I’ve listened to a few Democrats speaking about health care over the past week and this survey of solutions that Vox obtained from some Senators really alarmed me. It just seems that this is a great time to not just oppose the ACHA, but also to present an alternative so that people can hear how Democrats would approach fixing the ACA. Perhaps you are hearing better discussion from Democrats — I still don’t have TV so have no idea how they perform in the talking head space.
But there has to be solutions and ones that people will easily understand will help them. Here’s some ideas:
- Single Payer or at least Medicare for All. I get that there is not enough D support for this in either the House or the Senate. I will ask Dems to remember their grassroots here. We’ve been out in front of everything positive that has happened since January 20th and it is time for you to support us. And you need a North Star here. I have been listening to some reporting from NPR on health care in places where the “white working class” you are supposed to be talking to live and THESE Trump voters are talking about a single payer program.
It is well past time for Dems to get in front of this (and other economic) train. Americans need a serious fix to the health care problem and this is it. Buying into more half measures (like the HSAs Susan Collins has been talking about this weekend) is not a viable fix. All it does is make the owner of the HSA responsible for cost control. Getting 3 bids to treat a stroke is not an option. Single payer or Medicare for All might be impossible right now, but we need Dems all over to talk about this as a goal. Because you are ceding the messaging field to Rs who are busily trying to paint this as the worst thing since Communism. Your North Star CANNOT be unhappy fixes to Obamacare. You have to be pointed at a real solution, with real benefits to the Americans who need it.
- If we are fixing the ACA, then adding a Public Option or a Medicare Buy-In is a Must Have. Tell people that this will make sure that there is at least one option for insurance everywhere in the US. And may get insurers attention in terms of cost.
- Subsidize more insurance plans — this is how Medicare Advantage got fixed and works and even though the subsidies have decreased recently, the plans are popular and fairly robust.
- Let insurers move high risk patients to a pool outside of the regular insurance pools — the high risk pools or some reinsurance pool. Reinsurance could be funded by the Feds or some combo of the Feds and the insurer — this doesn’t matter as much as communicating that you are open to helping insurers to reduce their premiums to you. This would mean that the cost of very sick ACA patients have a smaller impact on the premiums for the larger insurance pool.
- Drop the idea of eliminating Medicaid or shifting it to states.
I’d be OK with a robust fix to Obamacare and the above bullets count as robust to me. If anything because there are a very great many insured who are at some risk of not being insured soon. And we have to make sure these people are taken care of. Insurance does work — but it works if you create a big pool of insured, and if at any given time only relatively small percentage of the insured are actually utilizing it for large bills. We also have to remember that insurance works if the providers aren’t incentivized to milk the system. Cost control has to be part of the long term fix, which is why I would just talk about Medicare for All. It is not a perfect solution, but most people understand how rates are set for Medicare and how that keeps the program robust.
Democrats need to be able to talk about what health care would look like if they were at the table or running Congress. They need to do that NOW. Bipartisanship is not your goal here — getting as many Americans access to the health care they need is. The good news here is that everyone wants to hear a solution and they ARE NOT HEARING ONE FROM THE GOP. And you must talk about it clearly and cleanly with a minimum of wonk-ese. If you sound like you are putting your finger in the wind and trying to minimize your risk, this is what people hear and will never trust that you will do what you say. Be clear, state your plan and then expand as you need to.
I don’t know what it would take for Democrats to get on the same page here, but we have to do much better than you have. Tom Carper’s performance on MTP provided me with no sense that he even understood the magnitude of the problem (much less a fix for it) — just that he wanted bipartisanship. I listened to Tom Perez a few weeks ago talk about fixes to ACA and he gave a mushmouthed answer too. Pick a solution, y’all. Get your elevator pitch down and start making your case for a better government with Democrats at the helm.
People are so ready to hear a plan. Great post, Cassandra!
I wholeheartedly support three of the four fixes, as well as the Medicare-for-all or single-payer alternative (and I would add another option, a Medicaid buy-in option, which could also serve as a public option). The one I am not sure about is the high-risk pool idea. From what I have read, high-risk pools are not good for the people who get shunted into them, and the problem of high costs for them can be addressed with them in the general pool of insured people — they would be flagged in some way to draw those same reinusurance funds to cover their higher than average costs to the system. I’ll see if I can find an article that explains this.
