The Medicare for All Act of 2017: The Policies

By Lambert Strether of Corrente.

Yesterday, I wrote on the politics of The Medicare for All Act of 2017 (“BernieCare”). Today, I’ll write on the policies. First, I’ll lay out, very sketchily, one or two differences between BernieCare and HR676 (“ConyersCare”) — as opposed, of course, to #LiberalsDontCare — which will have to serve as a placeholder for the full-throttle War and Peace-length post I should and will write on this topic[1]. Then, I’ll consider the health insurance industry workers that #MedicareForAll would displace. Finally, I’ll look at the fiscal issues (or rather, how to think about them). Spoiler alert: I’ll treat worker displacement and budget issues at a very high, talking-point level; it would be nice if some good faith wonks got down in the weeds on these topics but (with the exception of Gerald Friedman) they haven’t yet.

BernieCare vs. ConyersCare

Again, I want to express my gobsmackedness at having not one, but two #MedicareForAll bills introduced in Congress, both with a serious number of co-sponsors[1]; we have come a long way from the days of 2009, when Max Baucus refused to include single payer advocates in his hearing, and had them arrested when they protested; or when Obama sneered at “little single payer advocates.” It just goes to show that good things can happen in one’s own lifetime, which really matters to an old codger like me.

Here are two comparisons of BernieCare and ConyersCare. The first is a list from Dr. Margaret Flowers and the HOPE campaign, in mail; the second is a table from Health Over Profit. The first cites to the second. Looking at the table, this jumps out:

HOUSE: HR 676 SENATE: Medicare for All Act
Providers All who meet standards and are public or nonprofit (bans investor-owned facilities and phases them out over 15 years). All facilities must meet standards for staffing and quality. All who meet standards. Includes investor-owned facilities. All facilities must meet standards of staffing, competence, quality and satisfaction.

I’m very dubious about the unlimited inclusion of “investor-owned facilities” in BernieCare, because I’m dubious that profit-driven facilities can deliver care equitably. (See here for an illuminating description of profit vs. non-profit hospitals during Hurricane Katrina. Guess which facility triaged its patients, and which saved all of them?) Frankly, this seems to me like an open invitation for a neoliberal infestation and invasion even worse than we already have, fought out on the ground of “standards.” Less centrally than saving lives, there is the cost issue; most projections of #MedicareForAll assume that profit (and rental extraction) are squeezed out of the system as much as possible.

Reinforcing my fear of neoliberal infestation:

HOUSE: HR 676 SENATE: Medicare for All Act
Operating and capital expense budgets Global operating budgets for each facility and separate capital expense budgets, cannot co-mingle. No global operating budgets. Facilities can co-mingle operating and capital budgets. No mechanisms to control budgets.

On my cursory reading, “No global operating budgets” + ” investor-owned facilities” = Ginormous Bezzle.[2] Prove me wrong, please!

Helping Displaced Workers

Next, we have the issue of how to help the approximately 525,000 workers in the health industry (hat tip, marym) who would be displaced by #MedicareForAll.

At the outset, this wonkish objection to #MedicareForAll is hardly ever made in good faith; in policy terms, the political class doesn’t give a rats patootie about displaced workers; look at what’s happening to retail now, or, for that matter, the deindustrialization of the Rust Belt. Please don’t try to make me believe that these suddenly expressed tender concerns — “Will nobody think of the workers?” — are anything other than tactical.

That said, if the left does in fact put workers first, then for its own reasons, it needs to come up with a solution, since the need for one won’t go away. For example, supposed we ended the empire tomorrow. What about the workers at Bath Iron Works, say? Or suppose the finance sector were shrunken from its current hideously bloated, Shelob-like size to something more manageable? Granted, Greenwich will do OK no matter what, but what happens to the office workers and cleaners and food prep people and transport workers and HVAC techs and IT workers who kept Wall Street going, before all the towers went dark?

At the highest level, a Job Guarantee is the obvious answer, but that illustrates the requirement for the left — as the neoliberals have — to think in terms of whole systems, and not merely policies. (In other words, this is not a JG thread, and not a JG v. Big thread. For further reading, see especially here, and here, and here.) But as for policy, again the two bills:

HOUSE: HR 676 SENATE: Medicare for All Act
Transition for workers Displaced workers have first priority to be hired into new system, 2 years salary and training support. Temporary worker assistance for up to 5 years, capped at 1% of total budget.

