How to Medicare for All

The question of whether Medicare for All is the best way forward is being lost in the non-conversation about healthcare. The conservative viewpoint isn’t to do a fair evaluation of alternatives, but to deny problems exist, and so proposals like Medicare for All are attacked relentlessly as impossibilities while any sort of balanced approach is neglected. Sad.

But let’s say you want to Medicare for All, anyway. You have several different transitional problems to deal with.

Transitioning Jobs

Jobs are one of the problems. Lots of people working in for-profit roles in healthcare administration. They do things like formulate the most lucrative way to bill (basically reverse-accountants) insurers and the government. But they also do other things like process claims. Some of those jobs will vanish, while others will be reallocated through a government contracting system.

How many vanish depends on the flavor of the new system. If it keeps fee-for-service, it will be more expensive and retain more jobs. If it moves to billing by condition (instead of separate billing events for a cast, x-ray, etc., you bill for a “broken arm” treatment) or patient, that’s fewer jobs, but lower cost.

So you have a policy tradeoff of choosing cheap and dealing with more job loss and more retraining, or you choose more expensive and deal with higher taxes. Some of the expenses will be paid for by expanding other parts of the medical sphere to provide coverage to unserved and underserved communities and individuals. There will also be some increase in productivity as societal health improves and therefore workers are more productive (they are also more productive when they don’t have to expend a lot of time and effort understanding and navigating a mess of an insurance system). But it’s still a transitional choice to be made.

Transitioning Off Employer-Provided Insurance

This is a big one. The best way to handle it is to set aside a basic Medicare for All structure that will partially replace the employer’s insurance at the next renewal date. The employer can continue to provide a lower-cost supplement on top of that for some period of time (say a decade), which will allow the winding-down of both the firm’s employee-insurance responsibility and the private insurer’s market.

Think of it like any other natural transition. You have a car and drive everywhere. Then alternatives come up and you use them part of the time, where they make the most sense. As those alternatives improve in coverage and cost, you use your car less until you abandon it on the side of the freeway. . . .

The beauty of such a plan is that it lets insurers keep their most profitable business alive (bells and whistles) while they give up the most expensive part (core insurance, including catastrophic stuff). As long as such a plan’s guns are stuck to, it lets them wind down responsibly and with as little pain as possible.

Also, the fact that different employers will have different renewal periods means that the business should wind down in a fairly steady manner.

Age-Based Transitioning

There’s long been talk of expanding Medicare down to younger groups. Pre-retirees, usually. That can still be done in the transition, and it again should benefit private insurers during their twilight years, as older workers are more prone to health events.

The Tax-and-Cost Problem

How do you pay for it? Is there a pot of gold we can get and it’ll solve everything and we’ll eat our free lunch?

No. Good, old-fashioned taxes. Something like the existing work-credit system where you pay in will be part of it. General income taxes another part. A third part might be a periodic discounted credit-purchasing period. This would be equivalent of a sale. Everyone loves a sale, but the government never puts things on sale. If you let people buy up extra Medicare credits from time to time, they’ll help to top-off the trust fund. There are other things of this nature the government could do that make a lot of sense.

Point is, there are a lot of opportunities to do smart transitioning. It’s not that hard to see the path forward on something like Medicare for All. I’m not convinced it’s the only way forward, but I am convinced it is a way forward, and absent alternatives, none of which the Republicans have shown any desire to entertain anyway, we might as well take it.

If Everyone had to Buy Their Own Roads

The issue of healthcare continues to be politically potent, owing mostly to the fact that Republicans continue to politicize it while Democrats continue to push for universal healthcare.

The current healthcare system has five main insurance components:

  1. Employer-provided insurance (including government employees) ~50%
  2. Private insurance (purchased by the consumer) ~7%
  3. Medicare ~14%
  4. Medicaid ~20%
  5. Uninsured ~9%

One can imagine a society where everybody has to buy their own roads more directly, rather than having the government work it out. Employers, needing to have employees get to work, needing to ship goods, would form group plans where various roads would be available to employees and the company.

One can imagine that older folks, no longer working, would be subsidized in their road access by the government. Some private plans would be available for freelancers. Eventually, the poor might get some access to roads.

And then you would have the roadless. Folks that maybe had a single road to work, but their employer doesn’t need broad transportation, and has few employees, so the road options for those people are limited.

And maybe, if you don’t belong to a road access plan, you could still use a road. But they would charge you more. You’re extra traffic not accounted for in the planning and budgeting. You aren’t one of a hundred cars in a group that uses the road, so you don’t get a bulk-traffic discount.

And maybe, if you don’t belong to a road access plan, you can’t use some roads. They’re built for the members. The members don’t want you slowing them down. You’re excluded entirely. You can use the dirt paths, only. You’ll still get there, covered in dust and smelling like it.

