This month’s poll probes Democrats’ views about the general approaches to expanding health coverage and lowering costs put forward by the candidates; the public’s health care prio…
This month’s poll probes Democrats’ views about the general approaches to expanding health coverage and lowering costs put forward by the candidates; the public’s health care prio…
According to the Times:
The 1619 Project is a major initiative from The New York Times observing the 400th anniversary of the beginning of American slavery. It aims to re-frame the country’s history, understanding 1619 as our true founding, and placing the consequences of slavery and the contributions of black Americans at the very center of the story we tell ourselves about who we are.
As a student of American history, I was fully exposed to the current literature of the time regarding slavery, slaveholders, and the impact it had on the African-American culture and people, through my introduction to such historians as Eric Foner, Eugene Genovese, Leon Higginbotham, and John Blassingame, as well as from my three African-American/Sociology courses as an undergraduate.
So, I believe that this series by the Times, is not only needed, but timely, given the racial animus we see day after day from the White House, the far right, and on the Internet.
Readers of this blog have seen that I have advocated on behalf of Medicare for All/Single Payer, because of the many causes for our broken health care system. However, it is not solely based on economics, politics, or defending the profits of the insurers and pharmaceutical companies. But rather due to race, as Jeneen Interlandi writes.
According to Interlandi, the first federal health care program served freedmen after the Civil War, but white legislators argued that it would breed dependence.
This health care program, the medical division of the Freedmen’s Bureau addressed the health care crisis due to the smallpox virus spreading across the post-war South. And according to Jim Downs, white leaders were worried about black epidemics spilling into their communities, and wanted the former slaves to be healthy enough to go back to the plantation. However, they feared that free and healthy African-Americans would upend the racial hierarchy.
Interlandi describes how whenever there was some move to deal with health care, there was always some backlash or outright ignoring of the solutions to the problems facing the south in the post-war period and Reconstruction. Not only that, but when federal social programs were introduced, Southern Democrats (yes, but now they would be, and are Republicans) forced concessions to bar African-Americans from receiving the benefits of those programs, or the AMA barred black doctors, medical schools excluded black students, and most hospitals and clinics segregated black patients.
There is the story of the African-American doctor who discovered blood types, and died because he was refused admittance to a hospital because he was black. This story was brought to the attention of viewers of MASH when the subject of race was part of that episode’s plot.
In college, I wrote a paper on the Tuskegee Syphilis experiment that exposed African-American men to syphilis to observe the natural history of untreated syphilis; the African-American men in the study were only told they were receiving free health care from the United States government.
So those of you who oppose single payer health care should stop and consider if being the only nation in the Western world to not provide its citizens with universal health care should continue to be based on racial prejudice or simply because you want to profit by not doing so.
From the “I Think It’s Time for Another Rant” Department
In response to my last post, The Further Adventures of Ashley Furniture in Medical Travel, I received several comments about the facts presented in the article, which by the way was also published in The New York Times, A Mexican Hospital, an American Surgeon, and a $5,000 Check (Yes, a Check).
Now I don’t mind comments, I welcome them. But they should not be directed towards me personally, because I am not responsible for any misleading or inaccurate reporting by the author or authors of articles I write about.
Some of the comments should, rightly be directed to the individuals or organizations mentioned in the article, as they are the active participants in what the article was describing, namely the knee replacement surgery of the spouse of an employee of Ashley Furniture Company.
I would like to point out one fact I failed to mention. Ashley has sent about 150 employees or dependents to either Mexico or Costa Rica, and since 2016, they have saved $3.2 million in health care costs, according to Marcus Gagnon, the company’s manager of global benefits and health.
Mr. Gagnon, as a side note, was featured in two previous articles published by Medical Travel Today.Com back in October and November 2017. (See my posts: Ashley Furniture and Medical Travel, part 1 and Ashley Furniture and Medical Travel, part 2)
Points were raised as to why NASH is sending patients and exporting surgeons to other countries to perform cheaper surgery pricing? NASH stands for North American Specialty Hospital. To answer that question, go to the source, NASH.
Another point was raised about pricing, and it was mentioned that US facilities charge as low as $14,990 for a total knee replacement, implant included, as a transparent bundled case rate. Hotel room for that is $149 plus tax, no hospital overnight required. And that malpractice insurance has no additional cost, plus there is no need for expensive flights, passports, etc.
