It seems to me that a common mindset on this blog is that it would be nice for Boston to host the 2024 Summer Olympics, but that there are so many questions regarding the costs of such an event that without a solid framework on where the revenue will come from, its hard to really support the idea. I think its a reasonable view and one that I agree with. However, I have to wonder why the same rationale doesn’t apply to a single payer health care program.
Vermont has laid the groundwork for adopting a single payer system. But from what I understand, Vermont has not yet found a way to pay for it. I’ve seen estimates that implementing the plan will cost close to $2 billion annually. To put that in perspective, Vermont is a state where the total amount of revenue (both taxes and fees) collected in fiscal year 2013 was just over $5 billion and where close to 90% of the population already has health insurance. Its easy to point to Vermont as a success story, but the path to success still seems long and riddled with pitfalls.
In Massachusetts, almost 80% of the commercial health insurance market falls under 3 companies – BCBS of MA, HPHC, and Tufts. Taking a deeper dive into one of those entities, Harvard Pilgrim makes up almost 20% of the market and (based on its publicly available annual statement) collected almost $1.7 billion in MA premiums from over 300,000 plan members and paid out over $1.5 billion in medical expenses (including hospital expenses, professional services, referrals, and prescriptions). If $1.5 billion in costs represents 20% of the commercial market, then the total commercial market that would need to be replaced by a single payer system is at least $7.5 billion in new expenses (and that’s just paying the direct expenses, not including administrative/overhead expenses). The total revenue collected by the state of Massachusetts in FY 14 was just over $23 billion. Don Berwick’s website promises the creation of a panel to determine how to “get to yes” on single payer but doesn’t contain any specifics on where the 33% increase in tax revenue would come from.
Of course there are a lot of other logistical questions that would need to be determined. But I think the most important threshold question (and one that proponents of single payer should be expected to answer) is: Where does the $7.5 billion+ annually come from?
Just like medicare, money will come from a tax or fee — whatever you want to call it — but it will be considerably less for most than whatever we’re already paying to health insurance companies.
Is this really some big mystery?
BTW: The $2 billion figure for Vermont may sound big and scary and some nice anti-single payer propaganda… but that amounts to a little less than $3.2k per person, in a state that otherwise has the 5th highest premiums in the country.
The least expensive plan in the Affordable Care Act’s health exchange for Vermont costs $4k a year. The medium-level “Silver” plan costs $4750 a year.
So strip away the “Big Gov’ment” scaremongering and single payer is a huge cost savings.
Who cares if we’re paying our “premiums” to a government program instead of health insurance companies?
I think the average taxpayer would be happy to pay less and get as much or more than the alternative any day of the week once it goes into effect and people see the scaremongering isn’t true.
This is why single payer systems are overwhelmingly popular across the world — including in countries where conservative governments have long been in charge.
Sorry!
All this time I was worried about the lack of a specific plan to pay. I didn’t realize that the revenue would come from “a tax or fee.” I guess that settles it.
But in all seriousness, on the one hand I agree with some of your logic – government already mandates the levels of service, the premiums that insurance companies can charge, the reserves that they have to maintain, the percentage of their premiums that they are permitted to spend on administrative costs vs reimbursing expenses, etc. Its such a highly regulated industry that it wouldn’t be a huge jump to socialize it completely.
But on the other hand, the system of private insurance is already well established. Most people do not write a check to a health insurance company each month, they get it through their employment. The health insurance companies already have the administrative infrastructure in place to process premiums, evaluate risk, invest reserves, answer questions, pay valid claims, deny invalid claims, etc. There are significant up-front costs moving to single payer than simply taking the cheapest plan currently available and multiplying the annual premiums by the population.
I think single payer proponents need to do better than “a tax or fee” as the proposed funding mechanism.
We just don’t get to enjoy it until our mid 60s.
Changing that dynamic so we get a Medicare for All right off the bat can only make the program more popular, not less.
I have no doubt a transition would have a couple hiccups, but at the end of the day people will be glad to have a stress free system that costs significantly less, but equals or exceeds the level of care most have now.
We can do that if we want to – we need only to act boldly and be willing to follow the lead of the rest of the world, which has demonstrated time and time again that single payer costs less and delivers more – for all.
The state could allow employers to raise W2 income by the amount they used to pay in premiums (per employee), and arrange a way to exclude that from taxes.
The state could simultaneously allow employers to withhold the new health care tax from paychecks, just as state-mandated auto insurance was withheld from the paychecks of Digital Equipment Corporation for years.
This is easy to do and easy to make painless for employers and people motivated to do so.
But on the other hand, the system of tax paments is already well established. Most people do not write a check to the IRS each month, it gets paid via their employment paycheck.
“do better than ‘a tax or fee'”? Are you asking for the cost per person, or a different funding mechanism?
Cost containment under Single-Payer System (by cutting administrative costs and excess health insurance company executive salaries and lobbying expenses, etc.) would be easier than what the lobbyists created in 2006 for Massachusetts residents. As 2006 article by David Cohen and Judy Atkins noted: “According to the preliminary records, lobbyists for the health care industry were paid over $7.5 million in 2005, most of it for lobbying around this bill…. Insurance companies were the big spenders, with groups like the Massachusetts Hospital Association spending $263,000; Mass. Association of Health Plans spending $208,000, etc. With over 700,000 people going to be forced into health insurance plans, these companies stand to come out big winners.
“Blue Cross-Blue Shield and Partners Hospital Group spent almost $500,000 in lobbyist fees. Partners Hospital will get 15% of the $270 million in increased Medicare reimbursement that was also part of the health care legislation.” Ironically, prior to 2005 the official platform for Massachusetts’ Democratic Party pledged to work for the establishment of a more cost-containing Single Payer System, yet in 2014 neither Massachusetts gubernatorial candidate Coakley nor Grossman is apparently yet pledging to establish the Single Payer System that most Democratic voters in Massachusetts want to see established.
It’s hard to do “per person” calculations and apply them to this. Vermont’s population includes a lot of families with 2 or 3 children, if not more. By the “per person” math, it would be almost $13,000 to cover four people.
The Silver Plan is largely purchased by people who previously weren’t covered. For people who get a family plan that’s 80% paid for by their employer, the out-of-pocket premium is far lower than that number, or the $13,000 single payer would cost for four people, and it’s pre-tax. If the new plan is being funded by a tax, on whom does the tax fall? Do all workers pay a percentage of their income? Do people pay based on their family size? Do employers chip in? How much? If employers are freed of the burden of paying as much for health insurance as they do today, isn’t it unlikely that they’ll pass on those savings to their workers? Couldn’t workers see their total compensation from their employers go down while their tax bill goes up?
I don’t see how the “single payer tax” could be credited, or even deductible, on state income tax. Most people only pay a few thousand in Vermont income tax a year anyway. To discount for the health insurance tax would blow a whole in the general budget.
Longer term, if incomes for the vast majority of people continue to stagnate or decline as they’ve done for 40 years, while more income flows to the top, how will they fund the plan without placing even more of a burden on strapped families?
I’m rooting for Vermont here, and I know single payer plans (or modified versions of them) can work, but these details matter. We can’t just assume all, or most, people will be better off with the new plan without answering these questions.
The funny thing is, Gov. Shumlin didn’t come in with an existing plan. He said, Vermont is a progressive state with a history of being ahead of the country on social policy (gay rights and health care to name a few), and we are just going to go ahead and do better than just have an ACA exchange. He then got the best policy experts to design a system, and then once they designed a policy, pushed it through the legislature, which made some, but not many major, modifications.
I don’t see how Dr. Berwick can’t do the same thing. The President Clinton approach, designing a policy in-house, pushing it to a reluctant legislature, and watching it slowly die a death from a thousand cuts, is not a good approach. The President Obama approach-saying ‘we need unviersal coverage’ and letting the legislature design it-has also been a failed approach. What is needed is an approach that recognizes the goal-universal coverage-can be achieved through different means, has policy experts rather than legislators design the plan, and then pushes that well designed plan through. That is the Gov. Shumlin approach, and will likely be the Dr. Berwick approach. I don’t think anyone here is arguing it won’t be a painful, drawn out, political risky process. But I’d rather a candidate willing to stake their governorship on that proposal rather than one who is not willing to take any policy chances at all, frankly, like either of Dr. Berwick’s opponents.
Well we can assume all, or most, people will be better off under single payer than under the status quo. That is an assumption backed up by over five decades of peer reviewed comparative best practices analysis between the US and it’s industrialized peers. There is simply no contest. Now, we should answer the questions about ‘how are we going to pay for this?’, “how is this going to pass?’, “how will this affect taxes?’. But we answer those questions only after first asking ‘how do we deliver qualtiy care to everyone in an affordable manner?’-and the best answer to that question has always been single payer.
Your questions boil down to one ‘how does single payer practically happen in Massachusetts?’, and the first answer to that is ‘not at all” if we don’t elect a Governor willing to fight for it. The second answers about the how can only occur if we have a Governor willing to ask ‘why not now?’ and take the chance.
On how Vermont got there
is that single payer, as such, has been adopted by Vermont, but they still don’t know the answers to the questions power-wheels and I have asked. There is little question that, when you look at other countries’ experience, single payer is a better system. That’s not the issue here.
The issue here, as I see it, is how — precisely — we transition from our (unique) current system to a single-payer system. That involves figuring out how to avoid making it cost more for the large number of people who’ve had much, if not all, of their health insurance premiums paid by an employer as a benefit. A benefit that would be obsolete if we went to a true single-payer system. How do we prevent employers from pocketing the savings, making the transition an upward transfer of wealth in the short-to-medium term? It’s great to see agreement that these questions must be answered, or assertions that answers can be found, but I’m not seeing any detailed answers yet.
About your final point: to me this is a longer-term discussion. I’ve already expressed my views about blowing all political capital in Massachusetts on healthcare to the exclusion of other pressing issues.
… that power-wheels framed his questions in the form of “how do we add this new thing” (as though single payer is an olympic size additive set of features) I think it is non-sensical. If your questions are about transition and morphing from the multi-tentacular grasping octopi of bloated insurers to a single source of payment then the answer is that we don’t add a thing, we subtract: the process will be one of removing layers of bureaucracy and assumptions. This is something we’ve quite pointedly refused to do: the individual mandate only makes the the feds the payer of last resort, something distinct from the single (only) payer, and only adds yet one more layer to the fifteen or so other completely unnecessary layers already extant.
So the question, as I see it, really is just this: how do we get rid of private insurers without hurting the feelings of the private insurers….? Who do we placate present private insurers, most of whom have political clout and will use it to either stymie the process or exact revenge within the process??
We can’t.
So let us no longer bother to even try.
The short and sweet answer is that the CommonWealth simply assumes control over all health insurance companies by eminent domain, fires the bulk of that work force as un-neccessary, requires the remainder of the work force to stop saying ‘no’ and uses all the existing data to seed the data for billing and tracking. Blue Cross, Harvard Pilgrim and all the others become public utilities. Charlie Baker and all the other sponges can go piss up a rope.
There. I fixed it.
I take no issue with the general proposition that a single payer system void of profit-raking middlemen is more efficient and humane than our current system. I’m still waiting for any answers at all to my specific questions about implementation.
I just feel you are asking advocates to not only put the cart before the horse but build the cart before even getting a horse. I disagree completely-I think we have the momentum to follow VT’s lead and that it is worth the political capital. Casinos, paid leave, a higher minimum wage-these advances can be made at the ballot box this fall. Universal healthcare already passed at the ballot box in 2002-we need the political will to achieve it. That is created by the grassroots but also by leaders willing to stake their capital on success.
was not only in terms of Massachusetts but referenced Vermont, which already passed a single payer law but still hasn’t resolved those questions. In either state, having some sort of plan so average citizens don’t get soaked in the process doesn’t seem unreasonable. I don’t find the “cross that bridge when we come to it” argument reassuring. I’ve seen enough bad legislative compromises in my time that I’d like a bit more of a framework before I’m going to be gung ho about traveling down that road.
As for whether it’s worth it, I still say: medium term yes, short term no. We just hit near-universal adult coverage, we have other issues, and I believe we have to rebuild faith in the state government’s ability to do things right first while we watch and learn what works in terms of implementation.
I think that the bad compromises you fear occurred during the sausage making process of the legislature, precisely because people didn’t start out with a clear plan to begin with but thought the process would work itself out and implementation would take care of itself. That’s how we get stuck with a neoliberal reform that is an insurance company’s wet dream that nearly gets derailed by a faulty website.
Under that scenario we were vague, focused on keeping stakeholders happy, and focused on not causing too much transition anxiety. And it’s a reform that will do some good-but falls far short of what we all thought we could get. Unlike Washington, we have a best permanent majority on Beacon Hill. I’d rather have this fight now, with a Governor willing to fight it. Let DeLeo and his clones vote “No”-nothing would please me more since we could then use it as a litmus test to separate the wheat from the chaff and get the majority we deserve.
Vermont is still working out the details for how it’s single payer reform will be implemented-but the hard part-actually passing a real reform in the US-did happen and it happened because of leadership, a mandate for Governor Shumlin to get it done, and the work of the Progressive Party. If this campaign can build the infrastructure to create a better legislature than that’s a win even if the vote ends in a failure. But I’m tired of waiting, tired of accommodating DeLeo, and tired of incrementalism and compromising before we are even out of the gate. It hasn’t resulted in any significant victories I can think of-and frankly squandered solid mandates to lead.