One problem with HR676 is that retraining is a crock; it always comes up in the “skills mismatch” debate, and it turns out in practice that the only jobs retraining programs create are for professional trainers (which is why the Democrats love the idea). Other than that, both programs seem reasonable to me, especially giving displaced workers first priority; displaced workers please chime in![3] (I’m also assuming that the liberals Ladies and Lords Bountiful don’t sneak in their usual complex eligibility requirements, especially means-testing. For example, people should be able to cover their moving expenses to a new job without going through some sort of ritual to prove their worthiness. Or child care during a job search. And so on and on.)

One point that I don’t see made very often: Medical coding is currently used to figure out how to bill for health care services. This is, however, an insane perversion of the coding taxonomies, which were originally designed to classify health care delivery as such, not billing for health care. (If you don’t see a distinction here, you may be a neoliberal.) If we could re-engineer medical coding[4] by using its taxonomies for the purpose for which they were originally designed, we might learn a lot about how to deliver health care, besides saving a large number of skilled and well-paying jobs.

“How Are You Going to Pay For It?”

Unfortunately, as most NC readers know, the political class is brain-damaged about taxes (and in the sort of way that markets-first neoliberals like, since one effect of the brain damage is horror and repulsion at the concept that government — or even associations of volunteers assisted by government — can or should do anything). So, “The Federal government, as the currency issuer, would write a check for whatever Congress authorized” isn’t an answer that the political class can (as yet) process, at least without sparks and smoke coming from their ears.

Once again, and at a high level, here’s how the Swedes think about taxes:

Blyth: “Guess what the most popular government institution in Sweden is, year after year after year in surveys: The tax office.” Blyth then goes on to explain the policies that brought about that outcome. Obviously, we’re not at that point yet, and if it’s a prequisite for passing #MedicareForAll, that policy is in trouble. Nevertheless, we see what can be done. (My father, for example, always paid the maximum in taxes, in graitude for the New Deal and his service in World War II, followed by the GI Bill.)

Failing a revolution in attitudes toward tax, and failing an understanding by the general public that Federal taxes don’t fund Federal spending, we might try something like this (making up the figures):

Q: “How Are You Going to Pay For It?”

A: “Out of my right pocket, instead of my left.”

Q: [expression of bewilderment]

A: Right now, I pay $6000 a year for health care out of my left pocket, to the health insurance companies. Under #MedicareForAll, I’d pay $4000 a year for health care out of my right pocket, on April 15.

There’s no difference. I mean, except for the $2000 I’d save.

And no tax on time, a doctor of my choice instead of effing narrow networks, no co-pays, no [family blogging] paperwork when you’re coping with your diagnosis, and so on. A strategy like this might work as a sorely-needed conversation starter, at least. (Hat tip for pockets metaphor to you-know-who-you-are.)

Conclusion

Obviously, there’s much more to be said about #MedicareForAll. But what amazing progress in eight years, and against massive opposition, not only from conservatives, as we might expect[5], but especially from the liberal Democrats whose policies, politics, and persons were discredited in 2016. Hopefully, it won’t take another eight for the political class to do the right thing.

NOTES

[1] One topic I need to understand, and do not, is the institutional imperatives and constraints within which Sanders and Conyers are working. The West Wing retells this famous story (so famous I can’t find the original):

There was a freshman Democrat who came to Congress 50 years ago. He turned to a senior Democrat and said, “Where are the Republicans? I want to meet the enemy.” The senior Democrat said, “The Republicans aren’t the enemy. They’re the opposition. The Senate is the enemy.”

(In other words, our bicameral legislature is working as designed; see Federalist Papers 62.) Both Conyers and Sanders, in addition to their personal visions of what #MedicareForAll should look like, will have had to write their bills to acquire co-sponsors in their respective Houses. For example, I’d speculate that the long phase-in for Sanders care is about sponsor acquistion, and the same for the inclusion of for-profit facilities, as long as they meet standards. ‘Twas ever thus.

[2] It’s dangerous to assume that our body politic is healthier than it is, and our political class less corrupt. Like it or not, breaking the political power of the health insurance industry is central both to passing #MedicareForAll, and to keeping it (and us) healthy after its passage. If the health insurance industry is still in a position to bribe its way back into power after #MedicareForAll is passed, we might as well not have passed it at all, because the same logic of making profit by denying care will still drive the system.

[3] I wish I knew how health insurance back office operations are geographically distributed. Partly to know how eliminating/repurposing them would affect the 2018 and 2020 elections — “First, the mill closed; then, the Aetna call center closed….” — but also to know how often health insurance jobs are the only good jobs, or the only jobs, in their communities.

[4] Another reason to make for-profit entities go away.

