• Facebook
  • Twitter
  • Subscribe
  • RSS

‘Medicare for All’ Gains Second Senate Backer

health-costs-money-stethoscope

Kamala Harris, the junior Senator from California, has backed Bernie Sanders’ call for creation of a single-payer healthcare system via expansion of Medicare.

The Mercury News:

U.S. Sen. Kamala Harris announced Wednesday that she intends to support a congressional effort to expand Medicare to all Americans.

“I intend to co-sponsor the Medicaid-for-All bill,” California’s junior senator told several hundred people at a town hall at Oakland’s Beebe Memorial Cathedral, referring to Vermont Sen. Bernie Sanders’ Medicare-for-All proposal.

The bill, which Sanders plans to introduce next month, is essentially single-payer health care. It would expand the federal Medicare program, which mostly covers people age 65 and older, to all Americans. (Medicaid, which Harris mistakenly referred to, is a joint federal and state program that provides health coverage to the poor.)

Harris, who previously had said she supported the concept of single-payer health care but hadn’t come out in favor of any specific bill, is the first senator after Sanders to publicly endorse his plan. She said she was backing the bill ”because it’s the right thing to do.”

“Health care should be a right, not a privilege,” she said. “This should not be a partisan issue. It shouldn’t even be a bipartisan issue. It should be a nonpartisan issue.”

She also argued that a single-payer system care would make fiscal sense.

“It is so much better that people have a meaningful access to affordable health care at every stage of life — from birth onward,” she said. “The alternative is that taxpayers are paying huge amounts of money for them to get health care in an emergency room.”

Sanders thanked Harris in a tweet. “Let’s make health care a right, not a privilege,” he said.

Aside from the pedantic point that a service provided by individuals can’t be a “right,” I’m in agreement that universal coverage is fiscally prudent and good public policy. We’ve long known that the American healthcare system is simultaneously the most expensive among those in OECD nations and yet provides the worst outcomes. And, given that it’s a popular, existing program, I’ve long thought that lowering the Medicare eligibility age–and bringing those in less efficient government programs like Medicaid under its umbrella–was the logical solution. But, of course, it’s politically unthinkable right now.

Following the link to the description of Sanders’ plan, it’s clear he at least recognizes that:

Sanders acknowledges that it will take some time to move to a single-payer system. That’s why he says he’ll introduce a bill next month that expands the eligibility of Medicare to people between the ages of 55 and 64.

“That’s an interesting idea and one of the proposals that I will be bringing forth shortly, which I don’t think Republicans will support, will be to lower the age for Medicare eligibility to 55 years of age,” said Sanders. “That is one way to phase it in.”

Aside from partisanship, there’s legitimate fear in the public about what the transition would look like:

Retired Middlebury College political science professor Eric Davis says the people that Sanders needs to win over in this public policy debate are individuals who have relatively good employer sponsored health care policies. Davis says this group of consumers needs to see the benefits of Sanders’ plan.

“That what he’s proposing would be A) better, B) less expensive and C) would lead to better health outcomes without D) restricting their choice of doctors and providers,” said Davis.

As the old joke goes, pick two.

There’s little doubt that universal coverage under Medicare would provide better overall outcomes than our current system, which leaves many uninsured and incentivizes other to delay treatment until diseases get to advanced stages. It would almost certainly be cheaper on a per-capita basis, as well, since Medicare caps payouts better than private insurance—let alone billing at the “no insurance” rate. But, at least during the transition, people shifting off of private insurance to Medicare would have more restricted choice, since many providers don’t take Medicare patients—precisely because of those payout caps. Presumably, once Medicare became universal, few providers, indeed, could afford to opt out.

What neither of the linked stories covers is how much all of this would cost. A May 2016 Urban Institute study estimated that it would cost the federal government $32 trillion over 10 years–largely because it would mean absorbing costs currently borne by state and local governments and employers. A June 2016 Tax Policy Center study estimated that Sanders’ plan would “add $18 trillion to the national debt over a decade”—and that’s accounting for the $15.3 trillion they estimate his proposed tax hikes would bring in.  (The figures also include Sander’s desire to make college tuition free, but that only accounts for $807 billion over the period.)

Of course, those figures have to be offset by what the private insurance-based system costs individuals and businesses. If an individual is paying $800 a month for insurance, another $200 in deductibles and co-pays, and his employer is kicking in $500 in subsidies, that’s $1500. That’s a lot of maneuver room for offsetting taxes.  But the TPC study factors in Sanders’ preferred tax hikes.

