“Sanders’ ‘Medicare For All'”: The Devil Is In The Details
Bernie Sanders is a proud and self-described socialist, a veteran Vermont senator who wants to bring some European ideas to the United States. One of those ideas is a single-payer health care system: a government-funded program in which the patient bears little to no cost. Sanders describes it as “Medicare for all.”
It’s an excellent idea. The United States is the richest country in the world, and it ought to grant every citizen guaranteed access to doctors and hospitals. That’s what Canada, Japan and the countries of Western Europe have all done.
But Sanders is vague — and his supporters quite naive — about the prospects of bringing a single-payer system to the United States. He insists that he could accomplish that in a prospective first term “if many millions of people demand it.”
Here’s the rub: They won’t — at least not in the systematic and sustained manner that would be required to bring about that sort of, well, revolutionary change to the American medical-industrial complex.
There’s a reason that the U.S. doesn’t have “Medicare for all”: politics. Do Sanders and his supporters remember the epic battle to pass the Affordable Care Act?
Democrats have been trying to pass a version of universal health care since the days of Franklin Delano Roosevelt. But conservatives have fought every proposal that would increase access for ordinary Americans, including Medicare; Ronald Reagan, then a neophyte political activist, toured the country campaigning against it.
Bill Clinton made universal health care a cornerstone of his presidential campaign in 1992, and he appointed his wife, Hillary, to head a task force to propose legislation after he won. They tried mightily to pass it, but conservatives denounced it, and the insurance industry spent millions to defeat it.
That’s why President Barack Obama brought the insurance industry on board when he started toward the Affordable Care Act. He knew he needed their support to have a prayer of passage. So the ACA preserves the business of selling health insurance through private companies.
Still, it has helped millions of families; nearly 9 million more Americans had health insurance in 2014 than the year before, according to government data. Moreover, the ACA prevents insurance companies from banning patients because they are sick and prohibits insurers from placing “lifetime caps” on the amount of money any person can collect for health care.
Would a single-payer plan have been even better? You bet. But listen to Obama’s former aide, David Axelrod, describe the difficulties of trying to pass such a proposal.
“I support single-payer health care, but having gone through health reform, we couldn’t even get a national consensus around the public option! It was Democratic votes that were ultimately missing on that issue,” Axelrod remembered. (The public option was a proposal for a government-run health insurance plan to compete with private health insurers.)
History shows that Obama and his allies spent months trying to make the ACA more palatable to conservatives to entice a few GOP votes. Actually, the mandate requiring that all adults have health insurance was originally a conservative idea. While the federal government provides subsidies to help families with modest incomes buy insurance, it doesn’t pay the full cost. (Obamacare also sets aside billions for states to expand Medicaid, but the Supreme Court made that optional, and many states have refused to expand.)
Still, the ACA did not get a single Republican vote in the end — not one. Republicans are still trying to repeal the law, taking more than 60 votes in Congress and going to the Supreme Court with challenges. Most of those Republicans will be easily re-elected to Congress.
Given recent history, it’s clear that Sanders’ plan would face very long odds — and that’s before details become clear. The Vermont senator proposes an extraordinary range of patient care — dental and vision coverage, mental health care, long-term care — while, he says, saving trillions of dollars. Many health care experts say that can’t be done, so health care spending would likely increase. You don’t have to be a conservative voter to fear where that would lead us.
If Vermont’s audacious senator has a plan for overcoming an ultraconservative GOP caucus in Congress, a right-leaning U.S. Supreme Court, and millions of voters who still flinch from the word “socialist,” he ought to lay it out. It would be quite a revolutionary plan, indeed.
By: Cynthia Tucker Haynes, Pulitzer Prize Winner for commentary in 2007: The National Memo, February 13, 2016
“Utopian Fantasy?”: Bernie Sanders’s Single-Payer Health Care Plan Failed In Vermont
When Sen. Bernie Sanders regales his campaign crowds with a portrait of The Way Things Are Going to Be, his “Medicare for All” program takes center stage. In a Sanders administration, the candidate promises, every man, woman, and child in America will share in a government-run, government-funded health-care system.
