Category Archives: John Delaney

Poll: Dems more likely to support the ​candidate who backs Medicare for All over fixing Obamacare, Maybe and then there is Biden!

69477871_2236925356437111_1822674667475828736_nAitlin Oprysko noted that as the Democratic presidential field continues to grapple with plans to address health care, a significant majority of Democratic voters are more likely to back a 2020 primary candidate who supports “Medicare for All” than building on the Affordable Care Act, a new poll found.

According to the POLITICO/Morning Consult poll out Wednesday, 65 percent of Democratic primary voters would be more likely to support a candidate who wants to institute a single-payer health care system like Medicare for All; 13 percent said they’d be less likely to back a candidate based on that support.

While the Democratic base has essentially demanded that it’s White House hopefuls offer up a plan for universal health care, the party has devolved into infighting over the nuances of such plans, centering almost entirely on the role of private insurers in the health care market.

“Democrats are increasingly more inclined to back a 2020 candidate who supports Medicare for All versus revamping Obamacare,” said Tyler Sinclair, Morning Consult’s vice president. “In January, 57 percent of Democrats said they would be more likely to vote for a candidate who backs a Medicare for All health system over expanding the Affordable Care Act. That number has now risen to 65 percent.”

The issue has been one of the more contentious policy divides rippling through the extensive primary field. White House hopefuls like former Vice President Joe Biden, former Rep. John Delaney, and Sen. Michael Bennet have railed against the idea, arguing instead for building on Obamacare.

Biden’s front-runner status thus far has come close to being threatened by only Sens. Bernie Sanders and Elizabeth Warren, two of the most vocal proponents of Medicare for All, while some of the idea’s most vocal detractors have failed to gain traction in the race or have already dropped out.

But Biden this week made his most forceful case yet against scrapping one of the signature achievements of his tenure as vice president, dropping a one-minute ad in which he explains that health care is “deeply personal” to him.

“Obamacare is personal to me,” he says at the end of the spot, in which he invokes the unexpected death of his first wife and daughter and the cancer fight of his late son. “When I see the president try to tear it down, and others proposing to replace it and start over, that’s personal to me, too.”

Meanwhile, Sen. Kamala Harris’ faltering in recent polls has coincided with greater scrutiny and wavering when it comes to the role of private insurers in a potential Harris administration. Her plan has drawn criticism from both ends of the spectrum even as it’s been praised by health policy experts and former Obama administration officials.

On the left flank, Sanders and Warren have defended the proposal in the face of criticism from the center lane of the primary, and Sanders’ campaign has aggressively seized on Harris’ muddled messaging.

Overall, 53 percent of voters support Medicare for All, though fewer — 45 percent — say a candidate’s support for Medicare for All would make them more likely to vote for that candidate in a general election over one who would prioritize improving on Obamacare. The survey suggests a level of public support for single-payer health care that could take some sting out of Republicans’ plans to make Medicare for All a four-letter word they can wield against Democrats up and down the ballot in 2020.

The POLITICO/Morning Consult survey was conducted online Aug. 23-25 among a national sample of 1,987 registered voters, including 768 Democratic voters. Results from the full survey have a margin of error of plus or minus 2 points.

Morning Consult is a nonpartisan media and technology company that provides data-driven research and insights on politics, policy and business strategy. But here is a slightly different view on the desires of those Democrats!

Democrats Want Medicare for All … or Maybe Not

Yuval Rosenberg of the Fiscal Times reported that a new Morning Consult/Politico poll finds support among Democrats rising for candidates that favor Medicare for All overbuilding on the Affordable Care Act. The survey found a 52-point margin of support — the share of those who said they would be more likely to back a candidate minus the share who said they would be less likely — for a candidate that backs Medicare for All, up from 35 points in January.

The poll surveyed 1,987 registered voters, including 768 Democratic voters, and had an overall margin of error of 2 percentage points. The Democratic subsample has a margin of error of 4 percentage points.

The Morning Consult results are similar to the findings of a new Monmouth University poll in which 58% of Democratic voters say it is very important to them that the party nominate someone who supports “Medicare for All.” But the poll also found that most voters, 53%, say they want a system that allows people to opt into Medicare while maintaining a private insurance market — what policy experts call a “public option.” Just 22% say they want to switch to a system where a government-run health plan replaces private insurance.

That may help explain why the Morning Consult poll finds that former vice president Joe Biden, who favors expanding the ACA by adding a public option, holds a 13-point advantage over Sen. Bernie Sanders (I-Vt.), who has championed Medicare for All.

Another explanation: Voters have other issues on their minds. Leslie Dach, campaign chair for health care advocacy group Protect Our Care, told Morning Consult that the latest poll results showing continued support for Biden demonstrate that Democratic voters are driven by a desire to remove President Trump from the office more than by questions about health care. And on the issue of health care, they’re more responsive to pocketbook issues like drug costs and protections for people with pre-existing conditions than to broader questions about the future structure of the U.S. health care system.

Bernie Sanders calls for eliminating all medical debt at the South Carolina event

Bernie Sanders teases plan to eliminate all medical debt and how ridiculous it sounds and really is!!

Andrew Craft or Fox News reported that the Democratic presidential candidate Sen. Bernie Sanders, I-Vt., told an audience in South Carolina Friday that he is working on legislation that would “eliminate medical debt in this country.”

Sanders made the remark during a question-and-answer period following a town hall meeting in Florence on “Medicare-for-All.” A female attendee explained to Sanders that she doesn’t make enough money to qualify for ObamaCare and has a large amount of medical debt not covered by insurance.

When the woman asked Sanders if he had a plan for that, the self-described democratic socialist told her: “In another piece of legislation that we’re offering, we’re gonna eliminate medical debt in this country.”

The Sanders campaign confirmed to Fox News that the proposal was new, but details were scant.

“We are introducing legislation that would end all medical debt in this country,” Sanders told reporters as he departed the town hall. “The bottom line is it is an insane and cruel system, which says to people that they have to go deeply into debt or go bankrupt because of what? Because they came down with cancer or they came down with heart disease or they came down with Alzheimer’s, or whatever …

“In the midst of a dysfunctional healthcare system, we have to say to people that you cannot go bankrupt or end up in financial duress,” Sanders added. “That is cruel and something we’ve gotta handle. This is something that we’re working on and that we will introduce.”

Sanders has long touted his “Medicare-for-All” proposal, which would replace job-based and individual private health insurance with a government-run plan that guarantees coverage for all with no premiums, deductibles and only minimal copays for certain services. Health care has become a key issue in South Carolina, which is among the Republican-led states that turned down Medicaid expansion under the Affordable Care Act.

Sanders’ legislation does not specify new revenues, instead of providing a separate list of “options” that include higher taxes on the wealthy, corporations and employers while promising the middle class will be better off.

“You’re going to be paying more in taxes,” Sanders said Friday to a man asking how he’d benefit from Medicare for All if his employer currently pays for most of his premiums. “But at the end of the day, you’re going to be paying less for health care than you are right now. It will be comprehensive.”

The healthcare industry has become a favorite whipping boy for Sanders, who told his audience Friday: “Thirty years from now your kids and your grandchildren will be asking you was it really true? That there were people in America who could not go to the doctor when they wanted to? Was it really true that people went bankrupt because they could not pay their healthcare bills? And you will have to tell them, ‘Yes, it was.’ But together we are going to end that obscenity and we’re going to end it in the next few years.”

The new proposal is not the only debt that Sanders has called for canceling. He has repeatedly called for the elimination of $1.6 trillion in student loan debt as well and calling for public college and universities to be tuition-free.

According to the RealClearPolitics polling average, Sanders is the second choice among Democrats nationwide, garnering 17.1 percent of the vote. Former Vice President Joe Biden holds a comfortable lead with 28.9 percent support, while Elizabeth Warren is narrowly behind Sanders in third place at 16.5 percent support.

Sanders: Medicare for All means more taxes, better coverage

Meg Kinnard of the Associated Press reported that health care was the focus of Democratic presidential hopeful Bernie Sanders’ second day of campaigning in pivotal early-voting South Carolina, where lack of Medicaid expansion has left thousands unable to obtain health coverage.

The Vermont senator focused on “Medicare for All,” his signature proposal replacing job-based and individual private health insurance with a government-run plan that guarantees coverage for all with no premiums, deductibles and only minimal copays for certain services.

“While this health care system is not working for working families, it is working for one group of people,” Sanders told a crowd of 300 on Friday. “The function of a rational health care system is not to make billions for insurance companies and drug companies. It is to provide health care to every man woman and child as a human right.”

