The One State Taking A Big Run At Health Reform
Washington state just passed the countrys first public option plan, and its difficult birth carries a warning for national reformers.
11/25/2019 05:06 AM EST
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| Illustration by Abbey Lossing
When Eileen Cody, the most senior Democrat in Washington states House of Representatives, arrived in Olympia this year for the start of the legislative session, she knew health care reform would be at the very top of the agenda.
Although Washington had embraced the Medicaid expansion under Obamacare, the state was still reeling under double-digit insurance premium increases and a depressingly large number of uninsured residents. For years, the Legislature had been too divided to push through a meaningful policy fix. But 2018s blue-wave elections had given Democrats large majorities in the Statehouse, and many members were eager to use that political capital to do something big in health care.
Just how big was made clear to Cody at the first meeting of her new caucus. Standing before the 56 new and returning members in the partys main chambers, Cody took a quick poll. How many of you guys all think Medicare for All is a good idea? Cody recalls asking. And they all raised their hands.
Eileen Cody, a retired nurse who is the top Democrat in Washington states legislature, spearheaded the effort to pass what will be the first public option health care plan in the United States.|Chona Kasinger for POLITICO
Or, least, that was the theory.
The Agenda
A Shift In Family Costs Not An Increase
Framing this debate by fearmongering over higher taxes ignores that this money is already coming out of American families pockets. Right now, these costs actually amount to a regressive tax that every family pays no matter whether their wage-earner is a CEO or a secretary. We can discuss whether a Medicare for All program that uses our money to fund Medicare instead of financing private insurance companies is a good idea. But it is deeply misleading to pretend that this shift is an increase in family health care costs. It is not.
And no one should buy the myth that Medicare for All represents a government takeover of health care. It does not. Medicare for All is about paying for care, not providing it. Not one proposal suggests that health care delivery should become a government function . It offers Americans, at last, a simple way to assure that they have the coverage they need to see the doctors they want and use the hospitals they choose. Almost all doctors and hospitals would be in Medicares network, and no patients would have to check their insurance card to find out whom they can see and at what cost out of pocket.
Pediatrician Donald M. Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement, is a lecturer and former faculty member at the Harvard Medical School and was administrator of the Centers for Medicare and Medicaid Services in the Obama administration. Follow him on Twitter:
What Is Medicare For All
Medicare for All usually means that all Americans would be covered by a single-payer health care program that would replace all other existing public and private plans. The single payer would be the federal government agency that administers the insurance program.
Single-payer universal coverage would drastically change the current U.S. health care system, in which most people get health insurance from a private insurance company plan thats partially paid for by their employer.
According to the U.S. Census Bureau, 28 million people in the United States did not have any health insurance in 2020. Thats about 8.6% of the population.
Among the 91.4% of Americans who had health insurance that year, about two thirds had private insurance, and one third had government-provided coverage, such as Medicare or Medicaid. Employers provide health insurance for most Americans, covering 54.4% of the population.
There are other versions of single-payer universal health insurance. Medicare for All has become one of the versions that many political progressives are pushing for.
The name a politician uses to describe Medicare for All or a similar universal health insurance program seems to make a big difference. A poll taken in 2017 by the Kaiser Family Foundation found that, while only 48% of people approved of single-payer health care, 62% approved of Medicare for All.
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You Cant Cut Costs Without Cutting Quality
Democrats frequently point to the Nordic success stories as examples of how government-managed healthcare can save money. Little do they realize that these nations spend less on health care because they spend far more on social safety net services that help keep the poorest among them healthy.
Youd likely end up paying almost double as much as you currently do in taxes.
At the end of the day, the governments in Nordic countries spend far more per person, and in turn, their income taxes reach as high as 60 percent. In the US, even that level of taxation would not be enough. Bernie Sanderss single-payer proposal would cost a whopping $33 trillion over its first 10 years, or about three-fourths of everything we already spend.
In other words, youd likely end up paying almost double as much as you currently do in taxes .
Medicare-for-All proponents argue that this same estimate is actually $2 trillion less than what would be privately spent in those ten years. In other words, the doubled taxation would, for some, be offset by not having to buy health insurance.
But even these potential savings open up a Pandoras box of issues. For one thing, such a proposal would constitute taxation and redistribution the likes of which we havent seen since WWII, and such taxation is guaranteed to slow down and reverse the growth weve seen under President Trump.
You cant significantly cut costs without cutting quality.
Lets Say Medicare For All Happens How Would The Transition Occur
That depends on how disruptive of a model is adopted, said Alan Weil, JD, MPP, editor-in-chief of Health Affairs, a journal of health policy thought and research.