But the single-payer system that Sanders is evangelizing isn’t just a figment of progressive utopian fantasies. Single-payer health care has already been tried—and failed—in Sanders’s home state of Vermont, where the proposal collapsed under its own weight last year before it was ever implemented.
Deciding why it failed in Vermont is key to whether you buy into the candidate’s promise to extend the program nationwide.
According to critics, from The New York Times’ Paul Krugman to USA Today’s editorial board, Sanders’s single-payer plan is something between a well-intentioned fool’s errand and a political pipe dream, an unrealistic idea that has been proven not to work in the senator’s own backyard.
But closer to home, activists say Vermont’s failure even to implement its plan for universal health care was a failing of political will, not the policy itself. In better hands, they say, the policy can still work. To know the difference, it’s important to understand how Vermont got so close to single-payer in the first place.
In 2011, the state’s Democrat-controlled legislature approved a government-run, government-financed health-care system for all Vermonters. The state’s new Democratic governor, Peter Shumlin, signed the bill into law after campaigning on a pledge to enact single-payer himself. A cost estimate of the program, known as Green Mountain Care, was ordered, but long delayed.
Elections came and went, including Shumlin’s own 2014 reelection, which was so close Vermont law required the final decision to go to the legislature after Shumlin failed to win a majority of the vote in November. As the state waited for the legislature to take up the election results, Shumlin announced that he would not pursue single payer after all when the long-awaited financial projections showed “the promise and the peril” of a single-payer system. The promise, of course, was a chance to give nearly every Vermonter reliable access to quality health care.
But the very real peril came in the cost for the program, an estimated $4.3 billion a year, almost the size of the state’s entire $4.9 billion budget. To make up for the $2 billion shortfall, taxes would have to go up, a lot. Businesses would see an 11.5 percent payroll tax increase, on top of whatever they chose to provide for employee health care, while individual income taxes could jump by up to 9 percent. The report recommended against moving forward “due to the economic shock and transition issues,” and Shumlin agreed.
“I wanted to fix this at the state level. And I thought we could,” Shumlin said in a statement issued with the financial report. But he called implementing single-payer health care in 2015 “unwise and untenable.”
Despite the ominous budget projections at the time, single-payer advocates now say they believe Shumlin’s decision was purely political.
“Right up to the last gubernatorial election, Gov. Shumlin was saying he was going to do everything he could to make single-payer health care a reality in the state. That was quite frankly why we didn’t run a candidate against him,” said Kelly Mangan, the executive director of the Vermont Progressive Party. “Almost immediately, he turned around and said, ‘Oh, yeah, we can’t afford single-payer health care. It’s not going to happen.”
Mangan described single-payer advocates today as “fatigued and very disheartened.” As Vermont’s state budget continues to be squeezed by Medicaid costs, she said the possibility of returning to the issue any time soon seems unlikely. She also worries that Vermont’s example will damage future prospects nationally. “I think it will have a ripple effect. People will use it as an excuse to do nothing by saying, ‘If they couldn’t do it there, then it can’t be done,’” she said.
Dr. Gerald Friedman, an economics professor at UMass-Amherst and a part-time Vermonter, has worked with Sanders to develop and calculate the cost of his plan and says the budget wasn’t the problem for the Vermont proposal. The governor was the problem.
“On the economics, it would have been cheaper, but the governor just lost the political will,” Friedman said.
But the professor acknowledged that any national health care proposal from Sanders would face the same political headwinds that Shumlin ran into. “It’s going to be a tough road, and Vermont is a lesson,” he said. “It’s unfortunate that it happened the way it did.”
