A First Look at Pramila Jayapal’s “Medicare for All Act of 2019”, HR 1384

By Lambert Strether of Corrente.

I confess that I was prepared to disike HR1384, simply because liberal Democrats have played Lucy and the Football so many times. But much as I hate to admit it, this looks like a good bill. It’s definitely not timid incrementalism, and it does not exhibit the typical liberal Democrat misfeature of pre-negotiating a proposal down to a state of pissant-ness, simply because Republicans might say mean things. The full text of HR1384 is not yet officially available (!), but ACA Signups had a PDF, which I embed below as an Appendix; presumably they will not differ.

HR 1384 has significant union support: National Nurses United (NNU), as well as “the influential Service Employees International Union (SEIU), the National Education Association (NEA), the American Federation of Teachers (AFT) and the International Association of Machinists (IAM).” (To me, SEIU’s support is especially noteworthy, since SEIU strongly opposed single payer in 2009, even going to far as to refuse to cover it in the health care policy column it sponsored.) HR 1384 also has significant support from progressive NGOs.

Other facts about the HR1384: It has 106 co-sponsors, shamefully not including Pelosi, Hoyer, or Clyburn — Speaker, Majority Leader, and Majority Whip, respectively — and of the eleven whips, only three (John Lewis, Jan Schakowsky, and Sheila Jackson Lee), and not Cedric Richmond, Pete Aguilar, G. K. Butterfield, Henry Cuellar, Dan Kildee, Debbie Wasserman Schultz, Terri Sewell, or Peter Welch). In other words, the House leadership, so-called, strongly opposes Medicare for All. This will not be news of NC readers, and was predictable from the nature of the “Blue Wave” that Pelosi et al. organized (as we showed in our series of worksheets on the primaries). It’s also wonderfully clarifying to have battle lines drawn.

This will not be a comprehensive analysis of the bill[1], even though it weighs in at an impressively trim 120 pages. (The two bills that comprise the ACA are 906 and 55 pages respectively. I know that, as with lines of code, page counts for bills don’t provide a reliable measure of complexity, but an order of magnitude difference would seem to be an indicator.) Instead, I’m going to aggregate some fun tweets from Jayapal, ding Nancy Pelosi for either lying or being ignorant, and finally look at how the the word “profit” is used in the bill. (There are lots and lots of other interesting topics, including long-term care, reproductive care including abortion, pharma, and capital budgeting — and of course that hardy perennial “How you gonna pay for it? MR SUBLIMINAL Print money, like we do for wars and bank bailouts — but I will save those for another day. No doubt many of these topics will become salient as the rollout continues.

Jayapal Burns the Ships

Of the many fun quotes from Jayapal, this is the most fun:

“¯\_(ツ)_/¯” is pretty direct; something that it’s hard not to unsay (or however one walks back an emoji).

Here also Jayapal is impressively direct:

Finally, here is an interview with Jayapal:

NOTE Burning the ships: “”Burning your ships/your boats” means doing something that makes it impossible for yourself to turn back, especially if it is done wilfully and without necessity. The idiom derives from legends about conquerors who supposedly, upon landing their army in enemy country, ordered the invasion fleet to be burnt. Most people today have heard this tale about Hernan Cortez, but it is in fact centuries older than Cortez. The assumed benefit of such an act is that everyone on the team—whether it be an actual army intent on conquest, or any party pursuing a risky undertaking—will show maximum commitment if they know that retreat is impossible.” So I wonder which of the whips will be the first to break with Pelosi?

Nancy Pelosi Is Lying or Ignorant (Certainly on Dental)

Here is what Pelosi said in her recent Rolling Stone Interview:

When they say Medicare for All, people have to understand this: Medicare for All is not as good a benefit as the Affordable Care Act. It doesn’t have catastrophic [coverage] — you have to go buy it. It doesn’t have dental. It’s not as good as the plans that you can buy under the Affordable Care Act. So I say to them, come in with your ideas, but understand that we’re either gonna have to improve Medicare — for all, including seniors — or else people are not gonna get what they think they’re gonna get. And by the way, how’s it gonna be paid for?

