Kip Sullivan on Why the Bernie Sanders Bill Is Not Single Payer

Originally published at Corporate Crime Reporter.

Kip Sullivan is a 1972 graduate of Harvard Law School. He has spent most of his professional life not practicing law, but instead organizing to put the private health insurance companies out of business.

Translated – he’s an advocate for single payer national health insurance.

He is a prolific researcher and writer – posting at places like Health Care Blog and STAT.

* * *
What is single payer?

“Single payer has four elements,” Sullivan told Corporate Crime Reporter in an interview last week.

“First – one payer, not multiple risk bearing entities called insurance companies or health maintenance organizations (HMOs) or accountable care organizations (ACOs). One payer. All the risk lies with that one government payer.”

“Second, budgets for hospitals and nursing homes.”

“Three, uniform fee schedules for individual providers – doctors.”

“Four, price controls for drug companies.”

“Those are the four elements you need.”

And those four elements are reflected in the House bill HR 1384?

“Yes. And they were reflected in its predecessor, HR 676. And those four elements are reflected in a couple of state level bills, including the one our organization – Healthcare for All Minnesota and Minnesota PNHP support here in Minnesota.”

HR 1384 reflects your definition of single payer?


The Senate bill, Bernie Sanders’ bill, S 1129, does not reflect your definition of single payer. Why?

“It is missing two elements. It doesn’t have one payer. It authorizes multiple risk bearing entities called accountable care organizations. And because it authorizes these ACOs, it does not and cannot authorize hospital budgets.”

Under the single payer plan that you envision, the single payer, let’s call it Medicare, would set budgets for each of the nation’s hospitals. How many hospitals are there?

“About 5,500.”

Medicare would set budgets for each of the 5,500 hospitals?

“Yes under Pramila Jayapal’s House bill and under HR 676, directors of regions would set budgets. They would all be working under the Secretary of Health and Human Services.”

Why is it important that Medicare sets the budgets for each hospital?

“In order to maximize social control over the allocation of resources. Here in Minnesota a year ago, the Mayo Clinic, which began buying up everything in site back in the early 1990s, closed down the Ob/Gyn department in a hospital in a small town – Albert Lea, Minnesota. There was no consultation with Albert Lea residents. It infuriated people. There were demonstrations. But the CEO of Mayo did not relent. That was an example of a decision that should not be made by some overpaid CEO running a hospital clinic chain. It is the kind of decision that ought to be made by a democratically appointed or elected body with input from the affected community.”

Let’s look at the largest ACO in the country – Kaiser Permanente.

“They don’t call themselves an ACO, but you are absolutely correct. They fit the description.”

What do they call themselves?

“They call themselves either an HMO or an integrated delivery system.”

What percentage of patients in California are with Kaiser?

“I’m going to guess a third.”

Under HR 1384, Kaiser would be put out of business and all of those patients would be shifted to Medicare. Under the Bernie Sanders bill, S 1129, Kaiser would stay in existence?/em>

“Under HR 1384, Kaiser hospitals would not be bulldozed, nor would their clinics be bulldozed. Kaiser hospitals would each get their own budget, like every other hospital in California. Kaiser physicians would be paid on the same uniform fee schedule of all other doctors in America.”

“If there is something really good about the way Kaiser manages, supervises, pays or incentivizes doctors, there is absolutely no reason why Kaiser can’t continue to do that even after they lost control over how much each hospital is budgeted and how much they pay physicians.”

“What Kaiser will lose is the ability to use their enormous market power to extract enormous discounts from drug companies, equipment manufacturers and non-staff providers that other insurance companies cannot extract.”

Kaiser will lose that ability, but the federal government will have much greater power to negotiate drug prices nationwide.

“Yes. When the original HMO proponents went to Congress in 1970 and said – we need HMOs, the argument was not – we need HMOs to become the size of Fortune 500 companies so they can squash the rates paid to doctors and hospitals. That was never part of the bargain. They were supposed to have improved health and lower costs by eliminating unnecessary care and only unnecessary care. And they were somehow going to do a better job of getting women to get mammograms and get people to stop smoking. That was the great promise of HMOs.”

“Had the original HMO proponents been forthright they would have said – HMOs are really not going to do that great a job of reducing unnecessary care, they are not going to be any better than regular doctors at preventive services. What we really mean is – we’d like you the government to encourage the cartelization, the growth of enormous hospital clinic chains so that they can use their power to squash provider rates. The Congress would have said – we are not going to do that. If that’s what we want to do, squash provider rates, we can do that through Medicare.”

Why is the ACO provision still in Bernie’s bill?

“I wish I knew how it got there in the first place.”

It might be firms like Kaiser worried they will be put out of business?

“It might be. But the groupthink that grips American academics, think tanks and policy makers is so strong that even without support from the hospital and clinic chains, it would get in there. Kaiser didn’t even apply to become an ACO when Medicare opened up the opportunity. It’s the hospital and clinic chains.”

“The most plausible hypothesis is that Bernie has surrounded himself with advisors who are enamored with the latest version of managed care. The managed care diagnosis is that doctors are greedy or ignorant and they order services patients don’t need. And someone has to do the dirty work of making the doctors behave. And HMOs didn’t work that well. So now we are going to do ACOs. And ACOs are just HMOs on training wheels.”