Good question, Then why does the medical travel industry exist at all in the US, if what was commented is true? The fact is, it isn’t. That’s why Ashley, and HSM, a furniture manufacturer in North Carolina has been doing this for some time, as I have previously reported, and because I met the patient advocate for one of HSM’s employees at the ProMed event in 2014.
The patient in the KHN article, Donna Ferguson, also works for a furniture manufacturer in her Mississippi home town, and I bet that her employer was sure glad it wasn’t his dime that paid for her surgery, but that her husband’s company did.
Another point was made about the “concerns about quality of care” and the way Mexico does not require continuing education credits, and other criticisms of the Mexican health care system. Yet, as the article stated, they went beyond the JCI standards, and even got an extra autoclave to sterilize instruments more quickly.
Also, a comment was made about where the surgeon was from. In this instance, he was a Mayo Clinic trained, orthopedic surgeon from Milwaukee, and he would not have done this if he felt it would ruin his standing in the profession. Oh, and maybe there have been other physicians who have traveled to meet patients elsewhere. So what. The article was talking about this one, not a whole list of them.
Yes, I have not visited Galenia or Bumrungrad, as many of you have. That has been the point of my writing a blog for nearly seven years. But I have only been to three events, and only one invited me to speak. What am I, chopped liver? I post my articles to my blog and LinkedIn so that folks can read them and invite me.
Of course, I’d like to take fam tours of facilities. Of course, I’d like to meet other people in the industry, but since October 2012 when I began, I have struggled financially, personally, and medically to just stay alive. A little concern and interest on your part would have been nice.
The other points raised in the comments about the $5000 dollars she received and fees and patents, waiving deductibles and copayments were more than likely handled by Ashley’s medical travel plan administrator, IndusHealth, who also happened to be the administrator for HSM, and whose president I also met at ProMed in 2014. Again, I am only a messenger.
Finally, a comment was made that my next to last paragraph was a stretch. Perhaps so, but in light of this past weekend’s protests in Portland between anti-fascists and fascists, and the shootings in Dayton and El Paso, not to mention, three that were foiled last week, and Trump’s Nuremburg-style rallies, I can be forgiven if I want to express an idea that could bring some people to understand what the rest of the world is like.
I am not interested in what other protests happen around the world. I am only concerned, as far as Americans and medical travel are concerned, with showing them that there are no “shithole” countries, and that there are good and bad everywhere. I believe a little on-the-ground education, especially among the working class, white or otherwise, will improve racial and ethnic relations. Call me an idealist, but that is all we have to go on if we are ever going to have peace in the world.
There was something mentioned in the article that is kind of puzzling. A medical travel expert was quoted as saying that “Building a familiar culture in a foreign destination may be appealing to some American consumers, but I do not see it as a sustainable business.” If that is so, then why is he in the business in the first place, and why is he partnered with someone else on a podcast on that very subject, and who are both known in the medical travel world?
That’s the end of my rant. I invite anyone who wants to invite me to the next event or fam tour, to do so. Please let me know in advance what you are willing to pay for, and give me enough time to make arrangements for traveling with my medical condition, as traveling outside the US is somewhat problematic, depending on where it is, and other factors that might prevent me from doing so.
And again, Don’t Shoot Me, I’m Only the Messenger.
Now comes a new article, courtesy of Kaiser Health News, that shows just how American patients are saving money by having surgery in Cancun, Mexico for procedures such as knee surgery (are you listening, Workers’ Compsters?)
Not only are the patients traveling to Cancun, but so are the physicians from the US. As pictured below, Donna Ferguson, the wife of one of Ashley’s employees, is shown in the hospital in Cancun, along with her doctors, one of whom will be performing knee replacement surgery. As stated in the article, all she had to do was walk out of her hotel, and into the Galenia Hospital through a short hallway.
Donna’s surgeon, Dr. Thomas Parisi, from Milwaukee, had flown to Cancun the day before. To get this surgery, which she was getting for free, she would also receive a check when she got home. (I’ve said this before, but you never listened)
According to the article, the employees of Ashley receive a $5,000 payment from the company, and all their travel costs are covered. They use this option because they have no out-of-pocket copayments or deductibles, so it made financial sense for both a highly trained orthopedist and a patient from Mississippi to leave the US and meet at an upscale Mexican hospital. (Let’s see Trump try to built a wall to stop that!)