[5] And even some of them are willing to throw in the towel.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.

51 comments

  1. Jim Haygood

    Suppose we ended the empire tomorrow. What about the workers at Bath Iron Works?

    At around 18 percent of GDP, America’s health care empire is at least double the size of its global domination defense empire. Outlierz R Us:

    https://www.mercatus.org/sites/default/files/Chart%201%20small_1.png

    Grafting a Medicare payment system onto the existing health care cartel isn’t necessarily going to shrink it or subject its opaque, cartelized prices to antitrust enforcement. Imposing Medicare’s payment schedule on the entire system would implode it, since privately-paid care carries the freight for [roughly] at-cost Medicare and below-cost Medicaid. Never will Pfizer, Merck, United Healthcare, Aetna and Cigna accede to their own destruction.

    Slapping a shiny new Medicare-for-all badge on the same exorbitant status quo (much as Obamacare did) is the only realistic formula for either of these bills to ever emerge from Kongress. Health care to 20 pecent of GDP … yes we can!

    Reply
    1. Jim Haygood

      Cynthia makes the same point in more detail — from an informed insider’s perspective — in a 1:32 pm post in Links. Read it & weep …

      Reply
    2. Pat

      I would posit that Pfizer, Merck, United Healthcare, Aetna, Cigna and others have already acceded to their own destruction. At this point the fight is only for how long they can continue to exist in their current configuration. They are NOT making outsized profits because they keep costs low for Medicare and Medicaid patients, in fact many of them serve as few of them as possible or game the system to provide less then they should for much more then they should be able to charge.

      Our medical system is going to change. as it is already imploding. People have noticed they have to pay outsized prices for little or no actual health care, even when it is in the form of taxes (see the various subsidies being paid to the above via ACA, government and charity financed medical research they profit from, and on and on.) They are getting testy and more and more are no longer buying the bull provided by these groups. My personal belief is that ACA was meant to provide a several decade long respite from the growing call for real health care reform, which would mean the destruction of the for profit system. Unfortunately the very corporations you mention plus others all decided that the small step back that was needed to make that program work for the first decade or so was to much for their bottom lines and outsized bonuses. Instead of working together to bamboozle the public by keeping their profits low but reasonable, they all choose to game the system and keep going for the double digit or more increases from the cost of drugs, to the premiums, to the tests and services. Oops.

      Where we do agree is that slapping a shiny new name on the same old system is NOT going to work. The only thing that is will be removing the rentiers from the process either entirely or only allowing them to have a small percentage of the actual process say elective plastic surgey and insurance that provides for private rooms. That and an attitude and medical standards that are clear in that if you don’t want to be a part of the Medicare/Medicaid system the door is that way – don’t let it hit in your ass. Including but not limited to you will not have a medical license or be allowed to provide medical care without being a part of the system. Consider it the mandate for providing something that is a right and should have been treated as such by our supposedly advanced nation.

      Reply
  2. QC

    Love the Shelob metaphor!

    Wouldn’t a large proportion of job losses be the middle-managers and bean-counters who would be no longer needed, rather than say nursing staff?

    Reply
      1. TarheelDem

        With $2000/person per year in savings first year (insurance company 15% plus savings from not having all of the billing and collection workers you are worrying about) there will be demand for goods and services, and thus demand for jobs.

        IMHO, jobs is a false issue given which jobs are going to disappear and which are going to be needed. All the insurance benefits nurses can go back to practicing nursing with real people instead of “cases”.

        Reply
        1. Skip Intro

          Indeed, the savings to employers and consumers could reasonably be expected generate substantial demand. The small percent of the workforce actually displaced by the elimination of a huge parasite are being used as a ‘human shield’ by the parasite itself.

          Reply
  3. gardenbreads

    Many for-profit systems and individual hospitals would disappear under BernieCare with no legislation necessary. Medicare reimbursements are substantially lower than commercial payment rates. The business models of for-profit systems has been to avoid Medicare, Medicaid and charity patients at all costs. Even when for-profit systems have not explicitly avoided these patients explicitly the result has been that individual for-profits with large numbers of these patients have bankrupted leaving only hospitals with few Medicare/Medicaid patients. Non-profits and local government hospitals with large proportions of lower-paying patients have often been saved, taken over by stronger partners, raised donations to stay open or obtained increased government support to keep the doors open.

    Some of the stronger for-profit systems locate or acquire hospitals only in areas where it is the sole community provider or the strongest community provider and in which most of the population are commercially insured. Or they are surgical and specialty hospitals that cater to non-Medicare, non-Medicaid populations. Their models don’t work and would not be enormously profitable if they were to receive Medicare rates.

