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Bargaining power, progressive maximalism, and Medicare for All

The HuffPo has reported on a minor dust-up between Bernie Sanders and Alexandria Ocasio-Cortez over the politics of Medicare for All (see here, here, here, also Paul Waldman here).  The tl;dr summary is that AOC suggested that it is good politics for Sanders to insist on MFA, because this will give him more leverage in negotiations over a final bill, but that compromising on a public option is an acceptable outcome that would represent real progress.  Sanders shot back that his bill is already a compromise.  Of course, Sanders’ reply is consistent with AOC’s comments – he may be trying to maximize his bargaining power by pretending to rule out the possibility of further compromise.

My view (here) is that the only significant effect of insisting on MFA will be to make it less likely that the Democratic candidate wins the election.  To be clear, I think that a Democrat who insists on short-run implementation of MFA can win in 2020.  I just think running on MFA will make winning less likely, and that there is no reason to increase the chances of a second Trump term since a second Trump term would be a catastrophe and MFA will not pass no matter what happens in the election.  But AOC suggests one way my theory may be wrong:  perhaps electing a candidate who stakes out a maximalist negotiating position on MFA will help get a stronger reform package through Congress.

This is, unfortunately, wishful thinking.  The hard truth is that progressives will have essentially no bargaining power on the issues that they care about most strongly.  The reason is simple.  To have bargaining power in a negotiation, you need to be willing to walk away from the table and settle for the status quo.  But on the issues they care about most passionately – health care, climate change, etc. – progressives will be the least willing members of Congress to settle for the status quo.  If Congress is trying to decide whether to 1) add a public option to Obamacare or 2) implement full-blown Medicare for All, Sanders and AOC can threaten to oppose the public option all day – but no one will believe them.  Instead, legislation on key progressive priorities will be shaped almost entirely by the need to win over centrists and swing district legislators.  The votes of progressives will be taken for granted, full stop.

Of course, it is possible to argue that “insisting” on Medicare for All may help a bit at the margins.  Perhaps.  But in addition to its electoral costs, focusing on maximalist positions has two serious drawbacks.  First, the language of progressive maximalism is not persuasive to people who are not already progressive.  Second, staking out “tough” positions diverts the attention of progressives from the really critical task of designing policies that can attract support from their more moderate colleagues.  In the case of climate legislation, I will argue that these issues are of overwhelming importance.

I suspect that both AOC and Sanders know all this.  AOC’s comments suggest she understands the importance of compromise and incremental progress and is willing to provide leadership on this issue.  This is a hopeful sign – leadership by elected progressives will be critical to building a more strategic and effective brand of progressive politics in the United States.  But – as Sanders’ reaction shows – we have a long way to go.

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Bronze ACA Plans are Terrible. Bronze plans are often the best Choice

Andrew Sprung writes about the ACA. I read him quite often as his posts are expert analysis of the ACA and healthcare.  Mostly recently this commentary was posted by Andrew on the benefits of getting a Bronze plan as opposed to a Gold plan if facing large out of pocket expenses (premiums + deductibles).

“XPOSTFACTOID”   Mostly about the ACA: Obamacare to Trumpcare.

Bronze plans are terrible. Bronze plans are often the best choice.

In discussion of the ACA marketplace (and health insurance generally), deductibles are often used as a stand-in for out-of-pocket costs. Now here cometh David Anderson to remind us that a plan’s maximum out-of-pocket cost (MOOP) can be just as important — and that the MOOP often does not particularly correspond to metal level.

The highest allowable MOOP at all metal levels is $8,150 (a travesty by international rich country standards). Here is David’s mapping of the range of MOOP for gold plans in HealthCare.gov states. Dark green is $2,500 MOOP; dark red is $8,150.

As David points out, bronze plans will be a better deal for anyone who knows they’ll hit the out-of-pocket max. As he’s pointed out elsewhere (and in passing here), it takes a lot more spending to hit the high max in a gold plan — say, $30,000 — than in a bronze plan. That’s because once you meet your deductible (likely to be relatively low in a gold plan with high MOOP), a high percentage of ensuing costs will be covered in a gold plan until the MOOP is reached, at which point coverage goes to 100% for ensuing costs (if you stay in network).

