More On the Real Reason Healthcare Insurance Companies Are Now Encouraging Obamacare Enrollment
In light of some of the comments to my post yesterday arguing that that the real reason that healthcare insurance companies are now madly encouraging Obamacare enrollment is fear of a pro-public-option or pro-single-payer political juggernaut, I want to make clear that by single-payer I do not mean Medicare-for-all. Single-payer would be, in essence, “the public option” extended to everyone rather than limited to the 5% of Americans who have private healthcare insurance through the non-group (i.e., non-employer-provided) market. It is not tax-funded identical-for-all healthcare insurance, which is what Medicare is. I do think that eventually this country will have Medicare-for-all-type healthcare insurance, but not in the near term. If single-payer works well, then of course that would be the longterm solution, with no need for Medicare-for-all.
I also want to make a point about federalism as it relates to the ACA insurance-market exchanges and, especially, to Medicaid and, for that matter, to any other federal social-safety-network program. I said in my post yesterday what I think is obvious: that federalism has been a disaster for Obamacare. But I want to point out that the only reason that Medicaid works under current pre-Obamacare Medicaid is that that program came into being and was effectuated before the hard-right turn of the Republican Party. Ditto for food stamps. The really weird, but successful, argument by rightwing governors and state attorneys general to the Supreme Court in the ACA litigation on the Medicaid-expansion provision in the ACA is that, well, y’know, now that traditional Medicaid has been a part of each state’s law for decades, and is popular, it would be politically impossible for state legislators to end that program–the result under the ACA as the statute was written, if a state refused to agree to the ACA Medicaid expansion. This, they argued–successfully!–meant that the ACA was effectively coercive of state legislators and therefore infringed upon state sovereignty. On that “ground,” the Supreme Court struck down that part of the Medicaid portion of the ACA.
That’s also known as the conservatives-having-their-cake-and-eating-it-to theory of constitutional law. The argument was so deeply hubristic that its actual success is stunning and outrageous. But I have no idea why anyone would think that federalism must be a part of a national healthcare insurance law. It does not.
As for whether or not the public will catch on that the main problems with the Obamacare-exchanges-and-private-policies part of the Act is a failure of the healthcare insurance market and of the healthcare market itself–a question that several commenters raised–well, that was what my post was about. Yes, the public will catch on, once the Dems have a smart, committed, knowledgeable and articulate spokesperson with a high enough national profile to educate them about it. I expect that that will happen fairly soon.
Finally, although this should be the subject of a separate post, a hallmark of the current Supreme Court is how many really weird, outlandish rightwing arguments the current conservative-legal-movement five-member majority have made the law of the 50-state-soverign-lands. As I said in an ignored post here last weekend, the Court’s neo-federalism-on-steroids jurisprudence has quietly but profoundly and thoroughly upended federal-in-relation-to-state constitutional law as it had existed since the post-Civil War era. This is a deeply dangerous juggernaut.
I wish more readers would read that post. It does deal with really important stuff. Honestly.
The real reason for the ACA signup push? Adverse selection.
Important stuff, yes, but … I followed the 2000 Bush v. Gore proceedings closely, starting with the local judge who ruled based on an obsolete standard. It seemed to me that every step of the way, from court to court, rulings were predictable solely from the known political leanings of the judges involved, and supported by “reasoning” which seemed specious. (A violation of Bush’s rights to have a recount since it might do irreparable harm to his campaign?) That standard has held up pretty well ever since. So until we have reliable lie-detectors and objective artificial-intelligences as judges I don’t feel I have much to gain by dwelling on the minutia of judicial decisions. It is good that some do, though, so thanks.
Bev, I’m not following you on your idea of single payer vs public option vs medicare for all?
As to Medicaid. You are saying that they argued accepting the expansion dollar would have denied the states “freedom” to end Medicaid if they wanted too at sometime in the future (reason for the ending to be determined). What does popularity have to do with their argument?
And I did read your other post. It’s just that what do you say? I mean I’ve known for a while that the 5 supremely right all the time court is a personality of projection. The do as I say not as I do so don’t legislate from the bench thus being judicially activist. These are young judges. They ain’t going now where for a long time and no dem has the balls to consider judicial impeachment. Though if would make for wonderful story lines and plots for a long time. Talk about news as entertainment.
I mean, wouldn’t that be an act of turning the sword back on the aggressor. They impeach a president, we go after your judges.