And of course[2]:

All I want is the goal of every American having access to health care.

Not even “access,” but “the goal of access”! Clue stick: People don’t want access to health care. They want health care!

Back to coverage. First, dental. Contra Pelosi, from The Hill:

Jayapal’s legislation is the most comprehensive to date, including all primary care, hospital and outpatient services, prescription drugs, dental, vision, women’s reproductive services, maternity and newborn care, mental health, long-term services and supports for people with disabilities

(Note that dental is a really, really important form of health care, even if the 10% who don’t line up by the thousands for free dental clinic don’t understand or care about that.)

On “catastrophic,” I’m willing to be persuaded that there is some space for private insurance providers — surely a good thing, to a neoliberal like Pelosi? — but the whole idea of a special form of insurance for really, really bad medical events seems to stem from the mindset where health care coverage is not universal. For example, Title II, “SEC. 201. COMPREHENSIVE BENEFITS,” includes “Hospital services, including inpatient and outpatient hospital care, including 24-hour-a-day emergency services,” and “Emergency services and transportation.” That sounds like coverage for catastrophes to me. Aftercare too: “Rehabilitative and habilitative services and devices.” Why wouldn’t health care required as the result of a catastrophe be the same as any other kind of health care, and covered universally?

Ending Health Care for Profit

Here are the most significant places where the word “profit” appears in HR 1384:

From SEC. 301. PROVIDER PARTICIPATION AND STANDARDS; WHISTLEBLOWER PROTECTIONS.

Yes, the profit in the delivery of health care should be regarded as an ethical issue.

From SEC. 614. PAYMENT PROHIBITIONS; CAPITAL EXPENDITURES; SPECIAL PROJECTS.

Yes, you can’t have financialization schemes driving health care decisions.

And also from Section 614:

No, you can’t optimize for profitable procedures so you can build a new wing.

Now, I’m sure that even now, even now there are high-priced consultants working out how to game these provisions. Perhaps the more devious-minded of our readers would like to skim the text and beat them to the punch?

Conclusion

Again, there will be a good deal more to come on HR 1384. But on first reading, this cynical old codger finds it impressive; particularly the attempt to extirpate profit and profiteers of the system. That should put the cat among the pigeons2

NOTES

[1] Here is an incomplete list of of commentary, mostly from the usual suspects:

Pramila Jayapal thinks we can get to Medicare-for-all fast (interview) Pramila Jayapal, Vox (by Sarah Kliff).

Introducing HR 1384: Medicare for All Act of 2019 Adam Gaffney, Health Care for All NC

The House MFA Bill is Here! The House MFA Bill is Here! ACA Signups

What You Should Know About Progressives’ Ambitious New Medicare for All Bill New York Magazine

Pramila Jayapal Just Introduced The Most Ambitious Medicare-For-All Plan Yet Refinery 29

Pramila Jayapal to introduce Medicare for All bill that would overhaul nation’s health-care system Seattle Times

[2] Also this: “As Californians have said to me, ‘We get billions and billions of dollars out of the Affordable Care Act coming into California. Now they want to get rid of that.’ How are they gonna go to single-payer in California without the money from the Affordable Care Act?” Leaving the insanity of thinking that health care spending in California would fall to zero under HR1384, it’s all about the benjamins 🎶, isn’t it? Unless, of course, by “get billions and billions of dollars out” Pelosi, and her “Californians,” mean getting billions of dollars of bloat and looting “out” of the ACA. Then what Pelosi is saying would make sense, I suppose.

Appendix

Feel free to redistribute:

Medicare-for-All-Act-of-2019_02-27-19
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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.

