Category Archives: Medicaid

Social Determinants Of Health: A Public Health Concept In Conflict

Source: Social Determinants Of Health: A Public Health Concept In Conflict

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Obamacare: The Last Stage of Neoliberal Health Reform

In my recent review of the Introduction to Health Care under the Knife, the term “neoliberalism” was discussed as one of the themes the authors explored in diagnosing the root causes of the failure of the American health care system.

For review, the term neoliberalism refers to a modern politico-economic theory favoring free trade, privatization, minimal government intervention in business, reduced public expenditure on social services, etc. (Source: Collins English Dictionary – Complete and Unabridged, 12th Edition 2014)

As defined in Wikipedia, and as I wrote in my review, neoliberalism refers primarily to the 20th-century resurgence of 19th-century ideas associated with laissez-faire economic liberalism. Those ideas include economic liberalization policies such as privatization, austerity, deregulation, free trade and reductions in government spending in order to increase the role of the private sector in the economy and society. These market-based ideas and the policies they inspired constitute a paradigm shift away from the post-war Keynesian consensus which lasted from 1945 to 1980.

This recrudescence or resurgence gained momentum with the election of Ronald Reagan to the presidency, and with the Republican takeover of the House of Representatives in the 1994 midterm election, which made Newt Gingrich Speaker of the House, and implemented the Contract with America. (I’ve called it the Contract on America, for obvious reasons)

Yet, the full impact of neoliberalism was not felt until the rise of the TEA Party in the run-up to the passage of the Affordable Care Act, or Obamacare, and that led to the Freedom Caucus in the House that has tried unsuccessfully multiple times to repeal and replace Obamacare with basically nothing.

Economist Said E. Dawlabani, in his book, MEMEnomics, describes the period from 1932 to 1980, which includes the post-war Keynesian consensus, as the second MEMEnomic cycle, or “Patriotic Prosperity” MEME. The current period, from 1980 to the present, represents the third MEMEnomic cycle, or the “Only Money Matters” MEME.

It is in this period that the American health care system underwent a radical transformation from what some used to call a “calling profession” to a full-fledged capitalist enterprise no different from any other industry. This recrudescence of 19th century economic policies did not spring forth in 1980 fully formed, but rather had existed sub-rosa in the consciousness of many American conservatives.

In the early 1970’s, Richard Nixon’s administration came up with the concept of the Managed Care Organizations, or MCOs, as the first real attempt to apply neoliberalism to health care. As we shall see, this would not be the first time that neoliberal ideas would be implemented into health care reform.

In Chapter Seven, of their book, Health Care under the Knife, authors Howard Waitzkin and Ida Hellander, discuss the origins of Obamacare and the beginnings of neoliberal health care reform. They point to the year 1994 as a significant one for reform worldwide, as Colombia enacted a national program of “managed competition” that was mandated and partially funded by the World Bank. This reform replaced their prior health system and was based mostly on public hospitals and clinics.

1994 was also the year when then First Lady, Hillary Clinton spearheaded a proposal like the one Colombia enacted that was designed by the insurance industry. I am sure you all remember the Harry and Sally commercials that ran on television that sank her proposal before it ever saw the light of day?

What ultimately became Obamacare was the plan implemented in 2006 in Massachusetts by Mitt Romney, but that was later disavowed when he ran for President in 2012. Waitzkin and Hellander write that even though these programs were framed to improve access for the poor and underserved, these initiatives facilitated the efforts of for-profit insurance companies providing “managed care.”

Insurance companies, they also said, profited by denying or delaying necessary care through strategies such as utilization review and preauthorization requirements; cost-sharing such as co-payments, deductibles, co-insurance, and pharmacy tiers; limiting access to only certain physicians; and frequent redesign of benefits.

These proposals, the authors state, fostered neoliberalism. They promoted competing for-profit private insurance corporations, programs and institutions based in the public sector were cut back, and possibly privatized. Government budgets for public-sector health care were cut, private corporations gained access to public trust funds, and public hospitals and clinics entered competition with private institutions, with budgets determined by demand rather than supply. Finally, prior global budgets for safety-net institutions were not guaranteed, and insurance executives made operational decisions about services, superseding the authority of physicians and other clinicians.

