Navigating the Shifting Terrain of US Health Care Reform—Medicare for All, Single Payer, and the Public Option
Jonathan Oberlander - The Milbank Quarterly - | Early View, Perspective - September, 2019
Policy Points:
“Medicare for All” is an increasingly common term in US health care
reform debates, yet widespread confusion exists over its meaning.
The various meanings of Medicare for All and other related terms
reflect divergent political and philosophical assumptions about the
preferred direction of health care reform, as well as the hybrid
structure of the current Medicare program.
“Medicare for All” has emerged as a major flashpoint in American
politics. Its unexpected rise is, in part, a reaction to a decade of the
Affordable Care Act (ACA, also known as Obamacare)—an ironic
development given that the ACA embodies a reform model that builds on
private coverage and Medicaid. However, frustration with Obamacare’s
myriad political and policy limits as well as an unceasing struggle over
its repeal have increased support among many reformers for alternatives
that break with the status quo and substantially expand the federal
government’s role in health insurance.
Yet, just as Medicare for All is moving to center-stage in US health
care debates, supporters of the idea are fighting over where to define
its boundaries. If Medicare is to be expanded to all Americans, what
does that actually mean and how would it change existing insurance
arrangements? The answers may seem obvious. But Democratic presidential
candidates Senators Bernie Sanders and Kamala Harris have issued
Medicare for All plans that diverge substantially in their reform
visions. That divergence speaks to the broader debate over, and to the
complexity and confusion surrounding Medicare for All and related
proposals for establishing “Medicare-like” programs. This essay traces
the evolving language of health reform in the United States, clarifies
the various meanings of Medicare for All, and explores what the debate
over the label and other Medicare-related expansion plans, including the
public option, reveals about health care politics. The Shifting Language of Health Care Reform in the United States
Medicare for All is the latest in a long line of health reform terms
and slogans. A century ago, the first proposals for government-organized
sickness insurance in the United States spoke of “social insurance” or
“compulsory insurance.”1-3 The latter term underscored
reformers’ view that voluntary insurance, such as mutual benefit
societies organized by workers, was fundamentally flawed because “it
failed to make insurance universal,” “left without protection those who
most need it,” and imposed “the entire burden of the cost of
sick-insurance . . . upon the shoulders of the . . . workers.”1
Health insurance programs only would be viable, advocates of compulsory
insurance believed, if all eligible workers were required to
participate and if employers, workers, and the public were required to
share in financing such protection.
The idea of compulsory insurance persisted in US health policy for
decades, though the enactment of Social Security in 1935 provided a
programmatic platform that reshaped the language of health care
politics. In 1945, when Harry Truman became the first American president
to endorse universal coverage, he called for “expansion of our existing
compulsory social insurance system.”4 When Truman’s plan
failed to pass Congress and the administration narrowed its focus to
coverage for the elderly, reformers emphasized the goal of enacting
health insurance “through” or “under” Social Security, an aspiration
realized in 1965 with Medicare’s passage.5-7 Medicare’s
architects stressed the contributory nature of Social Security
financing, supplanting earlier references to compulsory insurance.
After 1965, plans that called for enacting a single insurance program
operated by the federal government, such as that proposed by
Massachusetts Senator Ted Kennedy in 1971, were commonly referred to as
national health insurance, though that term also was applied to
universal coverage proposals that relied on private insurance.8,9
Even though Kennedy embraced the aspiration of universalizing the type
of federal health insurance embodied by Medicare, he did not call for
Medicare for All, perhaps because of criticism at that time that
Medicare was overly solicitous of the medical care industry and
consequently had contributed to accelerating medical care spending.10
By 1969, Senate Finance Committee Chair Russell Long was warning that
Medicare, which initially had generous payment arrangements designed in
part to assuage medical providers and ensure their participation in
federal health insurance, had become a “runaway program.”6
For many reformers in the 1970s, Medicare was less a model than a part
of the problem in American medical care. Indeed, rather than building on
Medicare, Kennedy’s bill proposed repealing and subsuming it into a new
Health Security program (whose name echoed Social Security despite the
bypassing of Medicare).8
Meanwhile, Canada had enacted national health insurance. In
actuality, each provincial and territorial government had established
its own public insurance program, also known as Medicare, which was
jointly financed with the federal government. All provinces and
territories had implemented such arrangements by 1972.11 As
Canada managed to insure all its citizens while spending much less on
medical care than the United States, reformers in this country
increasingly began to call for adopting Canadian-style national health
insurance. By the 1990s, “single payer” had become the term of choice
for American reformers, including Physicians for a National Health
Program, who advocated replacing our mix of public and private coverage
with one government insurance program (plans that alternatively sought
to build on that mix were labelled as “universal health insurance” or
“universal coverage”).12-16
Single payer accurately described how medical services would be
financed in a Canadian-like system—hospitals and doctors would be paid
for covered services by one insurer. It also distinguished this approach
to financing medical care from “all payer” models, such as those used
in Germany and Japan, that relied on multiple regulated insurance plans
rather than one government program.16 Still, single payer was
ultimately a technical term that generated little public appeal, public
understanding, or political momentum.17 The label also
spawned confusion over exactly what arrangements constituted a
single-payer system. Did it encompass a British-style national health
service or just Canadian-style national health insurance? Even academic
experts could not agree.18
Reformers’ recent invocation of Medicare for All reflects a
significant change, and undoubtedly an improvement, in political
strategy. Medicare for All immediately connects proposals for government
insurance to a popular, familiar, and entrenched program that already
exists in the United States rather than to a confusing financing label
or a mostly unfamiliar and often vilified foreign insurance plan
(supporters of the metric system can attest to the limits of citing
international precedent as a means to securing changes in US policy).