Health care and how to reform the nation’s system is a critical debate among the candidates vying for the Democratic nomination. It’s under intense focus in states like South Carolina, home to the first-in-the-South 2020 primary, which is among the Republican-led states that turned down Medicaid expansion under the Affordable Care Act.

As a result of that decision, according to healthinsurance.org, a health insurance industry watchdog, about 92,000 South Carolinians are in the “coverage gap,” without access to insurance. This group of mostly low-income residents doesn’t qualify for subsidies on the exchange and is heavily reliant on emergency rooms and community clinics for care.

The lack of expansion has also had institutional ramifications, leading to the closures of hospitals in rural areas, tasked with serving a wide-reaching population and heavily reliant on Medicaid funds. According to the Sheps Center for Health Services Research at the University of North Carolina, 113 rural hospitals have closed since January 2010. Four of those facilities were in South Carolina.

While the overall notion of “Medicare for All” remains popular, some recent polling has shown softening support for the single-payer system, with hesitation at the idea of relinquishing private coverage altogether. Under Sanders’ legislation, it would be unlawful for insurers or employers to offer coverage for benefits provided by the new government-run plan.

Nationwide, 55% of Democrats and independent voters who lean Democratic said in a poll last month they’d prefer building on President Barack Obama’s Affordable Care Act instead of replacing it with Medicare for All. The survey by the nonpartisan Kaiser Family Foundation found that 39% would prefer Medicare for All. Majorities of liberals and moderates concurred.

Sanders’ legislation does not specify new revenues, instead of providing a separate list of “options” that include higher taxes on the wealthy, corporations and employers while promising the middle class will be better off.

“You’re going to be paying more in taxes,” Sanders said Friday to a man asking how he’d benefit from Medicare for All if his employer currently pays for most of his premiums. “But at the end of the day, you’re going to be paying less for health care than you are right now. It will be comprehensive.”

Sanders tallied up other personal expenses that would go away under his plan, including co-pays and medication costs over a $200-per-year cap. Sanders said he was also working on a proposal to eliminate medical debt, which he called the leading cause of consumer bankruptcy.

His campaign provided more details on Saturday, saying the plan would cancel an existing $81 billion in existing, past-due medical debt, with the federal government negotiating and paying off bills in collections. Sanders is proposing changes to a 2005 bankruptcy bill, which he blames for further hampering Americans’ abilities to regain their financial footing.

In early states including South Carolina, some voters continue to voice confusion as to exactly what various candidates in the vast Democratic field mean when they advocate for pieces of a Medicare for All plan. California Sen. Kamala Harris’ new plan would preserve a role for private insurance. New Jersey Sen. Cory Booker is open to step-by-step approaches.

Others including former Vice President Joe Biden have been blunt in criticizing the government-run system envisioned by Sanders.

Biden health plan aims far beyond the legacy of ‘Obamacare’

Ricardo Alonso-Zaldivar of the Associated Press noted that wrapping himself in the legacy of “Obamacare,” Joe Biden is offering restless Democrats a health care proposal that goes far beyond it, calling for a government plan almost anybody can join but stopping short of a total system remake. But why does he propose a health care plan, Obamacare, that he was sooooo proud of??

Recent polls show softening support for the full government-run system championed by Sen. Bernie Sanders, and Biden is pitching his approach in a new ad aimed at Democrats in Iowa. His “public option” would give virtually everyone the choice of a government plan like Medicare, as an alternative to private coverage, not a substitute.

“The fact of the matter is health care is personal to me,” Biden says in the ad, recalling his own family experiences with illness and loss. “Obamacare is personal to me. When I see the president try to tear it down and others propose to replace it and start over, that’s personal to me, too. We’ve got to build on what we did because every American deserves affordable health care.”

Biden’s health care gambit puts him somewhere center-left on the spectrum of ideas from Democratic presidential candidates.

Sanders and Massachusetts Sen. Elizabeth Warren are solidly behind “Medicare for All,” the government-run “single-payer” approach. California Sen. Kamala Harris is offering to retain private plans within a government system. Colorado Sen. Michael Bennet who is proposing a limited public option focused on areas with little insurer competition, calls it “the most effective way to cover everyone and lower costs.”

Sanders, in a veiled swipe, has accused Biden of “tinkering around the edges.” But Biden’s more ambitious public option would be open to people around the country, including those with employer coverage. That would set up a competition between a government plan and the mainstay of private coverage in the U.S.

“The Biden plan is modest in comparison to ‘Medicare for All,’ but it is by no means modest by historical standards,” said Larry Levitt of the nonpartisan Kaiser Family Foundation. “It goes well beyond even the most progressive proposals during the Affordable Care Act debate. It does show how the health care debate has shifted when this is considered a moderate proposal.”

Here’s a look:

THE BLUEPRINT

President Barack Obama’s former vice president builds on the ACA to address what former Democratic Senate aide John McDonough calls its “shortcomings, weaknesses, and pain points.”

Biden would provide more generous subsidies for “Obamacare’s” private policies, also lowering deductibles and copays. He’d let solidly middle-class people qualify for help paying their premiums, responding to complaints that they’re now priced out.

That’s for starters.

Biden adds his public option plan, something Obama couldn’t get through Congress when Democrats controlled it.

Biden’s version would be modeled on Medicare and open to just about any U.S. citizen or legal resident. One of its goals would be to provide free coverage for low-income people in states that have refused the ACA’s Medicaid expansion, including Texas and Florida.

And in a landmark change, Biden would open the public plan to people with access to job-based insurance if that’s what they want. Most workers don’t have such a choice now.

Campaign policy director Stef Feldman said Biden feels strongly that people with workplace coverage should have another choice.

It’s unclear how many people would switch from employer coverage to the public option, but the Kaiser Foundation’s Levitt notes, “It would be a voluntary shift on the part of workers.”

Under the plan, people who qualify for ACA subsidies would be able to use that money for public option premiums. “The public option and private insurance will hold each other accountable,” Feldman said.

But even as it gives consumers more choices, the public plan could undermine employer coverage, particularly if it draws away younger and healthier workers.

A coalition of insurers, hospitals and drug makers formed to fight “Medicare for All” is trying to derail the public option as well.

“It would be a dramatic policy change,” said McDonough, who teaches at the Harvard T.H. Chan School of Public Health. The prospect of payments pegged to Medicare’s lower rates “is already alarming the provider community.”

Another part of Biden’s plan would tackle the high cost of prescription drugs, an issue that President Donald Trump has sought to address.

His most significant idea would limit launch prices for cutting-edge drugs that can cost hundreds of thousands of dollars. He’d also hold pharmaceutical price increases to the inflation rate, allow Medicare to negotiate with drugmakers, and clear the way for patients to import drugs from abroad.

Overall, Biden’s campaign estimates his plan would cover 97% of those eligible.

He’d also restore Obama’s unpopular fines on people who go without health insurance, which were repealed by Congress.

THE POOR AND THE MIDDLE CLASS

“Obamacare” and the Republican backlash against it had unintended consequences both for low-income uninsured people and for middle-class consumers who once purchased their own policies but can no longer afford the high premiums.

Many GOP-led states have turned down the ACA’s Medicaid expansion. Nationally, nearly 5 million low-income people would gain coverage if all states expanded Medicaid. Biden would enroll them in the public option at no cost to them or their state.

That might well upset leaders in mostly Democratic states that embraced the Medicaid expansion and are helping pay for it. But campaign policy director Feldman says Biden “is done with” letting state politics interfere with coverage.

For middle-class people who buy their own health insurance, Biden would lift the ACA’s income limit on subsidies to help pay premiums.

ACA critic Robert Laszewski calls that a welcome fix. “Biden has done what needed to be done,” said Laszewski, a consultant and blogger. “The fundamental problem is that the middle class can’t afford the Obamacare policy.”

THE COST

After expected savings on prescription drugs and elsewhere, the Biden campaign estimates the plan’s net cost at $750 billion over 10 years, paid for by raising taxes on upper-income people and on investment income.

By comparison, “Medicare for All” is projected to cost $30 trillion to $40 trillion over 10 years.

While Biden’s plan clearly would cost less, health economist Gail Wilensky says she’s skeptical of the campaign number.

“Campaigns want to underestimate the cost and overestimate the benefits and make the financing sound easier than it will be,” said Wilensky, a longtime Republican adviser.

