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January 29, 2019 06:39 AM UTC

Tuesday Open Thread

  • 39 Comments
  • by: Colorado Pols

“A man can fail many times, but he isn’t a failure until he begins to blame somebody else.”

–John Burroughs

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39 thoughts on “Tuesday Open Thread”

  2. WOTD from Vox: "How to build a Medicare-for-all plan, explained by somebody who’s thought about it for 20 years"

    There's a good article discussing Medicare For All as opposed to Single Payer. It has some good answers about the key questions,  "How do we pay for it?" and "How do we avoid disruption, or fear of disruption?"

    Dylan Scott
    How does Medicare for America answer some of these questions?

    Jacob Hacker
    It says right up front it’s going to create a system of automatic enrollment. Every employer is required to either cover their workers or contribute to the cost of coverage. The idea is just like you get signed up for Social Security, you make contributions through payroll taxes, [and] employers will be ensuring you’re enrolled.

    …

    In very brief, here’s what this plan would do:

    The uninsured, people currently purchasing insurance in the Obamacare marketplaces, and Medicaid beneficiaries would automatically be enrolled in an improved Medicare program

    Employers could continue to offer private insurance, so long as it meets certain federal standards. Companies could also elect to send their workers to the public program and pay a contribution toward their employees’ premiums. Likewise, workers could voluntarily leave their job’s insurance for the new public plan.

    Participants would be required to pay premiums, on a sliding scale based on their income; people with lower incomes would pay no premium at all. Out-of-pocket costs would also be based on income and capped at $3,500 for an individual or $5,000 for a family.

    Doctors would be paid Medicare rates, with an additional increase provided for primary care doctors and mental health services.

    "How do we mitigate fears of disruption?"

    However, I think the choice that matters to people more is the choice of doctor and hospital, and that’s something that’s really under siege in the current system. The work on surprise medical bills really drives home how many people end up spending a lot of money because they go to a hospital and they discover while they maybe have coverage for the hospital’s surgical fee, they didn’t have coverage for the specific doctor that was sewing them up. I think knowing [that] every doctor and hospital in the country is accepting payment if you’re in a Medicare-like plan would be very valuable to people.

    "How do we pay for it"

    In Medicare for America, the primary source of financing is the redirection of existing funds. So if Medicaid beneficiaries are moving into this new Medicare plan, then you need to have those state contributions that would have been made to cover Medicaid go into the federal plan. It also has an income tax surcharge and some “sin taxes” — a soda tax, for example. It also has the payroll tax employers are making. Finally, there are premiums paid by individuals.

    1. Yeah, no.

      There are parts of this which are either poorly or not thought out at all.

      1) Claiming that private insurance pays slightly more than Medicare, when on average its 89% more.

      2) American healthcare is vastly overpriced, as is medical education.  The average new doctor graduates with ~$200K in debt.

      instead of comparing “the incomes of American physicians with those earned by doctors in other countries, a more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.” As he points out, “any college student bright enough to get into medical school surely will be able to land a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark,” Professor Reinhardt went on to say, “every American doctor can be said to be sorely underpaid. Furthermore,” he continues, “cutting doctors’ take-home pay would not really solve the health care cost crisis.” What a ludicrous idea!

      The total amount Americans pay their physicians, as Reinhardt reminds us, represents only about 20 percent of total national health spending. Of this total, close to half (editor’s note: higher now), is absorbed by physician practice expenses, including “malpractice premiums, but excluding the amortization of college and medical school debt. These debt figures become all that more important when one considers that in many countries – but not in the U.S. – medical education is free. And consider,” he adds, “that doctors in the U.S. train longer as well with four years of college, four years of medical school, three to seven years spent in residencies and even followed by an additional three years in fellowships.” Even if all physicians took a pay cut of 20 percent, the savings would amount to a minuscule two percent of our health bill. Mr. Baker and other critics are clearly barking up the wrong tree. Reinhardt finished his letter by saying that “such a policy (20 percent cut) would leave an understandably wholly demoralized medical profession to which we so often look to save our lives.”

      Any plan that ignores the monetary cost of tuition and the opportunity cost of  a decade of post-graduate education while cutting reimbursement will fail. Free tuition and debt forgiveness/ tuition refunds have to be a part of any plan that cuts physician compensation.

      It would be better to link physician compensation with cost effectiveness, as there are barely any significant enticements for docs to be more  cost efficient (or even knowledgeable about how much treatments cost.) Such a setup is morally fraught, as it places the interests of the doctor and patient at odds, and in our tort system, not doing the "best" for your patient puts you at risk.