The more specific we get now or ask the governor or legislature to be, the less likely it succeeds. Better to pass something that is vague on details and only specific in quality of care.
Pass a bill that funds a study on single payer rollout options with all the standards of care we want, with a mechanism caked in that pushes single payer through if the study comes out well – where we can demonstrate cost savings. (And we know it will.)
Build into the bill implementation by the commission set to oversee the project – either a new one or something like the health policy commission.
The whole thing would take a few years and be something of a grind, but would have the best chance of passing and delivering on the kind of system we all deserve.
I think it should be pointed out that all of your questions could have been directed at the Affordable Care Act.
In fact, the ACA is far more complicated and required a far more complicating rollout – creating exchanges with myriad insurance options in every state, with different levels of quality, cost and eligibility… that could change often. It had to intact with thousands of insurances in the private market, with Medicare and Medicaid.
It was a colossal undertaking.
Comparatively, single payer would be simple. There’s one basic opt-in, everyone has it and finding it is comparatively simple – creating a simple fee.
“It had to interact with thousands of insurances” (not “intact” with them).
“There’s one basic opt-in, everyone has it and funding it is comparatively easy” (not “finding” it).
Sorry about that – comments on my phone are dangerous.
I was just thinking about how all of these, “We need to see the details!” echoed some of the headshaking and cluckclucking that preceded the ACA debates.
The insistence on “give me the comprehensive details” is a campaign tactic to neutralize one candidate’s single payer advantage, (cynically) trading the larger goal we all supposedly agree with (single-payer healthcare) for the one-off electoral advantage.
If our Anti-Magic Wand friends all agree that Single Payer IS ultimately the best thing for healthcare and people, then let’s hear it from them how we get there. Step by step, on the street, legislatively, fiscally. If having one of the nation’s top healthcare policy experts set a Big Goal as Governor isn’t the path forward, then let’s hear it–what is?
I think what we hear from the Grossman and Coakley camps are basically “let us win now and the next guy gets you single payer”. But I honestly don’t see their “don’t rock the boat” attitude really separating themselves from Baker or building the kind of coalition we need to transform state politics. I am tired of Midnight Basketball-I want a real liberal achievement. Did LBJ wait to pass the Civil Rights Act or Medicare or did he move fast?
LBJ was a master who knew where the bodies were buried. It still took invoking the Kennedy assassination and people’s horror at Bull Connor and Philadelphia, Mississippi to get things through in a liberal era with a great economy.
To me this discussion is not about Berwick or anyone else, and I resent hotly the suggestion that my good faith questions on a major policy question make me Bill Kristol or a cynical campaign operative trying to score political points by pissing on single payer. Review this thread: supporters of only one candidate brought the governor’s race into it. The aspersions cast at those of us with questions and concerns only reinforce my discomfort with that campaign.
Let’s hear it.
I don’t read the comments from harmonywho attacking you or your support for any candidate. Instead, I read them as a more generic complaint against the nay-sayers — from both sides of the aisle — that, among other things, tossed single-payer and its advocates off the bus before it was even discussed in the ACA “negotations”. I think we’re seeing frustration at the entire process — including the current discussion about single payer in MA.
I also ask you to reconsider your comment about this issue’s relationship to the governor’s race. Single payer was brought into the governor’s race by one candidate. A candidate who the mainstream attempted to write off as some sort of quixotic neophyte who could be safely ignored.
It is a simple fact that Don Berwick rightly brought this issue into the governor’s race, where it correctly belongs, and dragged the other two candidates — together with their supporters and staffs — kicking and screaming.
So let me be clear — I like you, respect you, read every word you write here, and also come to different outcomes from you on several aspects of this race. I certainly do NOT view you as a Bill Kristol or a cynical campaign operative.
I just think you’re mistaken. 🙂
My Fri 4 Jul 12:17 PM comment is a response to the Thu 3 Jul 10:16 PM comment of fenway49, though you could never discern that from the presentation of comments on this page.
Appreciate it, but some of the comments unmistakably accuse me of raising questions only to prop up Steve Grossman at the expense of Don Berwick.
Harmonywho, July 3, 3:32 pm:
Clearly says my questions are intended to blunt the perceived political advantage of Don Berwick on this issue.
Harmonywho, July 4, 11:03 am:
Clearly says the whole discussion takes place in the context of the primary. My response: power-wheels didn’t post this six months ago. Perhaps Berwick’s advocacy for single payer has more people talking about it. Sure. That’s not the same thing as assuming my questions are designed to make Berwick or the idea of single payer look bad. I’m telling you, they’re not.
jconway, July 3, 1:11 pm:
Not about me directly, but also clearly brings the governor’s race into it.
And I didn’t single any one out nor was I thinking about any one in particular. “These kinds”. Also the question of Berwick was raised in the OP as well as the editor’s commentary.
Again splitting hairs and moving goal posts not to mention personalizing something that wasn’t showboat about you.
I still argue whether your intent or not the effect of this hyper critical pose toward details of implementation is to help Not Berwick and deflate our supposed common cause of achieving single payer.
I used the word “suggestion.” Tom’s comment used the word “attack.” I quoted from it without focusing on that particular word.
You said that people who support a different candidate ask questions are engaging in “a campaign tactic to neutralize one candidate’s single payer advantage, (cynically) trading the larger goal we all supposedly agree with (single-payer healthcare) for the one-off electoral advantage.”
Anyone who supports a different candidate and asked questions will consider herself/himself implicated by that assertion.
Does that mean nobody should ask? That wouldn’t be the effect if there were gpod answers forthcoming. I dispute that asking for three sentences going a bit beyond “there will be a tax and it will be cheaper” is being “hyper-critical.” The question raised in the original post seem reasonable. My asking follow-up questions (in response to people’s comments) is not “moving goalposts.” It’s saying the questions were not answered satisfactorily.
I’m asking because I wouldn’t want anyone on the left to push this one and fuck up royally. It’s got to be done right. To me that means having some kind of plausible answers ready for these questions. “How do we get this done without screwing people over?” shouldn’t be controversial. Hell, it’s the kind of question campaigns plant. “Gee, I’m glad you asked that…” The answer is not, “You’re a saboteur for asking.”
enough with the “intent”
But, when his aides told him “now is not the time” he responded with “than what the hell is the Presidency for?”. I haven’t seen a prominent Democrat ask that last question at all since LBJ left the White House and we haven’t heard that kind of attitude in the Corner Office in recent years. I think Deval Patrick came in with that kind of attitude, and inherited a bad economy that he managed well and a bad legislature he did not manage particularly well.
I get that you have sincere doubts about Berwick’s capabilities as a legislative leader, and I was not suggesting he, or anyone, could approach LBJ in terms of legislative accomplishments or acumen. What I am saying is, Grossman and Coakley are not even bothering to try, and I just don’t see either of them being successful nominees or Governors at this point. Berwick could very well fail, but he risks failure on attempting an achievement nobody has attempted in Massachusetts politics before. I think that is something worth fighting for. And he has some committed and successful legislators on his team to move the ball forward.
You are asking a campaign to answer questions that won’t be asked until conference committee, and I think that over learns some of the lessons we have learned from ACA and the Hillarycare debacles. Passing a bill hiring experts to hold the legislators hands through the design and implementation of the policy, as Vermont has, seems like a fairly good start.
I wasn’t asking “a campaign” anything at all. I was asking anyone on BMG familiar with a tentative proposal for some details. You guys interpreted this to be about Berwick. I said repeatedly it was a question about a policy, not about Berwick.
Appreciate the article (I only saw one). It tells me how a law was passed that sets a goal of single payer. It doesn’t tell me, even roughly, how that will be funded.
I just disagree with the idea that even offering a first stab at answering that can wait. It’s fine if a final program wouldn’t be hashed out until conference committee. But pointing a simple proposal like the one I quoted in my reply to mimolette shouldn’t be too hard.
This just doesn’t make sense to me. Absent the details on such a fundamental thing as the funding mechanism, I don’t think they really passed “a real reform” at all. Just a commitment to reform.
You’re making. I’m still not entirely sure they address my concerns. Transitioning from the current jumble to single payer may be administratively easier for government than the ACA rollout, but that doesn’t necessarily address the impact of the eventual fee on citizens. For all its complexity the ACA left many with employer-sponsored coverage largely unaffected.
Commission or not, at some point before passage these issues need to be addressed and I’d like to know before throwing my support to any particular bill. If people do get hosed somehow there will be blowback for the left for decades.
Mark Bernstein raised the idea of taking all current outlay by individuals and employers for a fund. Sounds good, but do we just follow existing amounts? We can’t. It would reward employers who have shifted costs to their workers and punish workers who’ve borne that burden. How to reconcile the presumed uniformity of coverage with the existing disparities in quality and cost? I’m not asking for a final proposal, but some explanation of how to address these questions would be nice.
Right now, people pay premiums.
With Single Payer, people wouldn’t need to pay premiums, but would pay a little more in taxes instead.
Overall, they’d pay less — maybe even a lot less.
None of us can be anymore detailed than that because we don’t have a specific proposal on the table yet — and can’t until there’s some commission given the task of coming up with one, with the resources necessary to do so.
But we can’t let the cart get before the horse. If you think the legislature is going to pass anything without having a commission look exhaustively at the issue to put real concrete options on the table (that would answer your questions), I’ve got a bridge on the Mystic River to sell you.
Let’s not shut down debate because we demand details before we’ve ever established anything that could even give them to us… but rest assured that when we have the details, the costs will be less and the system will be a lot simpler and save a lot of time and energy over what we have today.
I’m to have a debate, not stifle one. The debate seems to be “STFU with your stupid questions which are probably intended to sabotage the whole endeavor.”
So people won’t pay premiums, they’ll pay a tax instead. How much? My wife and I pay under $200 a month, and that’s pre-tax dollars, for a good plan that covers us both. The total premiums may be much higher than a single payer plan but we don’t pay most of that. Wouldn’t we pay more under the single payer plan? How much? If not, how? Reasonable questions, I think.
Of course I don’t think the legislature will pass anything without answering these questions. That’s why I am asking them. Just some sketchy picture of how we ensure a more efficient plan overall results in savings for average people and not big employers. Especially if we do it alone while DC is not on board. Federal tax issues are big here.
I’m not assured by an answer of “don’t fret, we’ll get back to you in 3 years.”
You’re writing the check for under $200 a month, but the rest of your coverage is still compensation. It’s just compensation delivered in kind, because of a quirk of U.S. history. There’s no particular reason to assume that a transition to a single-payer system would be structured to allow your employer to claw back that compensation as a windfall profit. My first impulse would be to say that you work this one out through the tax system, perhaps replacing employer contributions to private health insurance with employer contributions to the new single-payer system, with offsets against other taxes as necessary. If the numbers work as they have in other countries that use single-payer systems, you wouldn’t necessarily see your payments go up at all. The employer would see their payouts drop, but as long as you’re receiving coverage that’s at least as good as the coverage you were getting before, the value of your compensation package is as high as it was before the changeover.
But as I said, that’s no more than my first and unexamined thought about how you’d handle the problem on a mechanical level. There are no doubt dozens of others I’m not thinking of at the moment. Any one would have to be drafted carefully, and likely go through with technical errors that would need to be corrected later; but what piece of legislation addressing complex financial issues ever didn’t?
My point here is that once we’ve identified the issues, there’s usually a way to address them. There are a lot of those issues with something that’s a giant piece of our entire economy, and I do think it’s premature to demand that we figure out how we want to approach each and every one of them before the election. But I do agree with what I take to be your underlying point, that we need to make it clear that we all realize this kind of issue exists and will exist, and that those of us who think this is potentially doable should make some showing that we’re not pretending we’re going to solve them because rainbows and magic.
I’m not accusing you of “pretending [you’re] going to solve them because rainbows and magic. I’m saying that virtually everyone on this board has gotten past Step 1 – support for the basic concept. I thought the point of this thread was to move beyond that. It asked how we do it in Vermont, which is supposed to implement this in less than 3 years, and in Massachusetts, where a number of people are calling for a plan to be adopted within the next few years.
I think your suggestions in that direction (e.g. tax code) are very much on the right track. I’ve just been seeking a slightly more fleshed-out example of how that might work. What I did not intend is for this to become a continuation of the other, Grossman and Berwick, thread. I’m talking purely about policy ideas here.
I will say that, for those people who don’t pay most the premium themselves, I don’t believe for a second the employers will give them the part of their “compensation” the employer’s been paying to the insurance companies in cash instead absent a solid legal structure creating that incentive.
…since you share the goal?
Isn’t it incumbent on those of you who want to do this right now to answer that question? Shouldn’t it fall to those who’ve chosen to make this thread about a particular candidate who allegedly deserves our support specifically because of his desire to make this happen?
Your questions give off the distinct impression that you’re trying to call me out, suggesting that I don’t support the ultimate goal at all and I’m just asking to cause mischief. That’s not true. I came to this thread because I don’t exactly know how to get from A to B. Power-wheels wrote the post for that reason, for what I can tell. We’re seeking information and I’d expect the staunchest proponents to have some. Surely someone in some think tank has come up with a more specific vision of how it happens.
Petr is right – There is enough inefficiency in our current system that we should be able to get equal or better outcomes while minimizing losers in the shift. That will maximize political support and I’d say it’s more just. But I’m willing to say it’s a complex area and a lot thought would have to go into it.
Borrowing from others on this thread, such as stomv and mimolette, I’d tend to favor a payroll tax falling more heavily (or exclusively) on employers. In theory they still could save money if they don’t have to pay private premiums.