Some day when I’m king…..
Yeah, I was somewhat surprised to see after I posted this post this afternoon that Paul Krugman thinks of single-payer as Medicare-for-all. But then I realized that until the “public option” was considered during the drafting and redrafting of the ACA, single-payer did mean Medicare-for-all. But now, I think there are two possible types of single-payer: one, funded from an additional FICA tax or from the general tax fund paid for through higher graduated income taxes (Medicare for all), and another one, which would be basically the “public option” proposed for the ACA, except that unlike that “public option,” this one would be available to everyone. The proposed “public option” under the ACA would have been available only to people who have no access to group insurance plans. It would have competed with the private-insurance plans on the exchanges. People would have been able to choose from options offered through this public-option insurance system, and then would pay directly for the policy, with or without subsidies, just like they are doing through the private-market exchanges.
As for the Medicaid issue, the popularity-of-Medicaid-would-force-state-pols-to-agree-to-the-ACA-expansion-in-order-to-be-able-to-keep-Medicaid-and-therefore-were-being-coerced-to-agree-to-the-Medicaid-expansion-and-violate-their-state’s-sovereignty claim is every bit as bizarre and outrageous as it sounds. But, yes, that was the argument, and, yes, it worked.
Just a (non-thought out) angle for the future: when it comes time to switch to single payer, maybe we could back into it with Medicaid for everyone first. Medicaid could fill in the 20% missing from Medicare for instance (as it does now only for low incomes). I can’t really make up a list.
Next, move Medicaid under federal from state. Now, we would have everyone on the list and hooked up to the central system.
Medicare for everyone will have to pay a lot more than it does now. Right now Medicare patients are like the last empty seats on the airliner — can only take the cheap prices because others paid more.
Medicare pays embarrassingly little. The surgeon who did my hernia got $500 for opening up my internal organs and the anesthesiologist got $200. The dentist charges $1400 to do a root canal in a barber’s chair. [I have noticed dentists’ prices almost doubled in real terms since about 1995 though they are doing nothing new — perhaps they see medical insurance double and figure they can double too and nobody will notice.]
Doctors earnings are only 10% of medical costs; least of all need to soak them. More generally, if people want lower medical insurance sell them a policy that doesn’t cover any procedures available after the year 2000. Medical climbs ahead of inflation because you are getting more — put off the updated kitchen and save your life.
I had understood the “pubic option” discussion at the time of the pre- ACA passage to be the ability to buy into Medicare.
Beverly, I think you need to change how you use “single-payer”. Medicare is a demographically limited “single payer” health insurance system. You can tell because there is (to a good approximation) one payer, aka a single payer (there are also premiums charged to some individuals, but mostly it is funded by the government ultimately from taxes).
The “public option” as recently debated was NOT single payer. It was a government administered insurance option paid for from various sources intended to be in competition with privately administered plans. If it were the only option, and compulsory… well the premiums, etc start to look at lot like oddly named taxes and perhaps the distinction becomes meaningless.
Medicare-for-all is the purest form of single-payer within the realm of plausibility for our nation. Government collects taxes which fund an insurance program that it runs. Thus it is actually both single payer and single administrator.
Anyway re-purposing the words “single-payer” to cover the public option idea which is intended to have many payers is confusing and not useful. Attempting to exclude “medicare for all” from “single-payer” is downright incorrect. Of course “single-payer” encompasses more than “medicare for all”, many nations have single-payer systems and obviously none of them have our medicare program.
Besides, it is pointless to resist wikipedia!
Personally I think a very good way to achieve “medicare for all” is to start with “medicare for kids”. Expand medicare to cover everyone 0-18 (or 21 or 26). Its hard to argue against morally, kids are statistically cheap to insure, and families with young children are generally hurting in america. I also suspect that in this case the “slippery slope” may actually happen. We have a problem that people only experience the sort of healthcare security that is broadly available in most wealthy nations decades after their political attitudes have ossified, and not that long before they die. Get people aging out of medicare and into the morass of private health insurance just as they start voting and victory will follow.
BTW a problem with “medicaid for all” is that medicaid is poor peoples insurance. It’s a stigma. Those who think themselves middle class don’t want to be on medicaid.
Medicare, on the other hand, is very popular and its hard for crotchety old dad to criticize you too much for being on the same government insurance he is using.