Dr. Parisi spent less than 24 hours in Cancun, so no one could accuse him of slacking off to play golf, and was paid $2,700, which as the article stated, was three times what he would have gotten from Medicare. The cost of the surgery for Ashley was less than half of what it would have been in the US.
To understand better, just why Ashley is doing this for their employees and their families, let’s look at what the average knee replacement would cost in the US: about $30,000 — sometimes double or triple that; whereas in Mexico, at Galenia, it was only $12,000. according to Dr. Gabriela Flores Teón, the hospital’s medical director.
The standard charge for the night at Galenia is $300, compared to an average of $2,000 at US hospitals, said Dr. Flores.
But besides the big savings on the surgery, there was also savings on the cost of the medical device, made by a subsidiary of the Band-Aid people, J&J, in New Jersey. The implant cost $3,500 in Mexico, but nearly $8,000 in the US, Flores continued.
In case you WC hotshots were wondering, Galenia Hospital is not some fleabag hospital on the cheap. It is accredited by the international affiliation of the Joint Commission (JCI). They set the standards for hospitals in the US.
However, so that doctors and patients could feel comfortable with surgery, NASH (North American Speciality Hospital) based in Denver, and who has organized treatment for dozens of American patients at Galenia since 2017, along with Galenia, worked to go beyond those standards.
In the two SPOTLIGHT articles referenced above, the manager of global benefits and health at Ashley, Marcus Gagnon said, “We’ve had an overwhelming positive reaction from employees who have gone,”
The company has also sent about 140 employees or dependents for treatments at a hospital in Costa Rica, and together, the foreign medical facilities have saved Ashley $3.2 million in health care costs, said Gagnon. (Wake up, you WC guys! Why are you being so stubborn?)
Gagnon continued, “Even after the incentive payments and travel expenses, we still save about half the cost of paying for care in the United States,” “It’s been a nice option — not a magic bullet — but a nice option.”
So, if Ashley can do it, and if HSM could do it too, the so could you. Not all the hospitals outside of the US are fleabags. Galenia in Cancun is one example. Bumrungrad in Thailand is another, and there are plenty more around the world that cater to medical travel.
The whole point of my advocacy for medical travel and workers’ comp was so that American workers and their dependents like Donna could travel abroad and see what the world is really like, so that political, hate-filled rallies and incidents we are seeing everyday since the election of a white supremacist to the presidency, would not take place.
How else will the American worker learn about the real world beyond his borders if not this way? Certainly not from Fox News.
“Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one’s lifetime.”
― Mark Twain, The Innocents Abroad / Roughing It
Common Dreams and Business Insider both reported last week on polling that counters the right-wing narrative, and what some Democratic primary candidates are defending, that says that Americans like their employer-provided health care.
The survey, they wrote, showed that 59 percent of respondents who have employer-provided insurance “said they would support switching their employer-based health insurance to a government plan under Medicare for All” as long as quality of coverage would remain the same or improve.
The poll also found that Americans on government-run healthcare plans such as Medicare and Medicaid are more satisfied with their coverage than those on employer-sponsored plans, which have soared in cost over the past two decades.
According to BI, this is how the polling was broken down:
As reported in BI, the results highlight the fact that although a majority of Americans are fairly satisfied with their employer-based health coverage — which supports other polling on the subject — mainly people just like being covered in general, bearing little loyalty to a specific insurer.
Therefore, If the system provides equal or more comprehensive benefits, then broad swaths of Americans are likely to support it.
Medicare for All is not likely to pass anytime soon, but as more people come to see the benefits of such a program, compared to the rising cost of employer-based health insurance, that majority will only grow larger.
Those who advocate for Medicare for All need to keep pounding away at educating the public, and to make sure that coverage under Medicare for All is better than employer-based health care.
Don McCanne’s Quote-of-the-Day brings us an article from the Los Angeles Times by Michael Hiltzik about how useless health insurance companies are.
The most perplexing aspect of our current debate over healthcare and health coverage is the notion that Americans love their health insurance companies.
This bizarre idea surfaced most recently in the hand-wringing over proposals to do away with private coverage advocated by some of the candidates for the Democratic nomination for president. Oddly, this position has been treated as a vote-loser.
