Bernie Sanders is back. At his announcement in Burlington and at a huge rally in Brooklyn last weekend, near the beginning of his speech, he said:
We say to the private health insurance companies, whether you like it or not, the United States will join every other major country on earth and guarantee healthcare to all people as a right. All Americans are entitled to go to the doctor when they’re sick and not go bankrupt after staying in the hospital.
Yes. We will pass a Medicare for all single-payer program.
Today, we say to the pharmaceutical industry, that you will no longer charge the American people the highest prices in the world for prescription drugs, the result being that one out of five Americans cannot afford the prescriptions their doctors prescribe. The outrageous greed of the pharmaceutical industry is going to end. We are going to lower prescription drug prices in this country.
In 2016 Bernie was virtually alone in calling for “Medicare for all.” Now the majority of the fourteen Democratic candidates who have announced as presidential wannabes, and the six to ten yet to announce, say that they are advocates of Medicare for all. There is no question that the big issue of the midterm elections was healthcare, and the expectation is that healthcare will be one of the issues the Democrats will try to use to win in 2020 to make Donald Trump a one term mistake.
Many voters don’t know that Bernie Sanders filed a Medicare for all bill in the Senate in September 2017. His bill is co sponsored by sixteen other Democratic senators including five who have already announced as candidates for president and several others who are likely to announce soon. The announcement includes the statement:
Sixty percent of the American people want to “expand Medicare to provide health insurance to every American,” including 75 percent of Democrats, 58 percent of Independents, and 46 percent of Republicans, according to an April 2017 poll by The Economist/YouGov.
Those numbers are impressive and likely to be higher now, almost two years later, but that bill sits in the Senate and won’t get serious attention as long as Mitch McConnell is the majority leader. That said, something interesting happened in the stock market on Monday. The share prices of United Health Care, Anthem, and CVS which merged with Aetna last year, fell by significant amounts. Bernie’s bill was easy for the markets to ignore because most voters did not understand the underlying concepts or realize how everyone could benefit. Passage would require retaining the House and winning back the Senate and the presidency. Healthcare investors considered passage a long shot. But a new bill, just introduced by second term Congresswoman from Washington, Pramila Jayapal, has 100 co sponsors and things are going to be hard to predict once highly visible public committee hearings announced by Nancy Pelosi begin, and the public’s attention is focused on how they have been mistreated by the healthcare industry.
You know that feeling you get when you can no longer ignore the reality that you have been financially “screwed” by some credit card company or Comcast? Representative Jayapal is going to make sure that voters learn just why we pay twice the price for half as much healthcare as other developed countries. Representative Jayapal has no illusion that her bill will pass before the 2020 elections, but she will be “locked and loaded” for the moment that Democrats control the House, the Senate, and the Presidency. She predicts that Congressional hearings on her healthcare bill will change the narrative about universal healthcare options.
In the past Republicans blocked the efforts of Truman, Kennedy, and Clinton by aligning with the AMA and insurance companies in campaigns of fear. President Obama preprocessed the ACA and limited its scope to win the support of insurers, hospitals, the AMA, and big pharma so that they felt minimally threatened, if not advantaged. Representative Jayapal thinks it is time to have an educated electorate demanding that the healthcare abuse be ended. She will emphasize that the time has come to accept the principal that easily accessible healthcare for every person in America is one of the most important things we must accomplish if we are to assure a better future for generations to come.
Who is Pramila Jayapal? She is the first Indian American woman elected to congress. She immigrated here from India as a teenager. Her district covers most Seattle. She is the co chair of the Progressive Caucus. Unlike Anastasia Ocasio-Cortez, she has not tried to become influential by leveraging social media. She is an effective “inside strategist.” She convinced Nancy Pelosi to have public hearings to vet her bill. Her bill offers the most robust coverage ever suggested for all Americans, and is intended to completely replace all commercial insurance. To quote Vox:
Jayapal’s bill envisions a future where all Americans have health coverage and pay nothing out of pocket when they visit the doctor or hospital. Her plan, the Medicare for All Act of 2019, describes a benefit package that is more generous than what other single-payer countries, like England or Canada, currently offer. The benefits in Jayapal’s bill are even more generous than those included in Sen. Bernie Sanders (I-VT) Medicare-for-all plan.
