The Politics of Health Care Reform—Part 1
It is time, I think, to face the realpolitik of health care reform. This means asking a question few reformers dare to discuss: How will we win the Congressional votes needed to pass universal care?
The American Prospect’s Ezra Klein put this question on the table at “Take Back America’s” conference three weeks ago: “There are so many people in this town [D.C.] who do such smart policy thinking,” he observed, “but what we don’t give enough thought to is the politics of reform.” Yet this is a political problem. Without the votes,” Klein told his audience, “you don’t have a plan; you have a position.”
Some reformers seem to assume that if we elect a progressive president, he will “put the votes together” to achieve reform. But the fact is that even an optimistic, charismatic JFK wasn’t able to persuade Congress to unite behind healthcare for the elderly in the early 1960s—at a time when seniors were the poorest group in America. It was only after Kennedy was assassinated that a wily LBJ (who had grown up in Congress, knew where the bodies were buried on the Hill, and had won by a landslide) was able to leverage a martyred president’s last wishes to push Medicare legislation through Congress.
This time around, nailing the votes that would secure something like “Medicare for Everyone Who Wants It” will be much, much tougher. I see three major obstacles to reform:
--A Lack of Social Solidarity
--The High Cost of Care
--Lobbyists Who Will Resist Any Efforts to Control Costs
Success will depend on confronting these obstacles head-on. If we do that, I think we can win the votes needed to create a high-quality, affordable health care system for everyone. But we may need to reform Medicare first.
Different Groups Define “Health Care Reform” Differently
Begin with the problem of “social solidarity.” Polls show that the majority of Americans say that they want healthcare reform—but drill a little deeper, and you’ll find the polls show that different groups have very different priorities when they talk about “reform.”
For example, a Kaiser tracking poll released in October showed that 44 percent of Republican voters and 39 percent of Independents rated “reducing the cost of health care and health insurance” No. 1 as the health care issue that they would most like to hear presidential candidates discuss.
Only 21 percent of Republicans and 30 percent of Independents put “covering the uninsured” at the top of their list. By contrast, 44 percent of Democrats listed “covering the uninsured” first.
These responses are part of a trend. In poll after poll Republicans and many Independents define “reform” in terms of lowering the cost of care while Democrats identify “reform” with providing access for everyone
Meanwhile, when pollsters Greenberg, Quinlan, Rosner asked, “Which Values Should Guide Reform?” in November, a solid majority of Democrats chose “healthcare is a fundamental right– every American should be guaranteed coverage that can never be taken away” as one of the two most important ideas that should steer change. Only 21 percent of Republicans and 46 percent of Independents agreed.
A Kaiser poll released just last month shows that this is not just a difference between Republicans and Democrats. When Kaiser surveyed different income groups, it found that a mere 27 percent of those living in households earning over $75,000 rated universal coverage as one of the two most important issues in the coming election. By contrast, 50 percent of those in households where joint income equal less than $49,999 named health care as one of their two top concerns.
This makes sense. Wealthier Americans are not as concerned about health care because the majority have employer-based coverage-- and it many cases, it’s free.
A surprising sixteen percent of all “higher-wage full-time workers” who participate in an employer-based plan are not required to make any contribution to their premiums according to a 2007 report from the Employee Benefit Research Institute (EBRI). Their employer pays 100 percent of the premium. By contrast, only 8 percent of “lower-wage workers” covered by an employer-based plan enjoy a free ride. (EBRI defines “higher-wage” workers as those who earn more than $15 an hour, or over $60,000 a year in a household where two adults are working full-time.)
Of course most employers do ask workers to contribute, but once again, the more you make, the less you are asked to kick in. On average, a higher-paid worker chips in only 27 percent of the premium for a family plan. Lower-paid workers are expected to cover 34 percent of their premiums.
And that’s if the lower-paid worker can afford the 34 percent—plus a deductible and co-pays. Only 67 percent of lower-paid workers who have access to an employer-sponsored plan participate. Many just can’t afford it.
No wonder households earning less than $49,999 are much more likely to name universal coverage as one of their two top concerns.
The Difference Between the U.S. and Other Developed Countries
When asked why the U.S. is the only developed nation that does not provide healthcare for all of its citizens, many experts say that it is because we are a more “diverse” society—a coded reference to our racial and ethnic diversity. The French are willing to provide generous coverage for all because they feel that nothing is too good for another Frenchman. We, unfortunately, do not feel that way about each other.
But the truth is that many countries have a large immigrant population. For example, fifteen percent of Germany’s citizens are not German by birth, and one-third of that group is Turkish. Yet Germany’s spreads out a social safety net for everyone.
