” he said to the aides in his car. “Now they’re not only doing it, but it’s not even remarkable that they’re doing it. Politics change very quickly.”
A not-so-minor refinement to that thought would be: Politics change quickly as long as nothing is standing in the way. Nearly three decades have passed since Sanders and DeMoro began doing battle with the health industry and the political system. “What they do have is, they lie and they have an enormous amount of money — I get that,” Sanders conceded. “But I do think we’re at a moment in history where the American people are sick and tired of the insurance companies and drug companies. And I do believe we can beat them.”
For any movement, the answer to the question of how is not really legislative. The Rev. Martin Luther King Jr. had his dream. RoseAnn DeMoro told me hers recently. “I think it’s time now,” she said, smirking a bit as she studied her glass of white wine. “I think America needs to say to these C.E.O.s: ‘You’ve had your day. You’ve bought your 50 frigging yachts. But it’s over. Now let’s have health care in this country.’ ”/•/
https://www.nytimes.com/2019/08/27/magazine/medicare-for-all-democrats.html?
Fact check: Did Bernie just backtrack on Medicare for All?
Critics pounced on a tweak Sanders made this week to his signature plan, but they're being misleading.Speaking to labor officials in Iowa this week, Bernie Sanders unveiled a new twist to his “Medicare for All” plan. His centrist Democratic rivals pounced, accusing the original champion of government-run health care of softening his signature policy in order to placate angry union members.
Nonsense, his campaign responded.
Story Continued Below
So what's the deal?
The new provision is wonkish, so bear with us here. But bottom line, it would offer advantages to workers who negotiated health plans through their unions during the four years the country moved to a universal, single-payer system.
Here's a breakdown of Sanders' controversial tweak and what it actually amounts to:
How would it work?
Under Sanders’ new plan, companies with union-negotiated health care coverage would have to renegotiate their workers’ contracts. The National Labor Relations Board would oversee and enforce the negotiations once Medicare for All becomes law. Any resulting health care savings from the single-payer system would be required to be returned to workers in the form of higher wages or more generous benefits.Workers who don't belong to unions wouldn't qualify for that treatment.
This plan is a small part of a major, 1,900-word policy aimed at strengthening organized labor across the country that, among other things, calls for a dramatic expansion of collective bargaining.
Sanders’ proposal does not change anything in the Medicare for All legislation he unveiled in April, but adds requirements for the transition period that were not sketched out in the bill text.
Notably, the plan does not allow for more private health insurance. A critical part of the debate over Medicare for All has centered on the fact that Sanders’ bill would essentially abolish private insurance, and that remains the same under his new policy.
What did critics say?
Sanders’ rivals in the 2020 primary immediately slammed the new proposal, accusing him of backtracking from his hard-line opposition to private health insurance and characterizing it as an admission of the policy’s flaws.“Bernie’s rewrite is the latest example of a Medicare for All candidate moving away from the plan in the face of the fact that it’s both bad policy and bad politics,” said Sen. Michael Bennet (D-Colo.). “Now that Senator Sanders is reversing, Senator Warren and the other candidates should reconsider Medicare for All.”
Campaign aides to Kamala Harris, who originally signed onto Sanders’ bill before backing away from the proposal and introducing her own health care plan, seized on the announcement as well.
“Bernie’s backtrack doesn’t solve the problems with his plan, it just lets everyone know that they’re there,” added John Delaney, one of the primary race’s loudest opponents of the single-payer plan.
Other critics on social media pointed out that Sanders’ proposal follows some union leaders and members expressing concerns about Medicare for All, including directly to Sanders on the campaign trail in Iowa. Joe Biden, who opposes Medicare for All, said this week that union workers “don’t have to give up” their private insurance under his health care plan because labor organizations “negotiated really hard” for those benefits.
How did Sanders’ campaign respond?
Sanders’ aides took to social media to aggressively push back. Warren Gunnels, a senior adviser to Sanders, said on Twitter that he “didn’t amend” the Medicare for All bill and called a Washington Post headline about the proposal — "Sen. Bernie Sanders changes how Medicare-for-all plan treats union contracts in face of opposition by organized labor" — “bullshit” and “bogus.” Another staffer said the plan simply provided “additional value to worker contracts.”Sanders’ campaign told POLITICO that the question of whether companies or union members would receive the savings from eliminating private insurance was always one that needed to be answered — and the NLRB provides a way to direct those funds to organized workers. For non-union workers who lack contracts, they said, there’s no such mechanism.
“Organized workers sit down and negotiate an entire wage and benefits package, often including health care. Because at the end of the day both sides are just negotiating over the overall size of that aggregate package, the company has agreed to pay the workers a dollar amount of wages and benefits. Those agreements may be locked in for many years. That's really the key,” said Jeff Weaver, a top adviser to Sanders. “To lock in workers who made wage concessions for health care for years is not fair.”
Who’s right?
Sanders’ critics say the new policy is an admission the original plan was bad for unions. But the leaders of many major labor unions, including the SEIU, the American Federation of Teachers and the Association of Flight Attendants, say they support Medicare for All and believe their workers would benefit from free and comprehensive health coverage that they don’t have to bargain for.Yet the new details the campaign released do nod to the anxieties about the proposal that some key players in the labor world have raised. Even some of those who say many union workers are paying too much now for too little health care have a fear of the unknown, and the additional incentives Sanders is offering could go a ways toward assuaging those concerns.
"Bernie Sanders understands collective bargaining," said Sara Nelson, president of the Association of Flight Attendants. "He's making sure union members can capture the value we've previously negotiated in health care as increased wages or other contractual gains."
The claims that Sanders' plan would allow more private insurance seems to stem from the fact that his new proposal lets union members negotiate for private health benefits as long as they don't duplicate what's covered under Medicare for All (which is, essentially, everything). But Sanders has permitted that all along.
What's the upshot?
