All Care For All People
February 15, 2019 10:37 AM   Subscribe

“...Jayapal’s bill joins a crowded mess of at least eight other healthcare policies being bandied about among Democrats. I couldn’t fault anyone for getting confused when candidates talk about “Medicare for All,” or “Medicare Extra for All,” or “Medicare for America,” or the “public option.” The relatively simple problems of health finance have been made very complicated by people who make money off of healthcare. So what are all of the issues being discussed and what do they mean? What’s really “Medicare for All” and what’s not? How do existing bills stack up? And why does this matter?” The Only Guide To ‘Medicare For All’ You’ll Ever Need by Tim Faust (Splinter)
posted by The Whelk (25 comments total) 36 users marked this as a favorite
This is good - one of the better explanations I've read about all of the single payer/public option policies that have been floated recently, and why only Sander's bill comes close to fixing our current problems. I look forward to reading the new bill.
posted by hopeless romantique at 10:49 AM on February 15 [1 favorite]

Tim actually says that Sanders's bill is inadquate in one very important way - it ignores people in long-term care and leaves tehm to the for-profit industries taht already exist. This is apparently something that Jayapal's bill covers explicitly, and he endorsed it over the Sanders bill in his newsletter that he sent out yesterday.
posted by Space Coyote at 10:52 AM on February 15 [16 favorites]

>why only Sander's bill comes close to fixing our current problems.

Tim actually says that Sanders's bill is inadquate in one very important way...he endorsed [this bill] over the Sanders bill in his newsletter that he sent out yesterday.

Also discussed in the linked article, specifically this bit:
[There are] only two bills worth considering: Bernie Sanders’s “Medicare for All” bill in the Senate and Pramila Jayapal’s upcoming House version, The Medicare for All Act of 2019.
[Sanders's] bill comes close, but it isn’t there lacks is comprehensive coverage. Specifically, Sanders has a lousy plan for elder and long-term care...Sanders does not have a “Medicare for All” bill—he has a segregated healthcare bill which inflicts unnecessary and preventable harm on people with disabilities.

Jayapal’s bill, though, appears to meet all of the criteria for a proper single-payer plan. It includes long-term care with a preference toward home health. It sets guidelines for care but lets doctors overrule them. It is, by all accounts, the first actual robust single-payer bill of the post-ACA era. If you are looking for a bill to call “Medicare for All,” this is the one. It must not be permitted to be weakened [even though the bill] not perfect.
posted by cjelli at 11:07 AM on February 15 [16 favorites]

Tim actually says that Sanders's bill is inadquate in one very important way - it ignores people in long-term care and leaves tehm to the for-profit industries taht already exist.

Right, sorry, I meant that Sander's bill is the only one that comes close in comparison to the other bills that have already been floated - all of which use public options instead of a universal risk pool. But it still have problems, as the author points out.

Personally, I think Sander's bill doesn't do enough to address prescription medication - although it is a vast improvement on Medicare Part D (the current out-patient medication program). I'm looking forward to seeing whether the new bill touches on that at all.
posted by hopeless romantique at 11:09 AM on February 15 [1 favorite]

Kind of amazed the article omits one very essential point under "Fundamental Components of Single-Payer": cost controls

The government sets prices under single-payer systems. This is a really big deal and a pretty huge ideological shift for the US government. I get that Medicare sets prices now for people that are in that system, but expanding that to everyone is a really big shift.

I think it's fine and in the long run a lot better for the economy to not be wasting money on processing medical paperwork, but in the short term it's a big disruption. I think this needs to be very explicitly addressed.

But my complaint is just about how it gets done, not whether it should get done. The US medical system is terrible and needs to go.
posted by GuyZero at 11:35 AM on February 15 [12 favorites]

Goddamn I would be excited if we could give one good thing (universal healh care) to our kids among the giant shitpile of climate change, money in politics, and all the other things we have screwed up in he last twenty years.
posted by wenestvedt at 8:28 PM on February 15 [5 favorites]

Yeah, I've got a lot of issues with this article - it's clearly written by an American who hasn't really grokked the system he's advocating for or how it's going to be implemented in practice. Like GuyZero mentions, cost controls are huge, but he's thinking of Medicare as just a big insurer. That's not how it plays out in practice at all, especially if it's publicly owned. A universal public insurer doesn't have to "negotiate" prices. It mandates them, and the only response private hospitals have is to not offer that service (and then have to pay to move patients) or try and dismantle the system. A universal public insurer doesn't get the option to raise rates if it's not covering its costs, because those rates are called taxes. And if it's not a risk pool, the whole argument falls apart. (If it is a risk pool, you also have to have the conversation about moral hazard, too, and boy is this author not ready to have that conversation.)