Related Posts:

About James Joyner
James Joyner is the publisher of Outside the Beltway, an associate professor of security studies at the Marine Corps Command and Staff College, and a nonresident senior fellow at the Atlantic Council. He's a former Army officer and Desert Storm vet. He earned a PhD in political science from The University of Alabama. Views expressed here are his own. Follow James on Twitter.

Comments

  1. James Pearce says:

    She said she was backing the bill ”because it’s the right thing to do.”

    Pretty lucky that “the right thing to do” aligns so perfectly with Harris’s political ambitions, innit?

    Like or Dislike: Thumb up 1 Thumb down 13

  2. Not the IT Dept. says:

    Well, it would be pretty damn stupid if they didn’t.

    Highly-rated. Helpful or Unhelpful: Thumb up 18 Thumb down 0

  3. James Pearce says:

    @Not the IT Dept.: Point being, if not backing the bill would further her political career, that too would be the “right thing to do,” too.

    We need people who are willing to sacrifice their careers to implement good policies, not people who will see good policies laid wayside to further their careers.

    Like or Dislike: Thumb up 1 Thumb down 12

  4. al-Ameda says:

    With all due respect to Sanders and Kamala Harris …. but, really?

    In a smarter and more rational America, we would form a blue ribbon commission comprised of expert health policy people people like Uwe Reinhardt, who knows a lot about universal single-payer health insurance systems, and the commission would be charged with researching a plan that would transition us from Medicare into universal health insurance coverage, and determining the annual and future cost and the financing mechanism for ensuring that such a system is fiscally viable.

    Why am I not optimistic about the prospects for THAT happening.

    Like or Dislike: Thumb up 2 Thumb down 4

  5. Slugger says:

    Covering younger people under Medicare might be fairly inexpensive. They tend to have a lot less illness than us older folks. A large part of the medical care younger people need is covered under automobile insurance, workmen’s comp, and aid to mothers and children in the welfare system. It is worth exploring.

    Like or Dislike: Thumb up 6 Thumb down 1

  6. James Joyner says:

    @al-Ameda: I’m honestly not sure why what you propose is desirable. Medicare is already in existence, popular with the public, and it cuts costs by streamlining claims processing and imposing fee caps and other restrictions. How does adding an insurance company layer help things?

    Like or Dislike: Thumb up 6 Thumb down 0

  7. Tyrell says:

    Medicare as a choice would have been better than a complete new plan start up with a website that had major problems. But the votes in Congress probably weren’t there.
    What they should do is offer Medicare as an option for anyone.
    There would also be other options that would be attractive for the young people*. You can’t use the name “Medicare” and expect to attract young people. Unless the plan can get them to sign up in large numbers, forget it. Many of the young people are staying on their parents’ plans, are covered through work, or are just not interested.
    Bloomberg offered some reasons that “Medicare for all” may not be such a good idea. So it has some attractions and supporters, but also risks that will be brought out.
    * gym membership, orthodontics coverage, dermatology procedures, spa, personal trainers.
    Iowa’s only health insurance carrier seeks 57% increase
    “Where Obama Care has become unaffordable, short term health insurance can help” (Forbes)

    Like or Dislike: Thumb up 2 Thumb down 1

  8. SKI says:

    since many providers don’t take Medicare patients—precisely because of those payout caps

    From my perspective inside the industry, this is completely false.

    More than 90% of all physicians take Medicare and fewer than 2% of Medicare beneficiaries report issues with finding a physician to treat them. This access rate is equivalent to the rate and experience of the 55-65 cohort with private insurance.

    AND, the disparity between Medicare payment rates and commercial rates for physician practices is (a) shrinking and (b) highly variant depending on region. In Maryland, for example, Medicare is frequently a better payor for a independent physician than CareFirst’s base fee schedule.

    Like or Dislike: Thumb up 4 Thumb down 0

  9. SKI says:

    @SKI: In full disclosure, the two areas where this doesn’t apply are psych (where finding someone who takes insurance at all can be a challenge) and anesthesia (where Medicare has always paid a shockingly low amount in relation to everyone else).

