Home / General / The Next Step in the Health Care Debates

The Next Step in the Health Care Debates



Above: Hells yeah!

Yesterday was a great day. But let’s be clear–Trump and Ryan will treat the ACA as well as they treat any other part of the government, which means trying to undermine its effectiveness. And given how insurance companies are dropping out of the exchanges, there are real problems that need to be fixed. It’s not really on Democrats to defend the ACA as a static program because they originally passed it. What they should be saying is that the ACA was the best that could be in 2010 and yes it does have problems that need fixing. And they should be saying that the way to fix those problems is universal Medicare. And while I get that single-payer has been simplified on the left as the only possible solution for health care when in reality there are many possible roles, expanding Medicare into a single-payer type system does have certain advantages.

It also makes an excellent organizing signpost. Medicare for all is simple, easy to understand, and hard to argue against or distort. Most people know someone on Medicare who can testify to the generally good care, or who is counting the days until they can enroll and have the peace of mind that comes with quality coverage. Fabricated agitprop like the mythical ObamaCare “death panels” will be a much harder sell.

As Republicans do their level best to make sure as many poor people as possible go bankrupt from medical debt or die of preventable diseases, a single-payer counter-offer makes perfect policy and political sense. Even if you think it’s a bit hasty on the merits, it’s still a splendid way for the Democrats to demonstrate, loudly and clearly, that they are for quality health care for all.

That makes plenty of sense to me.

Also, organizing works. Keep doing it. If you flooded congressional phone lines for everything like for this bill, or even 10% of like this bill, we would have a far better nation.

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  • Lurking Canadian

    I’d like to see them resurrect the idea of a public option. The exchanges won’t work if no insurance company is willing to sell a policy on them, and that seems to be the next route of attack. Some kind of rule that says the Feds (or the state or somebody) needs to guarantee hat there will be an ACA compliant plan on the exchange even if they have to be the ones providing it gets the camel’s whole head into the tent.

    • Warren Terra

      Assuming the Republicans don’t manage to kill the Medicaid expansion money (which would hurt a lot of people, many of them Republican voters), the biggest problem the ACA has right now, and the easiest thing for Price and Trump to screw with administratively, is the exchanges and making sure plans are actually on offer, especially in rural areas. Offering a Public Option in such areas, or everywhere – buying into Medicare, for example – would be a fairly simple, explicable proposal.

      • cpinva

        yes. the huge advantage medicare has over any proposed new program, is that is up and running, and has been for decades. all that needs to be done is to scale it up, to cover everyone.

  • Incontinentia Buttocks

    Exactly. There are other ways than single payer to achieve true universality. The German system, for example, works great. But few in this country even understand how it works. Both enacting it and selling it to the public would be very difficult. In contrast, while Medicare for All would be difficult to achieve, it’s easy to explain and relatively easy to sell. That’s why I support Medicare for All. It’s not the only possible solution, but it’s the easiest one to achieve (not that achieving it will be easy).

    • Hondo

      Docs in germany hate their system.
      You would never get that past the AMA

      • cpinva

        “Docs in germany hate their system.”

        I assume that they have all emigrated to that bastion of libertarianism and the free, unfettered market place, Somalia?

      • John Revolta

        Maybe it wasn’t set up for the benefit of the fucking docs

        • mombrava

          This is what bothers me about Tom Price so much–he is willing to sell out patient care to improve profit margins for doctors. And he is so transparently obvious about it, as if medicine is really just another means of sticking it to people you regard as schmucks.

    • guthrie

      All the continental European models that I have read about basically have a lot of private provision, but it’s mostly non-profit or charity based. There are government regulations ensuring there is a lower base of care below which nobody falls, and methods of makind sure that even the poorest get that care.
      But they are also more expensive than the UK’s NHS, which despite years of marketisation and deliberate attempts to destroy, manages to be cheaper because of centralisations and comparative lack of paperwork.
      But as you say, it would be a very hard sell to people to put in place any of these systems. Path dependency is a real thing.

