Politically speaking at least, the single most brilliant ideological contribution to the Democratic primary this season comes from Pete Buttigieg:
Medicare for All WHO WANT IT.
It is unclear to me whether the numbers would work, but there is no doubt that it is a smart approach to handling the touchy issue of how to further expand health care access to get to universality without alienating the millions – notably including many union members who have spilled blood, sweat, and tears to get excellent health care benefits – who already have private health care plans they like.
The single worst framing of an issue comes on the same topic: telling millions of Americans that they must give up their private health care.
This is bad politics in part because it is, in part, silly: even single payer nations like France, Canada, and Great Britain allow for substantial private supplemental insurance.
So it is political folly to run on a platform of taking AWAY health care.
Buttigieg provides the smart alternative political frame.
Hopefully, Biden will steal the idea if Buttigieg falls short of gaining the nomination, and Warren will be able to use her remarkable political skills to extricate herself from her current position if she is our nominee – not an easy task when your opponent is as skilled at repetitively lying and reframing as this one is.
This discussion about health care insurance comes much closer to magical thinking than anything else we’ve talked about. Our candidates, other than Elizabeth Warren, appear to be driven by polls rather than reality. Our electorate is numbed by decades of dumbing down in our public education system, drowning in a flood of misinformation from our media (not just Fox News), and battered by a relentless economic siege from the already-wealthy. So our collective magical thinking is a symptom as well as cause of our economic and emotional distress about all this.
Old farts like me remember when America led the world in health care, by a long shot. Our outcomes, facilities, and providers were the envy of the world. Our insurance companies were apparently not making enough money — even though the two newest skyscrapers in Boston at the time were both built by insurance companies (the John Hancock tower and the Prudential tower). When I, as a 23 year old engineer at Digital Equipment Corporation, got sick or injured I went to Emerson hospital. I showed my company-provided insurance card (John Hancock, as I recall), signed one or two forms, and was escorted to the ER. No co-pays. No delays. No billing surprises in the mail. I got top-quality care and went about my business. I received a notification a few weeks later of what services were provided and what the insurance company paid for them. Case closed. It was a different and better world.
America then had a first-world health care system. It needs to be said that Democrats had dominated Congress for decades, Ronald Reagan was an aging Grade B former actor, and the highest marginal tax rate on income was more than 70%. The state of Massachusetts taxed “Unearned income” (capital gains and interest) at twice the regular rate of 5%.
Health insurance costs are driven by hard-nosed actuarial statistics combined with insatiable greed. Health care costs are inextricably tied to whatever health insurance system is in place. These drivers are not going to change.
That means that we need to manipulate the levers that control the machinery in careful and well-planned ways and in very specific sequences. It is not a time to randomly twist all the dials, flip all the switches, push all the buttons, and hope for the best. It is also not a time to sanctimoniously look at the system, say “that’s very complicated”, and walk away.
The fundamental principle that creates any insurance business is that a large group of people who don’t collect benefits collectively pay for the expenditures on behalf of a much smaller group of people who collect claims. Any insurance provider therefore increases profits in a limited number of ways:
– Charging more in premiums, fees, and whatever
– Disallowing as many claims as possible and paying as little as possible for the others
– Collecting premiums from as many people as possible and cancelling coverage for claimants as immediately as possible.
Health care providers in such a system increase profits in similarly limited number of ways:
– Perform as many procedures and services as the insurance companies will pay for.
– Fill every billable hour of every provider and piece of equipment with the most profitable billing code possible
– Constantly hire less costly people and work them longer hours
– Constantly replace labor with machines.
Whatever we call it, single-payer government-sponsored health care requires that EVERY American pay for their health care through taxes, just like public education, police, fire, and highways. No vouchers. No “charter school” equivalents. People who don’t use it pay just as much as people who do use it.
This approach is fundamentally incompatible with an insurance-driven system. It is also FAR less expensive. First world nations today achieve far better outcomes with this approach than we see in America.
The only way those “many union members who have spilled blood, sweat, and tears to get excellent health care benefits – who already have private health care plans they like” get their plans that they like is that millions MORE people pay — directly or indirectly — insurance premiums for far worse plans. As soon as a new health care system is put in place, those well-loved and carefully-negotiated plans will dry up. If they don’t, the companies that provided them will go away.
Current providers lose money on medicare patients — negotiated medicare reimbursement schedules are MUCH lower than private plans. Current providers make up their medicare losses by goods and services paid for by private health insurance. Current providers therefore maximize the goods and services they provide for non-medicare patients..
As soon as a new health care system is in place, that will start to change. Providers will perform fewer “routine” MRIs and CAT scans that provide a tiny medical benefit and generate large and predictable income streams.
Elizabeth Warren understands all this. She’s been engaged in this problem for decades. I don’t see any other candidates with a comparable grasp of how all this works. The reason that “Medicare for All” (ala Bernie Sanders) doesn’t work (beyond its name) is that the low Medicare out-of-pocket costs today only happen because today’s insurance companies get their profits from others. As soon as everyone has medicare, nobody will pay private insurance companies. When the dust settles, a working single-payer government-sponsored health care system will have only a coincidental relationship to today’s Medicare — whatever it’s name.