“Bernie was heavily influenced by what happened in Vermont. The whole world thinks that what failed in Vermont was a single payer. What failed in Vermont was a three ACO proposal, recommended by Governor Peter Shumlin. Shumlin was influenced by a report written by William Hsiao and Jonathan Gruber in 2011. The report claimed they were recommending a single payer system, but added in ACOs.”

“A single payer system with ACOs is an oxymoron. The experts were telling Shumlin that he can achieve the administrative savings of a single payer even if you insert these new fangled entities called ACOs. Of course, Bernie has been representing Vermont in Congress. He was quite aware of this report and of the people who started promoting it.”

“If you ask me where did Bernie get this nonsense, it came from that report and from the distorted discussion of the Vermont bill. One of my complaints of the national single payer movement is we never said – stop calling Shumlin’s bill single payer. We didn’t do that. And when it failed, the blowback came back at us.”

“I have been asked by Democrats here in Minnesota – if single payer can’t work in a blue state like Vermont, why do you expect it to work in Minnesota? And you have to start from scratch and say – what Shumlin was proposing was not a single payer. He was proposing to set up a state board. He was going to hire Blue Cross to negotiate with three gigantic hospital clinic chains in Vermont. They were going to call them ACOs. And then the chains would bear all risks and act like insurance companies. Why would you expect to save money when all you have done is roughly recreated the same system with some newfangled terminology?”

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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.


  1. rob

    bernie sanders shouldn’t get a “free pass” about his health insurance for all plan.
    It is certain he knows better, but still is pushing more garbage on the american people.
    Bernie has had the luxury of living in a tiny state where the political climate allows for its representatives to APPEAR progressive. And the big money players in vermont get to have the same system as everyone else… with no real restraint from the “elected officials”…
    Bernie has been in office a long time…. and except for pushing things that will realistically never happen, which gets him support from his base in vermont, he has never really done anything. Which he can’t really be blamed for because he is just one of many…. who would have join in together, to get anything “done”.
    bernie needs to show more than just some faux progressive BS.
    Jamila prayapal’s house bill shows the bernie bill to be what it is…. a fraud. And if bernie is standing behind his mistake….than he is a fraud too.
    Bernie may have pushed medicare for all….. because it was a good soundbite… we see that with his bill he never actually had any intentions of making it a reality. And if he was president tomorrow… he likely wouldn’t support a real bill like the one in the house….
    Having blue cross run anything is a crime…. in north Carolina…. they are as bad or worse than any other insurance company…. they screw people every day and take their money…. all while making billions in profit while they enjoy their not for profit tax status….
    If bernie and the vermont legislature are in bed with blue cross, they are the scum , like everyone else in the for profit healthcare racket.

    1. jrs

      Kamala Harris might get it too hard for her flip flopping. In some sense she might just be being more honest about the bill. Not that I think she’s a person of great integrity or anything – hardly. Advancing within a large blue states political machinery is also likely a different animal than being a Senator from Vermont.

      Voting? I’m just going to vote for the best on offer, without apology, as self-defense, as what can be done in the limited arena of the voting booth and keeping in mind this is no swing state, so primaries matter but general not so much. But fundamental system change is another matter.

      1. Dan

        Kamala Harris has no chance of defeating Trump in the general election, so whatever she claims is irrelevant.

        The San Francisco Chronicle, is where works her ex-legislator boyfriend, Willie Brown, the guy who launched her career.
        This is their 200th laudatory article of the year about Harris, and is the strongest part of her entire campaign; her alleged home town and base of power.
        To see how she’ll play in flyover country and the Midwest, read the comments about her in at the end of this latest article flogging her. Her people, indeed!

        “Aside from handing her an expensive BMW, Brown appointed her to two patronage positions in state government that paid handsomely — more than $400,000 over five years. In 1994, she took a six-month leave of absence from her Alameda County [deputy DA] job to join the Unemployment Insurance Appeals Board. Brown then appointed her to the California Medical Assistance Commission, where she served until 1998, attending two meetings a month for a $99,000 annual salary.”

        Then there’s Kamala the Cop, to live down.

        1. jrs

          If one doesn’t even have a poll to back them up I don’t know on what basis they are asserting who can beat Trump.

          I mean logically Trump should not have won, he could not be more manifestly unfit for office even considering his competition. But fitness for office has nothing to do with anything.

          Now polls may not be worth as much as they are hyped to be either, but at least they try to base their assertions on something as opposed to on nothing. And one can examine their assumptions in most cases for bias, like relying only on landlines etc..

          Personally I suspect local commenters might be the most unreliable “unofficial polls” on anyone, as they might bring up legitimate points of past record and policy of course and that’s the useful part, but as for using them for “unofficial polling”, they also seem to attract people with real axes to grind, extremes of the spectrum IMO. But I don’t know if anyone has really studied that or not.

          Post was probably taken as more of an endorsement of Harris than it was, more if it’s really true that the Bernie bill that Warren and Harris have also endorsed fwiw, doesn’t eliminate insurance companies (as per the article) then the flip flopping she has done can be seen in that context.