The accusations that Sanders is flip-flopping are inaccurate. The new proposal doesn't alter anything in the original bill and private insurance will still be virtually eliminated — even if does give union members a big advantage under the plan compared to non-unions workers with private insurance.https://www.politico.com/story/2019/08/22/bernie-sanders-medicare-for-all-fact-check-1472482
Op-Ed: Hello from Canada. Here’s how the Democratic candidates can dispel myths about single-payer healthcare
by Steven Lewis - LA Times - August 20, 2019
Hey America. Canada here. Yes, we’re still friends,
though we’re going through a bit of a rough patch. (Tariffs? Really?) We
wish you the best — even your president, although just 25% of us have confidence in him. Well, not just — that’s a big number. I’m kind of stunned.
Never mind. I’m writing to meddle in your election. Why? Healthcare. It could win it or lose it for the Democrats. I watched the July debates. It’s an impressive field; even the anti-vaxxer had her moments. Every candidate wants every American to have access to care. All agree the system is absurdly expensive, captured by insurers and pharma, and tragically unjust. So do most Americans. But there is no consensus on how to fix it. Many abhor the system as a whole, but like what they have.
That conundrum divides the front-runners into two camps. Transformers (led by Bernie Sanders and Elizabeth Warren) advocate for versions of “Medicare for all,” a single-payer system under which private insurance would disappear. Reformers (led by Joe Biden and Kamala Harris) advocate a public option (exiled from Obamacare) to compete alongside private insurance. The go-big camp believes the revolutionary moment has arrived, and that Democrats can win by seizing it. The Obamacare 2.0 camp considers single-payer too disruptive, radical and expensive to win over an electorate attached to private insurance plans and hostile to government-run programs.
Who’s right? Who knows? It’s easy to demonize single-payer. Choice — gone! Taxes — up! Government takeover! Rationing! Most people have health insurance. It is the devil they know, and single-payer offers them the devil they don’t. It’s hard to persuade them that single-payer is viable, and even harder to persuade them that it’s better.
As I watched the debates, I found myself barking at the TV: “Come on!” “You can do better than that!” “Bring your A game!” The case for incremental improvement rests on hoary myths and bad math. It’s no secret why people are opposed to change or are still on the fence. The Democrats need to deal head-on with concerns like these:
I like my private insurance plan and want to keep it. Really? I doubt you love your insurer, part of the cabal that skims off hundreds of billions of dollars a year from direct care. You may like your doctor, low co-pays and deductibles. All around the world, single-payer covers as much or more than your private insurance, often at half the cost. Administrative costs for single-payer are also a fraction of the costs of healthcare administration in the U.S.
Single-payer will raise my taxes. A tax-funded healthcare system needs tax revenues. The issue here is not what you pay in taxes; it’s what you keep in your pocket after taxes and (in this case) healthcare expenses. Even with so-called good insurance, you fork over for co-pays and deductibles and about $5,500 per family as your share of the average $19,600 total cost of premiums paid by your employer. Your income will be lower because your employer has to spend $14,000 a year on your healthcare insurance. The exorbitant cost of healthcare inflates the cost of goods and services made in the U.S. and the price you pay for them. Single-payer makes most people financially better off.
Employers should have to provide healthcare for workers. Health insurance is a huge burden and threat to business. It makes many businesses internationally uncompetitive. You shouldn’t have to stay in a job you don’t like just to keep your health insurance. Businesses should compete for workers on the basis of pay, working conditions and opportunity, not healthcare.
Under single-payer I won’t be able to choose my doctor or hospital. Big lie. Canadians can go to any family doctor they like, and the family doctor is the gatekeeper to specialists. So can the English, and the Spanish, and the Scots, and residents of most wealthy countries. Most Americans don’t have unrestricted choice without paying a big price for going out of network. Under single-payer, the norm is that people choose their providers. In the U.S., most insurers make the choice for you.
Single-payer is unaffordable. Compared to what? Healthcare in the U.S. is twice as expensive as in other wealthy countries. But that doesn’t mean Americans get more healthcare. Massive amounts of money are siphoned off to the insurance bureaucracy that buries doctors in paperwork and challenged claims, and tells patients where they can and cannot go for care. U.S. consumers pay the highest prices in the world for drugs. Single-payer greatly reduces the administrative burden, and has secured far lower drug prices in many other countries.
Single-payer may not provide everything I get now. That’s right, it may not. No program — private or public — offers everything to everyone in every circumstance. But healthcare in the U.S. is spectacularly abundant, and many patients get tests and procedures they don’t need. Healthcare costs twice as much for seniors in Miami as for seniors in Minneapolis, who are just as healthy and satisfied with their care. You want the right care, not necessarily the most care.
If how the U.S. organizes and pays for healthcare were based on dispassionate analysis on the part of fully informed citizens and uncompromised legislators, the status quo would have been shown the door decades ago. Those that stand to lose the most — pharma and insurers — are widely unloved. The monstrosity persists because of money, fear, inertia and deep suspicion of government as an instrument of good. These are formidable obstacles to overcome.
The anti-single-payer playbook is hardly a mystery. If you can’t win public hearts and minds in a contest with drug company felons and insurance oligarchs, and if you can’t get business behind a plan that liberates it from a crushing burden, it’s either a hopeless cause, or you’ve been outgunned.
If the Democrats can sell single-payer, they will likely win in 2020. The new president will have a mandate and the moral authority to get single-payer in place. (I know, there’s still Congress and the Supreme Court.) Job one is to beat Trump, but soon the catharsis will give way to the hard realities of reconstruction. U.S. healthcare is the symbol of a corrupt and broken polity, nothing remotely of, by or for the people. Single-payer isn’t perfect, but it’s incomparably better than the status quo.
The healthcare stakes are enormous. Choose your words carefully, Democratic candidates, and play your hands well.
Steven Lewis is a Canadian health policy analyst and researcher currently living in Australia.
Never mind. I’m writing to meddle in your election. Why? Healthcare. It could win it or lose it for the Democrats. I watched the July debates. It’s an impressive field; even the anti-vaxxer had her moments. Every candidate wants every American to have access to care. All agree the system is absurdly expensive, captured by insurers and pharma, and tragically unjust. So do most Americans. But there is no consensus on how to fix it. Many abhor the system as a whole, but like what they have.