And on and on the discussion goes as to what the eventual Democratic presidential candidate will actually stick with and possibly what we all may have to live with. More on this discussion in the many weeks before and after the 2020 election.

Hoping that you all are enjoying your Labor Day weekend and the “end” of summer!

The Real Costs of the U.S. Health-Care Mess, South Africa’s cost of Health Care and Rural Health Care and Gun Violence

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How health insurance works now, and how the candidates want it to work in the future is confusing and yes, very costly.

Matt Bruenig reviewed that with more than 20 people vying for the Democratic presidential nomination, it can be difficult to get a handle on the policy terrain. This is especially true in health care, where at least eight different plans are floating around, including from candidates whom few support, such as Michael Bennet, who wants to offer a public health plan in the small individual-insurance market.

Among the candidates polling in the double digits, three have offered actual health-care proposals (as opposed to vague statements): Joe Biden, Kamala Harris, and Bernie Sanders, whose Medicare for All plan is also supported by Elizabeth Warren. These plans are similar in the most general sense, in that they expand coverage and affordability, but they are dramatically different in their particulars and in what they tell voters about the respective candidates. To understand any of that, however, you have to understand how insurance works right now.

Americans get insurance from four main sources.

The first source is Medicare, which covers nearly all elderly people and some disabled people. The “core” program consists of Medicare Part A, which pays for hospital treatment, and Medicare Part B, which pays for doctor visits. Medicare Part D covers prescription drugs but is administered only by private insurance providers. Private Medigap plans provide supplemental insurance for some of the cost-sharing required by Parts A and B, while private Medicare Advantage plans essentially bundle all of the above into a single offering.

The second source is Medicaid, which covers low-income people and provides long-term care for disabled people. Medicaid is administered by states and jointly funded by state and federal governments. The Affordable Care Act expanded Medicaid eligibility up to the income ladder a bit, but some states did not go along with the expansion.

The third source is employer-sponsored insurance, which covers about 159 million workers, spouses, and children. Employer insurance is very costly, with the average family premium running just under $19,000 a year. For average wage workers living in a family of four, this premium is equal to 26.4 percent of their total labor compensation. If you count this premium as taxes for international comparison purposes, the average wage worker in the United States has the second-highest tax rate in the developed world, behind the Netherlands. As with Medicaid, employer insurance is very unstable, with people losing their insurance plan every time they separate from their job (66 million workers every year) or when their employer decides to change insurance carriers (15 percent of employers every year).

The final source is individual insurance purchased directly from a private insurer. Most of the people who buy this kind of insurance do so through the exchanges established by the Affordable Care Act. The exchanges provide income-based subsidies to individuals with incomes from 100 percent to 400 percent of the poverty line, but have mostly been a policy train wreck: Enrollments were 50 percent lower than predicted, insurers have quit the exchanges in droves, and the income cutoffs have caused disgruntlement among low-income participants who would rather have Medicaid and high-income participants who get no subsidy at all.

Despite all of this, or perhaps because of it, America still has about 30 million uninsured people, a number that is predicted to increase to 35 million by 2029. Conservative estimates suggest that there is one unnecessary death annually for every 830 uninsured people, meaning that America’s level of uninsurance leads to more than 35,000 unnecessary deaths every year.

Biden has centered his candidacy on his association with Barack Obama. Given this strategy, it’s no surprise that he has put out a health plan that is meant to be as similar to Obamacare as possible.

The plan keeps the current insurance regime intact while tweaking some of the rules to fix a few of the pain points identified above. He closes the hole created by some states not expanding Medicaid by enrolling everyone stuck in that hole into a new public health plan for free. He soothes the disgruntlement of high-income people who buy unsubsidized individual insurance by extending subsidies beyond 400 percent of the poverty line. And he slightly increases the subsidy amount for those buying subsidized individual insurance on the exchanges.

In addition to these rule tweaks, Biden also says that the new public option for everyone in the Medicaid hole will also be available in the individual and employer insurance markets, meaning that people in those markets can buy into that public option rather than rely on private insurance.

Biden is probably correct to say that his plan is the most similar to Obamacare. And just like Obamacare, Biden’s plan will leave a lot of Americans uninsured. Specifically, his own materials say that 3 percent of Americans will still be uninsured after his reforms, which means that about 10 million Americans will continue to lack insurance and about 12,000 will die each year due to uninsurance.

Sanders is running as a progressive democratic socialist who wants America to offer the kinds of benefits available in countries such as Denmark, Finland, Sweden, and Norway, or in even less left-wing countries such as Canada. Unlike Biden, he has no need or desire to wrap himself in the policies of the Obama era and has instead come out in favor of a single-payer Medicare for All system.

Under the Sanders plan, the federal government will provide comprehensive health insurance that covers nearly everything people associate with medical care, including prescription drugs, hearing, dental, and vision. Over the course of four years, every American will be transitioned to the new public health plan. Going forward, rather than getting money to providers through a mess of leaky insurance channels, all money will flow through the single Medicare channel, which will cover everyone.

So far, Sanders has not adopted a specific set of “pay-fors” for his Medicare for All program but has instead offered up lists of funding options. Although he has remained open on the specifics of funding Medicare for All, the overall Sanders vision is pretty clear: cut overall health spending while also redistributing health spending up the ladder so that the majority of families pay less for health care than they do now.

And this plan is plausible: The right-wing Mercatus Center found in 2018 that the Sanders plan reduces overall health spending by $2 trillion in the first 10 years. The nonpartisan Rand Corporation has constructed a similar single-payer plan, with pay-fors, for New York State that would result in health-care savings for all family income-groups below 1,000 percent of the poverty line ($276,100 for a family of four).

While Sanders’s support for Medicare for All helps promote his image as a supporter of universal social programs, Warren’s support for it helps boost her brand as a smart technocrat who understands good policy design. As Paul Krugman noted in 2007, a single-payer Medicare for All system is “simpler, easier to administer, and more efficient” than the “complicated, indirect” health-care system we have now. In general, single-payer systems are beloved by the wonk set because they are the most direct and cost-effective way to provide universal health insurance to a population.

If Biden’s plan is Obamacare 2.0 and the Sanders/Warren plan is wonky universalism, then Harris’s plan is a bizarre and confusing muddle that also has come to typify her campaign. Harris is the candidate who went hard after Biden for his views on busing many decades ago and then clarified the next day that her views are the same as Biden’s. She’s the candidate who said she wanted to get rid of private insurers and raised her hand when asked if she would be willing to swap out private insurance for Medicare for All, only to walk back both statements the very next day.

Harris’s health-care proposal, which is basically Medicare Advantage for All, is similar to the Sanders plan, except it takes 10 years to phase in instead of four and allows people to opt out of the public plan in favor of a private plan with identical coverage (similar to how Medicare Advantage works today). This weird hybrid allows Harris to insist that she is for Medicare for All while also saying that she is not getting rid of private insurance.

As readers can probably guess, I favor the Sanders plan on the merits. But what matters for voters may not be the particulars, which most voters will probably never be aware of, but rather what the plans say about the candidates. Voters who want Obama 2.0 will see in Biden’s health-care plan a reassuring fidelity to his predecessor. Voters interested in universal social programs or technocratic wonkiness will have another reason to like Sanders or Warren based on their Medicare for All plan. And voters who like Harris’s style and do not care about consistency can use Harris’s triangulated health-care policy to see what they want in her.

South Africa puts initial universal healthcare cost at $17 billion

I thought that it would be a great idea to see how much other countries are paying for their health care plans. Onke Ngcuka noted that South Africa published its draft National Health Insurance (NHI) bill on Thursday, with one senior official estimating universal healthcare for millions of poorer citizens would cost about 256 billion rands ($16.89 billion) to implement by 2022.

The bill creating an NHI Fund paves the way for a comprehensive overhaul of South Africa’s health system that would be one of the biggest policy changes since the ruling African National Congress ended white minority rule in 1994.

The existing health system in Africa’s most industrialized economy reflects broader racial and social inequalities that persist more than two decades after apartheid ended.

Less than 20 percent of South Africa’s population of 58 million can afford private healthcare, while a majority of poor blacks queue at understaffed state hospitals short of equipment.

Anban Pillay, deputy director-general at the health department, told reporters an initial Treasury estimate of 206 billion rand costs by 2022 was more likely to be 256 billion rands by the time final numbers had been reviewed.

The bill proposes that the NHI Fund, with a board and chief executive officer, also be funded from additional taxes.

“The day we have all been waiting for has arrived: today the National Health Insurance Bill is being introduced in parliament,” said Health Minister Zweli Mkhize at the briefing, adding that the pooling of existing public funds should help reduce costs.