BTW, Sen Coons is doing a live FB townhall on healthcare tonight at 6:30: https://www.facebook.com/senatorchriscoons
With numerous politicians of both parties in Big Pharma’s pocket (Chris & Tom, this means you) and subservient to Wall St. (Ditto) single payer will be tough, but it’s a fight worth having. As noted the Dems need to come out and advocate for single payer or at least a Medicare buy in. Also noted is that large swaths of the Republican base want single payer, everyone needs and wants healthcare . What’s really lacking is courage, like usual.
More thoughts on fixing the ACA.
So did we see Chris Coons’ Town Hall on Trumpcare last night?
Senator Coons is always an impressive speaker, but apparently the solution to the health care problem is bipartisanship. Which is not a solution. He did talk about restoring the risk corridors and the reinsurance provisions and maintaining the expansion, but THAT IS NOT A FIX TO THE ACA! It restores it to the place it was before the GOP started taking potshots at it. Fixing the ACA means getting in some long term stabilization and I don’t see how that happens unless there is a public option or medicare buy in. He also seemed to signal some openness to some GOP “market-based” solutions — which seem to mean the HSAs that Susan Collins is talking about. Another way people get screwed over for medical care. Unless you need very little of it.
Typical Demo, your way or the highway! Coons trying to work across the aisles & your still not happen.
I am all for single payer and have been for about 20 years. However, I continuously point out the over 55% of the entire u.s. population is currently covered by employer based private health insurance. I keep asking for ideas on how we get those people off that coverage……lots of studies tell us most are quite happy with this arrangement. In fact, much of the early opposition to the ACA came from this group concerned about losing their insurance, even though it was not portable when they left their job. So, do we just force them off? Or do we mandate employers to end this benefit, some of whom would love to spare that expense? Both of these solutions seem un-American and super authoritarian, don’t they? A public option would be an escape route from private insurance, but it would be an option, wouldn’t it? So, where are the ideas on how we democratically move to single payer?
“…over 55% of the entire u.s. population is currently covered by employer based private health insurance.” – stan merriman
That employer based based coverage can easily vanish when an employer decides to terminate an employee “for any reason or no reason”. Moreover, employer based coverage is not something you can bequeath to your kids, who once they turn 26, can join the 45%.
You apparently didn’t read that I acknowledged the lack of portability of employer insurance. But your thinking seems to suggest a gradual migration to single payer as employees leave plans or their plans leave them. A pretty reasonable start but not an overnight transformation demanded by many in the non-realist realm.
I think that if there is a solid single payer solution implemented, plenty of employers would be delighted to switch their employees to that. Because the employer would be out of paying for it, they would not have to administer it and it would save them money everywhere. To me, the thing that needs to be worked on is the compensation. Employer insurance is part of your compensation package and switching over to a single payer program would represent a decrease in pay for folks who would be switched to single payer.
No doubt plenty of employers would love to dump that costly burden……but what of the non-plenty employers who may be slow on the uptake or still see private plans as a way to differentiate benefits for “competition” purposes? Looks like a transitional approach will be necessary which is alright for most of us.
Given the overhead in dealing with employer sponsored insurance plans, I don’t know that very many firms would want that overhead as a differentiator because I imagine their Boards will have something to say about that. Still. If there is a single payer plan, it ought to come with an elimination of the tax-preferred status of employer sponsored plans, which would provide a great deal of incentive to move. Other incentives to move will come from the insurers themselves, who will increase premiums on those left with employer sponsored plans since their pools will be decreasing fast.
People with employer-sponsored coverage may not realize that they are getting tax-free benefits that self-employed people pay for in after-tax dollars. The employers get a tax break to help pay for it and employees don’t pay taxes on the value of it, even though it is part of their compensation. Yeah, a huge problem is how to wean people off their employer-subsidized insurance while compensating for it in actual wages (which would result in a tax increase) and also providing a comparable plan — which comes with huge sticker shock.
https://www.nytimes.com/2017/07/07/health/health-insurance-tax-deduction.html
“[E]conomists on the left and the right argue that to really rein in health costs, Congress should scale back or eliminate the tax exclusion on what employers pay toward employees’ health insurance premiums. Under current law, those premiums are not subject to the payroll or income taxes that are taken out of employees’ wages, an arrangement that vastly benefits middle- and upper-income people.
“That one policy tweak could reduce health care spending, stabilize the health insurance market and, according to Congressional Budget Office estimates, shrink the federal budget deficit by between $174 billion and $429 billion over a six-year period.”
