There's lots going on in healthcare reform these days - so lots of reading to be done. This blog posting is unsually long, but there are many very thoughtful articles here to be read and digested.
August 19, 2019 was a big day for The Business Roundtable (TBR), the
Washington, DC non-profit association of chief executive officers of
major US companies. The organization released a new “Statement on the
Purpose of the Corporation” signed by 183 CEOs declaring that the
interests of workers, customers, communities, and “other stakeholders”
should be as important as the interests of a company’s shareholders.1
This represented a significant change from its 1997 Statement that
declared “the principal object of a business is to generate economic
returns to its owners.”
While actions, not statements, will reveal
real intent over time, this change was noteworthy—including for the US
health care sector. The subject has deep roots in American society,
especially in the advocacy of the late economist Milton Friedman, who
derided corporate social responsibility as “fundamentally subversive”
and asserted that “there is one and only one social responsibility of
business—to use its resources and engage in activities designed to
increase its profits.”2
In the 1970s and 1980s,
Friedman’s notion powered a movement in the United States, Great
Britain, and around the globe called “neoliberalism” that promoted
deregulation, defanged labor unions, shrunken government, and ever lower
taxes. From business schools to high cathedrals of capitalism “greed is
good” became more than a movie line from Wall Street and its iconic Gordon Gekko. Binyamin Applebaum’s new book, The Economists’ Hour, lays out the neoliberal narrative, warts and all, in compelling detail.
In
recent years, polite rebellion has broken out in business circles
against the presumption of shareholder primacy. In January 2019,
BlackRock CEO Larry Fink, in an open letter to CEOs, asserted that
companies that “fulfill their purpose and responsibilities to
stakeholders reap rewards over the long term. Companies that ignore them
stumble and fall.”3 Back in 2009, then-Microsoft CEO Bill
Gates advocated for “creative capitalism” to confront societal needs,
while business strategy guru Michael Porter introduced “shared value”
into the business lexicon. Whole Foods CEO John Mackey has made hay with
his attempted movement and 2013 book Conscious Capitalism.
Today,
companies have many organizations, associations, and pathways with
which to engage in societal improvement and stakeholder engagement.
Environmental, social, and governance criteria (ESG) are the recognized
set of standards by which companies are measured for social
consciousness, among others.
What about US health care and this
neoliberal era in which we still breathe? The connections are multiple,
deep, and noteworthy. For starters, of the 183 CEO signers of the TBR
statement, only 11 come from companies primarily embedded in the health
sector, such as Pfizer, CVS Health, and Siemens, far less than a
proportionate share of health care’s 18% jumbo slice of the US economy.
And it is not difficult to view TBR’s statement as whitewash, especially
when signers include CEOs of Johnson & Johnson and Mallinckrodt
Pharmaceuticals, companies that are neck deep in the nation’s opioid
marketing scandal.
Influential US political and economic
historians refer to the period from the late 1970s through today as the
“Reagan era,” crowned during the presidency of Ronald Reagan who
declared in his inaugural address that “(i)n this present crisis,
government is not the solution to our problem, government is the
problem.” His term in office ushered in the modern era of tax cuts,
growing inequality, wage stagnation, diminished unionization, and
repeated assaults on government legitimacy. The “Neoliberal Era” may be a
better fit. An important question is whether Donald Trump represents
the end of this era or the start of something new.
Coincidentally
or not, in the early 1980s US national health spending as a percent of
gross domestic product (GDP) split from rates in other advanced nations
toward its current extreme outlier status. US spending on health
increased from about 8% of GDP in the late 1970s to 17.8% in 2017, far
ahead of the nation with the second highest rate of national spending on
health, Switzerland, at 12.2%.
In return for this massive
societal investment in medical care, we have the world’s most
technologically advanced health care system along with the highest
prices in the world for any category of medical services or products one
can imagine. The rush of private investment capital into our medical
sector has resulted in cutting-edge medical care, advanced drugs and
medical devices, and the highest salaries of any professionals in
American society.
In these 40 years, we also have seen three
consecutive years of declining life expectancy, a deep anomaly among our
international peers, humiliating rates of infant and maternal
mortality, shocking levels of gun violence, and extreme incidence of
overweight and obesity. As economist John Komlos has documented, during
World War II, native born Americans were the tallest among advanced
nations, both men and women—we are now among the shortest.4
For good measure, Americans are also among the most dissatisfied with
our health care system. For what it is worth, money doesn’t buy us good
health or happiness.
In this epoch, we have seen enormous growth
in private investor funding into a sector formerly dominated by
nonprofits or government, in hospitals, physician practices, home
health, hospice, air ambulances, and much more. The pharmaceutical
industry has always been for-profit, yet its extraordinary concentration
has ballooned its pricing structure. The for-profit health sector keeps
evolving, assuming new forms. As Gondi and Song document, between 2010
and 2017 the value of private equity deals involving acquisition of
health-related companies, mostly hospitals and physician practices,
increased 187% reaching $42.6 billion.5
Could the
investor dominance of much of US health care explain at least part of
our outlier status on health spending and outcomes? It is hard to
imagine that the investor-driven corporatization of American society
could have left medical care untouched. Even today, the most common
complaint from conservatives and Republicans about US health care is
that government regulation thwarts the free market.
The notion
that we could put this massive bulk of toothpaste back into the tube
seems preposterous. The economic and political power of the incumbent
system would easily stymie any serious challenge, including the apparent
one, a nationalized “Medicare for All” structure. Assuming anything of
this magnitude could get through Congress—or the Supreme Court—is a
daunting stretch. And yet, the real frustrations of Americans with a
system organized first and foremost to serve money and power before
patients deserve attention.
If, as the Business Roundtable
advocates, we are embarking on a new national conversation concerning
the role of the for-profit corporation in American society, perhaps we
should also instigate a parallel and sustained national examination and
conversation about the history, experience, and results from for-profit
corporatization of our health and medical care sector. It is clear that
this revolution produces good and bad results for American society and
for the world. Is it time for a reckoning? https://www.milbank.org/quarterly/articles/shareholders-stakeholders-and-us-health-care/
Comment by Don McCanne
It is important to understand the concept of neoliberalism. It has divided the political left in this nation. No longer is there an unwavering reliance on public social programs since many on the left now believe that the private sector should provide the prevailing influence (forget the right). Application of neoliberal ideology is responsible for flat wages, income and wealth inequality, diminishing worker representation, increasing tax inequity, and suppression of beneficial public regulation.
An extremely important current manifestation of the inequities of neoliberalism is the internal attack on the left against the single payer model of Medicare for All. The single payer concept is one of the most important that would correct the social injustices and health care injustices that are so prevalent in our nation. Not only would it finally ensure that everyone would have access to health care, it would also reduce the injustices inherent in income inequality, not to mention improving the way that we spend health care dollars so that we would be receiving greater value and higher quality of care. Yet the neoliberal element within the Democratic Party is conducting a vicious campaign designed to destroy support for an equitable Medicare for All, while vocally supporting one of the greatest contributors to health care injustice - the private insurance industry and the fragmented, dysfunctional financing system it supports. But then supporting private solutions to public problems is what neoliberalism is all about.
The neoliberals have reduced the Medicare for All debate down to merely allowing people to buy an individual government plan, misnamed Medicare, while leaving all of the other dysfunctions in place that cause high costs, impaired access, mediocre outcomes, and financial hardship. Sadly, checking the campaign donations received by the Democratic candidates who are opposing single payer Medicare for All will confirm their neoliberal bona fides.
John McDonough asks if it is time for a reckoning. Way past, I'd say.
Democratic naysayers are wrong on Medicare for All
By Jeffrey Sachs - CNN - November 19, 2019
(CNN)The American political debate over health care is absurd. Americans pay twice as much as any other nation
for health care, and then are told daily that they "can't afford" to
switch to a lower-cost system very similar to those of Canada and
Europe. If President Donald Trump and the plutocratic Republican party
were the only ones carrying this ridiculous message, it would be
understandable. Yet this message is also coming from media pundits
aligned with the Democratic Party and the most conservative wing of the
party.
Let's be clear on the central point. Medicare for All, as first proposed by Bernie Sanders and endorsed by Elizabeth Warren, is affordable precisely because it is cheaper, much cheaper, than the current system.
America's health care system relies on local monopolies (such
as a health care provider centered at the sole major hospital in a
city) and national monopolies, notably pharmaceutical companies holding
exclusive patents.
In other countries, the government sets delivery prices and typically pays the health bills through the budget. In the US, the monopolists set the prices.
The
sky-high revenues end up as huge corporate profits, wasteful
administrative costs, useless and even harmful advertising and lavish
salaries. Health care CEOs are making gargantuan salaries, many exceeding $10 million per year.
Who
loses? Almost all Americans, whose insurance costs and out-of-pocket
outlays inevitably lead to lower income because of unaffordable health
care costs, untreated chronic illnesses, premature mortality and
personal bankruptcies. Single-payer systems such as in Canada and Europe
are cheaper, fairer and have better outcomes.
A recent international comparison
of the performance of 11 national health systems on five main
dimensions (care process, access, efficiency, equity and health care
outcomes) ranked the US health system dead last.
Despite all
of this, the US pundits profess to be alarmed about the prospect of
Medicare for All. There has been a wave of op-eds and columns published
(for example, here and here and here)
declaring that Medicare for All would lead to massive tax increases,
and that Sanders' and Warren's support for Medicare for All threatens to
reelect Trump. It's ridiculous.
Both Sanders and Warren poll well against Trump, ahead in the overall
popular vote (though like all Democrats, facing headwinds of the
Electoral College).
And at this stage of a national campaign, the
goal should be to explain to voters the vast benefits of a single-payer
system rather than to prejudge the politics based on self-fulfilling
fearmongering.
Yes, one way or another, taxes would rise with
Medicare for All, but private health outlays would go down by much more.
Total health costs would fall.
That idea is not so hard to understand.
One influential pundit, economist Paul Krugman, has come around.
