Yesterday I posted a diary which generated a tremendous amount of feedback...and while it was evenly split positive and negative, that was also part of the problem: By choosing to line Dems/progressives up using the “Team Hillary/Team Bernie” angle, I opened up the 2016 primary wound again.
While there were legitimate reasons for using this framing, given the genuine difference in philosophy each had over the best way to approach the future of healthcare policy in America and how that is still one of the most pressing issues before the Democratic Party today, I decided that for now, at least, the damage I caused by reopening that wound overshadowed the valid points I was trying to make about the pros and cons of attempting to achieve Quality, Universal, Comprehensive, Affordable healthcare (preferably utilizing Single Payer as the primary payment mechanism) via an “incrementalist” approach vs. a “going for all the marbles” approach, both politically, economically and logistically.
I haven’t deleted the diary, but I’ve unpublished it for the moment; I need to think about whether it would be better to scrap it entirely or republish it.
In the meantime, I’m going to try and approach the same subject matter from a different angle.
With that in mind, the pie chart (donut chart?) at the top of the diary is my best estimate of the current healthcare coverage breakout of the entire U.S. population as of this summer...all 323 million or so of us.
The donut chart below is an accurate representation of what Bernie Sanders’ 2016 ”Medicare for All” proposal looked like when read as literally as possible: All 323 million of us covered under a single healthcare plan which would be called “Medicare” even though it would actually be quite different from Medicare as we know it today: According to Bernie’s plan at the time, it would be:
- 100% Universal (presumably including all ~11 million undocumented immigrants)
- 100% Comprehensive (covering every conceivable medical ailment, service, procedure, or medication under the sun)
- 100% Publicly funded (via large tax increases), and therefore would have…
- $0 out of pocket expenses of any sort for anyone (no premiums, co-pays or deductibles, period):
Now, before I go any further: THIS, precisely as presented above, is not going to happen. It simply isn’t. Even the most far-reaching, “pure” Single Payer plans like those in Canada and Taiwan don’t cover 100% of EVERYTHING. There’s some cost sharing involved for most people, even if it’s only a nominal amount.
With that in mind, here’s the most generous, most comprehensive, wide-scope universal single payer concept I could foresee having any chance of becoming reality:
When Bernie rolls out his new “Medicare for All” plan, the first question is whether it’s intended to be an actual, serious piece of legislation he’d like to get passed as it stands, or whether it’s a symbolic piece of legislation designed purely as a rallying cry to give Democrats a vision for the future when it comes to healthcare policy.
Now, Bernie has already gone on record as admitting that it will have zero chance whatsoever of actually passing a GOP-held House or Senate, so I’m going to define “serious” vs “symbolic” differently: If the Democrats actually reacquire control of both the House, Senate and White House, would he then push for this particular piece of legislation to become law, or would it still be a symbolic representation of an end goal which would come at a later date?
If it’s symbolic only (not just in a GOP environment but also in a Dem-held one), then the details and feasibility don’t matter all that much, I suppose.
If, however, this is intended as a serious, legitimate piece of legislation which he wants to actually pass, it will have to include details including (but not limited to) the following:
What’s the timeframe for implementation? Would it all go into effect immediately or over several years?
Would it cover U.S. citizens only? Legally residing residents? Undocumented immigrants?
Would the Hyde Amendment be repealed as part of it?
- If not, what provision, if any, would be made for women’s reproductive care?
- What about other controversial/religious issues like contraception, needle exchanges, living wills, EOL care and so forth?
- What provisions, if any, would be made for the 2-3 million people who work for the insurance industry, either directly or indirectly? Would they be retrained? Relocated?
What role, if any, would private, profit-based insurance carriers play going forward? What about non-profit carriers?
- If they’d be kept around, would they be providing supplemental coverage, administration of the public plan (a la Medicare Advantage), or both?
- Assuming they’d be put out of business or massively reduced in size, what provisions, if any, would be made for the millions of middle-class Americans who have stock/401Ks/etc in the insurance carriers?
How much would doctors/hospitals be paid/reimbursed for services? (Medicare reimburses about 80% as much as private insurance does; Medicaid only reimburses about 50% on average).
How would reimbursement rates for different services be established? (i.e. price controls)
- What about chiropractors, acupuncture, acupressure, etc? Covered or no?
- What about experimental drugs or techniques?
- Aside from the private Group and Individual markets, what happens to the existing programs including Medicare, Medicaid, the VA, the ACA exchanges themselves, the Indian Health Service, FEHB and so forth?
Oh, yeah, and one more thing:
How much will it cost, and how will you pay for it (whose taxes would go up, by how much, etc)?
There’s actually dozens or hundreds of other questions I could think of right off the bat. Most of them could be filled in later, but it seems to me that the ones I have bold-faced above should be reasonably expected to be in even the “1.0” version of a bill like this.
Assuming it passes muster on at least most of these items, the next question would be how feasible the major provisions, timeline, etc. might be after the Dems hypothetically retook the House, Senate and White House. For the moment, we have to operate on the assumption that this is unlikely to occur any sooner than January 2021.
Anyway, those are my initial thoughts the night before it’s introduced. I’ll write up my full analysis/response after I’ve had a chance to read through the entire bill tomorrow.