Campaigning against the supposed shortcomings of another nation’s health
insurance program or the imagined horrors of an abstract, future
“socialized medicine” system is one thing; trying to convince Americans
about the ostensible horrors of expanding Medicare, an immensely popular
program that tens of millions of persons know and rely on, is a more
difficult task. While public and policymakers’ understandings of the
philosophical principles and economic logic of social insurance may be
limited, appealing explicitly to Medicare expansion offers an
alternative, concrete way to talk about the virtues of social insurance.19
Polling data support the labelling change: Americans are much more
likely to register support for Medicare for All (or universal health
coverage) than single-payer health insurance.20 The turn to
Medicare for All also reflects the improved performance of Medicare,
whose relative success (compared to private insurers) in moderating
spending growth since the 1980s and maintaining low administrative costs
has bolstered the program’s reputation among reformers and policy
analysts.6,21-28 Medicare is often portrayed not merely as an
equitable platform through which to provide all Americans with
insurance, but as a symbol of administrative efficiency and cost
control.26-28 Medicare for All is thus seen as the key to
making health care a universal right, eliminating the problems of the
uninsured and underinsured, reining in spending and regulating prices in
the world’s most expensive health care system, and reducing the
prolific waste and administrative costs generated by convoluted billing
and insurance arrangements.13,14,29-34 The Pure and Hybrid Models of Medicare for All
The rise of Medicare for All has been accompanied by growing
confusion over its meaning. As the debate between Senators Sanders and
Harris over their respective health plans indicates, behind the label
lie competing conceptions. The pure model of Medicare for All seeks to
establish a national insurance program operated by the federal
government, prohibiting private insurance for services covered by the
publicly funded government plan. In contrast, the hybrid model would
allow private insurance plans that abide by federal regulations,
including those sponsored by employers, to operate alongside and within a
government-run Medicare program. Neither version of Medicare for All,
in fact, would extend Medicare in its current form to all Americans.
Instead, both would expand Medicare’s current benefit package to redress
its many limitations.35 Moreover, neither model would
actually enroll all persons in the United States into a single insurance
plan. Even in the pure model exemplified by legislation proposed by
Senator Sanders, the Veterans Health Administration and Indian Health
Service would remain intact, reflecting the political sensitivity of
disrupting established arrangements for those populations. Simply put,
Medicare for All plans would not cover all Americans.
These two visions of Medicare for All take their inspiration from
different sources. The pure model seeks to emulate Canada’s insurance
arrangements, albeit via a single national plan rather than a series of
programs administered by states. It largely displaces private insurance
with government coverage, just as Canada prohibits private insurance for
services covered by publicly funded insurance.36,37 But the
pure model, which also has been endorsed by Massachusetts Senator
Elizabeth Warren, albeit contingently, goes beyond Canadian Medicare in
one crucial respect. In Canada, there is first-dollar coverage, with no
patient cost-sharing, for services insured by the government. But there
is a robust supplementary private insurance market for services, such as
outpatient medications and dental services, that are not covered fully
by the government plan.36,37 Indeed, “private-sector spending . . . account[s] for 31% of total health expenditure” in Canada.38
However, current legislative versions of the pure Medicare for All
model are capacious in design, with no patient cost-sharing and
extraordinarily comprehensive benefits, including coverage of long-term
care and dental services.39,40 The comprehensiveness of the
proposed coverage is an antidote to trends in the United States of
rising patient cost-sharing and a growing problem of underinsurance. The
result, though, is that contemporary Medicare for All plans leave no
room for a meaningful supplemental market. And while some versions of
national health insurance legislation in the 1970s, including a bill
cosponsored by Senator Kennedy and House Ways and Means Committee chair
Wilbur Mills, relied on private insurers as administrative agents,
current conceptions of the pure model of Medicare for All do not
envision such a central role for them.9
The hybrid model of Medicare for All instead draws on existing
arrangements in Medicare, where 34% of program beneficiaries enroll in
private Medicare Advantage plans that contract with the federal
government.41 Medicare is a very different program today than
when it was enacted in 1965, with a much larger role for private
insurers (although from Medicare’s inception, private entities have
handled claims processing and beneficiaries have long carried private
supplemental coverage that fills in some of Medicare’s benefits gaps and
cost-sharing requirements).42 Enrollment in Medicare Advantage has more than tripled since 2000, reaching 22 million beneficiaries in 2019.41
Another part of Medicare that provides outpatient prescription drug
coverage, enacted in 2003, is composed entirely of private plans.43
In other words, while the appeal of Medicare for All rests largely on
the presumed advantages of government-run insurance, the reality is
that a significant portion of the current Medicare program is actually
privatized.44,45 The divide over Medicare for All, then,
reflects the complexities in Medicare and the differences between its
traditional component, where beneficiaries join a government program
that reimburses private providers for medical services, and Medicare
Advantage, where beneficiaries join private insurance plans that
contract with and are paid by the federal government. Because Medicare
currently embodies different approaches to health insurance, it lends
itself to competing conceptions of Medicare for All.
The pure and hybrid models advance varying goals, embody different
philosophies, and reflect different political calculations. The pure
model, which is how the health reform community has until now generally
understood Medicare for All, presumes that America’s various health care
pathologies can only be remedied by eliminating private insurance as a
major source of coverage. The goal is not simply to achieve universal
health insurance but to do it through a government program and without
relying to any meaningful degree on private insurers. Health security
will never be achieved, from this perspective, unless private insurance
is jettisoned because the corrosive effects of market forces are seen as
the central problem in American health policy.30,31 As a
summary of the Sanders plan puts it, “the ongoing failure of our health
care system is directly attributable to the fact that—unique among major
nations—it is primarily designed to . . . maximize profits for health
insurance companies, the pharmaceutical industry and medical equipment
suppliers.”39 The pure model of Medicare for All holds that
retaining private insurance as a primary source of coverage is
incompatible with creating an equitable and efficient health care
system.