That conundrum divides the front-runners into two camps. Transformers (led by Bernie Sanders and Elizabeth Warren) advocate for versions of “Medicare for all,” a single-payer system under which private insurance would disappear. Reformers (led by Joe Biden and Kamala Harris) advocate a public option (exiled from Obamacare) to compete alongside private insurance. The go-big camp believes the revolutionary moment has arrived, and that Democrats can win by seizing it. The Obamacare 2.0 camp considers single-payer too disruptive, radical and expensive to win over an electorate attached to private insurance plans and hostile to government-run programs.
Who’s right? Who knows? It’s easy to demonize single-payer. Choice — gone! Taxes — up! Government takeover! Rationing! Most people have health insurance. It is the devil they know, and single-payer offers them the devil they don’t. It’s hard to persuade them that single-payer is viable, and even harder to persuade them that it’s better.
As I watched the debates, I found myself barking at the TV: “Come on!” “You can do better than that!” “Bring your A game!” The case for incremental improvement rests on hoary myths and bad math. It’s no secret why people are opposed to change or are still on the fence. The Democrats need to deal head-on with concerns like these:
I like my private insurance plan and want to keep it. Really? I doubt you love your insurer, part of the cabal that skims off hundreds of billions of dollars a year from direct care. You may like your doctor, low co-pays and deductibles. All around the world, single-payer covers as much or more than your private insurance, often at half the cost. Administrative costs for single-payer are also a fraction of the costs of healthcare administration in the U.S.
Single-payer will raise my taxes. A tax-funded healthcare system needs tax revenues. The issue here is not what you pay in taxes; it’s what you keep in your pocket after taxes and (in this case) healthcare expenses. Even with so-called good insurance, you fork over for co-pays and deductibles and about $5,500 per family as your share of the average $19,600 total cost of premiums paid by your employer. Your income will be lower because your employer has to spend $14,000 a year on your healthcare insurance. The exorbitant cost of healthcare inflates the cost of goods and services made in the U.S. and the price you pay for them. Single-payer makes most people financially better off.
Employers should have to provide healthcare for workers. Health insurance is a huge burden and threat to business. It makes many businesses internationally uncompetitive. You shouldn’t have to stay in a job you don’t like just to keep your health insurance. Businesses should compete for workers on the basis of pay, working conditions and opportunity, not healthcare.
Under single-payer I won’t be able to choose my doctor or hospital. Big lie. Canadians can go to any family doctor they like, and the family doctor is the gatekeeper to specialists. So can the English, and the Spanish, and the Scots, and residents of most wealthy countries. Most Americans don’t have unrestricted choice without paying a big price for going out of network. Under single-payer, the norm is that people choose their providers. In the U.S., most insurers make the choice for you.
Single-payer is unaffordable. Compared to what? Healthcare in the U.S. is twice as expensive as in other wealthy countries. But that doesn’t mean Americans get more healthcare. Massive amounts of money are siphoned off to the insurance bureaucracy that buries doctors in paperwork and challenged claims, and tells patients where they can and cannot go for care. U.S. consumers pay the highest prices in the world for drugs. Single-payer greatly reduces the administrative burden, and has secured far lower drug prices in many other countries.
Single-payer may not provide everything I get now. That’s right, it may not. No program — private or public — offers everything to everyone in every circumstance. But healthcare in the U.S. is spectacularly abundant, and many patients get tests and procedures they don’t need. Healthcare costs twice as much for seniors in Miami as for seniors in Minneapolis, who are just as healthy and satisfied with their care. You want the right care, not necessarily the most care.
If how the U.S. organizes and pays for healthcare were based on dispassionate analysis on the part of fully informed citizens and uncompromised legislators, the status quo would have been shown the door decades ago. Those that stand to lose the most — pharma and insurers — are widely unloved. The monstrosity persists because of money, fear, inertia and deep suspicion of government as an instrument of good. These are formidable obstacles to overcome.
The anti-single-payer playbook is hardly a mystery. If you can’t win public hearts and minds in a contest with drug company felons and insurance oligarchs, and if you can’t get business behind a plan that liberates it from a crushing burden, it’s either a hopeless cause, or you’ve been outgunned.
If the Democrats can sell single-payer, they will likely win in 2020. The new president will have a mandate and the moral authority to get single-payer in place. (I know, there’s still Congress and the Supreme Court.) Job one is to beat Trump, but soon the catharsis will give way to the hard realities of reconstruction. U.S. healthcare is the symbol of a corrupt and broken polity, nothing remotely of, by or for the people. Single-payer isn’t perfect, but it’s incomparably better than the status quo.
The healthcare stakes are enormous. Choose your words carefully, Democratic candidates, and play your hands well.
Steven Lewis is a Canadian health policy analyst and researcher currently living in Australia.
https://www.latimes.com/opinion/story/2019-08-19/canada-medicare-for-all-single-payer-healthcare-warren-sanders
An International Perspective On The Paradoxes Of US Health Care
by Angèle Malâtre-Lansac - Health Affairs - August 28, 2019
Editor's Note: In addition to Angèle Malâtre-Lansac, this
post was conceived of and written by the 2018-2019 Harkness Fellows on
health care policy and practice listed at end of this post.
Each year, the Commonwealth Fund selects an international cohort of Harkness Fellows in health care policy and practice, consisting of mid-career researchers, policy makers, and practitioners with leading positions in their countries, who come to the US to study the health care system, work with renowned US health policy experts, and provide input to US health care and research, drawing on insights from their own international contexts.
Reflections on health care in the US are commonplace: In our view, what is less common are observations and reflections from health experts from seven other countries on US health care. What are the most surprising aspects of the US system through the lenses of 10 observers from Australia, France, Germany, the Netherlands, New Zealand, Norway, and England?
