The Good and The Bad of Health Care Reform

Let's start with The Bad - Obamacare.

The uninsured rate for those ages 45 to 64 jumped to 10.3% in 2018, up from 9.3% a year earlier, according to a report from the Centers for Disease Control and Prevention published Thursday.
It's the first time a government study has shown an increase in the rate, though polling and research groups had previously found that people had been losing their health insurance since President Donald Trump took office.

Then there is The Worse.

Though Medicaid is a federal program, states can proposition for changes in their administration of funds and benefits. If approved by the state Senate, HB955 would authorize Governor Ron DeSantis to ask the federal Department of Health and Human Services for a Section 1115 waiver, granting permission to impose a new work requirement of 20 hours per week on adult Medicaid recipients who aren't disabled. But 20 hours of work at Florida's minimum wage of $8.46 per hour would yield about $677 per month, well above the state's income limit of 33 percent of federal poverty level for Medicaid eligibility, creating a bind that's all but certain to eliminate coverage for Florida's very poor either way.

Have no fear, because here is The Good.

Washington state will become the first in the U.S. to offer a public option for health insurance to all its residents, according to ABC. The option, known as Cascade Care, will include tiered plans that will cover standard health services and are expected to cost up to 10 percent less than private insurance. The plans will be available to all Washington residents regardless of income.

The Washington legislature passed the plan in April, and Gov. Jay Inslee, who is running for president in 2020, is expected to sign it on Monday. Similar public options have been proposed in eight states, including Colorado and New Mexico, but Washington is the first to successfully pass a bill.

The model that will be put in place in Washington is one that’s supported by some of the centrist candidates running for office in 2020. It doesn’t cut out private insurance companies, but instead incorporates them into the public plan...With their new plan, Washington will avoid the obvious way of saving money on healthcare: cutting out insurance companies. Instead, Cascade Care lets insurance companies remain central to healthcare by hiring them to administer the plan.

And here is The Better.

The Congressional Budget Office issued a report on May 1, 2019 titled "Key Design Components and Considerations for Establishing a Single-Payer Health Care System." This report reviews a range of considerations as regards the design and implementation of a single- payer system as applied to the United States.
...The CBO does not take an explicit position as to whether a single-payer system will also deliver benefits for the 65 percent of the population which presently has full health-insurance coverage. On the one hand, the report does note both the prospects for both improved outcomes as well as reduced costs as regards this population cohort, observing that:

Unlike private insurers, which can experience substantial enrollee turnover over time, a single-payer system without that turnover would have a greater incentive to invest in measures to improve people’s health and in preventive measures that have been shown to reduce costs.

It is also the case that both the Jayapal and Sanders bills offer more extensive coverage than is currently provided under a typical employer-sponsored policy, including significant support for long-term care. Expanding coverage in such ways should further improve overall health outcomes for those already insured. But the CBO also recognizes that the expansion of coverage to the uninsured and underinsured will entail increased overall demands on the country’s supply of health care resources. It is therefore possible, as the report notes, that this could produce shortages in terms of availability of providers, which, in turn, could mean reductions in quality of care. This is a legitimate issue which the CBO has properly highlighted.

More specifically, the single-payer system will need to be capable of establishing measures through which the provision of provider services can increase to match the increased demand resulting from universal coverage. I examined this question in depth in a 200-page peer-reviewed study with co-authors released last November, "Economic Analysis of Medicare for All." In our study, we conclude that a single-payer system will produce major reductions in the administrative burdens throughout the whole health-care system. The CBO report also recognizes this prospect for major reductions in administrative burdens under single-payer. These dramatic cuts in administration will then mean significantly less paperwork for doctors and nurses, freeing them to spend more time treating patients. On balance, our study concluded that this effective increase in the providers’ available time to treat patients should roughly match the increased demand for their services resulting from universal coverage.
...
But the report does not take a position as to whether a U.S. single-payer system will be able to successfully control costs. Rather, the study concludes that:

The cost of a single-payer system would depend on various design choices such as the services covered, cost-sharing requirements, and provider payment rates.

In addition to those design choices, policymakers could consider using two other techniques to contain the growth of government spending on the single-payer plan and total health care spending: global budgets and utilization management. (p.26)

The CBO assessment here is indisputable. It is therefore incumbent on the designers of a single-payer system to consider the range of design choices with great care, to achieve the potential cost savings that are available through a well-designed system.