In the 2016 election cycle, Krugman railed against Medicare for All.
Yet after Warren laid out her proposal, Krugman supported Medicare for
All. In truth, he was simply returning to the economically sound observations that he had long made before 2016.
The
pundits seem to believe that Americans will rebel at "higher taxes."
Actually, Americans are much smarter than that. They know that their
current private health care payments, whether insurance premiums or
out-of-pocket, are nothing other than "taxes" they pay to stay alive.
They'll agree to pay higher taxes to the government if those new taxes
eliminate larger private health care bills -- again, there are "taxes"
by any other name -- that they now pay.
Some mainstream pundits are simply repeating what they hear
from Democratic Party conservatives and centrists, the wing that has
been dominant since Clinton's election in 1992. They are following the
lead of Nancy Pelosi, Pete Buttigieg and others who are trashing
Medicare for All.
What in the world are these leading Democratic Party politicians
doing in opposing the transition to a fairer, more efficient and lower
cost health care system? I would suggest it's not a lack of
understanding. It's the power of campaign financing. These Democrats are
funded by the status quo. The health sector contributed $265 million to federal campaigns in 2018, of which 56% went to Democrats. The sector spends nearly $500 million per year on lobbying. Money talks. Meanwhile, Americans go bankrupt or die early.
There
remains the issue of the best way to raise budget revenues for Medicare
for All. The basic answer is to use progressive taxation to fund the
program. In this way, the nation as a whole will pay much less for
health care and the vast majority of households will as well. The
highest income households will end up paying a bit more because their
funds will not only finance their own health care but will help to pay
the health care costs of the poorest households as well.
Sanders
rightly proposed a menu of options to pay for Medicare for All,
including payroll and income taxation. Warren has proposed one specific
approach: progressive taxes on the super-rich and the corporate sector
but also a surprisingly regressive "head tax" on companies. She took
great pride in not charging a penny of new income or payroll taxes on
middle class households. But the proposed head tax on companies would
hit wages indirectly and regressively.
Still, both Sanders' and
Warrens' approaches would result in a more equitable and less expensive
system. For most households, overall health care costs will decline.
The
most worrisome thing about Warren's statement as she introduced her
Medicare for All plan, is her emphasis on "not one penny" of new
middle-class taxes. Here we go again. The Democrats have, for far too
long, copied the Republican mantra about "no new taxes," even as our
public debt soars, our infrastructure and public services collapse and
inequality reaches stratospheric dimensions.
To
honor the silly stricture of "no new taxes" directly paid by
middle-class households, Warren ended up endorsing a regressive head tax
paid by the employer, which would end up hitting lower-wage workers
even though its paid by their employers.
Let's hope this blunder
is a one-time stumble for Warren. Most importantly, both Sanders and
Warren are pointing the correct way to reform America's costly, unfair
and inefficient health care system. And this is a goal that most
Americans support.
Top Economist Robert Pollin Answers Key Questions on the Emerging Divide Between Sanders and Warren on Medicare for All
"I
clearly don't think it is premature to have detailed discussions on
funding Medicare for All," says co-author of 200-page study on that
exact subject. "How Sanders or Warren should handle the matter
politically is another matter."
Economist Robert Pollin, co-director of the Political Economy
Research Institute (PERI) at the University of Massachusetts at Amherst,
admits there is no "perfect way to fund" Medicare for All but he
remains on a mission to explain why simplicity is key when it comes to
building a more efficient, more humane, and less costly alternative to
the current for-profit status quo.
Despite a detailed economic analysis he and his PERI colleagues put out last year—presented in a 200-page study titled "Economic Analysis of Medicare for All,"
which examines the costs and benefits of legislation introduced in
Congress by Sen. Bernie Sanders of Vermont in 2017—Pollin remains
frustrated by the failure of many to grasp, or be honest about, the
clear benefits of a single-payer system.
"The biggest thing that Americans will be enjoying will be
something that is already being enjoyed in other advanced economies—i.e.
guaranteed access to good-quality health care when one needs it, and
getting the needed care without worrying about whether one can make all
the various kinds of insurance payments." —Prof. Robert Pollin, PERI/UMassA proposal like the one put forth by Sanders in 2017, says Pollin—as well as the updated version now in the Senate as "The Medicare for All Act of 2019"
(pdf)—will drive down healthcare costs for the United States overall
even as everyone in the nation enjoys full and expanded coverage; even
as utilization of care goes up; and even as no family ever again faces
financial ruin due to tragic injury or unexpected illness.
The conversation around Medicare for All has been a focal point in
the 2020 Democratic presidential primary and with leading progressives
like Sanders and Sen. Elizabeth Warren facing off against their more
centrist top-tier rivals Joe Biden and Pete Buttigieg who oppose it, Common Dreams asked Pollin for his perspective on some of the key facets of the current debate.
The healthcare issue will almost certainly come up during Wednesday night's Democratic Debate, hosted by NBC News,
and candidates will once more try to make their case on the direction
the country must take to address the crisis of medical bankruptcies,
skyrocketing drug costs and insurance premiums, and the fact that tens
of millions in the U.S. remain uninsured or underinsured.
Sanders has long been recognized as the nation's leading political
champion of Medicare for All, but Warren—who has repeatedly said "I'm
with Bernie" on his plan—has, in recent weeks, carved her own path by
offering alternative approaches regarding key implementation issues. At
the beginning of the month, Warren put a detailed "pay-for" funding plan for Medicare for All in which she claimed
that unless you are "in the top 1%, Wall Street, or a big
corporation—congratulations, you don't pay a penny more and you're fully
covered."
Sanders, on the other hand, has admitted that under his approach
taxes would go up for some (but not all) middle class and working
families, but that without copays, deductibles, and higher costs of
care—they would come out way ahead financially and in terms of security.
While Warren's financing plan received praise by many, it also raised
flags for some longtime single-payer activists and policy experts who warn that her funding approach is more regressive than what Sanders has put forth. In an interview with ABC News on Nov. 3, Sanders said his plan was "much more progressive" than what Warren is proposing.
Last week, Warren unveiled a separate transition plan for Medicare for All, which once again drew both praise and condemnation
from progressive observers and experts. One of the key criticisms was
that Warren will essentially move, if elected, to institute a public
option styled on Medicare at the outset of her term and then
subsequently—no later than her third year in office, she said—would push
for Medicare for All.
"Nobody is purveying more nonsensical double-talk around Medicare for All than Biden."
With Buttigieg and Biden
both attacking Medicare for All with talking points that sound a lot
like the ones put forth by the insurance and pharmaceutical industries (not to mention Republicans),
Pollin says clarity on key matters is needed now more than ever.
Despite nearly two dozen interviews with journalists this month, he
lamented, many continue to get the big picture of the story wrong.
Having done extensive research on Medicare for All, the Green New
Deal, and the minimum wage—all key issues in the current primary—Pollin
has become a highly sought after economist lawmakers and campaign policy
shops. As such, he has provided input to both the Sanders and Warren
campaigns in recent months, though he is not backing either candidate
nor has he served in an official capacity for their campaigns.
In his interview with Common Dreams—a back and forth
exchange which took place via email over recent weeks—Pollin explained
that he was "just offering ideas as Bob Pollin, economics scribbler,
with nothing politically at stake" for either himself or his fellow
researchers at PERI. "I hope that this discussion helps clarify
questions for lots of people," Pollin said, "and also helps give an
additional boost of confidence to Medicare for All supporters, against
this relentless onslaught of outrageous attacks." Pollin had choice
words for both Buttigieg and Biden.
In order to get to the heart of understanding the economics of
Medicare for All, he said, what's needed most—beyond understanding the
basic concepts of cost-savings—is being "open-minded in weighing the
relative strengths and weaknesses" of the various ways such a proposal
can be funded.
"As for the financing plan, you can almost put mine on the back of a matchbook."
There are many important details to work through, says Pollin, but he
wants people to understand there is a very simple bottom line: The
United States of America can "deliver good-quality universal health
care" to all its residents for less overall cost than we are doing now.
Period.
"As for the financing plan, you can almost put mine on the back of a
matchbox," Pollin said, even as he recognized that the intense political
battles ahead will be anything but simple.
If and when Medicare for All is achieved, he notes, "The biggest
thing that Americans will be enjoying will be something that is already
being enjoyed in other advanced economies—i.e. guaranteed access to
good-quality health care when one needs it, and getting the needed care
without worrying about whether one can make all the various kinds of
insurance payments." Common Dreams: If it is “easy to pay for something that costs less,”
as you stated nearly a year ago when introducing PERI’s study that
reviewed the Medicare for All Act of 2017 (an earlier iteration of the
current bill in the U.S. Senate put forth by Sen. Bernie Sanders earlier
this year), why is it that the discussion around funding such a
proposal continues to be politically unsettling for candidates and mired
in complexities?
Robert Pollin: There are a few reasons for this, in my view. I’ll
start with the most important reason, which is willful obfuscation,
distortion or ignorance. I say willful because the basic facts
are available for anyone to grasp if they choose to do so. I know this
firsthand, since I have given about 20 or so interviews on exactly these
questions over the past month. I tell everyone the same simple story,
which is, in round numbers:
1. We can deliver good-quality universal health care to all U.S.
residents at approximately $3 trillion for the first year of operation.
2. Total public funding of U.S. health care is, right now, at about $2 trillion.
3. That means we need to raise another $1 trillion in additional
taxes, to substitute for the premiums, deductibles, co-pays, and
out-of-pocket costs we now pay to private insurance companies.
4.We can raise that additional $1 trillion in a variety of ways. In
my own proposal, I give priority to a simple set of new revenue sources
that will support increased equality—i.e. help reverse the sharp
long-term rise in inequality. My main proposals include, again, in round
numbers:
$600 billion from new business taxes. This will mean
a cut of about 8 percent on what businesses, on average, now spend on
covering their workers. We can get to $600 billion either through a 1.8
percent gross receipts tax or an 8.2% payroll tax. There are advantages
and disadvantages of both approaches.