          1. Dan

            “The Iowa poll, which surveyed 500 likely Iowa Democratic caucusgoers, showed a larger gap between the two. Mr. Biden was the first choice of 24 percent of likely Iowa caucusgoers, and Ms. Harris had 16 percent support.”

            Question, I see you don’t trust local commenters. How about local voters? So why did Harris move her national headquarters as far as possible, not to Iowa, or to South Carolina, but to the black backwater of Baltimore?

    2. Jack Parsons

      How did Sanders stay Senator for so long if he “has not really done anything”? For Vermont?
      Answer: he’s not a bill-starter, he’s a bill-rider. And very good at it.

      As to Harris- yeah, we know about her in the SF Bay Area, but that doesn’t matter. History doesn’t matter. The past doesn’t matter. What the zeitgeist wants is what matters. Trump is a classic American type- a fraud. Like Madoff, but caught several times and wriggled out of trouble each time. Americans love that! Williamson is another classic American type- a utopian religious nut. She’s not quite the right formula for the zeitgeist, but the fact that she got on that stage shows the relevance of America’s hunger for our stereotypes.

      1. Mac na Michomhairle

        It is fun and sometimes politically effective to make broad statements like yours about Sanders without backing any of it up. Also dishonest.

        I have been observing his career for 25 years. He has accomplished many things for VT and initiated many bills, successful and unsuccessful, in Congress. He is known for that.

        It is interesting to observe the evolution of the mainstream campaign to denigrate and stop him, as evidenced in the mainstream media and in your and other new posters comments

  2. Carla

    This interview is superb. I shared a previous Kip Sullivan piece that Lambert posted on NC with my local single payer group — the Cleveland chapter of the Single Payer Action Network of Ohio (SPAN Ohio). Unfortunately, they are into Democrat unity — gotta beat Trump first — etc.

    Physicians for a National Health Plan (PNHP) has endorsed Bernie’s bill. I can only hope that they can convince him to reconcile it with HR 1384. If not, and something like Bernie’s bill actually come to pass, we’re on another fools’ errand for a couple more generations — that is, if we actually HAVE a couple more generations.

    P.S. Don’t know why this is in italics; tried to change it but couldn’t.

    1. msmolly

      There’s an HTML code in the article that changed the remainder of the post. Maybe one of the editors can fix it.
      [Under HR 1384, Kaiser would be put out of business and all of those patients would be shifted to Medicare. Under the Bernie Sanders bill, S 1129, Kaiser would stay in existence?/em>]

    2. Oh

      I’m surprised to learn than PNHP is endorsing Bernie’s crummy ACO laen bill. It’s best to have the Senate pass the Premila Jaypal bill. It provides a lot more medical benefits and contains all the required elements. I was disappointed to learn about Berinie’s bill from a prior post at NC. (Hat tip to Lambert). If the Senate is allowed to even change one provision of the bill, they’ll FUBAR it and give us another ObummerCare.

  3. Bob Hertz

    Global budgets for hospitals would eliminate surprise billing, balance billing, insurance negotiation and delays, and similar wasteful administrative procedures.

    However the budgeting process would be a massive undertaking. The data gathering would be stupendous and the negotiations would be incredibly intense. I do not think that the current CMS staff in Washington could do it.

    Here is a brief and I think fair-minded description of the budgeting process….

  4. GramSci

    per Sullivan and HR1384:

    “Kaiser physicians would be paid on the same uniform fee schedule of all other doctors in America.”

    Does this mean that doctors in NYC will be paid the same as doctors in Mayberry?

    1. ambrit

      That might get a lot of “qualified” medical droids out of the big cities and back to the hinterlands where they are needed more. Basically, remove a major impetus to concentration.
      This would also bring some more spendable funds to the decaying Mayberry Central Business District.
      Thirdly, cutting physicians and associated personnel’s salaries, the assumed end result of this process, would remove a driving force behind one of the non-rational inflationary forces pushing up rents in the “tony” parts of america’s urban concatenations.
      All I can see are social goods resulting from this process. (Full disclosure; I am not a medical ‘Credentialed Professional,’ just a ‘deplorable’ victim of same.)

      1. shinola

        “Thirdly, cutting physicians and associated personnel’s salaries…”

        This brings up a related problem – the cost of obtaining a medical degree. According to what I’ve read recently (I think it was here in NC comments) the cost of becoming an M.D. in the US is in the 100’s of thousands of $$$. I don’t what a nursing degree costs these days but I doubt that it is cheap.

        The cost of becoming a medical professional would have to be significantly reduced.

        1. ambrit

          Agreed. Something like State sponsorship of medical education in return for “Public Service” might do the trick.
          An example, one of my Mother’s uncles was put through medical school in Scotland by his church. In return, he went to Africa as a Missionary Doctor for five years. When it came time for the children to go to high school level, he returned to Scotland with his family. One of his sons did the same thing later.

          1. Anon

            As I understand it, most medical schools and “teaching” hospitals get support from public funds. There seems to be a hierarchy of medical schools and teaching hospitals across the US, with varying levels of costs. (A Chief Resident physician at my local hospital said she received her medical degree in (of all places) Granada!)