Jeff, I am NOT excluding Medicare from my definition of single-payer. Just the opposite; I’m saying that Medicare-for-all is, clearly, by definition, a type of single-payer. The “public option,” as it was used in the draft of the ACA from which it was removed because Joe Lieberman vetoed it, was–at least as I understood it–an option to buy an insurance policy directly from a newly-created federal insurance pool, but that option would have been available only to people who have no access to employee-provided group insurance. In other words, the same people who qualify to buy insurance through the private-market exchanges would have qualified to buy insurance through the federal insurance pool instead. That’s what I mean when I say, “the public option,” because that’s what I understood the public option included in an earlier draft of the ACA to be.
Another type of single-payer would be the “public option” as it was constructed in that earlier draft of the ACA, except that this would be offered to everyone, including to employers who could buy their employee policies through it. This–THIS–is what I think, and hope, Democrats will start to propose. It will completely eliminate the OMG-my-employer-is-raising-our-employee-contribution-because-of-Obamacare silliness that has so taken hold because our dear leader has failed to refute it. It also, of course, would eliminate the OMG-my-wonderful-individual-market-insurance-is-being-eliminated-and-AnthemBlueCross-is-offering-me-a-much-more-expensive-policy-with-much-higher-deductibles-that-has-access-to-no-doctors-or-hospitals-much-less-my current-ones problem.
Well Jeff many of them manage to reconcile themselves with that since Medicaid is the only way to get public assistance for Long Term Care. Of course you have to impoverish yourself on paper by having transferred most major assets to others but that is mostly just sound estate planning for the middle class anyway.
But that is a throwaway point. I would suggest we already have a program for kids called SCHIPS that could be expanded without dragging Medicare into the picture at all. Medicare’s financing structure is screwy enough (for example it has both strongly progressive and somewhat regressive elements as between Part A and B) and is tied tight to Social Security for determining elibibility that try to shoehorn a single-payer program for kids into it doesn’t to me make much sense.
Also the whole terminology thing is messed up by the fact that various bills have been introduced under the Title ‘Medicare for All’ whose proposed systems share little with either Medicare or each other. For example the Kennedy-Dingell Medicare for All bill of 2007 was just the latest iteration of legislation they had been introduing for decades. While in 2009 we had the Conyers-Kucinich HR 676 ‘Medicare for All’ bill which would have replaced the entire medical system of the country with one that would have been way to the left of even the British NHS. As a mild example it would have dissolved the VA Medical system while banning doctors from having any ownership in clinics or hospitals. And would have totally transformed Medicare itself into just another cohort using the new system. Yet there it was in literal black and white ‘Medicare for All’.
Single-Payer is descriptive. ‘Medicare for All’ seems to mean whatever someone wants it to mean. And when this is combined (as all too often) with a total misunderstanding of even the current structure of the program hilarity tends to break out. Or tears of rage depending.
Daniel, there was a push by a small group of congressional Dems to make buy-into-Medicare an option, I believe, but it went nowhere. As long as Joe Lieberman’s and Max Baucus’s votes were needed, it was not ever going to go anywhere. So the public option became simply a separate newly-created federally-run insurance pool available to the people whose only other choice is what their only choice is now: private-market individual insurance plans bought through the exchanges.
Sure, people will take medicare when they have to (ie to pay for nursing home care), particularly when they are starting to get incapacitated (so they need nursing home care). But I think it’s a tougher sell to get them to vote to change their insurance to ‘medicaid’ than to ‘medicare’, though of course universalizing either would require some changes.
I suppose I’m being simplistic and easily manipulated by labels myself. When I personally talk about “medicare for more” or all or whatever my thinking is that we have a large reasonably well functioning sign-up and billing system in medicare that everybody knows how to deal with and grafting additional groups onto that system seems likely to avoid ACA exchange like debacles. The funding scheme would, of course, have to change to take in more revenue if it was to cover everyone (though only mildly to cover 0-18 because they are super cheap compared to 65+) and there would be lots of work to do, but it would tend to be incremental work (particularly as medicare does already provide coverage to non-seniors so it already knows how to do that). Medicaid funding seems no less problematic.
I also would prefer that we get everyone into the same boat so its a bit less natural to fund the program for one group far better than the program for another.
Take the VA, in the long run I suspect it would make sense to wrap it’s financing and billing into the single system. Now at least some existing VA healthcare providers would, I think very sensibly, remain to provide specialized care overwhelmingly for veterans, and retain a close association with the military to provide special services but the VA as a funding mechanism would be needlessly redundant. We do already have a model for military-enhanced medicare in tricare, so we could also do that if it seems like a great idea.