What distinguishes the U.S, suggests Princeton health care economist Uwe Reinhardt, is that the gaps between the poor, the lower middle class, the upper-middle class and the truly rich are so much greater in the U.S.
Not long ago, I attended a World Healthcare conference where Reinhardt explained that countries like Germany, Belgium, Canada, France, Denmark the Netherlands, Switzerland, Sweden, and Norway are all “predominantly middle class.” This creates the solidarity which makes it much easier to agree on a universal health care system.
By contrast, as the chart below shows, when it comes to income disparities, the U.S is a clear outlier. Compare the incomes of the top 20 percent to the bottom 20 percent in most developed countries, and you find the ratio is less than 6:1; in many cases it's 5;1. In the U.S. the ratio is roughly 9:1.
In countries where most people are “middle class,” groups living on different rungs of the income ladder still identify with each other. Some earn more; some earn less—but they are not living in different worlds.
By contrast, in the U.S, Reinhardt pointed out, the divisions are much sharper. “We have our fabulously wealthy ‘corporate aristocracy’—people who are not part of the U.S. They don’t participate in American life anymore; they have five homes all over the world.”
Then we have a class of families most would call “rich.” They aren’t billionaires, and they don’t have hundreds of millions of dollars socked away, but they may well live in a home worth several million dollars. They own second homes, drive the most expensive cars and send their children to private schools.
Move down another rung or two and you find an entirely different world of upper-middle class and lower-middle class Americans. This group covers a wide swathe of society ranging from those who are “comfortable,” live in a nice house, own two cars, and go on vacations—to those who worry about making the mortgage or rent, ever sending their children to college, and paying off credit-card debt. The poorest are the “working poor.” The households on these two rungs don’t see much of each other. They live in different neighborhoods; their children attend different schools and they shop in different stores.
Finally, on the lowest rung of a five-rung income ladder, Reinhardt observes, “America has its very poor—these are the people who were in New Orleans when Katrina hit, and who receive no services.”
Following his lecture, I asked Reinhardt whether he thought that, if we made a real commitment to healthcare reform, the U.S. could build a system that provided a high standard of care for most Americans.
Reinhardt didn’t hesitate: “No, never.”
Why not? I asked.
“Because there is no social solidarity in the U.S.”
Reinhardt is predicting that we cannot—and will not—pull together to create and finance a high-quality healthcare system for all Americans because we don’t identify with each other. Instead, we live in our separate pods, defined, to a large degree, by how much we earn, and what we can afford to buy.
So often, we’re told that the U.S. cannot do what other developed nations have done because “the U.S. is different”–not “exceptional,” just different in a way that is not to our credit.
I’m not willing to accept that diagnosis.
Nevertheless, if we are going to face up to the “realpolitik” of health care reform, we must acknowledge that, as Dr. Ezekiel J. Emanuel, Director of Bioethics at the National Institute of Health, recently put it in The Journal of the American Medical Association: “Without controlling healthcare costs, any attempts at universal coverage will be transient. . . . Fortunately . . . those who count in [our] political process—voters, employers, governors, and others—are concerned about [the] costs [of healthcare] in a way that they have not been genuinely concerned about the fate of the uninsured.”
In my next post, I’ll explain what Emmanuel means when he says “Fortunately,” why cost is, in fact, the major barrier to universal coverage, and how “those who count in our political process” can be used to overcome the final obstacle to reform.
Well my belief is that the path to Health Care Reform runs right through people waking up to the actual numbers on Social Security.
For the last couple of decades the Economic Right as used Social Security future 'bankruptcy' as a barrier to all kinds of proposals for increased social justice. The argument has fallen along the line of "We can't even afford Boomer retirement and now you want health coverage for kids!!". (With the subtext being that everything is the fault of us Boomers for being born.) Once people understand that 'crisis' in 2041 still equates to a check in real terms 25% better than similarly situated retirees get today (78% of 160%=125%, an improvement from the 2007 version of 75% of 160%=120%) and that the 2041 date is more likely than not to be postponed indefinitely (depletion retreated at a rate of more than a year per year from 1997 to 2004 and after a stall in 2005-2006 resumed its march in 2007.)
Depending on the severity of the current downturn, the numbers suggest that sometime in the 2010-2012 timeframe we will achieve undeniable indications that Social Security is fully funded over the foreseeable future and most importantly that the people who have been selling 'crisis' mostly knew this all along yet simply continued their campaign against it on purely ideological grounds. In short on this topic as on such matters as Iraq they are not just simply wrong, they are openly lying.