In contrast, the hybrid model is willing to leverage both public and
private insurance to cover all Americans. It makes a concession to
perceived political realities and attempts to lessen disruption by
preserving a significant role for private insurers and employers. It
also embraces the altered nature of Medicare, building on the
preexisting Medicare Advantage component. The growth of Medicare
Advantage has reshaped the politics of Medicare as well as its
programmatic character; more than 20 million beneficiaries are, after
all, accustomed to its benefits, creating a broad constituency (which is
led by private insurers) for maintaining Medicare Advantage.46
The hybrid model would not compel Medicare beneficiaries in those plans
to switch coverage, unlike the plan offered by Senator Sanders, which
would eliminate Medicare Advantage after a transition period (though
notably, his bill would eliminate the benefit gaps that such plans
typically fill).39,42 From this perspective, health care
reform requires compromise; the Harris plan argues that “this isn’t
about pursuing an ideology.”47 Advocates of the hybrid model
believe that the goal of enacting universal coverage justifies the
retention of private insurance. However, by preserving Medicare
Advantage, such models also inherit its problems, including a record of
federal overpayments to such plans.
The hybrid model reconfigures Medicare for All into a more flexible
reform vehicle that, like today’s Medicare program, accommodates both
government and private insurance.48 All Americans would not
be covered by a single insurer and medical providers would not be
reimbursed by a single payer, but instead nearly all persons would
either enroll in the public Medicare program or a private Medicare plan
approved by the federal government. While the notion that Medicare’s
dual public-private structure offers a politically appealing model to
expand insurance coverage is not new, previously these hybrid
arrangements, as well as retaining a role for employer-sponsored
coverage, had not commonly been packaged under the Medicare for All
banner.48 The hybrid model thus offers the rhetorical appeal
of Medicare for All (presumably an advantage in the Democratic
presidential primary) and the reality of preserving a major role for
private insurance (presumably an advantage in a general election and in
passing legislation through Congress). A Medicare-like Public Option
Adding to the confusion is a third health reform plan that departs
even further from the pure model by offering the promise of, as
presidential candidate and South Bend, Indiana Mayor Pete Buttigieg has
put it, “Medicare for all who want it.”49 In such models,
also proposed by former Vice President Joe Biden, Americans could join a
new “Medicare-like” or “Medicare-type” public option or otherwise
remain in their current health plan. In contrast to the previously
discussed iterations of Medicare for All, these plans would largely
leave the ACA intact—the goal is to build on and supplement Obamacare
rather than replace it with a new program.
Such plans are not Medicare for All, nor are they even Medicare for
More since they generally seek to establish a new Medicare-like program
rather than directly expand the current Medicare program (though some
members of Congress have proposed doing exactly that by allowing persons
aged 50 and older to buy into the program).50 Within the
public option category, there is substantial variation in who would be
eligible to join such a program, which would shape its potential
enrollment. Would a public plan be a residual option on the ACA
insurance marketplace for the uninsured, a destination for most
Americans, or something in between? Biden’s plan envisions a broad
program where both Americans without insurance and those with
employer-sponsored or individually purchased coverage could enroll.51
Other versions of the public option frame it as initiating a “glide
path” toward Medicare for All since enrollment in the new Medicare-like
program could be substantial if private insurers can’t compete
successfully with it.49 However, one person’s stepping stone
is another’s slippery slope. Opponents of the public option have cast it
as a “Trojan horse” for a single-payer system.52
One common feature that public option plans generally share is
leaving the current Medicare program intact while establishing a new
Medicare-like plan alongside it (though that doesn’t preclude proposing
improvements in the original Medicare benefits package).50
That hands-off stance could help to reassure Medicare beneficiaries who
are concerned that expanding Medicare to more or all Americans could
jeopardize their own medical care, a fear fed by Republicans’ warnings.
Indeed, while Democrats are debating the meaning of Medicare for All,
Republicans are trying to reframe such plans as “Medicare for None.”53,54
President Donald Trump has argued that “by eliminating Medicare as a
program for seniors, and outlawing the ability of Americans to enroll in
private and employer-based plans, the Democratic plan would inevitably
lead to the massive rationing of health care . . . Seniors would lose
access to their favorite doctors . . . today’s Medicare would be forced
to die.”54 While it may be harder to scare Americans about
the prospects of Medicare for All than the perils of a foreign system of
socialized insurance, Republicans are betting that Medicare
beneficiaries themselves can be scared about the risks of opening up
their program to others. A public option plan that does not envision
Medicare for All or enrolling more persons directly into the current
Medicare program might be more immune to such fearmongering aimed at
older Americans. Yet the history of US health care reform debates
demonstrates that fear of change can be successfully instilled by reform
opponents regardless of the facts.55,56
Ultimately, public option plans aim to advance the rhetoric of choice
while harnessing the benefits of association with Medicare without
triggering the political liabilities of Medicare for All. Labelling a
plan as Medicare-like capitalizes on Medicare’s popularity. It signals
as well that the new public option, which would amount to a sort of
“safe harbor” from commercial insurers, will not be governed by the
profit motive or engage in dubious insurance practices and will offer a
broad choice of medical providers. By retaining private insurance, it
also will offer a broad choice of health plans. In addition, public
option plans aim to use Medicare’s prices and purchasing power, which
has proven to be much stronger than that of private insurers, in order
to hold down costs.24,51,57-59 Private insurers would have to compete with a lower-cost public option, which could generate additional cost savings.48,59
Yet the political advantages of maintaining both government and private
insurance plans, appealing to the virtues of choice, and retaining much
of the status quo rather than establishing a single insurance pool also
entail significant policy tradeoffs. These include concerns over
whether costlier enrollees might disproportionately enroll in a public
insurance option and questions over how to sync the benefits and
financing of a new government-sponsored option with existing programs,
including Medicare and the ACA.