The diversity across US states is striking to us, particularly in terms of access to, and quality of, health care services. Perhaps, most surprising from our international perspective is the importance of political differences as a unique determinant of regional variations in health care performance. The ongoing debate over the Affordable Care Act (ACA) and the state-based variation in implementation of the ACA are vivid examples of this diversity and polarization within health care.
While there can be many benefits to diversity and choice, particularly in terms of tailoring services and resources to meet the specific needs of different populations and to ensure appropriate care, too much of a good thing can create problems. As an example, the sheer number of options individuals need to review and decide upon when considering a private health insurance plan or selecting a provider creates complexity, decision fatigue, and frustration.
In addition, although we hear a lot of discussion about the costs of care, it is surprising how little of the conversation is on the costs of care not delivered. Approximately 28.5 million Americans have no health insurance, and it’s well known that being uninsured negatively affects your health and is costly. There are costs for the individuals; for the families who rely on those individuals for financial and other forms of support; for the businesses whose employees are absent, unproductive, or retire early; for the health care system, which ends up providing more expensive reactive care; and for society at large.
Another stark difference between the US and our own countries is the high level of financial burden placed on its people. Prominent in the US health care system are the high-deductible health plans driven by the idea that cost-sharing obligations will encourage people to prioritize high-value care and reduce health care spending. Yet, recent evidence suggest that populations on such plans delay or skip essential care entirely and as a consequence, experience adverse effects.
Drug prices in the US are three to six times higher than in many European countries, despite decades of calls for change. Our countries use Health Technology Assessment (HTA)—a multidisciplinary approach that considers the clinical, economic, legal, ethical, and organizational aspects of new technologies such as drugs, devices, and procedures. The core principle is to determine the added value of new technologies compared to existing alternatives to inform authorities responsible for coverage and reimbursement decisions. Unlike in our countries, there is no single agency tasked with addressing this issue in the US.
In the US, governance is often unclear, and there is no shared understanding of what each actor in the health care system is accountable for (and to whom). At the end of the day, the entire system seems beholden to one thing: the “bottom line.” The lack of a commitment to universal coverage, as well as the many different stakeholders and multiplicity of intermediaries in the supply chain, might explain this phenomenon.
These lessons may not come as a great surprise to the many policy makers and researchers who have long studied and aspired to improve health care in the US. Our hope is that, by highlighting the challenges that stand out most acutely to us as outsiders, this international perspective may provoke thoughtful discussion about how to achieve better health outcomes. Addressing those great challenges is like tackling climate change—it’s both crucial and painful. Taking the necessary steps toward a greater good first requires agreement on what that looks like. The opportunity of the upcoming presidential campaign will undoubtedly make it possible to bring a new vision for the future of US health care.
2018-2019 Harkness Fellows on health care policy and practice from the Commonwealth Fund:
Angèle Malâtre-Lansac, France
Mary Docherty, UK
Unni Gopinathan, Norway
Cornelia Henschke, Germany
Prakash Jayakumar, UK
Nadine Kasparian, Australia
Grégoire Mercier, France
Huseyin Naci, UK
Andrew Old, New Zealand
Laura Shields-Zeeman, Netherlands
Each year, the Commonwealth Fund selects an international cohort of Harkness Fellows in health care policy and practice, consisting of mid-career researchers, policy makers, and practitioners with leading positions in their countries, who come to the US to study the health care system, work with renowned US health policy experts, and provide input to US health care and research, drawing on insights from their own international contexts.
Reflections on health care in the US are commonplace: In our view, what is less common are observations and reflections from health experts from seven other countries on US health care. What are the most surprising aspects of the US system through the lenses of 10 observers from Australia, France, Germany, the Netherlands, New Zealand, Norway, and England?
No Such Thing As The US Health Care System
The United States undeniably provides some of the best health care and is one of the most innovative nations in the world. Financial investments in health and medical research are the envy of us all. Pockets of excellence can be seen in so many places. However, one of our first realizations is that there is no such thing as a single, unified, and coordinated US health care system—but rather a complicated and fragmented health care marketplace. Variations between US states, communities, and health insurance plans are in many cases greater than the differences between our countries. There are many reasons for this, but key among them are our countries’ shared principle of universal health coverage (both within single and multi-payer systems) and our usually nationally negotiated prices.The diversity across US states is striking to us, particularly in terms of access to, and quality of, health care services. Perhaps, most surprising from our international perspective is the importance of political differences as a unique determinant of regional variations in health care performance. The ongoing debate over the Affordable Care Act (ACA) and the state-based variation in implementation of the ACA are vivid examples of this diversity and polarization within health care.
While there can be many benefits to diversity and choice, particularly in terms of tailoring services and resources to meet the specific needs of different populations and to ensure appropriate care, too much of a good thing can create problems. As an example, the sheer number of options individuals need to review and decide upon when considering a private health insurance plan or selecting a provider creates complexity, decision fatigue, and frustration.
Health Care As A Privilege, Not A Right
In our countries, there is a broad consensus on the role of the government in health care, as there is in education. Health care is considered a fundamental right. In the US, the federal government does not assume full responsibility for ensuring the right to health care for its citizens. The predominant narrative here frames health as a privilege. This plays out in many ways, but perhaps most notably it is advanced by proponents of work requirements for Medicaid, premised on the idea that access to health care is something to be earned. And yet, many US people cherish Medicare, a government program that provides universal coverage for people ages 65 years and older.In addition, although we hear a lot of discussion about the costs of care, it is surprising how little of the conversation is on the costs of care not delivered. Approximately 28.5 million Americans have no health insurance, and it’s well known that being uninsured negatively affects your health and is costly. There are costs for the individuals; for the families who rely on those individuals for financial and other forms of support; for the businesses whose employees are absent, unproductive, or retire early; for the health care system, which ends up providing more expensive reactive care; and for society at large.
Another stark difference between the US and our own countries is the high level of financial burden placed on its people. Prominent in the US health care system are the high-deductible health plans driven by the idea that cost-sharing obligations will encourage people to prioritize high-value care and reduce health care spending. Yet, recent evidence suggest that populations on such plans delay or skip essential care entirely and as a consequence, experience adverse effects.