Representative Jayapal’s own words can take your breath away and hearing them totally explains why healthcare stocks took a big hit:
“We mean a complete transformation of our health care system, and we mean a system where there are no private insurance companies that provide these core benefits. We mean universal care, everybody in, nobody out.”
She knows there are many issues to address, like a million people working in the health insurance industry who will need help transitioning to new employment. She lays out the barriers to passage of her bill in an excellent podcast interview with Sarah Kliff. I would recommend that you invest the hour required to hear it. Representative Jayapal has considered the potential barriers and has made strategic decisions that are driven by what she considers is an emergency. If events on our southern border are an emergency, then surely thirty million people without access to care, tens of millions more who are oppressed by the cost of their care, and many who die unnecessarily because of delays in getting the care they need surely constitute an emergency.
CNBC has presented a good overview of the bill:
- It would create a single-payer, government-funded health-care program within two years, eliminating the age 65 threshold for Medicare eligibility.
- It would not charge beneficiaries copays, premiums or deductibles.
- The plan would cover prescription drugs, vision, dental, mental health, substance abuse and maternal care. It would also provide universal coverage for long-term care for people with disabilities.
- The proposal notably does not include methods to pay for the health-care overhaul. Jayapal mentioned higher taxes on the wealthy or contributions from employers as potential ways to fund it.
The obvious benefit for everyone in this bill is that we will finally have true universal coverage without any concern about pre existing conditions. We would no longer suffer the inadequacies, the indignities, and the injustices of Medicaid coverage which varies unconscionably from red states to blue states. The most compelling point for middle class voters should be the elimination of out of pocket costs. For voters my age there is huge relief from paying for drugs, vision, and dental care, but the biggest drink of water is universal coverage for long term care. Many of our elderly patients get chronic long term care through Medicaid after they have expended all of their resources and jumped over a series of administrative barriers. Established businesses and those who want to create businesses will be free to do so without the costs and administrative hassles that exist now.
Since 85% of Americans are currently covered and many are fearful of change, I am sure that those who resist the bill will spend hundreds of millions of dollars on a campaign to induce fear of loss by emphasizing that this is a government takeover of healthcare. They will fill the airways with the message that has been effective before, that we can’t trust the government. They will say, “Obama said that if you like your current healthcare you can keep it. What is the government’s lie this time?”
Vice President Pence previewed the Republican strategy for 2020 with his recent CPAC speech. He announced that Progressive Democratic programs were the equivalent of socialism. He warned that if Democrats are elected we will have the same problems that they have in “socialist Europe.” I guess that he is counting on the fact that most Americans have not gotten the word that we trail every European country in life expectancy and in almost every metric of health and healthcare despite spending almost twice as much. To steal a thought from Al Gore, the Vice President is trying to resist a rational exploration of any of the “Inconvenient Truths” in healthcare by shifting the focus from healthcare to a dishonest fear of a slide into the captivity of socialism. Pence proclaimed that all of the achievements of America were rooted in our freedom, and that socialist programs were the equivalent of government oppression and the loss of freedom. His real zinger was:
“What Medicare for all really means is quality healthcare for none!”
If you want to hear the most aggressive parts of Mike Pence’s first campaign address of the 2020 election, click here and move the cursor to 36 minutes. You will hear “healthcare for none” at 36:30. As a Washington Post article points out, virtually ever speaker at the CPAC conference hammered home the concept that progressive Democrats were really socialists, and they are conspiring to rob Americans of their fundamental freedoms. 2020 is lining up to be round two of fear versus reasoned policy. The challenge to Representative Jayapal and all of the Democratic hopefuls for president will be to educate the public to the true benefits of conceptualizing healthcare as a right that can only be fairly and efficiently delivered through a single payer system that treats all citizens the same.
To my surprise, Representative Jayapal imagines that the system would initially be driven by fee for service payment. She reasons that value based reimbursement is an unproven, and not a widely adopted idea. Her strategy is to focus on the benefits that will follow enactment while continuing to keep the door open to further evolution of the finance system that supports the program. Despite my unease with FFS finance for the long term, I am still with her and hope that as she spends most of the next two years trying to educate the public to embrace the consumer benefit of Medicare for all she will learn that Fee For Service payment is a counter current to maximum benefit. Given the waste in our system, the uneven and unfair distribution of benefits, and the frustration that individual users experience as that try to move through the management of a problem, I would probably accept FFS finance as an initial mechanism for the majority of payments as long as it is seen as a transitional necessity.