But you’d have to look at the numbers. What impact on the job market of leveling out, through a uniform tax, employers who currently pay a lot for their workers’ insurance and those who don’t? And right now employers’ contributions to premiums, like employees’, are not subject to tax. To get more employers on board they’d have to be enough ahead that they won’t mind losing the “benefit” of having a relatively captive workforce. That might require tweaking some federal tax provisions. The knotty issue of a state like Massachusetts going forward is that we can’t count on a hostile House in DC to pass federal tax changes to make our plan work. I feel safe in saying they’d rather stymie us than smooth our path.
I keep asking, just as “staunch proponents” (You’re not a staunch proponent???) have been asked over/over.
I’m with you. A payroll tax or deduction, redirected from insurance premiums. And you are with RyePow and Petr, elsewhere on the thread. And yes, there’ll be political hiccups and practical delivery issues.
Having raised them, how will you solve them? And, absent a good enough solution, should we stop talking about advancing/moving towards single payer? And if so, when is it OK to start talking about it again?
What position WOULD you have “Staunchest Supporters” take vis-a-vis the real, bedeviling, complex and nearly insurmountable problems you’ve laid out?
I appreciate that there are real, important practical issues with getting from where we are now to where we want to be. And aside from the scare quotes, I agree with you about things like the need for mechanisms that ensure that neither the public overall nor employees who now receive healthcare coverage through their employment wind up picking up the portion of our overall healthcare insurance costs now paid by employers. The point of doing this is emphatically not, after all, to cut the compensation of every employee in Massachusetts, and I don’t imagine for a moment that the ordinary reasonable business wouldn’t try to do precisely that in the absence of mechanisms to prevent it.
But that said, at this point I’m not sure what more you want to see. We seem to be agreed on all the basic points, at least in principle: that the money going into healthcare under the current system should be more than adequate to fund it under a single-payer system, that making the transition is going to be tricky no matter what, that it’s going to take a lot of concentrated attention to making all the moving parts work to get from Point A to Point B. (Even our disagreement about how important it is to get this done may be more apparent than real, inasmuch as part of the reason I’m so concerned about it is the degree to which healthcare and associated costs are sucking up resources that we desperately need to address other collective problems.)
And I think it’s 100% reasonable to want to know that people who’re arguing that this is a goal worth spending a lot of public effort on aren’t pursuing the political equivalent of cold fusion. I’m not trying to avoid answering your questions (to the very limited extent I’m in any position to answer them), and I’m not trying to turn this into Grossman v. Berwick, Part II, The Sequel. I’m just not sure what there is that would fall somewhere in between “Here, I’ll show you the model revenue code provisions right now, along with three projections showing how the numbers play out under differing assumptions about economic growth in the state,” and “We know there’s a big pool of money, a pool more than sufficient to fund the new system, that’s currently fed by a few big streams and a zillion tiny springs; the job is to rechannel those cashflows, not to come up with extra funds not currently devoted to healthcare. And since this is a problem involving revenue and government, the tax code is a logical tool to work with that’s fortunately flexible enough that we can use it to correct for a lot of the issues we’re going to encounter; that’s the first place I’d be inclined to go.”
I took a cut at it before, and I gather it wasn’t specific enough to give you the sense of how this all might work that you’re looking for. But the thing is, the minute we go beyond the idea that we could use the tax code to ensure that employers who now provide healthcare benefits maintain employee compensation at the same levels they did prior to the changeover, we’re faced with unanswerable questions, because even if we could reasonably spend the time drafting purely speculative revenue code, we couldn’t do it without answers to policy questions that we haven’t even gotten to the point of asking yet. What’s the new public system benefit package going to be? If it’s the equivalent of a platinum plan, how do we handle employers who’ve been offering the equivalent of bronze? Are we going to use this opportunity to try to correct for the difference in cost for any plan between big companies that have been able to buy platinum insurance at relatively good giant-group rates and the much higher cost of that coverage to small employers who’ve been charged small group rates? And on, and on, and on, because as you know, this stuff is maddeningly intricate.
I’m not trying to avoid having this conversation, not at all, but maybe I’m failing to understand what precisely you’re looking for?
I also want to know/ask: Who are these people who want SINGLE PAYER RIGHT NOW?
Of course, if we COULD wave a magic wand, *I* personally WOULD wave it and have Single Payer RIGHT NOW.
Who here wouldn’t? Wouldn’t you, @fenway49, too??
But there is no magic wand, and NO ONE who “wants single payer” thinks that it will happen RIGHT NOW or next year — I doubt we’d get there even in 3-4 years. However, I know we WON’T get there without *strong* leadership .
The goal is single payer: everybody in, nobody out, payments pooled. The rest, to bastardize Hillel, is details. Smarter, more detail-oriented persons and worriers raise completely valid solutions and problems, and they have and they will continue to do so. And I thank you, Mimolette and others, for doing a great job at it.
We’re going to get to single-payer. Not tomorrow. Not today. Not next year. The question is when do we START getting there.
It’s a great comment and a real effort to engage and discuss. That’s all I’ve wanted. You yourself identify issues that would have to be resolved before we can put this in place. I’m not saying, at all, it can’t be done. I just wanted some outline on how. As I said in another comment:
If you don’t have it, you don’t have it. It’s fine just to say so. I looked for it myself (would have been easier to do that yesterday instead of all this sound and fury) and MassCare has a proposal. It says:
There you go. If he becomes governor, Dr. Berwick presumably will appoint a commission that may come up with different numbers. The details will be wrangled over in the usual way. I just wanted some kind of outline.
Or maybe it’s just my twisted sense of humor. But I now suspect that I’m even twitchier about the difficulties of implementation than you are, underneath all of our back-and-forth. Because I looked at that document and thought, “Okay, how does it address problems like ensuring that employers don’t reap windfall profits under the new funding structure? How do these tax numbers track with what employers are paying now? Isn’t that a lot of unrestricted regulatory authority being handed off, in a lot of areas likely to be difficult and controversial?”
And so on. All of those are things that (obviously enough) I would expect real-world implementation to address, but nothing there gives me any comfort about the sheer amount of work ahead.
No. To have Single Payer, we’d need to get a ACA waiver. To get a ACA waiver, we’d have to prove our insurance costs to individuals who need subsidies or free care would be at least as generous as they are currently — or better.
If we make a single payer system that would cost more to those least able to afford it, we’ll never get a waiver.
Your costs would be no higher than they are today — and probably a lot less.
We can already see how this works with our taxes and payroll taxes. If you don’t make enough money, you don’t pay taxes. If you make a very small sum of money, you can get a break on payroll taxes or even not have to pay them at all (including that currently existing government single payer plan called Medicare).
Massachusetts has income tax exemptions already on the books for state taxes. It would not only do the same for a single payer plan, but would have to in order to get an Affordable Care Act waiver to institute single payer.
And that’s all assuming we’d assess it as a tax. We could try assessing it as a fee or ‘premium’ and maybe even make it directly scale with wages. Whatever makes it easier to pass and less confusing for people is fine with me — they’re details we can all work out over time.
You are not going to pay higher premiums with single payer.
… that your issues, mostly, lie in the way in which you are thinking about this. You used the term “implementation.” Which term heavily implies what I spoke of earlier as the view expressed by power-wheels: that of the “olympic model”… wherein this ginormous new thing that’s adding to the infrastructure representing some risk of.. what? I don’t know.
The government, right now, collects taxes from all people and, in turn, use a portion of those taxes payment for some people to get comprehensive health care. Nothing new needs to be ‘implemented’. The transition is for the present system of taxes from all paying for some to morph into a system whereby taxes from all are used to pay for health care for all. Any processes, procedures or paradigms are already in place and the problem is one of scaling. No ‘implementation’ needs to happen. The private insurers need to go away. They need to be removed from the equation. It is that simple. A lot of problems go away when the private insurers do.
The question of benefits really lies between the employer and the employee. If, legally, the option to cover health care is no longer a benefit at play then the employer and employee have room to negotiate different salaries, or other benefits, out of the surplus. But that’s up to them…. maybe some employers will want to pocket the cash and stiff the workers… but absent the need to keep their healthcare the employee may well be willing to walk and negotiate a salary elsewhere so that’s a risk the employer runs. As for pulling the rug under existing benefits, I’d have to say that might fall under any profit-sharing programs at individual companies: removing a big cost would spike the profits of the company and the resulting profit sharing paradigm would come into play. Not every company has that, however… Yet other companies may choose to expand their workforce with the surplus. Maybe that can be codified in legislation to prevent a sudden upward distribution of wealth… But I’m not terribly worried about it.
Medicare taxes are withheld for the federal government. We’re talking about a state plan, so Vermont or Massachusetts would have to figure it out. To cover everyone would require more withholding. If the employer does not pass on savings people theoretically could get another job. Failing that they’re worse off out of pocket, a political loser.
Given the apparent lack of political support for a national single payer plan and the current dysfunction in DC, it’s hard to imagine something like federal tax credits to offset the new state tax or recoup the obsolete tax free insurance benefits getting passed.
I don’t think it’s as simple as you’re suggesting.
If employers don’t pass some/all of the healthcare savings onto employees, other employers will. Businesses compete for employees all the time. Some times one side seems to have the upper hand, other times the other side does, and it’s true that the lack of leverage by middle income employers (and lower income) is a problem.
Personally, I’m of the view that you don’t do it all at once. You work with the Feds to make MA citizens age 62 and up eligible for Medicare, including making a transfer payment from MA to USA. You put pregnant women (and their newborn children) on Medicare, both of them up through their child’s first year of life. You use Medicare to do all vaccinations, from MMR to flu. And, thanks to SCOTUS, you start with birth control.
There’s no reason why we can’t transition to the system by working around the edges, implementing new portions each year for 10 years in a row. In that way, it won’t be a sudden whack where the employer goes from paying a big chunk to insurers to paying nothing and the worker goes from being taxed to pay for none of this new system to all of it.
Alternatively, it could be implemented through a business tax instead of an income tax, so that the businesses pay more taxes the moment they pay less in insurance premiums…
I’m not asking for a detailed final plan right now. I’m just asking for some ways we could get from A to B without corporations gaming the system so working residents of Massachusetts end up paying more. These are interesting ideas worth considering. Thanks.
Concerning the labor market, I’m quite worried given how slack it’s been since the crash. We’re now touting the low MA unemployment rate but I don’t know anyone who’s feeling like workers have any leverage. And none of the people I know who’ve been let go in the last couple of years has had an easy time finding another position.
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Exhaustive and comprehensive. I’d like to hear yours, still, though!
There’s been a lot of this kind of general stuff:
You’re moving your goalposts, throwing bodies on the track, asking for “broad ideas” and “specific details” and “less broad ones” and “not specific details” and have lots of criticisms and concerns but, as a fellow advocate/believer in the long term goal of single-payer (if I’ve understood correctly), remain without any positive suggestions of your own.
Yes there are issues. Yes there are problems. Yes there are a variety of mechanisms and solutions, many of which have been suggested. Where they fall short, you have been very particular. So what IS the answer? And what is the point of the discussion today/now, if it isn’t a proxy battle for the Gov race? Why today? Why not 6 months ago?
Discussing Vermont’s implementation, summarized it repeatedly, and haven’t heard a peep from any critic or fellow supporter of Berwick’s efforts in reply. Obviously Vermont has major differences (differences I’ve discussed at length already!), but the main idea was getting the legislator to adopt a policy solution from a list of potential solutions with some costs worked out from a policy scholar-not a politician. Really get some health care economists and public policy thinkers to craft a plan, get the legislature to back one of those plans, and then vote on it and phase it in. The other implementation issues (websites and the like) can be worked out via the executive branch and the cabinet level agencies in charge of the final program. I really don’t see how that isn’t a fairly simple way to adopt a proposal, and it’s something MA is already looking to do to fix the DCFS mess-consult outside experts, draft some new policy options, pick one, then implement it.
How will we get insurance companies on board? How will we deal with opposition? How will we sell this-those are political questions. Good questions, but questions that are unrelated to how this policy can be realistically implemented. Vermont offers us a fairly straightforward model of how to get a legislature from Point A to Point B and it starts with electing a Governor who makes that his top priority.
I think a public option phase in, which was one of the options presented in Vermont, may be more feasible since we have so many private carriers. Or adopting a Swiss style system where a baseline level of care is established by a Mass based Medicare program that everyone is automatically enrolled into, and then supplementary and elective care can be provided by optional insurance people buy through our existing exchanges as individuals. But I think killing employer based insurance is absolutely essential to getting the most economic benefits and conversely getting the business community on board with the transition.
Another approach for incremental, around-the-edges, single-payer creep.
You can also do Hobby Lobby style religious exemptions for more and more (routine) things.
–“The Hobby Lobby Case Proves the Necessity of Single-Payer Healthcare,” LAT
Is full of profit-raking middle men – e.g. Insurance companies – that contract with the states to administer all or parts of the subscriber enrollment, provider credentialing, network development, claims payment, utilization review and customer service processes involved in paying for provider services. One has to expect a state single payer system to work the same way – the information technology systems to support these functions are complex and expensive enough that the state will hire them out to an organization already positioned to handle them.
That in spite of all those middlemen it still delivers a more affordable, cost efficient, and medically efficient standard of care to the most people?
There is never going to be a flawless health care system, maybe Heaven has one since there are no sick people there, but you will always have issues since humans get sick and humans are the ones in charge of the systems that make people well. What we can have is a system that is more affordable, more equitable, and more just than the system we currently have.