    Like or Dislike: Thumb up 3 Thumb down 0

  10. MarkedMan says:

    @James Pearce:

    We need people who are willing to sacrifice their careers to implement good policies

    Read more: http://www.outsidethebeltway.com/medicare-for-all-gains-second-senate-backer/#ixzz4rMCk0e00

    I understand the sentiment, but this is just not practical. In fact, as the modern Republican Party demonstrates, honorable politicians who sacrifice their careers simply end up being primaried out of office. I’m not saying they shouldn’t do the honorable thing, but rather that they should understand it is not going to change things. We need a steady and solid push to change the expectations and demands of the public from all types of public leaders, so that politicians can push us in that direction without sacrificing their careers.

    Like or Dislike: Thumb up 5 Thumb down 0

  11. Mikey says:

    @James Joyner:

    How does adding an insurance company layer help things?

    The German universal coverage system uses private insurance companies (mandated non-profit). And there are a LOT of them–for example, a resident of Bavaria has 55 from which to choose.

    I can only assume they have found efficiencies in this method, being German and all.

    Like or Dislike: Thumb up 2 Thumb down 0

  12. al-Ameda says:

    @James Joyner:

    @al-Ameda: I’m honestly not sure why what you propose is desirable. Medicare is already in existence, popular with the public, and it costs by streamlining claims processing and imposing fee caps and other restrictions. How does adding an insurance company layer help things?

    I happen to think there should definitely be a feasibility and cost benefit study.

    To me there are good questions, for example:
    [1] What is the added cost to go from Medicare for seniors to Medicare For All?
    [2] What would the health coverage plan be?
    [3] The Medicare Tax is now less than 2%, what would the new rate be?
    [4] Should private insurance companies be involved?
    Should they sell the national policy plan to all, with profit capped at 3-4%?

    I speak as a strong advocate of single-payer health insurance, however, why not analyze this before we jump in to insure well over 200 million more people without understanding what the coverage would be and how much funding we need to run it?

    Like or Dislike: Thumb up 1 Thumb down 0

  13. Mikey says:

    @al-Ameda: Speaking again of the German public system, their contribution is 14.6% of pay, split evenly between employer and employee, as our Social Security is. The insurance companies can tack on a little bit, usually about 1%, which is paid by the employee.

    There’s an earnings ceiling too, but I can’t recall what it is–again like our Social Security it is adjusted annually.

    There’s a basic level of coverage mandated by law, the insurance companies can offer more though (this is where that additional 1% employee contribution comes into play).

    I’m not sure what differences there are between the individual Bundesstaaten (states) but there must be some since every insurance company isn’t present in every Bundesstaat.

    Anyway, it seems we could do a lot worse than modeling our universal coverage after Germany’s. (Or France’s, or pretty much any of the others…any of them would probably be a great improvement over the shitty system we have now.)

    Like or Dislike: Thumb up 5 Thumb down 0

  14. Kylopod says:

    @MarkedMan: I agree, for the most part. Just as businesses have the profit motive, politicians have the vote motive, and it doesn’t get us very far to wring our hands and complain about it. But it’s also worth keeping in mind that when these pols make their motives obvious and transparent, it usually backfires on them. I’m not sure Hillary accomplished much by abandoning TPP, since nearly everyone saw the move as insincere and opportunistic. Kamala Harris has recently come under fire from Bernie Bros for being insufficiently progressive, and this looks like her way of throwing them a bone.

    Like or Dislike: Thumb up 0 Thumb down 0

  15. Gromitt Gunn says:

    @SKI: I’m going to second this. My area has two main health systems – Baylor Scott and White, and CHI St. Joseph. My employer gives me two options – Scott and White Health Plan, an HMO run by Baylor Scott and White, and a self-funded option administered by BC/BS of Texas that contracts with CHI St. Joseph. My mom’s Medicare Advantage Options are Scott and White’s Senior Care and a Humana plan that contracts with CHI St. Joseph.

    Most of the private providers in the area have contracted with one of the two main health systems. So as a consumer, you can opt to do all of your own care coordination, or you can decide to exist within one of the two health system bubbles.

    Like or Dislike: Thumb up 0 Thumb down 0

  16. Monala says:

    Among the conservatives on my FB feed, apparently the new thing is talking about getting rid of Medicare altogether, or at least raising the eligibility age to something like 72. Seriously.

    Like or Dislike: Thumb up 0 Thumb down 0

  17. Monala says:

    @Kylopod: So what?