The Hospital Association of South Africa (HASA), an industry body which represents private hospital groups including Netcare, Mediclinic and Life Healthcare, welcomed the release of the bill.

“We are committed to, and supportive of, the core purpose of the legislation, which is to ensure access to quality healthcare for all South Africans,” said HASA chairman Biren Valodia in a statement.

“TAX BURDEN”

The new bill is still to be debated in parliament with public input. It is unclear how long the legislative process will take, with the main opposition party Democratic Alliance suggesting the NHI, which has been in the works for around a decade, would strain the nation’s coffers.

“The DA is convinced that instead of being a vehicle to provide quality healthcare for all, this Bill will nationalize healthcare … and be an additional tax burden to already financially-stretched South Africans,” said Siviwe Gwarube, the DA’s shadow health minister, in a statement.

Successful implementation of NHI would be a boon for President Cyril Ramaphosa following May’s election the ANC won, but its cost comes at a tricky time in a struggling economy.

South Africa’s rand fell to touch an 11-month low on Wednesday, rocked by deepening concerns about the outlook for domestic growth with unemployment at its highest in over a decade and the economy skirting recession.

New taxation options for the Fund include evaluating a surcharge on income tax and small payroll-based taxes.

“There is no doubt that taxpayers will find the additional tax burden a bitter pill to swallow,” said Aneria Bouwer, a partner and tax specialist at Bowmans law firm.

The NHI is due to be implemented in phases before full operation by 2026. The government is looking to eventually shift into the new Fund approximately 150 billion rands a year from money earmarked for the provincial government sphere.

Rural hospitals take the spotlight in the coverage expansion debate

Susannah Luthi points out a fact of these health care plans which everyone refuses to believe. Opponents of the public option have funded an analysis that warns more rural hospitals may close if Americans leave commercial plans for Medicare.

With the focus on rural hospitals, the Partnership for America’s Health Care Future brings a sensitive issue for politicians into its fight against a Medicare buy-in. The policy has gone mainstream among Democratic presidential candidates and many Democratic lawmakers.

Rural hospitals could lose between 2.3% and 14% of their revenue if the U.S. opens up Medicare to people under 65, the consulting firm Navigant projected in its estimate. The analysis assumed just 22% of the remaining 30 million uninsured Americans would choose a Medicare plan. The study based its projections of financial losses primarily on people leaving the commercial market where payment rates are significantly higher than Medicare.

The estimate assumed Medicaid wouldn’t lose anyone to Medicare and plotted out various scenarios where up to half of the commercial market would shift to Medicare.

The analysis was commissioned by the Partnership for America’s Health Care Future, a coalition of hospitals, insurers and pharmaceutical companies fighting public option and single-payer proposals.

In their most drastic scenario of commercial insurance losses, co-authors Jeff Goldsmith and Jeff Leibach predict more than 55% of rural hospitals could risk closure, up from 21% who risk closure today according to their previous studies.

Leibach said the analysis was tailored to individual hospitals, accounting for hospitals that wouldn’t see cuts since they don’t have many commercially insured patients.

The spotlight on rural hospitals in the debate on who should pay for healthcare is common these days, particularly as politicians or the executive branch eye policies that could cut hospital or physician pay.

On Wednesday, Sen. Elizabeth Warren (D-Mass.) seemingly acknowledged this when she published her own proposal to raise Medicare rates for rural hospitals as part of her goal to implement single-payer or Medicare for All. She is running for the Democratic nomination for president for the 2020 election.

“Medicare already has special designations available to rural hospitals, but they must be updated to match the reality of rural areas,” Warren said in a post announcing a rural strategy as part of her campaign platform. “I will create a new designation that reimburses rural hospitals at a higher rate, relieves distance requirements and offers the flexibility of services by assessing the needs of their communities.”

Warren is a co-sponsor of the Medicare for All legislation by Sen. Bernie Sanders (I-Vt.), who is credited with the party’s leftward shift on the healthcare coverage question. But she is trying to differentiate herself from Sanders, and the criticisms about the potentially drastic pay cuts to hospitals have dogged single-payer debates.

Most experts acknowledge the need for a significant policy overhaul that lets rural hospitals adjust their business models. Those providers tend to have aging and sick patients; high rates of uninsured and public pay patients over those covered by commercial insurance; and fewer patients overall than their urban counterparts.

But lawmakers in Washington aren’t likely to act during this Congress. The major recent changes have mostly been driven by the Trump administration, where officials just last week finalized an overhaul of the Medicare wage index to help rural hospitals.

As political rhetoric around the public option or single-payer has gone mainstream this presidential primary season, rural hospitals will likely remain a talking point in the ideas to overhaul or reorganize the U.S.’s $3.3 trillion healthcare industry.

This was in evidence in May, when the House Budget Committee convened a hearing on Medicare for All to investigate some of the fiscal impacts. One Congressional Budget Office official said rural hospitals with mostly Medicaid, Medicare, and uninsured patients could actually see a boost in a redistribution of doctor and hospital pay.

But the CBO didn’t analyze specific legislation and offered a vague overview of how a single-payer system might look, rather than giving exact numbers.

The plight of rural hospitals has been used in lobbying tactics throughout this year — in Congress’ fight over how to end surprise medical bills as well as opposition to hospital contracting reforms proposed in the Senate.

And it has worked to some extent. Both House and Senate committees have made concessions to their surprise billing proposals to mollify some lawmakers’ worries.

New research finds restructuring Medicare Shared Savings Program can yield 40% savings in healthcare costs, bolstering payments to providers

As I reviewed in the last few posts, the evaluation of Medicare was underestimated regarding the cost of the program many times.  Ashley Smith reported that more than a trillion dollars were spent on healthcare in the United States in 2018, with Medicare and Medicaid accounting for some 37% of those expenditures. With healthcare costs expected to continue to rise by roughly 5% per year, a continued debate in healthcare policy is how to reduce costs without compromising quality.

As part of this effort, the Medicare Shared Savings Program was created to control escalating Medicare spending by giving healthcare providers incentives to deliver more efficient healthcare.

New research published in the INFORMS journal Operations Research offers a new approach that could substantially change the healthcare spending paradigm by utilizing performance-based incentives to drive down spending.

The researchers Anil Aswani and Zuo-Jun (Max) Shen of the University of California, Berkeley, and Auyon Siddiq of the University of California, Los Angeles found that redesigning the contract for the shared savings program to better align provider incentives with performance-based subsidies can both increase Medicare savings and increase providers’ reimbursement payments.

“Introducing performance-based subsidies can boost Medicare savings by up to 40% without compromising provider participation in the shared savings program,” said Aswani, a professor in the Industrial Engineering and Operations Research Department at UC Berkeley. “This contract can lead to improved outcomes for both Medicare and participating providers,” he continued.

So, again Medicare will be tweaked and reworked for the present aging population.

What will happen with the Medicare program if it applies to all and at what cost?

And finally, we physicians are on the front lines of caring for patients affected by the intentional or unintentional firearm-related injury. We care for those who experience a lifetime of physical and mental disability related to firearm injury and provides support for families affected by firearm-related injury and death. Physicians are the ones who inform families when their loved ones die as a result of the firearm-related injury. Firearm violence directly impacts physicians, their colleagues, and their families. In a recent survey of trauma surgeons, one-third of respondents had themselves been injured or had a family member or close friend(s) injured or killed by a firearm (38). As with other public health crises, firearm-related injury and death are preventable. The medical profession has an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues, and our society. Our organizations are committed to working with all stakeholders to identify reasonable, evidence-based solutions to stem firearm-related injury and death and will continue to speak out on the need to address the public health threat of firearms and I will discuss this in more detail in the following weeks.

First, we have to ignore the NRA and make a difference in order to decrease the increasing gun violence!!!!! I predict that if the President and the Republican Senate doesn’t make inroads they are doomed to fail in the 2020 election.

 

 

Medicare for All, funding and ‘impossible promises’ deeply divide Democrats during 2020 debate; and How Many More Shootings of Innocent people Can Our Society Tolerate?

 

promise312What a horrible week it has been! The debates were an embarrassment for all, both Democrats as well as everyone else. Who among those twenty who were on stage, spouting impossible strategies, attacking each other and in general making fools of themselves.

But the worst was the mass shootings this past weekend. Why should anybody be allowed to own assault weapons? We all need to finally do something about this epidemic of mass shootings. How many more innocent people do we have to lose before the Republicans, as well as the Democrats and our President, work together to solve this problem.

