You can be sure that tonight and tomorrow night I will be interested in the outcome of the Red Sox/Tampa Bay games, but I won’t be watching. My eyes and ears will be tuned to round two of the Democratic Presidential Primary Debates in Detroit. Since the last debate, one candidate has dropped out, Representative Eric Swalwell. That has made room for a new candidate Steve Bullock, the very personable Governor of Montana who was able to win as a Democrat even as President Trump carried Montana by a wide margin. If you click on the link attached to Bullock’s name, you will have an inkling of the attributes he might offer. It will be interesting to see how he will perform from an outside position in tonight’s lineup.
The pundits are expecting fireworks on Tuesday and Wednesday nights because it is probably true that a significant number of the candidates will have followed Representative Swalwell’s lead and will have dropped out before the next round of the debates in September in Houston. To qualify for Houston, a candidate must poll at 2% and have at least 130,000 donors. To qualify for the first two debates, the thresholds were 1% and 65,000. So far the candidates who have qualified for Houston are:
- Former Vice President Joe Biden
- South Bend, Indiana Mayor Pete Buttigieg
- California Sen. Kamala Harris
- Former Texas Rep. Beto O’Rourke
- Vermont Sen. Bernie Sanders
- Massachusetts Sen. Elizabeth Warren
Businessman Andrew Yang and former Housing and Urban Development Secretary Julian Castro have met the donor threshold as of this month but have not met the polling threshold.
New Jersey Sen. Cory Booker and Minnesota Sen. Amy Klobuchar have met the polling threshold but need additional donors.
It’s easy to deduce that it will be “do or die” on night one for Marianne Williamson, Rep. Tim Ryan, former Governor John Hickenlooper, former Rep. John Delaney, and the newcomer, Governor Steve Bullock. On night two, the contenders on the ropes are Senators Bennet and Gillibrand, Representative Gabbard, Governor Inslee, and Mayor Di Blasio. All will be hoping for an exchange like the one Julian Castro pulled off against a startled Beto O’Rourke, or that Kamala Harris scored against a confused looking Joe Biden in the first debate. The do or die nature of the event for half of its participants sets the stage for something interesting to happen.
I am hoping that the winnowing process will occur. It is time for us to move individual candidates asserting that they are “the one” to oust President Trump to a more substantive discussion of the real issues. The issues, especially the healthcare issues, are going to be areas of significant pushback for the president and other Republicans. As the picture in the header to this post suggests, while the Democrats are debating Medicare For All versus Medicare For “Those Who Want It,” other voices are beginning to ask whether we really need either one.
I usually enjoy reading my Sunday paper, but this Sunday my paper gave me heartburn when I opened it read and read near the bottom of the front page: “Election 2020: Despite calls to start over, U.S. health system covers over 90%.” The article was written by Richardo Alonso-Zaldivar of the Associated Press. Who is he? He is definitely not a member of any left leaning media outlets. He writes for RealClear Politics, and his AP healthcare pieces appear in many small town papers across the country. His recent pieces includes a challenge to some of Kamala Harris’s assertions: “AP FACT CHECK: Harris cherry-picks health insurance stats.” Looking down the long list of his articles going back over the last year, it is hard to detect bias, but it is also clear that in the two articles I have read there is pushback against the idea that there are problems with our healthcare system, and it is easy to see how many readers, especially if they feel comfortable with their current costs and coverage, might read one of these articles and say, “This is confusing. I think that I will vote against change and hope that what I enjoy persists.” The article begins in a way that is sure to attract attention. In the beginning the thesis seems to be, “Is there really a problem?”
America’s much-maligned health care system is covering 9 out of 10 people, a fact that hasn’t stopped the 2020 presidential candidates from refighting battles about how to provide coverage, from Bernie Sanders’ call for replacing private insurance with a government plan to President Donald Trump’s pledge to erase the Affordable Care Act and start over.
The politicians are depicting a system in meltdown. The numbers point to a different story, not as dire and more nuanced.