During the first round of televised debates on July 30 and 31, only four of the 20 candidates raised their hands when asked if they would ban private insurers as part of their proposals for universal coverage: Sens. Elizabeth Warren of Massachusetts, Bernie Sanders of Vermont and Kamala Harris of California, and New York Mayor Bill de Blasio. Harris later backed away, releasing a “Medicare for all” proposal that would accommodate private insurers at least for the first 10 years.
Health insurers have been successful at two things: Making money and getting the American public to believe they’re essential.
HEALTH INSURANCE EXPERT WENDELL POTTER
She should have stood her ground. The truth is that private health insurers have contributed nothing of value to the American healthcare system. Instead, they have raised costs and created an entitled class of administrators and executives who are fighting for their livelihoods, using customers’ premium dollars to do so.
“Health insurers have been successful at two things: Making money and getting the American public to believe they’re essential,” says Wendell Potter. He should know, since he spent decades as a corporate communications executive in the industry, including more than 10 years at Cigna.
The insurers’ success in making themselves seem essential accounts for the notion that Americans are so pleased with their private coverage that they’ll punish any politician who dares to take it away. But the American love affair with private insurance warrants close inspection.
Let’s start by examining what the insurers say are their positive contributions to healthcare. They claim to promote “consumer choice,” simplify “the health care experience for individuals and families,” address “the burden of chronic disease” and harness “data and technology to drive quality, efficiency, and consumer satisfaction.” (These claims all come from the website of the industry’s lobbying organization, America’s Health Insurance Plans (AHIP).
They’ve achieved none of these goals. The increasingly prevalent mode of health coverage in the group and individual markets is the the narrow network, which shrinks the roster of doctors and hospitals available to enrollees without heavy surcharges. The hoops that customers and providers often must jump through to get claims paid impose costly complexity on the system, not simplicity. Programs to manage chronic diseases remain rare, and the real threat to patients with those conditions was lack of access to insurance (until the Affordable Care Act made such exclusion illegal).
Private insurers don’t do nearly as well as Medicare in holding down costs, in part because the more they pay hospitals and doctors, the more they can charge in premiums and the more money flows to their bottom lines. They haven’t shown notable skill in managing chronic diseases or bringing pro-consumer innovations to the table.
Insurers cite these goals when they try to get mergers approved by government antitrust regulators. Anthem and Cigna, for example, asserted in 2016 that their merger would produce nearly $2 billion in “annual synergies,” thanks to improved “operational” and “network efficiencies.”
The pitch has a long history. The architects of a wave of health insurance mergers in the 2000s also proclaimed a new era of efficient technology and improved customer service, but studies of prior mergers show that this nirvana seldom comes to pass. The best example may be that of Aetna’s 1996 merger with U.S. Healthcare in a deal it hoped would give it access to the booming HMO market.
According to a 2004 analysis by UC Berkeley health economist James C. Robinson, the merger became a “near-death” experience for Aetna. The deal was expected to bring about “millions in enrollment and billions in revenue to pressure physicians and hospitals” to accept lower reimbursement rates, he wrote.
“The talk was all about complementarities, synergies, and economies of scale… The reality quickly turned out to be one of incompatible product designs, operating systems, sales forces, brand images, and corporate cultures.” Aetna surged from 13.7 million customers in 1996 to 21 million in 1999, but profits collapsed from a margin of nearly 14% in 1998 to a loss in 2001.
Even when they don’t happen, insurance merger deals cost customers billions of dollars. That’s what happened when two proposed deals — Aetna/Humana and Anthem/Cigna — broke down on a single day in 2017. The result was that Aetna owed Humana $1.8 billion and Anthem owed Cigna $1.85 billion in breakup fees — money taken out of the medical treatment economy and transferred from one set of shareholders to another.
In reality, Americans don’t like their private health insurance so much as blindly tolerate it. That’s because the vast majority of Americans don’t have a complex interaction with the healthcare system in any given year, and most never will. As we’ve reported before, 1% of patients account for more than one-fifth of all medical spending and 10% account for two-thirds. Fifty percent of patients account for only 3% of all spending.
Most families face at most a series of minor ailments that can be routinely managed — childhood immunizations, a broken arm here or there, a bout of the flu. The question is what happens when someone does have a complex issue and a complex claim — they’re hit by a truck or get a cancer diagnosis, for instance?