The narrative of Social Security bankruptcy has been so ingrained in peoples' heads, particularly those under the age of 40, that its shattering will come as a conceptual thunderbolt and perhaps wash away the mental barriers that hold back the premise of social solutions to social problems (i.e. Big Government) on the basis on the inherent superiority of market solutions. Once we redeem the legacy of the New Deal we can turn our attention towards reclaiming the premises of the Great Society. We CAN afford retirement security and health care for kids, and only propagandistic scare tactics have spooked most people into thinking those are in some inherent funding conflict.
We can call it the New New Deal.
April 8, 2008 1:25 PM | Reply | Permalink
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December 21, 2010 10:32 AM | Reply | Permalink
This is a smart blog. I mean it. You have so much knowledge about this issue, and so much passion. You also know how to make people rally behind it, obviously from the responses. Youve got a design here thats not too flashy, but makes a statement as big as what youre saying. Great job,children health indeed.
January 19, 2011 8:06 AM | Reply | Permalink
Nicely argued if unsurprising. "Universal health care" has been DOA since 1948. We can pray for a phoenix, but it ain't gonna happen!
The health care insurers and drug companies have done an excellent job in carving up the total health care beneficiaries into a number of classes whose self-interests are not held in common. Just look at the post-2000 classes most recently created -- Medicare Drug beneficiaries and Medicare Advantage Plan members, both subsidized by the government to make the companies and the beneficiaries allies.
What I'd like to see is a set of policy proposals which would undermine profit in the health care and drug industries. Reduce their profits and you reduce their power.
We should be like crabs, always sneak in to attack from the side least guarded.
April 8, 2008 2:00 PM | Reply | Permalink
Makes me think that Maggie Thatcher might have been wrong about Britain when she said there is no society as such, only families, but right if she had been referring to the US.
April 8, 2008 2:53 PM | Reply | Permalink
Families in the US too often consist of divorced parents, kids visiting one or the other on weekends, grandparents raising the kids, mom/dad living with boyfriend/girlfriend, or kids in foster care/group homes. Perhaps Maggie Thatcher wasn't referring to the US.
April 8, 2008 5:01 PM | Reply | Permalink
I do think that any hope of achieving universal healthcare has to begin with a leader at the top of the pile who believes in it. This is why Obama is the wrong choice for anyone committed to universal healthcare. Claims of campaign literature notwithstanding, he doesn't believe in it. He has publicly denounced "mandates," and a later caveat that "he might reconsider" is just campaign rhetoric, to put out whistlestop controversies.
You have to have the commitment up front, at the top. You have to have leadership on the issue. I don't believe we have anyone in the House or Senate with the political power to take the reins away from a sitting President and drive that carriage into the barn.
Allowing the accuracy of Mahar's analysis, with President Obama, we won't get the leadership and so we won't get out of the gate. We will get the leadership from President Clinton, but unless we get some fresh faces in the Congress along with the new President, we're still going to fall short in the next 4-8 years.
So, in any event, I'm pessimistic at this point that anything really wonderful will happen on this issue. My best-case assessment would be that we'll arrive at some "compromise" in which a few more million citizens will be insured. But, I don't see costs coming down, or quality of care improving significantly.
Heh-heh, by the time "universal" healthcare becomes a reality for most of America, I'll be in that class of citizens for whom its fundamental basis is a reality. I'll be on Medicare.
Thanks.
mp
April 8, 2008 3:34 PM | Reply | Permalink
I live in Massachusetts and I note one point to consider from the recent adoption of universal health care here.
Although much of the attention went to the fact that our photogenic ex-gov decided that universal health care was his ticket to the White House, the real tipping point was that Associated Industries of Massachusetts - the main business lobbying group - came out in favor of the idea and worked closely with the political, health care, labor, etc. folks to get it done. This is a 180 from the business community resistance that doomed Hillary-care in the 90's and its the result of the fact that 10+ years of reliance on 'free market solutions' like HMOs have failed by every measure except profits for the middlemen.
The political dynamic will be very different if a progressive administration can attract the support of the US business community. And there are lots of reasons to believe that it can.
April 8, 2008 3:47 PM | Reply | Permalink
I think you are on the right track about Health Care Reform needed because of High Health care costs.
The message that I see working now is that Jobs have left the US because of the high cost of employer-sponsored health insurance. Small-Business owners who are probably a big chunk of those Independents voting - are now starting to understand this part of the problem.
The Medicare for all message just screams to people about more government intervention. I wish it didn't but that is what I hear. We need to talk-up the VA health system where negotiating drug prices is really working to keep costs down.
In general, serious reform is difficult when you have millionaires in Congress with too-close ties to Wall Street and Corporations. We need an overhaul of Congress with Public Financing of Campaigns. Then we will get Real Health Care changes.