$200 billion from a 3.75 percent sales tax on non-necessities.
Spending on food, housing, and education will all be exempt. For
lower-income households, about half of all spending will be exempt from
the tax. Current Medicaid recipients will also get a tax credit to
offset their sales taxes on non-necessities.
$200 billion from a wealth tax of 0.38 percent.This would exempt the first $1 million in wealth.
5. It is straightforward to project these figures into a 10-year
framework, as is typically done in Washington policy circles. That is
because it is reasonable to conclude, conservatively, that once we
establish Medicare for All, health care spending is not likely to grow
more quickly than the rate at which the overall economy grows (more
likely health care spending will decline further as a share of the
economy). Because of this, the growth of the economy overall will itself
generate the needed additional tax revenue to finance Medicare for All
without having to increase anybody’s tax rate.
So, voila, that’s it: We need to raise $1 trillion in Year 1. We get
it from $600 billion in business taxes, and $200 billion respectively
from a sales tax and wealth tax. The additional revenues we will need in
subsequent years will come as a matter of course as the overall economy
grows. Simple, right?
Some of the journalists I have spoken to report this story
accurately, but at least half do not. As for presidential candidates, I
have to assume that, for example, Joe Biden and Pete Buttigieg are
engaging in deliberate obfuscation. This is for the purpose of
supporting their own proposals through which, to paraphrase Ralph Waldo
Emerson, ‘private health insurance companies remain in the saddle and
ride humankind.’ Leaving aside for the moment Warren’s specific pay-for
proposal which she released recently, what should the U.S.
public—assuming they remain skeptical or concerned about the price tags
they are being presented with—understand about Medicare for All’s
ability to deliver universal high-quality health care at lower costs to
everyone?
Those were, of course, the fundamental questions that my co-authors
and I worked on and tried to answer fairly and rigorously in our 2018
study. Here are the very basics of what we found:
1. We estimated that, as a high-end figure, total demand for health
care would rise by about 12 percent. This 12 percent estimate is higher than prominent critics of Medicare for All, including Prof. Kenneth Thorpe and Charles Blahous of the Mercatus Institute.
2. Working from the research literature, we estimated that Medicare
for All could generate total cost savings in the range of 19 percent
relative to our existing system. There are two huge sources of cost
savings: a) dramatic simplification of administrative costs by getting
rid of the current multi-payer system; and b) bringing down prescription
drug prices by an average of 40 percent. As it is, other advanced
economies are now spending between 50 – 60 percent less than we do now
while delivering, on average, better heath outcome to their populations.
3. As a general proposition, if all other advanced economies are
delivering universal health care with better overall health outcomes
than the U.S., and are spending roughly one-half of what the U.S. spends
per person, then it shouldn’t be such a stretch to think that we, in
the U.S., can design a Medicare for All system that can accomplish what
has long been a standard feature of how people live in other advanced
economies.
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Sanders has continued to say its premature in some ways
to have this detailed discussion about funding, but Warren apparently
felt it necessary to go to work on a plan that would prove that middle
class families would pay “not a penny” more in taxes. Is this more
politics than economics?
I clearly don’t think it is premature to have detailed discussions on
funding Medicare for All, since my co-authors and I wrote a 200-page
study which addresses exactly that question—how to fund Medicare for
All, in detail. How Sanders or Warren should handle the matter
politically is another matter. Again, as a matter of principle, as
opposed to politics, I actually favor middle-class people funding
Medicare for All in part. My view is reflected in my specific funding
proposal, that includes a sales tax on non-necessities. But as I note
above, in my proposal, most of the additional funding for Medicare for
All will come from business taxes and a wealth tax. The net result is
that, with my proposal, the U.S. middle class will get a financial
windfall under Medicare for All. We estimated that, for a household
earning at the U.S. median income of about $60,000 per year, savings on
health care costs—that is after getting rid of all premiums,
deductibles, co-pays, and out-of-pocket expenses but now paying the 3.75
percent sales tax on non-necessities—will be between $1,600 and $8,400
per year. The differences in savings are due to what kind of health
insurance this family will have had prior to Medicare for All. But the
point is these families will see between $1,600 and $8,400 more for
themselves under Medicare for All—the equivalent of an increase of
between roughly 3 and 14 percent in their available income. This is in
addition to now having full access to good-quality health care and never
having to experience any kinds of financial traumas when faced with a
serious health problem, for themselves or a family member. There seems to be confusion—or at least some debate—over what
constitutes a “tax” and what constitutes an “employer contribution”
when it comes to the pay-for plan that Warren put out on Friday. Can you
give some perspective on this?
It’s all the same thing. For political reasons, we don’t like to call
it a “tax” because people hate taxes. So fine. If that’s the big
hang-up, let’s call it an “employer contribution.” Or why not just stick
with the term “business premiums,” i.e. a payout to businesses fully
equivalent to the premiums they now pay to private insurance companies,
except now the funds will be moved into the big Medicare for All funding
pot. What is “tax incidence shifting” and what are candidates,
their surrogates, and/or outside analysts (including journalists)
getting wrong when they explore this terrain?
Tax incidence shifting is an important part of the overall story.
This term refers to, say, a business that pays a tax, but then raises
its prices, so that it shifts the burden of the tax onto its consumers. A
related example is when businesses shift their taxes—or for that matter
their health care premiums—onto their workers by reducing wages. We
need to try to keep track of these effects in thinking about the fairest
ways to finance Medicare for All. Here is one example that is pertinent
to the current debate. Many progressive analysts favor a payroll tax to
finance Medicare for All. I myself am not opposed per se. But we do
have to recognize that a payroll tax raises the costs for businesses to
hire more workers. All else equal, it therefore creates a disincentive
to hire workers and, correspondingly, an incentive to maybe buy a new
machine to increase production at the workplace rather bring on another
staff member. One way to handle this problem is to use a gross receipts
tax as the business revenue source rather than a payroll tax. With a
gross receipts tax, businesses are taxed on their total revenue,
regardless of whether their business operations use lots of workers or
relatively few workers. As such, the gross receipts tax does not build
in any disincentive to hire workers. The gross receipts tax does present
other problems of its own. The point is that there is no perfect way to
fund Medicare for All. We need to be open-minded in weighing the
relative strengths and weaknesses of the alternative approaches. But is there an important difference between Warren’s “head
tax”—a fixed fee which employers would pay to Medicare per
employee—compared to the payroll tax? The argument from critics like
Matt Bruenig at the People's Policy Project is that Warren’s head tax is
much more regressive than a payroll tax. What is your position on that?
The difference between a head tax and a payroll tax is as follows.
Let’s say you and I work for the same company. I earn $50,000 a year and
you earn $100,000. Under a head tax, the company would pay the same
amount in taxes for both you and me—let's say $6,000 for both of us. But
if we go with a payroll tax at 8 percent, then the company would pay
$4,000 for me as an employee but $8,000 for you, reflecting that your
wages are twice as high as mine. So clearly, the payroll tax is more
progressive. However, as I noted above, the overall idea of taxing
companies per employee in any way does discourage businesses from hiring
workers, all else equal. That is why, as I noted above, it may be
advantageous to consider taxing businesses based on their total
receipts, or revenues, regardless of whether their firms relies heavily
on employing workers or, rather, depends more on operating capital
equipment with a smaller workforce. It is also the case that, even if a
head tax is regressive—i.e. puts the tax burden disproportionately on
the lower-paid workers in a business firm—it doesn’t necessarily follow
that the overall Warren taxing proposal is going to end up regressive.
To determine that, we have to consider the full set of Warren tax
proposals, including the wealth tax and the Wall Street transaction tax.
Considering everything, I am nearly 100 percent certain that the Warren
tax plan will be highly progressive. In his initial review, The New Yorker’s John Cassidy concluded,
“On health care, as in other areas, Warren has shown a willingness to
consider remedies that go beyond the Washington consensus and get to the
heart of the matter. She cannot be faulted for lack of boldness.” Yet,
if not boldness—in your opinion—what could she be faulted for when it
comes to this proposal?
The main author of the Warren Medicare for All plan is Donald
Berwick, a former head of Medicare and Medicaid under President Obama.
Don is a person of very high integrity and intelligence. In fact, Don
worked very hard as a reviewer in helping my co-authors and me improve
our own Medicare for All study. I think what Don produced for Senator
Warren is quite serious and credible. I do have differences, and I look
forward to working through them with Don and members of the Warren
policy team (and I should declare an interest here: Warren staffers did
consult with me a bit as they worked out their plan with Don. But I was
never aware of where they were going with their overall approach. Nor
did I know in advance that Don was leading the work). At this point, my
two main differences with the Warren plan are: 1) I think their estimate
of the overall costs of operating Medicare for All are higher where I
put them; and 2) I favor a more simplified financing approach than what
they proposed. I say this, but I also recognize that they are operating
within a highly-charged political environment in offering their plan. In
my case, I am just offering ideas as Bob Pollin, economics scribbler,
with nothing politically at stake for me or my co-authors. Are you saying that Warren assumes overall that Medicare for
All will cost more than you believe it will? If so, can you explain why?
Second, what would you point to specifically in Warren’s financing plan
that is more complicated than you think it needs to be?
I am indeed saying that the Warren proposal estimates significantly
higher costs to cover everybody well than what I had estimated. Over a
decade, the Warren estimate is around $52 trillion. Mine is a bit under
$40 trillion. I am not yet sure where these differences are coming from.
The core assumptions of the Warren proposal are not that far off from
mine. This is what I look forward to discussing with Don Berwick in the
coming weeks. As for the financing plan, you can almost put mine on the
back of a matchbook—i.e. the business gross receipts or payroll tax,
generating $600 billion, and the sales tax on non-necessities and 0.38
percent wealth tax generating roughly $200 billion each. The Warren plan
would require a pretty large napkin, and somebody writing in small
print on both sides of that napkin. The main revenue source would still
be business taxes. But the plan then introduces proposals around
improving tax reinforcement, immigration and cuts to defense spending.