He also glosses over an important part of a universal system: standards. Simply put, you don't cover everything, because that means you cover treatments that aren't effective and diseases that were invented to sell drugs. You cover doctor and specialist diagnoses, obviously. Then, you use the system's access to every doctor to establish what is the most effective treatment(s) for each medical ailment, then cover those. This means a payment hand-out to a hospital doesn't work, because you need to be able to cover drugs sold at Walgreen's. (Walgreen's sell medicine, right?) But! You're not done, because you also need to mandate sick days for all employees for all illnesses, not just long-term ones, so that people can actually go to the doctor and get diagnosed when they first get sick.

Furthermore, he doesn't seem to have grasped that most of the existing socialist healthcare systems evolved out of what was already there, by necessity. Continuity of service is vital, which means you're probably going to have private companies delivering healthcare for a while as you build up the public system.

I wasn't pleased by the dismissal of the public option without evidence or argument. A public option can work, but they usually involve it being universal, and Americans usually don't make the distinction between 'universal' and 'single-payer'. Traditionally, a US-style public option doesn't cover everyone by default, but public options don't have to work like this. Australia's healthcare system is universal, but people can also choose* to take out private healthcare, and they get both.

But I think what I object to, and this is something I see a lot on the left, is the assumption that the only foe we have to fight are the people who like the status quo. There are those who'd prefer chaos and are waiting for any opportunity to induce it.
posted by Merus at 9:01 PM on February 15 [12 favorites]

Eh. I am a utilization nurse at the moment - one of the people whose jobs will disapear under single payer - and I can't wait. My job is stupid: I spend 1/3 of my day doing important stuff (getting folks the home health services they need after they leave the hospital for example), but the other 2/3 is either running computer analysis to see if the patients insurance will pay for services, or struggling to find needed post-hospital services for our un-or-underinsured patients.

One crap thing about "the public option" is that for middle income people, it is expensive. It doesn't release them from the things that free-at-point-of-service single payer would do. Right now, if you lose your job, you lose your healthcare. If you leave your husband, you could lose your health insurance. In an insurance-based system, you are stuck, you lack freedom.

But the reason I personally hate the public option, is it does not fix the problem our public hospitals are now burdened with, and our Medicaid patients are now suffering with. Medicaid is underresourced, and as a result, reimburses providers at shitty sub-par rates and therefore in certain contexts, poor people get shitty care.

I work in a public hospital, we're always broke because Medi-Cal (California MediCaid) reimburses at like half the rate of private insurance and Medicare. The result? We're always short staffed, struggle to provide our patients with the services they need. Medi-Cal reimburses $18 per visit for a home health nurse in California. $18!! Home Health nurses get paid $30-40/hr in California where the cost of living is very high. Do you think any home health companies want to accept MediCal? No. So patients who need home health just don't get it. Or they stay in the hospital for days or weeks they dont' need to be there. That's obviously very screwed up for the patient. But it's also screwed up for our public hospitals who eat the bill.

Having a "public option" means having a two tiered system. One for richer people, one for the rest of us. One payer that pays for everyone gives us all skin in the game. Make it capitated (pay to keep people well, don't pay fee-for-service) & make it free at the point of service, and make it the same coverage for everyone.
posted by latkes at 11:08 PM on February 15 [14 favorites]

Can someone explain what's wrong with a system like Germany's?
posted by schroedinger at 7:14 AM on February 17

Well I'm not like a Healthcare economist or anything, but while I agree Germany seems to have a very highly functional model, trying to create that in the US would require a degree of industrial regulation, as well as professional trade unionism that would be pretty challenging to implement. Creating single payer here is a huge lift. But trying to create the German system means totally redoing healthcare AND redoing how doctors organize themselves AND most challenging, create a highly regulated industry where we tightly cap expenditures and tightly control services. And what would happen to the existing for profit health plans? Would they be offered the chance to reorganize into non profits? What about the for profit hospitals? Would the government buy them?

Germany's system seems to work but given the realities of the US, I actually think single payer would be easier, and more robustly safe from being eroded down the line by moneyed interests.
posted by latkes at 7:48 AM on February 17 [2 favorites]

(Bringing this over from the Mega-Thread. I think it's an important topic on where one gets news, and how to judge the reporters.)