  • sibusisodan

    Are there any ways to do Medicare for All which are less vulnerable to the Republicans turning off the Federal money supply?

    Perhaps Medicare is sufficiently entrenched that this would be impossible. That would be good.

    But from here in Blighty, I’d like to make sure eyes are open about the ability of a ‘we don’t really believe in the state’ party to put it’s thumb subtly, deniably, on the funding windpipe.

    • No, but there is literally zero health plan that could survive that. Which is of course the problem, but that’s an endless fight that you have to have.

      • sibusisodan

        Definitely! I’d almost say passing the legislation is the easier bit…

      • Steve LaBonne

        I think that’s a significantly less daunting political fight if the money is not seen as flowing directly from the federal government to providers. And exponentially so in the particular case of women’s reproductive health care. I do not think single payer is an appropriate system for this country.

    • sharculese

      I don’t think so. As far as I understand it (which is not a lot, because it’s incomprehensible) the core principle of the Doctrine of Sovereign Dignitude of the States is that’s in mean and bad to tell Republican governors they have to accept more Medicare money.

      • humanoid.panda

        Medicare, unlike Medicaid, is a federal program. States are not involved with it.

        • sibusisodan

          Aaaah. Now the endless GOP plan of block grant and push to the states makes more sense.

        • efgoldman

          States are not involved with it.

          They are only to the extent that state insurance commissions license the various providers of supplemental (Medicare Advantage) plans, without which you can still go bankrupt on Medicare.

    • JohnT

      The NHS in England is having funding trouble but that has more to do with being the largest expenditure of a government that’s trying to cut everything rather than being the result of targeted victimisation. And the reason why the UK govt treats the NHS with some caution is the same reason that Medicare for All would have safer funding: It’s primarily for the olds. And old people vote. Without them any rightwing government in the US or the UK is a mirage within a dream. And if you take their healthcare away from them you’re killing them in a much more direct way than you killing uninsured 27-year olds. Medicaid in the US by contrast suffers the same fate that would await a hypothetical ‘NHS for the Poor’ in the UK: a grinding push towards oblivion, leavened only by a distaste for having the corpses of the poverty-stricken beggars literally littering the streets. But assault the current benefits of current old people and you won’t have enough seats left in the House in either country to form a cricket team.

  • Dr. Ronnie James, DO

    1) What does that cartoon even mean?
    2) That’s um not a caduceus.

    • J. Otto Pohl

      I think it is a reference to the fact that the USSR had socialized medicine although not particularly good socialized medicine compared to places like the UK. I have had quite a bit of experience with state hospitals and doctors in the UK, Kyrgyzstan, and Ghana. The British system works well. But, it depends in part on pilfering doctors and other medical workers from its former colonies like Ghana and other poorer countries. This causes problems of a lack of enough doctors in places like Ghana that also have British style health care but refuse to pay their doctors decent salaries. The post-Soviet health care system in Kyrgyzstan is a strange beast neither and other than dentistry which is fairly good the best thing is to try and not to have to go to a doctor. But, if you do go to an older one that actually trained in the USSR.

      • JohnT

        That’s surprising – I’d always heard that Soviet general physicians were well trained – it was a prestigious profession – but that dentistry was backwards as it was seen as somewhat cosmetic.

        Separately have you run into Cuban doctors on your travels? I often hear that the Cuban medical training was great, and that Cuban doctors were once to be found in many previously left-wing countries.

        • humanoid.panda

          The best Soviet doctors were very very good. But just like with engineers, the Soviet Union produced a lot of doctors, much more on per capita base than any Western country. Which meant that a lot of them were trained at sub par schools and then practiced in sub par hospitals.

        • J. Otto Pohl

          In post-Soviet Kyrgyzstan dentistry is quite good. But, lots of the rest of the medical system has deteriorated significantly. A lot of Soviet era doctors were Russians or other non-titulars and got pushed out of the country due to what the Kyrgyz government called “patriotism.” Russia no longer recongnizes medical degrees from Kyrgyzstan. Although suprisingly both India and Pakistan do and there is a huge industry providing medical “education” to people that failed to get into Indian med schools.