71 comments

  1. MaxFinger

    Thank you Lambert!
    “Burn the ships” great quote. Incrementalism has cost many people the benefits of being well. Good access, even if you have it, is limited to the for profit system. The medical care offered now is only for the benefit of the large corporations. Substandard care is the standard, so the bean counter can extract. I am glad the Jayapal appears to be on our side.

    1. polecat

      I sure hope the chariots are in good working order … same regarding the pikemen .. er .. persons ! Hope they’re fit as, as many spears will be needed to pierce those offending lobbists/consultants $hield$.
      Treat the hostages and refugees well .. and save the lash for Big Whip !

    1. BoulderMike

      Or to quote Cleo McDowell from Coming to America: “I feel like break dancing!”
      Thanks Lambert for the excellent post. And may I say, “Nancy Pelosi?????!!!!!?????, whaaaaat, ugh, sigh…..”

  2. neighbor7

    “All I want for Christmas is the goal of having access to dental for my two front teeth…”

  3. Pat

    If Pelosi’s definition of access resembles most Democratic leaderships’ definition of affordable it means you can have access that results in actual healthcare means two things. Either picking the right door at 4pm on the correct Tuesday of the particular month it is unlocked for three minutes. OR be able to buy the key with more money than most Americans make in six months and know who to purchase that key from.

    She needs to rot in hell spending her days attempting to get healthcare with an ACA plan as she avoids Zionists treating her like a Palestinian.

  4. Gary Gray

    Sell it as nationalism and tribalism. Why left of center group think went away from this after 1990, I have no clue. This is the American health care system baby. How dare you allow the free market internationalists control our health care with their debt based, bankers punk losers schemes!!!!!! Eff, the globalist Republicans and their schemers of death!!!!

  5. Synoia

    It quite possible that this health reform bill must take on the Cost of Student debt to medical professionals.

    For example: One family friend has two children one a dentist with a student debt of $600,000 and the second a doctor with a student debt of $400,000.

    It is ridiculous for the Medical Care for All to be soaked by Student Debt plus interest to provide a lower cost medical system.

    In addition both billing and pay-through-the-nose for individual medical procedures must end.

    1. Kurtismayfield

      The Feds already toss ~5B a year into medical training.. they should pay for the entire cost as the bone they toss to the Doctors. Yes the doctors will have to be “convinced” economically.

    2. KLG

      I teach medical students who graduate with an average debt of about $194,000, including ALL of their debt from undergraduate, graduate, and medical school. ‘Tis a lot, yes. Anyone with $600,000 on the books did something very wrong. While there can and should be room for some payment/forgiveness, these students all went in with their eyes wide open. Sorry to be lacking in apparent understanding, but this argument is really not any more persuasive than “What are all those CIGNA/United/Aetna employees gonna do when their companies go the way of buggy whip makers?” Same thing as miners, autoworkers, textile workers…or maybe we can finally have a political economy with a mind and a heart?

      1. Sanxi

        She’s got her data wrong, the centers for Medicare and Medicaid subsidized Med students to the tune of 600k but that isn’t in direct support or loans. The $194,000 while real is in no relationship to cost or reality like so many things in the ‘Heath Care’ system. No 4 star in military makes more than $273k no doctor should either. Don’t like it, become a banker.

      2. JohnnySacks

        What are all the CIGNA/United/Aetna employees gonna do? I dunno, possibly transition to jobs which provide a paycheck to actually help sick people? And it’s not as if Medicare for All is not going to need administrators, although what’s really going to be needed is an investigative and legal apparatus which will mercilessly rip the faces off anyone engaged in or abetting fraud.

        1. Eclair

          ” …. what’s really going to be needed is an investigative and legal apparatus which will mercilessly rip the faces off anyone engaged in or abetting fraud.”

          Thank you, JohnnySacks, for pointing that out.

        2. Oh

          As far I’m concerned all the CIGNA/United/Aetna?kaiser employees can go look for an honest living. Cry me a river.
          Do I feel bad for drug dealers who lose their vocation when drugs are legalized? Why should the insurance employees be treated differently?