While public option plans are not Medicare for All, they evidently do
represent what much of the public thinks of when they hear the term. In
a July 2019 Kaiser Family Foundation survey, 55% of Americans believed
that persons could keep their current plans obtained through work or
purchased individually under a Medicare for All plan.20 Put
another way, many Americans understand Medicare for All as making the
program available to all persons or perhaps all who need coverage, not
replacing all insurance with Medicare. Conclusion
Medicare for All is now receiving more serious consideration from
presidential candidates and lawmakers than at any time since the
program’s enactment over five decades ago. The debate over what Medicare
for All means and which model of Medicare (or Medicare-like) expansion
to pursue reflects persistent tensions in health policy between
pragmatism and principle, incremental and systemic reform, and building
on or tearing down the status quo. The current debate also reflects
efforts by different political factions and interests to frame Medicare
for All and related options in ways that, depending on their aspiration,
will either help or hinder its legislative prospects. The question is
whether Medicare will endure beyond 2020 as a prominent reform model
that defines the health care debate or whether we are witnessing an
ephemeral development that presages US health policy moving in yet
another direction. The 2020 elections could clarify which direction
reform will move in, but they are unlikely to resolve the longstanding
American debate over the promise and perils of government-sponsored
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Is America’s Health Care System a Fixer-Upper or a Teardown?
To understand the competing Democratic health care plans, consider an elaborate home construction metaphor.
by Margot Sanger-Katz - NYT - September 19, 2019
Imagine the United States health care system as a sort of
weird old house. There are various wings, added at different points in
history, featuring different architectural styles.
Maybe you pass
through a wardrobe and there’s a surprise bedroom on the other side, if
not Narnia. Some parts are really run down. In some places, the roof is
leaking or there are some other minor structural flaws. It’s also too
small for everyone to live in. But even if architecturally incoherent
and a bit leaky, it still works. No one would rather be homeless than
live in the house.
In Democratic politics, there
is agreement that the old house isn’t good enough, but disagreement
about just how possible — or affordable — fixing it will be. The biggest
fault line in the debate is between candidates who think our current
system can be salvaged with repairs and those who think it should be
torn down and built anew. Building a dream house eases the way to
simplification, but it increases potential disruption and cost.
The most limited Democratic plan, championed by House Speaker Nancy Pelosi, for example,
would deal with the house’s biggest structural issues. It would lower
the cost of health insurance for more people and fix some glitches in
Obamacare’s design — the home construction equivalent of patching the
roof, fixing a saggy porch and repainting. Residents could remain in
the house while such minor repairs took place. These changes would not
cost a ton of money. The house would still be weird. There would still
be some people without a place to live.
The Biden plan
The next tier of health care plans, like the one from Joe Biden,
would go further. Mr. Biden, too, would patch the roof and upgrade the
windows. But he’d also put on a big new wing: an expansion of the
Medicare program that would allow more people to join, sometimes called a
public option. Everyone living in the house can stay while the
renovations take place, though there might be disruptions. It would cost
more, more homeless people would now fit in, and some living in the
weirder wings might move into the new addition. People would pay for
housing through a mixture of taxes and rent.
There are a bunch of plans in this general category, including proposals
from Michael Bennet, Steve Bullock, Pete Buttigieg, John Delaney,
Julián Castro, Amy Klobuchar, Beto O’Rourke and Marianne Williamson.
They differ, mainly, in how many people in existing wings are allowed to
move into the new wing, and how large that wing will be.
Bernie Sanders wants to tear down the weird old house entirely and build his dream home.
It would be enormous and feature many wonderful amenities. When done,
there would be no homeless people at all, and everyone’s bedrooms would
look exactly the same. The weirdness would be gone. But the entire old
house would be gone, too, which some people might miss, and there could
be unanticipated cost overruns in the construction. Some people might
not enjoy the aesthetics of a modernist villa. While no one would have
to pay rent in exchange for housing there, most people would have to pay
more in taxes so the government could maintain the property.
Several
candidates have signed on, in whole or part, to the single-payer dream
house approach, including Cory Booker, Tulsi Gabbard, Elizabeth Warren
and Andrew Yang.
The Harris plan
Kamala Harris also wants to tear down the old weird house. But she doesn’t want to make everyone live in identical bedrooms. Her dream arrangement
involves more choices, but most of the basic architectural features
would be very similar. She would eliminate nearly every part of the
existing health insurance system and set up a new universal Medicare
program that includes options from private insurers. It’s like a housing
development with several slightly different model homes. The basic
architecture and amenities would all be the same, but families would be
able to choose some custom options, like paint color, countertops and
bed linens. It would also be expensive, and everyone would still need to
move.
The debate
At the debate last
week, you heard arguments between the teardown candidates and the
fixer-upper candidates about cost — and about change. Tearing down your
current house comes with risks that many candidates don’t want to take
on.
Although big changes to the health care system often garner
strong support in surveys, Americans frequently also tell pollsters that
they like their current insurance arrangements and would dislike giving
them up. The authors of some fixer-upper plans assume that only some
people are looking for a change, while other candidates assume that,
over time, nearly everyone will want to opt into a form of
government-run insurance.