The Price Problem
On average, the US spends twice as much as other Organization for Economic Cooperation and Development countries on health care without evidence of superior care or health outcomes. In fact, life expectancy is declining in the US while health care costs continue to rise. Grossly inflated drug and device prices, overall health care costs, and surprise billing are big challenges. Substantial administration and advertising costs are a further unintended consequence of the primacy placed on individual choice. Quite simply, everything is more expensive in the United States than it is in our countries.Drug prices in the US are three to six times higher than in many European countries, despite decades of calls for change. Our countries use Health Technology Assessment (HTA)—a multidisciplinary approach that considers the clinical, economic, legal, ethical, and organizational aspects of new technologies such as drugs, devices, and procedures. The core principle is to determine the added value of new technologies compared to existing alternatives to inform authorities responsible for coverage and reimbursement decisions. Unlike in our countries, there is no single agency tasked with addressing this issue in the US.
The Accountability Problem
In an article recently published in the New England Journal of Medicine, “The Not-My-Problem Problem,” Lisa Rosenbaum provides a persuasive account of the unintended consequences of diffusion of responsibility in a highly fragmented US health care system. According to the World Health Organization’s Health System Framework, well-functioning health care systems share several characteristics, including leadership and governance, factors that play essential roles in achieving the goals of health systems, regardless of how health systems are organized and designed.In the US, governance is often unclear, and there is no shared understanding of what each actor in the health care system is accountable for (and to whom). At the end of the day, the entire system seems beholden to one thing: the “bottom line.” The lack of a commitment to universal coverage, as well as the many different stakeholders and multiplicity of intermediaries in the supply chain, might explain this phenomenon.
These lessons may not come as a great surprise to the many policy makers and researchers who have long studied and aspired to improve health care in the US. Our hope is that, by highlighting the challenges that stand out most acutely to us as outsiders, this international perspective may provoke thoughtful discussion about how to achieve better health outcomes. Addressing those great challenges is like tackling climate change—it’s both crucial and painful. Taking the necessary steps toward a greater good first requires agreement on what that looks like. The opportunity of the upcoming presidential campaign will undoubtedly make it possible to bring a new vision for the future of US health care.
Author’s Note
Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.2018-2019 Harkness Fellows on health care policy and practice from the Commonwealth Fund:
Angèle Malâtre-Lansac, France
Mary Docherty, UK
Unni Gopinathan, Norway
Cornelia Henschke, Germany
Prakash Jayakumar, UK
Nadine Kasparian, Australia
Grégoire Mercier, France
Huseyin Naci, UK
Andrew Old, New Zealand
Laura Shields-Zeeman, Netherlands
Letter to the Editor
by Paul Leibow - the Ellsworth American - August 28, 2019
Thoughts on pre-existing conditions and lifetime caps
Dear
Editor: It appalls me that Sen. Collins has once again sided with Big
Pharma, Big Insurance and Big Trump over the interests of all Mainers.
Allowing an insurer to claim your disease is due to a “pre-existing
condition” is the ultimate fraud. Breast and other cancers do not just
come calling your name one sad morning. Cells start to grow and divide
irregularly due to inheritance, environmental poisons and chance over
decades. Just like the vascular abnormalities of heart attack and
stroke.
If
Mr. so-called President continues to monkey with Medicare and the
Affordable Care Act, he will trigger a “winner takes all” monopoly
capitalism financial stampede in health care insurance. We will
experience a total community health care meltdown that will affect so
many of our friends and neighbors, even if we personally scrape by.
“Insurance” is not spending $5 to avoid the vanishingly small risk
that a $200 package is lost in the mail. Insurance is meant to protect
American families from the overwhelming fear of arbitrarily losing everything they have worked their whole lives for — “the American Dream.”
Such denials happen many thousands of times as people all over America
exceed arbitrary decapitation by their health insurance provider after
they contract an expensive or chronic medical condition through no
fault of their own. Thankfully the Maine Legislature
outlawed such behavior in this state with the passage of LD1620, “An
Act to Protect Health Care Consumers Against Catastrophic Medical Debt.”
I was terrified! It was Feb. 3, 2010, and I was officially testifying
on behalf of the Maine Medical Association, and very confi dent that two
other prominent medical organizations supported me — Maine PSR and
Maine ACEP. I was a heart transplant recipient, after catching a virus
on the job in the ER at Eastern Maine Medical Center. I had just spent a
terrifying month trying to deal with my insurance company, which was
telling me I had reached a “lifetime maximum cap” on my health care.
Suddenly I couldn’t get so-called “prior approval” for my life-saving
miracle medications, though I had gotten many other reauthorizations
with only one error. I couldn’t get through to anybody in “customer
care” at my giant national “insurance” company who would tell me
anything.
I
couldn’t get a call back from my supposed in-hospital “case manager.” I
got dumped from answering machine to answering machine with never a
return call. I was told that I “did” and that I “did not” have insurance
within five minutes, by two different people trying to put me off.
My pharmacist couldn’t get through for “prior authorization” for
life-saving medications and my “benefits office” couldn’t get through
to begin to get any answers. I could
not get any help from the “practitioners” at the Brigham in Boston,
who assured me they had gotten “prior approval” for a $24,000 cardiac
catheterization but insurance said I hadn’t.
The procedure involved five or six people’s time over less than an
hour, a few hundred dollars of medical supplies and a huge machine that
took X-ray pictures of my heart. It was certainly worth a few thousand
dollars, but I then got a bill with a threatening invoice, obviously
derived from the “Chargemaster.” Few know what a “Chargemaster” is. It
is a secret book of fantasy “Medical Charges from Hell” that hospitals
invent, generally about three times the negotiated rates with insurance
companies. It is written in code that most hospital administrators
can’t interpret and secreted off-campus and can only be reviewed with
“special permission.” It is used to plea bargain innocent Americans
into paying financially lethal charges, while rapidly bleeding out their
life savings and taking their homes.