  6. mle detroit

    What? HR1384 does have catastrophic coverage? That would mean the end is in sight for Michigan’s hated no-fault auto insurance. Somebody tell Detroit Mayor Mike Duggan.

    1. Expat2uruguay

      Isn’t it true that this should result in a great drop in auto insurance rates? Or?

  7. mle detroit

    The bill needs hearing coverage too, considering how much hearing loss contributes to dementia and its attendant costs.

  8. ChrisPacific

    Well, that’s encouraging and has made me curious about Jayapal. Her political site isn’t all that notable and is liberally sprinkled with establishment Dem code words (lots of identity politics, and I lost count of the number of things she was “fighting for”). But there is substance there if you look more closely – yes, she is “fighting for” minimum wage, but she’s also taken action on it and has some accomplishments to her name. Maybe she is a sleeper agent? I will try and find time to watch the interview.

    1. Yikes

      For elective procedures that would not be insurance per say, but negotiated pricing/management. Any elective cosmetic procedure would by it’s nature not be an issue of risk, but of will.

      Some non-elective cosmetic/restorative surgery is covered by medicare/medicaid, it depends on how well the doctors can advocate.

  9. Carla

    BTW, happy (and a little surprised) to report that 3 of the 4 Democrats in the Ohio Congressional delegation have signed on to M4A: Marcia Fudge, Joyce Beatty and Tim Ryan. Marcy Kaptur, whom I believe is pro-life, has not and probably won’t due to her religious views.

    It’s very hard to look at and listen to Pelosi w/o a gag reflex kicking in.

  10. Jeffrey Fisher

    I really don’t understand the ‘catastrophic coverage’ comment.

    In the health insurance context ‘catastrophic coverage’ is the bad insurance with big deductibles that only helps you out with really big bills that come in a single year (worse than ACA bronze plans, which are pretty bad).

    They are a fairly good bet for healthy young males with lots of savings… aka the very easiest bit of the insurance problem… but a bet even for them.

    A good health insurance system has no use for such poor options.

    Their existence is a sign that your system is bad.

    1. Jeffrey Fisher

      Ah, maybe this is it?

      Medicare Part D drug coverage over $5100 per year is also called ‘Catastrophic coverage’. No idea what this M4A draft says about that. Hardly some ‘fundamental flaw’ even it is is not in this draft.

      1. marym

        From the Jayapal bill:

        “Prescription drugs and medical devices, including outpatient prescription drugs, medical de-
        vices, and biological products’’ are covered [Section 20.a.4] and the “prices to be paid for covered pharmaceuticals, medical supplies, medical technologies, and medically necessary equipment covered under this Act shall be negotiated annually by the Secretary [Section 616].”

        So M4A eliminates the need for Part D, including the ACA’s song-and-dance of closing the out-of-pocket “donut hole” between regular coverage and so-called catastrophic coverage (a different definition from what you correctly reference as a type of lower-premium, high-deductible health insurance).

  11. Darthbobber

    Burning the ships. I believe Sunzi (Sun tzu) tells the story of a general who, having brought his troops across the river, burns his boats and places his army in “death ground” with the river at their backs, to ensure that they saw victory as the only chance of survival.

    1. Big River Bandido

      General Daniel Morgan did the same thing with the Continental troops at Cowpens. Although they didn’t have any ships. He just posted them with their backs to the Catawba River. The militia understood there was nowhere to run.

      It worked, spectacularly.

    2. The Rev Kev

      Sun Tzu warns in his “Art of War” that you should never cut off an enemy from all escape but should leave at least one way out, even if it is illusionary. Otherwise the surrounded troops, knowing that they have no other option, will go full bore at their enemies and leave nothing in the tank to bust through the surrounding troops.