It then also introduces targeted taxes on the financial sector,
corporations and the richest 1 percent of households. This approach
could very well generate the needed revenues. But it does have many more
moving parts than what I proposed. More moving parts invites more
complications, which, in turn, offers more opportunities for attorneys
and accountants to come up with clever tax avoidance schemes. Mark Zandi, chief economist at Moody’s Analytics who admits he is “no fan of Medicare for All,” said in an CNN op-ed
last week that “Warren is right.. her Medicare for All plan won't raise
taxes on the middle class.” Zandi also said he valued that Warren had
come to an economist who doesn’t necessarily back the overall proposal
to check her numbers—which he said do check out. “That's the kind of
rigor we should expect from all of our presidential candidates,” he
wrote. You are an economist who states openly his support for Medicare
for All. If that is a moral position, how does that inform your analysis
of various plans and approaches?
My credo in all research work is “guilty until proven innocent.” That
is, we shouldn’t just accept any research findings at face value,
especially when it is research that supports our own prior convictions,
and most especially our own research. That is exactly why I asked many
leading experts in the field, including Don Berwick, to give our study
the most skeptical, rigorous reading that they could, and not worry in
the least about hurting anybody’s feelings. That is also why I posted
online all the reviews of our study, including the criticisms. If
someone such as myself has a prior position in favor of Medicare for
All, it is especially incumbent on us to demonstrate that our position
holds up under all types of honest skepticism. Otherwise, we are not
doing any favors to the causes we believe in. That is basically why it
took my co-authors and me 200 pages to convince ourselves that we had a
sound case, based on conservative assumptions, demonstrating that
Medicare for All could deliver universal high-quality care for all U.S.
residents at significantly lower costs than our present system. You wrote Sanders an open letter in October about funding
Medicare for All. Can you explain why you wrote that and explain briefly
what you expressed to him? RESPONSE:
Members of the Sanders policy staff asked me to write the open letter
to Senator Sanders. They did so because of the frustrations they have
felt about getting the story out clearly to the public that 1) Funding
Medicare for All doesn’t have to be all that complicated in its basics;
2) Medicare for All will deliver significant savings for most businesses
and households; and therefore 3) Medicare for All will also be an
important tool for fighting against the extreme rise of inequality that
we have experienced in the United States since the early 1980s, with the
onset of neoliberalism. Sanders “wrote the damn bill,” but do you perceive any
weaknesses in what the Senator has put forward in his signature
legislation or how he has talked about Medicare for All on the campaign
trail or in some of the primary debates thus far?
Of course, there are weaknesses in the Sanders bills of both 2017 and
2019. How could there not be? We are, after all, talking about a $3
trillion enterprise. It would be impossible to cover all features of the
system equally well in a single bill. That said, the overarching
intention of the Sanders bills is blazingly clear—to deliver a health
care system that is transformational in terms of improving the lives of
almost all of the 330 million people living in the U.S. today. In terms
of how Sen. Sanders has discussed the issue so far, I can only offer
praise. With the help of the California Nurses Association/National
Nurses United and other progressive organizations, Sen. Sanders has put
Medicare for All into the public consciousness to an unprecedented
extent. Tens and perhaps hundreds of millions of people now understand
that good-quality health care should be recognized as a basic right of
being alive. And as a basic right, nobody should ever have to face the
prospects of financial ruin due to health care needs. In the wake of the release last week of Warren’s transition
strategy for healthcare, some progressive critics warned that the
Senator’s plan to first bolster the Affordable Care Act and then offer
Medicare as an optional choice for those who want it over a private plan
would damage the movement to achieve full Medicare for All. Once again
there is a political side to this and an economic side, but how should
people reconcile the two? How does an “economics scribbler” such as
yourself think about these political realities?
The political realities are right there before us and can only be
ignored at our peril. What exactly we do about them is another matter.
Everyone should examine carefully the experience of the New Deal under
President Roosevelt in the 1930s. The New Deal has an historical halo
around it, with much justification, since it accomplished great advances
in toward building a more egalitarian society, including Social
Security and the minimum wage. At the same time, as Ira Katznelson
documented powerfully in his 2013 book Fear Itself, FDR compromised with
Southern racist politicians in enacting New Deal legislation, thus
upholding the virulent institutionalized racism of that era. Obviously,
we cannot accept a compromise of this nature to get Medicare for All
enacted. But we will have to make some compromises. There is no evidence
to date of which I am aware suggesting that getting a Congressional
majority in support of Medicare for All will be easy, even under a
President Sanders or Warren. Biden's deputy campaign manager, Kate Bedingfield, warned
last week that a healthcare approach like Warren's could lose Democrats
the general election. "We're not going to beat Donald Trump next year
with double talk on health care, and we're not going to beat him with a
plan that hikes taxes on the middle-class, kicks Americans off their
private insurance, and kills millions of jobs," Bedingfield said. What
do you say to that?
My response is that Ms. Bedingfield should practice what she
preaches. Nobody is purveying more nonsensical double-talk around
Medicare for All than Biden. Biden does not have the integrity to
recognize that Medicare for All will generate net savings for virtually
all U.S. residents—as I noted above, up to more than $8,000 per year for
some middle-income households. This is while it also eliminates the
trap of being ‘underinsured,’—i.e. having insurance, probably through
your employer, but still being unable to afford the deductibles and
co-pays that will result if you happen to get sick. One outside reviewer of the PERI study you and your
co-authors put out last year said that “despite stacking the deck”
against Medicare for All in terms of economic assumptions, the analysis
“convincingly demonstrates the substantial improvements in cost
efficiency” such a program will deliver. Savings of 3% to 14% for most
working families seems like a good deal. But can a Medicare for All Who
Want It, as Buttigieg calls this kind of plan, reap the kind of benefits
that would make it worth the political capital it would take to achieve
even this middling step? We saw what happened with the ACA.
Buttigieg’s public option approach cannot produce any
significant cost savings because it does not offer any opportunities for
administrative simplicity. This is no small matter. Above I noted that,
from our study, we estimate administrative simplification under
Medicare for All as constituting about 9 percent of total system costs.
Remember that the whole system would cost about $3.5 trillion to provide
universal insurance coverage within the existing health care
infrastructure. If, through implementing Medicare for All, we can
achieve 9 percent administration savings, that alone would therefore
amount to more than $300 billion. Let’s just say that is a serious level
of savings that would be foregone through any kind of public option
plan.
In your mind, what’s the most sensible way to transition from
what we have now to a Medicare for All system? On what kind of timeline
should it be done (and why) and what are the biggest challenges for a
smooth transition?
On purely analytic grounds, I think a strong case can be made for a
one-year transition. Keep in mind that roughly 50 percent of the
population is covered through employer plans. Employers regularly shop
around for cheaper plans and then frequently actually change plans. The
transition for businesses into Medicare for All will be easier than
switching, on a one-time basis, from one private plan to another. The
businesses will be strongly incentivized to make the switch to Medicare
for All, since, as soon as they do switch, they save money. Another 35
percent of the population are already covered with public plans—either
Medicare, Medicaid, the Defense Department, the VA, or other smaller
public programs. Switching these people from one public plan to another
one should not be especially challenging. Currently, we still have 9
percent of the population that are uninsured, and another 25 percent
that are underinsured. All of these people—the uninsured and
underinsured—will again have every incentive to sign up for Medicare for
All. It is going to get them access to health care in ways that they
have not yet experienced. Last question. It’s the year 2032. Medicare for All was
passed into law just over ten years ago and—despite early and determined
efforts to undercut it—legislation very similar to the Medicare for All
Act of 2019 has been firmly established into law. What are Americans
enjoying when it comes to the single-payer system now in place? What
have the biggest obstacles been so far and what are the system’s
shortcomings compared to what existed under the previous for-profit
system? Was the political battle worth it?
The biggest thing that Americans will be enjoying will be
something that is already being enjoyed in other advanced
economies—i.e. guaranteed access to good-quality health care when one
needs it, and getting the needed care without worrying about whether one
can make all the various kinds of insurance payments. As far as I can
tell, all the rest is commentary.
As health insurance, pharmaceutical and hospital companies
fight to prevent more politicians from backing Medicare for All, the
industry’s front group has turned to top Democratic consulting firms and
pro-business nonprofits for help, according to its 2018 tax return. The array of consultants includes presidential candidate Joe Biden’s pollster.
The Partnership for America’s Health Care Future (PAHCF), a
nonprofit created last year to oppose plans to create a comprehensive,
universal health care system, paid almost $760,000 to Bully Pulpit
Interactive, a communications and digital marketing firm that hasworked with the Democratic National Committee (DNC) and the Democratic Senatorial Campaign Committee (DSCC).
The dark money organization paid almost $185,000 to Anzalone Liszt Grove Research, a polling firm that hasbeenworking
with former Vice President Biden’s Democratic presidential campaign,
the DSCC, and the Democratic Congressional Campaign Committee (DCCC).
The firm recently tested attack lines
on Medicare for All for Third Way, a centrist Democratic think tank.
PAHCF also paid $140,000 to Blue Engine Message & Media, a firm that
was founded by former campaign staffers for President Barack Obama. (Blue Engine is now known as Seven Letter.)
PAHCF’s biggest vendor was Forbes Tate, a bipartisan lobbying
firm with ties to moderate Democrats. It paid the firm more than $1.7
million. The organization separately contributed almost $520,000 to
Center Forward, a centrist think tank that hosted a luxury retreat last year
where senior Democratic congressional staffers were invited to listen
to Center Forward board member Libby Greer, a Forbes Tate partner who
works for PAHCF, talk with a hospital lobbyist about health care. The
organization also paid $192,000 to Business Forward, a trade group that has beenwarning that business leaders are worried about Medicare for All.