Even with the Vermont debacle in the rearview mirror and Friedman’s own projections that Sanders’s “Medicare for All” would cost north of $14 trillion over 10 years, the politics of single-payer are still working for Sanders. The latest Kaiser poll showed 81 percent of Democrats favor a “Medicare for All” proposal, while 60 percent of independents favor it, too.
Clinton has dismissed Sanders’s proposal as unrealistic and a danger to the reforms that have already been enacted through the Affordable Care Act. That argument seems to be falling flat in New Hampshire, where the latest WMUR poll showed Sanders trouncing Clinton by nearly 30 points. But at least Clinton can count on some support when the campaign gets to Vermont. Gov. Shumlin, who will not run for reelection, has announced he’s with her.
By: Patricia Murphy, The Daily Beast, January 25, 2016
“Health Reform Realities”: A Simple, Straightforward Single-Payer System Just Isn’t Going To Happen
Health reform is the signature achievement of the Obama presidency. It was the biggest expansion of the social safety net since Medicare was established in the 1960s. It more or less achieves a goal — access to health insurance for all Americans — that progressives have been trying to reach for three generations. And it is already producing dramatic results, with the percentage of uninsured Americans falling to record lows.
Obamacare is, however, what engineers would call a kludge: a somewhat awkward, clumsy device with lots of moving parts. This makes it more expensive than it should be, and will probably always cause a significant number of people to fall through the cracks.
The question for progressives — a question that is now central to the Democratic primary — is whether these failings mean that they should re-litigate their own biggest political success in almost half a century, and try for something better.
My answer, as you might guess, is that they shouldn’t, that they should seek incremental change on health care (Bring back the public option!) and focus their main efforts on other issues — that is, that Bernie Sanders is wrong about this and Hillary Clinton is right. But the main point is that we should think clearly about why health reform looks the way it does.
If we could start from scratch, many, perhaps most, health economists would recommend single-payer, a Medicare-type program covering everyone. But single-payer wasn’t a politically feasible goal in America, for three big reasons that aren’t going away.
First, like it or not, incumbent players have a lot of power. Private insurers played a major part in killing health reform in the early 1990s, so this time around reformers went for a system that preserved their role and gave them plenty of new business.
Second, single-payer would require a lot of additional tax revenue — and we would be talking about taxes on the middle class, not just the wealthy. It’s true that higher taxes would be offset by a sharp reduction or even elimination of private insurance premiums, but it would be difficult to make that case to the broad public, especially given the chorus of misinformation you know would dominate the airwaves.
Finally, and I suspect most important, switching to single-payer would impose a lot of disruption on tens of millions of families who currently have good coverage through their employers. You might say that they would end up just as well off, and it might well be true for most people — although not those with especially good policies. But getting voters to believe that would be a very steep climb.
What this means, as the health policy expert Harold Pollack points out, is that a simple, straightforward single-payer system just isn’t going to happen. Even if you imagine a political earthquake that eliminated the power of the insurance industry and objections to higher taxes, you’d still have to protect the interests of workers with better-than-average coverage, so that in practice single-payer, American style, would be almost as kludgy as Obamacare.
Which brings me to the Affordable Care Act, which was designed to bypass these obstacles. It was careful to preserve and even enlarge the role of private insurers. Its measures to cover the uninsured rely on a combination of regulation and subsidies, rather than simply on an expansion of government programs, so that the on-budget cost is limited — and can, in fact, be covered without raising middle-class taxes. Perhaps most crucially, it leaves employer-based insurance intact, so that the great majority of Americans have experienced no disruption, in fact no change in their health-care experience.
Even so, achieving this reform was a close-run thing: Democrats barely got it through during the brief period when they controlled Congress. Is there any realistic prospect that a drastic overhaul could be enacted any time soon — say, in the next eight years? No.
You might say that it’s still worth trying. But politics, like life, involves trade-offs.
There are many items on the progressive agenda, ranging from an effective climate change policy, to making college affordable for all, to restoring some of the lost bargaining power of workers. Making progress on any of these items is going to be a hard slog, even if Democrats hold the White House and, less likely, retake the Senate. Indeed, room for maneuver will be limited even if a post-Trump Republican Party moves away from the scorched-earth opposition it offered President Obama.