You also heard a
debate about fairness and choice. Giving all Americans access to the
same housing arrangements means that no one will have to live in a
cramped attic. But it also means that some family members will have to
part with some of their favorite furniture. “Of the 160 million people
who like their health care now, they can keep it,” said Mr. Biden, of
the virtues of his fixer-upper proposal. “If they don’t like it, they
can leave.” By contrast, Ms. Warren emphasized the universal nature of a
teardown approach: “We’re going to do this by saying, everyone is
covered by Medicare for all; every health care provider is covered.”
The
“Medicare for all” system envisioned by Mr. Sanders would cover more
benefits than nearly any system in the world, but it would require
everyone to have the same type of insurance, with no easy workarounds
for patients who aren’t satisfied. Ms. Harris’s plan would allow more
choice, letting private plans operate alongside the government system.
But those tightly regulated products would not be allowed to differ
nearly as much as plans that exist in today’s system and would also
amount to a brand-new system.
The candidates also disagree on how
people should finance their ambitions. The fixer-upper candidates, for
the most part, favor a system in which most Americans would still need
to pay some form of rent to live in the house. The teardown candidates
think everyone’s housing costs should be financed by taxes instead of
direct payments.
A tax-financed system would mean big changes in who pays what for health care, and how.
A system that preserves a mix of taxes, premiums and direct payments
like deductibles would mean less rearranging of the financing of health
care and would probably require more modest tax increases.
This
is only a metaphor, of course. There are many ways the health care
system is not like a residence. But if you’ve ever renovated or built a
home, you know the emotional and budgetary stakes. The health care
system is personal to many Americans, just like their home. It’s no
surprise the debate has been so heated. https://www.nytimes.com/2019/09/19/upshot/health-care-home-metaphor.html?smid=nytcore-ios-share
25 Ways the Canadian Health Care System is Better than Obamacare for the 2020 Elections
Everybody
in, nobody out, free choice of doctor and hospital. It will produce far
less anxiety, dread, and fear. Can you hear that, Congress and the
White House?
By Ralph Nadar - Common Dreams - September 19, 2019
Dear America:
Costly complexity is baked into Obamacare, and although it has
improved access to healthcare for some, tens of millions of Americans
still cannot afford basic medical care for their family. No healthcare
system is without problems but Canadian-style single-payer — full
Medicare for all — is simple, affordable, comprehensive and universal
for all basic and emergency medical and hospital services.
In the mid-1960s, President Lyndon Johnson enrolled 20 million
elderly Americans into Medicare in six months. There were no websites.
They did it with index cards!
Below please find 25 ways the Canadian health care system — and the
resulting quality of life in Canada — is better than the chaotic,
wasteful and often cruel U.S. system.
Replace it with the much more efficient Medicare-for-all: everybody
in, nobody out, free choice of doctor and hospital. It will produce far
less anxiety, dread, and fear. Hear that, Congress and the White House! Number 25:
In Canada, everyone is covered automatically at birth – everybody in, nobody out. A human right.
In the United States, under Obamacare, 28 million Americans (9
percent) are still uninsured and 85 million Americans (26 percent) are
underinsured. Obamacare is made even worse by Trumpcare restrictions.
(See Trumpcare by John Geyman MD (2019)). Number 24:
In Canada, the health system is designed to put people, not profits, first.
In the United States, Obamacare has done little to curb insurance
industry profits and in fact has increased the concentrated insurance
industry’s massive profits. Number 23:
In Canada, coverage is not tied to a job or dependent on your income –
rich and poor are in the same system, the best guaranty of quality.
In the United States, under Obamacare, much still depends on your job
or income. Lose your job or lose your income, and you might lose your
existing health insurance or have to settle for lesser coverage. Number 22:
In Canada, health care coverage stays with you for your entire life.
In the United States, under Obamacare, for tens of millions of
Americans, health care coverage stays with you only for as long as you
can afford your insurance. Number 21:
In Canada, you can freely choose your doctors and hospitals and keep them.
In the United States, under Obamacare, the in-network list of places
where you can get treated is shrinking – thus restricting freedom of
choice – and if you want to go out of network, you pay dearly for it. Number 20:
In Canada, the health care system is funded by income, sales and
corporate taxes that, combined, are much lower than what Americans pay
in insurance premiums directly and indirectly per employer.
In the United States, under Obamacare, for thousands of Americans,
it’s pay or die – if you can’t pay, you die. That’s why many thousands
will still die every year under Obamacare from lack of health insurance
to get diagnosed and treated in time. The survivors are confronted with
very high, often unregulated drug prices. Number 19:
In Canada, there are no complex hospital or doctor bills. In fact, usually you don’t even see a bill.
In the United States, under Obamacare, hospital and doctor bills are
terribly complex, replete with massive billing fraud estimated to be at
least $350 billion a year by Harvard Professor Malcolm Sparrow. Number 18:
In Canada, costs are controlled. Canada pays 10 percent of its GDP for its health care system, covering everyone.
In the United States, under Obamacare, costs continue to skyrocket.
The U.S. currently pays 17.9 percent of its GDP and still doesn’t cover
tens of millions of people. Number 17:
In Canada, it is unheard of for anyone to go bankrupt due to health care costs.
In the United States, health-care-driven bankruptcy will continue to plague Americans. Number 16:
In Canada, simplicity leads to major savings in administrative costs and overhead.
In the United States, under Obamacare, often staggering complexity ratchets up huge administrative costs and overhead. Number 15:
In Canada, when you go to a doctor or hospital the first thing they ask you is: “What’s wrong?”
In the United States, the first thing they ask you is: “What kind of insurance do you have?” Number 14:
In Canada, the government negotiates drug prices so they are more affordable.