Oh, also medicaid is state based, while medicare is national. That’s one very important difference in fundamental structure, on which people will have different opinions.
Ok, I understand what you are saying now Bev via all the discussion.
I guess we can wait and see how Vermont makes out with their “single payer” system which they are building.
Actually, Medicaid could be useful as a transition to single-payer if it paid a portion of all bills (it doesn’t pay much). That way you could keep your old insurance setup whatever that might be while getting on the government roll too.
Couldn’t clearly tell you why that would help but it might let people approach joining the new system with fear — they could transition to full government coverage when and if they chose. Eventually, after enough had transitioned and everybody else saw how it worked, every body could cross-over.
A possible psychological aid — for worried legislators too! (I’m beginning to convince myself it might actually be a good idea. :-])
Jeff Medicare would have to take in huge amounts of new revenue to cover any expansion.
Right now Medicare Part A can be said to be funded 40 : 20 You pay in for 40 and collect for 20. And assuming equal cohorts you get the same ratio of payers to payees. By switching that to 30 : 30 you at stroke add 50% to the pool of beneficiaries AND lose the contribution they formerly were ,making to cover the 20.
Because while you can say http future beneficiaries are paying for their own care they re doing over their entire worklives and of course in reality the dollars are going from their pockets to other peoples medicl providers.
That is just for the 55% covered by Part A. There is another 33% that comes out of the general fund for Parts b and D that would need to be financed as well.
There eels to be som belief that Medicare is largely funded by retiree premiums but really that only covers something like 10-12% of cost. And a big hunk of th rest is already being funded by his new population you would have be eligible. Or do they just keep paying SECA and ALSO pony up for their own Part A.
Break it down to cash flow and txt incidence me the thing isn’t simple at all
Yea, obviously. More money, as I said. Also, obviously, the amount of money is proportional to the expansion.
Expand to everyone, then you need enough money to pay for nearly all the healthcare in america. Expand to just one random person and you need about $10,000.
When I said a ‘mild’ expansion would be needed to cover 0-18 I mean in comparison to current spending and other limited expansion proposals, like covering 55-65. 0-18 is a far cheaper group to provide healthcare for.
Lifetime healthcare expenditures. One of those charts that starts out at 0 years old with all the healthcare you will ever use, on average, and goes to 95 years when almost everyone is dead. So if you look at well lets use that middle line just because it is between the male and female lines (though that isn’t actually what it is for), but we are just ball-parking here.
So 0-18 costs about 50% of 55-65, and 8.3% of 65-95. Thus the funding required would be on the order of 108% of current to add 0-18 to medicare. 116% to add 55-65. 10% or so funding increase needed. I’ll call that mild.
Disregarding my vague term ‘mild’ the issue is entirely non-unique to medicare expansion. ANY kind of single payer healthcare system has to collect the revenue.
It makes absolutely no fundamental difference whether that system is growing out of medicaid or medicare or the va or a public option or the bureau of alcohol, tobacco and firearms. None of these programs is over-funded by hundreds of billions of dollars an can be turned into universal single-payer without additional revenue (heck the public option doesn’t even exist).
I don’t think 0-18 year olds are funding medicare to any noticeable degree. Very few of them are employed, and vanishingly few of those make significant income.
So, basically, sure, revenue is needed. However this is not at all an argument against using medicare as the base because revenue is needed for every option.
I am aware that medicare is largely tax financed, I said so previously. I’m not laying out an exact funding scheme. Vaguely we redirect existing tax revenues (eg schip becomes redundant) and increase other taxes. Certainly there are lots of details to work out, but the only straitjacket is the law, and we are talking about changing the law here. Collect the revenue, fund the program. The only real problems are the politics of collecting the revenue and providing the benefits.
For 0-18 I think pretty much all of these issues are mitigated because it’s for kids, they are cheap, they are not employed, a good chunk of them are on government insurance already etc. They, simply put, are simpler. They are more uniform.
18-64 is really a lot more complicated. To go to full single payer you really need to start thinking hard about the transition. How to phase it in. How to give everyone time to adapt. Titanic amounts of money will stop flowing the way they used to flow. Figuring out how to turn all that into taxes, or whatever really is complicated.