“We gamble every year that we’re going to stay healthy and injury-free,” Potter says. When we lose the gamble, that’s when all the inadequacies of the private insurance system come to the fore. Confronted with the prospect of expensive claims, private insurers try to constrain customers’ choices — limiting recovery days spent in the hospital, limiting doctors’ latitude to try different therapies, demanding to be consulted before approving surgical interventions.
Indeed, the history of American healthcare reform is largely a chronicle of steps taken to protect the unserved groups from commercial health insurance practices.
When commercial health insurance became insinuated into the American healthcare system following World War II via employer plans, it quickly became clear who was left behind — “those who were retired, out of work, self-employed, or obliged to take a low-paying job without fringes,” sociologist Paul Starr wrote in his magisterial 1982 book, “The Social Transformation of American Medicine.”The process even left those groups worse off, Starr observed, because insurance contributed to medical inflation while insulating only those with health plans. “Government intervention was required just to address the inequities.”
Insurers wouldn’t cover the aged or retirees, so Medicare was born in 1965. Insurers refused to cover kidney disease patients needing dialysis, so Congress in 1973 carved out an exception allowing those patients to enroll in Medicare at any age. (So much for addressing the “burden of chronic disease.”)
Individual buyers were charged much more for coverage than those buying group plans through their employers — or barred from the marketplace entirely because of their medical conditions — the Affordable Care Act required insurers to accept all applicants and, as compensation, required all individuals to carry at least minimal coverage.
The health insurance industry’s most telling contribution to the debate over healthcare reform has been “to scare people about other healthcare systems,” Potter told me. As a consequence, discussions about whether or how to remove private companies from the healthcare system are chiefly political, not practical.
The Affordable Care Act allowed private insurers to continue playing a role in delivering coverage not because they were any good at it but because their wealth and size made them formidable adversaries to reform if they chose to fight it. They were sufficiently mollified to remain out of the fray, but some of the big insurers then did their best to undermine the individual insurance exchanges once they were launched in 2015.
Even as individual Americans fret over losing their private health insurance, big employers have begun to see the light. Boeing, among other big employers, is experimenting with bypassing health insurers as intermediaries with providers by contracting directly with major health systems in Southern California, Seattle and other regions where it has major plants. It would not be surprising to see the joint venture of Amazon, Berkshire Hathaway and JP Morgan Chase try a similar approach in its quest to bring down costs.
That’s an ironic development, since the private insurers first entered the market precisely by offering to play the role of intermediaries for big employers. But instead of fulfilling the promise of efficiency and cost control, they became rent-seeking profiteers themselves.
There’s no doubt that it will take years to wean the American healthcare system off the private insurance model; Kamala Harris’s proposal may be merely a recognition of the necessary time frame. It’s true that some countries with universal healthcare systems preserve roles for private insurance, including coverage for services the government chooses to leave out of its own programs or providing preferential access to specialists, at a price.
But the private insurers’ central position in America’s system is an anachronism dating back some 75 years. The sooner it’s dispensed with, the better — and healthier — America will be. The next time a debate moderator asks presidential candidates if they favor doing away with private insurance, let’s see all the hands go up.
The multilateral debating society that is known as the 2019 Democratic Debates has now had four such contests, and in keeping with the previous post, Medicare for All and the Democratic Debates, I want to discuss the issue of health care.
This was the first topic of the evening, and on both nights, it was a contentious, and long debate. The first night saw Sens. Sanders and Warren debating the other eight contenders over Medicare for All versus a public option.
The second night was more of the same, however, only NYC mayor Bill de Blasio argued for full MFA, while Sen. Kamala Harris argued for her plan that would enroll some Americans right away, while taking ten years to fully implement. All the rest, including former V.P. Joe Biden argued for either repairing the ACA, or adding a public option as a Medicare buy-in.
As I will report later in this article, there is a problem with the idea of a Medicare buy-in or a public option, and its impact on the ACA.
But before I do, I would like to discuss a few areas that seem to be missing from the candidate’s talking points on health care that need to be answered, addressed, or clarified. The CNN moderators, as was pointed out at one part of the debate, was questioning the candidates with what were essentially Republican talking points about MFA.
One area that was somewhat glossed over on the first night was the issue of middle class taxes being raised to pay for MFA. MSNBC host Chris Matthews of Hardball questioned Sen. Warren several times after the debate in the spin room on this very subject, yet she danced around the question by talking more about the savings people would receive.
