Healthcare has claimed its prime spot in the great zodiac of policy issues in the 2020 Democratic presidential primary. As it should: Tens of thousands of Americans die a year from lack of health insurance, and in total, nearly half of American adults under 65 are either uninsured or underinsured, meaning they have insurance plans which don’t cover what they need at prices they can afford.
In the coming weeks, Rep. Pramila Jayapal (D-WA) is set to release a new “Medicare for All” bill. I’m generally inclined to distrust the policy gestures of elected officials, but I’ve read a detailed overview of the bill from Jayapal’s office and I’m happy to say that this bill is astonishingly strong, and should become the baseline for federal legislation toward single-payer healthcare. (I’ll discuss why in a minute.)
But Jayapal’s bill joins a crowded mess of at least eight other healthcare policies being bandied about among Democrats. I couldn’t fault anyone for getting confused when candidates talk about “Medicare for All,” or “Medicare Extra for All,” or “Medicare for America,” or the “public option.” The relatively simple problems of health finance have been made very complicated by people who make money off of healthcare. So what are all of the issues being discussed and what do they mean? What’s really “Medicare for All” and what’s not? How do existing bills stack up? And why does this matter?
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The problem of American health finance—not care, but finance—can be expressed in two complementary points:
- It is extremely profitable to charge a sick person as much as possible, so long as someone is footing the bill.
- It is not profitable to insure people who are sick or who are likely to become sick.
This is the way things work now. Hospitals, manufacturers, and their various middlemen jack up costs, while insurance companies demand massive public subsidies to keep them from jettisoning people who most need insurance. If insurers can’t get those subsidies, they increase your costs of purchasing and using your insurance plan to compensate for the jacked-up costs.
Staring down these problems are the corporate dorks and the feckless policy dweebs whose policy prescriptions, whose wildest visions, continually place corporations in charge of our healthcare, and ensure that American public money subsidizes them for failing at it. If you hear 2020 candidates talk about the rot of American healthcare, look out if they float a “pragmatic policy solution” or talk about plans named something like “Medicare Extra As A Service... For You!” (If they’re polite, perhaps they will at least say they support “Medicare for All” before announcing they’d be open to keeping the feet of private insurance companies on our throats).
These pathetic programs, which usually revolve around a “public option,” are what happens when politicians understand the need for a massive change but lack the moral imagination to do anything but genuflect to existing structures. They are, in reality, corporate bailout packages which do very little for you, but quite a bit for the Aetnas and the Sacklers and the Joe Manchins.
On the other hand, you have federal single-payer, often called “Medicare for All.” Healthcare plans in the single-payer mold pool all the money currently spent on healthcare to insure every person in America. By pooling this buying power into one giant public insurer (the single payer), “Medicare for All” has much more leverage to determine prices through negotiation. It can say, “oh, we’re only going to pay $200 for an MRI instead of $1,000; or, “our data shows that a knee replacement costs $15,000 to perform even though you bill five times that amount; take it or leave it,” and since it’s the only insurer in town, the hospital has to take it. This isn’t radical — virtually every other country with universal coverage has a form of aggressive rate-setting. (And it lets the hospital spend a lot less money on massive towers of billing staff.)
It’s cheaper, it’s nicer, it’s better, and it lets you go to the doctor without paying anything. Yet a lot of inadequate policies are attempting to crib the name—including, paradoxically, the one advanced by Bernie Sanders.
Fundamental Components of Single-Payer
“Medicare for All” is a misnomer. If anything, true single-payer would be a significant improvement and expansion of Medicare, which has all kinds of loopholes, exclusions, and out-of-pocket costs.
Here is what a health policy must have to truly be a “single-payer” or “Medicare for All” program.
A single, mandatory risk pool
At the core of single-payer is the promise to cover all care, for all people. This means that all are included—but nobody can take their contributions and go play ball elsewhere. This is what’s known as the “universal risk pool.”
A “risk pool” is the pooling together of many peoples’ insurance money. Not many people need very expensive healthcare at once—50% of healthcare spending comes from 5% of the population. Many people who need expensive healthcare will only need it for a short period of time (e.g. a car accident or hip surgery). As a result, the larger the risk pool grows, the more able it is to sustain itself (at a significant discount relative to our fragmented private-insurance model). If rich people or people who are currently not in need of healthcare are permitted to, say, take their contributions out of the risk pool and spend it on a private option, the risk pool weakens (and, in turn, becomes less able to negotiate lower prices).