As the President of the American Medical Association stated:

“The devastating gun violence tragedies in our nation this weekend are heartbreaking to physicians across America. We see the victims in our emergency departments and deliver trauma care to the injured, provide psychiatric care to the survivors, and console the families of the deceased. The frequency and scale of these mass shootings demand action.

“Everyone in America, including immigrants, aspires to the ideals of life, liberty, and pursuit of happiness. Those shared values – not hatred or division – are the guiding light for efforts to achieve a more perfect union.

“Common-sense steps, broadly supported by the American public, must be advanced by policymakers to prevent avoidable deaths and injuries caused by gun violence. We must also address the pathology of hatred that has too often fueled these mass murders and casualties.”

Brittany De Lea when reviewing the Democrat presidential hopefuls noted that Democratic contenders for the 2020 presidential election spent a sizable amount of time during the second round of debates detailing the divide over how the party plans to reform the U.S. health care system – while largely avoiding to address how they would pay for their individual proposals.

Massachusetts Sen. Elizabeth Warren dodged a point-blank question from moderators as to whether middle-class families would pay more in taxes in order to fund a transition to a Medicare for All system.

Instead, she said several times that “giant corporations” and “billionaires” would pay more. She noted that “total costs” for middle-class households would go down.

Independent Vermont Sen. Bernie Sanders said during the first round of Democratic debates in Miami that taxes on middle-class families would rise but added that those costs would be offset by lower overall health care costs. Warren seemed to refer to this plan of action also.

Sanders and Warren quickly became targets on the debate stage for his proposed plan, which she supports, to transition to a Medicare for All system where there is no role for private insurers.

Former Maryland Congressman John Delaney (and even though I am not a big fan of Mr. Delaney, he is the only one that makes any sense with regard to health care) said Sanders’ plan would lead to an “underfunded system,” where wealthy people would be able to access care at the expense of everyone else. He also said hospitals would be forced to close.

Delaney asked why the party had to be “so extreme,” adding that the Democrats’ health care debate may not be so much about health care as it was an “anti-private sector strategy.” In his opening statement, he appeared to throw jabs at Sanders and Warren for “impossible promises” that would get Trump reelected.

Former Texas lawmaker Beto O’Rourke said taxes would not rise on middle-class taxpayers, but he also does not believe in taking away people’s choice for the private insurance they have.

Minnesota Sen. Amy Klobuchar said there needed to be a public option, as did former Colorado Gov. John Hickenlooper.

South Bend, Indiana, Mayor Pete Buttigieg thought the availability of a public alternative would incentivize people to walk away from their workplace plans.

Earlier this week, California Sen. Kamala Harris unveiled her vision for a transition to a Medicare for All system over a 10-year phase-in period, which called for no tax increase on families earning less than $100,000. She instead said a Wall Street financial transaction tax would help fund the proposal.

Harris is scheduled to appear during Wednesday’s night debate in Detroit, alongside former Vice President Joe Biden whose campaign has already criticized her health care plan.

Health care comes in focus, this time as a risk for Democrats

Ricardo Alonso-Zaldivar reported that the Democratic presidential candidates are split over eliminating employer-provided health insurance under “Medicare for All.”

The risk is that history has shown voters are wary of disruptions to job-based insurance, the mainstay of coverage for Americans over three generations.

Those divisions were on display in the two Democratic debates this week, with Sens. Bernie Sanders and Elizabeth Warren calling for a complete switch to government-run health insurance for all. In rebuttal, former Vice President Joe Biden asserted, “Obamacare is working” and promised to add a public option. Sen. Kamala Harris was in the middle with a new Medicare for All concept that preserves private insurance plans employers could sponsor and phases in more gradually. Other candidates fall along that spectrum.

The debates had the feel of an old video clip for Jim McDermott, a former Democratic congressman from Washington state who spent most of his career trying to move a Sanders-style “single-payer” plan and now thinks Biden is onto something.

“There is a principle in society and in human beings that says the devil you know is better than the devil you don’t know,” said McDermott, a psychiatrist before becoming a politician. “I was a single-payer advocate since medical school. But I hit every rock in the road trying to get it done. This idea that you are going to take out what is known and replace it with a new government program — that’s dead on arrival.”

Warren, D-Mass., was having none of that talk Monday night on the debate stage. “Democrats win when we figure out what is right, and we get out there and fight for it,” she asserted.

Confronting former Rep. John Delaney, D-Md., a moderate, Warren said, “I don’t understand why anybody goes to all the trouble of running for president of the United States just to talk about what we really can’t do and shouldn’t fight for. … I don’t get it.”

Here’s a look at options put forward by Democrats and the employer-based system that progressives would replace:

MEDICARE FOR ALL

The Medicare for All plan advocated by Sanders and Warren would replace America’s hybrid system of employer, government and individual coverage with a single government plan paid for by taxes. Benefits would be comprehensive, and everybody would be covered, but the potential cost could range from $30 trillion to $40 trillion over 10 years. It would be unlawful for private insurers or employers to offer coverage for benefits provided under the government plan.

“If you want stability in the health care system, if you want a system which gives you freedom of choice with regard to doctor or hospital, which is a system which will not bankrupt you, the answer is to get rid of the profiteering of the drug companies and the insurance companies,” said Sanders, a Vermont senator.

BUILDING ON OBAMACARE

On the other end is the Biden plan, which would boost the Affordable Care Act and create a new public option enabling people to buy subsidized government coverage.

“The way to build this and get to it immediately is to build on Obamacare,” he said.

The plan wouldn’t cover everyone, but the Biden campaign says it would reach 97% of the population, up from about 90% currently. The campaign says it would cost $750 billion over 10 years. Biden would leave employer insurance largely untouched.

Other moderate candidates take similar approaches. For example, Colorado Sen. Michael Bennet’s plan is built on a Medicare buy-in initially available in areas that have a shortage of insurers or high costs.

THE NEW ENTRANT

The Harris plan is the new entrant, a version of Medicare for All that preserves a role for private plans closely regulated by the government and allows employers to sponsor such plans. The campaign says it would cover everybody. The total cost is uncertain, but Harris says she would not raise taxes on households making less than $100,000.

“It’s time that we separate employers from the kind of health care people get. And under my plan, we do that,” Harris said.

Harris’ plan might well reduce employer coverage, while Sanders’ plan would replace it. Either would be a momentous change.

Job-based coverage took hold during the World War II years, when the government encouraged employers and unions to settle on health care benefits instead of wage increases that could feed inflation. According to the Congressional Budget Office, employers currently cover about 160 million people under age 65 — or about half the population.

A poll this week from the nonpartisan Kaiser Family Foundation underscored the popularity of employer coverage. Among people 18-64 with workplace plans, 86% rated their coverage as good or excellent.

Republicans already have felt the backlash from trying to tamper with employer coverage.

As the GOP presidential nominee in 2008, the Arizona Sen. John McCain proposed replacing the long-standing tax-free status of employer health care with a tax credit that came with some limits. McCain’s goal was to cut spending and expand access. But Democrats slammed it as a tax on health insurance, and it contributed to McCain’s defeat by Barack Obama.

“The potential to change employer-sponsored insurance in any way was viewed extremely negatively by the public,” said economist Douglas Holtz-Eakin, who served as McCain’s policy director. “That is the Achilles’ heel of Medicare for All — no question about it.”

These Are the Health-Care Questions That Matter Most

Max Nisen then noted that Health care got headline billing at both of this week’s second round of Democratic presidential debates. Unfortunately for voters, neither was very illuminating.

The biggest culprit was the format. Jumping between 10 candidates every 30 seconds made any substantive debate and discussion impossible. The moderators also deserve blame; they asked myopic questions intended to provoke conflict instead of getting any new information. And the candidates didn’t exactly help; there was a lot of sniping and not a lot of clear explanation of what they wanted to do.