Sen. Sanders agreed with Joe Biden when he said that those pushing Medicare for All without a middle-class tax hike are living in a “fantasy world.” In addition, Sanders said, that he knows middle-class taxes will go up, but maintained that the American people could still end up saving money on the other side.
In a CNN interview with Jake Tapper, Sanders said the following:
“The first thing that we have to understand is, under Medicare for all, similar to what Canada has, people are not gonna pay any premiums. They’re not gonna pay any deductibles. They’re not going to pay any co-payments. So if you call a premium a tax, we’re getting rid of that. But I do believe that, in a progressive way, people will have to pay taxes. The wealthy will obviously pay the lion’s share of the taxes, but at the end of the day, the vast majority of the American people will pay substantially less for the health care they now receive because we’re going to do away with hundreds of billion dollars of administrative waste. We’re gonna do away with the incredible profiteering of the insurance companies and the drug companies. People will be paying, in some cases, more in taxes, but overall, because they’re not gonna pay premiums or deductibles, co-payments, they’ll be paying less for their health care.”
Another area missing from the debates was the issue of what to do about union contracts. Rep. Tim Ryan (OH) made that a point in both debate appearances, and the question still has not been fully addressed, even though Sen. Sanders said he was very pro-union.
Finally, three other areas mentioned in the debates, but that may not have been fully discussed or explained, was the issues of private insurance and employer-based insurance. The third issue, pre-existing conditions was only mentioned in the post-debate analysis from the political pundits. At many times, it was argued by the anti-MFA candidates that those advocating MFA wanted to take away such insurance from over 150 million Americans. But as the following two articles suggest, private insurance and employer-based plans are part of the problem.
As reported by CheatSheet, the Supreme Court decision mandating that a for-profit corporation — in this case, Hobby Lobby — can actually mandate the types of healthcare provisions its employees receive, all based on the religious beliefs of the company’s owners. Hobby Lobby’s arguments were based on a stack of flawed science and misunderstood concepts, and the fact that the Supreme Court ruled that an employer’s particular religious belief — which can be made up off the top off their heads, for all the Court cares — now takes precedent over the medical needs of their employees.
CheatSheet concluded that the case in itself is ridiculous, but it brings us to one important conclusion: The era of employer-sponsored health care needs to end.
Reed Abelson in The New York Times wrote the following article, reprinted here in its entirety:
The New York Times
July 29, 2019
How a Medicare Buy-In or Public Option Could Threaten Obamacare
By Reed Abelson
It seems a simple enough proposition: Give people the choice to buy into Medicare, the popular federal insurance program for those over 65.
Former Vice President Joseph R. Biden Jr. is one of the Democratic presidential contenders who favor this kind of buy-in, often called the public option. They view it as a more gradual, politically pragmatic alternative to the Medicare-for-all proposal championed by Senator Bernie Sanders, which would abolish private health insurance altogether.
A public option, supporters say, is the logical next step in the expansion of access begun under the Affordable Care Act, passed while Mr. Biden was in office. “We have to protect and build on Obamacare,” he said.
But depending on its design, a public option may well threaten the A.C.A. in unexpected ways.
A government plan, even a Medicare buy-in, could shrink the number of customers buying policies on the Obamacare markets, making them less appealing for leading insurers, according to many health insurers, policy analysts and even some Democrats.
In urban markets, “a public option could come in and soak up all of the demand of the A.C.A. market,” said Craig Garthwaite, a health economist at the Kellogg School of Management at Northwestern University.
And in rural markets, insurers that are now profitable because they are often the only choices may find it difficult to make money if they faced competition from the federal government.
Some insurers could decide that a smaller and uncertain market is not worth their effort.
If the public option program also matched the rates Medicare paid to hospitals and doctors, “I think it would be really hard to compete,” Mr. Garthwaite said. Even leading insurers do not have the leverage to demand lower prices from hospitals and other providers that the government has.
Whether to implement a public option or Medicare buy-in has become a defining question among Democratic presidential candidates and is likely to be a contentious topic at this week’s debates.
On Monday, Senator Kamala Harris took an alternate route, unveiling a plan that would allow private insurers to participate in a Medicare-for-all scheme, akin to their role currently offering private plans under Medicare Advantage.
The recent spate of proposals reprises some of the most difficult questions leading up to the passage of the A.C.A., in many ways a compromise over widely divergent views of the role of the government in ensuring access to care.