April 8, 2008 4:00 PM | Reply | Permalink
I think what Maggie has really done here is to identify the larger problem those of us on the left would like to see acknowledged by the "progressives". Our "war" is difficult on all fronts because we battle on each issue this same lack of social solidarity. Little nuanced policy twists will never get around that. We need the courage to fight the war and not just surrender one battle after another. If not, I fear that when we have lost the war for good, we will have lost all claim to representative democracy and will become just another oligarchy with the masses serving a few plutocrats.
After all, an excellent way of keeping costs down, if controlling costs is your primary goal, is to simply refuse service. Hillary's recent anecdote, true or not, follows that model. Don't serve that pregnant woman if she doesn't have $100 and when both she and her child die, you've got your costs down to $0.00.
April 8, 2008 6:32 PM | Reply | Permalink
Re: The households on these two rungs don’t see much of each other.
Not sure I agree with this. I'm on the Upper Middle Class rung, yet I see the working poor all the time. I think it's impossible not to see these people unless you're so self-absorbed you'll trip over your own shadow. These are the ringing up your groceries, cutting your neighbor's lawn, working on the road crews, handing your fast food order out the drive through window. You see them in stalled out junkers on the freeway occasionally, or waiting at bus-stops. And of course they're dragging their kids through your local Walmart. Sure, you don't socialize much with them* but you do know they're there.
* Because I'm gay I actually do socialize with people well out of my social class, at least those who share my orientation, which trumps class to some extent in my demographic. There's a subset of working poor who might be called voluntarily working poor-- or Bohemian working poor-- mostly young people who are nightlife critters, lean on older, higher income friends for help when they need it, and seem to think life ought to be one giant party.
Re: "Universal health care" has been DOA since 1948. We can pray for a phoenix, but it ain't gonna happen!
Disagree here too. We won't get single payor (if that's what you mean) but we will get something that calls itself "universal healthcare" and tries to be that. This isn't 1994, let alone 1948. The corporate interests have figured out that they will do better if they can offload at least some of their workers' healthcare costs on the government. See: Walmart tutoring its emplpyees on how to apply for Medicaid.
April 8, 2008 10:05 PM | Reply | Permalink
I think the approach that's been taken is one that best serves the opposition to universal healthcare and not the goal of healthcare.
You can begin by neutralizing and softening up opposition.
For starters, if I own stock in a health insurance company, government run health care is tantamount to a takings of my assets. To soften up the opposition, you have to promise to buy them out and a fair and reasonable price, all the while reminding them that they are part of the problem (carrot and stick).
The people behind the resistance to Healthcare reform are the people who make lots of money today because they have a vested interest in today's system. You have to buy their interest and in doing so, resistance will disappear.
(This is more affordable than it would first appear.)
Then there's the arguments. Lets address those. First there's the argument that government run healthcare is socialized health care. Turn the argument on its ear.
First start by saying that all forms of insurance are a form of socialism: I pay my car insurance company money, you have an accident, my money goes to pay for fixing your car. That is how insurance works: that in essence is socialism. So you are already used to it.
Second, instead of advocating for government run health care, when what we really want is universal single payer (at least initially - to save cost) argue for single payer universal health insurance that is provided by a private provider.
The next question is: what? How could this be? Here is where we get into specifics, and the answer is really quite easy.
One of the problems with change is people fear that it will be worse than before and irreversible. So give them something they know and understand.
Argue for a model based upon the Telecom system circa 1979: A highly regulated, private, single payer, universal system run by a private oligopoly. It worked well for the telecom industry, it will work well for health care, at least as a stepping stone to something even better.
(note we are still under the same regime, we've merely changed some of the rules, adopting surgically placed islands of competition where we feel they will not undermine the integrity of the system.)
Argue that the way to get to this model with health care, is the same way we got there with telecom: by forcing company mergers.
That way, people with real interests are bought out. That way we aren't moving to a system we are unfamiliar with or that has not been tried or tested. That's how you beat their arguments and over come their resistance. (all the while reminding them that the alternative is Medicare for all and profits for none).
The cost of the merger will be covered by the efficiencies gained. Let me remind you that Canada's health care bureaucracy is smaller than Blue Cross of New England.
The regulatory body can consist of all stakeholders including doctors, nurses, hospitals, consumer groups, labor, etc.... to get a balanced well thought out regulation.
Then, we can decide whether we want that private entity to be 'for profit' or 'not for profit' or 'non profit' corporation.
If it is non-profit, or not-for-profit, that might mean one more, bigger buy out. At this point, we'll be able to better guess what is the best next step.