It is hard to imagine a system that is worse than what we have now. It is exciting to move from defending the accomplishments of the ACA against continual attacks to the design phase of a more just system of care. As I contemplate the source of the most misery and frustration in our current delivery system, it is cost of care for the covered, the lack of care for at least ten percent of the population, and the huge variability that exists from state to state with Medicaid that rise to the level of requiring action now. Our system of care robs everyone, no matter what their economic status is, as it compromises our collective future. Tolerating the damage that it does to the poorest and most broken among us is an embarrassing stain on the dignity of our country.
I’m a Democratic voter and I’d like to express an opinion regarding the Medicare-for-All option that is being discussed by all the Democratic Presidential candidates.
Because I am a volunteer SHIP (State Health Insurance + Assistance Program) counselor (who provides Seniors with free advice regarding Medicare choices), I have some insights into how our current healthcare systems work.
I think it is great that the Democrats are looking at how the USA can achieve universal healthcare, since we are one of the only major countries that doesn’t already have this.
I believe this can be a winning issue for Democrats because it is obvious that Republicans only talk about providing good health care, but don’t really do anything about it – which is why “Repeal and Replace (Obamacare)” really turned out to be “Repeal and no Replace”.
But I think Democrats need to avoid the trap of causing too much “breakage” in trying to achieve the universal healthcare goal. That’s why Obama said “If you like your current healthcare, you can keep it”. But he found that was a difficult promise to keep. Fortunately I think there is a way of achieving universal healthcare without much breakage – via the Medicare-for-All option.
But first, people need to know how Medicare works today. Most people, or at least most politicians, seem to think that Medicare represents a single-payer healthcare system; it does not. Essentially there are 2 ways to get Medicare today. One way is to get Medicare A (hospitalization coverage) and Medicare B (medical/doctor coverage) from the government, and then to augment that coverage with a drug plan (Medicare D) from one of the many private insurance companies that Medicare approves (and regulates). This insurance coverage can optionally be augmented with additional Supplement insurance from other private insurance companies approved and regulated by Medicare.
The second way to get Medicare is to get a Medicare Advantage plan from private insurance companies approved and regulated by Medicare; these Medicare Advantage plans include the equivalent of Medicare A, B, and D insurance, but can be tailored by the individual insurance companies. These insurance companies are basically competing for customers versus the “government” option. As a result, they often add extras, such as limited dental or vision coverage, to make their Medicare Advantage plans more attractive to customers.
In many cases their Medicare Advantage plans are very similar to the plans workers get from their employers or are available on the Affordable Care Act (ACA) marketplaces. That’s not surprising because these Medicare Advantage plans are offered by the same insurance companies that sell plans to employers and who offer plans on the ACA marketplaces – companies like Blue Cross Blue Shield, Aetna, UnitedHealthcare, etc. But a big difference is that the premiums, copays, and deductibles are usually significantly lower than the comparable workplace or marketplace plans; for example, there are no large deductibles in Medicare Advantage plans. That is because the Medicare Advantage plans are competing against the Medicare government option. As a result, the current Medicare-for-Seniors system seems to work very well; the cost to seniors is pretty reasonable, there aren’t any restrictions due to pre-conditions, and seniors have their choice of coverage options – either from the government or from private insurance companies. The competition between the government option and the private Medicare Advantage plans seems to work well; the majority of seniors choose the government option, but the percentage with Medicare Advantage plans is increasing.
So a simple way of achieving affordable universal healthcare would be to add the same or similar government Medicare A+B option to the ACA marketplaces, while still allowing the same private insurance ACA marketplace plans. Since the private insurance ACA plans would now be competing with the government option, it seems reasonable that these plans will lower their costs just like Medicare Advantage plans do. In turn these same private companies would also be incented to lower the costs of their workplace policies.
Another important piece of providing affordable universal healthcare is decreasing the current cost of drugs. This can be achieved by allowing Medicare to negotiate drug prices in the same way that Medicaid and VA negotiate drug prices and/or by allowing Americans to get drugs from other countries, like Canada.
Thanks for considering my arguments for how to achieve affordable universal healthcare for all American.
— Peter Bowen
P.S. I am sending this note to the DNC and to all the Democratic Presidential candidates in the hope of gaining a consensus on this very important issue.