I am sure I speak for most of the 100,000plus patients I have treated,
many of them at the worst times of their lives, perhaps even for the
majority owners and executives of insurance companies. No hard-working
American should ever be subject to arbitrary death by disease, death by
neglect, death by bureaucracy or death by lawyer.
Paul A. Liebow, MD Bucksport and Great Cranberry Island
Opioid Treatment Is Used Vastly More in States That Expanded Medicaid
by Abby Goodnough - NYT - August 21, 2019
States that expanded Medicaid under the Affordable Care Act
have seen a much bigger increase in prescriptions for a medication that
treats opioid addiction than states that chose not to expand the
program, a new study has found.
The study, by researchers at the Urban Institute, a nonprofit research group, adds to the evidence that the 2010 health care law is playing a significant role in addressing the opioid epidemic. The researchers found that the number of Medicaid-covered prescriptions for buprenorphine, which eases cravings and withdrawal symptoms, increased almost fivefold nationally — to 6.2 million from 1.3 million — between 2011 and 2018.
“Expanding Medicaid is probably the most important thing states can do to increase treatment rates,” said Lisa Clemans-Cope, the study’s lead author. “But even some states that did expand Medicaid look like they are falling short in meeting the treatment needs.”
Over the period the researchers studied, the opioid epidemic was worsening and many states — led mostly by Democrats, but sometimes by Republicans — chose to expand coverage under Medicaid, the joint federal and state health insurance program for poor people. The Affordable Care Act gave states the option of covering many more adults through Medicaid, which covers a disproportionate share of people with opioid addiction, starting in 2014.
The study, by researchers at the Urban Institute, a nonprofit research group, adds to the evidence that the 2010 health care law is playing a significant role in addressing the opioid epidemic. The researchers found that the number of Medicaid-covered prescriptions for buprenorphine, which eases cravings and withdrawal symptoms, increased almost fivefold nationally — to 6.2 million from 1.3 million — between 2011 and 2018.
“Expanding Medicaid is probably the most important thing states can do to increase treatment rates,” said Lisa Clemans-Cope, the study’s lead author. “But even some states that did expand Medicaid look like they are falling short in meeting the treatment needs.”
Over the period the researchers studied, the opioid epidemic was worsening and many states — led mostly by Democrats, but sometimes by Republicans — chose to expand coverage under Medicaid, the joint federal and state health insurance program for poor people. The Affordable Care Act gave states the option of covering many more adults through Medicaid, which covers a disproportionate share of people with opioid addiction, starting in 2014.
The
law also vastly expanded access to addiction treatment by designating
it as an “essential benefit” that must be covered through the Obamacare
marketplaces and expanded Medicaid. Buprenorphine is one of three
medications that the Food and Drug Administration has approved to treat
opioid addiction; there is substantial evidence that it sharply reduces the risk of dying from an overdose.
Hundreds of thousands of Americans have died from opioid overdoses over the past decade, including nearly 48,000 last year, and most people with opioid addiction are not getting treatment, according to government studies.
The study found that, on average, the rate of Medicaid-covered prescriptions for buprenorphine was much lower in states that did not expand the program; most of those states are in the South and Great Plains. In all, 33 states and the District of Columbia have expanded Medicaid since 2014 and 14 have not; they are largely led by Republicans who oppose it on partisan, ideological and fiscal grounds. In three other states — Idaho, Nebraska and Utah — voters approved ballot measures last fall directing their legislatures to expand Medicaid, but they have not yet done so.
All five of the states with the highest buprenorphine prescribing rates for Medicaid recipients — Vermont, West Virginia, Kentucky, Montana and Ohio — expanded Medicaid. West Virginia, Kentucky and Ohio also have among the highest overdose rates in the nation, but overdose deaths fell in all three states last year.
Only one of the five states with the lowest buprenorphine prescribing rates in Medicaid — Arkansas — expanded the program. The other four were Texas, South Dakota, Florida and Kansas. The researchers noted that there could be other reasons for the lower number of prescriptions in some states, such as lower rates of opioid addiction or more restrictions on prescribing buprenorphine, as Arkansas has. But such factors, they said, could not explain the huge difference in prescribing rates.
Hundreds of thousands of Americans have died from opioid overdoses over the past decade, including nearly 48,000 last year, and most people with opioid addiction are not getting treatment, according to government studies.
The study found that, on average, the rate of Medicaid-covered prescriptions for buprenorphine was much lower in states that did not expand the program; most of those states are in the South and Great Plains. In all, 33 states and the District of Columbia have expanded Medicaid since 2014 and 14 have not; they are largely led by Republicans who oppose it on partisan, ideological and fiscal grounds. In three other states — Idaho, Nebraska and Utah — voters approved ballot measures last fall directing their legislatures to expand Medicaid, but they have not yet done so.
All five of the states with the highest buprenorphine prescribing rates for Medicaid recipients — Vermont, West Virginia, Kentucky, Montana and Ohio — expanded Medicaid. West Virginia, Kentucky and Ohio also have among the highest overdose rates in the nation, but overdose deaths fell in all three states last year.
Only one of the five states with the lowest buprenorphine prescribing rates in Medicaid — Arkansas — expanded the program. The other four were Texas, South Dakota, Florida and Kansas. The researchers noted that there could be other reasons for the lower number of prescriptions in some states, such as lower rates of opioid addiction or more restrictions on prescribing buprenorphine, as Arkansas has. But such factors, they said, could not explain the huge difference in prescribing rates.
States that have chosen not to expand Medicaid have depended on several billion dollars in grants that Congress has doled out since 2017 for treatment, prevention and recovery services, but the money is scheduled to run out next year. The Trump administration is also supporting a Republican-led court case seeking to overturn the Affordable Care Act, including the expansion of the Medicaid program.
Even among the states with large increases in buprenorphine prescribing, there was wide variation. Vermont had by far the highest rate: 1,210 buprenorphine prescriptions for every 1,000 Medicaid enrollees in 2018. The next highest rate, in West Virginia, was 827 prescriptions per 1,000 enrollees.