At that point we will have private healthcare, which the Republican's say they want, and we have universal single payer, which democrats want.
The Telecom/utility model was a very good model to use.
It should be argued, that while Health care is not a commodity or a utility, health insurance is and should be treated as such and organized as such. So that model is valid for this case.
If your goal is government run health care, then you can view this model is a stepping stone to that. As we step away from the current model, it will be easier to migrate to alternative models and easier to understand what model would be best.
The problem is stepping away from the current model that has so many vested interests. This is how you do that.
Once we have this model, we will have achieved all the goals of universal single payer health care. But still we may want to move it into a more government run model and there are lots of models to choose from: The Postal Service, Social Security, Medicare, Medicaid, the Veterans Administration ... just to name a few.
The key is finding a way to soften both the stance and the arguements to healthcare reform. Buying out peoples interest is key.
Other arguments to keep in the fore is the cost to business - how much business is lost to other countries because they have better and cheeper health care? How big of a drag on our economy is that. How can we compete with other societies if our cost or so much higher?
Also, the cost to personal freedom - how many people stay in jobs they don't belong in because of healthcare? Then there's the arguement about entrepreneurship. How many good ideas never got off the ground because people didn't want to risk losing health care? How much has our economy been held back by lack of entrepreneurship?
And again, remind everyone that all insurance is a form of socialism. The real question is whether it will be private or public. And as long as it's public, remind them that the bigger the pool of participants, the lower the total cost and the better the overall product.
My thinking is once greedy Republicans with a vested interest realize they can profit from consolidation if they go along with this plan (versus the risk of losing everything if they don't) they'll fold on the table and collect their chips.
At that point we'll have what we want.
None of the proposed models show how to get from here to there.
This makes me think that most people aren't serious about the problem.
I've outlined here a clear path on how to get from here to there. I don't think it is that hard. This gives everybody what they want.
April 8, 2008 11:23 PM | Reply | Permalink
Thanks to all of you for your comments. Below, some individual replies.
Bruce—You are entirely right—Social Security is not going broke.
But Social Security and Medicare have completely different sources of funding.
And Medicare, I am afraid, is going broke. So we need to figure out how to
reduce Medicare spending.
The good news is that we can make Medicare better by weeding out hazardous
over-treatment and putting the money into much-needed preventive care, primary
care and chronic disease management.
Ellen—I think we can move” crab-like” on the for-profit health industry. See the
next two parts of this post.
Tom Wright wrote: “Makes me think that Maggie Thatcher might have been wrong about Britain when she said there is no society as such, only families, but right if she had been referring to the US”—I agree
MichaelPowe—
I’m just not sure how committed Obama is to health care. His plan is much sketchier than Clinton’s or Edwards’, so it’s hard to tell.
If he is elected (which, at this point seems likely ), my hope is that Clinton would become Senate Majority Leader. In that position, she could get a lot done in term of putting together a rational plan, fighting the lobbyists etc. And Obama could be the speaker who would inspire people to go along. He might be able to push the theme of
solidarity.
At this moment, that’s my best hope.
Rodhoff—You wrote: “The political dynamic will be very different if a progressive administration can attract the support of the US business community. And there are lots of reasons to believe that it can”
I agree—though I should add that some in the business community are just looking for lower costs without being concerned about the quality of care or universal coverage. But there are enlightened people who understand that we can have higher quality and lower costs (the two actually go hand in hand) if weed out the waste, and refuse to pay for over-priced products. .
Aly—You wrote: “The Medicare for all message just screams to people about more government intervention. I wish it didn't but that is what I hear. We need to talk-up the VA health system where negotiating drug prices is really working to keep costs down”.
“In general, serious reform is difficult when you have millionaires in Congress with too-close ties to Wall Street and Corporations. We need an overhaul of Congress with Public Financing of Campaigns. Then we will get Real Health Care changes.”
I think you’ve hit the nail on the head on both points. I really wish we could get campaign finance reform. Bit no one is talking about it these days (in large part because everyone is trying to raise money for a campagin.) It would make health care reform much, much easier.
The VA, and the way it negotiates discounts on drugs (paying 50% less than Medicare for many of the most popular Medicare drugs) is a model. Also, everyone needs to spread the word: “Walter Reed hospital in Washington is not part of the VA, and is not run the VA. The Army runs Walter Reed.
The VA has problems because it has been severely underfunded during the Bush administration, but it still delivers much better care than many hospitals.
JonF 311—You write “The corporate interests have figured out that they will do better if they can offload at least some of their workers' healthcare costs on the government.” I agree with you. I think you see where
I’m heading in this three-part post.