The next debates may well be an improvement, as a more stringent cutoff should help to narrow the field and give candidates added time to engage in thoughtful discourse. Regardless, here are the issues that matter, and should be at the heart of any discussion:

The issue of how candidates would propose paying for their various health-care plans has been framed in the debates by the question, “Will you raise middle-class taxes?” That’s a limited and unhelpful approach. Raising taxes shouldn’t be a yes or no question; it’s a trade-off. Americans already pay a lot for health care in the form of premiums, deductibles, co-payments, and doctor’s bills. Why is that regressive system, which rations care by income, different or better than a more progressive tax?  Insurer and drug maker profits, both of which got airtime at the debates, are only a part of the problem when it comes to America’s high health costs.  The disproportionately high prices Americans pay for care are a bigger issue. What we pay hospitals and doctors, and how we can bring those costs down, are crucial issues that the candidates have barely discussed. What’s their plan there? The first round of debates saw the moderators ask candidates to raise their hands if they would eliminate private health coverage. Round two did essentially the same thing without the roll call. The idea of wiping out private insurance seems to be a flashpoint, but there doesn’t seem to be as much interest in questioning the merits of the current, mostly employer-based system. It’s no utopia. Americans unwillingly lose or change employer coverage all the time, and our fragmented system does an awful job of keeping costs down. People who support eliminating or substantially reducing the role of private coverage deserve scrutiny, but so do those who want to retain it. What’s so great about the status quo?

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As the field narrows, voters need specifics. A chunk of the field has been remarkably vague. Answers to these questions could offer some clarity:

For Senator Elizabeth Warren: Are there any differences between your vision of “Medicare for All” and Senator Bernie Sanders’s? There’s wiggle room here; his plan is more expansive (and expensive) than single-payer systems in countries like Canada.  For Senator Kamala Harris: What will your plan cover and how much will it cost? The skeletal outline of Harris’s plan lacks details on premiums and what patients would have to pay for out of pocket. She didn’t clarify matters at the debate.  For former Vice President Joe Biden: Will people with access to employer insurance be eligible for subsidies in your public option plan? If the answer is no or restrictive, his public option could have a relatively limited impact. It the answer is yes, his $750 billion cost estimate should head to the dustbin.  For the morass of candidates who pay lip service to Medicare for All but want to keep private insurance but don’t have a specific plan: What exactly do you want?

Health care is the most important issue for Democrats, according to polling. We need to find a way to have a discussion that does it justice.

Democrats’ Health-Care Feud Eclipses Message That Won in 2018

So, what have we learned from these debates? John Tozl realizes that in the four evenings of Democratic presidential debates since June, one phrase appeared for the first time on Wednesday: “pre-existing conditions.”

New Jersey Senator Cory Booker uttered it in his remarks on health care, chiding fellow Democrats for their infighting as Republicans wage a legal battle to undo the Affordable Care Act, which prohibits insurers from charging people more for being sick.

“The person who is enjoying this debate the most tonight is Donald Trump,” he said. “There is a court case working through the system that’s going to gut the Affordable Care Act and actually gut protections on pre-existing conditions,” Booker said, citing litigation in which the Trump administration and Republican-controlled states seeking to strike down Obamacare.

Over two nights this week, the 20 candidates spent at least an hour fiercely arguing over health-care plans, most of which are significantly more expansive than what the party enacted a decade ago in the Affordable Care Act. It’s a sign of how important the issue will be in the bid to unseat Trump, and how the party’s position has shifted leftward.

In November, Democrats won control of the House on the strength of their message to protect people with pre-existing conditions. That provision, a fundamental change to America’s private insurance market, is central to the ACA, the party’s most significant domestic policy achievement in a generation.

Booker’s attempt to unify his fractious colleagues against their common opponent stood out, because most of the discussion of health care, which kicked off the debate as it did on Tuesday, but the party’s divisions into sharp focus.

Biden v. Harris

Senator Kamala Harris of California and former Vice President Joe Biden tried to discredit each other’s proposals. Biden says he wants to build on the Affordable Care Act while expanding access to health insurance through a public insurance option.

Harris, in a plan, unveiled this week, likewise favors a public option but wants to sever the link between employment and health insurance, allowing people instead to buy into public or private versions of Medicare, the federal health-care program for seniors.

Harris took Biden to task over a plan that fails to insure everyone, saying his plan would leave 10 million people without insurance.

“For a Democrat to be running for president in America with a plan that does not cover everyone, I think is without excuse,” she said.

Biden accused Harris of having had “several plans so far” and called her proposal a budget-buster that would kick people off health plans they like.

“You can’t beat President Trump with double-talk on this plan,” he said.

Other candidates split along similar lines, with Colorado Senator Michael Bennet saying Harris’s proposal “bans employer-based insurance and taxes the middle class to the tune of $30 trillion.”

New York Mayor Bill de Blasio argued for a more sweeping approach, like the Medicare for All policies embraced by Senators Bernie Sanders and Elizabeth Warren.

“I don’t understand why Democrats on this stage are fear-mongering about universal health care,” he said. “Why are we not going to be the party that does something bold, that says we don’t need to depend on private insurance?”

How Bold?

The question any candidate will eventually have to answer is how bold a plan they believe voters in a general election want.

In 2018, Democrats running for Congress attacked Republicans for trying to repeal the ACA and then, when that failed, asking courts to find it unconstitutional. Scrapping the law would mean about 20 million people lose health insurance.

About two-thirds of the public, including half of Republicans, say preserving protections for people with pre-existing conditions is important, according to polls by the Kaiser Family Foundation, a nonprofit health research group.

More than a quarter of adults under 65 have pre-existing conditions, Kaiser estimates.

But that message has been mostly absent from the primary debates, where health-care talk highlights the divisions between the party’s progressive left-wing and its more moderate center.

Warren and Sanders weren’t on stage Wednesday, but their presence was looming. They’re both leading candidates and have deeply embraced Medicare for All plans that replace private insurance with a government plan. Bernie is an idiot, especially in his come back that he knows about Medicare for All since he wrote the bill. He has no idea of the far-reaching effect of Medicare for all. Our practice just reviewed our payments from Medicare over the last few years as well as the continued discounts that are applied to our services and noted that if we had to count on Medicare as our only health care payer that we as well as many rural hospitals would go out of business.

I refer you all back to John Delaney’s responses to the Medicare for All discussion. In the middle of a vigorous argument over Medicare for All during the Democratic debate tonight, former Representative John Delaney pointed out the reason he doesn’t support moving all Americans onto Medicare: It generally pays doctors and hospitals less than private-insurance companies do.

Because of that, some have predicted that if private insurance ends, and Medicare for All becomes the law of the land, many hospitals will close, because they simply won’t be able to afford to stay open at Medicare’s rates. Fact-checkers have pointed out that while some hospitals would do worse under Medicare for All, some would do better. But Delaney insisted tonight that all the hospital administrators he’s spoken with have said they would close if they were paid at the Medicare rate for every bill.

Whichever candidate emerges from the primary will have to take their health plans not just to fervent Democrats, but to a general electorate as well.

More on Medicare

If you remember from last week I reviewed the inability of our federal designers to accurately estimate the cost of the Medicare program and the redesign expanding the Medicaid programs mandating the states expand their Medicaid programs to provide comprehensive coverage for all the medically needy by 1977.

The additional provision of the 1972 legislation was the establishment of the Professional Standards Review Organizations (PSROs), whose function it was to assume responsibility for monitoring the costs, degree of utilization, and quality of care of medical services offered under Medicare and Medicaid. It was hoped that these PSROs would compel hospitals to act more efficiently. In keeping with this set of goals, in 1974 a reimbursement cap was instituted that limited hospitals from charging more than 120 percent of the mean of routine costs in effect in similar facilities, a limit eventually reduced to 112 percent named as Section 223 limits. But despite these attempts at holding down costs, they continued to escalate inasmuch as hospitals were still reimbursed on the basis of their expenses and the caps that were instituted applied only to room and board and not to ancillary services, which remained unregulated.

Now think about the same happening on a bigger scale with the proposed Medicare for All. Those that are proposing this “Grand Plan” need to understand the complexities issues, which need to be considered before touting the superiority of such a plan. Otherwise, the plan will fail!! Stop your sputtering arrogance Bernie, Kamala, and Elizabeth, etc. Get real and do you research, your homework before you yell and scream!!!!!!

More to Come!

Kamala Harris Says ‘Medicare for All’ Wouldn’t End Private Insurance. It Would! and More on Healthcare and the Democratic Debate!

harris314Sahil Kapur reported that Kamala Harris says she supports “Medicare for All,” and she has cosponsored legislation with Bernie Sanders. But unlike her Democratic presidential rival, she says the plan wouldn’t end private insurance.

That’s misleading. The measure would outlaw all private insurance for medically necessary services but allow a sliver to remain for supplemental coverage. It would force the roughly 150 million Americans who are insured through their employer to switch to a government-run program.