What we can have is a Canadian style system, one that is obviously imperfect, wait times may be longer and certain elective and alternative medicines are under far stricter coverage guidelines than they are in a private plan.
It’s little things-like standardizing the kind of replacement knee you choose-that Medicare or a single payer system are very good at. And those little things add up to a more efficient system.
But Medicare reimbursement rates don’t cover the cost of services at Massachusetts hospitals and provider organizations. The result has been that provider organizations have sought higher reimbursements from private insurers, pushing up their rates and effectively subsidizing the public program while making private insurance appear less efficient.
If hospitals had only Medicare and public programs as currently reimbursed, they couldn’t make it financially. Many are already struggling with only 40-50% of cases being paid under Medicare and other public programs, as noted in this recent Boston Globe article.
The shortfall due to low reimbursement rates from Medicare has been a concern for some years – the Mass. Hospital Association put out this piece several years ago: Hospital Costs in Context (MHA). This piece critical of Partners, “Behind the Ledger – A Look at Partners” includes a chart showing losses from Medicare and other government insurance.
I’m skeptical of the claims made for single payer and don’t think we should rush in, particularly with the opportunity to learn from Vermont’s experience as they implement their law in 2017.
We’d have to be slightly more generous than medicare rates, but I think you and many others underestimate by orders of magnitudes the extra costs it takes to have so many different insurances and figuring all of that mess out — time and money keeping nurses and doctors away from patients, and money spent on more administration instead of more nurses and doctors.
Take all of that out by streamlining things by leaps and bounds and we’re going to have a very different, better and less costly system. If you’re having a difficult time wrapping your head around that… please look at almost every other single health payment system that exists all across the developed world (and beyond in some cases).
PS The Mass Hospital Association is a corporate industry group of lobbyists that care about hospital profits. They’re about as reliable and trustworthy on health issues as the NRA is on gun safety.
Of course the MHA is against single payer. So what?
PPS. We’re all going to wait to see Vermont implement their law in 2017 regardless; there’s no way we’d ever be able to move things along fast enough to do something before then regardless.
But it would be nice to see the legislature in the meantime pass a bill that studies the issue in depth, that looks at Vermont in depth, and sets us in motion to be able to institute our own plan after we’ve spent the necessary time to figure everything out.
We can learn from Vermont and do it better in the process.
It’s a straight up study of hospital finances. The Globe article and piece critical of Partners make the same point: if you had only Medicare reimbursements in the system, at current rates, Mass. hospitals wouldn’t be making it. Roughly a fifth of them are having trouble making it now, and most of the others are in the black by small percentages 3-5%.
Hospital billing is going to remain a significant labor cost even in a single payer model done at the state level because Mass. hospitals draw something on the order of 6% of patients (somewhere else in this post, I estimated that at 1.3M visits per year) from out of state and because medical billing in a fee-for-service world is a complex, code-based activity, even if the hospital is billing the insurance company or companies contracted to run the state’s single payer plan, instead of companies contracted with employers and individuals.
… it is a rather hand-wavey study of hospital finance in a cruel and inefficient system… It is anything but straight up in that it makes no mention of the cruelty while casting sly insinuations about the inefficiency somehow being due to the parsimony of medicare.
Hospitals, in the system we have, might be the sickest patient of all…
Since my local hospitals suffer from distortions in reimbursement rates, and have a disproportionately poor and sick patient load, I’m not going to argue with you about the existence of a genuine issue with under-reimbursement and cost-shifting.
But. That’s one of the things that we have an opportunity to fix, and one of the things that I expect a well-designed replacement system to address. If you think about this as the kind of systemic problem that the nation used to address with the old regulated-industries model, it may be simpler: the specific issues with Medicare/Medicaid as it exists at this moment drop out. We want to get rid of the distortions and the expenses inherent in our multiple payers and increasingly intricate contracts for networks, differing levels of coverage, differing levels of reimbursement, etc. We expect significant efficiencies from doing that, as well as more transparency and fairness. We also want to recapture a lot of the money now going to insurance company profits (or to insane executive compensation in lieu of showing profits). Hypothetically, we could achieve the same goals with a strongly regulated single private insurer, or even with multiple private insurers who all offer a single plan administered under the same rules (I’d have to look this up, but I have a vague memory that Switzerland may use a system on that model).
Medicare for all, as a slogan, isn’t intended to mean that anyone expects or intends to replace the current patchwork by giving everybody Medicare exactly as it exists today. No one who thinks about this stuff is under any illusions that Medicare is perfect as it is. The idea is that it makes a starting point for a single-payer system that functions without making the entire healthcare system a government enterprise — without the state assuming ownership and control of hospitals, physician practices, and so on. Medicare-for-all is already different from Medicare for some, precisely because it doesn’t allow the cost-shifting that Medicare as it exists requires and encourages. It stands for a better Medicare, not for a mindless replication of existing issues.
That wouldn’t matter if any of the points you’re raising were impossible to address. But they’re not. They aren’t problems that inevitably result from this form of single-payer, that every iteration of it will suffer from by its very nature. They’re eminently fixable, and the kind of thing that argues for careful design and implementation, not against doing it at all.
=$3.2k per person.
Obviously, coming up with an average like that is a rather simple and blunt tool, but that would be the “average” cost to taxpayers in Vermont if the total cost was $2 billion.
The direct comparisons to the health exchange plans was to put these costs in context.
No matter how you slice it, though, a $3.2k per person average cost for health care in Vermont is not a bad price in comparison to the market.
As I said above, obviously there would be a few hiccups. The federal government would still have to provide the same that it is under the ASA. Some tax issues would have to be worked out.
None of these more complicated issues are unsolvable or even all that more complicated than the current system, though. The rest of the world has figured it out — I have no doubt that Vermont can, too.
Al
Thanks Ryepower12 for such a clear answer here. I suggest that folks go online and watch for free, the very humorous documentary film,” Sicko” produced by my old friend Michael Moore if they wish to really grasp this point. In that film he looks at the Health Care systems in Canada, England, France and Cuba. The folks in all of these countries were much happier with their systems than Americans have been with ours. Moore also reviews the history of how the Republicans misrepresented the truth to the American people regarding the changes that Hillary wanted to make with Healthcare during the Clinton era. It is enlightening to look back at this and see that we could have been so much farther ahead with healthcare if we hadn’t believed the lies and disinformation campaign that killed reform then.
…the video currently on the front page, my interview with Don Berwick, where he explains how we can and should get there.
Yes, of course John. My reference to Sicko was more about hearing how folks in other countries who have Single Payer view their health care systems.
I think the question is how the transition to single-payer works concretely. I don’t think asking or answering that question is a matter of indulging in “lies” or “disinformation” or even “scare tactics”.
I’m particularly curious about historical experiences, e.g., how the transition happened in countries that now have single payer.
Right wing backed corporate fronts, and the industry itself, engaged in very misleading ads in the 1990’s fights. Every part of “Harry and Louise” was a lie. So that is what lspinti was talking about, or the BS about Canada the Troll and Keller were engaging in.
I think actually watching the video, and listening to Berwick’s more detailed responses, will show that his plan is actually fairly solid.
The Olympics, whether you are for or against them, are something that we don’t, presently, have. Health care is something we, right now, possess. So the analogy breaks down fairly quickly: implement something brand new and not done before (here) vs re-structure an existing component of the economy. What we are talking about is juggling the money that is paid now through several different, and inefficient, gatekeepers or funneling the money through one, and only one which acts as administrator and not gatekeeper.
But each of those expenses listed represents an administrative process and subsequent decision on care. In the case of the expenses the decision came down as ‘yes’. A ‘no’ decision still eats administrative costs, even if no expenses were paid, and raises the cost overall. The present health insurance model, more or less arbitrarily, tries to balance the ‘yes’ and ‘no’ decisions with a view to the solvency of the insurer rather than medical efficacy.
Although, as you point out, 80% of the CommonWealth market falls under 3 companies, that is not three pools: each company has multiple plans and multiple pricing for different payers like employers, supplemental and families and wholly separate plans and pricing for prescriptions versus procedures. There are, probably, hundreds of pools and they are defined actuarially, again with a view to solvency rather than medical efficacy, and a key component of each is the number and type of people they exclude. Each of these separate pools has administrative overhead. This does not even take into account legacy plans from mergers and buyouts, but such plans can throw the curve drastically. On top of that, there is an overhead to the overhead, for bringing the paperwork of the different pools under the umbrella of the three companies. It really is a cruelly inefficient system.
Since ‘single payer’ is also ‘single pool’ there are will be no arbitrary reason to deny care: if the pool is defined, succinctly, as ‘everyone’ then exclusionary administrative overhead, a key component of the present system, simply disappears. The ‘no’ decisions will decrease drastically in the limit of medical necessity and preventative care, because there will be no need to make the determination, first, that patient X is in a pool and secondly, the pool they are in provides services for the particular ailment/condition from which patient X suffers. As preventative care becomes the norm (rather than preventive administration) overall costs will decrease As the size of the pool is increased to the largest possible size (everyone…) then individual dollars will go farther towards medical procedures and administrative overhead reduces to raising taxes, signing checks and policing for fraud. If you don’t exclude people, you won’t have to pay the cost of excluding people: which costs include the discernment of whom to exclude ad the burden the excluded place on the entire system… precisely because they were excluded in the first place.
It’s not at all clear that any increase is certain nor that premiums paid today would somehow not translate to taxes (or fees) paid tomorrow. Yet, even if the short term costs of transition are extreme, in the long term it’s an incredibly good call… The costs would have to be several orders of magnitude higher than a 33% increase to justify maintaining the present system…
A well-designed single payer system will also save the tremendous costs that currently go toward administration of our insanely complex reimbursement/payment system, on every level. The current administrative burden imposes costs at every level. It means more people in physicians’ offices who have to know more about how to bill and code than about how to recognize when a patient needs to be seen right away instead of given the “next available appointment.” It means people in medical offices and hospital administrations that spend their time reviewing and negotiating insurance contracts rather than providing anything resembling health care. It means health care providers who could be spending more time with a patient, if only they didn’t have to be on the phone advocating for something that patient needed, and arguing that it’s supposed to be covered under their plan. It means hospital administrators spending their time devising arcane fee schedules that shift costs in response to their best guess at what the patient load will be like, and what mix of insurance plans the population it serves will have.
And of course, current costs also include the wasted hours and considerable stress placed on the people in need of health care who have to navigate the system.
All of these and more are true costs, deadweight losses that inflate the price of healthcare without providing any value in exchange. A good single-payer system should allow us to recapture a lot of this loss, and thereby offset at least a good chunk of the costs of making the transition. Ultimately, of course, whatever the formal financing mechanism for single-payer is, the cost savings should mean that it’s a wash or an improvement for individuals and businesses: if there is a single-payer tax, but it’s lower than your previous health insurance premium, you’re still ahead of the game.
Administration to deal with different payers won’t go away if single-payer is implemented at the state level, as, presumably MA won’t paying for care for any one who presents here, only for MA residents.
But those are special cases. There’s an enormous difference between Brigham and Women’s needing some people to help deal with out-of-state reimbursements (though they’ll still need fewer than if they also had to deal with multiple insurers and plans and networks for Massachusetts patients) and having your Cooley Dickensons and North Adams Regionals keeping staff to deal with a dozen different plans and payers.
You’ve raised this more than once, though, which suggests that it’s something you’re seriously concerned about. Do you have numbers we should be looking at, or more information about how out-of-state patient billing is handled at these institutions now?
A 2009 study had MA hospital admission rates at 124 per 1000 residents vs. the national average of 116 per 1000 residents. If you assume MA residents aren’t significantly unhealthier on average than other states, the difference is out-of-state utilization. Multiplying the difference by the number of hospital visits gets you about 50,000 out of state admissions per year. If you assume the same ~6% out-of-state ratio applies for ambulatory hospital visits, you get 1,250,000 additional visits, for a total of 1,300,000 hospital cases.
… and say this is bunk. The difference might be Romneycare versus none other. Context matters… and in a state that in 2006 passed a bill seeking to cover all CommonWealth residents, and by 2009 had, it was purported, raised the percentage of uninsured to some 97%, might, indeed, be expected to see a greater number of hospital admissions. MA residents aren’t significantly unhealthier, but they are significantly more insured.
What did you think would happen? Did you assume that the baseline health of the previously insured somehow mirrors the baseline health of the population as a total? As though it’s a linear function? Where would that kind of logic come from?
Typically in the US people sick enough to require hospital admission are admitted regardless of ability to pay (recall repurposing the so-called free care pool to pay for insurance was one of the key parts of Romneycare) so admissions would be the healthcare stat least sensitive to differences in percentage insured between states. Not true for primary care or other services. 6% certainly is in line with what we see at the hospital where I work.
People sick enough to require hospital admission are always admitted regardless of ability to pay, but are rarely diagnosed as such until the situation is life threatening. As insurance rates are increased diagnosese would be expected to increase as well. As more people are insured, more people will see the doctor. As the doctors see more people more diagnosese will be undertaken. As more diagnoses are undertaken a concomitant increase in hospital admission is likely to be seen… well before the situation is dire.
This is especially true when you consider that a subset of the previously un-insured were uninsured because of care denial (refusal actually)… either pre-existing or overly expensive conditions or those on the other side of a catastrophic condition that exhausted… The sickest part of the population is often the least insured but not insuring them has not changed the underlying conditions nor the population metrics.