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Surprise Billing To Be Resolved in February 2020 to be Enacted in 2022

I had wondered why the Senate (Schumer) had backed off on legislation controlling surprise billing. It turns out there is a House bill also and I am sure they are going back and forth on this. Recently, two bills have emerged in the House and one from the Senate. Medscape, “House Committees Advance Bills to Address Surprise Billing.”

Of course if Congress’s butt was on the line, a solution would have been found quickly and enacted in 2020. At the end, see which one I would back.

The House Ways and Means Committee bill passed by a voice vote bipartisan bill. It seeks to establish more use of third-party negotiators ( arbitration) for settling certain disputes about payment for out-of-network care. This bill has the support of the American Hospital Association and the American College of Emergency Physicians. The American Medical Association also praised the committee’s reliance on mediation for disputes on bills.

The House Education and Labor Committee advanced a hybrid proposal seeking to use established prices in local markets to resolve many disputes about out-of-network bills. Key to this bill is the use of arbitration above a certain cost. Bills greater than $750 or in the case of air ambulance services $25,000; clinicians and insurers could turn to arbitration for an independent dispute resolution. House Education and Labor passed this bill in a 32-13 mixed vote with some Republicans and Democrats opposing and in favor.

The latest Senate Health, Education, Labor and Pensions (HELP) Committee of legislative proposals also addresses surprise medical billing. The HELP bill called for mandating that insurers reimburse out-of-network costs on the basis of their own median rates for in-network providers.

The Education and Labor Committee bill is estimated to save $24 billion, the Senate HELPS bill is estimated to save $25 billion, and the Ways and Means’ bill would save almost $18 billion  all over 10 years. It is suggested the greater use of arbitration in the Ways and Means’ bill will result in less savings.

Read on about the private equity involved and providers.

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Doctor Surprise Billing

This doctor is a bit much; but, he gets a point across which I have been making also. The issue(s) Dr. ZDogg  is describing about what commercial healthcare insurance, Medicare Advantage plans, hospitals, and now doctors are doing needs to be told over and over again. Schumer and the Senate have to release the portion of the House Budget bill that dealt with Surprise billing.

ZDoggMD reacts to ridiculous medical bills, MedPage Today, February 6, 2020

 

Going to her PCP located in Manhattan, a woman complains of a sore throat. Forget the Manhattan part of this as various versions (surprise billing)  of this situation are happening everywhere. The doctor swabbed the throat, sent it off to the lab, ordered some tests, and then gave her a prescription for antibiotics. She took her meds and went on vacation feeling better.

The tests came back negative. She later received a bill for ~$26,000.

The  lab was out of network which usually results with insurance only paying a portion of the bill and the patient the balance unless the insurance negotiates a lesser charge (hospital 3rd party employees) which they will pay. This is another version of Surprise Billing, not in a hospital setting, which we have heard so much about, and the patient gets screwed with the balance of the Surprise Billing.

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Progressive idealism and Medicare For All

I have suggested (here and here) that idealism is leading progressives astray.  Idealism leads progressives to ignore the political opposition that their proposals will encounter, and the need to win over reluctant allies through policy design, messaging, and – yes – compromise.

A clear example of the pitfalls of progressive idealism is provided by the current debate over Medicare for All.

The case for single payer health insurance in the United States is quite strong but treating Medicare for All as a short-term policy goal is a serious political error.  The problem is not just that immediate implementation of single-payer health insurance will meet insurmountable political resistance, which of course it will.  MFA turns social insurance – which should be one of the Democrats’ greatest electoral advantages – into a serious liability.  If the election is close, which at this point seems quite possible, this unforced error may result in a second term for Trump.  Since re-electing Trump would be a calamity, and MFA has virtually no chance of being passed even if the Democrats hit the trifecta and win the presidency and both houses of Congress, this is a huge mistake.