    Like or Dislike: Thumb up 0 Thumb down 2

  18. CET says:

    @Tyrell:

    What they should do is offer Medicare as an option for anyone.
    There would also be other options that would be attractive for the young people*.

    Two thoughts:

    1) In principle, I really like the idea of an opt-in system that will (if it works) gradually become the de facto option for most people. It seems like it would be great for the self-employed and small businesses, and I would expect larger companies to start offering a ‘bonus’ for people who cover their own benefits and shrink the company’s insurance pool.** My only hesitation here is that we might end up in weird situation where a large part of the middle class is double-paying for health care (once through their increased taxes, and again through the portion of their upkeep cost that their employer uses to pay for insurance rather than salary).

    **I’m thinking that if some version of the ACA lasts long enough, this is probably where we are headed.

    2) On behalf of health young people, a plan can appeal to us by being cheap and offering care for catastrophic events. I need a plan that covers me if I end up in the ER with 4 broken ribs and a sucking chest wound. I’d rather save the excess money and take care of my own gym membership or the hundred bucks it costs me once a year to get contact lenses.

    Even if we’re talking about something that comes out of everyone’s taxes, I still think it’s bad policy (and worse optics) to lard it down with spa visits and the like. Make it cover the important stuff, and keep the tax increases as low as is feasible – it’s going to be expensive enough already.

    Like or Dislike: Thumb up 4 Thumb down 0

  19. michael reynolds says:

    If the end product – health care – costs us $1, then shifting that $1 to Medicare doesn’t cost us anything. Every dollar of health care costs is paid by someone – taxpayer, premium payer, corporate premium payer. So long as we don’t increase the net amount of health care it doesn’t cost us collectively anything more than it does now. Indeed it eliminates the entire profit of the insurance companies and gives Medicare unprecedented power to negotiate with Big Pharma and the hospitals. It only balloons the deficit if we refuse to pay for it.

    Like or Dislike: Thumb up 2 Thumb down 0

  20. James Pearce says:

    @Monala:

    So what?

    Progressives hoping for an electable Democrat might find themselves shackled to an unelectable law-and-order type who, when convenient, makes progressive noises.

    Like or Dislike: Thumb up 0 Thumb down 1

  21. Monala says:

    @James Pearce:

    1. Why do you consider her unelectable?

    2. If she actually follows through with her support, then it’s not simply “progressive noise,” regardless of her motives.

    Like or Dislike: Thumb up 1 Thumb down 0

  22. Kylopod says:

    @Monala:

    1. “Unelectable” is a meaningless term in today’s politics. Anyone who wins the nomination of a major party automatically becomes electable. Period.

    2. It’s about commitment. I believe–and I’ve been arguing this for years–that had Hillary and not Obama been elected president in 2008, there’s a good chance she would not have pursued health-care reform. First of all, Obama chose to pursue it against the advice of many of his advisors, who felt he should concentrate entirely on the financial crisis. While they didn’t anticipate how unpopular the bill would become, they all knew that it was going to be controversial and that it would require a lot of political capital. Hillary, who had already been at the forefront of a comprehensive health-care bill that went down in flames and did serious damage to her husband’s presidency in its early stages, would probably have been a tad less eager to go through all that a second time–and this is from a politician already known for her cautiousness.

    Now, I’m not saying that if you elect a true-blue progressive, single-payer will automatically happen. Indeed, there are circumstances where a Democrat who doesn’t have much personal investment in the issue would have a greater chance of passing it than a Bernie Sanders type. A party can effectively lock candidates into an agenda, just as Republicans have been locked into tax-cutting for over a generation, and the candidate’s savviness when working with Congress has to be taken into account, not just their ideological leanings.

    Still, when you see a candidate pandering on this issue like Harris clearly is, there are two ways to look at it. On the one hand, it’s a sign of the increasing influence that single-payer supporters are having on the party, and that matters regardless of the candidate. On the other hand, it doesn’t give us any confidence that she would pursue it in the event that she has to make a tough choice on prioritizing the agenda, as Obama did in 2009.

    Like or Dislike: Thumb up 0 Thumb down 0

  23. Hal_10000 says:

    @James Joyner:

    How does adding an insurance company layer help things?

    That layer is already there. Medicare is administered by private insurance companies. It’s one of the ways the feds pretend it’s efficient.