Despite its Democratic consultant roster, PAHCF has spent much
of the past year and a half criticizing the party’s leading presidential
contenders. The organization has regularly slammed the Medicare for All proposals offered by Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts. It has alsoattacked
former Vice President Joe Biden and South Bend, Ind., Mayor Pete
Buttigieg for their plans to create a public health insurance option.
“While Medicare for All would eliminate private health coverage
overnight, Joe Biden’s public option and other new government health
insurance systems would eliminate it over time,” the organization tweeted during the September Democratic debate.
In response to questions, Anzalone Lizst Grove partner John
Anzalone said via email, “ALG is a polling firm and we did a project in
mid-2018 for PAHCF assessing voters’ views of the health care system,
including keeping and improving on Obamacare and baseline knowledge and
views on Medicare for All. This was the only project we conducted for
PAHCF and have done no work for them since then.”
Jana Plat, the programming director at Business Forward, said
her group hasn’t worked with PAHCF this year either. “We worked with the
Partnership in 2018, have not worked with them this year,” she wrote in
an email. “Our programming has focused on the ACA and reproductive
healthcare. We’ve spent 10 years on the [Affordable Care Act], from
helping pass it, to protecting it, to improving it.”
PAHCF’s list of members includes dozens of trade organizations
and companies, but its tax return shows the organization has been led by
executives at a few of the nation’s most influential health-care
lobbying groups – America’s Health Insurance Plans (AHIP), which
represents health insurers in Washington; Pharmaceutical Research and
Manufacturers of America (PhRMA), D.C.’s top drug lobby; the Federation
of American Hospitals (FAH), a trade group for investor-owned hospitals;
and the American Medical Association, which represents physicians.
The PAHCF filing lists AHIP executive vice president David
Merritt as its president and PhRMA lobbyist Scott Olsen as its
treasurer. The board of directors list also includes Jeff Cohen, but he left
FAH this summer and is no longer on the board, according to a PAHCF
spokesperson. Richard Deem, a senior vice president of the American
Medical Association (AMA) named in the filing, has left the board as
well, the spokesperson said. The AMA dropped out of the organization over the summer.
It’s not clear how much any of these organizations have donated to PAHCF. Tax returns filed by PhRMA and FAH for 2018 didn’t list any grants to the group. As MapLight previously reported, trade groups can finance front groups’ advocacy efforts without naming the organizations in their tax returns.
PAHCF reported raising $5.1 million in 2018. While the
organization isn’t required to disclose its donors in its tax return,
its filing shows its largest donor was $500,000. It received eight
contributions of $300,000.
The American College of Radiology Association contributed at least $300,000 to PAHCF in 2018, according to their tax return. Tenet Healthcare, an investor-owned hospital company, donated $41,000 last year before kicking in $588,000 earlier this year
PAHCF has ramped up its spending in recent months, running television advertisements during Democratic presidential debates and making big ad buys
in Iowa. “The politicians may call it Medicare for All, Medicare buy-in
or the public option,” the ads claim. “But they mean the same thing.
Higher taxes or higher premiums, lower quality care.”
Americans experience worse health outcomes
than people in wealthy countries that have adopted single-payer style
health care systems. Medicare for All would require people to pay more
in taxes, but they would no longer have to pay health insurance
premiums, deductibles or co-payments.
On Monday, PAHCF releaseda study
by FTI Consulting asserting that a public option could “eventually
cause the elimination” of all private health insurance plans offered on
state exchanges created under the Affordable Care Act, the 2010
Democratic health care law.
Their reasoning: “The government would be expected to set
premiums for the public option approximately 25 percent below market
value for comparable private insurance plans.” This story was produced in partnership between The American Prospect and MapLight.
Many
presidents have failed to pass major health care legislation. She
shared a detailed list that doesn’t require congressional approval.
by Margot Sanger-Katz - November 16, 2019
The Democratic presidential candidates have been fighting
over whether they should try to replace the health insurance system with
a single government-run plan or create a government-run plan that
Americans could choose to join.
But hidden outside this big debate is a harsh reality: If Democrats fail to retake control of the Senate, neither plan has much of a chance to become law.
Elizabeth Warren, the Massachusetts senator, has allied herself with the “Medicare for all” wing of the party, saying she would propose a single-payer system. But on Friday, she released a second plan, a sort of steppingstone along the way that would create a more optional government program. Her transition plan is engineered to pass with only a majority of Senate votes, instead of the 60 usually needed to overcome a filibuster.
But
it also includes a long and detailed list of the things she would do if
she couldn’t get Congress on board. That section of the report, which
is likely to get less attention and draw less criticism than the rest,
actually tells us a lot about what health care policy would probably be
like in a Warren administration.
President
Trump was elected in part on a promise to transform the health care
system. His efforts to repeal and replace the Affordable Care Act have
been unsuccessful, as Republicans in the Senate are unable to agree on
any one solution.
But he has used his regulatory authority to make many of the changes he was unable to achieve through Congress, like expanding the availability of insurance plans that cover fewer benefits; reducing federal funding of Planned Parenthood; permitting states to establish work requirements for Medicaid benefits; and increasing the size of special accounts that workers can use to save money for health care expenses.
He has also pursued other regulatory projects in health care, like his proposal, finalized on Friday, that would require hospitals to publicize the prices they have negotiated with insurance companies. He is allowing states to import drugs from Canada through regulatory power, and aiming to overhaul care for patients with renal disease.
So
what would Warren do? Her regulatory agenda can be divided into a few
broad categories. But over all, she views executive authority in the
same broad way that Trump does. Several of her proposals are likely to
end up in court — as several of his have.
Here are the big areas where she has regulatory ideas.
Reverse Trump administration policies
One
big chunk of her plan would reverse some Obamacare regulations
established by the Trump administration. She would return funding to
Planned Parenthood and other reproductive health groups that also offer
abortion services, for example. She would restore funding to publicize
insurance options. She would eliminate new requirements on Medicaid
beneficiaries, such as work requirements and premiums. And she would
change rules to restrict the sale of so-called short-term health plans,
which don’t follow all the Affordable Care Act’s rules.
She
would restore an Obama-administration policy that provided civil rights
protections to transgender patients and women with a history of
abortions, among other groups.
Expand benefits in existing insurance programs
She
would seek to offer subsidies to new groups of people to help them buy
health insurance under Obamacare, including legal noncitizen immigrants
and the families of people who can obtain coverage for only themselves
through work.
She would also seek to add a dental benefit to the Medicare program,by
reinterpreting language in the statute that says dental care can be
covered only if it is “medically necessary.” And she would change
aspects of the Medicaid program, making it easier for states to offer
coverage to more people, even if it will cost the government more.
She
would write new rules for a 2008 law that requires insurers to cover
mental health care in the same way they cover care for physical
ailments. The goal is to expand coverage for mental illness and
substance abuse across different types of insurance.
Lower drug prices
Ms.
Warren’s regulatory agenda is perhaps most aggressive in its efforts to
limit drug prices. She proposes that the federal government employ
never-before-used authority to rescind existing patents on medications
that were developed with the help of government funding. She would also
expand an infrequently used authority so that the government itself
could manufacture certain drugs in public health emergencies. Among the
drugs and devices she would target are insulin, EpiPens, antibiotics and
medications for hepatitis C, H.I.V. and opioid overdoses.
The
list of policies above does not include everything that Ms. Warren has
proposed. She’d also like to beef up antitrust enforcement in health
care, for example. But it gives a sense of the breadth of things she
would try to do in health care, even without Congress’s help.
President
Trump is far from alone in failing to enact his preferred health
policies through legislation. Several presidents before him have
struggled to pass major health overhauls. As Democrats head into another
debate next week, the moderators may want to consider asking candidates
what’s on their health care regulatory wish lists. The answer may be
far more useful in predicting the shape of their policy agenda than the
details of their legislative dreams. https://www.nytimes.com/2019/11/16/upshot/elizabeth-warren-backup-plan.html?smid=nytcore-ios-share
How Elizabeth Warren Got to ‘Yes’ On Medicare for All
By Shane Goldmacher, Sarah Kliff and Thomas Kaplan - NYT - November 17, 2019
Health
care had not been a driving issue for the Massachusetts senator. But
the expansive $20.5 trillion package could come to define her candidacy
anyway.
Two days before Senator Elizabeth Warren rolled out a
fundamental reimagining of America’s health care and tax system — a
$20.5 trillion package that would dwarf all her previous plans combined —
she was working the phones to personally preview her proposal and sell
it to a select group of political influencers.
One was Paul
Krugman, the Nobel Prize-winning economist and New York Times columnist,
who had written skeptically days earlier that her plan to pay for
“Medicare for all” was a “make-or-break moment”
for her, if not the whole 2020 race. Another call was to Representative
Pramila Jayapal, the lead sponsor of Medicare for all legislation in
the House and a leading liberal as the co-chair of the Congressional
Progressive Caucus.
“Pramila,” Ms. Warren told her, “we’re gonna do this.”
She
would soon need every ally possible: Ms. Warren’s announcement of her
Medicare for all financing package is perhaps the riskiest political bet
of her campaign. Her Democratic rivals have attacked her plan as
unfeasible and some voters worry that it is too radical. Ms. Warren
would guarantee government health coverage to every American for the
first time, erase the existing system of private insurance that
currently covers more than 170 million people
and pay for it with huge new taxes on corporations and the wealthy but
not, her campaign claimed, with “one penny” from the middle class.
The
sprawling plan is the culmination of Ms. Warren’s yearslong journey
toward a full embrace of Medicare for all and a clear sign that she
believes her path to the Democratic nomination, and her party’s to the
White House, is through full-throated liberalism.
And
yet the politics of health care have always been thorny — they powered
the Democratic takeover of the House in 2018 and the Republican wave in
2010. Ms. Warren appeared to nod to that reality on Friday, announcing a
two-step transition plan that would give her up to three years to try
to pass Medicare for all.
The twist is that health care was
never supposed to define Ms. Warren’s candidacy. That was Senator Bernie
Sanders’s signature issue. Ms. Warren had entered the race and gained
momentum with a populist agenda focused on breaking up Big Tech,
tackling corruption in Washington and on Wall Street, and making
corporations and the wealthiest Americans pay more in taxes.