If we literally eliminate all private insurance and give everyone a Medicare card, it would probably be implemented by age groups, Weil said.
People would have a few years to transition, and once its your turn, youd move from private coverage and into this plan, Weil said. Because the vast majority of providers take Medicare now, conceptually, its not that complicated.
Although the current Medicare program truly is. While it covers basic costs, many people still pay extra for Medicare Advantage, which is similar to a private health insurance plan.
If legislators decide to keep that around, open enrollment will be necessary.
Youre not just being mailed a card, but you could also have a choice of five plans, said Weil. Preserve that option and that offers a layer of complexity.
Architects of a single-payer health system will also have to tweak Medicare to make it suitable for people who arent only 65 or over.
Youd have to come up with billing codes and payment rates and enroll a bunch of pediatricians and providers who arent currently involved with Medicare, Weil noted. Theres a lot that would need to happen behind the scenes.
Katie Keith, JD, MPH
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Will Quality Of Care Go Down
The rhetorical response to single-payer health insurance is that its government-controlled healthcare. Its then used to argue that the government would be making important decisions about the care you get and dont get, and who you see, Weil said.
But Medicare for All could actually give you more choice than private insurance.
With Medicare, you can go to any doctor, Weil said. I have private insurance and have a lot more restrictions as to who I see.
Medicare For All: An Enormous Risk For Democrats
WASHINGTON As the negative consequences of one-size-fits-all new government health insurance systems become clearer, Medicare for All risks antagonizing critical Democratic bloc by promising to end their healthcare plans. The Washington Examinerreports:
olling among people with private coverage, particularly among those who get their coverage through work show that most people with employer plans are happy with them they also show that the public balks at the idea of gutting private insurance or the government becoming more involved in healthcare. Those facts indicate that the Democratic Party would be taking an enormous risk in campaigning on a platform that would end private plans. Such a platform plank would endanger the votes of a bloc that is now critical to the partys coalition, namely middle-class and professional, suburban voters who get coverage through their employers.
A poll released late last year by the Kaiser Family Foundation and the Cook Political Report finds that nearly two-thirds of swing voters in the key states of Michigan, Minnesota, Pennsylvania and Wisconsin rate Medicare for All as a bad idea. In fact, The Wall Street Journalreports that in Michigan, supporters of a single-payer health care system are finding a tough audience.
Previous reporting has also made clear the political risks of embracing a one-size-fits-all system:
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M4a Actually Devalues Lives
Medicare for All will devalue lives that arent useful to the government. While it seems unthinkable that a society would put able-bodied workers ahead of children and the elderly , this is the incentive that socialized medicine creates. Just as water flows downhill, bad incentives eventually erode government policy to serve government.
Of course, policymakers should continue to talk about how expensive Medicare for All is. A $32-trillion price tag is concerning. But they should take care to emphasize that, even if we had the tax dollars necessary to fund it, those dollars arent the greatest cost of socialized medicine.
Like Your Insurance Too Bad
Move on to what? To a government takeover that has proven ineffective and deadly all over the world?
After her jaw-dropping declaration, Harris was asked what shed say to those Americans who like the insurance they have, which according to a recent poll, is 71 percent of employed Americans. Harriss answer was, effectively, too bad.
Lets eliminate all that, Harris said, speaking about private insurance and the hassle of getting approval for certain costly procedures. Lets move on.
Move on to what? To a government takeover that has proven ineffective and deadly all over the world?
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Feds: You Must Be Vaxxed But We Don’t Have To Be
Likewise, seniors here will have to brace themselves for shortages if Congress expands Medicare to younger people. Its already tough for 65-and-overs to find a doctor willing to accept Medicares stingy payments. More than a fifth of doctors are turning away new Medicare patients, according to a Kaiser Family Foundation survey.
Expanding Medicare will suddenly invite some 10 million more patients to compete for the same doctor appointments and surgery slots a sudden 20 percent increase in demand.
A year ago, when Hillary Clinton proposed expanding Medicare to people in their 50s, hospital organizations howled in protest, warning that it would threaten seniors access to care. Hospitals and doctors will devise ways to avoid treating them.
Thats because Medicare pays only about 90 cents for every dollar of care, shortchanging hospitals and doctors. They take the payments, and then shift the unmet costs onto patients with private insurance. But the more Medicare is expanded, the harder the cost shifting will become. And the more doors will be slammed shut in seniors faces.
Seniors bore the brunt of costs under the Affordable Care Act. It robbed over $700 billion from Medicare over a decade to fund entitlements for younger people. Cuts to Medicare paid for half of ObamaCares coverage expansion. ObamaCare also set up the Independent Payment Advisory Board, an unelected panel with rationing powers alarmingly similar to Britains NHS.