    Like or Dislike: Thumb up 0 Thumb down 0

  24. An Interested Party says:

    Pretty lucky that “the right thing to do” aligns so perfectly with Harris’s political ambitions, innit?

    Yes, yes, we all are quite familiar with your standard shtick of beating up on certain Democrats and certain Democratic constituencies, but who exactly do you see as a profile in courage these days…well, maybe other than yourself, of course…

    Like or Dislike: Thumb up 2 Thumb down 0

  25. MarkedMan says:

    One thing that doesn’t get discussed enough is the incredible amount of US healthcare dollars that are spent on administrative overhead for billing and payments. First, the 100’s of thousands (millions?) of people that work for the insurance companies. Next, the gigantic billing department that every hospital in the US has. Then the number of people employed in every doctor’s office, X-ray clinic, rehabilitation center, and on and on. The reimbursement strategy departments for pharmaceutical and Med Device companies. The lobbyists and consultants for all of the above. Next, add in the floor space, utilities, computers, and so forth that they use. 30% is in the ballpark and may be low. If we had the same administrative overhead as the next most expensive country we would be within shouting distance of their cost. And if we allowed negotiation for drugs it would probably move us into “casual conversation” distance.

    Like or Dislike: Thumb up 1 Thumb down 0

  26. James Pearce says:

    @Monala:

    Why do you consider her unelectable?

    She’s a Democrat from California, for one. Fair or not, true or not, “California Democrats” conjure up images in the minds of millions of Americans, and for many of them, it’s not good. Her legal career will be mined for oppo research, with plenty of “hypocrisy” ammo. I mean, she wasn’t some constitutional scholar. She was a prosecutor. I’m sure some of the air-headed lefties who light up when they see her on TV would turn green if they knew some of the stuff she did and supported back then. She’s also a junior Senator, being set up to run against “the businessman” CEO so many people say they wanted, an incumbent no less. “Executive experience” will be the only thing people talk about.

    Sure, the nazis will hate her because she’s black and the cavemen will hate her because she’s a woman, but I don’t think that’s what’s going to bury her.

    If she actually follows through with her support, then it’s not simply “progressive noise,” regardless of her motives.

    True, but if she doesn’t spend the next few years working on this, making all the phone calls, taking all the meetings, then she’s not really supporting it. I mean, she’s “supporting” it, like I do, with good vibes and “thoughts and prayers,” but “Medicare for All” is going to be a herculean effort that might require someone devoting their career to it. Is Kamala Harris that person?

    Like or Dislike: Thumb up 0 Thumb down 1

  27. MarkedMan says:

    Most universal coverage systems in the world aren’t single payer. There are all sorts of ways to achieve the universal coverage goal and, in fact, single payer systems aren’t even the most cost effective, nor the most highly rated by their users. Bernie, in his usual d*ckish way, has picked an issue that he doesn’t much understand, made no effort to see if there are potential allies, and then drew some arbitrary line in the sand and started sending his obnoxious fan-boys to denigrate anyone that isn’t sloganeering the same way he does.

    This is why Bernie has never passed a single piece of nationally important legislation in his entire career. He is all about Bernie, all the time. Everyone else is a sell out.

    Like or Dislike: Thumb up 2 Thumb down 0

  28. MarkedMan says:

    This Fox News talking point that there is some incredible number of doctors that don’t take Medicare is rubbish. Five years ago we passed the point where 50% of all payments to hospitals are done via Medicare or Medicaid. There isn’t a general hospital in the US that could remotely afford to turn away those patients. And while there are certainly individual doctors who may not take it, they are certainly not a hugely rising tide. As someone who has moved around quite a bit and have gone through numerous iterations of having to find new doctors, the idea that all doctors accept all private plans is just a joke. This is just another Republi-fact endlessly repeated on Fox and completely bogus given the slightest investigation.

    Like or Dislike: Thumb up 5 Thumb down 0

  29. wr says:

    @James Pearce: “She’s also a junior Senator, being set up to run against “the businessman” CEO so many people say they wanted, an incumbent no less. “Executive experience” will be the only thing people talk about.”

    You think that in 2020 people will be looking for a CEO president with executive experience? You really don’t understand anything about politics, do you? That ship has sailed for a generation, taking with it the presidential dreams of every businessman billionaire out there. We now know what it looks like to have a CEO president…

    Like or Dislike: Thumb up 1 Thumb down 0

  30. James Joyner says:

    @SKI: Interesting. I always had the impression that it could be hard to use Medicare. I don’t know if that’s just a myth or maybe the way it was 20 years ago and isn’t anymore.