      Surgical devices, medical supplies, and pharmaceuticals are only purchased at a physician's order. Better alignment of financial incentives with clinical outcomes is needed.  Ultimately the word no-one wants to say has to come up, but rationing is what we're talking about. Whatever the number is, there is a finite amount that can be spent on health care, and a top-down price cap is less likely to be successful than a rational set of incentives and payments based on value. 

      2. Dr. Daft , you have some valid concerns. There are doctors who still support Medicare for All. You wrote:

        Better alignment of financial incentives with clinical outcomes is needed.  Ultimately the word no-one wants to say has to come up, but rationing is what we're talking about. Whatever the number is, there is a finite amount that can be spent on health care, and a top-down price cap is less likely to be successful than a rational set of incentives and payments based on value. 

        I agree that "Medicare for All" can't possibly cover everything. Unless we overturn the Hyde amendment, for example, it won't cover abortion. It doesn't cover abortion now, possibly because most people in their 60s have no need of an abortion. Abortion coverage is a whole nother battle, and that will probably be the hill the GOP chooses to die on – their whole moral authority on everything is based on opposition to abortion. Drone strikes on civilian children? A-OK. Locking kids up in cages at the border? A necessary measure against terrorism. Cutting school lunches and WIC payments for pregnant poor women? We all have to make sacrifices. But by golly, we must protect the fetus from moment of conception.

        So  I anticipate that Medicare for All (MFA) would ration care: it would not cover abortion, probably not gender reassignment surgery, elective plastic surgery, and a host of other procedures unless patients can make a case that it is necessary to save a life. 

        Hence, people would still purchase private supplemental insurance to cover what MFA wouldn't.

        Medical students and future doctors seem to agree with you when they call for an end to the profit motive in health care, and say that equal access to health care for everyone would eliminate one of the biggest long term cost increasers. Their arguments are essentially that being uninsured drives up costs later, and that administrative cost savings  through elimination or downsizing of the billing bureaucracy would pay for MFA costs, and that there isn't any need or effect of cutting doctor incomes. Do you agree with those arguments?

        Dr. Paris, writing for Common Dreams, argues:

        At the national level, single payer would cut about $504 billion annually in administrative costs. In other words, single payer works by cutting administrative waste and corporate profits, not doctor incomes.

         

        1. Good points.  I would add two more:  education offers probably the highest return on investment (ROI) of any investment we could make since taxes on the increased marginal income thus generated will over the person's lifetime more than pay back the investment resulting in GDP growth, better health, etc.  Why wouldn't we as a nation choose to invest our taxpayer dollars there?

          Secondly, the savings in administrative overhead works both ways.  Eliminating hundreds of different insurance forms and coverage rules and approvals saves the providers from needing a small army of office workers, and the doctors from all that paperwork, allowing more time to do what they went to medical school to do.  That is over and above the vastly lower admin costs of Medicare.  For-profit healthcare is not the same as free market healthcare as long as there is no price transparency or fair competition.

  3. Kamala Harris hit it out of the park last night on CNN's town hall in Iowa.  The Democratic crowd was wowed.  This was after an outstanding campaign announcement in Oakland attended by 20,000 people.  Beginning to remind me of someone twelve years ago who also had a great rollout.  What was his unusual name again?

  7. That's an interesting statement.  I'd need to see more to feel like she meant it, but it would let me immediately exclude any Dem candidate who didn't agree…

    1. That’s interesting. I’m not old enough for Medicare but my understanding is that it does not cover everything and most folks need supplemental insurance. But if we are abolishing private insurance, from where do we get supplemental coverage?

      1. We'd need to reform Medicare in the process of expanding it to eliminate the need to get supplemental coverage. A comprehensive Medicare for All bill would need to expand Medicare to cover everyone, expand Medicare coverage to cover much more, ensure that Medicare applies to things we don't currently cover, such as abortion, and probably levee taxes to pay for it all.

      2. I would suggest that private insurance will never be “eliminated”.  Risks, and the choice to have an ability to insure against them via some type of private business contract, will never go away.

        I believe that what Harris meant, is that the systemic reliance on this private insurance arrangement for basic universal care and treatments has not worked, and that it is far past the time that this should have been replaced by a system that can not be exploited and rapaciously manipulated by the insatiable greed of Wall Street and investors.

        1. I mean, we could very easily eliminate private insurance. If the healthcare industry got nationalized (or fully socialized, tho that would require more extensive changes), healthcare could simply be free at point of access for everyone, completely eliminating the need for any insurance.