          Ghana had Cuban doctors, particularly ob-gyn specialists. But, all of them worked in the far north where nobody else wanted to work. Given the doctor shortage due to emigration to the UK, Canada, and Australia getting a poorly paid position in Accra was easy enough. Why work for even less in the middle of nowhere? The only Cubans I met in Ghana were Spanish language lecturers at the university.

      • ajay

        The British system works well. But, it depends in part on pilfering doctors and other medical workers from its former colonies like Ghana

        “Pilfering” in this case means “employing immigrants”.

      2) Unfortunately the livestock have long since fled.

      • Lurking Canadian

        But waitaminute! Criticism of Russia is just McCarthyism, which Reublicans hate because otherwise men will use the ladies room.

        Or words to that effect.

    • DFH no.6

      1) Yeah, really. Like, has the sort-of but-not-really caduceus snake (representing who, exactly?) foolishly grabbed onto the hammer of socialized medicine but is now freaking out because it’s about to get sliced in half by the sickle of socialized medicine (not helpfully labelled as such like the hammer, but we figure it probably is cuz communism). Or something else entirely? Not getting it.

      • Woodrowfan

        It’s a right wing cartoon. It’s not supposed to make sense if you actually think about it

    • MD Rackham

      Brookins’ main gig is drawing and “writing” the daily Pluggers cartoon, so there is a long history of not making sense.

  • Murc

    What they should be saying is that the ACA was the best that could be in 2010 and yes it does have problems that need fixing.

    With respect, Erik, I think this would be a mistake except in intra-party policy debates. If the Democrats are saying “the ACA has problems that need fixing” and the Republicans are saying “the ACA is terribad and we’re going to give you something awesome and better!” then even if they’re lying the narrative becomes “even the Democrats admit they fucked up!”

    We should, absolutely, be pushing Medicare for All. That’s a simple slogan for a good policy that could get a lot of traction. But we shouldn’t be taking a nuanced stand on the ACA until and unless we can translate words into action. Until then, our only talking points should be “the ACA insures millions of Americans who went without before and that’s a good thing, and to the extent that it isn’t working it is the fault of the Republicans.”

    • Brett

      I think we should start by demanding that an all-ages Medicare-opt-in be available as a public option (or Medicaid, whichever is politically easier). That wouldn’t undermine our position on the ACA in any way, since the public option was part of the promised bill back in 2008 – we can just say it was temporarily delayed.

      Doing it Medicaid would have some advantages. A couple of states could get out ahead and go full single-payer that way, especially if insurers are fleeing from their marketplaces.

  • Derelict

    Medicare for all would be nice, but it’s an open question as to whether Medicare as it presently exists will survive the next 6 months. Ryan has already unveiled his plan to voucherize it, and he’s had this wet dream even longer than his block-grant Medicaid fantasy. Meanwhile, HHS Secretary Price has made it his lifelong goal to simply eliminate Medicare completely. And Trump is enough of a dunderhead that he would sign a bill that ended Medicare, or turned it into worthless vouchers.

    • Brett

      They’d have to kill the filibuster to voucher-ize Medicare, and I do not think they’d even get all of their Republican Senatorial votes for it (never mind any Democrats). It would be extremely easy to demagogue it as a hand-out to private insurance companies, which it is.

    • Steve LaBonne

      I’m feeling cautiously optimistic that the AHCA debacle has left them without any appetite for fucking with Medicare any time soon. Especially since tax “reform” isn’t going to be anything like the stroll in the park that you might think.

    • sharculese

      Ryan has already unveiled his plan to voucherize it, and he’s had this wet dream even longer than his block-grant Medicaid fantasy.

      Has he unveiled his plan for succeeding at voucherizing it?

      • Lurking Canadian

        They didn’t have fifty Senate votes to kill Obamacare, which they have been demonizing since literally before it was signed.

        I’d say it’s something of a stretch to say they’ e got the votes to kill Medicare.

    • IM

      He isn’t able to abolish Obamacare;

      this won’t even pas the House.