Also, I suspect that by virtue of being part of what is seen as a “minority” is this country, you are more aware of
‘the different classes of people living around you, performing services, etc.—and more capable of imagining what their lives are like. I am afraid that, for many middle-class and upper-middle class Americans, the “working poor” really are invisible.
As a well-educated reader on my blog wrote recently: “I can’t believe that people on that rung make so little money!” My reply is always the same: “I can’t believe that George W. Bush is our
president, but there you are. . . .It’s a fact.
Bluebell—
I agree with you—I think social solidarity is key. And I’m not willing to give up on the idea. Especially as we move into a steep recession, I think more and more
people who are on the 3rd or maybe even the 4th rung of a five-rung income ladder will
realize how easy it would be to slip down a rung—and just what a steep drop that would be (now that the gaps between rungs are so wide.)
So I think more and more people may begin to realize that “There but for fortune . . .”
Tim—First of all, none of the reform-minded presidential candidates
has talked about eliminating the private insurance industry, so there is
no need for a buy-out.
What people are talking about is creating a public-sector insurance product that
is something like “Medicare for anyone who wants it” and letting it compete with
private insurers.
For the competition to be fair, private insurers would have to compete with the
public insurer on a level playing field. This would mean that private insurers could
no longer “cherry –pick” healthy patients and refuse to sell insurance to any one who is sick (as they can in many states) or make the price prohibitively expensive for anyone
with pre-existing conditions (as they can in many states.)
Instead, insurers would have to sell insurance to anyone who wants to buy it at the
same price for everyone in a given community. This is what they do in New York State. Meanwhile Medicare for all would sell its product to anyone who wants it at the same price for anyone in a given community.
The other regulation is that insurers would no longer be able to sell policies that don’t really protect people—“Swiss Cheese” policies that are filled with holes, or high-deductible policies with such a high deductible that people can’t afford to use it. (Research shows that when people have a high-deductible policy, they are just as likely to put off needed care as they are to postpone unnecessary care. Then, they become sicker, and all of us end up paying the price (either when they go on Medicare, or earlier, when they wind up in a hospital which then has to shift the cost of covering them to other, well-insured patients.)
Why not just go to single payer and forget about private insurance? Because 80% of Americans like the insurance that they have and Do Not want to give it up. In most cases it is employer-based insurance and their employer is paying more than 50% of the cost.
They do not want to switch to something like the AT&T of health insurance. They don’t know what it would be like—they fear it wouldn’t be as good.
Virtually No One in Congress is going to vote to tell people you Must now give up the
insurance you have and switch to single payer—whether the single payer is in the private sector or the public sector. This is a political reality. It just is not going to happen. Every poll shows that when you ask them about healthcare what Americans most want is Choice Choice. Choice. They are terrified of not having a choice.
But what many Congressmen will vote for is something that tells Americans “you have a choice—you can keep your employer-based insurance, or you can pick public –sector insurance”.
Because” Medicare for all has many fewer expenses” (no need to market, to pay lobbyists, to provide profits for investors, to pay for underwriting (to figure out how to avoid selling to sick people ) and no need for multi-million dollar exec salaries and bonuses, it’s clear that “Medicare For Anyone Who Wants It” should be able to offer more coverage for less money.
Some people say government can never do anything as efficiently as the private sector.
So let them compete and we’ll find out. It’s likely that many private insurers will find that it’s too hard to compete, and will drop out. Meanwhile, if Medicare For Anyone Who Wants it” is good, people will vote with their feet and switch from private-sector insurance. (IF they do that, their employer will then contribute what he now contributes to their private insurance to a fund that helps pay for Medicare For Anyone . . .)
(If you own shares in a private insurer and feel they would be beaten if they think about selling your shares. It’s not up to the government to bail you out if you purchased stock in a company that just can’t make it. Some private insurers would make it—Kaiser Permanente, for example, would probably do well.
Let me put it this way: Warren Buffet loves insurance. Most of Berkshire Hathaway is
made up of insurance holdings. Does he own health insurance? No. Why not?
April 9, 2008 3:46 PM | Reply | Permalink
Thanks to all of you for your comments. Below, some individual replies.
Bruce—You are entirely right—Social Security is not going broke.
But Social Security and Medicare have completely different sources of funding.
And Medicare, I am afraid, is going broke. So we need to figure out how to
reduce Medicare spending.
The good news is that we can make Medicare better by weeding out hazardous
over-treatment and putting the money into much-needed preventive care, primary
care and chronic disease management.
Ellen—I think we can move” crab-like” on the for-profit health industry. See the
next two parts of this post.
