One thing that I've noticed here on Daily Kos is that everyone has an opinion on health care - and typically these opinions are uninformed. This isn't a bad thing. Health insurance and health care are complicated things. We have a lot of options to choose from when we engage in this health care debate - and as we discuss what the proposals are for legislation. I thought it would be helpful to compile a glossary and to explain what I think would be the best plan.
First things first, Single Payer, National Health Care, Universal Health Care, Medicare for All, and Public Option are not the same thing. Some of these may share qualities, and some may fall under the definition of others, but at the moment, many Kossacks are using these interchangeably or interpreting them this way. When we call our Representatives or debate one another about our health insurance options and proposed legislation, we need to be very specific and clear with what we're advocating. If we say we want "Medicare for all" but we mean that we want a public option, we're not really going to get what we want. So here's my attempt to define these and make the differences clear for people - please add suggestions to help clarify in the comments.
I'll be pulling as many definitions as I'm able from the Library of Medicine - which is part of National Institutes of Health (NIH) and the Dept. of Health and Human Services (HHS).
Single Payer:
An approach to health care financing with only one source of money for paying health care providers. The scope may be national (the Canadian System), state-wide, or community-based. The payer may be a governmental unit or other entity such as an insurance company. The proposed advantages include administrative simplicity for patients and providers, and resulting significant savings in overhead costs. Link.
Basically, most of the options above (Medicare for all, public option, universal health care) would fall under this definition - they would be considered single payer options. Single payer is just an approach to financing a health care system. Single payer does not refer to who makes coverage decisions - it's soley about who pays.
This means - if you come into a diary that advocates for a "public option" like the one Schumer suggested, - and you post a comment like this:
No public option! Single payer NOW!!!
You would be wrong. A public option like what Schumer is proposing is in fact a type of single payer plan. In most cases the "single payer" fund is the Government, but that is not a requirement.
Universal Health Care:
Typically, when people refer to this - what they mean to say is Universal Health Care Coverage - it's not uncommon to drop off the "coverage" part because it's implied.
Health insurance coverage for all persons in a state or country, rather than for some subset of the population. It may extend to the unemployed as well as to the employed; to aliens as well as to citizens; for pre-existing conditions as well as for current illnesses; for mental as well as for physical conditions. Link.
While single payer refers to a payment system, Universal Health Care is about who is covered. A single payer system could provide universal health care, but it could also place restrictions on coverage. Therefore, a single payer system does not necessarily mean that there will be universal health care coverage. This is a very important distinction.
What we're primarily talking about here is access. A public option could or could not have universal health care. A good example to refer to here would be Medicare - Medicare does NOT provide universal health care coverage. Medicare provides coverage to a very specific population - there is nothing universal about it.
One other important note here - universal health care coverage can be provided in two ways - on an individual basis alone, or on a family basis. In other words, we could have a universal health care plan that provides coverage to anyone willing to pay, but the plan could operate solely for individuals...meaning that every person would have to pay premiums, deductibles, and copayments. In this situation, we would have a plan that provides universal health care coverage, but that plan may not be an affordable option for families due to individual costs.
Medicare For All:
A few things about Medicare that are really important.
- Medicare is an individual plan. There is no family coverage with Medicare. In other words - costs are on an individual basis. Each individual has premiums, deductibles, and copayments.
- It provides basic hospital and medical coverage to high risk groups - the elderly and the disabled.
- There is no vision or dental coverage.
- Preventive coverage is very limited.
- Prescription drug coverage is available provided you are willing to pay extra premiums, deductibles, and copayments.
- Part A coverage is paid for by taxes only for those who have worked more than 10 years (40 quarters) in their lifetimes. If you have not worked the required number of quarters, you pay Part A premiums of several hundred dollars per month - right now the cost is over $400/mo.
Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance ( MEDICARE PART A) and supplementary medical insurance ( MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976). Link.
I've written about Medicare costs a few times in comments, but I had a diary specifically about Medicare costs, An Explanation of Medicare - it's not as cheap as you think it is.
Here is the rundown of costs per person for Medicare:
Part A premiums - over $400/month unless you qualify to get it for free because you've worked over 40 quarters in your lifetime.
Part B premiums - $96.40/month (unless you qualify for the highest level of Medicaid and then Medicaid pays for you).
Part D premiums and copays - average premium is $28/month. Copays vary, but the donut hole is HUGE and most don't qualify for extra help. You have to make less than $16,000/yr individually or $22,000/yr if married to qualify for extra help.
Yearly deductible for Part B - $135.00
Yearly deductible for Part D - varies, but the standard is $295.00
Deductible for Part A - $1069 per benefit period. Benefit period is defined as starting the day you enter the hospital and ending 60 days after you have been discharged from the hospital. So, you could have up to 5 benefit periods each year.