          1. Unless of course people are dissatisfied with how the government manages the health care industry and are willing to pay for private insurance. (Think about how well run the post office is. Or the division of motor vehicles.)

            Much like public schools are available to all but if you really want to send your children to a private school, you may – on your own dime.

              1. lol…..last week, I went into the post office – during the shutdown no less – and only saw four people in line. When I got to the counter, the relatively pleasant woman told me they had no stamps to sell. 

                WTF, were the postage stamp printers furloughed, too.

              2. Are you saying that all the medical professional would have to work for the government and no one else? Because that's quite a breath-taking suggestion.

                1. I mean, do you not know how nationalizing an industry works?

                  Like, it’s not even something I support, but it would be a way to end private insurance. We could do it fairly easily and it would make all healthcare free at point of use.

                    1. Oh, nationalization isn't anything near my goal. It's the goal of moderate social democrats. I want a full socialization of the economy to break down class division and end production for profit in general rather than simply moving it from capitalist control to state control.

                    3. It didn't happen in Venezuela? They didn't even nationalize things? It's working out great for the Zapatistas, tho.

                    4. When V was a youngster his goal was to become a world-champion buckboard racer.  When I was a kid my goal was to be an interstellar astronaut, . .

                      or Bugs Bunny (I always wanted to keep my options open). . .

                      . . . we both had much better chances than that of living in any country where John Lennon’s Imagine lyrics ever become economic policy reality.

                    5. Yeah. Good thing no one here is suggesting we guide policy based upon some rich wife beater's song. I mean, you could reduce the long history of political theory and political economy into post-capitalistic economics to some song no one cares about, but that doesn't really serve as an effective critique of said long history of political theory and political economy.

      3. It is even more complicated than you know.
        We are the only country in the developed world that makes medical insurance so damn complicated.
        My advice is: don't even think about until you are 1 year away from being eligible.

      4. Did you read the Vox explainer about how to implement Medicare for All – Leaving in place employer health insurance? 

        The main points are:
        (1) Just like present medicare, everybody is automatically opted in.
        (2) Employers must offer their employees insurance or else pay an insurance premium into the Medicare system. 
        (3) Costs to the individual are relative to income.
        (4) Leaving in place the employer insurance, makes for minimal market disruption.

        You know and we all know that the system is totally screwed up. Either fix it, or we'll end up (happily) with Single Payer.

        Obamacare was a partial step forward, but still has to contend with all the craziness built in to our private health care system:
        (1) Insurance profits (25 – 30% compared to Medicare's 5%)
        (2) Doctor incomes (50-100% higher than other countries)
        (3) Cost shifting because your health care costs have to cover people who aren't enrolled.
        (4) Pharma, which enjoys monopoly pricing, (Prices are 100-1,000% higher than other countries.

        Single payer advocates can point out how easy it would be to get a 50% cut in our health care prices.

        1. I think your last point is one of the most important ones, P.H. Reining in the pharmaceutical industry would lower the cost of healthcare substantially.   First step? Ban consumer advertising. There is no good reason to advertise prescription drugs to consumers. Patients coming to appointments and demanding a high priced, brand-name drug they saw in a magazine when an older generic will work as well or better, is absurd. Second, forbid drug-makers from changing a molecule and claiming a patent for a "brand-new" drug; or getting a new patent for a drug that has a useful side effect. E.g. Welbutrin is an anti-depressant. One of its side-effects is reducing or eliminating smoking urges. So when the patent ended for Welbutrin, they jiggled a molecule, got a new patent and called the drug Zyban. Now they are back to getting top-dollar for it again.

  9. The Ex-Gov gets noticed a couple of times in the WAPO today.

    — Former Colorado governor John Hickenlooper (D) returned to Iowa as he nears a final decision on launching a presidential bid. The Denver Post’s Nic Garcia reports: “Hickenlooper, the two-term governor who finished his term earlier this month, articulated his vision of governing that is based more on consensus building and less on conflict. At a house party in this Des Moines suburb, he also shared his personal and political biography while answering questions about health care, immigration and abortion rights. ‘I’m not just frustrated — I’m over-the-top angry about what’s happened to the country in such a short period of time,’ he said, adding: ‘I don’t think there is anyone else that can reliably — as I can — beat Donald Trump. … My whole public life has been about bringing people together.’” [WAPO bolding]

    Anyone of you more experienced political types ever seen Hickenlooper "over-the-top angry"?

    And Jennifer Rubin continues her appreciation, with a Hick photo at the top of one of her columns:  Watch out for the governors in 2020

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