Vermont has had one of the most ambitious expansions of opioid addiction treatment in the country, including in prisons and hospital emergency rooms. The researchers said its high prescribing rate could also reflect higher dosing — patients taking two eight-milligram tablets of buprenorphine at a time, for example.
The study did not look at prescribing data for naltrexone, another medication approved to treat opioid addiction. A third medication, methadone, is dispensed at highly regulated clinics rather than prescribed. It is possible that in some regions with low buprenorphine prescribing rates, naltrexone or methadone are more commonly used.
Dr. G. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness, said that the findings were useful but that researchers should also study the quality of care that people on buprenorphine are getting from state to state.
“Expanding the use of these evidence based, F.D.A.-approved treatments is an important first step in improving care for opioid-use disorder,” he said. “But all too often, treatment courses are short, and care for opioid addiction is fragmented from all of the other health care needs that people have.”
https://www.nytimes.com/2019/08/21/health/opioids-treatment-medicaid.html?smid=nytcore-ios-share
Why Doctors Still Offer Treatments That May Not Help
by Austin Frakt - NYT - August 26, 2019
When
your doctor gives you health advice, and your insurer pays for the
recommended treatment, you probably presume it’s based on solid
evidence. But a great deal of clinical practice that’s covered by private insurers and public programs isn’t.
The British Medical Journal sifted through the evidence for thousands of medical treatments to assess which are beneficial and which aren’t. According to the analysis, there is evidence of some benefit for just over 40 percent of them. Only 3 percent are ineffective or harmful; a further 6 percent are unlikely to be helpful. But a whopping 50 percent are of unknown effectiveness. We haven’t done the studies.
Sometimes uncertain and experimental treatments are warranted; patients may even welcome them. When there is no known cure for a fatal or severely debilitating health condition, trying something uncertain — as evidence is gathered — is a reasonable approach, provided the patient is informed and consents.
“We have lots of effective treatments, many of which were originally experimental,” said Dr. Jason H. Wasfy, an assistant professor of medicine at Harvard Medical School and a cardiologist at Massachusetts General Hospital. “But not every experimental treatment ends up effective, and many aren’t better than existing alternatives. It’s important to collect and analyze the evidence so we can stop doing things that don’t work to minimize patient harm.”
The British Medical Journal sifted through the evidence for thousands of medical treatments to assess which are beneficial and which aren’t. According to the analysis, there is evidence of some benefit for just over 40 percent of them. Only 3 percent are ineffective or harmful; a further 6 percent are unlikely to be helpful. But a whopping 50 percent are of unknown effectiveness. We haven’t done the studies.
Sometimes uncertain and experimental treatments are warranted; patients may even welcome them. When there is no known cure for a fatal or severely debilitating health condition, trying something uncertain — as evidence is gathered — is a reasonable approach, provided the patient is informed and consents.
“We have lots of effective treatments, many of which were originally experimental,” said Dr. Jason H. Wasfy, an assistant professor of medicine at Harvard Medical School and a cardiologist at Massachusetts General Hospital. “But not every experimental treatment ends up effective, and many aren’t better than existing alternatives. It’s important to collect and analyze the evidence so we can stop doing things that don’t work to minimize patient harm.”
In many cases, routinely delivered treatments aren’t rigorously tested for years. Benefits are assumed, harms ignored.
This might have killed George Washington. At 67 years old and a few months shy of three years after his presidency, Washington reportedly awoke short of breath, with a sore throat, and soon developed a fever. Over the next 12 hours, doctors drained 40 percent of his blood, among other questionable treatments. Then he died.
Washington surely had a serious illness. Theories include croup, diphtheria, pneumonia and acute bacterial epiglottitis. Whatever it was, bloodletting did little but cause additional misery, and most likely hastened his death.
Though the procedure was common at the time for a variety of ailments, its benefits were based on theory, not rigorous evidence. In the era of modern medicine, this may strike some as primitive and ignorant.
Yet, hundreds of years later, the same thing still happens (though fortunately not with bloodletting).
This might have killed George Washington. At 67 years old and a few months shy of three years after his presidency, Washington reportedly awoke short of breath, with a sore throat, and soon developed a fever. Over the next 12 hours, doctors drained 40 percent of his blood, among other questionable treatments. Then he died.
Washington surely had a serious illness. Theories include croup, diphtheria, pneumonia and acute bacterial epiglottitis. Whatever it was, bloodletting did little but cause additional misery, and most likely hastened his death.
Though the procedure was common at the time for a variety of ailments, its benefits were based on theory, not rigorous evidence. In the era of modern medicine, this may strike some as primitive and ignorant.
Yet, hundreds of years later, the same thing still happens (though fortunately not with bloodletting).
In
the late 1970s, some doctors thought they had found a way to treat
breast cancer patients with what would otherwise be lethal doses of
chemotherapy. The approach involved harvesting bone marrow stem cells
from the patients before treatment and reintroducing them afterward.
Fueled by encouraging comments from doctors, the 1980s news media reported higher chemotherapy doses as the means to survival. Yet there was no compelling evidence that bone marrow transplants protected patients.
But, told they would, many patients fought insurers in court to get them. Under pressure from Congress, in 1994 all health plans for federal workers were required to cover the treatment. Yet not a single randomized trial had been done.
Finally, in 1995, the first randomized trial was published, with impressive results: Half of women who received bone marrow transplants had no subsequent evidence of a tumor, compared with just 4 percent in the control group. But these results didn’t hold up, with four subsequent clinical trials contradicting them. The approach was recognized for what it was: ineffective at best, lethal at worst.
Wishful thinking that runs ahead of or goes against research findings is behind today’s opioid epidemic, too. Despite a lack of solid evidence, for years many believed that modern opioid medications were not addictive. It’s now abundantly clear they are. But the damage is done.