But
her decision to remake the health care system is now a major part of the
2020 debate, and Ms. Warren’s upward momentum in the polls has stalled
as her opponents have assailed her. Political strategists say the sheer
scope of her plan and her support for ending private insurance threaten
to subsume her candidacy.
“She took most, if not all, of her
chips and put them on this — and I do think it took a lot of political
guts,” said Chris Lehane, a veteran Democratic strategist who worked in
the Clinton White House. “By going big on health care, she will either
go to the White House on this issue or go home because of it.”
How
Ms. Warren came to put together her blueprint, including her
determination to avoid middle-class tax increases, offers a revealing
window into the methodical way that she operates, her approach to
political balancing acts and how she might govern as president. It is a
story that begins with Ms. Warren researching medical bankruptcies at
Harvard nearly two decades ago and ends with her as a front-runner for
the Democratic nomination, rolling out a plan while under siege from her
rivals for more specifics.
Throughout, Ms.
Warren has kept one eye trained on policy and the other on realpolitik:
protecting her aspirational brand of liberalism and robbing Republicans
(and her Democratic rivals) of a potent talking point about middle-class
taxes. She ignored those in the Democratic establishment who had warned
her against eliminating private insurance, and ultimately settled on a
proposal whose math loosely adds up but that many, even within her
party, see as mostly a values statement.
The transition she
announced Friday focuses her first 100 days on a public health
insurance plan closer to what her more moderate rivals have championed —
drawing instant condemnation that she was trying to have it both ways.
“We’re not going to beat Donald Trump next year with double talk on
health care,” Kate Bedingfield, a deputy campaign manager for Mr. Biden,
said on Friday.
The backlash seemed to ensure that Ms. Warren
will face even more pressure to explain her stance in the Democratic
debate in Atlanta on Wednesday.
“Up until putting a price tag on
Medicare for all she had imposed her will on the primary and dictated
the tempo on her terms,” Mr. Lehane said. “This is first time that she
is having to react and not follow her campaign script.”
A plan conspicuous by its absence
Ms.
Warren had a plan for everything. That was her calling card almost from
the start of the race. But health care was conspicuous it its absence,
all the way back to her first trip to Iowa, when she barely mentioned Medicare for all. In June, Ms. Warren simply tucked into the slipstream of her liberal rival, Mr. Sanders, on his signature issue.
“I’m with Bernie on Medicare for all,” she said at the first debate.
But
by fall, health care was emerging as the No. 1 issue in the campaign,
and the absence of a plan was increasingly untenable. She was dogged for
weeks by questions about whom she would raise taxes on, saying only
that total costs for the middle class would go down.
“Your signature, senator, is to have a plan for everything,” Mayor Pete Buttigieg took aim at the last debate. “Except this.”
What
few people knew then was that Ms. Warren and her Boston-based team had
been privately crunching numbers since at least late August, working
with the internal imperative to craft a package without hiking
middle-class taxes, according to interviews with people directly
involved in the process.
The onslaught at the debate
accelerated the timeline. One academic described working so hard with
Warren officials in late October that he was distracted from his
teaching duties; another said she made final edits on a letter endorsing
Ms. Warren’s math in her car at her child’s school during a Halloween
parade.
“Syria is easier compared to this,” said one Warren adviser, granted anonymity to speak about the process of crafting a plan.
Kristen
Orthman, Ms. Warren’s communications director, said the campaign had
not been and would not be buffeted by “the cable news flavor of the
week.”
“We are running a campaign on identifying what’s broken,
presenting big ideas to fix it, and building a grass-roots movement to
make it happen and that’s exactly what we did here,” Ms. Orthman said.
Now Ms. Warren, who declined to be interviewed for this article,
must sell her plan to a Democratic Party deeply concerned about ceding
any political advantage to President Trump next fall.
Skeptics
of Medicare for all have ranged from Hillary Clinton to House Speaker
Nancy Pelosi to former President Barack Obama, who on Friday night
issued a warning of his own about disrupting people’s existing
insurance. “Eighty-five percent of the country has health care,” Mr.
Obama said. “They may not love it, but it roughly works for them.”
Kathleen
Sebelius, who had a front-row seat to the health care wars of the last
decade as Mr. Obama’s first secretary of health and human services,
sounded a similar note of caution. “We saw the Republicans very
effectively demagogue the issue,” she said.
Even some of Ms. Warren’s supporters are wary.
“It
still kind of scares me,” said Eric Spera, a 40-year-old who attended a
recent town hall in Goose Creek, S.C. “I love her. I think she’s the
best candidate that there is. But that’s the only drawback I have with
her.”
Yet in some ways, Ms. Warren has almost proceeded as if her
announcement did not happen. On the stump, she only glancingly mentions
health care. And speaking to reporters the day after unveiling her
Medicare for all financing plan, she uncharacteristically stumbled over the specifics, insisting, incorrectly, that only billionaires would see their taxes go up.
From skeptic to supporter
Nearly
two decades earlier, Ms. Warren was meeting with fellow Harvard
researchers in her light-filled office at the university’s Radcliffe
Institute to pore over hundreds of accounts of how Americans went
bankrupt.
The same answer kept popping up: medical bills.
“We
started to hear things like, ‘I have diabetes and I can’t afford to
save,’ and older people who had no savings left because of their medical
bills,” said Deborah Thorne, a researcher who worked closely with Ms.
Warren on the project. “I do think you could have watched our views
evolving then, both for Elizabeth and me.”
Ms.
Thorne recalled one story that stood out especially: a middle-aged man
who had spent hours debating with his wife about whether to go to the
emergency room for a second heart attack; they were worried about the
bills they could not afford to pay after the first one.
“Both of
us were so moved by the data and the people’s experiences, it made it
clear to us: This isn’t working,” Ms. Thorne said. “So what would?”
In 2008, Ms. Thorne and Ms. Warren co-wrote a book chapter
where they described single-payer health care as “the most obvious
solution” to medical bankruptcy. A few paragraphs later though, they
acknowledged that other policy options exist “if single-payer health
insurance is politically unacceptable.”
In Ms. Warren’s 2012
Senate run, her lone competitive race against a Republican, she resisted
endorsing a government-run health care program, saying “you’ve got to stay with what’s possible,” an echo of what former Vice President Joseph R. Biden Jr. now says.
Four
year later another member of the Harvard research team, Steffie
Woolhandler, a longtime single-payer advocate, traveled to Washington to
make her case for Medicare for all to Ms. Warren. But the senator
demurred, saying that she would prioritize “supporting the Affordable
Care Act and helping Democrats hold onto the Senate” in the upcoming
election.
But a year later, it was Ms. Warren reaching out,
inviting Ms. Woolhandler to her Massachusetts home on June 19, 2017.
There, over tea on an indoor porch, Ms. Warren peppered her with
questions about the economics of Medicare for all.
“She seemed to
be thinking through the economics — essentially, why can other nations
with single-payer spend no more than we do and cover everybody?” Ms.
Woolhandler said.
Days later, she called for single-payer for the first time.
And in September, she signed onto Mr. Sanders’s single-payer
legislation. Mr. Sanders has framed health care chiefly as a matter of
human rights, a way to provide medical care to the masses. Ms. Warren
focused on eliminating the medical bankruptcies she had seen in her
research.
Under Medicare for all, she said at the time, “Families don’t have to bear the costs of heartbreaking medical disasters on their own.”
But
she stopped well short that day of saying it was the only way to
proceed. “Everything should be on the table,” she said. “Medicare for
all is one way.”
An early 2020 “litmus test”
The
Sanders legislation represented an early 2020 ideological crossroads,
not only for Ms. Warren but for much of the presidential primary field.
Multiple advisers to potential candidates said the decision on whether
to join with Mr. Sanders, who had made Medicare for all central to his
insurgent 2016 campaign, presented one of the first sorting moments of
the coming primary.
“There are people who thought it was a litmus
test for being able to run for president,” said Senator Michael Bennet, a
moderate Democrat who is using a long-shot presidential bid to warn his
party about the electoral risk of Medicare for all.
But long after endorsing the Sanders bill, Ms. Warren’s language on Medicare for all remained fluid.
Image
The Medicare for all bill, written by Mr. Sanders, was an ideological test for Ms. Warren and other presidential candidates.Credit...Tom Brenner for The New York Times
In
March 2019, at a CNN forum, she said there were “a lot of different
pathways” for universal coverage, and that private insurers “could”
still have a role. By June, Ms. Warren was more unequivocal, raising her
hand at the first presidential debate to endorse doing away with
private insurers entirely.
Still, she allowed herself room to
maneuver, especially on how the program would be paid for. She
repeatedly refused to rule out raising middle-class taxes, saying only
that she would lower overall costs. The tension came to a head in a July
post-debate interview, when Chris Matthews, pressed her in a live
interview on MSNBC to say what would happen to taxes. Over and over, she
refused to answer.
By September, the headlineswereeverywhere:
The candidate with a plan for everything did not have one for the issue
at the center of the race. The tax question became so commonplace that
Ms. Warren even got advice from the late-night host Stephen Colbert, who
recommended she compare it to taxes for public schools.
Behind
the scenes, her team was already pressing to get the senator on firmer
rhetorical and financial footing. Two long-serving Warren aides, Jon
Donenberg and Bharat Ramamurti, were spearheading the effort to develop a
financing plan over the summer, with Mr. Donenberg briefing Ms. Warren
on various cost options.
But the plan was not quite cooked yet by
the time she stepped on the debate stage in Ohio with a bull’s-eye on
her back. She had just caught Mr. Biden in national polling averages for
the first time, and staked out a lead in Iowa.
A final rush
The
attacks began almost immediately. First came Mr. Buttigieg. Then
Senator Amy Klobuchar (“At least Bernie’s being honest here,” she said).
Then Mr. Biden (“On the single most important thing facing the American
public,” he said, “I think it’s awfully important to be straightforward
with them.”)