    • SNF

      You could’ve made this argument a few months ago, but after the past week I don’t think you can really say that Medicare will be gone by the end of the Trump presidency.

      They couldn’t even eliminate the ACA, which would’ve been a much easier thing to do than eliminating Medicare.

  • altofront

    If Universal Medicare is too heavy a lift, enormous good would still be done by lowering the age of eligibility to 55 or 50 (perhaps with a means-tested premium to make it more politically palatable). It’s an extremely precarious financial time of life for many, and I can’t believe that insurers really want to cover this group, which is much more expensive than the younger cohorts.

  • nemdam

    I think advocating Medicare-for-all right now would erase any advantage the Democrats now have on healthcare. Make no mistake, the Democrats just won a huge victory by finally settling the debate that the government has a role in providing everyone with healthcare and that they are the only party that can do it. This is an advantage we must not squander. But as much us we all like it, Medicare-for-all is not popular because it means everyone will get their health insurance plan replaced and their taxes will be raised. Advocating for this will make the Republicans the party of the now popular status quo and the Democrats the party of an unpopular health care expansion. We should instead go for reforms that won’t cause such a predictably large backlash like a public option, bigger subsidies, bulk negotiation of prescription drugs, demanding insurance companies spend even more on care, etc.

    Yes, all other industrialized countries have universal healthcare, but they all do it their own unique way, and if the only path for the US to do is to build on Obamacare, then that’s the path we should take.

    • Lurking Canadian

      Letting people buy their coverage from Medicare is not raising everybody’s taxes or replacing everybody’s plan.

      • nemdam

        Medicare-for-all is not Medicare buy-in. I am on board with a Medicare buy-in.

      • “Medicare-for-all” does, unfortunately, sound like Medicare will be a mandatory replacement for everything. “Medicare for everyone” has the same problem (to my ear), and “(Make) Medicare available for all/everyone” is way too long and clunky. But what about “Medicare-for-anyone”? Again to my ear (but perhaps only mine), “anyone” suggests possibility without necessity, in contrast to “everyone” or “all”.


        • Schadenboner


    • kvs

      Higher taxes should still mean more take-home pay because employers wouldn’t be paying for private insurance anymore.

      • Redwood Rhiadra

        Except employers *do* pay half of the Medicare payroll tax, and that would be increased by a significant amount (at least tripled, probably quadrupled.) Whether that comes to more or less than the employer portion of current health insurance will probably vary from employer to employer depending on how good their plans are, but I *highly* doubt anybody would see an increase in their gross pay enough to cover the extra payroll tax. (Even for employers that *would* get a cost break, you can bet they’ll just keep the extra money rather than turning it into a raise.)

      • SNF

        That would result in wage increases in the long run, but are you sure it would happen immediately?

        I suspect that if we switched to single payer, a lot of employers would get rid of the money they spend on health insurance, while barely increasing wages, if at all. Eventually things would change, but I’m skeptical employers would immediately give everyone massive raises because of the money saved on healthcare.

  • stonetools

    My unpopular take is that pushing for single payer would be a mistake and would be overreach by liberals. The public rejected the Republican’s attempt to foist on them a crappy plan worse than the ACA; it did not sign to to Medicare for All, which would be another huge disruption of the health care system, not matter how leftists try to portray it as being simple and cheap. Moreover, interests like health care providers and Big Pharma, which were on our side for not wrecking the ACA, would be on the other side or the sidelines if we tried to leap to single payer.
    Let’s go with the current public consensus, which is for fixing the ACA. There are lots of options for that, some of which even a few Republicans might be persuaded on.

    1. Increase the subsidies for the exchanges so as to make it cheaper for consumers
    2. Restore the risk corridors so as to lure insurers into the personal insurance market
    3. A public option for counties & states with fewer than three insurers.
    4. Pushing out expanded medicaid to all 50 states.
    5. More money for low cost health clinics.

    Now these things won’t make leftists gasm the way single payer does, but they would go a hell of way to improving the ACA and providing better health care for most people, which after all is the goal, not achieving some ideologically pure aim. There are probably lots more than this that would improve the ACA, but this will be a start.