After a shaky start, the federal and state Obamacare marketplaces are surprisingly robust, despite repeated attempts by Republicans to weaken them. They provide insurance to 11 million customers, many of whom receive generous federal subsidies to help pay for coverage.
The A.C.A. is now a solidly profitable business for insurers, with several expanding options after earlier threats to leave. For example, Centene, a for-profit insurer, controls about a fifth of the market, offering plans in 20 states. It is expected to bring in roughly $10 billion in revenues this year by selling Obamacare policies.
In spite of stock drops because of investors’ concerns over Medicare-for-all proposals, for-profit health insurers have generally thrived since the law’s passage.
But a buy-in shift in insurance coverage could profoundly unsettle the nation’s private health sector, which makes up almost a fifth of the United States economy. Depending on who is allowed to sign up for the plan, it could also rock the employer-based system that now covers some 160 million Americans.
In a recent ad, Mr. Biden features a woman who wants to keep her current coverage. “I have my own private insurance — I don’t want to lose it,” she said.
A spokesman for Mr. Biden argued that a public option can extend the success of the Affordable Care Act.
“Joe Biden thinks it would be an egregious mistake to undo the A.C.A., and he will stand against anyone — regardless of their party — who tries to do so,” said Andrew Bates, a spokesman for Mr. Biden, in an email.
Major insurers and hospital chains, pharmaceutical companies and the American Medical Association have joined forces to try to derail efforts like Medicare-for-all and the public option. Mr. Sanders denounced these powerful interests in a recent speech.
“The debate we are currently having in this campaign and all over this country has nothing to do with health care, but it has everything to do with the greed and profits of the health care industry,” he said.
Other critics of the public option, including Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, argue Democrats’ programs will lead to a “complete government takeover.”
“These proposals are the largest threats to the American health care system,” she said in a speech earlier this month.
Some experts predict that private insurers will adapt, while others warn that the government could wind up taking on the sickest customers with high medical bills, leaving the healthier, profitable ones to private insurers.
It’s uncertain whether hospitals, on the other hand, could thrive under some versions of the public option. If the nation’s 5,300 hospitals were paid at much lower rates by a government plan — rates resembling those of Medicare — they might lose tens of billions of dollars, the industry claims. Some would close.
One variant of the public option — letting people over 50 or 55 buy into Medicare — is often depicted as less drastic than a universal, single-payer program. But this option would also be problematic, experts said.
This consumer demographic is quite valuable to insurers, hospitals and doctors.
Middle-aged and older Americans have become the bedrock of the Obamacare market. Some insurers say this demographic makes up about half of the people enrolled in their A.C.A. plans and, unlike younger people who come and go, is a reliable and profitable source of business for the insurance companies.
The aging-related health issues of people in this group guarantee regular doctor visits for everything from rising blood pressure to diabetes, and they account for a steady stream of lucrative joint replacements and cardiac stent procedures.
The 55-to-64 age group, for example, accounts for 13 percent of the nation’s population, but generates 20 percent of all health care spending, according to the Kaiser Family Foundation.
People age 55–64 are responsible for one fifth of total health spending and account for a sizable share of the private insurance market. People 65 and older are eligible for Medicare and account for one third of total spending.
By The New York Times | Sources: Kaiser Family Foundation; Dept. of Health & Human Services. Data from 2016
Several experts said that designing a buy-in program that is compatible with the existing public and private plans could be daunting.
“You’d have to do it carefully,” said Representative Donna Shalala, a Florida Democrat who served as the secretary of health and human services under President Bill Clinton.
Linda Blumberg, a health policy expert at the Urban Institute, a nonpartisan think tank, agreed.
“The idea of Medicare buy-ins was taken very seriously before there was an Affordable Care Act,” she said. “In the context of the A.C.A., it’s a lot more complicated to do that.”
Many dismiss concerns about whether insurers can compete.
“Any time a market shrinks in America, insurers don’t like it,” said Andy Slavitt, the former acting Medicare administrator under President Obama and a former insurance executive. Mr. Slavitt noted that insurers raised similar concerns about the federal law when it was introduced. “They’ll figure it out,” he said.
In Los Angeles County, five private insurers that sell insurance in the A.C.A. market already compete with L.A. Care Health Plan, which views itself as a kind of public option, said John Baackes, the plan’s chief executive.