Will Medicare For All Solve All The Problems Of Our Healthcare System
The honest, although somewhat dissatisfying answer at this stage is It depends, said Keith.
This would be a brand new, very ambitious program that would require a lot of changes in the way healthcare is paid for in the United States. There are likely to be at least some unintended consequences and other costs in the form of higher taxes, at least for some people, she said.
But if the bills work as well in real life as they look on paper? People would be insulated from out-of-pocket costs like high prescription costs and surprise hospital bills, Keith said.
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How Likely Is It That Medicare For All Will Happen
Likely, but not any time soon, guesses Weil.
I think were divided politically in lots of ways as a country, he explained. I dont see our political process able to metabolize change on this scale.
Plus, healthcare providers, legislators, policy makers, and insurance providers are still trying to wrap their heads around what this change would mean.
On the other side of optimism, McDonough stresses that Medicare for All would have to accomplish what looks like a Herculean task in todays world pass a divided U.S. Congress.
From his perspective, McDonough said financially and administratively, Medicare for All could be achieved, recognizing some significant disruption and confusion as a certainty.
Looking at the current roadmap to healthcare reform of any kind, McDonough said unless the Democrats control the Senate with at least 60 votes, Medicare for All would not be achievable in 2021, even with a President Sanders.
Right now, according to nonpartisan polling, the odds of Democrats retaining a majority in the U.S. Senate is less than 50 percent, he added.
When citizens are polled on the subject, they agree that the concept of Medicare for All sounds good, said Weil. But when you start to talk about disruption in coverage and the potential of taxes to go up, peoples support starts to weaken, he said.
In other words, you may despise your health insurance, but at least you understand just how awful it is.
Additional reporting by Brian Mastroianni
Pros And Cons Of Medicare For All
The advantages and drawbacks of this program partially depend on your income bracket. If you make less than $250,000, Sanders additional tax will not affect you. If you make more than $250,000 a year, or are in the top 0.1 % of household, Sanders tax to pay for Medicare for All would be a con for you.
In addition, universal healthcare requires healthy people to pay for medical care for the sick. However, that is how all health insurance programs work. Everyone buys in and pays the costs of health insurance, but the insurance company only pays when someone needs medical care or coverage. In every insurance plan, healthier people absorb the costs incurred by sicker people.
Heres a breakdown of some of the most important benefits of a Medicare for All system:
On the flip side, here are some potential issues associated with Medicare for All:
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Tips For Keeping Your Finances Healthy
- Whatever the outcome on Medicare for All, it is important to keep yourself physically and financially healthy. If you are concerned about budgeting with healthcare costs, you may want to look into a financial advisor. Finding a qualified financial advisor doesnt have to be hard. SmartAssets free tool matches you with up to three financial advisors who serve your area, and you can interview your advisor matches at no cost to decide which one is right for you. If youre ready to find an advisor who can help you achieve your financial goals, get started now.
- A health savings account may be a good option for younger people who are worried about potential healthcare costs. HSAs can greatly reduce monthly premiums.
What Good Is A Nod And A Wink
It is true that the platform states that, We are proud that our party welcomes advocates who want to build on and strengthen the Affordable Care Act and those who support a Medicare for All approach. Some progressives view this as a victory. The HuffPost proclaimed that, Medicare for All Gets Nod In Democratic Platform for First Time Ever. And Politico quoted the Sanders campaign political director, Analilia Mejia, as saying, Support for Medicare for All has never been mentioned in a Democratic Party platform. Its inclusion now is significant.
This concession is weak tea indeed considering the depth of the crisis we are now in and the concomitant paradigm shift in Americans thinking about health care. Our for-profit, commodified health care system has proven woefully inadequate in the face of the worst public health disaster in over a century. The resulting economic crisis has accelerated the meltdown of our employment-based health insurance system. Workers will not soon forget how precarious their shrinking health care benefits really are. And the Black Lives Matter uprisings have brought to the fore the racial disparities that undergird the industrialized worlds most unequal health care system.
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Other Medicare And Medicaid Expansion Bills
The legislation would limit the amount of Medicare that would cover all Medicare users. The Medicare at 50 Act was passed in March 2019 by Rep. Debbie Stabenow . Under Medicare at fifty legislation, individuals in a median age range can enroll in Medicare. In addition to expanding age coverage, Medicares current health insurance plan will also provide Medicare Part A , Part B and Part D . In addition there may be an option in acquiring Medicare by private health insurers called the Medicare Advantage program.
It would pay for every medically necessary service, including dental and vision care, mental healthcare and prescription drugs. There would be no copays or deductibles , with the exception of prescription drugs, though the cost would be limited to $200 a year.