    @al-Ameda: @Mikey: Dave Schuler has long argued that we have to cap earnings if we’re going to model ourselves on a European system. I’m not sure that’s culturally possible here.

    @MarkedMan: Dunno. I haven’t watched Fox News in ages. My mom’s been on Medicare for years now and has Tricare as her supplemental, so she pays essentially nothing.

    Like or Dislike: Thumb up 0 Thumb down 0

  31. Mikey says:

    @James Joyner:

    Dave Schuler has long argued that we have to cap earnings if we’re going to model ourselves on a European system. I’m not sure that’s culturally possible here.

    Not sure if I was clear enough, or perhaps I am misunderstanding your response–the “earnings cap” to which I referred is the max on which contributions are based. Like our Social Security, where we don’t pay FICA on income above $127.2K (for 2017, it changes every year), Germans only pay the health care deduction up to a specific annual income level (around 50K Euros).

    Like or Dislike: Thumb up 1 Thumb down 0

  32. Not the IT Dept. says:

    Every other industrialized country in the world has some form of universal health care and somehow the sky hasn’t fallen. Universal healthcare here would allow people in low-employment locations to move to high-employment locations for work without fear of losing protection from their family. The scary-scary-ooooo-soooo-scary arguments against UH are really not very substantial. Let’s get on with it already.

    Like or Dislike: Thumb up 1 Thumb down 0

  33. SKI says:

    @James Joyner:

    Interesting. I always had the impression that it could be hard to use Medicare. I don’t know if that’s just a myth or maybe the way it was 20 years ago and isn’t anymore.

    It was a well crafted myth – at least for the past 25 years or so. Every time Congress adjusts payment rates down, there would be a whole outburst of stories planted about how doctors were dropping Medicare and how patients would be harmed. There was never more than handful of doctors.

    More recently, we had a similar batch of stories about doctors but now it is about them retiring rather than using EMRs. Again, it isn’t a common occurrence but the switch from “dropping Medicare” to “retiring” is instructive. As noted above, the government pays for well over 50% of all health care today. It simply isn’t economically feasible for a practice to not take Medicare absent very unusual situations (a large enough panel of patients both wealthy and devoted enough to pay you cash instead of using their Medicare benefits).

    Like or Dislike: Thumb up 2 Thumb down 0

  34. MarkedMan says:

    @SKI: There has been a very real change over the past thirty years for individual physicians and it has been leading some to retire, and a lot more to become employees rather than the independent businessmen which was once the norm. When I was a boy growing up on Chicago’s south side, our family doctor’s office had two examining rooms, a waiting room and a front office/receptionist area. The staff was the doctor and his wife, who was his nurse and receptionist. My families medical records simply disappeared when he retired. Today, for the first time in years, I have a GP who works for herself. She has five examining rooms, an aid, and three or four people dealing with appointments and billing. They are constantly dealing with insurance companies and there are more and more demands for their billing and records to be electronically available to hospitals, imaging centers etc. In the US there is no standard for this (because “free market is always the best”) so there is a nightmare of competing systems that are only partially work together, as well as patches updates, “comsensus standards” that come and go and change. So many younger physicians say the heck with it, and give up the small business manger part and take a salaried position with a group. Despite all this, our medical records still disappear when an entity goes out of business and usually has to manually transferred to another provider.

    Like or Dislike: Thumb up 0 Thumb down 0

  35. SKI says:

    @James Joyner:

    Dave Schuler has long argued that we have to cap earnings if we’re going to model ourselves on a European system. I’m not sure that’s culturally possible here.

    Yeah, that isn’t remotely accurate.

    We can easily move to model based on one of the European countries (which covers a ton of different structures) without changing all that much. At the most minimal level, all we would have to do would be to divorce insurance coverage from employment (which would help our companies compete globally), put a relatively small tax in place that approximates what corporations + individuals spend on insurance now, continue the essential benefits rules and the exchanges already in place in ACA, and pay insurance companies the base subsidy directly from federal coffers for each enrollee.