    3. Vastydeep

      “Burn the boats!” is a management technique that Jim (Good to Great) Collins taught in his Entrepreneurship & Small Business class at Stanford as an essential. He attributed it to Cortés as well, but I’m sure he would be pleased by a lineage deeper into history.

  12. Ignacio

    This looks like excellent progress in health care if approved and a kick in Obama’s a.. legacy. In this way it should appeal to Trump: “watch, Mr. O, i did it muuuch better than you”.

    1. KLG

      I give that a 70:30 chance when The Donald finds himself in electoral mud up to the end of his necktie.

  13. mpinco

    By eliminating profit you will eliminate innovation and the desire to create a better solution. The end result will be stagnation of medicine.

    1. Charger01

      LOL. You think Medicare rates will stifle innovation? The insurance market and providers will still have a profit, dude. Roche and Pfizer will still produce the same drugs around the world for 20-120% profit.Nothing will change except to exclude a portion of the populatiin that depends on PRIVATE insurance to allow they access to healthcare (billing) at prenegoitated rates….as the private rates have ALWAYS BEEN INDEXED FROM THE MEDICARE RATES! You are simply weaning off the middleman from the transaction.

    2. KLG

      As Tom Stone writes below, virtually all of the innovation you speak of is funded by the National Institutes of Health, Medical Research Council, Wellcome Trust, CNRS, Eli Broad and Paul Allen, et al., and a host of smaller private foundations (AHA, ACS, Cancer Research UK). The profits are often privatized, however, courtesy of the Bayh-Dole Act of 1980 in the United States. Since the mid-1980s, when I was very fortunate to work on an academic project at the Roche Institute of Molecular Biology (RIP) on the Hoffman-LaRoche campus in Nutley, NJ, Big Pharma spends more on advertising and marketing and buying up smaller companies (grown fat and productive starting with NIH $$) than on research and development. Alas. Oh, I almost forgot. They also scam the patent system by making inconsequential modifications to their moneymakers. M4A will kick them hard, but that will cause no harm to biomedical science. Eli Lilly stockholders might want to think ahead, however.

      Of all the important drugs in the universe, Gleevec (Imatinib) is the only one that comes readily to mind that came straight out of industry; feel free to add others to the list. And even then, had NIH and MRC not funded fundamental research on protein phosphorylation and had the Philadelphia Chromosome (a translocation that results in the oncogenic BCR-ABL protein kinase) not been discovered and characterized at Fox Chase Cancer Center and the University of Pennsylvania, Nicholas Lydon and colleagues at Ciba-Geigy (RIP) would have had nothing to work with. Nothing.

    3. Big River Bandido

      By itself, the skyrocketing rate of doctors burning out shows that medicine is already a stagnant field.

    4. Jeffrey Fisher

      There is *another* epi pen shortage going on now (they also had one last year) with Mylan making something like $250 and 900% profit on every unit it manages to actually produce it still has somehow managed to lose the ability to reliably produce the things.

    5. Ignacio

      Innovation is when the CEO of an insurance company rents a charter private fligth to the Seycchelles, you mean?

    6. Jonas Salk

      Edward R. Murrow: Who owns the patent on this vaccine?

      Well, the people, I would say. There is no patent. Could you patent the sun?

  14. Cameron

    I love the bill but doesn’t section 2 line 19 about “net revenue to the provider” damage hospitals? One of the biggest reasons to move to single payer or even an NHS in my mind is because the federal government can provide a backstop to clinics and hospitals that doesn’t exist now! In other words, increase reimbursement over the underfunded Medicaid status quo, and lift hospital’s bottom lines. I think the goal of cost control to the *government* in single payer should come second to reversing the closing of rural hospitals and the stress on urban hospitals.

  15. Tom Stone

    Of course Pelosi is lying, she’s confident that no MSM shill would dare call her on it.
    As for “Killing Innovation” what universe do you live in?
    Most of the innovation over the last 50 years has been paid for with tax dollars.