South Africa is a good counterexample. There, citizens may withdraw from the public healthcare option and enroll in private insurance instead. As a result, one-sixth of the population—the privately insured—spends just under half of South Africa’s health expenditures. These people are disproportionately wealthy and white. Meanwhile, the public insurer can’t negotiate prices and covers a disproportionate amount of sick people. Private carveouts from the national risk pool has virtually reenacted healthcare apartheid in South Africa.
When people ask about the “future of private insurance alongside public healthcare,” they refer to a combination of three things:
- Duplicative basic insurance, which covers the core functions of healthcare, like primary care, the emergency department, or surgery;
- Supplementary insurance, which covers things not addressed by public insurance, like how pharmaceuticals are treated in some countries; and
- Complementary insurance, which offers bells and whistles on top of the public offering to make money off rich people who want luxury.
Duplicative products prompted the collapse of South African public insurance and are thus not permissible; the public option makes all current private insurance duplicative, and is therefore an lousy plan. An inadequately comprehensive public insurance model, which requires the existence of supplementary insurance, rations specialized care to those who have money, and is therefore unjust. The last option, complementary insurance, is also revolting to me (imagine The Wing but for one-person hospital rooms). I’m not sure to what extent it’s possible to prevent rich people from forming clubs to buy special rich-people things, but it is unacceptable to let that luxury spending be used to dilute or splinter the risk pool.
“All care for all people” must also mean “all care.” Whatever care a person needs—medical, dental, mental, vision, reproductive, long-term, and more—must be covered. Playing “catch-up” with other countries is not enough: we are capable of, and should, provide a higher standard of care than any currently-existing single-payer program on the globe. Generally, care eligibility is determined by “medical necessity,” because the health finance world lives in utmost terror of someone who gets recreational heart surgery. I don’t disagree with the rule, though I would add a specific pathway for people seeking trans healthcare, who would otherwise need a clinical diagnosis of some type of disorder to get the healthcare they need—a situation which results in some trans people dropping out of the healthcare system.
Worth special mention is the coverage of all elder care, long-term care (LTC), and home-and community-based services (HCBS). Long-term care affects most families in America: two-thirds of seniors will require some sort of living assistance, while people with disabilities often need help maneuvering around their homes and lives. The American system for dealing with this is utterly broken.
Medicare refuses to cover long-term care, and thus the problem is shunted to either private insurance or Medicaid. Private insurance often refuses to cover people who need long-term care, or covers them only at exorbitant rates—and unlike other preexisting conditions, the need for long-term care was virtually neglected by the Affordable Care Act. This leaves much of the work to savings accounts and Medicaid. But Medicaid isn’t great, either. Stay too long in a long-term care facility, for instance, and Medicaid can put a lien on your house—with interest. So funding long-term care in full lets families stay together and gives elders the care they need without shredding their savings or forcing their children to quit their jobs to take care of them.
Healthcare or assistance given to a person in their home—usually referred to as “home or community based services”—is equally essential. For people with disabilities, life without HCBS can be a dystopia of regulations and misery. If home health isn’t available from a state Medicaid program, people with disabilities are often removed from their homes and families and sent to die in structurally negligent nursing homes under the care of deeply overworked and underpaid caregivers privately contracted out to the state. And even if HCBS is offered, its means-testing restrictions can be brutal and oppressive. Disabled couples with too much money in the bank—$22,000 in New York, plus a max of $1,233 in monthly income—often need to spend down or divorce to qualify. In New Jersey, a person who needs home health is only eligible for the program if they have less than $2000 in the bank—and I’ve spoken with people who have a $2000-a-year income cap. (This also presumes the person receives as many caregiver hours as they need, which is not often the case).
LTC/HCBS are fundamental to healthcare—fundamental to the basic dignity of personhood, even—yet for some reason they have been bandied around as if they were auxiliary “maybe” components of various healthcare bills. This is utterly unacceptable. Meanwhile, the field is becoming increasingly corporatized. There will be 1.2 million home health aides by the year 2020, and in states like Iowa and Arkansas, where some state legislators literally work directly for nursing home companies, we’re seeing private long-term care providers (corporate nursing homes, basically, regardless of whether they’re ostensibly “non-profit”) receive sweetheart deals from state Medicaid programs—then turn around and slash care budgets, underpay staff, neglect and abuse their patients, and pocket the profit.
In America, you can build the most ghoulish, most cynical, most cold-bloodedly evil program imaginable, and get a government contract for it—so long as you only hurt disabled people or people in jail.
Standards, payment, and oversight at the federal level.
This one’s quick. The federal government must set minimum standards for care and guarantee prices and payment. When states can pick and choose what care they offer, their smaller budgets and inability to deficit spend gives them a financial incentive to cut costs and save money, and people die.