            1. ambrit

              True. I’ve read that Cuba’s best “soft power” weapon is it’s “Socialist Missionary Doctors,” who help out in foreign climes.
              We have been fooled, by and large, into accepting financial return on investment as the primary measure of “worth” for any endeavour. National Health, if and when it comes to America, will of necessity challenge that assumption. A truly daunting task, but needed.

            2. Kurtismayfield

              The US government puts in ~$5billion into Medical training and education. The total budgets of the Medical schools are about $20 Billion. The US could find Medical education 100%.. but then there wouldn’t be the control of debt.

              1. rob

                were the congress wise enough to pass the 112th congress’s HR 2990 “the NEED act”,
                and end private banks creating our money,
                we would have the ability for congress to fund medical education as one of the ways the treasury would inject the debt free US dollars created by the treasury, into the economy at large.
                We could train more doctors/nurses and others and stop requiring them to work more than 8 or 10 hour shifts…. so maybe they wouldn’t make so many mistakes and maybe start killing LESS people per year than guns/drugs/sleeping drivers/etc.

  5. GM

    There is a lot of obfuscation on single payer, even by the people who are advocating for it.

    You will often see them saying “We are not going to eliminate private insurance”, “Everything stays the same, it’s just that the government is now the insurer”, and other statements of the sort.

    This is quite divorced from the reality of the situation.

    First, it fails to identify the actual cause of the high prices. It is not just the insurance companies imposing a tax on society. Prices are high because everyone in the chain is a for-profit entity — the insurers, but also the doctors, the hospitals, the drug companies, the medical device manufacturers, biotech companies, etc., etc. Medical schools too even if they are officially non-profits.

    Second, it fails to look sufficiently far into the future and anticipate what will happen as times goes on. As long as there are private “supplemental” options and private for-profit hospitals, the rich will use those, and this will create a two-tier system — one for the rich and another for everyone else. And once the rich have their own system, they have no incentive to maintain the state-funded one. Which, even if implemented, will be chipped away at, gradually defunded, and eventually crippled. Which will have a doubly disastrous effect — not only will the system crumble at some point but this will give ammunition to the “free-marker” ideologues who will now be able to say “See, we told you it cannot work”.

    That sort of gradual dismantlement of social services is what happens everywhere where the possibility for the rich and powerful to segregate from the rest of society is allowed.

    It should not be difficult to see that there cannot be a stable solution that works in the interests of society as a whole that does not involve nationalizing the whole health care system, i.e. hospitals, doctors, drug and device manufacturers, etc. and also outlawing private practices.

    The reason government-run health care worked as well as it did in the Soviet Union (and it did work very well, do not believe the propaganda) was that the whole supply chain was entirely controlled by the government and the profit motive was entirely taken out of the system.

    Given the political climate, it is understandable why people do not want to tell it as it is. But I also have the feeling that it is not just a political calculation, and that many simply indeed do not grasp the core of the problem.

    P.S. Looks like someone forgot to close an html italic in the main text, and it is carrying into the comments.

    1. Jules Dickson

      Thanks for the comment, and for pointing out the formatting issue. Fixed it. Thanks!

    2. jefemt

      Care providers in my extended family and Doc friends consistently state that INSURANCE adds 30 to 40 cents on the dollar in cost. That cost contributes not one bit to CARE.

      The notion of insuring the health of a mortal being that is born to die, and who will become sick repeatedly over time, is a bad bet.

      Lording the fear of one’s health and well being, or worse yet, that of ones family/child/parents– and profiting from that fear– is morally reprehensible. Biggest salaries in the world in health INSURANCE.

      Take all the unemployed INSURANCE actuaries and give he best of them a whack at the work of driving costs down, outcomes up.

      The thing we need to get to is care for all, cradle to grave, and how to best manage and cost SHARE, not cost shift like some Ponzi scheme. Might there still be a ‘we’ in he US ?

    3. Oh

      Most people don’t know how badly they get ripped off by the current healthcare system. Besides they’ve swallowed the oft repeated propaganda “Government can’t do naything right”. Unfortunately, they don’t include the defense department, Congress and the judicial system in their definition of government. I agree with you that the healthcare system needs to be nationalized, including pharmas and the medical device manufacture. Most people will not understand this and will recoil when we say that because they have no knowledge of how the profiting entitities prey on the sick.

  6. GramSci

    per Sullivan:

    “[Shumlin] was going to hire Blue Cross to negotiate with three gigantic hospital clinic chains in Vermont.”

    Is it essential to M4A that hospital chains be broken up? Even relatively (proportionately) small chains such as in Vermont?

    1. Arizona Slim

      Hiring Blue Cross to negotiate with three gigantic hospital clinic chains? Oh, man. Does this sound like fertile ground for insider deals or what?

      1. GramSci

        I understand the implication that Shumlin consequently vetoed Vermont’s single payer because BCBS quoted too high a price, but I thought Bernie’s plan was to require competitive bids, and to determine the overall budget?