Harris is trying to find a narrow path between two competing constituencies in the Democratic Party. On one side are progressives who passionately support so-called single payer insurance and are pushing the party to the left. On the other is the party establishment, which believes that calling for an end to private insurance for millions would be political suicide against President Donald Trump in 2020.

Her attempts to please both camps could become a vulnerability for a campaign that is surging after a strong performance in last week’s debates, though allies say her rhetoric about a role for private insurance would be more politically viable in a general election.

Misunderstood Question

The issue has tripped up the California senator almost from the moment she began her candidacy. During the debates in Miami last week, Harris and Sanders raised their hands when NBC’s Lester Holt asked which candidates would “abolish their private health insurance in favor of a government-run plan.” She retreated the next day, saying she thought Holt was referring to her personal insurance plan and answered “no” when asked if private coverage insurance should end.

She ran into a similar problem in January, when her campaign walked back a comment she made at a CNN town hall calling for getting “rid of” private insurance structures.

Larry Levitt, a health policy expert at the nonpartisan Kaiser Family Foundation, said the intent of the Sanders bill is clear.

“As a practical matter, Senator Sanders’ Medicare for all bill would mean the end of private health insurance,” he said. “Employer health benefits would no longer exist, and private insurance would be prohibited from duplicating the coverage under Medicare.”

Splitting Hairs

Sanders last week criticized Harris for splitting hairs, without mentioning her by name.

“If you support Medicare for All, you have to be willing to end the greed of the health insurance and pharmaceutical industries,” he said. “That means boldly transforming our dysfunctional system by ending the use of private health insurance, except to cover non-essential care like cosmetic surgeries.”

In an email, Harris spokesman Ian Sams responded: “Kamala’s position is and has always been every American would get insurance through the single payer plan, and private insurance would exist to cover anything supplemental, as is expressly outlined in the Medicare for All bill. Seems like Bernie is saying that, too.”

Other 2020 candidates — Elizabeth Warren, Cory Booker, and Kirsten Gillibrand — also cosponsored Sanders’s bill.

‘I’m With Bernie’

Warren has given a far more direct endorsement than Harris of the idea of eliminating private insurance.

“I’m with Bernie on Medicare for All,” she said on the first night of the Democratic debates. “There are a lot of politicians who say, oh, it’s just not possible, we just can’t do it, have a lot of political reasons for this. What they’re really telling you is they just won’t fight for it.”

At the other end of the spectrum is former Vice President Joe Biden, who said he wants to build on Obamacare by adding a government-run plan to the menu of options, a provision that progressives tried and failed to add in 2009 amid opposition from centrist Democrats.

“Everyone, whether they have private insurance or employer insurance and no insurance, they, in fact, can buy in the exchange to a Medicare-like plan,” Biden said in the debate.

Hedging her position, Harris has also cosponsored “Medicare X” legislation by Senator Michael Bennet of Colorado, another Democratic presidential candidate who’s running as a moderate. That measure would preserve private coverage while allowing Americans to buy into a government-run plan. But she said Friday on MSNBC she favors single payer with only supplemental private insurance.

An issue that united the party in 2018 has the potential to fracture it in 2020.

Abby Goodnough and Thomas Kaplan reported on the Democratic party debate and that It was a command as much as a question, intended to put an end to months of equivocating and obfuscating on the issue: Which of the Democratic presidential candidates on the debate stage supported abolishing private health insurance in favor of a single government-run plan? Show of hands, please.

Just four arms went up over the two nights — Senator Elizabeth Warren of Massachusetts and Mayor Bill de Blasio of New York on Wednesday, and Senators Bernie Sanders of Vermont and Kamala Harris of California on Thursday — even though five candidates who kept their hands at their sides have signed onto bills in Congress that would do exactly that.

And after the debate, Ms. Harris said that she had misunderstood the question, suggesting she had not meant to raise her hand either.

The response and ensuing confusion reflected one of the deepest fault lines among Democrats heading into 2020 — on an issue the party hopes to use as a cudgel against President Trump as effectively as it did last fall when their vow to protect the Affordable Care Act helped them recapture the House.

Though Democrats owned the health care issue in 2018, pointing a way forward — tear up the current system and start over or build on gains in coverage and care that the Obama health law achieved — is proving tricky for the party’s presidential candidates.

The challenge is to avoid alienating both the progressives, whose support they will need in the primary and the more moderate voters, without whom they cannot survive the general election.

We surveyed all the candidates for details of their positions on health care. Here’s what they said:

‘Medicare for All’ vs. ‘Public Option’: The 2020 Field Is Split, Our

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In shooting up her hand and saying, “I’m with Bernie,” Ms. Warren seemed to have made the calculation that proving herself as unequivocal as Mr. Sanders in the quest for universal government-run health insurance was crucial to building the left-wing support she needs, including from some of his loyalists.

During the early months of the Democratic primary race, Ms. Warren has gained attention with her steady stream of detailed policy plans on a variety of subjects. But before Wednesday’s debate, she had been less than crystal clear about how she would expand access to health care— and particularly on the role, that private insurers should play under the type of Medicare-for-all system that she is calling for.

“I think lots of progressives were very happy to see her clarify her position,” said Waleed Shahid, the communications director for Justice Democrats, a group that seeks to elect progressive House candidates.

Ms. Harris had more overtly waffled on the future of private insurance before the debates, yet raised her hand just as quickly as Mr. Sanders when one of the moderators asked who favored abolishing it.

After the debate, she immediately walked it back, saying she understood the question to be asking whether she would give up her own private insurance.

Asked point-blank on MSNBC’s “Morning Joe” on Friday morning whether she believed that private insurance should be eliminated in the United States, Ms. Harris responded, “No.”

“I am a proponent of ‘Medicare for all,’” she said. “Private insurance will exist for supplemental coverage.” Mr. Sanders’s Medicare for All Act, which she co-sponsored, would allow private coverage for elective procedures, like cosmetic surgery, not covered by the government plan.

John Delaney, a former Maryland congressman who is also seeking the Democratic presidential nomination, is taking every possible opportunity to warn that the party is at risk of turning health care from a winning issue into a liability.

“We won on health care in 2018, and if we go down the path with Medicare for all, we’ll lose on it in 2020,” he said in an interview. “Right now, about half of our citizens have private insurance and most of them like it. And you just can’t win elections on taking something away from the American people that they like. It’s just not common sense.”

Ironically, support for universal government-run health insurance could provoke the same counterattack from Republicans that the Democrats used so potently after the Trump administration tried to repeal and replace the Affordable Care Act.

“Trump and the Republicans will spend a billion dollars telling the American people that the Democrats want to take away your health insurance,” Mr. Delaney said, “and he would be correct.”

Mr. Trump appears to be adopting just such a strategy. In a recent Rose Garden appearance, he warned that more than 120 Democrats had signed onto Medicare for all legislation — a “massive government takeover of health care,” as he put it — that would expand Medicare to cover all Americans, make the program’s benefits more generous and eliminate most deductibles and co-payments.

“That’s going to hurt a lot of people,” Mr. Trump said. “Their plan would eliminate Medicare as we know it and terminate the private health insurance of 180 million Americans.”

Remaining imprecise on the issue could have been a vulnerability for Ms. Warren in particular as she tries to compete with Mr. Sanders. “Elizabeth Warren Has a Plan for Everything — Except Health Care,” read the headline of a recent article published by Jacobin, the socialist magazine.

But her outright call for eliminating private coverage would create new risks if she were to become the Democratic nominee.

“She didn’t have to fall into that trap,” said Paul Starr, a professor of sociology and public affairs at Princeton who was a health policy adviser in the Clinton White House.

Not only would abolishing private insurance disrupt coverage for many people who are satisfied with their private coverage, Mr. Starr said, but generating the revenue needed to finance a single-payer health care system “would be just an overwhelming political task.”

“If in coming weeks and months it’s that raising of the hand that gets replayed again and again, then I think it’s going to damage her,” he said.

With Mr. Trump and his surrogates likely to step up their attack in the coming months, it was not particularly surprising to hear most of the Democrats walk a more cautious line — even the ones who have co-sponsored Mr. Sanders’s single-payer bill or a House version that would, in fact, put everyone into government-run coverage, including Senator Cory Booker of New Jersey, Senator Kirsten Gillibrand of New York and Representative Tulsi Gabbard of Hawaii.

All three were more vague when questioned about eliminating private insurance. Mr. Booker said he favored keeping it but did not explain why and Ms. Gabbard said merely that it deserved “some form of a role.”

Many candidates — including some who say their ultimate goal is a government-run system — support a system in which people would have the option to buy into Medicare or a similar public insurance program, but private insurers could still compete for their business.