  16. Michael

    Curious what happens to the $135.50 deduction for Medicare from my SS payment each month.
    Since my first check is in 8 days, I would assume I get to keep it all since its Money I paid into the system.
    Others may get nothing?

    1. marym

      Jayapal said they’ll publish additional documents to discuss funding options. It’s not included in the initial text of the bill. Previous attempts at M4A did include some type of payroll tax, and studies of those similar bills suggest that whatever people are paying now, as taxes or premiums, nearly everyone except maybe the top 5% would pay less.

  17. Big River Bandido

    Even though the leadership doesn’t want this bill to pass, they recognize that it has zero chance of enactment in this Congress. For that very reason, they might actually push it.

  18. David Balding

    Here I go with an incremental suggestion. Please Hear me out before you have an aneurysm of anger!!

    Implementation: At, and forever thereafter, a given date, every newborn baby in the US gets a Medicare card. Likewise, at that time the age for Medicare is decreased by one year and each year is decreased by another year. This gets the system up and running. In theory it would take about 30 years for all to be covered and transition the insurance companies and their employees to find a new line of work.
    Likely, that in a few years the pressure to ramp up the implementation will get to healthcare for all in much less than 30 years.
    MEDICARE FOR ALL

    1. coboarts

      The reason that I wouldn’t feel that an incremental approach is needed to bring in M4A is because everything needed to make it work is and has been in place for both the healthcare delivery and the job dislocation. There is no massive societal shift required. Health insurance employees etc. lose their jobs. We already have unemployment insurance and large swaths of Americans losing their livelihoods is rather a regular occurrence.

    2. Lambert Strether Post author

      Kennedy proposed a stepped decrease in the age eligibility of five years per year, IIRC, before Obama did whatever he did to his mind. So it’s not prima facie aneurysm-worthy.

      However, I think we’re well past the point for incrementalism. We tried that in 2009 and here we are. Fool me once….

  19. Jeremy Grimm

    This bill is only 120 pages long! I hope it can stay relatively short.

    What does the bill say about reducing the costs for medical care, medicines, and dental care?

  20. polecat

    You know, in this particular case, If Nancy were to pass it …. without looking to see what was in it .. I’d be good with it.

  21. RubyDog

    OK, seems like an excellent opening shot, well thought out and addressing the root problems with the current system. But what will it take for this or anything resembling it to become a reality?
    First we would need strong majorities in both houses of Congress. Secondly we need a president who believes and is committed to the cause, and who has both the rhetorical, persuasive skills to use the bully pulpit to win over the public, and the political skills and muscle (ala LBJ?) to overcome the financial might of the pharma/insurance/medical industrial complex. They are going to fight tooth and nail against this, using any and all lies and bribery of government to prevent any change to the status quo.
    Before any of that happens, government and campaign finance reform would likely have to come first, otherwise even large Democratic majorities can easily be bought.

    1. Eclair

      “But what will it take for this or anything resembling it to become a reality?”

      All of what you mention, RubyDog. Plus, massive public support, including peaceful sit-ins at Congressional Offices. And to get that going, we might need wide-spread knocking-on-doors to point out the benefits of Medicare-for-All. Dissatisfaction with our current health care system goes across party lines. We have family and friends who are long-time conservative Republicans, but we are in total accord on this. They are working class/farming Republicans, though. Not Country Club Republicans.

      1. Lambert Strether Post author

        People having their hospital beds wheeled onto the National Mall to give their stupid, unnecessary, profit-driven deaths meaning. Literal die-ins in Congressional offices. Gawd knows there are enough anecdotes. So bring it home to the perps….

  22. bmeisen

    Thanks Lambert.

    The notion of supplementary catastrophic health insurance is freaky. Freakier that Pelosi refers to it is although there seems to be provision in sec. 201.

