Two recent threads (this one and this one) have me convinced that:
[ol]
[li]Universal healthcare coverage would be better in almost all respects than the system we have now.[/li][li]Changing over to a UHC system will be a wrenching transition that could be catastrophic if handled wrong.[/li][/ol]
Let’s leave the red/blue politics out of this – assume we have elected leadership that wants to get it done with at least a clear majority of voters who support the change.
Further assumptions:
[ul]
[li]We have a multi-trillion dollar health insurance insudtry and millions of Americans who like their coverage as is. Wipiing all that out overnight is politically unfeasible.[/li][li]Our “clear majority of voters” understands that taxes may go up, but a drastic hike (say, 2x) will not go over well.[/li][li]Americans will be patient but only to a point. If things go badly for too long, the political will to transition to UHC may disappear.[/li][/ul]
Given all that, how do we get it done? Where do we start?
Well, I disagree with your first two assumptions, so we would have to start there. This would involve a massive communication effort:
[ul]
[li]To convince people that this is about health care, not health insurance.[/li][li]That the cost would go down. Yes, taxes would go up, but that would be offset by insurance costs going away. (We would probably have to convince employers to give the money they are spending on health insurance over to the employees as compensation. That would go a long way to helping explain the math. Pay goes up + taxes go up, but insurance cost goes away.)[/ul][/li]
Second, we would have to spend a lot of money paying off everyone getting rich off health insurance and health care now, because that aspect has to go away. Obviously to me, this is the group who will fight any changes the hardest. So the communications to voters has to be clear that these opponents are going to go full bore trying to convince them otherwise.
Start cutting off the for-profit system at both ends, while poking holes in it in the middle.
That is, gradually expand medicare coverage by lowering the age at which you are eligible to join it. Say, lower the age by one year for every two years that pass.
Also expand it by making kids born today eligible. Who could object to babies being given care? These kids will then grow up having always had coverage, so by the time they’re voting age, it will just be normal to them. Also consider adding in their older siblings in a gradual way, similar to how we’re getting older people on to medicare.
And then poke holes in the middle. Don’t force anyone to switch to medicare. If they like their coverage, let them keep it. But make it easy to switch to the public option. The one thing I would mandate is that employers make healthcare costs explicit - show people how much of their paycheck is going to these plans, and then do the same with their tax bill when they switch. When enough people do the math on how much the public option costs as compared to the private system, the rate of people switching will likely accelerate.
It will likely take decades to completely convert to a public system, which gives the insurance companies more than enough time to adjust to the change, so there won’t be major employment losses all at once.
I skimmed Warren’s doc but most of it is campaign rhetoric. Has anyone filleted out the actual, workable steps of her plan from the pie-in-the-sky campaign promises?
You disagree that we have a multi-trillion dollar health insurance industry and millions of Americans who like the coverage they have now? And that UHC will almost certainly require higher taxes?
I agree with you that voters will be persuaded to accept higher taxes if they take home more pay and pay no health insurance premiums, and that insurance companies will fight tooth and nail to protect their revenue streams. A huge part of this transition will be ongoing PR.
But what I’m really hoping to learn is what actual steps will be taken to implement UHC. Not how to sell it, but how to do it.
Is anything going to replace the employer-covered part of health insurance?
I thought the idea was that individuals no longer paid for insurance, but their taxes went up to cover it instead. Wouldn’t corporate taxes also go up, to replace the company part of health insurance? If not, great, but I am not sure how you could force companies to increase salaries.
Not only insurance companies - doctors and hospitals.
As mentioned, health care providers, on average, lose money treating Medicare patients. You would need to convince them that they won’t lose money, because they can fire all their administrative staff (or most of them).
If Medicare administrative costs are 2%, and private insurance is 10%, then doctors can tell if they are losing, on average, more or less than the difference between 2 and 8%.
I expect that you will have to decide whether or not to allow private insurance, like Medicare supplemental insurance. If you allow it, the price is going to go up, and you would need to add that to the total cost of what the average person is paying, and if they can’t pay it, where the money comes from, if anywhere.
It won’t matter how much supplemental insurance costs if it’s truly supplemental. Most countries with sane health coverage systems have private insurance available on top of the government-run system, but most people don’t bother with it, because they don’t need it.