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Comments

(1) years after Conyers had first proposed HR 676, which, by 2008, had 100 co-sponsors, all from the House Progressive Caucus that Sanders founded as soon as he got to the House;

(2) After 2008 Candidate Obama mocked government health care, which was never the issue, taking a gratuitous pot shot at the USPS while he was at it;

(3) After 2008 Candidate Obama promised a strong public option, saying (correctly) that a strong public option was the only way to keep down costs;

(4) after since-disgraced Anthony Weiner finally got Dem Speaker Pelosi to promise to take up HR 676, which promise she broke, allegedly "in fairness" to newly-inaugurated Dem President Obama;

(5)After Obama refused FOIA reguests from the ACLU for White House visitors' logs, which, as it turned out, showed "visits" from Big PHRMA and other big medical providers;

(6)After the "visits" were moved from the White House to a nearby greasy spoon, so that they would not continue to show on the logs;

(7) After several members of the White House sneered at "the left of the left, for trying (in vain) to hold Obama to his campaign promise of a strong public option;

(8) After Obama changed his story about the public option from the only way to control costs to "only a sliver'"

(9) After Baucus, who later got a plum ambassadorship to China, drafted the bill together with a lobbyist for the health insurance industry, then let Susan Collins make it worse;

(10) After the bill finally passed by reconciliation in March 2010;

(11) After a beautiful, sweet young man I knew died because he could not afford both his rent and his medication; and he chose rent.

(12) After Obamacare began failing, as Democrats knew it would, claiming they passed it knowing it would need improvement--as if they'd ever again get a Dem in the White while also having an overwhelming majority in the House and sixty Dems in the Senate--which, btw, they claimed was not sufficient to get a good bill anyway!

After all that, my dears, was when I vowed to myself, in March, 2010, never to vote Democratic again. However, I broke that promise to myself when Sanders ran as a Democrat in the Democratic primary, whereupon Democrats screwed me again.\

There's probably a lesson there somewhere, if only I could figure it out. /s

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dkmich's picture

@HenryAWallace

Obama, Pelosi, Biden - the list is ad infinitum - I figured it out too.

Great diary gjohnsit. Love that it is all encompassing on an issue that is so important to this country. Maybe all the people with no health care will then be able to afford their crappy $15/hr jobs.

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"Religion is what keeps the poor from murdering the rich."--Napoleon

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@HenryAWallace for all those dots the media just can't seem(refuse?) to connect.

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@Snode

Unless it's something like invading Iraq. In that case, the msm pretends the Emperor's new dots are compelling!

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dkmich's picture

The supplemental programs have been very successful. The only change I would make to them is that all private insurers have to be non-profit. I had to buy a supplemental policy for my mom at age 90. BC/BS in MI, which is a great non-profit company and unable to refuse anyone in Michigan, gave her supplemental coverage for $120/month. Where Medicare ended, they picked up.

If everyone in this country was on a version of Medicare and had to have supplemental purchased from a company like BC/BS Michigan, I'd be ok with that.

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"Religion is what keeps the poor from murdering the rich."--Napoleon

*donate to c99 *like us on Facebook *follow us on Twitter

@dkmich
i know that in at least one canadian province supplemental insurance was in the past available -- for example, you could get coverage that would guarantee you a semiprivate or private hospital room, rather than a ward room and so on.

however, i don't know whether that supplemental insurance was purchased from a private company or from the province's publicly owned/administered system. it occurs to me that one of the big advantages of single payer is exactly that it is single payer. if there are a dozen different companies providing supplemental coverage, then we're back to where we are now, with doctors and hospitals needing extra admin staff to navigate the paperwork (though that paperwork would, of course, be much reduced). perhaps if the government dictated the exact forms of supplemental insurance that were permissible, as well as the billing standards and so on ...