I wonder if you are under the impression that any of the proponents of single payer care are themselves under the impression that a more efficient and compassionate health care system will mean less health care overall. On the contrary, it will mean more health care. More people insured will mean more hospital admissions. Doctors are going to get pretty busy. Your hospital will be busier. The hope is that such care will be better, earlier and more comprehensive but certainly not lesser, quantitatively…
Because whether we find ourselves trying to move to single payer or not, it’s a reasonable question and one that’s worth engaging with. But I have to agree with petr that there are too many variables to assume that the difference between our admission rates and the national rates makes a good proxy for percentage of admissions of out-of-state patients. There are too many other potential reasons for the discrepancy — and anyway, before this would be meaningful we’d need to look at more precise comparables, like admission rates from Northeast states, not at a nationwide average.
If rates in Mississippi and Alabama are 72 per 1000 residents (wild hypothetical, made up entirely out of my own head and not intended to disparage any state), that might mean Mississippi and Alabama were healthier than Massachusetts; it might mean that lots of Mississippi and Alabama people were being treated outside their home states, or it might mean that people who’d be admitted if they presented with a given medical problem in Massachusetts aren’t admitted in Alabama — or don’t go to the hospital in Alabama because they expect to be turned away. Et cetera.
If our admission rates are higher than average, in other words, we need to know why, not simply assume that we can attribute all the differential to out-of-state patients. We would/will also need to look at what the out-of-state patients who come here are being treated here for, in which of our hospitals. (I’d assume that most of them are referred here because they have non-routine medical issues of the kind that need the most specialized care in the world: the kind of thing where there’s one surgical team in the world that has a good success rate with a complex procedure, or one oncology practice that’s doing cutting-edge research on the treatment of tumors with a particular set of markers, and so on. Or, on a slightly less extreme level, because they’re not great surgical risks but need complex surgery, and their home town doctors want them to see the specialist at Beth Israel who does two of a procedure a day, rather than having the surgery done locally by someone who sees one patient who needs the procedure a year. Because you’re not going to travel to Massachusetts to have your gallbladder removed, right? But that’s just speculation; it’s no substitute for knowing the actual numbers.)
These are things we’d need to think about in building a single-payer system, because you’re right: we’d need a mechanism to handle reimbursements from this patient pool, and people to do the day-to-day work. But there’s still no reason to think that doing that would require the staff levels we see now, or contribute to the distortions and cost-shifting our current multiple-payer system does.
All that said, it looks as though we’re both speculating. Without a better numbers, all we can really do is note the existence of the practical issue. But it’s one that every single-payer system has to deal with on some level, and even your suggested numbers don’t indicate that it would make single payer not worth doing. Or if they do, I’m afraid I’m missing something about how.
Very Big Picture: take the money people (and employers) now pay for health insurance, co-pays, and other out of pocket expenses. Put it in a pool. That’s where the money comes from. (This has been another episode of simple answers to simple questions.)
In point of fact, you probably only need about 75% of that money. So you can keep 12% for a rainy day, and give the rest back to the taxpayers.
You might get extra savings. For example, you no longer need to pay salaries for the people whose job it is to find reasons your life-saving treatment isn’t covered. (Sorry! So sad.) And you no longer need to pay for the ads on TV and radio and buses.
Sure, there are complexities; we *like* to talk about policy, we *like* complexities. All those people in the “sorry — we found a reason you aren’t covered” business will need new jobs. All sorts of paperwork will change — it’ll be simpler, but it’ll be different and that’s going to disrupt lots of medical offices. We’ll sort it out.
But the basic idea is not that complex.
Got questions? Sit down for ten minutes with Don Berwick. I’m serious: you can do that, and he can do it too. Get as detailed as you like. He’ll lay out a plan and a bunch of options and alternatives.
And I don’t know how to achieve it.
But I do know that anyone imagining that this is easy is kidding themselves. We’re talking about one-sixth of the largest economy on Earth, plus considerable resistance to change from powerful constituencies.
but there are two different problems you’re describing — policy and politics.
The policy problem can be navigated, especially coming from the perspective that it can be tweaked to be made better over time even if there are some hiccups along the way.
The politics problem seems the more complicated and difficult to me — undoing decades of misinformation in the public and billions in the hands of interested parties. Even there, though, the issue can and will be solved eventually — even with the ASA’s band-aid, our system will eventually necessitate the transition toward something at least similar to single payer because that’s the only system that can deliver the quality deserved by all at a price that can be afforded.
…but federally I’ve always figured it was simple matter of amending the enabling legislation for Medicare to eliminate the age 65 minimum.
1) At the State Level
We look to VT and see how they adopted their system and figure out a way to achieve it on the significantly larger and more complex scale required in Massachusetts. VT hired a Harvard health care economist to guide the legislature through the adoption of the policy, he came up with four proposals that would work for VT. One simply expanded it’s existing (and generous) Dynasaur and Green Mountain Care program to cover more of the middle class than the ACA does, another was a public option, a third was a cooperative model utilizing the single HMO VT had, and the last was single payer. He said single payer made the most sense, and the legislature adopted it.
In MA, with a stronger and more reluctant insurance industry, we may need to pursue an incremental approach-an opt in public option designed like Medicare is on the federal level available to everyone. But Dr. Berwick as a health economist himself, and someone familiar with teh VT approach, will gather a team of policy planners to craft a policy and has a team of legislators to actually enact it. That is the two pronged approach I am seeing.
2) What does he mean by Medicare for All
He doesn’t literally mean adapting the federal program or getting a waiver for MA residents, it’s a neat framing device since Medicare polls well while scray sounding ‘socialized medicine’ does not. But the goal is to essentially create a state Medicare system that every resident can opt into.
3) Is it easy or hard
The policy is actually quite easy, but as rye pointed out, the politics will be incredibly hard. But I say to the ‘magic wand’ naysayers, that the Berwick team recognizes it will take far more than a magic wand and it will take an animated grassroots to push for it during the process. To paraphrase Kennedy, we just to do these great things not because they are easy but because they are hard. This can be a policy Apollo project triumph for our state, one that will reduce costs for actual MA taxpayers and health care users, while also showing the country and the world the important ideological argument that America is more than ready and eager to join the rest of the industrialized world in providing health care to all it’s citizens. That is a fight worth having, worth fighting, and worth losing if need be, but I’d rather we fight than sit on our hands and pat ourselves on the back and ‘call it a day’ at Romneycare as Berwicks Democratic and Republican opponents alike would have us do.
No, of course it’s not going to be easy on a political level. I don’t think anyone is under the impression that it will be. But incredibly hard and impossible are very different things. And you’ve got a much better chance of doing the incredibly hard thing if you don’t start off believing that you can’t do it at all.
All things are ready if our minds be so, right?
And what the hell, I’d be willing to pay a new tax as well, something proportionate to my meager income. It will sure be nice to not to have to pay these exorbitant insurance premiums anymore.
Only fear and the enormous clout of insurance companies prevent this from becoming a reality, as far as I can tell.
the state constitution prohibits?
Putting that aside, I’m strongly in favor of higher taxes on the highest earners as a general matter. But health insurance systems generally have dedicated revenue streams. They don’t come from the general budget. How on earth are we going to sell a tax on “the rich” to pay for health insurance for everyone, something traditionally paid for by the insured themselves or their employers?
…the jockeying to deflate its *political* advantages for some politicians/candidates is underway. A playbook for opponents, adapted, in brackets, to current context:
…in other words, deflate the lofty goal by repetitive rhetorical reframing of the small bore details.
No doubt that the specifics of implementation of single-payer reforms are complicated, enormous and fraught with political challenges–and to achieve it, experts and leaders will have to execute.
But as we have learned again and again, when we pre-compromise our vision, we end up with very little.
We didn’t get civil rights reforms because of small bore realism about what was and wasn’t possible. We got it because brave people demanded it and brave leaders took up the cause, rejecting the timidity wrapped in pretenses of “realism”. We set the goal then we make it happen.
You get a person on the moon because you say, “this is what we want to happen; now let’s figure out how to get there,” not by saying, “we can’t get there from here.”
These kinds of posts/questions are valid, in a larger context, but they are not sincere in this specific context. They are meant to distract and deflate on the issue of single-payer, because and only because it’s giving one candidate an advantage.
I ran across this article yesterday, when looking thru the Hobby Lobby commentary, and while the overall tone is much stronger than I’d apply here, it’s an interesting evaluation of the “realists” versus the “big change” activists of the past, and has some parallels here:
Of the two, I’d say women’s liberation fits better than the moon launch. Nobody was against going to the moon, but there was (is) resistance to women’s rights.
I agree generally that we shouldn’t limit ourselves in advance, but we have to know what we’re up against too. Doctors, for example.
FWIW, I happen to know a lot of health care professionals, including doctors, and you can’t find more passionate critics of the status quo or stronger supporters of single payer. Of course, there are many doctors out there to Protect Theirs, which might mean protecting the broken system we have now. They are on the wrong side of history.
And we need current information, because some of what a lot of us have assumed about it has either changed or is in the process of changing. I think doctors may be in the process of becoming our allies, overall, if they’re not there already. Cautious allies, but allies nevertheless. It would have been different 20 years ago, but that was before insurers turned themselves into the Big Bad of medicine.
in “repetitive rhetorical reframing of the small bore details.” I just want to know what the broad strokes of the plan would be, and “there will be some kind of tax or fee and everyone will get health insurance from the state” is a little too broad.
I know, though, that opponents will do exactly what the Kristol memo suggests and that citizens will, in fact, have concerns about “the effect of proposed reforms on individual American citizens and their families.” Proponents should have good answers when they do. Suggesting that everyone who asks the question is channeling his/her inner Bill Kristol won’t cut it.
The federal Medicare for All ideas have centered around increasing the 1.45% Medicare payroll tax to 5%. That would apply to both employee and employer.
Given that people would no longer need to pay health insurance premiums, that would be a huge cost savings for most taxpayers.
http://www.medicareforall.org/pages/Tax
Broad enough?
For a federal plan this would be great if the numbers work. For a state plan it might be more (fewer economies of scale). But using this number “taxes” go up 3.5%. If workers don’t have to pay premiums they could come out ahead, but only if enough of that money is added to their pay. If they don’t pay premiums, still the case for at least some people, they lose absent a raise they may not get.
Presumably both members of a couple would pay this 5%, whereas often only one pays the premium now. Stuff like this. I’m not saying it can’t work. I just want to know how to protect hard-working stiffs from coming out behind.
With premiums much higher than that. Take away whose premiums and they’re ahead.
???
What percentage of the population out there doesn’t pay any premiums? I’m willing to bet it’s astoundingly small — and largely centered around jobs which are decidedly not filled by working stiffs. It’s a detail that can work out, nonetheless.
Those who make so little income that they get medicare or are on Com Care or are otherwise so heavily subsidized that their costs would be less than 3.5% of their income would still get it for free or subsidized. That is something that would of course make it into any legislation — in fact, it would almost certainly be mandated through ACA.
I’m not talking about people who already qualify form ComCare or Medicare. Imagine a couple with both people working. Together they make about $100,000. They’re not poor, per se, but they’re not rich in most of eastern Massachusetts either. Right now they get their insurance through one member of the couple, who pays $185 per month because the employer picks up 80%. The total premium is over $10,000 a year, but the employee’s $185 monthly contribution represents only about a $120 cash loss because it would be taxed if not going to health insurance premiums.
$185 x 12 = $2,220
$120 x 12 = $1,440
A 3.5% additional tax on $100,000 of taxable income = $3,500
Tell me how that couple doesn’t come out way behind?
In Massachusetts (and in the U.S.) we have a bit of a demographic donut hole. A lot of people in that $75K-$115K range vote Republican because they make too much to qualify for any subsidies but not enough to feel comfortable paying for big-ticket items out of pocket. They feel squeezed and screwed by liberal policies, rightly or wrongly. I say we fail to consider how they fare at our political peril.
100% employer-paid insurance is much more rare than it used to be, but as recently as 2012 16% of American workers still had it. Not all of them are high-income. My cousin is 25. He works for an employment agency in New York. Made about $35K last year. But insurance was 100% paid by employer.
The linked article says that, in 2012, the average employee’s burden for a single plan was $951 (pre-tax). A 3.5% tax exceeds $951 for anyone making over about $27K. For a family plan, employees contributed an average of $4,316 (again pre-tax). They’re more likely to do better with your proposal, but the half or so of workers who pay less than that still might pay more with a 3.5% tax for a single-payer plan than they do now.
I have no doubt these problems could be fixed but we can’t just pretend they don’t exist.
It’s not supposed to be a gift bestowed upon you by kindly and generous employers. If your employer kicks in $2000/month toward your insurance, that’s $2,000 you don’t see in cash on your paycheck.
Of course, we’ve been conditioned to think of insurance as a special prize, not an EARNED benefit, and now the Hobby Lobby case codifies it.
–“The Illogic of Employer-Sponsored Health Insurance,” NYT
on this. Insurance would not be considered a prize or a gift from a munificent employer if you understand that system. Many people don’t. In their minds, they “make” $50,000 or whatever number. Generally their own contribution to premiums comes out of that, but the employer’s share is never considered as part of their compensation even though it is.
Absent a legal requirement to direct some of those savings to workers (which I think is unlikely), I don’t see employers doing it willingly. It would take leverage on the part of workers, which is sorely lacking in an era of slack labor markets and weak unions. Even back in the 90s Alice Rivlin told Congress that inflation wasn’t coming despite low official unemployment precisely because, compared to previous generations, workers felt less confident about demanding raises. That’s gotten much worse.