Government surveys show that about 90% of the population has coverage , largely preserving gains from President Barack Obama’s years. Independent experts estimate that more than one-half of the roughly 30 million uninsured people in the country are eligible for health insurance through existing programs.
It would not be surprising for a person who is not a healthcare policy wonk to read those opening paragraphs and wonder if they are being subjected to political hyperbole. Alonso-Zaldivar then suggests, and he may be right, that the real issue for most Americans (especially that 90% with coverage) is not whether or not they should vote for universal access, but rather the cost of their care. They want lower costs. Their anxiety is not about who is not covered. Their anxiety is whether or not their costs will continue to rise. Here he quotes Michael Bennet, the senator from Colorado who is one of the candidates that no one knows about.
“We need to have a debate about coverage and cost, and we have seen less focus on cost than we have on coverage,” said Colorado Sen. Michael Bennet. He is among the Democratic presidential candidates who favor building on the current system, not replacing it entirely, as does Sanders. “The cost issue is a huge issue for the country and for families,” Bennet said.
The other fear or worry is being “underinsured.”
A report this year by the Commonwealth Fund think tank in New York found fewer uninsured Americans than in 2010 but more who are “underinsured,” a term that describes policyholders exposed to high out-of-pocket costs, when compared with their individual incomes. The report estimated 44 million Americans were underinsured in 2018, compared with 29 million in 2010 when the law was passed. That’s about a 50% increase, with the greatest jump among people with employer coverage.
He quotes Drew Altman of the Kaiser Family Foundation:
“When Democrats talk about universal coverage more than health care costs, they are playing to the dreams of activists and progressives … much less to the actual concerns of the 90 percent who have coverage today.”
All of these statements are true, as is his next statement about the totality of Bernie Sanders’ program:
Sanders’ office responds that the Vermont senator’s “Medicare for All” plan would solve both the coverage and cost problems for individual Americans. Medical care would be provided with no deductibles or copays. No one would be uninsured or underinsured.
“The simple answer is that our health care system becomes more unmanageable for more and more Americans every year,” Sanders spokesman Keane Bhatt said in a statement. “This is not a system that needs a few tweaks. This is a system that needs a complete overhaul.”
But then he takes away a little of the impact of the Sanders position by implying that Bernie is going too far, and if he isn’t, there would still be little likelihood that his program would be passed by Congress. The link below is to an article that he wrote in May that raises questions about the feasibility of the Sanders plan.
But other countries that provide coverage for all and are held up by Sanders as models for the U.S. don’t offer benefits as generous as he’s proposing. If he is elected president, there’s no way of telling how his plan would emerge from Congress, or even whether something like it could pass.
After trying to refocus the discussion about the wisdom and presentation of the various Democratic proposals Alonso-Zaldivar turns his attention to the Republicans:
On the other side of the political spectrum, Trump is talking about big changes. His administration is seeking to have federal courts declare the entire Obama-era health care law unconstitutional, jeopardizing coverage for 20 million people, jettisoning protections for patients with preexisting conditions, and upending the rest of the 970-page statute, now nearly 10 years old.
The president says there’s nothing to worry about. Earlier this summer Trump told ABC News that he was working on a plan that would provide “phenomenal health care,” protect people with preexisting conditions, and would be “less expensive than ‘Obamacare’ by a lot.”
White House spokesman Judd Deere said in a statement that the Obama law was “sold and passed on a litany of broken promises” and now “Democrats are proposing even more radical government takeovers of our health care system.”
At this juncture I was feeling a little better, but was wondering just how many of Alonso-Zaldivar’s readers read past the comments and analysis that suggested that the Democrats had it all wrong to get to his coments about President Trump’s attacks on the ACA. I realized that it wasn’t what he said, but how he said it, and the innuendo that I was reading into the article, that was my real source of concern. Healthcare was the defining issue of the 2018 election, and it has seemed like it would also be at least as important in 2020. Focusing on critical issues like the president’s threat to coverage for pre existing conditions, rather than the president’s poor behavior, has always been an attractive strategy for Democrats to consider. He then presented me with a segue to a piece that I had been planning to bring to your attention when he wrote:
Economist Sara Collins of the Commonwealth Fund, who led the study about underinsured Americans, says cost and coverage problems are intertwined. Citing the Democrats’ debate over Medicare for All, she says what’s missing from that discussion is that “one doesn’t have to go that far in order to improve the financial situation for millions of people — you can do that with much more targeted, incremental policies.”