Rather than running on a platform calling for immediate implementation of MFA, Democrats should promise to protect and modestly expand Social Security, Medicare, and Medicaid, in ways that will visibly help struggling Americans.  They should increase Social Security payments for seniors with limited income and assets and for the very old.  They should push to expand health insurance coverage, to improve drug coverage, and for a public option at least in rural areas.  They should promise paid family leave and expanded tax credits for families with children.  What they should not do is insist on dismantling the existing system of employer-based coverage in a big-bang transition to a single-payer system.

Social insurance should be a huge electoral advantage for Democrats . . . 

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Does America Hate Its Children?

December 2012,  Robert Reich wrote about America’s children   .   .   .    Remember the Children.

“America’s children seem to be shortchanged on almost every issue we face as a society.

Not only are we failing to protect our children from deranged people wielding semi-automatic guns.

We’re not protecting them from poverty. The rate of child poverty keeps rising – even faster than the rate of adult poverty. We now have the highest rate of child poverty in the developed world.

And we’re not protecting their health. Rates of child diabetes and asthma continue to climb. America has the third-worst rate of infant mortality among 30 industrialized nations and the second-highest rate of teenage pregnancy, after Mexico.

If we go over the “fiscal cliff” without a budget deal, several programs focused on the well-being of children will be axed – education, child nutrition, school lunches, children’s health, Head Start.

Even if we avoid the cliff, any “grand bargain” to tame to deficit is likely to jeopardize them.

The Urban Institute projects the share of federal spending on children (outlays and tax expenditures) will drop from 15 percent last year to 12 percent in 2022.

At the same time, states and localities have been slashing preschool and after-school programs, child care, family services, recreation, and mental-health services.

It seems as if every one of usual major interests have political clout – except children. They can’t vote. They don’t make major campaign donations. They can’t hire fleets of lobbyists.

Yet they’re America’s future.

If you follow the link to Robert Reich’s commentary you can read what major interests have the clout and dominate America’s interests.

 

Eight years later, January 2020 and Paul Krugman is asked a question by a correspondent.

“What important issue aren’t we talking about?”

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VFW Demands Apology from Trump

for Downplaying Brain Injuries Suffered from Iranian Attack, CNN, Veronica Stracqualursi, January 2020

It is bad enough for trump to have evaded the draft multiple times giving heel spurs as a reason for doing so; but here we are and now, trump can tell us what is a serious injury and what is not. If he would just shut up, which will not happen, things might settle down. As it goes, anything to deflect and get the attention off of impeachment.

(CNN)President Donald Trump said he does not consider potential brain injuries to be as serious as physical combat wounds, downplaying the severity of US service members being treated for concussion symptoms from an Iranian attack as “headaches.”

During the World Economic Forum in Davos, Switzerland, Trump was asked to explain the discrepancy between his previous comments that no US service member was harmed in the January 8 Iranian missile attack on Al-Asad airbase in Iraq, and the latest reports of US troops being treated for injuries sustained in that attack.

“No, I heard that they had headaches, and a couple of other things, but I would say, and I can report, it’s not very serious,” Trump replied during the news conference.

The reporter pressed, “So you don’t consider potential traumatic brain injury serious?”

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Thoughts and Feelings on cancer

I have begun to keep a daily journal on my thoughts and feelings in the lead-up to my diagnosis and treatment of cancer, a dedifferentiated lymphosarcoma in the groin area.  Sharing these thoughts was not my first or second impulse until Bill encouraged me to keep notes of my progress and publish  them (from the  point of view on our medical system and the more personal journey in considering my own mortality and experience).

I have a second surgery scheduled for Jan. 27; and then about 4-6 weeks later, I start a course of radiation 5 days a week for 33 treatments.  I am greatful to have adequate insurance through medicare and medex blue cross/blue shield of MA. Dana Farber hospital has a bone cancer and sarcoma treatment center that has experience in my rather uncommon cancer and body location.  My surgery will be at the Brigham and Womans Hospital, which is the big building next to Dana Farber, since DF does not provide those services. There is a close coordination between staff.

My Dec. 2 surgery by a urologist at another excellent regional hospital (Newton-Wellesley) was part of an exploratory and diagnostic survey and included the removal of a ‘growth’ that also needed a biopsy, a needle biopsy being inadequate due to the nature of lipomas.  The first surgery turned into a more extensive 4 hour attempt at ‘clean margins’ which failed.  The Mass General Hospital was consulted on the biopsied samples. Newton Wellesly has close ties to MGH as the cancer was not easily recognized and the consult was needed.