If this is to be accepted, employees need to be educated about the actual cost of their insurance so they understand what is happening, first of all. Then maybe for a few years allow everyone to take insurance premiums (within reason, say, the cost of an ACA Silver plan for that state and that age and income level?) right off the top of their taxable income (so they don’t get hit with both the out-of-pocket costs AND the increase in taxes owed because of an increase in wages), and then gradually reduce the percentage of insurance premiums that can be taken as a deduction.
I think that moving toward a Medicare-for-all type system (single payer but multi-provider), where contributions for a basic set of health services (maybe the essential health benefits) are made to the government as part of wage withholding for employees and self-employment taxes for self-employed people, with the option of purchasing supplemental insurance from commercial companies competing with each other for our business, is the most feasible option. There will have to be a massive effort to get adults to sign up (maybe for kids it becomes a motor-voter-health combo — you are automatically signed up when you get a drivers license or ID, or when you register to vote, or upon getting your first salaried job), but as time goes on, you just enter the system at birth.
In this situation, I guess Medicaid still exists more or less as it is for very low-income people and people with disabilities. Medicaid would still have to be applied for, but you wouldn’t have to change insurers constantly if your income were in flux, because the insurer for both systems is the US government — the only question would be how much, if anything, you were contributing for the care you receive.
That’s doable, right? 😉
Other thoughts: Single payer eliminates reasons for employers to discriminate against women of child-bearing age and people with disabilities and chronic diseases, because the employer is off the hook for higher insurance premiums within their own employee risk pool. Employees are free to change jobs if they get a better offer and can move around the country more freely because they are not tied in to a job with an insurance plan. Employers might not like that, but it’s great for the economy. Households can budget with greater certainty knowing what they will owe at their projected income level. You won’t have to get married to an acquaintance just to get health insurance. Families can have children on their own schedule, not on their employers’ schedules. More salaried income paid in cash dollars means more spending, but also maybe more savings for lower income salaried workers.
What are the downsides in economic terms?
Thanks Cassandra and Paula for a really good discussion.
I have been saying for years that besides saving money, single-payer will also unleash a huge wave of entrepreneurial activity. I know many people that have been unwilling to strike out on their own because of a need for health insurance for their children. Even a Medicare/Medicaid buy-in would be enough to kick that off.
The Affordable Care Act could have done that if it had been shored up and there was an ability to really control costs. The first step to resolve that would to reverse the law against negotiation with drug companies.
As for employer-provided healthcare, we could extend the health savings accounts to allow them to pay premiums from those and find ways to encourage employers to fund employees’ healthcare through funding those. In addition, employers could woo employees by offering supplemental insurance (this is also where you can keep the health insurance industry from dying) to offset the costs of things that the public-option/medicare buy-in/single-payer system doesn’t cover. Plus, insurance companies can compete for administration of the new programs.
To sum up, entrepreneurial employees win, employers win, the rest of employees win, insurance companies narrowly lose, pharmaceutical companies lose, the rest of the world probably loses (since the drug companies will spread out the load). Also, ideologues that think this is creeping socialism/communism lose (which, honestly, is the only thing standing in the way).
Back in 2008 over 62% of employers, with employees from 3-199 offered healthcare benefits! That is a large number. In 2009 SBE reports that only 49.3 percent of self-employed workers have employment-based health coverage. It did not indicate if that individual received insurance from a spouse.
I know my Wife started her own business and worked very hard, has over 50 employees. But, when she started out, I had the coverage. She still brought people on, not providing much in benefits. Now a different story.
Bottomline, the current administration can’t even pass a budget and we want them to provide healthcare? That is scary!!
Anono, I see your concern, but I don’t think that there’s any version single payer being proposed that stipulates the government to provide healthcare. Most call for the government to collect insurance premiums and pay for some bundle of services (whether that’s something like ACA’s essential benefits or something else) and, as the insurer of record, negotiate lower costs with healthcare providers, pharmaceutical companies, diagnostic laboratories, etc., and pay them for providing medical services.
I’ve had to help my mother with her annual Medicare sign-ups for the past maybe five-six years, and I’ve been really impressed with how the program is administered — at least at the consumer level. The healthcare exchanges also work well now (admittedly they were overwhelmed when first rolled out), and my experience with Delaware’s Medicaid program was not too painful, even given all the changes the first year Medicaid was expanded. Certainly, everyone who needed to get paid got paid.
Our government has a lot of experience collecting money from us out of every paycheck or every quarter, keeping accounts, sending out notices, paying bills — and that would be it main responsibility. Luckily it wouldn’t be our elected representatives doing this work, and I think that as long as they keep their hands out of the cookie jar, some version of this is feasible, at least on the technical level.