Copayments -
Part B is 80%-20% of the Medicare approved amount. Every visit to the doctor costs SOME money. It may not be a ton of money, but it adds up.
Durable Medical Equipment is 80%-20% - anyone need a motorized wheelchair? Have a few hundred bucks to pay for it? And there's a lot of equipment that isn't covered by Medicare at all, or has limits on it (diabetic testing strips, for instance) - those are out of pocket costs you have to add in.
Most beneficiaries buy Medigap policies which pick up these extra costs, but then they are paying 3 premiums per month -
Part B - $96.40
Part D - avg. $28
Medigap - can vary in cost from $80-$500 per month - depending on when you sign up for the policy and how much extra coverage you are buying.
People here suggest that Medicare could be modified to fix some of these problems. Sure - it could. But the biggest problem is one that isn't fixable by changes to the structure of Medicare.
Medicare beneficiaries are a high-risk pool. The costs for the program are high because the health care costs are high overall. When we talk about offering an insurance option for the "public" the biggest concern for most people is cost. Can families afford the coverage? Can individuals afford the coverage? The fewer high risk/high cost people in the pool, the cheaper the coverage will be.
There are three high-risk/high cost groups -
- Women of child-bearing age.
- People who are disabled.
- The elderly.
Two of these groups already have a health care program in Medicare - there are modifications needed to help lower costs for them and to make the program more effective, but those are much easier things to fix if we leave it as an independent system. The third risk group would be the only group that would be part of an insurance option for the "public" - but if we're spreading that risk over several million people and providing good preventive coverage (including access to family planning), then the overall costs can be kept in a much more affordable range.
One reason to avoid a Medicare for All system altogether would be insolvency. The Part A hospital fund is projected to lose solvency in 2017. The Part B fund is fine for the long-term. It's the Part A hospital fund - the one that most people pay no premium for due to taxes - that's going broke. There are a few reasons for this - rising health care costs is one, but the influx of Boomers is another. We can definitely make this fund solvent - that isn't a huge "problem", but it's yet another fight with Congress.
Public Option:
Right now, we have a few "public" options - Medicare, Medicaid, SCHIP, etc. At this point, it's probably safe to assume that the public option would essentially be a single payer program. The program could be funded in a few different ways -
- Premiums could be paid by beneficiaries either directly or through direct deposit, etc.
- Premiums could be paid by employers.
- Premiums could be paid by a combination - both employers and beneficiaries.
- Premiums could be deducted as a tax either from the beneficiary or the employer or both.
Administrative costs will be kept low - similar to how Medicare's Administrative costs are currently kept low, around 2%.
The plan is able to negotiate rates with providers and suppliers to keep costs low. There may be deductibles and copayments in addition to premiums. Health care costs for beneficiaries will be paid out of this fund.
"The Public Option" is really a pretty vague concept, but for the most part - the public option suggestions we have seen so far are basically all single payer plans...it's just that the fund isn't necessarily going to be made up of taxes and managed by Congress.
The Debate:
Last week, the NYT had an article, Schumer Offers Middle Ground on Health Care, in which Senator Schumer introduced what he called a "compromise" for a public option.
Point by point response to Schumer's "compromise":
The public plan must be self-sustaining. It should pay claims with money raised from premiums and co-payments. It should not receive tax revenue or appropriations from the government.
Good. It should be self-sustaining. If it is self-sustaining then providers and patients make the medical decisions, not Congress. At the moment, Congress decides what services are covered by Medicare. The states partner with the Federal government to decide what is covered by Medicaid. I don't want Congress to determine what is covered and what isn't covered by a new public plan. I want those decisions to be made by qualified physicians.
I'll provide an example: Medicare covers abortion only if the pregnancy is the result of incest or rape, or if the woman's life is at risk.
Why? Because Congress decides what Medicare covers. I don't want Congress threatenting to pull funding from a public plan. I certainly don't want Congress to determine whether or not this public plan can use cures for diseases that may have been discovered using stem cell research, nor do I want to have the fight about whether or not birth control or abortion should be covered. And if you think Republicans won't try this - let me refer you to Devilstower's post yesterday, Missouri GOP uses cancer center for leverage.
Government control of a public plan is a disaster. Today someone actually told me that they thought this would be okay because the public plan would be throught of as a "third rail". It "might" be...but I'm not willing to take that chance.
The public plan should pay doctors and hospitals more than what Medicare pays. Medicare rates, set by law and regulation, are often lower than what private insurers pay.
There's no reason this is a bad thing. Medicare pays out based on several things - location and cost both factor into how much a service will be paid for by Medicare. In other words, a mammogram in Chicago may cost less than a mammogram in Seattle. A public plan should have its own negotiating power. At the moment, insurance companies negotiate prices with doctors/hospitals. The public option we create should have the ability to do that as well - and when you're talking about potentially tens of millions of Americans joining this public option, the negotiating ability is strengthened, so it will likely pay out less than any private plan would, but may not pay out less than what Medicare pays - of course, again, this depends on location and other factors.