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The earth is a multibillion-year-old sphere.
The Nazis killed millions of Jews.
On 9/11/01, a Boeing 757 (AA Flight 77) flew into the Pentagon.
If you can't accept these indisputable facts, I can't fake an interest in your opinions about anything else.

dkmich's picture

@UntimelyRippd

If the govt tried to sell different levels of coverage (supplemental), I could hear the screams of discrimination against poor people. Medicare alone is better than Medicaid and not good enough all alone. Not only would taxes have to increase to pay for universal coverage, but people would also get stuck with substantial co-pays. I don't know what the solution is. For people with good coverage, they have the best of the system. For those with no coverage or bad coverage, they're totally screwed. I think the good coverage people have to be phased or grandfathered in somehow, or they will attack universal heath care with the help of insurance industry until they kill it.

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"Religion is what keeps the poor from murdering the rich."--Napoleon

*donate to c99 *like us on Facebook *follow us on Twitter

@dkmich
For several years I had MediCal (CA Medicaid) then Medicare supplemented by MediCal, finally Medicare without MediCal.
MediCal alone gave the best care. Hands down.
Note: this was because MediCal's coverage was regulated by California, but when I switched to Medicare it's requirements reverted to the federal standards, which are poorer than California's.

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A PROUD Hillary hater since 1993

Unabashed Liberal's picture

@UntimelyRippd

standardized (federally). The various State Depts of Insurance have a say regarding some very narrow issues pertaining to these plans; however, the Plan benefits, and the procedures for filing the claims are identical for like-numbered plans, regardless of the insurer.

Which is rather interesting, IMO, considering the fact that monthly/yearly premium costs can, and often do, vary considerably. They are sold/charged as: 1) Attained-Age 2) Issue-Age, or 3) Community Rated plans or policies.

Mollie

I think dogs are the most amazing creatures; they give unconditional love. For me they are the role model for being alive.
~~Gilda Radner, Comedienne

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"The power of accurate observation is commonly called cynicism by those who have not got it."
--George Bernard Shaw, Irish Dramatist & Socialist
"We [corporations] are the government!" Actor John Colicos (1978)

@Unabashed Liberal
it's almost like it was designed by people who wanted something that worked, rather than something that maximized profit by minimizing service.

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2 users have voted.

The earth is a multibillion-year-old sphere.
The Nazis killed millions of Jews.
On 9/11/01, a Boeing 757 (AA Flight 77) flew into the Pentagon.
If you can't accept these indisputable facts, I can't fake an interest in your opinions about anything else.

@dkmich

I am sorry I ever favored using the term "Medicare for All." (Again, my apologies to Big Al.)

That term leaves the door wide open for the asshats in D.C. to title any crappy legislation "Medicare for All." (Hey, they took a bill that shredded the Bill of Rights and then some, and titled it "Patriot Act;" and it turns out, "Green New Deal" is only a title. They have no specific plan.)

We need to be demanding single payer. We won't get it. We won't get anything resembling Medicare as we know it, either. But, single payer should be our starting point.

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1/3 of the federal poverty level? huh? so it's not enough just to be living hand to mouth, you need to be ... what, homeless?

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7 users have voted.

The earth is a multibillion-year-old sphere.
The Nazis killed millions of Jews.
On 9/11/01, a Boeing 757 (AA Flight 77) flew into the Pentagon.
If you can't accept these indisputable facts, I can't fake an interest in your opinions about anything else.

to 55, and free up the oldsters to maybe move on from a job they @UntimelyRippd have to have for insurance, and make room for the young to take that job. It would be a start, nothing would have to be invented.

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Unabashed Liberal's picture

@Snode

but the premiums aren't subsidized by the government, unless one qualifies under the same guidelines that apply to the ACA Exchanges.

And, most of the various proposed (public option) plans are 'managed care'--along the lines of the private Medicare Advantage plans.

Mollie

I think dogs are the most amazing creatures; they give unconditional love. For me they are the role model for being alive.
~~Gilda Radner, Comedienne

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2 users have voted.

"The power of accurate observation is commonly called cynicism by those who have not got it."
--George Bernard Shaw, Irish Dramatist & Socialist
"We [corporations] are the government!" Actor John Colicos (1978)

edg's picture

@UntimelyRippd

I looked at Florida's medicaid site and other sources and found nothing about 33% of FPL. The income limit for a single person, no children, no disability was stated as $891, which is about 85% of FPL.

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travelerxxx's picture

@edg

I think UntimelyRippd is speaking to the section in the original gjohnsit essay where a quote from this article is highlighted.