    CMS has been good over the years uncovering and recovering gaming by these hospitals such as unusually large numbers of emergency patients being admitted, unusual long observation stays, unusual numbers of high cost or long length-of-stay outliers, etc. Fraud and abuse checks are successful at detecting these sorts of patterns and I would expect CMS to continue this if Medicare were expanded.

    Reply
  4. Deschain

    On the pockets metaphor: you have to figure out a way to answer the rejoinder you’re going to get from the people who are lucky enough to have their employer pay a majority of their healthcare costs, because they’ll initially view this as making them pay more; and you have to figure out a way to make sure the employer savings from this gets passed down to workers in increased wages/salary (because that’s how you answer the question above.)

    Reply
    1. marym

      I’m not aware of Sanders or Conyers, or advocates of their bills, proposing a selling point of employers paying more in salary. The argument is that most people will pay less out-of-pocket for premiums, copays, deductibles.

      The white paper for the Sanders bill, suggesting a number of funding alternatives, includes an employer tax. HR 676 references an additional payroll tax, but doesn’t specify the source. The Friedman analysis (PDF)of HR 676 treats this as an employer-paid tax. The Friedman analysis concluded that 95% of people (all but the top 5% of income earners) would pay less out-of-pocket

      Reply
  5. Jonf

    I still don’t understand how displaced workers will be handled. What does 2 years salary and training mean? You want to pay over half a million people 2 years salary? Same for Bernie’s plan. How much does this come to in dollars to the displaced worker and in total?

    I still think you cannot simply shut down the industry without some payment. I mean sure you can, but talk about a shit fight. We don’t need this kind of enemy. Thousands of people have invested in this even Sally’s mom. Are we really going to walk away with the “well, you knew the risk of investing”.

    It is easy to say we will just print up the money. Try talking to the full congress like that. In the end you are going to have to say out loud how much money it all costs and where it is coming from – and saying I own the printing press won’t work.

    I actually think this could work if we transition it properly and are honest about the cost. After all we already pay for it but out of that other pocket.

    Reply
  6. grayslady

    Regarding laid-off workers, marym made an interesting point the other day that the insurance companies (including those for Part D in Medicare) have already outsourced much of the work offshore. I know from experience when having to deal with “customer service”, that I routinely have my call answered by someone in the Phillipines. I then ask to speak with someone located in the U.S., and my call is re-routed to a person who actually lives in the U.S. and is familiar with Medicare. Other than health insurance executives, I think the people most likely to be displaced–who are U.S. citizens, living in the U.S.–are data entry personnel in hospitals and doctors’ offices. Since data entry is unlikely to disappear from all U.S. businesses, I don’t see retraining as a major issue. Those people can work in any number of offices, including municipal government, private industry, academia, etc.

    Reply
    1. Rook

      There are a lot more people working for health insurance companies in the US than you may realize. I don’t know how many associates work at my company but I once heard there were over 15,000 employed in my city alone (not sure if that includes part timers or not) and there are other facilities around the country. And that’s just one company. A lot of those people are employed to actually do the insurance stuff, there are a lot of employees that take care of the infrastructure of the company (like IT, HR, etc that you find in any big company), and then there are employees that do business tasks (like analytics, reporting, etc). I don’t know how many jobs are outsourced but I’m under the impression it is a small percentage of the total number of employees.

      So I do think a sudden end to the industry would be a pretty big deal for a lot of people and a lot of cities. Not everyone would need to be retrained (I think worker retraining is mostly just BS that’s used by politicians to make outsourcing jobs more palatable). If you manage the servers for an insurance company, it’s not really that different to go manage the servers somewhere else, for example. But I think it’s just the sudden loss of a big employer and thousands of good-paying jobs that would be difficult.

      The sad truth is that there just aren’t enough jobs out there for everyone (insurance industry or not). It’s an issue that’s been ignored for too long. I really think we need something big – like another New Deal-style jobs program – to get more people working. I don’t know what the solution is, but it’s something that needs to be addressed and I hope it will be hashed out as Medicare for All is debated.

      Providing Medicare for All is the right thing to do and I hope it passes, even if it means I lose a good job.

      Reply
      1. marym

        Thank you for the view on the ground. Advocates for Medicare for All need to take this issue as seriously as any of the components of the bills. It’s encouraging that both bills at least acknowledge the issue and propose some measures.