    Ideally we would also have a “public option” to ensure there is always a baseline insurance coverage option available. (If there is a hell, Joe Lieberman has bought himself a prime spot for single-handedly killing the public option in ACA)

    Like or Dislike: Thumb up 1 Thumb down 0

  36. SKI says:

    BTW, if you want an easy primer on some of the European models, Dr. Aaron Carrol (of the Incidental Economist crew, the NYT op-ed page) did a great series on them on his Healthcare Triage youtube channel.

    International Health Care Systems playlist

    Like or Dislike: Thumb up 0 Thumb down 0

  37. SKI says:

    @MarkedMan: Absolutely there has been a change. The economic costs of maintaining a more technologically complicated infrastructure and the higher standards required in terms of coordinating care lead towards larger and more centralized care systems.

    Health systems, or large physician groups (hundreds of doctors), benefit from economies of scale as well as their bargaining power with insurance companies that comes with their larger size.

    As for medical records disappearing, there are actual federal and state laws about that and most providers care enough to protect their patients when they are leaving practice.

    Like or Dislike: Thumb up 0 Thumb down 0

  38. SKI says:

    I should further note that these drivers towards consolidation are the same ones in every other industry.

    When I graduated law school 20+ years ago, only 1 person in my class went out on their own.

    The independent grocery store, electronics store, gas station, etc. are all increasingly rare.

    Like or Dislike: Thumb up 0 Thumb down 0

  39. James Pearce says:

    @wr:

    You really don’t understand anything about politics, do you?

    If you don’t like my argument, attack it, not me.

    Yes, I absolutely think that if Kamala Harris runs against Donald Trump, “executive experience” will be a phrase we hear endlessly repeated: from Trump supporters, from Harris supporters, from pundits, and the candidates themselves. It’s cheap and easy and talking about that will take enough air out of the room that they’ll find it convenient not to talk about other, more pressing things.

    Like or Dislike: Thumb up 0 Thumb down 0

  40. CET says:

    @SKI:

    So, on the one hand, I completely agree that separating healthcare from employment (or at least having a viable way to maintain affordable healthcare that doesn’t come from your employer) is a must. I also think that if people who call themselves ‘conservatives’ were serious about helping small business, the self-employed, etc, etc. doing this would be near the top of their list.

    On the other hand, we come to this:

    relatively small tax in place that approximates what corporations + individuals spend on insurance now

    Define ‘relatively small.’ As Reynolds noted, the total cost of the system is probably going to be similar-ish regardless. My understanding is that a reasonable ballpark to use for benefits is that they cost about 20% of a persons salary. That (and the cost estimates for pretty much any variation of universal healthcare) lead me to think that we are going to be talking about a pretty substantial tax increase. I think that is a defensible policy choice, but it’s not something that can be glossed over.

    I’m also a little bit concerned that we’ll end up in an even deeper version of the demographic hole we’re already in (were the care for a shrinking and aging population eats an ever larger portion of the nation’s productivity), but I don’t have a good long term solution for that one, other than immigration, economic growth, and making the care as efficient per dollar as possible.

    Like or Dislike: Thumb up 0 Thumb down 0

  41. SKI says:

    @CET:

    Define ‘relatively small.’ As Reynolds noted, the total cost of the system is probably going to be similar-ish regardless. My understanding is that a reasonable ballpark to use for benefits is that they cost about 20% of a persons salary. That (and the cost estimates for pretty much any variation of universal healthcare) lead me to think that we are going to be talking about a pretty substantial tax increase.

    You are forgetting we are already covering half that total health care cost from taxes already.

    And that employers are already spending 8% of total comp on private health insurance (as of the June BLS report) – and amount that doesn’t cover the household spend, btw.

    The difference between what we are already paying between taxes plus employer withholds from compensation and what the system would actually cost overall isn’t all that great and probably less than those amounts plus household spend.

    Like or Dislike: Thumb up 0 Thumb down 0

  42. SKI says:

    To break it down another way, total GDI is about $16.7 Trillion and total NHE is about $3.3 Trillion.

    That is we spend 21% of our national compensation on healthcare. But ~50% is already covered by existing government spending and taxes.

    And another 8% of Compensation is currently being covered by employer-based spending on health coverage

    So we would need to pay for – through a combination of taxes and maintaining out of pocket spending about 2.5% of $3.3 Trillion.

    In 2014, OOP spending was ~$330 Billion.

    the most recent federal data that examined all out-of-pocket health care spending in aggregate — not just limited to people with private insurance — found that in 2014, out-of-pocket expenses crept up by only 1.3 percent, to reach $329.8 billion. That is the fifth lowest rise in out-of-pocket spending on record.