It's not yet Florida law. Were I betting however, my money would be saying that they will pass the proposal and that it will be signed into Florida law. I would expect other severely regressive states to follow in kind.

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edg's picture

@travelerxxx

The article states 33% like it's a current fact, not that it will be part of the proposed law.

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travelerxxx's picture

@edg

The article states 33% like it's a current fact, not that it will be part of the proposed law.

You're right, it does speak as though it's current.

I went over the Florida info, and I can't find it. Then again, I'm not so sure they'd want to emphasize it. Thing is, the author doubles down on it later in the article with this statement (all bold mine):

"Florida is unique in that it's the only state to propose Medicaid work requirements that refused to expand Medicaid under the Affordable Care Act. In expansion states, where the income qualifications were relaxed via the ACA, all adults are covered up to 138 percent of the poverty line. Not so in Florida, where the only adults with Medicaid eligibility are either disabled or very poor parents whose income falls below 33 percent of the federal poverty level."

I don't know the answer.

I see the author, Alexander Sammon, bills himself as a "reporter-researcher at The New Republic and a contributing writer at Pacific Standard," but maybe he's not a very good one. Or perhaps he is a very good one - maybe better than we are. I dunno. I can't prove it either way. Too confusing; maybe purposefully too confusing. I have enough trouble with Texas laws.

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smiley7's picture

Medicare for all which has explicit choices and regulations for subsidy plans would be a simpler and faster way to go as the system is in place and loved by most seniors with plans F and G (58% of seniors) myself included.

It's important to note that insurance companies are taking profits in traditional Medicare subsidies.

However, it is tantamount that HMO's or Advantage plans do not, repeat do not make into any new legislation; they are a boondoggle.

Having said this; Bernie's plan is more inclusive, provides more coverage, long-term care, for instance, and covers everyone 100%.

Considering the present money Feds and states spend on Medicaid, underwriting Obamacare, health clinics and so on; it's not difficult for me to appreciate Bernie's plan can be payed for with better outcomes for everyone.

Shooting from the hip as we know how complex this is, but common sense speaks when lobbyists are not involved.

Good speed to any legislator out there committed to making healthcare a long overdue reality for everyone in this wealthy country.

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dkmich's picture

@smiley7

How does he pay 100% and keep the same level of coverage those of us with Cadillac plans currently have? I have Medicare and supplemental provided to me by my retirement plan. One day I will need to add the cost of each up, plus my co-pays and deductibles, to see what I actually pay.

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"Religion is what keeps the poor from murdering the rich."--Napoleon

*donate to c99 *like us on Facebook *follow us on Twitter

smiley7's picture

@dkmich
present medicare:

"The Sanders plan is more generous than the plans Americans currently receive at work too. Most employer-sponsored plans last year had a deductible of more than $1,000. It is more generous than the current Medicare program, which covers Americans over 65 and has seniors pay 20 percent of their doctor visit costs even after they meet their deductibles.
[...}
It would bar employers from offering separate plans that compete with this new, government-run option. It would sunset Medicare and Medicaid, transitioning their enrollees into the new universal plan. It would, however, allow two existing health systems to continue to operate as they do now: the Veterans Affairs health system and the Indian Health Services.

Those who do qualify for the new universal Medicare plan would get four years to transition into the new coverage. In the interim, they would have the option to buy into Medicare or another publicly run option that does not currently exist.

Eventually, though, they would all end up in the same plan, which includes an especially robust set of benefits. It would cover hospital visits, primary care, medical devices, lab services, maternity care, and prescription drugs as well as vision and dental benefits.

The plan is significantly more generous than the single-payer plans run by America’s peer countries. The Canadian health care system, for example, does not cover vision or dental care, prescription drugs, rehabilitative services, or home health services. Instead, two-thirds of Canadians take out private insurance policies to cover these benefits. The Netherlands has a similar set of benefits (it also excludes dental and vision care), as does Australia.

What’s more, the Sanders plan does not subject consumers to any out-of-pocket spending on health aside from prescriptions drugs. This means there would be no charge when you go to the doctor, no copayments when you visit the emergency room. All those services would be covered fully by the universal Medicare plan.

A pdf of options Sanders put forward for paying for this is here: https://www.sanders.senate.gov/download/options-to-finance-medicare-for-...