From a hotel room thousands of miles away, Donald
Berwick, a former federal health care official, had watched it unfold
with growing frustration. For six weeks, he had been stealthily working
with Ms. Warren’s campaign to develop a comprehensive way to pay for
Medicare for all.
“Senator Warren was under
tremendous pressure,” Dr. Berwick said. “It was the same question again
and again: Where is your plan? Where is your plan? That’s her thing, she
has plans.” But he said that he and Simon Johnson, an M.I.T. economist
close to Ms. Warren, were not rushed by campaign officials after they
began working together at the end of August.
Ms.
Warren’s own staff had produced the initial outline of her proposal and
began circulating it among a small network of economists and academics,
both for input and, eventually, public validation.
“It did kick
into a higher gear after the last debate,” said Mark Zandi, chief
economist of Moody’s Analytics, whom the campaign has consulted on this
and other policy proposals.
The Warren campaign also tipped the
progressive group Data for Progress about her proposal; it rushed a poll
into the field on Oct. 30 and 31, and released its favorable results on
Nov. 1, the same day as Ms. Warren’s plan.
The proposal
immediately came under attack from Ms. Warren’s rivals, chiefly Mr.
Biden, who said “she’s making it up.” His campaign manager recently
warned that Medicare for all could cost Democrats the House.
Ms.
Jayapal, the Seattle congresswoman whom Ms. Warren called before
releasing her plan, said it was a milestone to have a front-runner fully
embrace government-provided Medicare for all.
“It
was tricky political terrain because it was Bernie’s issue,” said Ms.
Jayapal, who has not endorsed a Democratic candidate. “She had to figure
out a way to not step on that but also make the issue her own.”
At
a campaign event in North Carolina recently, Ms. Warren delivered an
emphatic rejoinder to those who said it was misguided and impossible to
enact.
“You don’t get what you don’t fight for,” she said.
Less
than 30 minutes earlier, Ms. Warren had been asked to list the first
three bills she would want to sign into law. Medicare for all did not
make the cut. https://www.nytimes.com/2019/11/17/us/politics/elizabeth-warren-medicare-for-all.html?action=click&module=Well&pgtype=Homepage§ion=Politics
Bernie Sanders Draws Contrast With Elizabeth Warren On ‘Medicare For All’
But the Vermont senator declined to criticize his progressive Democratic rival.
by Daniel Marans - Huffington Post - November 16, 2019
In an effort to distinguish himself from rival presidential candidate Elizabeth Warren, Bernie Sanders emphasized on Friday that if elected president, he would immediately pursue the complete enactment of a “Medicare for All” single-payer health care system, including the elimination of the vast majority of private health insurance coverage.
Sen. Warren, the Massachusetts Democrat who two weeks ago introduced her own plan
to finance Medicare for All without raising middle-class taxes,
announced earlier on Friday that she would also pursue implementation of
her plan in stages. She said she would move immediately to introduce a
public option and lower the Medicare eligibility age to 50 and then, in
the third year of her presidency, she would begin phasing out duplicative private health insurance.
Speaking at a campaign rally-cum-press conference in Oakland, California, where he was formally accepting the endorsement of the National Nurses United labor union, Sen. Sanders staked out a contrasting approach.
“With National Nurses United at my side, during the first week of our
presidency, we are going to introduce the legislation that will bring
Medicare for All to everyone in this country,” the Vermont independent
said to a cheering crowd of nurses clad in the union’s signature red
T-shirts.
The 150,000-member union, which is especially strong in California,
is perhaps the country’s leading institutional proponent of Medicare for
All. While it had been considering throwing its weight behind Warren,
the union cited Sanders’ decades of consistent support for a single-payer health care system in explaining its endorsement.
Asked at the press conference whether Warren’s plan is a departure from his plan, Sanders answered diplomatically.
“I will let Senator Warren speak for herself, but this is what I
believe,” he said before being cut off by the knowing laughs of the
nurses assembled before him.
Addressing the laughter, he joked, “See, that’s being very tactical.”
He explained that he does not see any value in deferring a
confrontation with the private insurance companies and pharmaceutical
companies that will stand in the way of a single-payer system.
“That’s a fight that’s going to have to happen,” Sanders said.
“I will engage that struggle on day one of my administration, not put it
off for several years.”
Of course, Sanders’ Medicare for All legislation features a four-year phase-in period during
which he would gradually lower the Medicare eligibility age before
making the program completely universal. But unlike Warren, he has
decided not to decouple the plan’s most controversial feature ― the
abolition of private insurance for practices covered by the new,
expanded Medicare program ― from the expansion of coverage. And by
refusing to postpone implementation of the full Medicare for All
legislation to the third year of his presidency, he does not risk ― as
Warren’s left-wing critics fear of her plan ― facing a more hostile
Congress and being forced to defer the policy’s enactment indefinitely.
The gentle tone of Sanders’ remarks about Warren reflect a
non-aggression pact that the two candidates struck prior to announcing
their plans to run for the White House. Sanders’ campaign aides have
shown signs of straying from the terms of that accord, but Sanders himself has rarely, if ever, offered anything more than veiled criticism of Warren.
But Medicare for All is still something of a political obstacle course for Warren, who has scrambled to respond to a monthslong drumbeat
of pressure springing from her initial embrace of Sanders’ legislation.
She released her plan to finance the single-payer legislation after
weeks of questions from journalists and attacks from more moderate
rivals demanding to know whether her plan to finance the plan would lead
to middle-class tax increases.
Before relenting and producing a plan to pay for Medicare for All
that limited the tax increases to the wealthy and corporations, Warren
had been reiterating that the vast majority of Americans’ underlying
costs would go down under her plan without specifying whether that meant
that the elimination of out-of-pocket costs would offset a tax
increase. (Sanders has openly stated that his health care plan will
raise taxes on middle-income earners, but justified it on the grounds
that the tax increases would be lower than overall savings.)
The presidential campaign of South Bend, Indiana, Mayor Pete
Buttigieg, a moderate contender who perhaps exerted the most effective
pressure on Warren, continued to blast her in a Friday statement.
Campaign spokeswoman Lis Smith argued that Warren’s decision to embrace
the public option, which Buttigieg has labeled “Medicare for All Who
Want It,” was an effort to “paper over a very serious policy problem,
which is that she wants to force 150 million people off their private
insurance- whether they like it or not.”
“Despite adopting Pete’s language of ‘choice,’ her plan is still a
‘my way or the highway’ approach that would eradicate choice for
millions of Americans,” Smith continued. https://www.huffpost.com/entry/bernie-sanders-elizabeth-warren-medicare-for-all-national-nurses-united_n_5dcf2ea2e4b0294748174d48
Doing the Health Care Two-Step
Medium-size reform creates the conditions for bigger things.
by Paul Krugman - NYT - November 1`8, 2019
Recent state elections — the Democratic landslide in
Virginia, followed by Democratic gubernatorial victories in Kentucky and
Louisiana — have been bad news for Donald Trump.
Among other
things, the election results vindicate polls indicating that Trump is
historically unpopular. All of these races were in part referendums on
Trump, who put a lot of effort into backing his preferred candidates. And in each case voters gave him a clear thumbs down.
Beyond
offering a verdict on Trump, however, I’d argue that the state
elections offered some guidance on an issue that has divided Democrats,
namely health care. What the results suggested to me was the virtue of
medium-size reform: incremental enough to have a good chance of being
enacted, big enough to provide tangible benefits that voters don’t want
taken away.
Remember, there was a third governor’s race, in
Mississippi, in which the G.O.P. held on. True, Mississippi is a very
red state, which Trump won by 18 points
in 2016. But Louisiana and Kentucky are or were, if anything, even
redder, with Trump margins of 20 and 30 points respectively. So what
made the difference?
Personalities surely
mattered. Louisiana’s re-elected John Bel Edwards was widely liked,
Kentucky’s defeated Matt Bevin widely disliked. Demography probably also
mattered. Urban and especially suburban voters have turned hard against
Trump, but rural voters haven’t, at least so far — and Mississippi is one of the few states left with a majority-rural population.
But
there’s another difference among the three states. Kentucky and
Louisiana took advantage of the Affordable Care Act to expand Medicaid,
leading to steep drops
in the number of uninsured residents; Mississippi hasn’t. This meant
that voting Democratic in Kentucky and Louisiana meant voting to
preserve past policy success, while the same vote in Mississippi was at
best about hope for future reform — a much less powerful motivator.
Back in 2010, as Obamacare was about to squeak through Congress, Nancy Pelosi famously declared,
“We have to pass the bill so that you can find out what is in it.” This
line was willfully misrepresented by Republicans (and some reporters
who should have known better) as an admission that there was something
underhanded about the way the legislation was enacted. What she meant,
however, was that voters wouldn’t fully appreciate the A.C.A. until they
experienced its benefits in real life.
It took years to get
there, but in the end Pelosi was proved right, as health care became a
winning issue for Democrats. In the 2018 midterms and in subsequent
state elections, voters punished politicians whom they suspected of
wanting to undermine key achievements like protection for pre-existing
conditions and, yes, Medicaid expansion.
And this political
reality has arguably set the stage for further action. At this point, as
far as I can tell, all of the contenders for the Democratic
presidential nomination are calling for a significant expansion of the
government’s role in health care, although they differ about how far and
how fast to go.
Which brings me to the latest development in intra-Democratic policy disputes: Elizabeth Warren’s proposal
for a two-step approach to health reform. Her idea is to start with
actions — some requiring no legislation at all, others requiring only a
simple Senate majority — that would greatly expand health insurance
coverage. These actions would, if successful, deliver tangible benefits
to millions.
They would not, however, amount to the full Bernie,
eliminating private insurance and going full single-payer. Warren still
says that this is her eventual intention, and has laid out a plan to pay
for such a system. But any legislative push would wait three years,
giving time for voters to see the benefits of the initial changes.