        It’s up to us to demand a detailed analysis of the situation (number of people, skill sets, locations, whether early retirement or such options are available, etc.) in order to develop good solutions for individual workers and in some cases for communities where job losses would be concentrated.

        I agree this is part of a larger problem, and that discussions about job loss, and job and income guarantees should start with identifying all the work that needs to be done, and a commitment to another New Deal. I don’t want people working in the insurance industry to lose their jobs. I want those that aren’t ready to retire to be working at all the millions of things that need to be done in our country.

        Reply
    2. Jonf

      The Sanders plan leaves a hell of a lot out. It is really an aspirational plan at this point. To make this real the costs to implement and the full cost and who pays needs to be flushed out.

      Reply
        1. jonf

          Thank you for that link. I have two comments on it: (1) it doesn’t address the two points I’ve been something of a pest on – what happens to employees that lose their jobs and what happens to investors in companies and (2) it is a collection of sources that are in the teeth of the current Trump push to cut taxes e.g. inheritance tax.. I do like the idea of taxing corporations – presumably equivalent to what they pay today.

          It is still aspirational, basically what he says, but we should not fool ourselves. We need a real plan.

          Reply
  7. Anon

    Great series and I’m especially glad that comments are back, but a question wrt Canada’s system:

    Are there any drawbacks/limitations to their system? I’ve seen it (and Europe’s system) touted as a golden standard, but there are very few infallible institutions in this world, if any (or at least, none come to mind right now).

    Also, I’ve seen throughout the years browsing here and in the comments at length that federal taxes don’t fund federal spending – can anyone expand on that or link to a NC article that explains it better?

    Thanks for writing, Lambert!

    Reply
    1. Yves Smith

      I don’t think the right question is what the drawbacks are, but where if anywhere the Canadian system falls short relative to the US system. Canada does have queuing for elective procedures, and the waits for them are longer than in the US.

      As for Federal taxes don’t fund Federal spending, here are some links:

      http://neweconomicperspectives.org/2014/05/taxes-mmt-approach.html

      http://hir.harvard.edu/article/?a=2853

      The Bank of England has published papers, including a primer, that supports the MMT view.

      Reply
      1. Anon

        Thanks for the links, Yves. I’ll give them a read. I guess a longer wait for universal coverage isn’t that bad of a trade-off in the grand scheme of things, especially with everyone taken care of and a lot of money saved.

        Reply
    2. FiddlerHill

      Re: Canadian health care: My daughter enrolled last August at the University of British Columbia. Like all international students, she was required to purchase health coverage through BC’s universal health care system (MSP). She receives complete hospital and doctor coverage — no co-pays, no cap, no deductible. Her premium is $900 — for the YEAR. She has been to see doctors several times since then, and I’ve yet to see any drawbacks or limitations. But even if there are some, they are surely well worth the lower price tag for complete health care.

      Reply
  8. Leftcoastindie

    500,000+ jobs wow. Most of the claims jobs will still exist. The IT departments, if it is any thing like the life insurance industry, have been gutted, so those people are already gone. Marketing is one of the largest departments in insurance companies – think sales people and companies are always looking for good sales people, So there is really not that many people left I would think.

    Reply
  9. Cynthia

    Keep in mind, Hurricane Katrina happened before Obamacare came into existence and before neoliberalism had fully destroyed our charitable, put-patients-first healthcare system. Thanks to Obamacare and the neoliberal looting of our healthcare system, non-profit hospitals, many of which are academic teaching hospitals, have been transformed into for-profit hospitals. So if Charity Hospital in New Orleans were still around today, I’d bet money on it would run like a for-profit hospital, no different than, say, a hospital owned by Tenet Healthcare.

    Reply
  10. Grumpy Engineer

    Something is wrong with the math in these “Medicare-for-all” proposals.

    The healthcare industry employs nearly 13 million people (http://www.kff.org/other/state-indicator/total-health-care-employment/) and consumes nearly 18% of GDP.

    Under Medicare-for-all, total healthcare employment will drop by 525,000 (a reduction of 4%) and yet costs will be reduced to the point where it consumes a mere 10% of GDP (a reduction of 44%)? Paint me skeptical. Something doesn’t add up here. Either the savings will be less than anticipated, or the job losses will be greater than anticipated.

    Reply
      1. Grumpy Engineer

        Not equivalent. But definitely proportional. After all, employment costs are where the vast bulk of healthcare spending goes. And yes, I’m aware that some of it goes into excess profits, but there’s not enough margin to permit a 44% spending cut while cutting payrolls by only 4%.