So progressives must set some priorities. And it’s really hard to see, given this picture, why it makes any sense to spend political capital on a quixotic attempt at a do-over, not of a political failure, but of health reform — their biggest victory in many years.
By: Paul Krugman, Op-Ed Columnist, The New York Times, January 18, 2016
“The Problem Is The Politics”: Sanders’ Single-Payer Plan Is A Distraction
If you’ve successfully landed on the beaches, but your forces are still taking heavy fire, what do you do? Do you concentrate on trying to hold the line and make further advances or do you sit in a circle and design a better landing craft?
The problem with Bernie Sanders’ health care vision isn’t the vision. His raw outline for a greatly simplified and less expensive health-care system is excellent in theory. The problem is the politics — the reality of which battle-scarred Hillary Clinton clearly has the better grasp.
This was the message Clinton tried to convey in the Sunday Democratic debate. Her most potent point on health-care reform centered on recalling the “public option” fiasco during the fight for the Affordable Care Act.
The public option was to be a government-run health plan competing with the private offerings in the health-care exchanges. It was a no-brainer to keep the insurance companies on a shorter leash. But, as Clinton noted, “even when the Democrats were in charge of the Congress, we couldn’t get the votes for that.”
John E. McDonough, a health policy expert at Harvard, has also been through the health-care wars. As a Massachusetts state legislator, McDonough led an unsuccessful campaign to bring single-payer to his liberal state. In a recent New England Journal of Medicine article, he explained why a similar effort in Sanders’ own state of Vermont failed.
Vermont was the great hope for we fans of single-payer. (I was waving pompoms.) The state is progressive and one footstep from Canada. Gov. Peter Shumlin was totally onboard. He spent four years trying to make a single-payer plan happen. Three major-league studies showed that it was economically feasible.
But even in Vermont, a clear public mandate for single payer never materialized. A rebellion against it almost cost Shumlin the governor’s job.
Asked about this on Sunday, Sanders took a swipe at Shumlin (who has endorsed Clinton).
“Let me just say that you might want to ask the governor of the state of Vermont why he could not do it,” Sanders responded. “I’m not the governor. I’m the senator from the state of Vermont.”
Yes, and as senator from Vermont, Sanders introduced several single-payer bills that went nowhere. The most recent one, the 2013 American Health Security Act, attracted not a single co-sponsor.
The plan Sanders released two hours before the debate remains too sketchy for a reliable independent analysis, according to McDonough. But lack of detail isn’t his biggest concern. It’s opening a new front in the battle to defend Obamacare.
“Republicans sent a bill to the President’s desk last week that would eliminate health insurance for 22 million Americans by 2018,” McDonough wrote me. “This is not beanbag. It’s the real deal, and we have to focus where it matters the most.”
“Bernie wants to lead us on a distraction tour while Republicans want to kill the progress we have made.”
How far have we come? Thanks to Obamacare, almost 18 million formerly uninsured Americans now have health coverage. A report just out of Georgetown University has the rate of uninsured Hispanic children falling to a historic low.
Insurers can no longer turn down people with pre-existing conditions. And important politically, Obamacare has demonstrated that universal coverage is doable without creating mass unemployment or “exploding” deficits. On the contrary.
Making Obamacare more Medicare-like through incremental steps may not feed the romantic urge to reinvent health-care reform from scratch, but there’s no other road, not in the America of 2016. Finally, let’s not forget that vanguard of reform is still on the beaches and taking fire.
Correction: The health policy expert at Harvard is John E. McDonough, not Thomas. We regret the error. This article has been updated to reflect that change.
By: Froma Harrop, Featured Post, The National Memo, January 19, 2016
Medicare Saves Money: Ensuring Health Care At A Cost The Nation Can Afford
Every once in a while a politician comes up with an idea that’s so bad, so wrongheaded, that you’re almost grateful. For really bad ideas can help illustrate the extent to which policy discourse has gone off the rails.