    2. ambrit

      A viable work around here is for full nationalization, to not break up the regional hospital/clinic chains, but to subsume them all into one socially controlled chain; ie. National Health.
      As a commenter above mentioned, under the old Soviet Union, basic health care was a State monopoly, and functioned fairly well.
      Unless someone is secretly a Social Darwinist, and figures that the deaths of the less socially “connected” members of the society is a positive thing, the inclusion of the profit motive in the provision of health care has no moral or ethical purpose.

  7. Rodger Malcolm Mitchell

    Medicare already has made all these financial decisions. Why reinvent the wheel? Simply lower the participation age from 65 to 0. Then it truly would be MEDICARE for all.

    1. katiebird

      Because it needs to be expanded and improved. For example, It only covers 20% of charges unless you buy supplemental insurance. It doesn’t cover dental or vision. And even when it covers a procedure, it might not cover everything a person wants. Like with cataract surgery, it only covers one vision correction. It won’t pay full price for a multifocal lens. Or distance AND astigmatism.

      And if we lowered the age….. Would we each have to have our own supplemental plans as we do now? And individual part D plans. I shudder to think how complicated that would be every year!

      Lowering the age might be an improvement. But we would still be struggling with many of the issues we have now.

      1. jefemt

        I went to a Medicare meeting, hosted by a congressional candidate, with a panel of local experts. I thought it was going to be a plug/push for medicare for all. Instead, it was a war-story peppered 1.5 hour tutorial on what changes to be aware of and steer around for the upcoming year. I was aghast at how many in the room seemed to not be getting attended to, denied care, and what a ridiculous system it was. BUT, no better than private care situations that a well-insured 45 year old might have to deal with, frankly.

        It was so byzantine, unnecessarily complicated, and yes, seemed to indicate that the system was trying to bypass or skirt care in many situations.

        Medicare needs to be improved, streamlined, made efficient, and cover everything—including comfortable, compassionate end-of-life treatments— whether tat sad reality is for a terminally ill child, or an 88 year old loved elder.

        Finally, same care/ access for all folks- self employed, military- congress—especially congress— how can they legislate on policies that they themselves are not participating in, personally?

        May we all work toward a positive, sensible, resource conserving effective care-for- all policy and system!

        1. ambrit

          Our experience with the Medicare funded, privately run Hospice Industry is that Medicare already imposes a resource cap through something similar to an HMO system.
          The Hospice provider is paid a set amount per day to manage the individual case. In our case, that is $169.00 USD per day. We have, so far, settled into a routine of seeing a nurse once a week. Said nurses having a high turnover rate, since, the nurses have to supply their own vehicles and cover a multi county area and deal with between a dozen to twenty or so patients per nurse.
          We are generally struggling with the provider over the types and amounts of supplies provided to us for use on the cancer symptoms. Generally, a fairly strict, “one size fits all” regimen is used. If, as an example, Phyl wants more Silver Alginate bandage material to use on the tumours, (this stuff soaks up exudate, and the silver component is microbiocidal,) she has been told that ‘best practice’ demands that it only be used for two weeks. This ‘best practice’ is debated in the field, but has the backing of some powerful ‘actors’ in the field, it seems. So, we obtain our own Silver Alginate material over the internet. A medical supply that Medicare could underwrite ends up as a private expense. The same applies to pain medications. (This has been mentioned before, so, that nightmare can wait for another day/night.)
          Bottom line: Someone is making big bucks, and it isn’t me.

          1. katiebird

            I am so sorry, ambrit.

            “Best practice demands” that phrase infuriates me. Especially for Hospice Patients. Best Practice should be whatever products give the most comfort!

            1. ambrit

              Thanks katiebird.
              What is probably a feature of this ‘rent extraction’ scheme is the lack of transparency of the funding and disbursal streams of the “Public Private” entities involved in the provision of medical ‘care.’
              As an observation “from the trenches,” those nurses who have ‘moved on’ from working for this particular hospice company seem to be the older, more experienced persons. I suspect that such smaller companies as this, in the medical field at least, are acting as feeder sites into the higher paying organizations. There seems to also be a factor of training involved. Younger, less experienced medical personnel, in this case nurses, also probably do not know enough yet about the field to know when to push back against the management on issues related to the work. This is a perfect incubator for, to steal a line from Professor Black, a “criminogenic environment.”
              Peace and much love.

        2. Carl

          Sorry, at 58 I cannot “work toward” anything anymore, I have to accept things the way they are. I’ve been studying this predatory system for the last 15 years, and it’s clear to me that change isn’t on the horizon. The entities involved make way too much money to let go without a fight to the death, and the political will just flat isn’t there (see the democrat party’s marginalization of Sanders). I need healthcare now, I will need more in the future, and I won’t get it in the US. The choice is easy. IMHO, articles like this accompanied with commentary where we endlessly debate what would be the ideal system, is mental masturbation.

        1. katiebird

          You are correct! I meant that we are left with responsibility for 20%. I think I need more coffee!!

          1. ambrit

            “Discuss your caffeine needs with your Healthcare Provider before embarking on a program of ‘Early Morning Caffeine Enhancement.'”
            “BUZZ Responsibly.”

    2. Carla

      Although Medicare has been significantly crapified over the last 2 to 3 decades, it remains far and away superior to the insurance coverage 90 percent of Americans are able to wring from the private sector, so Rodger Malcolm Mitchell’s proposal would be a big WIN for most people.