Here I thought you’d only implied this, but you flat out said it. And you’re totally wrong and I don’t appreciate it.
And I haven’t appreciated much of what you’ve said, and think you’re flat out wrong. But that’s what happens in dialogue over contentious issues. The contention here is a mystifying, “We all want single payer. You don’t have the right details,” which only makes sense when taken in a political context. I appreciate that you are disagreeing with my assessment and as such, I will try to read your interest in a politically neutral light, but it’s not how it’s come across so far.
Again, what’s the solution, if the broad and the specifics are too fraught with the problems you’ve painstakingly pointed out?
Is it:
“it will never work; you shouldn’t bother trying”?
“you’ve got the wrong answers, but there’s a right one; I expect YOU to find it by following my criticisms about whatever you just said”?
If it will never work and we shoudln’t bother trying, why are we talking about it right now, if it has nothing to do with the Gov’s race?
If there’s a right answer, and you have a better understanding of the details and complexities, by all means, TELL US because I really want to move beyond the wasteful, expensive, not-terrific-in-terms-of-health-outcomes, unequal, frustrating, inefficient system that we have today.
It might be useful, harmonywho, to take fenway49 literally and not to try to dive into his or her intentions secret or otherwise.
Also you are under no compulsion to answer fenway49’s questions, but your non-responses have become repetitive and not usefully so, in my opinion.
I’m not seeing (or feeling) any ad hominem. I’m asking questions, as questions have been asked of “us” (the “staunch supporters”).
I see repetitive questioning coming from the Non-Staunch Supporters, and valiant and thorough responses from Staunch Supporters. And more questions. That’s all fine and fair, but so is asking questions back in return.
I do agree; repetitive questioning and covering the ground that’s already been covered isn’t particularly useful in resolving the question of single-payer healthcare, but repetitive questioning/retreading covered ground does serve to distract the larger political conversation. Whether that is the intention or not; it is an effect.
If you had a magic wand, would you wave it and enact single-payer healthcare today/now? Are you a staunch supporter of Single Payer? Or a not staunch supporter?
Since no magic wand exists, how would YOU get us there? How would you deal with the Big Corporate interests, the scare-mongering, the legislative timidity and lack of bully-pulpit leadership on the issue? How specifically would you take the Money and put it into The Pool? Write a check? EFT? Payroll tax? WIthholding?
is, frankly, useless and unilluminating.
But I didn’t raise it.
Up above, fenway49 suggested that people really committed to this issue might be able to answer some of his/her questions because, well, they must have thought about it more. That’s not an unreasonable guess. That’s what was meant by staunchness.
This has been transformed by you into questioning whether a preference for single payer was weak or strong.
Please read my earlier question about “staunchness” with the problematic phrase replaced with “are you really committed to single payer? ”
The questions still stand.
Some of us favor stuff but we are not experts in it. By “committed”, fenway49 seemed to mean committed enough to have done enough research so as to be expert at.
Apparently neither fenway49 nor you are committed in this manner.
To say something is “ad hominem” is to say you are trying to move the focus from the content of what is being said to characteristics of the speaker. So while you may not be “feeling” any ad hominem (whatever that means), it is precisely what you’re doing.
Stop being so ad hominemy at me!! (Did I use it right?) You’re distracting from the issues and making it all about me.
(Mark Bernstein seemed to advocate that above, too.)
However, as I think about that it’s pretty complicated. The Commonwealth would be taxing employers based on a counter-factual. Businesses, for example, don’t have the same sized payroll year to year. Such a fee or tax would have to be very carefully legislated to avoid perverse incentives. Imagine an employer covering 80% of premiums now. If the new regime goes in effect in two years, the employer has an incentive to cut premium support in the intervening year. And sometimes, when business is not doing well, employers do precisely that.
Labor, by wide margins, supports single payer.
Plus, your calculations ignore any income exemptions that would exist.
That family wouldn’t be paying the 3.5 on the first 20 to 30k they’re making, so their yearly payments would be more like $2,450 to $2,800, without factoring any other income exemptions (like interest payments on loans or the mortgage, kids, etc).
that exempted the first 20-30K or allowed itemized deductions. That’s purely income tax in my experience.
I don’t oppose single payer. Just want a rough sketch of the funding. Why is that so wrong?
And every time you ask for rough sketches, why are you really asking for incredible details?
And why, after details are given, do you then every into BS DFW territory ignoring previous details, like the fact that we’d need a waiver for ACA which would require cost savings beyond the exchange for anyone eligible currently – which in turn would require large personal exemptions in any single payer tax?
I’m beginning to think you aren’t entering into this conversation earnestly.
Peace out.
Who hit the nail right on the head. Key takeaways:
All I was asking for was the contours of a plan that gets this done without hurting people who already get decent coverage through an employer at little personal cost. Finally I looked it up myself. It says this:
Something like that is all I wanted. At least mimolette was willing to have a back-and-forth and then say, you know, there are a lot of big things to be worked out. Some of you guys, though…
Suggesting that “large personal exemptions” in a payroll tax is the only way to get an ACA waiver when it could more cheaply be achieved by subsidizing the 15% or so currently on the exchange rather than giving everyone in Massachusetts a pass on the first $40K of income or something. Saying I go “into BS DFW territory.” Saying I’m not earnest. Saying the intent is to score points against a particular political candidate. Saying I’m “moving the goalposts” when the original question never was answered.
If you actually read my comments instead of jumping to conclusions, you’ll see an effort to reach understanding. I thanked people, including you, for every detail provided. Frankly, the hysterical bullshit I’ve been subjected to suggests a policy that might not be ready for prime time. If this is how things go with me, good luck with the 98% of people to my right.
Peace out.
At least, I’m not. Using a BMG post as a means of assessing the viability of single payer is really weird. And the only hysteria I’m seeing is from you.
The original post asked how it would be paid for. Ryan said, “Duh, a tax instead of premiums to BCBS et al.” The original poster and I both said, “well, that’s a little vague.” Everything else followed from that.
Offering some policy details, when the post specifically asks for them, is not unreasonable on BMG. I googled it and found something pretty easily. We had a post a while back on a more equitable tax system. People said, “Look, the constitution requires the flat tax. We amend or, barring that, we increase the income tax rate to X, raise the personal exemption to Y, and cut the regressive sales tax to Z. Same or more revenue, progressive instead of regressive. The Act to Invest lays out a vision.” It’s that simple.
Ideally, someone comes forward with a single paragraph like the one I found, someone else says, “Yeah, but this could be an issue,” and then another smart person says, “Well, we could do this instead.” An intelligent dialogue.
As for hysteria, your first substantive comment said:
Your second substantive comment said:
You say these assertions of insincerity is not directed at any one person, but it’s obviously directed at people who (1) support another candidate, and (2) are asking questions about single payer’s details. That’s me. It may not be just me, but it is me. And it’s calling my sincerity into question. That’s what “not sincere” and “cynically” mean. Ryan quite specifically said I, as in me personally, was not being earnest. How would you have me take that?
I greatly admire the passion and energy you bring to the causes you fight for. We definitely agree on far more than we disagree on. Dismissively impugning the motives of allies is unnecessary and counterproductive.
As does KBusch for her contribution.
We just can’t pass a bill to find out what is in it, we already tried that with Obamacare and looked what happened, insurance cancellations, premiums spiking on middle class income wage earners not eligible for subsidies, high deductibles, premier hospitals out of network.
It is appropriate to ask how we will fund single payer. Simple answers like “tax the rich” or “tax corporations” are not acceptable. Do public union contracts need to be renegotiated since they will lose their h/c insurance? Do we just tax wages? Why not a sales tax on everyone, including food and clothes (1% let’s say) IMO, everyone, including those making minimum wage, must and need to contribute something to the cause as well as non-profits (all of them).
You’re doing a lot of that yourself, the difference is that I’m not taking offense and posting about it because I expect this sort of thing in political debate. I guess I expect that everyone else thinks the same, but if you’d like I can pull the quotes where you are dismissing the efforts and ideas of others, but why? Who cares? I don’t; this is what happens when you have points of contention. People discuss their ideas and, often on BMG, there are passive aggressive slams and subtextual disses. It’s Chinatown, IMO, so I tend to try to take it when aimed at me and move forward. I don’t see any profit in dwelling on it.
You’re right: I think it’s the height of disingenuousness to pretend there’s no political subtext abt the Gov race. You refute that. I didn’t mean it as a personal insult, but you take it as such. So now what?
I’m fine with asserting it and you refuting it. It’s your word against my interpretation, and i take your word under advisement, but again I dont actually see the big deal. This IS politics. I don’t mean this as cold as it is going to sound, but who cares? If I were ever to meet you in a bar I’d give you a big hug and buy you a beer because I think you rock. Regardless of the sturm und drang about motives and intention and umbrage and insult.
I’m utterly serious that your skeptical and critical POV on roll-out of single payer is valid and your efforts at SOLVING the hypothetical conundrums (conundra?), thru suggestions and thought experiments, would be beneficial to bringing us, on this thread, to single payer prime time. Why you don’t want to do that is unclear, especially if gub. politics is not part of your agenda. And again, who cares? Your reasons are yours.
If you want broad answers and specific details in response to your questions, read back thru all the other comments not about politics. They’re there. I imagine it’s frustrating for those commentators that their substantive contributions have been rolled up into my distracting contributions.
I think this thread has successfully proved that the argument, “Our current healthcare system has a lot of waste and can be replaced by single-payer healthcare system by rechanneling those extra dollars” is completely convincing — completing convincing, that is, for getting Don Berwick supporters to support Don Berwick.
This is a most excellent accomplishment.
Exactly. They even have a playbook:
It seems we are agreeing that these efforts to shift focus to “what EXACTLY are you going to do/give us details!” has a relationship to historical efforts trying to undermine progressive reforms as a whole.
Calls to “SHOW US THE PLAN IN GLORIOUS DETAILS” (often ignoring good — great — faith efforts by people like rye, mimolette, jconway, others, doing just that *as well as* point out why that’s kind of a weird request at this stage) remind me of when the GOP was saying, for-ever, “WHERE’S OBAMA’S BUDGET?!!!” Knowing full well that any budget submitted would be (1) voted down by Boehner’s House and (2) that they would use any line items in the budget to yell “SOCIALIST!” or whatever the fluck.
As people Here to Help single-payer NOT get railroaded by the conservatives — bring in the solutions, don’t just pat yourselves on the back for uniquely zeroing in on the problems! Help us beat the Conservatives!
Or don’t. But why not?
This is a discussion almost entirely among liberals. It is not an attempt to shift the focus in the general election at all.
A welcome enlightening moment for folk who get lost in the thread. Deep Breaths everybody
Just the primary.
from a payroll tax that exempts the final ($X – $117k) of wages, so why not the first $y of wages? There’s prior art, no?
But if you exempt the first dollars and not the last (most earners don’t get to 117K), you’re exempting everyone. Which is fine in one sense, but don’t you have trouble generating enough revenue? We’d have to see the numbers crunched.
Perhaps the threshold can be tied to the in-state poverty line. That should exempt no more than half the worker population (unfortunately, it probably IS about half), and perhaps even provide an incentive for other workers and their employers to encourage pay increases for our lowest-paid workers.
There is plenty of wealth and income in Massachusetts, health care costs fall most heavily on our least affluent residents, and workers under the poverty line should not have to pay so that our more affluent workers can buy more Red Sox tickets and gas for their jet skis, snow mobiles, and pickup trucks.
Exempt workers under the poverty line, make the resulting rate high enough to balance the books, and raise the capital gains and estate taxes if more money is needed.
My only concern with tying lots of policies to a single number (be it poverty line, minimum wage, or whatever) is that it amplifies the pressure to keep that number artificially low. Pressure from small-gov’t folks, pressure from businesses, and simply pressure from budgetarians who do the math and determine that an increase in that number (poverty line, minimum wage, etc.) will now cost the budget $X instead of $Y, where $X > $Y.
The flip side is that it gives activists a single knob to try and turn, instead of having dozens of simultaneous efforts to try and adjust all the knobs, levers, and switches available to improve the lives of the poorest in the community.
The program could exempt the first $10k or $25k or some other number. I just used $117k because that’s what SSI uses.
Alternatively, $y != $117k.
But exempting income over 117K (or any number you choose) means no exemption for those who don’t make as much. Exempting the first 10K or 25K or 40K or whatever gives an exemption to everyone. That’s of course what we do with the income tax so perhaps it could work just fine. Maybe the exemption could be the same as the state income tax exemption.
Whatever single-payer might involve, if it means that businesses could just stop paying employee health insurance premiums and keep the money for themselves …
… it would have been rushed through the Massachusetts legislature faster than greased lightning.
…in my post that David put on the front page, around 18 minutes in he talks about his plans for single payer – emphasizing that it is a simplified payment system, with care delivery remaining the same or improving as resources are freed up to concentrate on care.
http://vps28478.inmotionhosting.com/~bluema24/2014/07/don-berwicks-appearance-on-my-locall-access-tv-show-all-politics-is-local/
It’s at 18:36, by the way.
He doesn’t speak about the transition though.
Sorry
I thought I heard Don say in John’s 1 hr interview that the existing monies we pay into healthcare (insurance premium) would remain and pooled into one single payer system.
So if one works for a large national company, would those who work in MA would be decoupled from their employer sponsored insurance plan, join the state Medicare/single payer system and the employer is expected to pay the same insurance premiums but just send the monies to the MA Dept of Treasury?