        Only if healthcare providers were routinely achieving 70% profit margins could we realistically expect to keep 96% of the employees around while cutting costs by 44%. Alas, 20% profits margins are more typical: https://www.forbes.com/sites/liyanchen/2015/12/21/the-most-profitable-industries-in-2016/.

        Now please note… I think that the US healthcare system is terribly inefficient and could desperately use some profit- and cost-cutting efforts. But we should be realistic about the side effects. 4% job losses in an industry facing a 44% spending cut is unrealistic.

        Reply
        1. Lambert Strether Post author

          Without reviewing several years of work by PNHP and many others, I can’t undertake the arithmetic (which is not the topic of the post in any case). If you look at the per capita spending for other countries, the US is an extra-ordinary outlier, leading one to think there is, in fact, an X-factor producing results as disproportionate as we agree they are.

          That said, one factor you’re certainly leaving out is the ability of the single payer system to use its bargaining power, especially with pharmaceuticals

          Reply
          1. jefemt

            We must not sweep cost-containment under the rug. I would imagine we could use some of that administrative staff to work on cost accounting. But it ultimately, and quite simply is a matter of the ‘collective we’ stepping up and saying, ‘ENOUGH!!!”
            Controls of costs of procedures, meds, etc. need to come to the fore. Wages, administrative pay.

            This for the system for the 98% of us that need a system of CARE that benefits us. The 2% must be forced to pay in, not be able to opt-out, as they do with social security. We all need to participate in any system. Lord knows the 2% will have access to additional care–whatever they want, wherever they want it. We must not let anyone ‘opt out’, starting with congress, the President, the military, state and federal workers. All for one, one for all. And, lets not ignore executive pay as part of cost containment- United Health continues to be my poster boy— this from 2007, Dollar Bill McGuire, United Health:

            “Dollar Bill” has made lots of news with cash-and-stock paydays that have topped $100 million in recent years — and he’s still sitting atop stock options valued at $1.6 billion. McGuire’s admiring outside board members — 10 of whom have become millionaires through the sale of their own appreciated stock in recent years — have defended his league-leading compensation on grounds that the giant health insurer’s stock price has been a superb performer.” (Minneapolis Star Tribune )
            Howzabout a simple Ben-and-Jerry’s Ice cream approach: the highest wage paid will not exceed 7 times the lowest wage paid? Cost containment- honest discussion, lay the body bare.
            I firmly believe that paretos law holds true in those who provide care: they care about patients, the work is fascinating, and it is NOT about the money. There are some in care that are in it for the dough. Now Insurance, nothing to do with care, all about money, and transfer of wealth.

            Bottom line: in my mind, health care should be construed as a utility. Regulated and managed for the lowest cost, highest outcome, for the society at large. The notion that one can insure the health of a mortal frail human is silly. What we are after is access to and receiving reasonable care on our life’s journey. It’s not free, we all need to pay.
            And we should pay, not employers— they should not use health as a stick to lord over the workers. Self-employed artists, salarymen, home-makers— all participate in the same way.

            Great article, love the comparisons… and delighted to see we again have an opportunity to dialogue and prompt thinking through comments.Thank you!

            Reply
    1. Jack

      I think it would add up if you checked the numbers, more so than what is being put out by the MSM and our politicians. In the US for 2016, the average spending per person for health care was $10,345. That’s everyone, no insurance individuals as well. Compare that to two US health care systems with patients who typically need a lot of care, Medicare and the VA. Medicare cost per enrollee in 2014 was $10,986. The VA in 2015 was $6000 (this doesn’t cover costs to build the initial facilities). Which system in the US has consistently had the best health outcomes? The VA believe it or not (one citation here, but there are many others; https://www.forbes.com/sites/harlankrumholz/2014/05/23/3-things-to-know-before-you-rush-to-judgment-about-va-health-system/#7c652ca055e4). The VA can treat its covered population and deliver the best outcomes because 1. it has an electronic health record system that’s primary function is to record treatment, not costs. 2. It negotiates drug prices (Medicare is not allowed to) 3. It practices preventative care as one of its primary goals, where in reality all other systems do not. 4. Its doctors and staff are paid a base salary and their income is not measured by how many tests or procedures are performed. So just extrapolate the VA cost of $6000 per patient for the entire US population and you get $1.94 trillion, only 60% of the current per person expenditure in the US. Also, remember the VA is treating a population that requires a high level of care. So I can easily see how the cost can come down from over $10,000 per person to only $4000. Its going to take a lot of reforms, not just having a single payer and doing away with the insurance industry for the most part. The AMA will have to let the number of doctors increase (they currently throttle the number of doctors). Legal reforms will be necessary. An electronic record system will have to be put in place. Big pharma will have to be significantly curtailed in its lust for high profits. But it can certainly be done and improve the health outcomes for all Americans, including the ones covered by private insurance now. And it can be done and save money over what is currently being spent. I wouldn’t worry about the displaced health care admin workers. If you save the economy over a trillion dollars in health care spending, plus give everyone the peace of mind of knowing that if they get sick they will be taken care of, then I think the economy will take off and provide jobs that need to be filled.