In the United States, under Obamacare, Congress made it specifically
illegal for the government to negotiate drug prices for volume
purchases. As a result, drug prices remain exorbitant and continue to
skyrocket.
SCROLL TO CONTINUE WITH CONTENT
Number 13:
In Canada, the government health care funds are not profitably diverted to the top one percent.
In the United States, under Obamacare, health care funds will
continue to flow to the top. In 2017, the CEO of Aetna alone made a
whopping $59 million. Number 12:
In Canada, there are no required co-pays or deductibles in inscrutable contracts.
In the United States, under Obamacare, the deductibles and co-pays
will continue to be unaffordable for many millions of Americans. Fine
print traps are everywhere. Number 11:
In Canada, the health care system contributes to social solidarity and national pride.
In the United States, Obamacare is divisive, with rich and poor in
different systems and tens of millions left out or with sorely limited
benefits. Number 10:
In Canada, delays in health care are not due to the cost of insurance.
In the United States, under Obamacare, patients without health
insurance or who are underinsured delay or forgo care and put their
lives at risk. Number 9:
In Canada, nobody dies due to lack of health insurance.
In the United States, tens of thousands of Americans will continue to
die every year because they lack health insurance or can’t pay much
higher prices for drugs, medical devices, and health care itself. Number 8:
In Canada, health care on average costs half as much, per person, as
in the United States. And in Canada, unlike in the United States,
everyone is covered.
In the United States, a majority support Medicare-for-all. But they
are being blocked by lawmakers and their corporate paymasters. Number 7:
In Canada, the tax payments to fund the health care system are
modestly progressive – the lowest 20 percent pays 6 percent of income
into the system while the highest 20 percent pays 8 percent.
In the United States, under Obamacare, the poor pay a larger share of their income for health care than the affluent. Number 6:
In Canada, people use GoFundMe to start new businesses.
In the United States, fully one in three GoFundMe fundraisers are now
to raise money to pay medical bills. Recently, one American was
rejected for a heart transplant because she couldn’t afford the
follow-up care. Her insurance company suggested she raise the money
through GoFundMe. Number 5:
In Canada, people avoid prison at all costs.
In the United States, some Americans commit minor crimes so that they can get to prison and receive free health care. Number 4:
In Canada, people look forward to the benefits of early retirement.
In the United States, people delay retirement to 65 to avoid being uninsured. Number 3:
In Canada, Nobel Prize winners hold on to their medal and pass it down to their children and grandchildren.
In the United States, a Nobel Prize winner sold his medal to help pay for his medical bills.
Leon Lederman won a Nobel Prize in 1988 for his pioneering physics
research. But in 2015, the physicist, who passed away in November 2018,
sold his Nobel Prize medal for $765,000 to pay his mounting medical
bills. Number 2:
In Canada, the system is simple. You get a health care card when you
are born. And you swipe it when you go to a doctor or hospital. End of
story.
In the United States, Obamacare’s 954 pages plus regulations (the
Canadian Medicare Bill was 13 pages) is so complex that then Speaker of
the House Nancy Pelosi said before passage “we have to pass the bill so
that you can find out what is in it, away from the fog of the
controversy.” Number 1:
In Canada, the majority of citizens love their health care system.
In the United States, a growing majority of citizens, physicians, and
nurses prefer the Canadian type system – Medicare-for-all, free choice
of doctor and hospital , everybody in, nobody out and far less expensive
with better outcomes overall.
It’s decision time, America! https://www.commondreams.org/views/2019/09/19/25-ways-canadian-health-care-system-better-obamacare-2020-elections?
Medicaid expansion expected to draw more older, rural Mainers
by Joe Lawlor - Portland Press Herald - September 18, 2019
When Medicaid expansion is fully implemented in Maine, those who
enroll are projected to be older rural residents who are more likely to
suffer from mental health and other chronic conditions and have gone
years without seeing a doctor compared to other adult Mainers, according
to a report released Tuesday.
Betsy Plummer, 56, of South Paris, was newly eligible for Medicaid
when she signed up in April after having gone several months without
insurance.
“I fell between the cracks,” said Plummer, describing how her chronic
conditions, including fibromyalgia, anxiety and depression, worsened
when she was uninsured. She can now get medications for all three
conditions for $9 per month. “When I didn’t have insurance, I didn’t go
to the doctor’s office. I was always worried about things, but I’m not
worried about medical bills anymore.”
Medicaid expansion began in Maine when Democratic Gov. Janet Mills took
over on Jan. 2 for former Gov. Paul LePage, a Republican. LePage
opposed Medicaid expansion and refused to implement it even after voters
approved it in a statewide referendum in 2017. Medicaid expansion is a
voluntary program under the Affordable Care Act, with the federal
government picking up 90 percent of the cost of expansion.
About 37,000 low-income Mainers – mostly childless adults ages 18-64 –
have signed up for Medicaid since January, and experts predict that
when fully in effect by 2020, about 70,000 to 80,000 Mainers will gain
coverage under expansion. The low-cost insurance under Medicaid
expansion covers those who earn up to 138 percent of the federal poverty
level, or $28,676 for a family of three.
The report on the enrollee population – conducted by the nonprofit
Maine Health Access Foundation and the University of Southern Maine –
combines five years of Maine residents’ responses to health surveys for
the federal U.S. Centers for Disease Control and Prevention with the
projected expansion population.
“It helps to paint a picture of the Mainers who are gaining access to
health care,” said Barbara Leonard, president and CEO of the Maine
Health Access Foundation. The foundation is a nonpartisan, nonprofit
organization that promotes access to quality health care through
research and grant awards.