I don’t know if “Medicare for all who want it” even makes sense in an America with single-payer government-sponsored health care. I suspect that what Mr. Buttigieg is not saying (most likely because he doesn’t realize it) is that everyone will want medicare because a government-provided plan that works well enough to make a difference will cause ALL those private plans that people say they like to go away. Those private plans will go away because those companies won’t be able to collect the premiums that fund them.
The ACA is dead. The decision by our government to remove the penalty for not having insurance killed it. It might take months, it might take a few years, but it’s dead. The relentless efforts of the GOP finally came to fruition. The most enduring legacy of Barack Obama is crumbling.
Like it or not, we must replace it with something. That something will be different from what we got in 2008 because America of 2020 is different from America of 2008. “Preserving the ACA” is not an option, unless we somehow put those penalties back in place.
Single-payer government-sponsored health care is the ONLY system that works. We can call it whatever we like, but it is the only system that works.
Isn’t our K-12 education public for all who want it? We don’t outright ban private schools.
I don’t doubt that boutique health care providers will emerge, analogous to private schools. Those will be health care providers, not insurance companies. I expect them to be fully legal. One of the issues that society will have to solve is how to regulate them — just as we’ve worked out how to handle private schools. Private health care providers are likely to provide excellent health care in exchange for very high costs.
Like private schools, those boutique health care providers will be an option available only to the wealthy. There will be calls for vouchers, and those call should be rejected.
There is no analog to health insurance companies in education. The current health insurance industry is a cancer that is an accident of history. A major purpose of single-payer government-sponsored health care is to eradicate it.
I would agree that once we have a completely public health system we should not provide vouchers for people to pay for private insurers, but education is exactly the analogy that has come to my mind for sometime. Ideally, the public system would be so good that private would be basically moot, but it seems we have two different ideas for what that means.
Can you please name one existing “insurance” company that provides “coverage” for education?
^I think the analogy makes sense. It’s a two tier system. Public for everybody, private for those who want it. Pete’s framing is actually good and would work for Warren or Sanders plans too. I just think Pete is being a bit of a dink about his plan being that different from the others.
Tens of thousands of GM workers had private insurance they liked and that they had negotiated. That was until they went on strike and the greedy GM executives cancelled their insurance, putting lives at risk. Linking health insurance to employment is awful. True expanded Medicare for All is the answer.
Here’s a story about the world of private insurance. There are thousands and thousands of stories like this every year.
Buttigieg can take his cute tagline and shove it.
There’s honestly no difference between M4A and a public option other than marketing and whether you make it an opt in or an opt out. Both proposals create a more robust single payer government health plan.
In one version it’s opt out. Very few people will opt out of using it, since they will still have to pay for it with their taxes and will have most of their coverage needs met by single payer. But you’ll get your anti vaxxers and religious types who don’t want to enjoy coverage, and your really rich types that want concierge services. So those folks won’t be participating in the system, but they will be insignificant.
In the other version it’s opt in and a lot of people won’t opt in. They’ll be the same fear mothering around enrollment that there was with ACA. The government plan will be one plan out of many on the exchanges. I don’t doubt that more and more employers will offload their employees onto those exchanges with a robust public option. Maybe even those vaunted union plans (I’m a union member and I’d take single payer over what I have).
And in about 20 years it’ll ultimately look a lot like single payer. I think if we push for M4A at the starting gate we’re more likely to get a stronger public plan in the end. If we start with just a public option like Obama already did we’ll end up with less in the end.
So I have little patience for the moderates who hated the public option eight years ago and now view it as a bulwark against single payer or the M4A diehards who don’t recognize that a public option gets us single payer in the end.
Biden and the DSAers May not be wise enough to realize this, but the ACA put the country on an irreversible course to single payer. It’s just a question of when we get there and how many people we cover along the way. As soon as preconditions were out and the plans were regulated, it became harder and harder to make money off of healthcare. I’d rather we cover the most people the soonest, so I’m for M4A.
That means dead people and medical bankruptcies, so yes, there is a big difference between the ideas that is more than just marketing.
That’s fair. I used to work at a bankruptcy law firm in Chicago and our lead filing were save the house cases (I worked from 09-12, so the height of the housing crisis) and medical debt. A friend who still works at the firm went from a Republican opponent of ACA to a Warren supporting independent in part because he saw all the medical case filings go down. Granted, nationally its gotten a lot worse.
I’m also coming around on college debt forgiveness. At the end of the day, it would be a huge stimulus to the economy and if the banks can get a bailout, why not the middle class? Either the government should write it off or it should at least be dischargeable. I have other thoughts on that, but the whole ‘milennials dont buy houses’ trope is really annoying. Hard to buy a real house when I’m paying off the equivalent of one for my two degrees…
No one is running on a platform of taking away health care.
Buttigieg is very deft, and I mean that in the best possible way. And I think that Sanders has expressly proposed what you might call “mandatory medicare,” in which the government is the only insurer. So it is a distinction with a difference.
But actual Medicare is optional, and many people elect not to take it after they turn 65. So “Medicare for all who want it” is “Medicare for all.”
I’m not against it. I think it would mean the end of most private insurance in any case. I mean, if I’m running a business today with 100 employees and dealing with the bothers of administration of health care benefits, I will just make it easier for my employees to go to Medicare, by making my offering hard to get.