    The elephant in the room is mandatory coverage: catastrophic is an issue only if the premium pool is insufficient to efficiently cover all claim exposure associated with human health, for example an unexpected 6-yr bout with breast cancer that ends in intense paliative care and death. To guarantee a premium pool to efficiently cover all claim exposure for a population of 330 million you can’t let people opt out. It doesn’t work without mandatory coverage. That’s what most other first world democracies figured out and that’s why for example in Germany insurers are posting big reserves and rebating payments while covering catastrophes and dental and and and.

  23. DonCoyote

    How to make a profit from Medicare-For-All: Hollywood Accounting (Joan Didion, 46 years ago):

    In fact the byzantine but very efficient economics of the business render such rhetoric even more meaningless than it sounds: the studios still put up almost all the money. The studios still control all effective distribution. In return for financing and distributing the average “independent” picture, the studio gets not only the largest share (at least half) of any profit made by the picture, but, more significantly, 100 percent of what the picture brings in up to a point called “the break-even,” or “break,” an arbitrary figure usually set at 2.7 or 2.8 times the actual, or “negative,” cost of the picture.Most significant of all, the “break-even” never represents the point at which the studio actually breaks even on any given production; that point occurs, except on paper, long before, since the studio has already received 10 to 25 percent of the picture’s budget as an “overhead” charge, has received additional rental and other fees for any services actually rendered the production company, and continues to receive, throughout the picture’s release, a fee amounting to about a third of the picture’s income as a “distribution” charge. In other words there is considerable income hidden in the risk itself, and the ideal picture from the studio’s point of view is often said to be the picture that makes one dollar less than break-even. More perfect survival bookkeeping has been devised, but mainly in Chicago and Las Vegas.

    And, still going on today: Lying, Cheating and “Reprehensible” Studio Fraud.

    I will leave it as an exercise to the readers for how to rebrand and update this grift for M4A, but *I* think it needs a yyyyyyyyyyyyyyuge marketing budget and “distribution fee” system (for the ID cards maybe). But no profits will be made: “believe me” (“What, Democrats in Disarray? No, they have a plan…believe me”)

  24. Stratos

    I hope this helps millions of rural citizens. Hospitals have been folding in rural America at an accelerated pace for years now.

  25. Dan

    All progressive Democrats should just get behind John Conyers’ original Medicare For All Act, H.R. 676 (number since surrendered and issued to military legislation…oh the irony). All subsequent legislation has been watered down at the behest of the insatiable profit seekers.

    H.R. 676 was only 30 pages, double-spaced, and was supported by hundreds of trade union locals and councils.

    These new “progressive” proposals, by both Bernie and Jayapal, may actually have the long-term effect of completely gutting Medicare:

    https://dissidentvoice.org/2019/03/corporate-and-progressive-democrats-threaten-medicare-itself/

    1. Jeremy Grimm

      Some interesting counterpoint to the hopeful praise for Jayapal’s bill but without reading both bills it’s difficult to reach a judgment. I tend to mistrust a bill, in spite of goodies up front when the bill grows beyond a certain number of pages. Some noxious creatures can crawl in under cover of 500+ pages of legalese or even 100+ pages.

    2. Oh

      Thanks for the link. According to the information in the article, both Sanders and Jayapal seem to be appeasing the DimRat leadership. Bad idea.

  26. Allegorio

    I’d like to put in a plug for a National Health Service in addition to and not instead of Medicare for all. Two selling points, access for people living in rural areas not served by the private medical establishment, and as a first defense against pandemics and promotion of public health. It can be sold as a national security issue.

  27. Bob Hertz

    Prohibiting profits may be a good sound bite, but it would be a monster to actually impose in practice.

    The entire drug industry, the entire device industry, and virtually the entire testing industry is driven by profits. Doctors frequently invest in these industries and get a share of profits. Even urgent care centers are run for profits.

    Even if we got close to imposing this law, I believe that the government would be forced to buy out the current owners. There is billions right there and endless court cases.

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