The report found that 28 percent of the expansion population reports
being in “poor health” versus 9 percent of the general population. One
in five Mainers in the expansion population hadn’t seen a doctor for a
routine checkup in at least five years.
Other findings include: -46 percent of the expansion population is rural, compared with 32 percent of adult Mainers. – 29 percent of the expansion population smokes cigarettes, compared with 14 percent of adult Mainers. – 36 percent have chronic mental, emotional or physical limitations, compared with 16 percent of adult Mainers. – 45 percent have high blood cholesterol, compared with 32 percent of Mainers.
Erika Ziller, assistant professor of public health for the University
of Southern Maine and one of the authors of the report, said the study
shows that low-income Mainers, many of whom do not qualify for
disability, but “are not doing well, with either their mental or
physical health,” stand to benefit.
“There is a lot of pent-up demand for health services, because people
have a lot of health issues that haven’t been taken care of for years,”
Ziller said. “If they live in rural Maine, employment opportunities may
be limited and many employers don’t offer health insurance.”
Although the study projects that 45 percent of expansion enrollees
will be age 55-64, a younger population has signed up so far. According
to Maine Department of Health and Human Services enrollment figures, of
the 37,187 Medicaid sign-ups, 12,154 enrollees, or 33 percent, are
adults ages 19-29, while 9,766 enrollees, or 26 percent, are ages 50-64.
Ziller said the age profile of Medicaid expansion enrollees could
change by the time it’s fully in effect in 2020. One possible factor is
that many over age 50 already had signed up for Affordable Care Act
marketplace insurance and won’t be transitioned to Medicaid until 2020.
About 10,000 people in Maine fall into that category, according to
estimates from the Kaiser Family Foundation, although that figure
includes all adult ages, not just older adults.
Jackie Farwell, spokeswoman for the Maine DHHS, said the federal
government sent out about 10,000 letters to ACA marketplace enrollees in
April who would likely qualify for Medicaid, inviting them to sign up
for Medicaid. It’s unknown how many of them signed up, but most will
likely be transitioned to Medicaid by 2020. That’s because during the
fall enrollment period to choose ACA plans for 2020, those who are
eligible for Medicaid won’t qualify for the ACA subsidies that make the
insurance affordable.
Maine DHHS officials expressed surprise in August at the volume of
young adults who have signed up for Medicaid, as they expected an older
population to be among the first to enroll.
“This claims information is preliminary and does not necessarily
represent what the experience for expansion enrollees will be when the
expansion is fully implemented,” the department said in an Aug. 16
update posted on the Maine DHHS website. “We may not have a full picture
of the health profile of the expansion population for a number of
months.” https://www.pressherald.com/2019/09/17/medicaid-expansion-expected-to-draw-more-older-rural-mainers/
Calais hospital files for bankruptcy protection as contract impasse with nurses continues
by Nick Sambides, Jr. - Bangor Daily News - September 17, 2019
Calais Regional Hospital filed
for Chapter 11 bankruptcy protection on Tuesday, but hospital officials
promised that the 25-bed facility would stay open as the bankruptcy case
proceeds.
The hospital blamed the bankruptcy filing in U.S. Bankruptcy
Court in Bangor on a number of factors, including a drop in paying and
insured patients; increased levels of care the hospital has had to
provide for free; inadequate reimbursement from MaineCare, the state’s
Medicaid program; and increasing regulatory requirements.
The hospital has lost money every year since 2007, according
to its annual tax filings, though officials said Tuesday the size of
the hospital’s losses shrank to $574,600 last year from $2.64 million in
2014.
Serving much of Washington County and employing about 275
workers, the Calais hospital is the second rural Maine hospital to file
for bankruptcy protection this year.
The Calais filing comes 11 days after the hospital’s nursing staff voted to put the option of a strike on the table
in contract negotiations that have dragged on for almost a year. Todd
Ricker, a labor representative for the Maine State Nurses Association
who has been leading negotiations for the nurse, said the timing of the
bankruptcy filing is no coincidence.
Hospital managers told the union during negotiations that
the hospital was having its “best financial year in a decade” and they
repeatedly denied any intention of seeking bankruptcy protection, Ricker
said.
“This just follows their pattern of doing business in recent
years. None of them take responsibility for how they have mismanaged
the place for years,” Ricker said. “It’s all about external factors. We
are looking for them to take responsibility for their own mistakes.”
Hospital spokeswoman DeeDee Travis said the hospital’s
decision to file for bankruptcy protection had nothing to do with
ongoing negotiations but “everything to do with keeping the doors open
at Calais Regional Hospital.”
“We appreciate our nurses and they play a critical part in
providing care, but we have a responsibility to our 275 employees and
our community to keep health care accessible in the region and jobs in
this community,” Travis said.
“We have worked hard over the past few years to get to the
point where Chapter 11 is an option, and it’s a healthy step for us at
this point,” she added. “Restructuring strengthens the hospital’s
long-term financial position.”
Calais Regional Hospital’s bankruptcy filing comes even
after the state implemented an expansion of its Medicaid program, giving
more low-income adults a means to pay for their health care.
Enrollment, however, has happened more slowly than some projected.
The U.S. Government Accountability Office found last year
that fewer rural hospitals closed in states that expanded Medicaid under
the federal Affordable Care Act from 2013 to 2017. Those that closed
often had previous financial struggles.
The Calais bankruptcy also follows a few years during which the hospital cut services to rein in expenses. It closed its obstetrics department in 2017 and ended outpatient cancer care
last year. The hospital had also contracted with a Tennessee company,
Quorum Health Resources, to manage the hospital. It ended that
arrangement last year.
Organizations seek Chapter 11 protection to gain time so they can reorganize their operations and eventually pay off debts.