Finding out Dan Pfeiffer of Pod Save America has ties to GoFundMe, which makes a bulk of money off medical fundraising, is opposed to Medicare for all is just ....

Other than the fact that he was a board member from 2015 to 2017, what is the source of the worry? As a recent convert to Pod Save America, I'd be interested to hear some specifics. I find the level of political discussion there to be quite substantive, with (ex-)insider views on subtle policy nuances. They do a great job of analyzing the various candidates' policies and approaches without getting into horse-racey stuff. They've been especially focused on the medicare for all debate, specifically who supports plans with continued private insurance or not. If their are conflicts of interests with those reporting and analyzing the news, that's important to air. But I'm not prepared to dismiss quality news sources without some similarly nuanced specifics.

The Washington Post reporting on the Bezos/Amazon stories is another interesting case. The fact that it is owned by the billionaire in question is well known, but I don't see them pulling any punches, or reporting anything that's at odds with other sources. If that's naive of me, I'd love to see some examples. I guess I'm saying if there are substantive issues with the reporting, let's be specific and point to actual issues, rather than dismissing them with a broad brush for supposed structural conflicts of interest.
posted by jetsetsc at 8:19 AM on February 17 [1 favorite]

> Can someone explain what's wrong with a system like Germany's?

Speaking for myself, I have no ideological objection to Germany's health care system. It seems like it works pretty well for them. What I care about is making sure everyone in this country has access to health care.

The main problem is that switching to a system of competing non-profit insurers like Germany has would be a major overhaul and intricate to implement. latkes clearly knows more about the German system than I do, so I'll leave it at that.

Elsewhere, I commented that people who sincerely wanted universal coverage but also wanted to preserve a dominant role for private health insurers might take a look at the Netherlands. They have a system that's a lot like the ACA, but with subsidies in place to guarantee coverage to unemployed people and people with low incomes. Dutch health care ranks pretty well in the EU in terms of citizens' satisfaction, per capita costs, and outcomes (a low rate of deaths from treatable illnesses). I'd be happy if something similar got implemented here, but I don't think that's an option anyone is looking at or talking about.
posted by nangar at 10:50 AM on February 17 [1 favorite]

Can someone explain what's wrong with a system like Germany's?

There's nothing really wrong with it; as with everything, it's a question of getting there from here.

As GuyZero says, the fundamental shift is in the pricing model, not the payment model. Here's the Swiss reimbursement tarif for 2019. [pdf, in French] It covers all providers and all insurers. It's public. Lots of countries do this. Providers have flexibility in what they charge, but to the patient it's presented as "X amount over the reimbursement rate" and you can buy secondary insurance to cover that.

Alex Harrowell wrote a great piece on "Coasian hells" last year, noting that the problem with US healthcare is that it is structured as a network of opaque contracts from top to bottom, in which parties make claims and secondary claims and counterclaims:
The purpose of the system is what it does, as they say, but it’s worth noting that Stafford Beer’s aphorism refers to the system, not to any particular actor within it. Even trying to bear down on the pure administrative overhead is likely to run into the problem that, although hordes of claims managers, lawyers, and claims-management software developers are a parasitic load on the whole system, they are vital for any given hospital, insurer, or whatever. Therefore, the system is likely to unite in homeostatic self-defence against change unless some drastic triggering event intervenes.
As Harrowell says, the awfulness "is an aspect of the system, not any one component or group of components." That's why "but I like my doctor" or "but I like my insurance plan" or conversely pinning the blame on particular entities misses the point. The system -- the contractual model, the claims model, the model of networks and member discounts and preferred rates and Bistromathic pricing -- is the problem.
posted by holgate at 11:00 AM on February 17 [5 favorites]

Seeing as the argument against single payer is usually cost, has anyone reputable ever done a cost estimate once all the extraneous features of the current system (eg, accounting overhead, price inflation) has been excised? The current price of healthcare as a starter would obviously be misleading, but none of the figures I've seen bandied about have mentioned they have attempted to estimate even a ballpark based on the efficiencies of a single payer system (this may be because I haven't read closely enough).
posted by Sparx at 11:49 AM on February 17 [1 favorite]

has anyone reputable ever done a cost estimate once all the extraneous features of the current system (eg, accounting overhead, price inflation) has been excised?
I'd like to see a formal study cited, but even just looking at generalities it's clear that we aren't getting the optimal results. If you compare the amount spent as percent of GDP we lead the world by a considerable amount. But there are numerous metrics such as infant mortality where we lag far behind many countries.
posted by Surely This at 11:59 AM on February 17

What's interesting is that the Koch and PERI estimates are so similar: both estimate around $3.2 trillion currently being spent annually on healthcare in the US (around 1/6 of the entire economy), vs around $3 trillion if we switch to Medicare for All -- a savings of around $200 billion a year (ie about 1% of GNP).
posted by chortly at 12:48 PM on February 17 [3 favorites]

has anyone reputable ever done a cost estimate once all the extraneous features of the current system (eg, accounting overhead, price inflation) has been excised?