      That said, with escalating crapification already baked in to existing Medicare, we should ALWAYS call for “Expanded, Improved Medicare for ALL,” which of course Pramila Jayapal’s bill would provide.

  8. Susan the other`

    Thanks for this interview. I’ve been wondering why Bernie has failed to discuss this. He knows he’s not promoting the best deal, but he’s locked in by previous agreements most likely. It would not surprise me if he quietly promoted Jayapal’s HR1384. Despite his compromise, he’s still the guy who got it all going in 2016. That took a lot of courage.

  9. GramSci

    What is Kip Sullivan talking about? Sorry, but my pdf viewer can’t seem to find any term like “Accountable Care Organization” in s1129. Can someone help me find a chapter-subsection reference to what he is talking about? Thanks.

      1. GramSci

        Thank you, marym!  Mr. Sullivan’s PDF, to which you linked, is quite compelling. We should all be concerned about the camel getting its nose into the tent, but I don’t see how the “Pediatric Accountable Care Organizations” which are sunsetted in HR1384-903(a)(5)(C) are comparable to behemoths like the Kaiser network or BCBS, nor do I see how the Vermont’s failure to implement single-payer can be attributed simply to BCBS assuming a kind of super-ACO role. Vermont is a small, poor state, and it should have surprised no one that the US MIC (Medical Industrial Complex) was resolved to and capable of crushing its attempt at single-payer.

        As Susan the Other remarked above, under Public Law 111-148 Sec 2706, each “Pediatric Accountable Care Organization demonstration project” is contracted “for not less that a 3-year period”, which qualifies for me as a “previous agreement” that Sec. 611(b) of Bernie’s bill was not wrong to exempt.

        I agree that HR 1384 is the superior bill, and I even worry at times that Bernie is sheepdogging me–but not on this issue.

        Even if Bernie gets elected in a landslide, he’s not going to change the Senate (or the Democratic House!) enough to pass single payer in his first two years.  At this point in the campaign it is perhaps more important for Bernie to keep his version of the M4A bill consistent and unchanged.

        1. marym

          The list of sunset programs in the House bill gives an interesting perspective on where “camels” like privatization, administrative overhead, and fraud can find a way into the tent. I make no claims to understand any of the details about these programs, and we’re a big, diverse country so some flexibility is probably important, but we really need to minimize potential points of failure.

    1. Yves Smith

      See the comment above by marym. ACOs are preserved by incorporating payment provisions from existing legislation. Clever in a bad way.

  10. clonalantibody

    The problem appears to be coming from this small section of S1129 – Sec 611(b)

    (b) APPLICATION OF CURRENT AND PLANNED PAYMENT REFORMS.—Any payment reform activities or demonstrations planned or implemented with respect to such title XVIII as of the date of the enactment of this Act shall apply to benefits under this Act, including any reform activities or demonstrations planned or implemented under the provisions of, or amendments made by, the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10) and the Patient Protection and Affordable Care Act (Public Law 111–148).

    Kip Sullivan discusses this in another article – Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: One Is a Lot Better Than the Other

    The problem arises from the question – “How do you pay for organizations like Kaiser? And how will such organizations be affected and changed without affecting patient care for the worse and rather to make patient care better?”

  11. whiteylockmandoubled

    While I prefer the Jayapal bill to the Sanders bill on most counts, Kip Sullivan’s analysis is distorted, in some ways trivially, and in some ways dangerously. Progressives should not accept the idea that the Sanders bill is somehow not a single payer system. Sullivan is demonstrably wrong on this front.

    If you define an apple as a pink fruit that grows on grapefruit trees that you peel and eat, you can claim that a Golden Delicious is not an apple. Sullivan does this in a couple of ways.

    First, Sullivan asserts that a single payer system must reimburse hospitals through global budgets. That is false. Just plain not true. I don’t know why Sullivan makes that claim, but he is 100% wrong. That may be Sullivan’s preferred method of hospital payment — it’s my preferred method, it’s Physicians for a National Health Program’s preferred method, and it’s the Jayapal bill’s proposed method of reimbursing hospitals — but it is in no way necessary for a single payer system.

    A single payer system can quite easily choose to reimburse hospitals on a fee-for-service basis. Collect taxes, and use them to pay claims from hospitals. Single payer, but no hospital global budgets. Or it could pay hospitals through a mix of global budgets, fee for service or other payment styles. Indeed, the traditional Medicare program pays hospitals for inpatient care through a mix of payment styles– a flat rate based on the patient’s diagnosis, with formulas that add different amounts based on a hospital’s local labor costs, the amount of teaching a hospital does, and other factors. Hospitals also receive separate Graduate Medical Education funding streams, lump sums based on the economic profile of their patient load, and payments to compensate them when they have an unusual number of extremely expensive cases.

    All of these are subject to gaming (as would be future global budgets), but they are perfectly consistent with a single payer system. Note that PNHP now calls for global budgets “like systems in Canada and SCOTLAND.” That’s because the NHPs in other parts of the UK do not reimburse hospitals this way. Again, I think it’s the best way, but any definition of single payer that claims you must reimburse hospitals through global budgets is a phony definition. A single payer means a single entity pays the bills. How the bills are paid is up to policymakers.