Americans love the open road (it’s even called the open road). They love their cars. They would never stand for limitations on their ability to cruise. We should not stand for it for healthcare.

The friction that would be caused by having to have special maps to figure out which roads you could use, filling out forms at intersections, constantly worrying about making a wrong turn, are mirrored in the healthcare system where Americans are constantly dealing with red tape from provider networks, drug coverage conundrums, and claims processes.

It’s long past time to open American healthcare.

It’s about 14 weeks until the midterm elections.

Medicare for All Cometh

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.

When an Experiment is Unneeded

The Republican-championed laboratories of democracy, the states, could be used to figure out what’s needed for healthcare in the 21st century. Let the states tinker, find out what works, and then we’ll see it spread.

But those experiments are not needed. We have scores of experiments conducted all over the world. We have all these examples of healthy healthcare in all these other countries. We just don’t have the political will to enact the sensible and sane in the USA.

Now, in Europe each state has its own healthcare system, and the US might still divide a universal system into per-state systems. But the Europeans also have the EHIC system, which allows for dependable treatment when traveling (both unplanned care and for chronic treatment).

The US might still do things different than Europe and the 58 countries with universal care. But the idea that we can’t figure out a problem that 58 other countries have? The amount of denial required to reach that conclusion could only be described as gross negligence.

We don’t need to experiment with allowing states to ignore real insurance in favor of slimmed-down plans that will result in financial burdens on the infirm. We don’t need new work requirements that undermine the definition of universal. We might make some minor use of high-risk pools, but we know the basic shapes that universal coverage come in.

It is high time that any party that seeks national recognition in the US would have a plan for universal coverage. That is a low bar for 2018. The Democrats currently seek a single-payer medicare-for-all style system. If the Republicans do not answer with a 50-states-plus-DC alternative, it will only be a matter of time before CMS is charged with overseeing healthcare across this nation.

We don’t need an experiment. The time where an AHCA or a BCRA might have reflected something the US would do is gone. The cardboard reads “Universal Healthcare or Bust!”

Mandate Alternatives

Donald Trump will personally ask everybody to buy insurance, really really nicely. And if they push back, he will offer them $7 million in tax incentives.

Or maybe everybody who has coverage will be entered into an annual lottery where someone will win $big$bucks$.

Or we can bring back the draft and weight selection against those who do not have coverage.

Not talking electoral mandates—those are apparently a dead concept, circa 1980s. Talking about the health insurance mandate.

So, first we should understand that the Obamacare mandate is meant to serve two purposes:

  1. Avoid having too few young and healthy people so that the pool can pay for the care of the sick members.
  2. Avoid having too many people without insurance that end up needing care.

Insurance isn’t just for old people. It’s also for the random event. Young people lacking insurance raises the cost of the whole healthcare system one of them gets a sudden illness they can’t pay for.

The problem with the Republican alternatives so far is that they tend to only address the first purpose: making sure that the pool is mostly healthy. They tend to do this by creating high-risk pools. These pools are government-subsidized so that the regular market is free of the sickest folks.

The Republicans are calling for a form of socialized medicine whereby the worst costs are still borne by taxpayers, while the artificially-healthy market is free to line the pockets of insurers.

Now, such a scheme could work. It’s just that the Republicans will not be willing to take it to its logical conclusion: creating one risk pool (either nationally or per state) for all catastrophic coverage, and relegating health insurance to something more like an add-on that helps pay for the first 10-20% of coverage only. This is more like the risk equalization pools used in parts of Europe, and those still require young people to carry insurance.

Indeed, one expects that if the high-risk-pool system is put back in place, there will be a strong incentive for future governments to expand it into a full-on single-payer system. Historically high-risk pools have been underfunded, leading to higher premiums and deductibles. Their existence was one of the motivations for health insurance reform (i.e., Obamacare) in the first place.

Now that we’ve had a first round of insurance reform, one expects that the government will be compelled to repeatedly reform it until they get to a system that works. People will not be content to let this go, as tens of millions lose insurance, the systemic uncertainty grows, and all the while the corporations produce record profits. There will be pressure to keep fixing this system.

The Republicans don’t really try to tackle the enrollment problem, the fact that a lot of young people will tend not to buy insurance. They seem to believe, for some unclear reason, that if you make insurance cheaper it will entice young people to act responsibly (despite the fact that it’s already relatively cheap for them). It just doesn’t work that way. Coverage is not on their radar. Unless and until health insurance becomes a fashion statement, don’t expect the youth to seek it out.

Thus, it seems implausible that there exists an alternative to a health insurance mandate (taken-as-read that single-payer is a mandate too).