    Taking just Large Employer plans – deductibles, coinsurance and copays alone covered 14.6% of total health care expenditures for those plans.

    Traditionally, larger employers are more generous with their benefits, people covered by smaller employers are paying more out of pocket (“Workers at smaller firms must pay an average of $2,069 out of pocket before insurance payments kick in, versus $1,238 for workers at firms with 200 or more employees.)

    Also, people currently not covered by their employers are already fully OOP on the exchanges.

    The money is already in the system.

    Like or Dislike: Thumb up 1 Thumb down 0

  43. Mikey says:

    @SKI:

    The money is already in the system.

    Also remember the big figures–per capita spending on health care is more than double the OECD average, and we spend over 17% of GDP on heath care (compared to the European universal-coverage nations at 10%-12%).

    Like or Dislike: Thumb up 0 Thumb down 0

  44. Tyrell says:

    @CET: Think about this: we had a family member injured playing ball, ankle injury. We went to the ER. Big mistake. Two xrays (ankle sprain), a pain prescription, and a wrap* ended up costing $1300.
    Sometime later I told my regular doctor and he said that would have cost around $300 at his office. There is a lesson there somewhere and it is about hospital costs. I don’t have time to get in a discussion about the myriad ER problems and some sensible solutions.
    *$400 for a wrap/brace that cost $70 at a local pharmacy or at the Wal-Mart.

    Like or Dislike: Thumb up 0 Thumb down 0

  45. CET says:

    @SKI:

    The difference between what we are already paying between taxes plus employer withholds from compensation and what the system would actually cost overall isn’t all that great and probably less than those amounts plus household spend.

    Short version: I’m pretty sure we agree on the substance, just not on the phrasing.

    Long version:

    I completely agree with the notion that if you count both employer and government spending, a universal system probably won’t cost much more (depending on the details). But since pretty much any system that divorces coverage from employment will shift most/all of the employer expenses to the government*, it seems likely that the large increase in government expenses will result in significant tax increases.

    In principle, I would expect people’s compensation from their employers to increase by a corresponding amount, since the employers no longer pay for healthcare. But I don’t think most companies will do that out of the goodness of their hearts (won’t somebody think of the shareholders!). In selling pretty much any flavor of universal coverage to voters, I think it’ll be important that we are up front about the fact that taxes will go up**, but that employees should expect their pay to go up by ~20% as well, and if it doesn’t, it’s because their employer is pocketing the extra money.

    *Caveat: Depending on how the system works, I suppose that might be offset by making people buy their own plans if they can afford it. But my suspicion is that it will be politically unfeasible to make the middle class buy their own plans while also subsidizing universal coverage for the poor.

    **Even given very progressive taxation, I think the evidence indicates we’re not going to be able to pay for this just by increasing taxes on the top 5-10%.

    Like or Dislike: Thumb up 1 Thumb down 0

  46. Just 'nutha ig'nint cracker says:

    @CET: Tyrell is probably thinking of programs such as Silver Sneakers where seniors who go with Medicare Supplement Plans F and higher get *free* gym memberships and other goodies. I looked into it at the time that I signed up for my Supplement Plan. It was an okay deal, I guess–it would only cost me about $200/month more to get my $140/year gym membership for *free*. I expect that most young people would probably pass on that, too.

    Retired Middlebury College political science professor Eric Davis says the people that Sanders needs to win over in this public policy debate are individuals who have relatively good employer sponsored health care policies.

    This problem is easier to solve than we realize. If we let TrumpCare pass, within 5 years, no employers will be offering *relatively good* health care policies. They may not be offering health care policies at all. Bernie’s just ahead of the curve.

    Like or Dislike: Thumb up 0 Thumb down 0

  47. Just 'nutha ig'nint cracker says:

    @Hal_10000: True dat! I was asking my doctor about something that had happened with a prescription when I changed over to Medicare. He told me (and I quote):

    Kaiser doesn’t actually cover you anymore. Kaiser only administers your coverage based on Medicare and other relevant Federal rules. Give the pharmacy your request and if it’s permitted, the pharmacy will do it.

    (Which is probably another reason why the lowest cost supplemental policy represents the best deal for most retirees.)

    Like or Dislike: Thumb up 0 Thumb down 0