Also, what if an employer dumps their health insurance benefit, who makes up the shortfall in lost revenue? And if there is an additional separate tax to fund single payer and businesses find it onerous, then they may relocate out of Massachusetts.
These are some concerns I have if we go it alone in MA with single payer. Don needs to get on talk radio so these questions can be vetted and our concerns alleviated.
Employers would have to be mandated to contribute.
Just like with Medicare.
For most businesses, they would save money, since single payer costs less than private insurance.
MA is unlikely to go it alone since Vermont has a head start… but should we, we probably won’t be alone for long – because the high quality of care and cost savings will have other states quickly following. That’s how Canada got single payer – one province enacted it, then the rest of the country saw how great it was and quickly followed.
I did not know that about Canada and how they enacted single payer.
And they’ve come out of those talks happy, because they see it as saving them money on their healthcare costs, and thus as a tremendous pro-business move. I agree that the word has to get out about this, because we’re practically conditioned to think of this kind of system as a form of anti-business, anti-growth, redistributionist social engineering. But when you dig down and look at the current system and the potential for savings, it turns out to be — dare I say it? — a model of old-fashioned fiscal responsibility.
I’m serious: if you have doubts, go to one of the berwick “meet and greets” and talk it out. He does this off-the-charts well. It’s not pablum; go into the weeds, he’ll go there. Go to 40.000 feet, he’ll go there, too.
His web site has the schedule.
It’s reassuring that Dr. Berwick can answer these questions and I’m interested in how he does so. I don’t see details on his site.
In general, one can expect single payer to bring down costs by somewhere between 5% and 15%. The question is how to craft legislation such that that reduction doesn’t end up costing some sector of the population more than before. Now, it certainly seems reasonable that that could be achievable. Reasonable but not certain. Our political opponents, by the way, are very good at exploiting uncertainty, so the more buttoned up such questions can be the better the political prospects. For example, people transitioning from from employer-mostly-paid expensive health insurance to 100%-employee-paid cheaper-but-better health insurance are going to be, well, quite unhappy. Figuring out broadly how to avoid that doesn’t seem like a small, minute legislative detail. And maybe it’s as simple as getting companies to pay premiums to the state.
In addition, to needing a new bureaucracy and maybe a set of coverage rules, we’ll also have to handle the sunsetting of private insurance carefully. If private insurance ends December 31, 2016, private insurers are going to have a lot incentive to do stuff that’s anti-social and harmful: delaying treatment until after the state takes over, not paying up on obligations because there are no longer any customers to keep happy, becoming slower or more complicated or more resistant especially in the final months.
Oh, and could I point out that conservatives are going to be quite excellent at providing a list of stuff to worry about? Pre-emption and grabbing control of the story now would be very helpful.
Gov. Shumlin has already talked about companies that moved to NH from VT that are moving back now that the biggest chunk of their labor costs has been taken care if by the state. I have this one shred of sympathy with Hobby Lobby-they shouldn’t be in the health care business! Neither should any employer. What business person, if they had the option of living in a system where that cost was picked up by the entire community, choose to live in the system we have?
Alabama spent half a billion in tax credits to lure an auto maker to their state and they ended up building the factory in Germany and Ireland because those two counties have single payer and an educated work force. This goes to the bottom line of our competitiveness.
Any insurance system, private or public, requires policies as to what it will and won’t cover. No medical insurance system has an infinite pool of funds into which to tap. Surely, too, a public system should be more humane, more scientific, more, outcomes-focused.
But working out all those rules is a large scale effort. Some of the science is inconclusive. There are a lot of medical conditions. Can we crib from France, here? Is it simply sufficient to use whatever Medicare and Medicaid already do? Maybe their rules aren’t really applicable to a larger insurance pool.
It would also seem to require setting up a state bureaucracy of some sort. Surely it will be smaller and easier to administer than all the redundant private insurance bureaucracies. It will still require some putting together. Such a bureaucracy has to be efficient and fair. As in really efficient and really fair.
Why? It will be under a lot more pressure and scrutiny. What happens when a private insurer screws up? The news reports it like a mishap befalling someone. Now think about what will happen when a public insurer screws up: it becomes a scandal, it will appear on conservative chain emails, etc.
It’s possible all this has been answered, but, as I think it through, it’s no small thing either.
I agree that these are difficult and intricate questions with difficult and intricate answers. That’s why I tend to rely on those who have made a career of successfully asking and answering them.
One of those is currently running for governor. I’m most interested in the responses of that candidate and his staff.
I tend to be less interested in challenges raised by those who may have a political agenda with respect to that candidate unless those challenges are a response to proposals made by the aforementioned professional.
One question I had is, “How did France do it?” The French have one of the better systems. How did they bring it online?
Well if you look at the dates countries began to institute single payer, you’ll note that most of them did so many, many years ago. In Norway it was 1912. So it’s not as if many of them have had to make a transition similar to that necessary in the U.S.
In the case of France, wage earners were brought into the system in 1945 and it was gradually expanded decade by decade. Farmers, for example, were brought in in 1961. It achieved universality in 2000. So that experience doesn’t look at all relevant to the Commonwealth.
The Spanish system is one of the more recent European single-payer systems. I haven’t looked yet into how they brought that on line.
You and I have been, um, the most prolific commenters on the thread. While I was out getting rained on you’ve posted several times. I’ll try to address it here.
Power-wheels asked for some details on how it would be paid for. Ryan said in essence, “a tax or fee – per person it will cost less than what we have now.” Power-wheels said that wasn’t quite specific enough. I agreed and said you can’t just divide total cost by population. Ryan later agreed it was a “blunt” tool. To my mind that math tells me it can be done. It doesn’t tell me how to do it.
I’ve just asked for a little more detail. Not a 200-page final bill with all the answers. Just something like, “According to X organization, single payer could be implemented in Massachusetts with a payroll tax of approximately Y percent, imposed exclusively on employers. This would generate sufficient revenue to subsidize, at least temporarily, smaller employers who currently pay less than that in healthcare costs.” With rough figures that have been worked out.
Instead I got:
The insistence on “give me the comprehensive details” is a campaign tactic to neutralize one candidate’s single payer advantage, (cynically) trading the larger goal we all supposedly agree with (single-payer healthcare) for the one-off electoral advantage.
I said “staunchest proponents.” That implies it’s relative. I’ve thought for 20 years that single payer (or something like it, as in France) is the best system. But I still have questions about the conversion process. I’m willing to say I’m not as staunch a supporter as those who’ve rallied behind a candidate for governor specifically because they support his vision of making this happen in the relatively short term.
I don’t know what’s so hard to understand there.
Why is it my job to solve them? I try to keep up on policy proposals but I don’t know everything. Here I’m just asking the intelligent, informed people of BMG for suggestions.
No. But other people get to talk too.
Is the discussion that prompted Ta Nahesi-Coates Reparations article. The article, which is probably the best written and most intelligently articulated point by point article I’ve ever read on the subject clearly answers two basic questions. Are reparations justified by history? Yes they clearly are. And who should ultimately pay? Clearly the United States federal government, as the Germans compensated Israel and the US compensated Japanese American internees. The other questions-the pragmatic implementation questions-are about the only ones his critics can throw up. And his reply was great, than pass John Conyers bill, pass that bill and actually get the economists and experts to come in and craft a proposal that is fair and makes sense. But we don’t get to Point B or C if we can’t even pass by Point A.
Vermont already did this. I have outlined how-they got a John Hopkins educated, Harvard tenured, health economist, who has already created successful plans in other countries like Singapore and Spain, to come up with a proposal that would best fit the conditions of their state. His first recommendation was single payer, he addressed the entire legislature, and they voted on it, and it passed. We can do that in MA. It may be that a public option or a different form of single payer is a better fit for our infinitely more complex state, with a stronger insurance industry resistant to change, and with our fairly more fiscally conservative political climate and economic status. But we won’t get to Point B-where the expert comes in-if we can’t get to Point A-where we decide that Romneycare isn’t good enough and we want more.
That is all Dr. Berwick and his supporters on this thread are arguing for, just as all Mr. Coates was arguing for is that the Congress actually have a study on the feasibility. Let’s just agree that we need to do more on this issue-and see the feasible ways it can be implemented. I see no commitment from the other candidates to discuss a real path forward for a feasible implementation other than the vaguest of platitudes from the frontrunner and downright condescension about the idea from the other challenger. I don’t see why Dr. Berwick has to endure additional scrutiny about his athletic abilities if he is the only player who has even bothered to bring a ball to the game.
Fenway, this is meant with respect and appreciation, because I have always admired your POV and thoughtfulness.
You have made both my comments and others’ objections about you and directed at you, and, speaking for myself only, my comments haven’t been about you, until this latest development, but part of a larger conversation/dialogue. A whole thread, a whole discussion board, a larger universe of conversations.
When you say, “Instead I got [your offensive characterizations directed at me and dismissing all of my good and valid questions that have nothing to do with the Gov’s race]”, you are not only placing an (unfilled) expectation on my one comment to Address All The Good Questions Satisfactorily, you’re ignoring everyone else’s substantive and valid responses that have appeared elsewhere.
Why isn’t it your job? Why is it my job? Why is it anyone’s job? As a community of intelligent and informed people, you are doing what you’ve accused me of doing — avoiding substance and engagement in the solutions you want to see. My reasons for doing so are that my grasp is more generalized, and I see others (who have already answered) addressing them with more details and supporting evidence/links.
From everything I’ve ever read from you, you’re smart and thoughtful. In my experience, someone who has criticisms of something always has an idea about how things SHOULD be. And, having professed your good faith (ie, your engagement [primarily cutting down the idea of implementing single payer and expressing disappointment in others’ efforts] in this issue isn’t a proxy battle in the Governor’s race), why not extend your engagement in solving the problem? It’s just a discussion board, and you can contribute your positive ideas as well as criticize others’.
Or not — it’s fine either way, but it is tiresome that there’s this tsk-tsking disappointment over ‘lack of good answers’ or whatever directed at ‘staunchest supporters’, expecting them to be experts on some floating set of problems when:
1) there are ACTUALLY experts out there who are working on it and haven’t figured it out yet
and
2) those who are tsk-tsking could be BOTH positing tough/good questions AND trying to help answer them.
A subtext of all of these discussions FEELS LIKE that (1) (above) means we shouldn’t move to single payer at all, and that any conversation saying we should is naive and wasted, and I cannot help but feel like that is, yes, a proxy battle in the Governor’s race.
It seems very disingenuous to me to claim that we are talking SO MUCH about single payer today generally and here specifically because of reasons quite distinct from the Gov’s race. Maybe for you personally there’s zero connection, and your particular need for these details is simply because Power Wheels happened to raise the question. Having raised the question, do you really think there is not a connection? I think you’re savvier than that, though I do not know you personally. But it doesn’t really matter one way or another. The conversation is happening and there are actual legitimate issues to discuss (and they have been discussed with great insight by mimolette, rye, others). It’s entirely possible for a Legitimate Conversation About the Issues to have an associated political benefit of casting doubt on a competitor’s standing in a race. Two birds/one stone!
It doesn’t matter whatever whether that’s your intention. I’m pointing out the effect, and that’s neither an insult to you nor a refusal to continue talking about single-payer implementation, in my personally dilettanteish and ItsJustTheInternet way. I dislike subtext in political dialogue. I like text, and naming the POLITICAL interests that this “C’mon Dreamers, Single Payer Is Unrealistic” serves is me trying to say what I think, surface a subtext.
It’s not an insult to you particularly or even an insult generally. If Not-Berwick supporters ARE using Single Payer as tactic to neutralize a Berwick advantage, then I’m here, as a Pro Berwick and Pro Single Payer Person, to call it out as a means of trying to neutralize. Not as a campaign operative, but as a person who likes to yak on the internet and likes to have straightforward, text not subtext, conversations.
Yes!
Suppose there was a hospital whose patient scheduling and information system was tied to old-fashioned DOS systems with black screens and green characters. The system failed all the time, patients couldn’t reliably make or change appointments, care providers couldn’t reliably get patient information. The IT department, although acknowledging the issues, privately “joked” all the time about how great the system actually was — their salaries were high, they had no fear of layoffs, their budgets were always approved. The hospital was itself in serious financial trouble, and so the cost of replacing the antique system precluded (in the administration’s view) replacing it.
As it turns out, the Executive Director of the hospital (who manages everything) is retiring, and so the executive board is recruiting candidates to replace her. Two of the three have been working for or with the hospital their entire lives. One came up through the ranks of the IT department. Both have long-standing personal and professional ties to the IT department and are very aware of and sensitive to the potential disruption a new system will cause for the current staff of the IT department. Interestingly, the third candidate came to their attention at the recommendation of a major donor (the chairman of a bank). The candidate had led the successful replacement of a similar system within the bank. Said the donor: “We were all apprehensive, and our IT people told us the new system would never work and that this guy would just screw things up. But he delivered on-time and only a little over budget, and the new system is ten times better than the old one. Now we’re just sorry we didn’t make this change years ago”.
The executive board has been arguing and debating among themselves for weeks about the three candidates. The outsider created quite a stir when he said “The first priority of whoever you choose must be to replace your antique information system. Your institution will continue to bleed money until you do.” When asked what, specifically, he would propose to replace it, how much it would cost, and which departments he would change first, he replied “I can’t tell you until I get here, because your institution and the system that you need to replace is unique. I’m happy to tell you what we did at the bank.” The executive board then proceeded to argue among itself about what processors, network connections, and displays the new system should use, when they should be deployed, and what each department should budget for all that. Several members of the board were disappointed that the outsider declined to express an opinion about those questions.
