Medicare for All Cometh

Posted in society by Adam

16 September 201712 October 2021

Senator Bernie Sanders of Vermont has introduced his much-touted Medicare-for-All bill with a good slate of cosponsors joining the effort. And it sets the opposition out to pick at the draft with calls of calamity.

There are those opposed on principle, but the most common criticism seems to have to do with cost, which is interesting in itself. Basically, if you aren’t opposed to the idea that everybody be covered, and be covered through a Medicare-style system, then all you have left is to say that we need to work out the details (or maintain, farcically, that no iteration can work).

Arguing that a Medicare system isn’t workable, period, doesn’t fly. Medicare itself is strong evidence that it is workable. Other countries have their own systems, too. Universal healthcare is entirely achievable.

Cost is the main target now. How to fund it, and are the benefits correct?

The benefits are possibly too generous, but not by a lot. They would be adjusted down in any serious negotiation to pass this bill. That would lower the costs, at least a little. But serious costs, the bulk, would remain.

To pay for this bill, or one like it, will require new revenues. Primarily, there will be new taxes imposed on some combination of employment and income. The tax increases will be offset by the reduction or elimination of individual and corporate costs for healthcare. There is a reasonable expectation that the tax burden will be less than the current burden of paying for healthcare, as there is widespread agreement that healthcare costs are artificially high.

People don’t want to pay taxes. That’s mostly a function of an anti-American narrative built by the right wing. ‘Taxation is theft,’ and other such nonsense. Taxation is debt. It is owed, not taken. Norquist doesn’t say to the restaurateur after his meal, ‘I want you to sign this pledge saying you’ll never adjust the cost of your food.’

More importantly, within the range of contemplatable taxes (i.e., up to the actual revenue needed to fund government), tax isn’t a problem. It’s a distortion in the minds of the wealthy that has led to such fear of taxes, even to the point where they are happy to overspend on a necessity like healthcare to avoid a lesser tax. That sort of distortion begs correction.

Given the inability of the Republican party to offer an alternative proposal that could even pretend to be universal, Medicare for All or some other system will happen. Taxes will be raised to pay for it. If the Republicans don’t like that, their only possible move is to formulate a state-level plan that ensures universal coverage. They will have to fight like hell, and with haste, to get it enacted in all 50 states before the Democrats have a chance to set up a national healthcare system. They will need to solve portability between states, too.

But they have run the clock out on not moving the nation to universal coverage.

Scenarios for the Adoption of Single-Payer in the US

Posted in society by Adam

30 January 2016

Some have dismissed the idea of Medicare-for-all or a single-payer healthcare system in the United States as implausible (or even impossible). They see it as a bridge too far (or as one Brookings Institute reprint put it (Brookings: 26 January 2016: “The impossible (pipe) dream—single-payer health reform”), “‘You can’t get there from here.'”). I’m going to look, briefly, at six scenario-types that could (eventually) deliver single payer to our shores.

Disaster
Via Pharmaceutical regulation
Via state experimentation
Via cultural maturity
Incrementally
Technological

Disaster

Manmade or natural, it doesn’t matter. World War II played a role in socialized medicine coming up in Europe. A major pandemic or other breakdown of the US healthcare system could largely do the same here. We continue to have tens of millions of uninsured persons, and during a big enough health crisis that would probably require a legislative remedy.

Pharmaceutical regulation

Drug prices are too high, and between insurance companies and the lack of price negotiation by Medicare, they aren’t going down anytime soon. If a combination of legislative inaction and increasing demand (in the economic sense) makes the problem bad enough, legislators may be forced (by public outcry) to come down hard on pharmaceutical companies. Were that to happen, once people saw a major regulatory success (in the form of single-payer for drugs), they might just decide they want it for the rest of the system, too.

State experimentation

In 2016 Colorado will vote on Amendment 69, ColoradoCare. Now if Colorado didn’t have some recent history to back up the idea of it going against the grain, we might just dismiss this push for a state-based single-payer system. But they do have that history, and who knows? It might work.

Vermont passed a law in 2011 for a single-payer system, but that plan proved unworkable and was scrapped in 2014.

But if any state succeeds with single-payer, others will follow. If they can actually save their state money and improve outcomes, their neighbors will want to get in on it.

Cultural maturity

With the rise of the Internet, with social media allowing people to see Europeans boggling over the state of US healthcare, people will sooner or later realize that overpaying for our healthcare is just plain dumb. Take drug prices, which the pharma companies claim sustain drug development. Either the rest of the world are freeloaders, or the US are chumps. The same goes for the rest of the healthcare system. It might take another 20 years, but at some point the culture will reach the point where it demands a single payer system. (This is, of course, the Bernie Sanders approach; whether the issue is ripe enough now remains to be seen.)