      Reply
      1. VietnamVet

        This is right. The only way to cut healthcare costs from $10,000 to $6,000 per year per person is to get the government right smack in the middle of the system to stop the extortion, provide preventative medicine for everyone and restore the public health service. Taxes would replace insurance. There are two choices; either follow Canada’s lead and reverse the decline in US life expectancy or continue to devolve into Mexican 3rd world anarchy.

        Reply
  11. Rojo

    When Chavez gave food subsidies to the poor, empty shelves were shown around the world. Of course what had happened was the empty shelf in the store just replaced the empty shelf in the poor person’s pantry.

    But you DO have to account for this. If a whole bunch of people who haven’t had healthcare for years suddenly get it, doctor’s phones are ring off the hook. Pampered professionals not getting an appointment for months will get above-the-fold coverage.

    Get out in front of this. Nursing and PA scholarships — displaced insurance workers, especially mid-life — get first dibs.

    Reply
  12. Jonathan Holland Becnel

    Back in 2010 I went to a Tea Party Express Protest on the Capitol steps in Baton Rouge, LA to protest THEM lol

    Little did I know I was being hoodwinked by the Neoliberal democrats.

    Nice to see that it was for something!

    Reply
  13. EoH

    That neoliberals designed their version of medical coding for billing purposes might explain that one can now earn a bachelor’s degree in medical coding. It cries out for reversion to coding for medical care if one wants to drive out useless-but-for-profit taking coding as billing.

    Currently, coding is designed to game the system, and to charge patients for every last resource and muscle movement engaged in by hospital staff. Eight dollars for an aspirin anyone? Oh, and three for the paper cup.

    Reply
  14. Too Late For Nostalgia

    Excellent and informative article on this critical subject.

    Note 2: “…breaking the political power of the health insurance industry is central both to passing #MedicareForAll, and to keeping it (and us) healthy after its passage.” So true. Probably a big battle.

    Seeing Professor Mark Blyth on video made my day. Great speaker, blunt, and right.

    Reply
  15. Tim

    I had a pleasant conversation with a lawyer in training from Houston Texas on a flight. He seemed relatively moderate. He himself wants a fix to our health care, and his only objection to single payer was that it would never pass.

    My answer was that the information age is doing its work. Nobody hates being screwed over as much as a republican does, and now the data is showing just how screwed over we are with our system, compared to the government run alternatives in other countries.

    Right now Republicans voters are wrestling with that incongruence (Regan said the scariest thing is somebody saying they’re from the government and they are here to help, yet all those other countries with government run health care aren’t being screwed like we are). Hopefully they will emerge from the other side having progressed in their understanding that you can be screwed by corrupted governments or profit seeking corporations, you just have to pick the lesser of evils for each scenario.

    Reply
    1. Too Late For Nostalgia

      Tim,
      It’s great this information is getting out to Republicans.

      If Republicans continue to pay high monthly payments and deductibles, their belief systems can change.

      I hope.

      Reply
  16. ChiGal in Carolina

    Not to put too fine a point on it, but Dr. Margaret Flowers heads Health Over Profit for Everyone (H.O.P.E.). There is no separate “Hope Campaign” and both those items are from the same chart, which I believe I posted on your first post on the topic.

    Thanks for highlighting the concerning contrasts, you are, again and as ever, perspicacious!

    Reply
    1. ChiGal in Carolina

      “and both those items are from the same chart”…

      but you knew that! read over the intro too fast, mea culpa

      Reply
  17. Laughingsong

    I’m just glad we seem to finally be getting the health care debate we need. I both hope for and dread the delving into particulars, and the expected misinformation, respectively. Someone like me whose ability to research and reason is not the best, well, we depend on the debate and research. There are so many ideologies and assumptions!