The other two candidates were more forthright. “Those are excellent questions, questions we ask all the time. Until we know the answers to those, we should not even consider replacing the existing system.” When asked about that replacement, they answered that it certainly was old. They suggested that the hospital have an analysis performed, and that the hospital defer any action until after the results of the analysis were in. They both said that replacement would be very disruptive, that the new systems other hospitals were using didn’t really work as well, and that anyone who tried to replace it was likely to just screw things up. They were evasive when asked about the sources of their opinion.
All this leads to a few questions:
1. How shall we characterize the response of the “outsider” candidate to the questions about the specifics of the replacement system? Is he being candid and professional, or simply evasive?
2. How constructive is the internal debate about the specifics of a new implementation?
3. How constructive is the response of the two “insider” candidates?
4. Which of the three should get the job?
I read some rave reviews about the issue section of Don Berwick’s website so I decided to check it out, and given the topic at hand I first opened the health care section. Regarding single payer Dr. Berwick says:
Notice he does NOT say he is going to implement single payer on day one. He says he will appoint a panel to investigate and report back on possible methods. That sounds to me a lot like having a conversation. Therefore, I would say to the Berwick supporters don’t disparage another candidate for wanting to have a conversation and to supporters of other candidates don’t treat Dr. Berwick like he thinks he can wave his wand because he clearly does not believe that. I think everyone on this thread (possibly even DFW) supports the goal of single payer so let’s refrain from jumping down each other’s throats quite so hard over what is a best a slight difference in approach and emphasis and return the discussion to the best way to achieve the goal.
But even if implementing single payer is akin to Moses parting the Red Sea, Don Berwick is the only candidate in the Democratic Primary who is against opening casinos in Massachusetts. This predatory sin tax will disproportionately hit lower income wage earners and do ireputable harm to families, their children, and the surrounding communities inside the impact zone of a casino facility.
Don deserves the nomination on his brave stance against casinos. But we all should ask any and all questions about implemting single payer when 48-49 states don’t have it.
Fenway is arguing that even having that level of involvement is jumping the gun without a full itemization for how it will be paid- but the proposal is the exact same kind as the one Vermont passed and will implement in three years. The very same concept-get a policy architect to craft a series of options and have the leg vote on it. That’s a lot more concrete than waving a magic wand or not doing anthing-Coakley and Grossman aren’t even pledged to having even this kind of action. So I’ll agree with you it’s not a magic wand proposal-but where I disagree is that it is a mere conversation. This is the Vermont road map to a T.
…but in any case my comment about remembering we’re on the same side and not attacking each other over details stands.
That is harmonywho’s reading of Fenway49, but it doesn’t match anything Fenway49 position in this thread — and, in fact, Fenway49 has been pretty clear about not asking for a “full itemization”.
I would agree with harmony regarding the shifting goalposts. I feel I have been a bit more dispassionate than she has in my engagement with Fenway, but I understand her frustration. We may just have to call it a day on this one-I feel that Berwick is proposing a substantial leap forward in progressive politics and policy for this state. The very kind of wake up call to the stale establishment that Fenway and others have been begging for in the past. This is the exact same roadmap Vermont took-and Vermont now has an implementable plan with a price tag-one they are still trying to fully fund admittedly. But they are now three years in front of us.
We shouldn’t let those details mire us down as it did for Hillarycare and Obamacare-massively complicated schemes designed to assuage the insurance industry and the middle class while failing to actually deliver the policy they need most. I honestly see nobody else in this race saying they will move beyond Romneycare but Berwick. And to hold him to a higher standard of policy rigor than those opponents seems a bit unfair.
As Rye has pointed out, the funding mechanism will likely be simpler and cost less for consumers than the status quo, as I have stated, the appoint an expert to consult the legislature model has worked quite well for Vermont. Fenway seems to believe this program will waste political capital, distract us from other progressive goals, and if Vermont ends up failing-push us down the cliff with them. He may be right in that regard, but I feel failing to take that chance squanders a political opportunity and puts a Republican in the Corner Office.
The questions raised don’t seem like details to me.
In fact, they sound like the stuff one could easily end up having to address in a gubernatorial campaign. Arguments that might make liberals comfortable can end up being completely unconvincing to those more skeptical of government.
It strikes me as odd too that there are so few sources on how the transition to single payer gets done. Spain has had one of the more recent transitions yet I haven’t dug up anything on their experience.
The Spanish experience isn’t particularly relevant either.
I was trying to figure out where this came from. So I reread the entire thread. (And, as a result, special props to mimolette, by the way.)
I think that came from an exchange Friday morning. 8:54, harmonywho:
There have been MANY ideas.
?
Exhaustive and comprehensive. I’d like to hear yours, still, though!
to which Fenway49 responded with a series of quotes introduced with “Where? There’s been a lot of this kind of general stuff.”
Now I noticed some of the more substantitve replies came after Friday morning.
Even so, harmonywho’s words, “exhaustive and comprehensive,” set a rather high bar which I don’t think anyone has met, tried to meet, or could meet on this exchange. I’d guess that harmonywho’s wording was born of frustration and fenway49’s of defensiveness at accusations that he was just posting for Grossman’s sake.
In any case, if that’s the evidence of goal post moving, I’m not convinced.
We have many, many great posters here from whom I learn a lot, but mimolette is an excellent addition. Smart, thoughtful, fair, always willing to engage in an agreeable way. I should start taking notes.
and, yet, every time anyone has failed to give a full itemization, we get posts from him complaining about it.
It’s like going to a restaurant and telling the waiter “just get me a good steak” and then chiding them for not getting the Filet Mignon, then saying, “all I wanted was a good steak.”
He says he wants rough sketches. Many rough sketches have been given. Many sketches that are so detailed they could hang on the fracking Museum of Fine Arts have been given. Then more complaints about the lack of rough sketches.
It’s disingenuous and a bit annoying that you’d cling to that aspect.
This is not abstract for me. My father was “downsized” in 1995. My mother had a very serious pre-existing condition. My parents lost just about all they had paying out of pocket for COBRA, then for insurance on the private market that cost a ton and didn’t cover everything. In my view my mother died in large part due to the stress of all this.
Even before that, since spending time in Europe as a high school student and learning about the systems there, I’ve supported the idea of a single-payer type system in the U.S. That whole time my big question has been, “How do we transition from what we have to that?” In any big change there are potential winners and losers. I’d like to minimize the losers among the general public. I think that’s good, humane policy and smart politics too.
So power-wheels asked the question I’ve been asking myself for 20 years. To me it’s nothing to do with Don Berwick or the election. Perhaps the discussion in the primary is the reason power-wheels posted this now, but the primary is not the reason I asked my questions. And certainly not to score political points for or against any candidate.
We still live in a time of widespread economic unease and, justified or not, profound doubt about the ability of government and big liberal programs to make life better for ordinary people. I’d like to emerge from that era, but the quickest way ensure people stay cynical is to have a huge change like this without getting it right.
It’s just my basic personality to want my ducks lined up in a row before going forward. We rightly excoriated Mitt Romney in 2012 for refusing to divulge any details of his big tax plan. I don’t think we can propose a major policy change without the most elementary of preliminary sketches. To the extent Vermont’s done that, I find it more troubling than inspiring. I predict a lot of ill-conceived 11th-hour sausage making in Montpelier in 2 years.
As for what I was seeking: I finally did what I should have done all along. I googled it and posted something. That may not become law but it’s a blueprint of how to fund.
Sorry for frustrating anyone. I’d only say that the original response (with 12, no 13, uprates) was “a tax or a fee.” To the extent any more details at all were offered it was because I and others kept asking for them. I do thank Ryepower, jconway, mimolette, petr, somervilletom, stomv, and anyone else I missed for contributing those ideas. And I thank harmonywho for the hypothetical hug and beer offer, and for bringing it every single day. Enough words spilled, that’s about it.
… I don’t think you consider what a big win that universal single payer health care would be. To my way of thinking, whatever happens in the transition, if we come out the other side with universal single payer health care, it will be worth it. Or, put another way, there are no ‘losers’ possible here, if we get that. Private health insurers will be out, but I view them as losers already for their willing collusion in the system that contributed to the death of your mother.
I think that in the short term the disruption to employer/employee benefits packages are likely to be painful, and we’ll certainly, see short term losses. I think we might have to iterate on a taxation scheme before we get it right, also… I think, too, that in the short to medium term we’ll actually see greater stresses on the health care system as we perform the secondary, put more important, transition from a crisis driven hero model to more medically sound and efficient care.
I think the only danger, and we’re already well mired in it, is to be continually derailed and sidetracked as we proceed. I think Romneycare is the half-measure we fear and people are hurting now because of it… perhaps less people are hurting under Romneycare than under the previous, but that’s not a victory so much as a diminishing of the pain. The ACA is just a continuation of that and we know it’s not going to work as well as single payer.
It ought to be no surprise to you that I think we should abandon the half-measures entirely and swing for the fences. Yeah, it will be disruptive. Yeah it will hurt. But I think it will be worth it. I think it akin to the Civil Rights struggles where people were willing to be beaten and hosed and jailed and bullied for the cause because both the cause and the prize was worth it.
This stuff is personal for me, too, for a lot of reasons. And I do think that a lot of the heat in these threads has to do with the conversation happening in the middle of a primary season.
But I think those of us who’re backing Don Berwick in the primary have, perhaps paradoxically, a special reason to be grateful to you. It’s relatively unusual to have a candidate whose expertise in a given area of policy is way beyond anything his supporters are likely to be able to bring to a discussion. We have to be able to talk about these issues coherently despite our comparative lack of expertise, and having the chance to test our own understanding and knowledge here, among people who share our ultimate goals, is in fact enormously helpful.
I’d say more, but I have to go drive all over the state for the rest of the day. But before the conversation ended, I did want to be sure I’d said that much.
I’ve spent a fortune on skyrocketing COBRA and health care costs for my children since my first divorce in 1988. I’ve watched premiums go through the stratosphere while all those “cost savings” have been translated into less coverage, higher co-pays, and more routine and utterly unnecessary procedures.
I ran my own businesses through most of those years, and so I saw the runaway costs first-hand from an employers point of view. The company premiums for one venture’s group coverage nearly doubled because one of our valued employees had a deaf two year old and another’s wife was treated for post-partum depression.
Companies in my industry exploited mandated COBRA coverage to unload health care costs onto employees at exorbitant rates by arranging for frequent company acquisitions and layoffs. Company “A” proudly promotes its health care benefit program — and doesn’t mention that it isn’t available if the employee is still eligible for COBRA from a prior employer (at exorbitant rates). Company discounts from a carrier don’t apply to COBRA premiums, so an already-expensive family premium doubles when the employee is laid off.
I think many of us share the pain articulated by fenway49. I think we MUST solve this problem. I think many of us feel betrayed by the way that a promising Democratic presidential candidate dismissed single-payer before negotiations even started, and then passed a Republican plan that is, at its heart, a guaranteed revenue program for an already out-of-control health insurance industry.
I suspect that truly effective single-payer programs won’t happen until the federal government leads the way. The programs in Vermont and Massachusetts are, in my view, necessary exercises that ultimately will show that national action is required.
I hope it will come to pass in time for my grandchildren to benefit from it.
I honestly don’t think this discussion ever got particularly heated or uncivil, and if I contributed in a way that made people feel that way, than I will apologize. But I view this the same way I viewed all the arguments I had with Hillary supporters back in 2008-the kind of arguments that make our movement come forward with better ideas, better policies, and better ways of discussing them with people on the fence. This thread was BMG at it’s best in my view-providing a forum for us to discuss that.
I get where Fenway is coming from, not just from the personal side, but also from the fact that so many bright promises on the health care front have been major disappointments in our lifetimes. Truman, Kennedy, Lyndon Johnson, Nixon of all people, Teddy Kennedy with Carter, and Clinton and Obama all tried to get major health care reforms passed. And only Obama’s reform-which we know only goes a third of the way to where we need to be-was the one that passed. The political capital to ensure universal coverage and cost containment within the flawed private-employer based architecture, was spend, and it’s gone. It is unlikely at the federal level we can have action like that for 20 years.
But I take heart with other social reforms. Gay marriage was a radical social experiment in Massachusetts passed by unelected judges without the consent of the people. The conservatives are right that this statement is fact, I happen to believe the judges had the rights to protect that minority and that it was a radical experiment whose time had come, but that statement is largely true. Now, we have seen several states actually vote to pass gay marriage at the ballot box. Bans are coming down left and right, and especially in states on the right. The steady stream of progress is not making news anymore.
Colorado and Washington passed, on their own, sensible marijuana legalization policies that are generating unprecedented revenues for their state, reducing the crime and incarceration rates, and expanding freedom. I am confident that like marriage equality, the chips will begin to fall on that issue, as even right wing ideologues like Rick Perry and Rand Paul recognize the lost revenue and ideological inconsistencies in the failed War on Drugs.
I think we can have the same movement with single payer healthcare. The polls show a majority of Americans support it, a solid supermajority in blue states such as ours, and it is time we had the leadership that listened to the people and bucked the special interests trying to stop a reform that would rightly put them out of business. MA lead the way on gay marriage, what was once radical is now common sense and centrist, and we can make the same waves with single payer healthcare. I would rather we take the risk and fall short, than avoid the risk and maintain an unjust status quo any longer, that leaves far too many of our friends, neighbors, and loved ones behind.