Tom Wright wrote: “Makes me think that Maggie Thatcher might have been wrong about Britain when she said there is no society as such, only families, but right if she had been referring to the US”—I agree
MichaelPowe—
I’m just not sure how committed Obama is to health care. His plan is much sketchier than Clinton’s or Edwards’, so it’s hard to tell.
If he is elected (which, at this point seems likely ), my hope is that Clinton would become Senate Majority Leader. In that position, she could get a lot done in term of putting together a rational plan, fighting the lobbyists etc. And Obama could be the speaker who would inspire people to go along. He might be able to push the theme of
solidarity.
At this moment, that’s my best hope.
Rodhoff—You wrote: “The political dynamic will be very different if a progressive administration can attract the support of the US business community. And there are lots of reasons to believe that it can”
I agree—though I should add that some in the business community are just looking for lower costs without being concerned about the quality of care or universal coverage. But there are enlightened people who understand that we can have higher quality and lower costs (the two actually go hand in hand) if weed out the waste, and refuse to pay for over-priced products. .
Aly—You wrote: “The Medicare for all message just screams to people about more government intervention. I wish it didn't but that is what I hear. We need to talk-up the VA health system where negotiating drug prices is really working to keep costs down”.
“In general, serious reform is difficult when you have millionaires in Congress with too-close ties to Wall Street and Corporations. We need an overhaul of Congress with Public Financing of Campaigns. Then we will get Real Health Care changes.”
I think you’ve hit the nail on the head on both points. I really wish we could get campaign finance reform. Bit no one is talking about it these days (in large part because everyone is trying to raise money for a campagin.) It would make health care reform much, much easier.
The VA, and the way it negotiates discounts on drugs (paying 50% less than Medicare for many of the most popular Medicare drugs) is a model. Also, everyone needs to spread the word: “Walter Reed hospital in Washington is not part of the VA, and is not run the VA. The Army runs Walter Reed.
The VA has problems because it has been severely underfunded during the Bush administration, but it still delivers much better care than many hospitals.
JonF 311—You write “The corporate interests have figured out that they will do better if they can offload at least some of their workers' healthcare costs on the government.” I agree with you. I think you see where
I’m heading in this three-part post.
Also, I suspect that by virtue of being part of what is seen as a “minority” is this country, you are more aware of
‘the different classes of people living around you, performing services, etc.—and more capable of imagining what their lives are like. I am afraid that, for many middle-class and upper-middle class Americans, the “working poor” really are invisible.
As a well-educated reader on my blog wrote recently: “I can’t believe that people on that rung make so little money!” My reply is always the same: “I can’t believe that George W. Bush is our
president, but there you are. . . .It’s a fact.
Bluebell—
I agree with you—I think social solidarity is key. And I’m not willing to give up on the idea. Especially as we move into a steep recession, I think more and more
people who are on the 3rd or maybe even the 4th rung of a five-rung income ladder will
realize how easy it would be to slip down a rung—and just what a steep drop that would be (now that the gaps between rungs are so wide.)
So I think more and more people may begin to realize that “There but for fortune . . .”
Tim—First of all, none of the reform-minded presidential candidates
has talked about eliminating the private insurance industry, so there is
no need for a buy-out.
What people are talking about is creating a public-sector insurance product that
is something like “Medicare for anyone who wants it” and letting it compete with
private insurers.
For the competition to be fair, private insurers would have to compete with the
public insurer on a level playing field. This would mean that private insurers could
no longer “cherry –pick” healthy patients and refuse to sell insurance to any one who is sick (as they can in many states) or make the price prohibitively expensive for anyone
with pre-existing conditions (as they can in many states.)
Instead, insurers would have to sell insurance to anyone who wants to buy it at the
same price for everyone in a given community. This is what they do in New York State. Meanwhile Medicare for all would sell its product to anyone who wants it at the same price for anyone in a given community.
The other regulation is that insurers would no longer be able to sell policies that don’t really protect people—“Swiss Cheese” policies that are filled with holes, or high-deductible policies with such a high deductible that people can’t afford to use it. (Research shows that when people have a high-deductible policy, they are just as likely to put off needed care as they are to postpone unnecessary care. Then, they become sicker, and all of us end up paying the price (either when they go on Medicare, or earlier, when they wind up in a hospital which then has to shift the cost of covering them to other, well-insured patients.)
Why not just go to single payer and forget about private insurance? Because 80% of Americans like the insurance that they have and Do Not want to give it up. In most cases it is employer-based insurance and their employer is paying more than 50% of the cost.
They do not want to switch to something like the AT&T of health insurance. They don’t know what it would be like—they fear it wouldn’t be as good.