    I’ve been giving it a go and trying to digest the, I guess you would call them the Technical Aspects of implementation . On the job losses: every country I know of that has universal health still does have an insurance industry, so I don’t know if that 525,000 number cited above is shrinkage or elimination. But I would think there would still be health insurance. Also, as mentioned by a few people above, at least some of those skills would still be needed in the new government healthcare delivery. Further, I have talked to people who seem to think that doctors and nurses themselves would be losing jobs, but considering how many rural healthcare deserts there are, I would think that new clinics and hospitals would start to appear, adding jobs in places that could use both the jobs and the care. Also, SMEs would at least theoretically be freed from the health insurance benefit costs, and that could spur more hiring (they say I’m a dreamer…..).

    Reply
  18. rps

    This is really a game of catch up with countries that provide first class modern socialized medicine rather than the convoluted spiel of ‘what ifs’ in the consideration of inclusive healthcare for all. It’s not as if we, the USA, are the frontline pioneers in advocating a plan for Universal Health Care. Frankly, we are far far behind the times and should look toward the countries that have successfully implemented Universal Health care and take the best from those systems. Our mindset as the world leaders in social innovation from FDR to LBJ was surpassed in the late 20th century, leaving the USA in the dust.

    JFK’s Rice moon speech is best remembered for “We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard.” Yet Kennedy acknowledged “To be sure, we are behind, and will be behind for some time in manned flight. But we do not intend to stay behind, and in this decade, we shall make up and move ahead.”

    Today we are far far behind first class world nations once again.

    Reply
  19. Synoia

    A little edit:

    Right now, I pay $6000 a year for health care out of my right pocket, to the health insurance companies. Under #MedicareForAll, I’d pay $4000 a year for health care out of my left pocket, on April 15.

    When you pay out of your right pocket it’s capitalism.

    When you pay out of your left pocket, pay less, it’s “Socialism”, or even (gasp) communism.

    The difference is the 01.%’s take. What a poor starving billionaire to do about this attack on his Great American Values? Actually do some real value added work, like build something, or continue to fiscally beat the wage slaves (Moar rent! Moar Rent?

    Reply
  20. Kim Kaufman

    “[3] I wish I knew how health insurance back office operations are geographically distributed. Partly to know how eliminating/repurposing them would affect the 2018 and 2020 elections — “First, the mill closed; then, the Aetna call center closed….” — but also to know how often health insurance jobs are the only good jobs, or the only jobs, in their communities. “

    I knew someone who did it from his home. He worked for one of the big companies, don’t remember which and it was at least six years ago. He got calls all day long and was the person approving or not whether the company would pay it. So they may not all be in call centers.

    Reply
  21. Emorej a Hong Kong

    If care is no longer deterred by costs, presumably demand for (and nursing and paramedic employment opportunities in) the following will all increase:
    1. Preventive check-ups
    2. Non-emergency treatment
    3. Longer-lived Seniors who need hands-on reminding and motivating to follow medical advice

    The last could transform many aspects of our economy and its geographical dispersion (not to mention quality of life and community), if the new system paid a living wage to people making house-calls to Seniors:

    >”Did you take all your pills today? Here’s your new batch;
    Let’s check your blood pressure, do your exercises,
    and round up some neighbors for group exercises.”

    Reply
  22. George Phillies

    Your studies on this issue are most appreciated.

    Meanwhile, at the other end, there is a new proposal to repeal the ACA, with a Bill starting in the Senate. However, there is a Constitutional issue perhaps with that Bill.The ACA survived a Supreme Court challenge because one Justice claimed it was a revenue measure and hence constitutional. However, revenue measures must begin in the House, not the Senate. Perhaps ‘reconciliation’ is the evasion.

    Reply
  23. Altandmain

    The real question is how to get any universal healthcare bill to pass?

    This will be opposed not just be the GOP, but by neoliberal Democrats, eager to retire rich and work for the HMOs.

    It will be a 2 front war to get this passed.

    Reply
  24. Anonymous

    Read the link on Katrina and Charity (non-profit) vs Memorial (for-profit). And I have to say that I think that there’s a deeper problem in healthcare these days. I had the misfortune to have a parent put on hospice and spent many, many hours talking to caregivers who had spent years in the Florida nursing home system. The simple fact is that our medical professionals are trained to undervalue the lives of the elderly and disabled. They over-medicate this population, then attribute the side effects of the medication to character defects or illness. And I suspect that a large portion of the elderly population in the U.S. is dying of untreated constipation due the medications that they are one (and the fact that standard for offering more pills for treatment of constipation is one tiny bowel movement every three days). The idea of a medical professional performing a manual evacuation of impacted bowels is apparently unthinkable (in which every doctor is trained — and many nurses can be trained).

    End rant. Sorry for the details but I’m disgusted by what I’ve seen.

    Reply

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