Collins co authored with David Blumenthal, the President of the Commonwealth Fund, an op ed published in the LA Times on July 23rd that was entitled: “Medicare for All’ isn’t the only way to cover everybody.” Reading the short op ed would be good prep for the debates.
Former Vice President Joe Biden last week introduced his healthcare plan, which expands on the Affordable Care Act. It’s already the subject of much debate, but it has served one important purpose — it reminded us that “Medicare for All” isn’t the only way to get to universal health coverage.
Biden’s plan, like other recent proposals, suggests that universal coverage would not require a complete overhaul of the health system or the elimination of a meaningful private insurance market. In fact, private insurance, public insurance, choice, competition, workplace benefits and universal coverage are fully compatible, and most other wealthy nations with universal coverage employ a combination of all of them.
They outline how European countries are able to cover everyone and do it with better quality and outcomes than we get at half the cost.
- First, European countries that rely on private plans simplify things tremendously by standardizing the benefits that all private plans offer. This cuts down on the inefficiency and waste that arise when everyone’s plan covers different things at a different price.
- Standardized benefits also simplify things for people and reduce the time they have to spend choosing among plans, as well as ensure that they are covered for health services essential to their health and well-being.
- So that no one is bankrupted by their healthcare costs, European countries place limits on what people have to pay…if they are very sick or have a chronic illness, out-of-pocket costs are capped at 1% of income.
Collins and Blumenthal add a little depth to their discussion and connect what would work better in the future to what the ACA has already done:
The ACA has already helped to reduce some healthcare costs by requiring free preventive care in private plans, limiting expenses for low-income people in the individual market, banning benefit limits, and preventing insurers from excluding pre existing conditions. A universal coverage plan relying on private insurance would have to go further, by capping what anyone would pay in private insurance, perhaps as a percent of income as Germany does.
Universal coverage that relies heavily on private insurance would also need to require or arrange for all Americans to enroll in health insurance — as the ACA originally required before the individual mandate penalty was repealed by Congress. Other countries that use a private system impose this requirement to ensure that healthy people participate, which helps make insurance more affordable for all.
They suggest “auto enrollment” which is really a behavioral economics strategy. With substantial cost supports, once enrolled, few people would unenroll, but they would have the option. They suggest a maximum of 10% of income as the limit that anyone would pay. They realize that they are speculating and finish realistically by saying:
The point is not that the details described here are the best that can be devised. The point is that universal coverage can be achieved through a mix of approaches — as it has been in other countries — and does not necessarily require having a single public plan.
Americans are worried about affording their healthcare. The effectiveness of the policy crafted to address that concern matters far more than its label.
If that is not too much pre reading for the debates, let me give you one more article worth your attention. It was written by the very reliable Julie Rovner, a senior healthcare writer at the Kaiser News Service. The article written July 22 is “Biden’s ‘Incremental’ Health Plan Still Would Be A Heavy Lift.” It is a good companion read to the op ed piece by Collins and Blumenthal because it shows how Biden’s suggestions build on, or return to, some of the suggestions for coverage that were considered a bridge too far in 2009 and 2010, but seem like logical next steps now given the perspective that we might need a more incremental approach to universal coverage compared to Medicare For All.
I hope that on Friday I will be able to report just how effectively the debates treated the healthcare questions. I am certain that no matter what is said we will have taken another step in the process of deciding what might be possible versus what would be wonderful, but is unlikely. I accepted long ago that the road to the Triple Aim is not a super highway. It has always been, and is likely to remain, more like a hike up a steep and narrow mountain trail. Success will come from many careful small steps.
