What 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?

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!