Local implementation and flexibility
That said, healthcare is local. Healthcare needs in Brooklyn, Boston, Birmingham, and Butte are all different from each other. Keeping the delivery of single-payer funding as close to the ground as possible lets it be more responsive to both the needs of the people and democratic pressure. Let a San Francisco health agency use funds to put people in homes; let a rural Iowan one spend on transport services to bring people in rural areas to their dialysis appointments.
There are many more things a single payer can do, or should do; or tools it can build for itself. But only a program with these basic principles qualifies as single-payer, or the “Medicare for All” name.
There are at least six bills with confusing names currently floating around Congress. Among them: Rep. Rosa DeLauro (D-CT) and Rep. Jan Schakowsky (D-IL)’s “Medicare for America Act”; Sen. Brian Schatz (D-HI) and Rep. Ben Ray Lujan (D-NM)’s Medicaid buy-in bill; plus policy guidelines from the Urban Institute (“Healthy America”) and the Center for American Progress (“Medicare Extra for All”). Just the other day, 368 members of Congress signed a letter sponsored by lobbyist group America’s Health Insurance Plans (AHIP) praising the Medicare Advantage plan, which opens the door to privatization of the system. Almost all of these plans are a variation on the public option and each one fails to meet the principles I’ve just laid out, since they ultimately they seek to sustain the private insurance market, which is like trying to dig your way out of quicksand with a bucket.
This leaves only two bills worth considering: Bernie Sanders’s “Medicare for All” bill in the Senate and Pramila Jayapal’s upcoming House version, The Medicare for All Act of 2019.
Bernie’s bill comes close, but it isn’t there yet. (I’ve said as much before.) It satisfies three of the four pillars of single-payer. What it lacks is comprehensive coverage. Specifically, Sanders has a lousy plan for elder and long-term care. His bill delegates long-term care to state Medicaid programs—the same process which currently results in the medieval policies causing all this abuse and misery. When insurance companies and other corporations build for-profit nursing homes and then win contracts to administer Medicaid, they just pack their halls with any available body, and reward local lawmakers handsomely for it. Just a few weeks ago, an ex-judge in Arkansas was caught accepting bribes from nursing home companies in a scheme directed by a former state representative. Meanwhile, in Kentucky, the former medical director of a nursing home is passing legislation intended to make it much harder for patients to sue nursing homes for malpractice. It is a perpetuation of barbarism, and it should be a simple fix, but Sanders and the other Senate Democrats haven’t flinched. Until they do, Sanders does not have a “Medicare for All” bill—he has a segregated healthcare bill which inflicts unnecessary and preventable harm on people with disabilities.
Jayapal’s bill, though, appears to meet all of the criteria for a proper single-payer plan. It includes long-term care with a preference toward home health. It sets guidelines for care but lets doctors overrule them. It is, by all accounts, the first actual robust single-payer bill of the post-ACA era. If you are looking for a bill to call “Medicare for All,” this is the one. It must not be permitted to be weakened.
The bill is not perfect. Early commentators fretted when they noticed it dropped a requirement for all providers to become not-for-profit companies in order to be eligible for single-payer payment. This is understandable—we want to “remove profit from healthcare,” after all—but less compelling to me, as “non-profit” is merely a tax designation. Non-profits like the $8 billion Cleveland Clinic, the 78-hospital Ascension health system, or the University of Pittsburgh Medical Center are all non-profits with incredible histories of grift and fraud—UPMC, to me, is best known for opening food banks for the employees it underpays.
A strong series of budgetary tools lets Jayapal’s single-payer program keep providers on a tight leash. One tool is global budgeting, or the advance determination of the national healthcare budget, which is used to set baseline budget agreements for the year and pay hospitals in guaranteed blanket sums based on expected activity. By saying, “last year you spent $2 million dollars, and we can pretty reasonably predict that this year you’ll need $2.1 million dollars for all your services,” the single payer can pay hospitals fairly while minimizing the hospital’s ability to rack up line items and gouge the government. Further tools include prohibitions on providers using single-payer payments for profit, union-busting, marketing, or federal campaign contributions. A single payer cannot remove profit from healthcare on its own (nor could an American NHS), but at least we can give it the muscle to spar with its worst monsters on equal footing.
If the program has all this power to determine how money can be used, I think it should go further in determining how funds for long-term care can and cannot be used—perhaps to guarantee a minimum hourly wage for long-term-care caregivers, alongside increased standards and oversight of LTC services.
