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“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

January 21, 2016 Posted by | Bernie Sanders, Health Reform, Hillary Clinton, Single Payer | , , , , , , , , | 1 Comment

“Saving That ‘Worthless’ Medicaid”: The Idea Of ‘Worthless’ Is Correlated To The Idea Of The Life Of Poor Folks Being ‘Worthless’

As noted earlier today, it’s the 50th anniversary of the enactment of Medicare and Medicaid.

I strongly suspect the former will get more attention, because it’s a non-means tested program with an extremely powerful bipartisan constituency (despite constant GOP efforts to screw over future beneficiaries via a phased-in voucherization or some other way to shift costs to old folks). Everybody’s either on it or going to go on it if they live long enough.

Medicaid’s another matter, of course. It’s means-tested with the states having significant control over eligibility and benefits, which means it involves different sets of people (particularly now that half the states have accepted the ACA’s Medicaid expansion while half haven’t) and significantly different benefits and service delivery models in different states. With the exception of a little-understood long-term care component that pays for nursing home care for people who have disposed of most of their assets, Medicaid is a poor folks program–you know, for those people–which because it is state (and to some extent locally) operated means these poor folks are not necessarily dealing with the friendliest policy-makers, administrators or providers, particularly given Medicaid’s relatively low reimbursement rates.

But to the Republicans who have all pretty much agreed upon a policy of “block-granting” Medicaid, which means dumping the Medicaid population on the states with a fixed (and ultimately declining) sum of money and letting them do whatever they want to do with them, the question about Medicaid isn’t whether its structure and financing are giving the poor the kind of health care the rest of us would want, but instead whether it’s worth anything at all. That’s largely the function of prejudice plus a 2013 study in Oregon of people receiving and not receiving Medicaid benefits which provided some startling-sounding data on how little real benefit Medicaid created. It’s hard to read any conservative discussion of Medicaid and not hear the Oregon study “proved” Medicaid’s worthless.

So that’s why with Medicaid’s fate perhaps hanging in the balance after the upcoming election, three excellent policy writers, Harold Pollack, Bill Gardner and Timothy Just, have written an explanation of the Oregon study that rebuts its invidious use.

[P]erhaps the most important limitation of the study stems from an assumption that many readers would be unlikely to notice. [The Oregon researchers] placed a very low value—$25,000—on a year of additional life for Medicaid beneficiaries. The typical threshold used in health services research is much larger, in recent studies far above $100,000 per additional year of (healthy) life. Yet because the median income of the Oregon study participants was about one-fourth of the median income in the United States, the researchers chose to value an additional life-year at about one-fourth of the usual threshold. This assumption powerfully frames everything that follows in this analysis. After all, if you start out by assuming that Medicaid beneficiaries’ lives are worth very little, you will find that it is not worth spending much money to prolong them.

So the idea of Medicaid being “worthless” is closely correlated with the idea of the life of poor folks being relatively “worthless” (there are defensible reasons for this valuation in the study itself, but not for the way it’s being used by anti-Medicaid ax-grinders) as well. If you don’t share that premise, you shouldn’t share the related conclusion, either.

In any event, progressives should gird up their loins for a fight to save Medicaid in the near future. I’ve thought of myself as a warrior for the continuation of Medicaid ever since I was drawn into the 1981 Reagan Budget fight, wherein the administration suffered a rare defeat in its efforts to “cap” federal Medicaid spending, thus gradually making it a state-financed program. The fight just ahead could be even tougher.

 

By: Ed Kilgore, Contributing Writer, Political Animal Blog, The Washington Monthly, July 30, 2015

August 2, 2015 Posted by | Medicaid, Medicaid Expansion, Medicare | , , , , , , , , | 1 Comment

   

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