And so it was with Senator Joseph Lieberman’s proposal, released last week, to raise the age for Medicare eligibility from 65 to 67.
Like Republicans who want to end Medicare as we know it and replace it with (grossly inadequate) insurance vouchers, Mr. Lieberman describes his proposal as a way to save Medicare. It wouldn’t actually do that. But more to the point, our goal shouldn’t be to “save Medicare,” whatever that means. It should be to ensure that Americans get the health care they need, at a cost the nation can afford.
And here’s what you need to know: Medicare actually saves money — a lot of money — compared with relying on private insurance companies. And this in turn means that pushing people out of Medicare, in addition to depriving many Americans of needed care, would almost surely end up increasing total health care costs.
The idea of Medicare as a money-saving program may seem hard to grasp. After all, hasn’t Medicare spending risen dramatically over time? Yes, it has: adjusting for overall inflation, Medicare spending per beneficiary rose more than 400 percent from 1969 to 2009.
But inflation-adjusted premiums on private health insurance rose more than 700 percent over the same period. So while it’s true that Medicare has done an inadequate job of controlling costs, the private sector has done much worse. And if we deny Medicare to 65- and 66-year-olds, we’ll be forcing them to get private insurance — if they can — that will cost much more than it would have cost to provide the same coverage through Medicare.
By the way, we have direct evidence about the higher costs of private insurance via the Medicare Advantage program, which allows Medicare beneficiaries to get their coverage through the private sector. This was supposed to save money; in fact, the program costs taxpayers substantially more per beneficiary than traditional Medicare.
And then there’s the international evidence. The United States has the most privatized health care system in the advanced world; it also has, by far, the most expensive care, without gaining any clear advantage in quality for all that spending. Health is one area in which the public sector consistently does a better job than the private sector at controlling costs.
Indeed, as the economist (and former Reagan adviser) Bruce Bartlett points out, high U.S. private spending on health care, compared with spending in other advanced countries, just about wipes out any benefit we might receive from our relatively low tax burden. So where’s the gain from pushing seniors out of an admittedly expensive system, Medicare, into even more expensive private health insurance?
Wait, it gets worse. Not every 65- or 66-year-old denied Medicare would be able to get private coverage — in fact, many would find themselves uninsured. So what would these seniors do?
Well, as the health economists Austin Frakt and Aaron Carroll document, right now Americans in their early 60s without health insurance routinely delay needed care, only to become very expensive Medicare recipients once they reach 65. This pattern would be even stronger and more destructive if Medicare eligibility were delayed. As a result, Mr. Frakt and Mr. Carroll suggest, Medicare spending might actually go up, not down, under Mr. Lieberman’s proposal.
O.K., the obvious question: If Medicare is so much better than private insurance, why didn’t the Affordable Care Act simply extend Medicare to cover everyone? The answer, of course, was interest-group politics: realistically, given the insurance industry’s power, Medicare for all wasn’t going to pass, so advocates of universal coverage, myself included, were willing to settle for half a loaf. But the fact that it seemed politically necessary to accept a second-best solution for younger Americans is no reason to start dismantling the superior system we already have for those 65 and over.
Now, none of what I have said should be taken as a reason to be complacent about rising health care costs. Both Medicare and private insurance will be unsustainable unless there are major cost-control efforts — the kind of efforts that are actually in the Affordable Care Act, and which Republicans demagogued with cries of “death panels.”
The point, however, is that privatizing health insurance for seniors, which is what Mr. Lieberman is in effect proposing — and which is the essence of the G.O.P. plan — hurts rather than helps the cause of cost control. If we really want to hold down costs, we should be seeking to offer Medicare-type programs to as many Americans as possible.
By: Paul Krugman, Op-Ed Columnist, The New York Times, June 12, 2011
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