Incrementally

We already have Medicare, which is mostly single-payer (I’m not old enough to have the alphabet soup of parts B-D memorized, but I know that somewhere in there is some private insurance, too). Medicaid, too (disregarding the federal-state split). One of the ACA’s population-coverage improvements was via Medicaid expansion. That could just happen a couple more times, and before you know it: a single payer system.

There are other opportunities for incrementalism here. If unionizing comes back in vogue, for example, and many of the unions join up to build some gigantic insurance cooperative over time, it could be transitioned to a single-payer system.

Technological

Technology is going to be an ever-greater part of medicine going forward, just as it has been since its modern advent. The need for automation to offset labor requirements will be a huge driver in the coming decades. Depending on how fast and how far technology can go in medicine, single-payer may just come down to a sort of use tax (like that on gasoline) at some point. In this scenario the health care infrastructure may be so expensive and integrated (think the Interstate Highway System) that it requires single-payer. Or maybe it’s just mostly so cheap that the only remaining need for insurance is de-facto single-payer.

Just to be clear, I don’t think single-payer will happen short of the 2020s. But to say it’s impossible? Just use a little imagination.

This is not to say single-payer is inevitable. It may become moot. But if the US continues to overpay for healthcare, sooner or later it will become inevitable. If the interests in this field can’t or won’t work to keep prices in check until they’re on par with the rest of the world, single-payer will become inevitable.

Fiscal Cliff

Posted in unAmerican by Adam

10 November 2012

Overview of the fiscal cliff.

With the election done, the question turns to the approaching crisis of budget, taxes, and social programs.

Back in June, 2001 the Congress lowered tax rates. Again in 2003. Together these actions comprised the Bush Tax Cuts. Set to expire in 2010 (at the time of passage, it was thought (or claimed to have been thought) that larger reform would be accomplished by then), they have been extended to the end of 2012. And there’s currently no deal to extend them further, leading to a situation whereby tax rates revert to their former levels (which can be sneakily called rate hikes).

Budget sequestration. Enacted in August of 2011. This is the set up to a perverse game of chicken, in which the Democrats and Republicans tie themselves together and race headlong at the cliff, and if either fails to turn away in time, we all go over.

All of the non-exempt departmental budgets will be cut by a quarter-percent.

But what is the cliff itself? It is a combination of lower revenues from the tax cuts, which created the trench, and increasing costs/outlays, creating the ramp. We’re moving along a curve, and come the end of the year (technically the cliff hits in a more nuanced way), the curve drops off and the trench closes up as revenues increase due to rates returning to normal.

It’s not really as much of a cliff as a ramp. Into a revenue wall.

The fear is that the turmoil of decreased government spending, coupled with increase pressure from taxes, will lead to a recession.

All of this is overshadowed by the larger fear that the government no longer functions properly, and won’t deal with the underlying causes of the cliff in a meaningful manner.

That is, between the military budget, Social Security, Medicare, and the broken tax code, we face long-term debt and deficit issues that impact our ability to adhere to our values.

The Republicans believe that we should cut the government down to size, except for the military.

The Democrats believe we should raise revenues through tax increases.

In many ways, the entire cliff is built out of the same sort of crisis the Republican party should be going through in the wake of the 2012 election. They have shown an inability to adjust their values to the modern world. They weren’t willing to take up immigration reform when it was their own president, George W. Bush, pushing for it. They continue to try to enact draconian measures against women, including efforts to block access to contraception and abortion.

We face a similar crisis of values. Our military is too large. Our prisons are too full. Our tax system offers perverse incentives. Our medical system uses misguided payment arrangements such as fee-for-service. And so on.

Big military replaced the value of security. Big prisons replaced the value of justice. Tax loopholes replaced the value of government by the people. Fee-for-service and similar money-first schemes replaced the value of pursuit of happiness.

Reelection and career politician replaced the value of government of the people.

Our underlying values are still strong, but their weak counterparts, their value-for-dummies equivalents, are detriments to the functioning of our system.

The supposed traditionalists, the Republicans, are not calling for a return to our true, core values. But the Democrats are silent on most of them as well (notable exceptions being things like equality under the law when they call for recognition of marriage).

In the end, it’s unclear whether the fiscal cliff will scare the congresscritters into action.