My attention to detail is on purpose as it is a demonstration of the benefit of  living near world class hospitals, privelege of choice and access to them, and not worrying so far about the crushing cost if I had to pay out of pocket. This stands in contrast to what many Americans face in rural parts of the country.

I have notified most of the Bears; but, I want readers to know that Bill and Eric will be on top of things.

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Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: Part 2

Part 2 discusses why we must have the government issue payments to hospitals, clinics, etc. and also set the budgets for hospitals and this is how they are paid rather than billing multiple insurers and also patients. There is also only one payer. The later part is what I have been pounding on repeatedly. Forget prices and work with cost data. It is then we have a much clearer picture of the costs of healthcare and we can begin to control prices.

Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: One Is a Lot Better Than the Other, Healthcare for All Minnesota, Kip Sullivan, May 8, 2019

What is an ACO and why is it a defect?

Congress included in the Affordable Care Act of 2010 (aka Obamacare) a section (Section 3022) requiring CMS to establish an ACO program within the traditional FFS Medicare program. It is not clear why Congress chose to use ACOs. Congress was warned in 2008 by the Congressional Budget Office (CBO) that ACOs would not save money for Medicare. The simplest way to describe ACOs is to say they are HMOs in training. Like HMOs, they are corporations that own or contract with chains of hospitals and clinics; they have the equivalent of enrollees; they attempt to keep their “enrollees” from seeking care outside their networks; they bear insurance risk (that is, they are paid on a per-enrollee basis and in exchange are obligated to provide medically necessary services to their enrollees); and because they are risk-bearing organizations, they generate overhead costs similar to those created by traditional insurance companies.

More on ACOs and the absence of Single Payer budgets past the leap

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Rep Jayapal and Sen Sanders’ Have Introduced Medicare for All Bills: Part 1

I have exchanged emails with Kip Sullivan several times and believe he has the clearest explanation on Single Payer. I have found him to be a good source for the two Single Payer bills in Congress today. Unfortunately, it is a long explanation and it can not be summed up on one page or in the amount of time you would spend watching the news at 10 PM. To compensate for the length of the presentation, I have broken it down into two parts. I hope you take some time and read it.

Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: One Is a Lot Better Than the Other,” Healthcare for All Minnesota, Kip Sullivan, May 8, 2019

Two bills that are called “Medicare for all” bills by their supporters have just been introduced in Congress. On February 27, Representative Pramila Jayapal introduced the Medicare For All Act of 2019, HR 1384, in the House of Representatives. On April 10, Senator Bernie Sanders introduced a bill bearing the same name in the Senate, S 1129. The cost-containment section in Representative Jayapal’s bill will cut health care costs substantially without slashing the incomes of doctors and hospitals. Senator Sanders’ bill cannot do that.

In this article, I explain the differences in the cost containment sections of the two bills and call upon Senator Sanders to correct two defects in his bill that minimize its ability to reduce costs. Defect number one: S 1129 authorizes a new form of insurance company called the “accountable care organization” (ACO). Defect number two: S 1129 fails to authorize budgets for hospitals. Representative Jayapal’s bill, on the other hand, explicitly repeals the federal law authorizing ACOs, and it authorizes budgets for individual hospitals.

I write this essay as both a long-time organizer, writer and speaker for a single-payer (the older name for “Medicare for all” system) and a strong supporter of Senator Sanders. Bernie’s enthusiastic support for a “single payer” solution to the American health care crisis has added millions of new supporters to the single-payer movement. But precisely because he is now the most recognizable face of the single-payer movement, it is extremely important that all of us, whether we’re already in the single-payer movement or we just long for a sane and humane health care system, encourage Bernie to fix the defects in his bill.

To explain the two defects in S 1129, I must first explain why a single-payer bill like Representative Jayapal’s will be effective at cutting the high cost of American health care. I begin by explaining the origin and meaning of the “single payer” label. I will then describe the two defects in S 1129 in more detail.

Past the leap, the origin of Single Payer

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