    But that’s not particularly important. What is important, and very dangerous, is Sullivan’s conflation of Kaiser with current ACOs. Kaiser is not an ACO. It is a fully-insured HMO. Thus, by agreeing with his questioner, Sullivan implies, although does not directly say, that Sanders is preserving private non-profit insurers (which is what Kaiser is) in the Senate bill, presumably through some form of subcontracting, like the current “Medicare Advantage” boondoggle. That is, again, absolutely false. Two parts of S 1129 make this abundantly clear:

    1. Section states, without any qualification “it shall be unlawful for—
    (1) a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act; or
    (2) an employer to provide benefits for an employee, former employee, or the dependents of an employee or former employee that duplicate the benefits provided under this Act.

    That is the definition of single payer. The government is the only insurer for benefits covered by the law.

    2. For good measure, Section 103 says flatly and in its entirety, “Any individual entitled to benefits under this Act may obtain health services from any institution, agency, or individual qualified to participate under this Act.”. In other words, free choice of provider, full stop, no qualifications. Kaiser will not be accepting premiums that give it any right to in any way constrain patients’ access to providers of their choice, nor will the law impose any financial penalties on patients who see any participating provider.

    Sullivan is correct that Section 611(b) says that “Any payment reform activities or demonstrations planned or implemented with respect to such title XVIII as of the date of the enactment of this Act shall apply to benefits under this Act,…”, which preserves the current Medicare ACO program.

    These are experimental payments, structured around the existing “traditional” Medicare reimbursement system, the latter of which S 1129 preserves in full. The ACO “payment reform” is dumb for a bunch of reasons, but it’s not Kaiser, it’s not full-blown insurance subcontracting. Current Medicare ACOs put a relatively small portion of payments for hospitals and doctors who form voluntary networks at risk for achieving certain cost and “quality” benchmarks. Those networks are voluntary, patients who are part of traditional Medicare are free to see providers outside the network with no financial penalty, and many patients don’t even know their providers are in an ACO network.

    These are generally bad ideas, in part because the incentives to skimp on care are not always transparent to patients, and frankly, the “quality” indicators are mostly bullshit. While advocates have rightly warned that the current ACO program could develop into more managed care, right now, they are simply experimental fee-for-service payments with lots of data reporting and some portion of the payments at risk for performance. That has nothing to do with whether or not S 1129 is a single payer bill.

    What is bizarrely ironic about Sullivan is that he criticizes Sanders for preserving a (failing btw) experimental form of reimbursement, while the House bill that Sullivan likes will actually impose a much more extreme version of ACO payment on the entire system. “Global budgets” are capitation payments, so the bill contains within it the very incentives for undertreatment that Sullivan and others scorn in ACOs. In the end, I support global budgeting for hospitals, but it’s worth pointing out how warped Sullivan’s criticisms are.

    Medicare for All will restructure a sixth of the U.S. economy. Under that umbrella, there are many important policy disagreements that need to be worked through. The Senate and House versions of Medicare for All differ on some of these, but both are single payer proposals, end of story.

    It’s fun to be tough-minded NC readers, furrow our brows and posture at not “giving Sanders a pass.” But in this case, Kip Sullivan either has absolutely no idea what he’s talking about, or is misleading readers (or listeners, given the source). Not helpful.

    1. Kip Sullivan

      Whitey appears to be very confused, but it’s difficult to determine what it is he’s confused about.

      Let me attempt to ferret out the causes with two questions.

      (1) Whitey, why do you call yourself a single-payer supporter?

      Here’s my reason: I believe America will never achieve universal health insurance without cutting the high cost of health care in the US prior to, or simultaneously with, the extension of coverage to all of us. Do you agree with that?

      (2) Are you among the people who think any bill that purports to achieve universal coverage should be called a “single payer” bill even if it does not get rid of the insurance industry (Bernie’s bill does not)? I don’t. I believe we need a new name for such bills. Instead of “single-payer,” I suggest “single-trough,” as in, all the HMOs/ACOs sup at the same public trough. Single-trough bills cannot cut costs, either at all, or sufficiently to pay for universal coverage. Single-payer bills can.

      1. run75441

        I believe America will never achieve universal health insurance without cutting the high cost of health care in the US prior to, or simultaneously with, the extension of coverage to all of us. Do you agree with that?

        Three JAMA papers and one Commonwealth funded Health Affairs paper support your contention as well as my own opinion citing these documents as dealing with the high costs of the various portions of healthcare now rather than later. The latest being “Trends in Prices of Popular Brand-Name Prescription Drugs in the United States” released May 2019 and touching upon on annual and biannual price increases from 2012 – 2017 for 39 of the most prescribed drugs. And the generic versions that exist follow suit.

        The industry itself has imposed a newer pricing mechanism based upon value to society, healthcare, quality of life, and clinically is making it even more predatory as this is a moral justification difficult to refute . . . except it is based upon profits. Novartis set the list price of Kymriah for pediatric use at $475,000 (well below the ICER’ cost effectiveness value of $1.6 million) and $373,000 for adult cancers. WHO in its recent paper has set the average return for $1 invested of $14.50. There is no end to this in sight.