MAJOR UPDATE: OK, the sentence above is half true. The full text and official 3-page summary of the final version of the bill are now available publicly. I still have to read the full text (96 pages), but here’s my initial thoughts based on the summary (links to both available at ACASignups.net):
To answer my own questions from above:
TIMEFRAME? About 5 years from being signed into law through full implementation (coverage for children <18 starts on Jan. 1st the year after it’s signed, everyone else’s coverage starts Jan. 1st on the 4th year after it’s signed).
UNDOCUMENTED IMMIGRANTS? Yes, apparently they’d be covered.
HYDE AMENDMENT? It’s mentioned in passing but the wording is too vague for me to get a fix on.
OTHER RELIGIOUS STUFF? Not mentioned in the summary.
INSURANCE EMPLOYEES? Reference to a nonspecific “fund” to provide assistance to “displaced health insurance administration workers”.
PRIVATE INSURERS? Legally banned from covering anything already covered by the new law (which is pretty much everything under the sun). They could still provide elective plastic surgery and other nonessential stuff (lasik, I would imagine). That’s it, though.
MEDICARE ADVANTAGE? No mention of either in the summary, but it sounds like nope, it’d be entirely public, no private administration.
401Ks/STOCKS? No mention of any of this; sounds like middle-class portfolios would have to move their eggs into a different basket before that 5 years is up.
DOCTOR/HOSPITAL REIMBURSEMENTS? From the summary, it sounds pretty much like they’d receive current Medicare rates, which means about a 20% pay/revenue cut for most of them.
WHO SETS THE RATES? There’s some sort of advisory board which would be established to set regulations for a whole mess of stuff, which appears to include setting “expenditures” which I presume means provider payment levels. Basically, it’d be up to the HHS Secretary.
ACUPUNCTURE/ETC INCLUDED? Not specified in the summary, but given that it seems to cover just about everything else...
EXPERIMENTAL DRUGS/TECHNIQUES? See above.
WHAT HAPPENS TO EXISTING PROGRAMS? Gone across the board, w/possible exception of the IHS and VA (wording unclear in summary)
Here’s the big one that’s missing from both the summary and the bill itself:
- HOW MUCH WOULD IT COST/HOW WOULD IT BE PAID FOR?
Well, once again, there would supposedly be ZERO out of pocket costs for anyone...no premiums, co-pays or deductibles. The only exception noted is that some prescription drugs could have a co-pay, but otherwise, zilch.
That means the entire thing would be 100% covered by taxpayer dollars. About $1 Trillion would come from repurposing of all current federal healthcare spending. Since we spend around $3.2 trillion/year total on healthcare, assuming no cost savings, that’d leave around $2.2 trillion to cover. Up to $300B of that would theoretically come from the extra employer payroll revenue, so that’s around $1.9 trillion per year (again, assuming no savings).
However, the summary itself doesn’t give any indication of just how much those savings would amount to (remember, you’re covering an additional 28 million people and covering most of the 323 million people more comprehensively than they are now), and there’s apparently no mention whatsoever in the bill language itself of just what sort of new/increased taxes he has in mind (who would pay them, at what rates, etc).
I still plan on reading over the full language, but in general I’ll say this:
The Good News: Unlike last year’s plan, which I couldn’t take seriously at all, this is at least fairly detailed and at least acknowledges many of the big-ticket items. It’s basically 1/2 of a comprehensive bill, to put it in those terms, and some amount of thought has been put into it, which is all good to hear.
The Bad News: Aside from the feasibility question of some of the proposed provisions, without any info whatsoever on the funding mechanism or levels, Bernie has pretty much painted himself into the same corner that Vermont did a few years back: “How are you gonna pay for it?” is gonna be the most obvious Achilles heel. Interestingly, last year, “How to pay for it” was the only detail that he did include in any detail at all.
As I said above, the first question is whether this is meant as a serious bill which the Dems would actually expect to pass if they controlled Congress, or simply a symbolic bill meant purely to “rally the troops” and pave a vision for the general direction. My preliminary conclusion is that it’s partly the former, but mostly the latter.
As I’ve said before:
Bernie Sanders has been a U.S. Senator or U.S. Congressman for 27 years. He understands how these political games are played. He understands that you "can't start negotiations on the 50-yard line" and that you have to ask for more than you're willing to settle for in order to get as much of what you want as possible, etc etc.
In a situation like that, sure, you try to get co-sponsors, etc...but for the love of God, don't make not signing on into an ultimatum. There are plenty of great sitting Democratic members of the House, Senate, state legislatures and so on who support universal coverage of some sort but don't necessarily think that this particular plan is the best way to go about getting there.
The problem with this strategy, in other words, is that it only works if your supporters understand what you're doing and are on board with it.
As long as everyone seeking Universal Coverage of any sort (Single Payer or otherwise) understands and is OK with the idea that this is meant as more of a general, long-term vision and that the actual major bill that hopefully gets passed probably would be quite different and would likely fall quite a bit short of what’s laid out here, fair enough.
If, however, you truly believe that this particular bill (or one very close to it) will actually become the law of the land, you’re probably going to be disappointed.
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