    • pharmazevt

      Please explain, why it would be a disruption, if Medicare itself (the part that addresses the sickest portion of the population) does work.

      • Redwood Rhiadra

        Because by and large, people like their insurance plans – even the crap ones. This is why they bitched when the ACA forced some of the worst plans off the market.

        In short, most folks DON’T want to to see their insurance to be replaced with Medicare. Even if Medicare is better.

        Yes, it’s irrational. People aren’t rational.

  • Davis X. Machina

    The next step is some Bernie grandstanding.

    From RoseAnn DeMoro


    This when HR676 is in the hopper — and has been, annually, since the dinosaurs ruled Rock Creek Park.

    • nemdam

      I’m sure once Mitch McConnell sees BernieCare has been introduced, he will see that The Revolution is on and will have no choice but to pass it.

      • Davis X. Machina

        I’m sure John Conyers is classier than I am, but this little exercise in what the car companies call ‘badge engineering‘ would set me off.

        He builds it, and at the end of the assembly line they put a nice “BERNIE!” badge on the grille.

        • nemdam

          He only did that because he knew Bernie was going to do it first and wanted to be as popular as Bernie. And the Democrats are feeble.

  • RPorrofatto

    I think these CEO’s…
    David Cordani, Cigna: $17.3 million
    Mark Bertolini, Aetna: $17.3 million
    Stephen Hemsley, United Health: $14.5 million
    Joseph Swedish, Anthem: $13.6 million
    Bruce Broussard, Humana: $10.3 million

    … and their colleagues in other health insurance companies might object a tad to Medicare for all, and they have the lobbying clout and $$$ to make it even more difficult for Repubs to support it, no less recalcitrant Democrats.

    Maybe it would be more politically feasible if it were more along the lines of Medicare Advantage, where the insurance companies make a nice piece of change administering Medicare coverage. But then the more you make it attractive to private insurers the more it may start to look like Obamacare.

  • pharmazevt

    Ler’s do some math.
    2015 healthcare expenses per person were $9,990.
    Medicare covers 80% (yes, I know, but we’ll make it simple for now).
    So, new medicare tax must cover $9,990*0.8=$7,992 per person per year.
    2015 medicare tax receipts $527B; population 320M; so, $1,647. (Yes, I KNOW that not all people pay medicare tax.)
    Current medicare tax rate is 2.9%.
    So, roughly speaking, to finance the proposal, the new medicare tax should be 2,9%*$7,992/$1,647= 14,0%.
    How that will affect the current payers?
    Mind that currently empolyers pay health premiums, and with the universal medicare, they will not have to, at least not all of it.
    What is health premium over the wages currently? Will make some wild estimate.
    Average net compensation in 2015 (from SSA site) was $46,110.
    Average employer-paid portion of health insurance per empolyee in 2015 was $12,612, and an employee’s portion $4,720 (from Kaiser family foundation site).
    However, this is typically for the family. Assuming family is at average 2.2 persons, employer’s burden for one insured person is about $5,730 or 12,4% of the salary bill; and employee’s, per insured, was about $2,145, or 4,7%.
    So. If employers pay Unicare tax of 12.4+1.45=13.85%, do NOT pay what they currently pay as their part of premiums, and pay what is currently an employee’s portion into buying supplemental insurance that would bring the benefits in line with current popular plans (HMO), and the employees continue paying their 1.45%, the net effect would be either zero, or positive for employers.
    Looks like a doable plan! Now, the people who love the freedom of being morons (the most cherished American freedom) would never let it happen.

  • stonetools

    What The Democrats should be doing also is attacking the Republicans’ attempts to undermine the ACA. That has been under reported and has not been the focus of Democratic campaigning. They have done and are doing everything they can to wreck the ACA and have had some success. It’s time we highlight this, especially now that Trump has said outright that he wants the ACA to “explode”. I would prefer the Democrats to do this, than bang on about something-single payer- that the majority of the electorate doesn’t want.

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