I believe there may be a new iteration of the above, but can't recall where i saw it; anyways; maybe we'll get the c99 healthcare series going, been discussing it.

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@smiley7 @smiley7 @smiley7 missing stuff in the Canadian system altho having lived/worked there for many years I know it fairly well, at least as it was in the time I spent there but there have been changes since then so I wanted an update.

First of all my son, my daughter with my two grandsons were all born in BC and have never lived elsewhere and she says "kids and adults get free eye exams...not glasses unless you have a private plan".

She reminds me that dental for sure isn't covered (but I've read about the NDP pushing for it) except for checkups for kids and "I THINK fillings are covered if you are low income" (her caps).

She said rehabs are covered if your doctor prescribes it. However rehab for certain disabilities is covered (for which one of my grandson's is a beneficiary), she also adds that car accident rehab is part of car insurance, rehab for cancer is covered ("so I'm not sure what they mean there") and home health service is covered if you have a "severely disabled child or adult...but not for the elderly".
She just added "kids get glasses if they are disabled under the disability coverage".

I want to add one little story and just imagine this happening to a parent (non rich) in the US.

My youngest grandson, Caelan, told her one day that he was feeling really funny "in the head" and felt pain in his chest, left side, and she thought about different things that could cause it all from something like heartburn, indigestion, along with other possibilities but did she watch and wait to see if it would pass?

No, she thought about that stuff on the way to the doctor because there was no thought about 'cost' and just like always the first question asked when you go to a doctor is "what's wrong?" not what insurance do you carry, or if you have the co-pay problem which would make many parents hesitating about going to a health care provider and hoping it will pass asap.
Sometimes that can have terrible consequences if someone waits too long for medical help but I'm happy to say that Caelan had an MRI,blood tests, you name it and he turned out fine (I don't remember what the doc said that brought it all on, this was a couple of years ago).

My daughter also has right wing cousins living in New Orleans, tRump, Palin fans, and I do feel they truly love Adrienne but argue with her about "big govt." should have nothing to do with health care, and of course I'm always on her side of the argument but only she can flat out nail them into silence sometimes.
Like her offering up a photo of the "bill" she got for all those tests and it is spot on, the paper is blank.

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smiley7's picture

@aliasalias
a fight over priorities and profit.

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@dkmich
(disclaimer: this is from a newspaper article published just after "Hillarycare" i.e. mid 1990s)50% of a doctor's costs are related to billing - including collections, legal and court costs, and refusals to pay - by insurance companies. The doctor writing the article charged uninsured patients 1/2 what she charged the insured and made more money doing so, so much more she refused to accept any private insurance.

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A PROUD Hillary hater since 1993

on "worse". Who says they can't craft legislation. How many dems went along with the work requirement to not look like they support deadbeats? Then watch as it's used to kick the poor sick to the curb. Oh yeah! Those dems, they'll fight for us.

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edg's picture

@Snode

to put more people into prison, to change "welfare as we know it", to loosen banking regulations, and for trade agreements that eliminated those pesky overpaid American jobs. He was a fighter. Just not for us.

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studentofearth's picture

federal antitrust laws. Then appropriate oversight of kickbacks, rebates, price setting, profit distortion and anticompetitive activity insurance related may be achievable. Then address special "discount" pricing for hospitals, long-term care and on-line pharmacies that shift costs to the general public under the guise of shifting market share of a product.

Ideally Medicare for All would not include insurance companies only a payment system like Medicare Part A. The Veterans Affairs health system and the Indian Health Services that employ the healthcare providers and facilities would be very difficult to implement politically nationwide. It would be interesting if they were allowed to compete with the private companies outside their narrow base of eligible patients. Like private insurance providers the quality of care varies in different parts of the country.

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Still yourself, deep water can absorb many disturbances with minimal reaction.
--When the opening appears release yourself.

that in the short term M4A would mean increased pressure on doctors and clinics. I noticed exactly that in my MediCal hospital clinic when Obamacare "forced" people to seek coverage (all were people "forced" to admit that they were eligible for Medicaid, though CA's eligibility was more generous than the federal) Eventually earlier care will lead to savings, but we will have to admit that there will be some implementation costs.
BTW, in my experience doctors in MediCal clinics - without profit pressure - are much better doctors, even with the pressure.

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A PROUD Hillary hater since 1993