Jayapal (and Sanders) also currently leave the Indian Health Service (IHS) alone, though the current IHS funding model is disastrous. The amount spent per-capita for Natives is a third of that spent nationally. This isn’t because Native people have three times better health factors and health outcomes: men on the Sioux Rosebud reservation in South Dakota have a life expectancy of 47 years. Several factors drive this inequity:
- IHS funding is dispensed as a fixed amount of money on a predetermined schedule, and is not updated for inflation or cost increases.
- IHS hospitals in rural areas often need to contract with private providers for services outside their capabilities, which come at exorbitant rates and receive inadequate Medicare funding.
Removing the block and comprehensively overhauling the IHS budget and permissions would be cheap and relatively simple and should be included in any Medicare for All bill. Next to prisoners, it is hard to imagine a part of the American population so explicitly wounded by racial and economic segregation in healthcare. We must reverse the gears of this misery.
Beyond the Bill
But no bill, including Jayapal’s, is enough. No bill, on its own, could be enough.
For the past hundred years, every time the insiders—the well-meaning senators, the well-meaning policy writers, the well-meaning union or nonprofit leaders—have taken on the insurance industry, they’ve written a bill and waved it around and tried to gin up support among the grassroots. And then they were beaten by a reactionary establishment that is capable of outmaneuvering, outfoxing, and outgunning health reform. They lost in the ‘40s, they lost in the ‘60s, they lost in the ‘70s, they lost a few times in the ‘90s, and they lost in the 2000s.
But when these well-meaning people lose, it is not the senators or union leaders or policy thinkers who find their suffering compounded. It is the people in who live Section 8 housing; the people in prison; people whose backyards are dumping grounds for toxic waste; people with disabilities forced out of their homes; poor mothers and poor children; the people who have been denied work, care, or dignity.
The policy wonks maintain a fantasy that they are important. They rub a little lucky charm and believe their big brains and their tools and their toolkits are where laws come from. They are wrong. They have tragically misunderstood the rules of the game. There is nothing in their power which can comprehend an opposition willing to block popular laws and popular decisions; willing to go nuclear in fights over health and well-being; willing to stampede off a cliff to serve the narrow interests of wealth. They are impotent.
And thus the wonks, even the really nice ones, are not enough. Bills, even the really nice ones, are not enough. Even a socialist president is incapable of passing single-payer by him or herself. When Jayapal’s bill—our first, best articulation of single-payer—or anything like it is passed, it will be on the backs of a massive popular movement. Policy people like to say that you pass a bill, and then you hold politicians’ feet to the fire. Sure. But first, you must build the fire.
What is the reason that the Disability Integration Act (DIA), which lets people with disabilities receive long-term care at home, exists? Not the spontaneous kindness of co-sponsor Chuck Schumer. It was the constant work of popular activist groups like ADAPT, who wrote the bill—and whom you might remember for saving Medicaid for the rest of us during the ACA repeal debates—or hero activist Ady Barkan. They pushed, they pulled, they called, they screamed, they showed up with a list of demands, and they got a bill. (Why did it stall in the House and the Senate despite bipartisan support? Because temporarily able-bodied people haven’t shown up yet).
Why is Medicaid expansion going to happen in Maine? The Maine People’s Alliance launched a massive statewide campaign for minimum wage increases, won, then turned its supporters out to expand Medicaid as a ballot measure—and then to crush its ruling GOP party, infamous for its disembowelment of Maine’s welfare programs, when it actively refused to comply. Their example gives hope to the people of Utah, who are watching their own successful Medicaid expansion vote be overruled by craven elected officials pushing a partial and punitive measure.
Why is Medicaid expansion going to happen in Idaho? Because of Reclaim Idaho, a grassroots popular movement which started out winning school financing in its’ founders tiny ski town. It grew by driving all over the state in a big green RV and getting Medicaid expansion on the ballot, which it won in 35 of 44 counties for a final vote of 62% in favor—despite no visible “blue wave” in the state. Every attempt to block the movement has failed, most recently a court case. What will happen in Idaho when Medicaid is expanded? Whatever the people who make up Reclaim Idaho decide they want to win next.
This is how you build the fire. These popular movements which win material gains are the components of a giant, searing flame in which politicians will be incinerated, while new and more fearful ones line up behind them, to fill the void from among us. There will be no singular popular vertical campaign that wins Jayapal’s bill or any other future bill toward single-payer, or for health justice beyond it. When it is won, it will be won by a patchwork of smaller movements: of local efforts to win power, which thread together in a great tapestry.
This is something the wonk envies, fears, and cannot understand. This is power.
Disclosure: the author works in the insurance industry. His views are his own and not those of his employer.