Officials in Calais expect the hospital to emerge from
bankruptcy protection in a stronger financial position, Boula said in a
statement.
“We remain committed to providing exceptional patient care
during the Chapter 11 process,” Boula said. “All departments are
operating as usual, and our talented team is focused on delivering
high-quality health care services to our community.”
The nurses union has said that its members are not asking
for any new concessions because the hospital has struggled financially
for years. In 2017, the most recent year for which hospital tax data
are available, Calais Regional Hospital took in $34.2 million in
revenue and had $36.3 million in expenses, resulting in a $2.2 million
loss.
But the union has objected to proposed changes the hospital
has proposed to their health insurance and paid-time-off policy.
Administrators have said the changes are modest and meant to give the
union members the same level of benefits as other hospital employees.
US healthcare is booming. So why do one in five workers live in poverty?
by Milli LeGrain - The Guardian - September 18, 2019
“One of the biggest challenges is explaining that you are not a maid.
That your job is not to clean up after everyone,” said Marisol Rivera,
who has been caring for elderly and disabled clients in their New York
homes for 20 years.
Rivera is one of the millions of women now employed in the US’s
fastest-growing job sector: healthcare. Driven by an ageing population
and propped up by government funds, in 2017 healthcare jobs surpassed
manufacturing and retail – once the two driving forces of employment in
the US. And by all predictions it will keep on growing.
Job growth in the US has broken all records and healthcare has been
the leading force in that growth. But wages? Wages are another story.
One that shows how women, and particularly women of color, have been
left behind even in the hottest job market in US history.
There are now 18 million healthcare workers
in the United States – 80% of whom are women – and healthcare
employment is projected to grow 18% from 2016 to 2026, much faster than
the average for all occupations, according to the Bureau of Labor Statistics.
As baby boomers age, jobs looking after the elderly and disabled are
growing exponentially. Today there are 2 million home care workers like
Marisol as well as 2.4 million nursing assistants in nursing homes and
other institutions. Nine out of 10 home care workers are women, 25% are African American and 25% are immigrants. Many of them are undocumented.
Home health aides work long hours, often with no benefits, paid
vacation or sick leave and without the backing of a union. The job
entails everything from helping patients with their daily personal
tasks, assistance with basic medical care, to light housework and
keeping patients company. But the potential for exploitation is high.
The kind Marisol calls “extra work”.
The job is physically strenuous and ranks high on the list for
work-related accidents. It is also emotionally taxing. Deborah O’Bryant,
a home health aide for the past 12 years, remembers one of her hardest
experiences was caring for a cancer patient: “I had to take her to
radiation every day. She could not speak. I learned how to read lips.”
And yet many of these workers fail to earn a living wage. According to government data, healthcare support occupations such as home health aides had a median annual wage of $24,060 in May 2018, lower than the median annual wage for all occupations in the economy.
According to a report by Paraprofessional Healthcare Institute (PHI),
a not-for-profit organization based in New York City that works to
improve long-term services and support for elders and individuals with
disabilities, in 2017, one in five home care workers lived below the
federal poverty line and over half relied on some form of public assistance.
Caitlin Connolly, an expert at the National Employment Law Project
(NELP) sees a direct link between low wages in the care giving sector
and the legacy of slavery. African American women who didn’t work the
fields had to provide unpaid household care for white families. Even
after emancipation those former slaves and their descendants were kept
out of good-paying industries and denied the protections given to other
workers. “Up until 2015, home care workers did not have the right to a
federal minimum wage,” she says. Care workers were even excluded from
the protections provided by the landmark Fair Labor Standards Act of
1938 to accommodate southern segregationists.
And despite the demands of an ageing US population and the tight
labor market, wages for women across the United States remain lower than
men’s. According to the Institute for Women’s Policy Research, female
home health aides and registered nurses earn 92% of their male
counterparts’ wages.
Able to earn more elsewhere, it appears men are ditching healthcare.
Nora Higgins, a nurse practitioner who teaches at nursing school has
witnessed how men have been dropping out of her classes since she
started teaching back in 2001. “Out of a class of 90 there used to be 12
to 15 [men]. Now there are only a handful,” she says.
Across all occupations, female full-time employees earn 80 cents for
every dollar that a man earns. And the gap is far worse for women of
color. On average black women in the US are paid 38% less than white men.
The fight for equal pay is back on the political agenda. Megan Rapinoe
and the US women’s national soccer team have taken up the mantle by
suing the US Soccer Federation. The US women’s team continues to earn
significantly less than the men, despite being more successful and
bringing in more money. Senator Elizabeth Warren, a Democratic
presidential candidate, has announced her plan for an executive action
to “boost wages for women of color and open up new pathways to the
leadership positions they deserve”, on day one of her presidency, if
elected.
Some states have moved to boost wages for all by imposing higher
minimum wages. New York has mandated a minimum wage of $15 an hour to
workers like Marisol and Deborah since January.
And yet experts such as economist Elise Gould at the Economic Policy
Institute warn that “wage growth is slower than we should expect in a
fully healthy economy”.
And while unemployment is at record lows with 6.1 million unemployed
persons in July, the figures don’t speak to the number of people of
working age who have dropped out of the workforce entirely because of
low wages or the high cost of childcare. “Neither men nor women are back
to their pre-recession participation levels,” says Gould.
It’s a predicament that hurts employers, too, as they struggle to
keep people on the job. This year, the home care industry turnover rate
reached an all-time high of 82%.
“Turnover rates are astronomical,” says Caitlin Connolly at NELP. This
has a huge impact on the quality of services. And the number of people
65 years and older is due to double by 2030. “How can we keep up?” asks
Connolly. “We need to improve the quality of these jobs.”
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