Sanders
supporters are, predictably, crying betrayal. For them it’s all or
nothing: a commitment to single-payer has to be in the legislation from
Day 1.
The trouble with such demands, aside from the strong
probability that proposing elimination of private insurance would be a
liability in the general election, is that such legislation would almost
certainly fail to pass even a Democratic Senate. So all or nothing
would, in practice, mean nothing.
But is Warren giving up on
Medicare for All? After all, what she’s offering isn’t really a
transition plan in the usual sense, since there’s no guarantee that Step
2 would ever happen.
The lesson I take from the politics of
Obamacare, however, is that successful health reform, even if
incomplete, creates the preconditions for further reform. What looks
impossible now might look very different once tens of millions of
additional people have actual experience with expanded Medicare, and can
compare it with private insurance.
Although I’ve long argued
against making Medicare for All a purity test, there is a good case for
eventually going single-payer. But the only way that’s going to happen
is via something like Warren’s approach: initial reforms that deliver
concrete benefits, and maybe provide a steppingstone to something even
bigger. https://www.nytimes.com/2019/11/18/opinion/medicare-for-all.html
Warren’s very good transition plan
by David Leonhardt - NYT - November 19, 2019
Health care is a great political issue for Democrats — or at least it should be. Many Americans areanxiousabout medical costs, and yet Republicans have spent yearspushing plansthat would increase costs for most families. For Democrats, the playbook should be simple enough: Promise to make health care more affordable.
The plan that Elizabeth Warrenreleasedlast week takes this approach. It would, among many other things, use the 1980 Bayh-Dole Act to push down the price of drugs that were developed with government funding. It would also create low-cost federal insurance coverage, like Medicare, that anyone could purchase. Warren’s plan,Larry Levittof the Kaiser Family Foundation says, “would provide cost relief to a lot of people.”
My one major criticism is that Warren should have started with this plan, rather than firstcommittingherself to a Medicare for All plan that would abolish private insurance. The plan she released last week lays out a two-year transition period that would include immediate changes, before she would ask Congress to pass Medicare for All. Her hope is that the transition plan — especially a universal Medicare buy-in — would make Americans more supportive of abolishing private insurance.
That’s clearly a gamble, because she is trying to win a presidential election before a universal buy-in exists. And mandatory Medicare for All is one of the few ways for Democrats to get on the wrong side of the politics of health care.
Supporters of Medicare for All like to claim otherwise, by citing polls withfavorably wordedquestions, but there is abundant evidence that it is unpopular.Multiple polls showthat most Americans oppose abolishing private insurance. More telling, in 2018, Democratic House candidates who supported Medicare for All “performed worse than those who did not, even when controlling for other factors,”Alan Abramowitzrecently wrote for Sabato’s Crystal Ball. For the Democrats who simply talked about reducing costs, by contrast, health care was ahighly effectiveissue.
Warren’s larger economic agenda is the most ambitious plan from any current presidential candidate for improving the living standards of most Americans, as I’vewrittenbefore, and I wish she had taken a different approach on health care. She could have said that Medicare for All was her ultimate goal but emphasized measures like the one she proposed last week.
Once she made that mistake, though, she did about as good of a job minimizing the damage as she could have. The question now is whether she can spend less time talking about a proposal that scares many voters — Medicare for All — and more time talking about the popular and achievable ideas in her transition plan.
Even progressives who are committed to Medicare for All should favor that approach. It’s the only plausible way the United States is going to make such a radical change to its health care system
Surgery for Blocked Arteries Is Often Unwarranted, Researchers Find
Drug therapy alone may save lives as effectively as bypass or stenting procedures, a large federal study showed.
The
findings of a large federal study on bypass surgeries and stents call
into question the medical care provided to tens of thousands of heart
disease patients with blocked coronary arteries, scientists reported at
the annual meeting of the American Heart Association on Saturday.
The
new study found that patients who received drug therapy alone did not
experience more heart attacks or die more often than those who also
received bypass surgery or stents, tiny wire cages used to open narrowed
arteries.
That finding held true for patients with several
severely blocked coronary arteries. Stenting and bypass procedures,
however, did help some patients with intractable chest pain, called
angina.
“You would think that if you fix the blockage the patient
will feel better or do better,” said Dr. Alice Jacobs, director of Cath
Lab and Interventional Cardiology at Boston University. The study, she
added, “certainly will challenge our clinical thinking.”
This
is far from the first study to suggest that stents and bypass are
overused. But previous results have not deterred doctors, who have
called earlier research on the subject inconclusive and the design of
the trials flawed.
Previous studies did not adequately control
for risk factors, like LDL cholesterol, that might have affected
outcomes, said Dr. Elliott Antman, a senior physician at Brigham and
Women’s Hospital in Boston. Nor did those trials include today’s
improved stents, which secrete drugs intended to prevent opened arteries
from closing again.
With its size and rigorous design, the new
study, called Ischemia, was intended to settle questions about the
benefits of stents and bypass.
“This is an extraordinarily
important trial,” said Dr. Glenn Levine, director of cardiac care at
Baylor College of Medicine in Houston.
The results will be
incorporated into treatment guidelines, added Dr. Levine, who sits on
the guidelines committee of the American Heart Association.
The participants in Ischemia were not experiencing a heart attack, like Senator Bernie Sanders,
nor did they have blockages of the left main coronary artery, two
situations in which opening arteries with stents can be lifesaving.
Instead, the patients had narrowed arteries that were discovered with
exercise stress tests.
With 5,179 participants followed for a
median of three and a half years, Ischemia is the largest trial to
address the effect of opening blocked arteries in nonemergency
situations and the first to include today’s powerful drug regimens,
which doctors refer to as medical therapy.
All the patients had
moderate to severe blockages in coronary arteries. Most had some history
of chest pain, although one in three had no chest pain in the month
before enrollment in the study. One in five experienced chest pain at
least once a week.
All participants were regularly counseled to
adhere to medical therapy. Depending on the patient’s condition, the
therapy variously included high doses of statins and other
cholesterol-lowering drugs, blood pressure medications, aspirin and, for
those with heart damage, a drug to slow the heart rate. Those who got
stents also took powerful anti-clotting drugs for six months to a year.
Patients
were randomly assigned to have medical therapy alone or an intervention
and medical therapy. Of those in the intervention group, three-quarters
received stents; the others received bypass surgery.
The number
of deaths among those who had stents or bypass was 145, compared to 144
among the patients who received medication alone. The number of patients
who had heart attacks was 276 in the stent and bypass group, compared
with 314 in the medication group, an insignificant difference.
Dr.
Judith Hochman, senior associate dean of clinical sciences at N.Y.U.
Langone Health and chair of the study, had expected that those with the
most severe chest pain and blockages would benefit from stents or
bypass.
But “there was no suggestion that any subgroup benefited,” she said.
Ischemia’s
results are consistent with current understanding of heart disease.
Researchers have learned that a patient with a narrowed artery may have
plaques not just in a single blocked area, but throughout the coronary
arteries.
There is no way to predict which of those plaques will
break open and cause a heart attack. Stents and bypass treat only areas
that are obviously narrowed, but medical therapy treats the entire
arterial system.
Yet when a cardiologist sees a blockage, the
temptation for doctor and patient alike is to get rid of it quickly,
said Dr. David Maron, director of preventive cardiology at Stanford
University, the study’s other co-chair.
When an exercise stress
test indicates a narrowing, most doctors send patients to a cardiac
catheterization lab to look for blockages, Dr. Maron said. If there is a
blockage, the usual practice is to open it with a stent.
If
stenting is not feasible — because of the configuration of the patient’s
arteries, for example — bypass surgery is usually the next step.
Patients
with abnormal stress tests should talk to their doctors about the
options, Dr. Maron said. If a patient has chest pain despite taking
recommended medications, a stent or bypass might help improve quality of
life.
Still, he said, patients have time to make considered decisions.
“You
don’t have to rush to the cath lab because, OMG, you will have a heart
attack soon or drop dead,” Dr. Maron said. “If you have had no angina in
the last month, there is no benefit to an invasive strategy.”
Stenting
costs an average of $25,000 per patient; bypass surgery costs an
average of $45,000 in the United States. The nation could save more than
$775 million a year by not giving stents to the 31,000 patients who get
the devices even though they have no chest pain, Dr. Hochman said.
But
the conventional wisdom among cardiologists is that the sort of medical
therapy that patients got in Ischemia is just not feasible in the real
world, said Dr. William E. Boden, scientific director of the clinical
trials network at VA Boston Healthcare System, who was a member of the
study’s leadership committee.
Doctors often say that making sure patients adhere to the therapy is “too demanding, and we don’t have time for it,” he said.
But
getting a stent does not obviate the need for medical therapy, Dr.
Boden noted. Since patients with stents need an additional anti-clotting
drug, they actually wind up taking more medication than patients who
are treated with drugs alone.
About a third of stent patients
develop chest pain again within 30 days to six months and end up with
receiving another stent, Dr. Boden added.
“We have to finally get
past the whining about how hard optimal medical therapy is and begin in
earnest to educate our patients as to what works and is effective and
what isn’t,” Dr. Boden said. https://www.nytimes.com/2019/11/16/health/heart-disease-stents-bypass.html
Report: Health Insurance Costs Rising For Those With Employer-Sponsored Plans
Health insurance costs are becoming less affordable for those with employer-sponsored plans, according to a new report from the Commonwealth Fund.
Senior
scientist David Radley says over the past decade, employee
contributions to deductibles and premiums have increased 11.5% across
the U.S. And, he says, Maine's costs are even higher.
"In Maine, those combined costs account for almost 12 percent of median income," Radley says.
And those
insurance costs have outpaced growth in median income during that time,
says Radley. The average out-of-pocket cost for employer-sponsored
health plans in Maine is more than $7,800 per year.
Radley says
those costs have been taking a larger bite out of household budgets for
the past decade. "The annual rate of growth in employee premium
contributions and in deductibles is still higher than the annual rate of
growth in wages," he says.
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