As I was trying to say in my earlier comment, "cutting things out of the system" doesn't change the system if the system remains built upon the current contractual model.

But: the OECD's per capita per year and GDP numbers are good rules of thumb. The closest comparison to the US would likely be Switzerland, where the system reformed late and a lot of private-sector cost is built in, compared to its European peers. So it'd be a stretch to reduce those numbers to the $6000 / 10% GDP average, but getting down to ~$8,000 (20%) or to 13% of GDP saves about $750m dollars a year.

People are people. The cost of universal healthcare across developed nations doesn't vary that much. There are costs involved in serving geographically large nations with sparsely-populated regions, but Australia and Canada manage it. There's also a massive amount of deferred / undertreated healthcare that would need to be provided -- though ACA plans and especially Medicaid expansion have begun that process.
posted by holgate at 1:05 PM on February 17 [2 favorites]

It's not so much that I'd want to preserve a dominant role for private health insurers as I think that it is possible for them to have a place in a healthcare system if very tightly regulated. And I think it is more economically and politically feasible to have a system with a heavily subsidized public option and a tightly regulated private insurance industry taking a smaller role than it is to wipe away private insurance entirely. Give everyone access to a basic Medicaid*-like standard (because gosh, there is a reason so many people on Medicare have private insurance and it is because Medicare is full of gaps) and allow access to private insurance and whatever that entails if they want. It's like, let's have a UBI and guaranteed decent housing and a social welfare system that regards humans as more than trash, but it doesn't mean getting a job won't result in higher income and you don't have access to bigger/whatever housing if you pay extra.

Ideally you start out the program heavily subsidized and then transition to everyone getting the standard, period.

* Goes without saying that I mean the good Medicaid programs, the ones administered by the states that give a shit
posted by schroedinger at 4:36 AM on February 18 [2 favorites]

There's another new plan out there that's kind of fishing for a middle ground between Medicare for All and a public option (how awesome is it that that's the middle ground in the party nowadays?), essentially a pathway to single payer: the Medicare for America Act from Reps DeLauro and Schakowsky. Here's a good summary. In short, there's a new government-run health plan, but employers could continue to offer benefits, and employees could choose their plan (the current language seems a bit vague on this point, in terms of who pays for what and how that works with subsides). There would still be premiums and cost sharing mechanisms for those making more, but with much more generous subsidies, extending to those with higher incomes, and out-of-pocket caps. The bill also goes out of its way to address home and community-based care for people with disabilities.

There are some missing details, and a lack of real cost controls is concerning, but it's an intriguing model as we get a series of health care plans that all are playing with the question of how many parts of the system can we drastically change at once (or as I like to think of it: how many different parts of the health care industry are going to simultaneously declare war). I do slightly share Jonathan Cohn's skepticism though: "A skeptical take on the proposal is that it’s just ambitious enough to carry the same political liabilities as something like the Sanders bill but not ambitious enough to carry its strengths."
posted by zachlipton at 12:21 PM on February 18

That plan seems... unexciting to say the least. From a consumer standpoint, they still rely on employers for insurance coverage, are eligible for subsidies if they are under/unemployed (in some states), and benefit from no price controls? Isn't that the exact same experience for the consumer offered right now?
posted by FakeFreyja at 1:27 PM on February 18 [1 favorite]

This Vox explainer was posted in the current Politics Megathread and I found it to be helpful as well.
posted by Mental Wimp at 2:12 PM on March 1

Sarders plan now includs Long Term Care, thanks to pressure from disability activist groups, pushing it closer to Jayapal’s plan.
posted by The Whelk at 8:04 PM on March 8 [1 favorite]

Finding out Dan Pfeiffer of Pod Save America has ties to GoFundMe, which makes a bulk of money off medical fundraising, is opposed to Medicare for all is just ....

GoFundMe CEO talks about his company's place in healthcare financing.
posted by Jpfed at 8:08 PM on March 9

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