        The role of ACOs was supposedly far different than what it has turned out to be. Indeed it was meant to provide an improved quality of service and outcome without the fees imposed for access. Instead it has become a tool for the consolidation of hospitals, clinicals, and practices into it the ACO as measured by the Herfindahl-Hirschman Index. The industry is far more concentrated than previously. One outcome has been hospital-prices for inpatient care growing 42 percent 2007-2014 (Health Affairs).

        I agree not attacking the high costs of healthcare and fee for services outcomes now, we are doomed to continue such under another name and not achieve the results we are striving for today.

        I am in a hurry today and apologize for my brevity and lack of better detail to explain my position .

    2. Bob Hertz

      Given the sheer complexity of how hospitals are paid today, I want to restate that moving to global budgets — however desirable — would be a monstrously complex task. The global budgets would have to be set in some way by geographic region….but then how do you compensate Mayo Clinic, whose main hospital is in the modest city of Rochester MN. If the global budgets come in with less money than a hospital got the year before single payer, what then? Layoffs?
      What if a hospital is paying off large dollars in construction bonds? What if one hospital has an aggressive nurses’s union and higher expenses? I just do not know how you do this in an acceptable time frame.

      By the way, on October 3, 1951, Dodgers and Giants for the title, Whitey Lockman doubles and Mueller went to third. That brought up Bobby Thompson who hit his famous home run.

      Why all the secrecy with names on these comments, though? Who besides other wonks like us is watching?

      1. tegnost

        What if a hospital is paying off large dollars in construction bonds? What if one hospital has an aggressive nurses’s union and higher expenses? I just do not know how you do this in an acceptable time frame.
        Well Bob that sounds an like an awful problem for administrators who care mostly about their personal care, not health care. The construction bonds and QE are in my opinion joined at the hip. Were the bonds created to create a more health care centered hospital or a more profit centered hospital? And those mean aggressive nurses need to be paid?Where is my fainting couch? Have they never heard of florence nightingale. Higher expenses? Could you open your eyes and look around, because everything in the us is more expensive, except wages, (that would be inflationary). The medical industry grift is indefensible. Regarding acceptable time frames, incrementalism seems to me like going to a hill primed for landslide and taking one grain of sand away at regular intervals and excoriating the waterlogged remainder to wait until you’re ready for it to slide. Regarding the various handles people use, I don’t want my boss reading my personal thoughts and attributing them to me and then getting blacklisted because I think people, as an example, who have TDS are intellectually impaired. I can see though that, if you’re defending status quo, using your own name is less hazardous (if in fact that’s what you’re doing, it’s the internet after all, a hostile environment). One should protect oneself.
        And a citation re nightingale…
        “Nightingale was friends with UK war secretary Sidney Herbert, and he gave her permission to round up 38 volunteers and treat the wounded at a field hospital in Scutari.”
        Volunteers are cheap. MBA’s not so much…

  12. Tomonthebeach

    I like this argument and the bill. However, I think acceptance would increase if payment for services was NOT contingent on the provider organization under some Medicare cap. It makes a whole lot of sense to put all providers (on a voluntary basis of course) on the federal payroll. Physicians and ancillary healthcare providers for NIH and VA and DOD are just about as happy with our income and working hours as those of us in university settings like med schools.

    Allowing concierge independent practices paid out of pocket or by private insurance undercuts arguments of communism by both patient and provider groups. However such services should be purchased – just like today – over and above the taxes everybody (employers and employees) must pay for M4A.

  13. Jack Parsons

    This is all pointless- the next Dem president will not be able to build anything. But they can destroy Republican power bases: banks, radio stations, the military’s oil use. The trick is to pick a candidate who will cheerfully wreak havoc.

      1. jrs

        destroying Republican power bases? Where do you get that idea? Trump gives them everything they want. He actually does play power politics and locks in Republican advantage. Now banks are probably more a Dem power base than a Republican one, but Trump is not after them either, he has nothing against TBTFs.

        I agree it’s a war and the next President needs to wage it, over the long term and over the short term do as much as they can with executive power, and take on governmental reform if they can and do everything they can to limit R power and then the bluedogs in their own party, but first the R’s. Because it really must be fought to the death and fought to win.

  14. JerryDenim

    Nice post. Very educational. Jayapal’s 1384 certainly seems to be the true single-payer legislation. Sanders’ bill has major shortcomings, and sure he probably needs to be pushed, but is there anyone in the Presidential race currently with a more-detailed and better plan than Sanders that has any credibility? Elizabeth Warren has finally come around to supporting the idea of Medicare for All, but last I heard, her only policy details are “I’m with Bernie”. I’m not hearing “Jayapal” or “1384” so who exactly is offering anything better than Sanders? Yang’s and Williamson type candidates don’t count. Serious politicians with track records only.

    Pretty depressing really seeing almost all the candidates, including Sanders muddy the waters on this topic. I can’t remember the headline exactly, but I seem to recall an Onion piece along the lines of “Kamala Harris announces United Health Single Payer Plan with $5000 deductible and 30% co-pay”

    Too accurate. Too painful.

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