There are countless other examples of common treatments and medical advice provided without good evidence: magnesium supplements for leg cramps; oxygen therapy for acute myocardial infarction; IV saline for certain kidney disease patients; the avoidance of peanuts to prevent allergies in children; many knee and spine operations; tight blood sugar control in critically ill patients; clear liquid diets before colonoscopies; bed rest to prevent preterm birth; the prescribing of unnecessary medications, to list just a few. In some of these cases, there is even evidence of harm.
It is not uncommon for newer evidence to contradict what had been standard practice. A study by an Oregon Health & Science University School of Medicine physician, Vinay Prasad, and colleagues examined 363 articles in the New England Journal of Medicine from 2001 to 2010 that addressed an existing medical practice. Forty percent of the articles found the existing practice to be ineffective or harmful.
Fueled by encouraging comments from doctors, the 1980s news media reported higher chemotherapy doses as the means to survival. Yet there was no compelling evidence that bone marrow transplants protected patients.
But, told they would, many patients fought insurers in court to get them. Under pressure from Congress, in 1994 all health plans for federal workers were required to cover the treatment. Yet not a single randomized trial had been done.
Finally, in 1995, the first randomized trial was published, with impressive results: Half of women who received bone marrow transplants had no subsequent evidence of a tumor, compared with just 4 percent in the control group. But these results didn’t hold up, with four subsequent clinical trials contradicting them. The approach was recognized for what it was: ineffective at best, lethal at worst.
Wishful thinking that runs ahead of or goes against research findings is behind today’s opioid epidemic, too. Despite a lack of solid evidence, for years many believed that modern opioid medications were not addictive. It’s now abundantly clear they are. But the damage is done.
There are countless other examples of common treatments and medical advice provided without good evidence: magnesium supplements for leg cramps; oxygen therapy for acute myocardial infarction; IV saline for certain kidney disease patients; the avoidance of peanuts to prevent allergies in children; many knee and spine operations; tight blood sugar control in critically ill patients; clear liquid diets before colonoscopies; bed rest to prevent preterm birth; the prescribing of unnecessary medications, to list just a few. In some of these cases, there is even evidence of harm.
It is not uncommon for newer evidence to contradict what had been standard practice. A study by an Oregon Health & Science University School of Medicine physician, Vinay Prasad, and colleagues examined 363 articles in the New England Journal of Medicine from 2001 to 2010 that addressed an existing medical practice. Forty percent of the articles found the existing practice to be ineffective or harmful.
Some of these reversals are well known. For example, three articles contradicted hormone replacement therapy for postmenopausal women. Another three reported increased risk of heart attacks and strokes from the painkiller Vioxx.
Looked at one way, medical reversals like these reflect a failure; we didn’t gather enough evidence before a practice became commonplace. But in another way, they were at least a partial success: Science eventually caught up with practice. That doesn’t always happen.
“Only a fraction of unproven medical practice is reassessed,” said Dr. Prasad, who is co-author of a book on medical reversals, along with Adam Cifu, a University of Chicago physician.
Dr. Prasad’s work is part of a growing movement to identify harmful and wasteful care and purge it from health care systems. The American Board of Internal Medicine’s Choosing Wisely campaign identifies five practices in each of dozens of clinical specialties that lack evidence, cause harm, or for which better approaches exist. The organization that assessed the value of treatments in England has identified more than 800 practices that officials there feel should not be delivered.
It’s an uphill battle. Even when we learn something doesn’t make us better, it’s hard to get the system to stop doing it. It takes years or even decades to reverse medical convention. Some practitioners cling to weak evidence of effectiveness even when strong evidence of lack of effectiveness exists.
This is not unique to clinical medicine. It exists in health policy, too. Much of what we do lacks evidence; and even when evidence mounts that a policy is ineffective, our political system often caters to invested stakeholders who benefit from it.
An honest assessment of the state of science behind clinical practice and health policy is humbling. Though many things we do and pay for are effective, there is a lot we don’t know. That’s inevitable. What isn’t inevitable — and where the real problems lie — is assuming, without evidence, that something works.
Looked at one way, medical reversals like these reflect a failure; we didn’t gather enough evidence before a practice became commonplace. But in another way, they were at least a partial success: Science eventually caught up with practice. That doesn’t always happen.
“Only a fraction of unproven medical practice is reassessed,” said Dr. Prasad, who is co-author of a book on medical reversals, along with Adam Cifu, a University of Chicago physician.
Dr. Prasad’s work is part of a growing movement to identify harmful and wasteful care and purge it from health care systems. The American Board of Internal Medicine’s Choosing Wisely campaign identifies five practices in each of dozens of clinical specialties that lack evidence, cause harm, or for which better approaches exist. The organization that assessed the value of treatments in England has identified more than 800 practices that officials there feel should not be delivered.
It’s an uphill battle. Even when we learn something doesn’t make us better, it’s hard to get the system to stop doing it. It takes years or even decades to reverse medical convention. Some practitioners cling to weak evidence of effectiveness even when strong evidence of lack of effectiveness exists.
This is not unique to clinical medicine. It exists in health policy, too. Much of what we do lacks evidence; and even when evidence mounts that a policy is ineffective, our political system often caters to invested stakeholders who benefit from it.
An honest assessment of the state of science behind clinical practice and health policy is humbling. Though many things we do and pay for are effective, there is a lot we don’t know. That’s inevitable. What isn’t inevitable — and where the real problems lie — is assuming, without evidence, that something works.
Austin Frakt is director of
the Partnered Evidence-Based Policy Resource Center at the V.A. Boston
Healthcare System; associate professor with Boston University’s School
of Public Health; and adjunct associate professor with the Harvard T.H.
Chan School of Public Health. He blogs at The Incidental Economist. @afrakt
https://www.nytimes.com/2019/08/26/upshot/why-doctors-still-offer-treatments-that-may-not-help.html?
https://www.nytimes.com/2019/08/26/upshot/why-doctors-still-offer-treatments-that-may-not-help.html?
Op-Art: The Shame of Crowdfunding Health Care
by Dustin Harbin - NYT - August 23, 2019
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