I only started reading her “plans” yesterday, so, not an expert. There’s a lobbying tax, that’s supposed to be one of the first things to pass.
“Under my lobbying tax proposal, companies that spend between $500,000 and $1 million per year on lobbying, calculated on a quarterly basis, will pay a 35% tax on those expenditures. For every dollar above $1 million spent on lobbying, the rate will increase to 60% – and for every dollar above $5 million, it will increase to 75%.”
She also wants to ban all financial contributions from lobbyists to political campaigns, impose a two year moratorium between leaving a lobbyist job and working for the feds (with exceptions if it is in the national interest?), ban top officials from ever becoming lobbyists after leaving office (for life), and ban other federal employees from lobbying their former office/agency/etc within 2 to 6 years of leaving.
Say what you will about constitutionality or desirability, all of these lobbyist reforms if successful will cripple the ability for pharmaceutical and insurance companies to push back through government channels.
Second, during the transition phase she proposes cutting down on drug prices with antitrust actions, “compulsory licensing authority” (the government pays the patent holder a nominal fee and compells them to grant licenses), and finally the option of forcing patent holders that received federal funding to license drug patents using what is called “march-in rights”. These last two options open the market for generic drugs by destroying the patent holder’s monopoly, which brings prices down, in theory.
For older off-patent drugs such as insulin and epinephrine, she seems to want the government to directly produce or issue contracts for manufacture of such drugs, to bring prices down while the country is transitioning to M4A.
Thanks for diving in, but these “reforms” are AFAICT pure campaign rhetoric. Everyone hates lobbyists and Big Pharma, amirite? But even if they were constitutional, which I doubt, silencing the opposition and suing Big Pharma are not the kind of tactics I’m hoping to learn about.
What will the government offer? What will they prohibit? How (if at all) will they work with the existing insurance infrastructure? What will be phased in, and how?
For example … I’ve heard it proposed on these boards that the age of eligibility for Medicare simply be lowered by some increment each year until everyone is covered. Is that possible? Feasible? A good idea?
Yeah, although the drug stuff I tried to summarize is pretty concrete - govt. directly produces drugs for cheap to bring down costs now.
Here’s a relevant bit,
“Coverage under the new Medicare for All option will be immediately free for children under the age of 18 and for families making at or below 200% of the federal poverty level (about $51,000 for a family of four). For all others, the cost will be modest, and eventually, coverage under this plan will be free for everyone.”
basically meaning stage one is covering everyone that meets what is now expanded Medicaid, but federally administered.
Another relevant bit,
“any person over the age of 50 will be eligible for expanded coverage under the existing Medicare program”
So, she is expanding the existing Medicare program to age 50.
That only leaves people ages 19-49 that live in families making 201% or more of the federal poverty level. The plan, from what I can gather, is to start out by strengthening existing ACA marketplace plans, then introduce a public option with lower and lower premiums/copays every year until it is eventually free.
Again, it’s not about insurance. Do you “like” your auto insurance? Or do you “like” driving?
Regarding taxes - yes, taxes will go up, because the cost will shift from employee/employer paid to taxes instead. Whether I pay it from one line item (insurance) or the other (taxes), I’m still paying it. It is the overall cost that is important.
Communications and messaging is an actual step. Any successful transition relies on effective communications and messaging.
Well, that has to be addressed. What employers are spending on health insurance is already considered employee compensation, but it doesn’t go to the employee directly. Many modern employers provide their employees with information on how much they are paying for the individual employee’s health insurance. “See, I’m paying you $60,000 in salary, plus $12,000 in insurance costs, so your total compensation is $72,000.” My proposal is that by eliminating insurance costs, employers turn that compensation amount over to employees as salary. Now, in real life, employers would most likely try to muck with that and keep that money themselves, so that is why I’m saying we (the gov’t) would have to force their hands on this issue to make the whole transition work.
Basically just expand medicare. Private hospitals and doctors would then bill medicare (like they do now). Billing rates would be negotiated.
Raise medicare taxes.
Allow companies to drop private insurance.
Eventually most people will get their healthcare thru the expanded medicare system with only some using private insurance or paying out of pocket if they want extra care (like they currently do in Canada and Europe).