The government should not compel doctors and hospitals to participate in a public plan just because they participate in Medicare.
The government shouldn't be forcing anyone to participate in this plan. The participation - just like Medicare - should be voluntary. That doesn't mean doctors and hospitals won't participate - they will likely jump to participate because they will have access to SO many more insured customers it would only make sense for them to participate.
To prevent the government from serving as both "player and umpire," the officials who manage a public plan should be different from those who regulate the insurance market.
This is simple - the fox shouldn't guard the hen house. The regulators shouldn't be the same people managing the public health insurance plan...because it will be seen as regulating only to benefit itself and push others out of business. We wouldn't be happy if AETNA was in charge of regulating insurance, we shouldn't want the same exact people in charge of managing and regulating. That's just common sense. What if I want to file a complaint against the public plan because I feel they violated an insurance regulation - would I want the same people managing the plan and creating the regulations? No. For my own safety, I wouldn't want that.
And if that hasn't convinced you - ask yourself - "How would President Bush manage a public plan?" The answer alone should be more than enough to convince you.
As it stands right now there are some federal insurance laws. But there are also state insurance laws - this is why some Prescription drug plans are better than others - some states have laws that require those plans to operate in a certain way and some plans opt out of working in those states for that reason. There's nothing wrong with this.
Tom Daschle argues in Newsweek that A public plan will reduce costs and improve access. His article includes a nice retort against those private plans who are crying about being unable to compete with a public plan:
Allow a public health-insurance plan or accept the fact that you are in for far more regulation as we construct a new system without it.
I love that response - accept it or we'll regulate you to death.
The Kaiser Foundation has done some public opinion polling - link here. The numbers here are great:
Almost eight in ten Americans (78%) favor requiring health insurance companies to cover anyone who applies, even if they have a pre-existing condition. This support remains high (72%) even when the public is given the argument often made that such a change may raise health insurance costs for healthier people even as it lowers them for the less healthy. Support is bipartisan: a clear majority of Democrats (77%), political independents (78%) and Republicans (58%) support eliminating exclusions for preexisting conditions.
Similarly, over six in ten Americans strongly or somewhat favor limiting the administrative expenses health insurance companies can claim (65%) and even the profits these companies can earn (62%). These proposals garner support across party identification as well, with majorities of Democrats (71%), political independents (59%) and Republicans (55%) backing government limits on health insurance company profits.
Roughly half the public believes there is not enough government regulation of health care costs (51%) or the price of prescription drugs (52%). When examined by political identification, a majority of Democrats (61%) and political independents (52%) think there is not enough regulation of health care costs, while just under four in ten (37%) Republicans think similarly.
A public option could do all these things and we could change the insurance laws so that there is no such thing as a pre-existing condition. I'm guessing this is what Schumer was referring to - that the public option would have to follow the same rules as private insurance companies. Simple fix - eliminate pre-existing conditions altogether. This is something that all our Democratic Presidential candidates supported during the primary and it's something the vast majority of Democrats support now.
How can you help:
Please call your Senators and your House Reps and let them know what kind of health care plan you would like to see. Try to be specific. When I call Senators Grassley and Harkin and Congressman Dave Loebsack, I refer them to this article, Majority of Iowans want public health insurance plan. I have written and called and emailed. I've been very specific in my ask:
- We need a public option.
- Senator Schumer's proposals are a fair "compromise" for a public option, provided we eliminate pre-existing conditions.
- The public plan should not be a for-profit plan.
- The public plan should be allowed to negotiate fees for services and prescription drugs from providers, suppiers, and pharmaceutical companies.
If you call asking for a "single payer" option - you could be asking for several things. Try to be more specific.
If you call and say that you want Medicare for All - again, please be specific. Do you want Medicare for all as it stands right now? Do you want a program similar to Medicare, but something that provides family and individual coverage?
I can tell you right now - these changes are already in the works. There are already attempts to further regulate Medicare Advantage plans (eliminating many plans altogether) and eliminate fraud in the Medicare system. There are already attempts to improve quality of care in hospitals so patients don't have to return weeks after they've been discharged for the same problem - only because they weren't given information on how to deal with their problems. These changes will save money - billions per year, in fact. These are the very same cost-cutting efforts that the private insurers promised to focus on yesterday at the White House.
When we make these calls and write these letters - we need to be informed, use the right terminology, and come across as organized and rational adults.
The polls support us. The time is right. Let's ask for a public option and explain what our desired vision of that public option is so we get what we want, not what they interpret or think we want.