The insurer offers the least expensive H.M.O. plan in the county by paying roughly Medicare rates. “We’ve proved that the public option can be healthy competition,” he said.
But the major insurance companies, which were instrumental in defeating the public option when Congress first considered making it a feature of the A.C.A., are already flexing their lobbying muscle and waging public campaigns.
In Connecticut, fierce lobbying by health insurers helped kill a state version of the public option this spring. Cigna resisted passage of the bill, threatening to leave the state. “The proposal design was ill-conceived and simply did not work,” the company said in a statement.
Blue Cross plans could lose 60 percent of their revenues from the individual market if people over 50 are shifted to Medicare, said Kris Haltmeyer, an executive with the Blue Cross Blue Shield Association, citing an analysis the company conducted. He said it might not make sense for plans to stay in the A.C.A. markets.
Siphoning off such a large group of customers could also lead to a 10 percent increase in premiums for the remaining pool of insured people, according to the Blue Cross analysis. More younger people with expensive medical conditions have enrolled than insurers expected, and insurers would have to increase premiums to cover their costs, Mr. Haltmeyer said.
Tricia Neuman, a senior vice president at the Kaiser Family Foundation, which studies insurance markets, said a government buy-in that attracted older Americans could indeed raise premiums for those who remained in the A.C.A. markets, especially if those consumers had high medical costs.
But some experts countered that prognosis, predicting that premiums could go down if older Americans, whose health care costs are generally expensive, moved into a Medicare-like program.
“The insurance companies are wrong about opposing the public option,” Ms. Shalala said.
Dr. David Blumenthal, the president of the Commonwealth Fund, a foundation that funds health care research, said a government plan that attracted people with expensive conditions could prove costly.
“You might, as a taxpayer, become concerned that they would be more like high-risk pools,” he said.
Jonathan Gruber, an M.I.T. economist who advised the Obama administration during the development of the A.C.A., likes Mr. Biden’s plan and argues there is a way to design a public option that does not shut out the private insurers.
“It’s all about threading the needle of making a public option that helps the failing system and not making the doctors and insurers go to the mat,” he said.
Many experts point to private Medicare Advantage plans, which now cover one-third of those eligible for Medicare, as proof that private insurers can coexist with the government.
But the real value of a public option, some say, would stem from the pressure to lower prices for medical care as insurers were forced to compete with the lower-paying government plans, like Medicare.
Washington State recently passed the country’s first public option, capping prices as part of its plan to provide a public alternative to all residents by 2021.
“It’s couched in this language in expanding coverage, but it does it by regulating prices,” said Sabrina Corlette, a health policy researcher at Georgetown University.
The hospital industry would most likely fight just as hard to defeat any proposal that would convert a profitable group of customers, Americans who are privately covered at present, into Medicare beneficiaries.
Private insurers often pay hospitals double or triple what Medicare pays them, according to a recent study from the nonprofit Rand Corporation.
While Ms. Shalala supports a public option as an alternative to “Medicare for All,” she is clear about how challenging it will be to preserve both Obamacare and the private insurance market. “You can’t do it off the top of your head,” she said.
So, let’s see, the Republicans want to kill the ACA, and others want to fix it. But adding a public option, or including a Medicare buy-in, might harm the ACA. On the other hand, it has been shown that both private insurance and employer-based insurance are part of the problem.
The idea that people like their private plans, whether obtained from their employer, or from private insurance companies directly, and is part of the problem is being left out of the discussion.
And debate moderators who ask those questions to candidates are only echoing Republican talking points, or worse, taking their cues from the drug manufacturers and insurance companies.
So if neither fixing ACA, adding a public option, or providing a Medicare buy-in will solve the enormous complexity and confusion that the broken and dysfunctional health care system represents, that only leaves one alternative: Medicare for All, while currently not likely to be enacted, nevertheless is popular with the public until the issue of taxes is mentioned.
The moderate candidates, are either defending the drug and insurance companies because of campaign contributions, or have been part of the health care industry, such as former Congressman John Delaney, and therefore is an unlikely spokesman for progressive change. Let’s hope that he and the other bottom-tier candidates drop out soon, so that perhaps these other issues can be discussed and debated.
How the campaign will turn out, and who the Democrats will nominate is still far off in the future, but who ever is nominated, will have to eventually deal with the reality that health care must be solved, and that the march towards single payer will have already begun.