Virtually No One in Congress is going to vote to tell people you Must now give up the
insurance you have and switch to single payer—whether the single payer is in the private sector or the public sector. This is a political reality. It just is not going to happen. Every poll shows that when you ask them about healthcare what Americans most want is Choice Choice. Choice. They are terrified of not having a choice.
But what many Congressmen will vote for is something that tells Americans “you have a choice—you can keep your employer-based insurance, or you can pick public –sector insurance”.
Because” Medicare for all has many fewer expenses” (no need to market, to pay lobbyists, to provide profits for investors, to pay for underwriting (to figure out how to avoid selling to sick people ) and no need for multi-million dollar exec salaries and bonuses, it’s clear that “Medicare For Anyone Who Wants It” should be able to offer more coverage for less money.
Some people say government can never do anything as efficiently as the private sector.
So let them compete and we’ll find out. It’s likely that many private insurers will find that it’s too hard to compete, and will drop out. Meanwhile, if Medicare For Anyone Who Wants it” is good, people will vote with their feet and switch from private-sector insurance. (IF they do that, their employer will then contribute what he now contributes to their private insurance to a fund that helps pay for Medicare For Anyone . . .)
(If you own shares in a private insurer and feel they would be beaten if they think about selling your shares. It’s not up to the government to bail you out if you purchased stock in a company that just can’t make it. Some private insurers would make it—Kaiser Permanente, for example, would probably do well.
Let me put it this way: Warren Buffet loves insurance. Most of Berkshire Hathaway is
made up of insurance holdings. Does he own health insurance? No. Why not?
April 9, 2008 3:46 PM | Reply | Permalink
The good news is that we can make Medicare better by weeding out hazardous over-treatment and putting the money into much-needed preventive care, primary care and chronic disease management.
For what they're worth, two interesting counterclaims:
Chronic Disease Management: Medicare Health Support pilot programs are being terminated inasmuch as "the preliminary data indicate that the government is unlikely to save money."
Preventive Care: Ezra Klein argues that preventive care may be socially defensible but is unlikely to save the system money.
April 10, 2008 11:51 AM | Reply | Permalink
Ellen—
Thanks for the comment.
You are right: the chronic disease management program isn’t working, and I’ll address why it isn’t working in a later post.
But the fact that one pilot program isn’t working oesn’t mean that chronic disease management won’t save money—or spare needless suffering. If we learn how to manage diabetes, patients won’t wind up hospitalized where first their toes, then a foot, then part of a leg is amputated. And they won’t wind up blind.
Chronic disease management is an infant science—other developed nations also are struggling with it. Though some are doing a better job than we are: we could learn from them.
I didn’t say that more preventive care would save Medicare money. I said it would make the quality of care better.
What Ezra has pointed out is simply that if people receive good preventive care, they live longer. And that means they
receive Medicare benefits for more years.
We do know that when you weed out hazardous over-treatment(unnecessary tests, procedures, medications, hospitalizations)you save money and improve quality. I’ll be talking more about
that in the next posts.
April 10, 2008 1:46 PM | Reply | Permalink
I would be interested in hearing a little more about how New York (and any other state) got community rating, and how it is working. Did it effect prices, and if so, how? Did it expand coverage, and how much? Was the battle difficult to pass it? And when did it take place (since one of the current problems is that health care is so much bigger as a percent of GDP than it was when other countries achieved universal care, and everything is thereby more difficult, more vested interests, etc.)
April 11, 2008 3:06 PM | Reply | Permalink
Lets first start of with the good news. We have many problems but one of which is not is they're transport company called Auto transporters which provided them the best car service money can buy. But lets begin with the problem of “social solidarity.” Results show that the most Americans say that they want health care reform—but drill a little deeper, and you’ll find the results show that different groups have very different priorities when they talk about “reform.”
June 28, 2010 2:26 PM | Reply | Permalink
Success will depend on confronting these obstacles head-on. If we do that, I think we can win the votes needed to create a high-quality, affordable health care car transport system for everyone. But we may need to reform Medicare first.
July 7, 2010 11:58 PM | Reply | Permalink
erved, “but what we don’t give enough thought to is the politics of reform.” Yet this is a political problem. Without the votes,” Klein told his audience, “you do bag suppliers
September 1, 2010 9:24 AM | Reply | Permalink
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April 11, 2011 5:48 AM | Reply | Permalink
I think the polls initiated for the peoples' feedback aren't the most conclusive evidences. I once talked about this with a friend of mine who has a steroids for sale business. We concluded that, at one moment people can have their likings and sureness, but suddenly, they're in sympathy with somebody's ideas and all the judgments are drastically changed. That's why a reform is possible even if the preliminary reports show otherwise.
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May 4, 2011 8:58 AM | Reply | Permalink