Ms. Gillibrand was eager to point out that she had written the portion of the Sanders bill allowing four years for Americans to transition to their new government coverage by providing such a choice.

“I believe we need to get to universal health care as a right and not a privilege — to single-payer,” Ms. Gillibrand said. “The quickest way you get there is you create competition with the insurers. God bless the insurers. If they want to compete, they can certainly try.”

More likely, though, she contended, is that “people will choose Medicare, you will transition, we will get to Medicare for all.”

The hesitancy to fully embrace the abolition of private insurance isn’t surprising considering the polling on the issue, which has consistently found that support for Medicare for all drops off quickly when voters are told it would eliminate their private, employer-provided plans and most likely raise taxes.

The poll results also help explain why so many candidates — including former Vice President Joseph R. Biden Jr., Senator Michael Bennet of Colorado, Mayor Pete Buttigieg of South Bend, Ind., Gov. Jay Inslee of Washington, Senator Amy Klobuchar of Minnesota and former Representative Beto O’Rourke of Texas — say they would keep private insurance but add a “public option” to buy coverage in a government-run health plan that would create competition and potentially drive down prices.

Some candidates support bills that would allow people who do not get insurance through a job, or those 50 and older, to pay a premium to buy a Medicare plan that would be the same as what is now available to people 65 and older. Others prefer the idea of setting up a new public plan, run by the government, that anyone could buy — a “Medicare-for-all-who-want-it” approach.

Mr. Buttigieg used that very phrase on Thursday and suggested he was fine with keeping private insurance for everything but the most basic care.

“Let’s remember,” he said, “even in countries that have outright socialized medicine — like England — even there, there’s still a private sector. That’s fine. It’s just that for our primary care, we can’t be relying on the tender mercies of the corporate system.”

Mr. Biden noted that creating a public option to compete with private insurance could be done much quicker than a complete overhaul of the health care system.

“Urgency matters,” Mr. Biden said, referring to people like his son Beau, who died of brain cancer in 2015. “We must move now.”

How might Medicare for All reshape health care in the U.S.?

As the Democrats pummel us all with their various forms of a single-payer, Medicare for All, healthcare systems, Sharita Forrest noted that a recent Kaiser Family Foundation poll indicates that support for a single-payer health system is increasing among American consumers, but many people are confused about how a program like “Medicare for All” would actually affect them. University of Illinois professor emeritus of community health Thomas W. O”Rourke, an expert on health policy analysis, spoke with News Bureau research editor Sharita Forrest.

How might a single-payer system such as Medicare for All differ from what we have now?

Under a true single-payer program, coverage would be universal, with every resident covered from birth to death. Health care would become a public service funded through taxes, much like the public schools, the fire department and the military.

It would detach health care from employment. Most Americans receive private health insurance under a shared-cost arrangement with their employers or through Medicare. If you lose or change your job, you may lose your insurance and access to care unless you can pay the full cost yourself.

Coverage would be portable and accessible across the country, without geographical, economic or bureaucratic obstacles such as narrow provider networks.

Various politicians are proposing different types of health care programs. What are the key differences to watch for?

Many politicians and think tanks have proposed plans that are not actual single-payer plans but have similar-sounding names such as “Medicare Extra.”

The key questions to ask are: Who is covered? What benefits are included? How is it funded? Who pays? And what are the roles of the government and the private sector in controlling and managing costs?

A true single-payer plan:

  • Provides universal coverage for everyone.
  • Covers all medically necessary care—including inpatient and outpatient services, drugs, mental health, reproductive health, dental, vision, and long-term care—and virtually every provider is in the network.
  • Covers 100 percent of costs without premiums, copays or deductibles.
  • Maximizes administrative efficiencies and exerts cost-control measures such as global budgeting for hospitals, negotiated fee schedules, and drug prices, and bulk purchasing of drugs and other supplies.
  • Is nonprofit and does not include a role for private health insurance except that private insurers could offer supplemental plans that pay for extras like cosmetic surgery that aren’t covered by the government plan.

What would the federal government’s role be in a single-payer system?

The government would finance the system, but, importantly, not own or operate it. It would be publicly funded but privately operated.

There are many options for funding it, including payroll taxes, taxes on Wall Street trades, increased taxes on high-income earners or taxes on investments and interest.

If the program followed other countries’ examples, it would reduce costs by consolidating administrative tasks and eliminating insurers’ profits. Because there would be one payer instead of multiple payers with thousands of plans, the government could leverage its purchasing power to exert cost controls that currently don’t exist.

Critics argue that a single-payer program would end up costing consumers more. Can such comprehensive care be provided without burdensome tax hikes?

It would require a modest tax increase, true, but eliminating health insurance premiums, copays, high out-of-pocket costs would offset that and runaway price increases. The taxes would be progressive, based on income. Therefore, many families would experience broader coverage with comparable or reduced expenditures.

Our current system wastes hundreds of billions of dollars annually, in part because providers have to deal with many different insurance carriers and bill each patient individually.

A 2003 study in the New England Journal of Medicine estimated that administrative costs are responsible for 31 percent of U.S. health care costs, compared with about 17 percent in Canada. Through simplified administration and greater efficiency, some researchers estimate that Medicare for All would save more than $500 billion a year.

According to a Commonwealth Fund report, the U.S. ranks last among 11 industrialized countries on health care quality, efficiency, access to care, equity and outcomes such as infant mortality and longevity.

If the U.S. were in the Health Olympics, we would never make it to the medal podiums.

By 2025, health care costs in the U.S. are expected to rise to one-fifth of our economy. Some people say we can’t afford to provide universal coverage when actually we can’t afford not to provide it.

Opponents deride single-payer plans as socialized medicine that facilitates greater government encroachment into their lives and deprives them of choice. Is that an accurate depiction?

Americans are concerned about affordability, access, and quality. They value their relationship with their clinicians, not their health insurance companies.

Currently, we have the illusion of choice. Our employers choose our health plan, and our insurance companies determine which providers we can see and when—unless we want to cover all of the costs ourselves.

Under a true Medicare for All program, choice and access would expand.

What are the main obstacles to implementing a single-payer system?

There seems to be a lack of public understanding. Health care is a complex topic, and there are so many different proposals and so much misinformation and disinformation. Expect much more in the months ahead.

Entrenched interests—including insurers, many health care providers, the pharmaceutical industry and medical device makers—don’t want to give up their profits. We’re already seeing the pushback in the media.

Many lawmakers aren’t going to get behind a single-payer plan until it’s politically expedient.

There was an interesting comment made this past week, President Trump can’t win the 2020 election but the Democratic Party policies will be responsible for their loss, where they reach into all of our pockets and pick every cent and dollar that we have earned. How true!!

Some more history regarding Medicare and now, Medicaid!

Title XIX: Medicaid. The 1965 legislation provided states a number of options regarding their level of participation in Medicaid, ranging from opting out of the program entirely to including all covered services for all eligible classes of persons. The federal government provided matching funds for two of the three groups stipulated in the legislation (the “categorically needy” and those “categorically linked,”) while in the case of the third group (“not categorically linked but medically indigent”) only administrative funds (and no medical expenses) were matched. Each state was required to include members of the first group, the categorically needy, in the medical care program acceptable to the Department of Health, Education, and Welfare, while the inclusion of the other groups was optional. Eligibility standards varied (and continued to vary) from state to state, depending on the state legislation. The three groups were:

  1. The Categorically Needy. This group included all persons receiving federally matching public welfare assistance, including Families and Dependent Children, the permanently and totally disabled, the blind, and the elderly whose resources fell below welfare-stipulated levels. The federal government matched state expenditures from 50 to 80 percent, depending on the state’s per capita income.
  2. The Categorically Linked. This class included persons who fell into one of the four federally assisted categories whose resources exceeded the ceiling for cash assistance. Should the state designate members of this class as medically indigent, benefits had to be extended to all four subgroups. The amount of federal matching funds was determined by the same formula as was used for the Categorically Needy.
  3. Not Categorically Linked but Medically Indigent. Members of this group could include those eligible for the statewide general assistance and those between the ages of twenty-one and sixty-five deemed medically indigent. State operating expenses were not matched by the federal government, who confined their grants to match the costs of administering the program if the benefits extended to members of this group were comparable to those provided to other groups.

Next, I will cover the benefits that the various states were required to provide recipients.

These all sound like great ideas unless one realizes the limitations of reimbursements to hospitals, physicians and other care givers.