I’m not sure the government would have to step in. If company A is willing to apply the insurance savings to compensation and offer $72,000, while company B decides to split the difference and offer $66,000, who will attract better employees? Especially when employees no longer have to worry about the complexities of changing their coverage when they change jobs?
Thanks! The other major example is Senator Sanders’s plan. I found a summary of the transitioning [:
"*It would bar employers from offering separate plans that compete with this new, government-run option. It would largely sunset Medicare and Medicaid, transitioning their enrollees into the new universal plan. It would, however, allow two existing health systems to continue to operate as they do now: the Veterans Affairs health system and the Indian Health Services.
Those who qualify for the new universal Medicare plan would get four years to transition into the new coverage. In the interim, they would have the option to buy into Medicare or another publicly run option that does not currently exist.
Eventually, though, they would all end up in the same plan*[…]"
But, you know, gotta check the source. I grabbed a link to [URL=https://www.congress.gov/bill/116th-congress/senate-bill/1129/text]the actual bill](]on Vox[/URL). You can read the transition in Title X (sections 1001-1015), via a clickable hyperlink in the bill’s table of contents.
The “transition period” lasts four years, during which time you can still get insurance through current means. He wants to set the Medicare A & B out of pocket limits to $1,500/yr and eliminate the annual deductibles starting the next Jan 1. He is going to freeze the donut-hole at $305 (down from $6350) for four years, and then he is getting rid of the 5% coinsurance rate after reaching the end of the hole. Medicare also will offer dental, vision, and hearing services, with an 80%/20% split. He is removing the 24 month wait period for new Medicare enrollees with disabilities. Finally, he is prohibiting Medi-gap plans from discriminating based on prior medical conditions.
Meanwhile the government works out the logistics of getting everyone enrolled in the upcoming M4A plan, setting up the agencies, printing cards, writing regulations, etc. Four years after the act is passed, the new Medicare for All plan goes live.
You do it by putting an additional tax on the funds that they get as the difference. You don’t force anybody to do anything, but you prod to induce the behavior that you want. I prefer that. You won’t get 100% of those funds back into the worker, but its probably the most plausible way of getting that done.
Me, I’d start with what you want to end up with. What will it look like? Where are the monies for it going to come from, and what is it going to cost? What are the projected growth curves going forward? How will the program work, exactly…what services will be available and to whom? Basically, nail down the details on what the final system will be, what it will cost, what it will provide and to whom it will provide them. Once you have that, and assuming you can get people on board with that, then figure out your transition plan…how do we get from where we are today to this final goal? What will that cost, and what services will be available and to whom will they be available through the transition?
That’s where I’d start. The trouble is kind of in your title though…‘(not a political discussion)’. Sadly, that’s what this is…it’s what it has to be. Because you are going to need both major parties on board to do this. So you are going to have to come up with a compromise system, which will probably mean both the end goal and the transition isn’t going to make anyone happy. But if you don’t get both parties on board, and just one party shoves it down the other parties throat, then eventually the worm will turn, and the other party will be on top, and they will make it their mission to cripple or neuter your program. They probably won’t kill it, instead, it will change and be watered down. Rinse and repeat through changes in politics, and you will end up right back where we are.
Why would you need a tax-based stick and carrot (or any other kind) when the free market (yes, I went there) would incentivize employers to funnel as much of the savings as possible into employee compensation?
Absolutely true. But my secret (impossibly naive) hope is that if a reasonable plan toward the goal of UHC can be constructed, it will help bridge this political gap. You may never overcome the “It’s wrong” argument, but you might be able to overcome the “It’s impossible” argument.
Corporations are better at seeing the long view and doing what you said. Most people don’t work for corporate conglomerates anymore though, they work for small businesses, and small businesses will pocket the money, they always do. I am part owner of a small business, and have worked for over 15 in my career. My brother owns a small business. They will always pocket the money because “today’s numbers” are “today’s numbers” and if they have to let some of what they put in their pocket back out at a later date, it will have been in their pocket for quite a while. You are assuming too much. Restaurants are terrible at paying minimum wage differentials, and they are required to do so by law.
You generally drag people up a mountain kicking and screaming, not down as they say.