The roots of neoliberal health reform emerged from the Cold War military policy, and the authors cite economist Alain Enthoven providing much of the intellectual framework for those efforts. Enthoven was the Assistant Secretary of Defense under Robert S. McNamara during both the Kennedy and Johnson administrations. While he was at the Pentagon, between 1961 and 1969, he led a group of analysts who developed the “planning-programming-budgeting-system” (PPBS) and cost-benefit analysis, that intended to promote more cost-effective spending decisions for military expenditures. Enthoven became the principal architect, the authors indicate, of “managed competition”, which became the prevailing model for the Clinton, Romney, and Obama health care reforms, as well as the neoliberal reforms around the world.

The following table highlights the complementary themes in the military PPBS and managed competition in health care.

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Sources: See note 11, page 273.

Enthoven continued to campaign for his idea throughout the 1970s and 1980s and collaborated with managed care and insurance executives to refine the proposal after being rejected by the Carter administration. The group that met in Jackson Hole, Wyoming, which included Enthoven and Paul Ellwood, was funded by the five largest insurance corporations, as well as the 1992 Clinton presidential campaign, and wife Hillary’s Health Security Act.

The authors state that Barack Obama, while a state legislator in Illinois, favored a single payer approach, but changed his position as a presidential candidate. In 2008, he received the largest financial contributions in history from the insurance industry, that was three times more the contributions of his rival, John McCain.

The neoliberal health agenda, the authors write, including Obamacare, emerged as one component of a worldwide agenda developed by the World Bank, the International Monetary Fund, and other international financial institutions. The agenda to promote market-driven health care, facilitated access to public-sector health and social security trust funds by multinational corporations, according to Waitzkin and Hellander. The various attempts in the US by the Republican Party to privatize Social Security is an example of this agenda.

An underlying ideology claimed that corporate executives could achieve superior quality and efficiency by “managing” medical services in the marketplace, but without any evidence to support it, the authors contend. Health reform proposals from different countries have resembled one another closely and conform to a cookie-cutter template. Table 2 describes the six features of nearly all neoliberal reform initiatives.

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† Sources: patients, employers, public sector trust (“solidarity”) funds (the latter being “contributory” for employed workers, and “subsidized” for low income and unemployed).
‡ Sources: patients, public sector trust funds – Medicaid, Medicare.

The six features of neoliberal health reform are as follows:

  1. Organizations of providers – large, privately controlled organizations of health care providers, operate under direct control or strong influence of private insurance corporations, in collaboration with hospitals and health systems, may employ health care providers directly, or may contract with providers in a preferred network. In Obamacare, they are called Accountable Care Organizations (ACOs), supported only in Medicare, but Obamacare accelerated organizational consolidation in anticipation of broader implementation.

In this model, for-profit managed care organizations (MCOs) offer health plans competitively. In reality, competition is restrained by the small number of organizations large enough to meet the new laws’ financial and infrastructure requirements, as well as by the consolidation in the private insurance industry. They contract with or employ large numbers of health practitioners. Instead, physicians and hospitals are absorbed into MCOs.

  1. Organizations of purchasers – large organizations purchasing or facilitating the purchase of private health insurance, usually through MCOs. Under Obamacare, the federal and state health insurance “exchanges”—later renamed “marketplaces” to reflect reality of private, government-subsidized corporations—fulfill a similar role.
  2. Constriction of public hospitals and safety net providers – public hospitals at the state, county, or municipal levels compete for patients covered under public programs like Medicaid or Medicare with private, for-profit hospitals participating as subsidiaries or contractors of insurance companies or MCOs. With less public-sector funding, public hospitals reduce services and programs, and many eventually close. Under Obamacare, multiple public hospitals have closed or have remained on the brink of closure. Note: This is a subject I have written about in prior posts about Medicaid expansion.
  3. Tiered benefits packages – defined in hierarchical terms, minimum package of benefits viewed as essential, individuals and employers can buy additional coverage, poor and near poor in Medicaid eligible for benefits that used to be free of cost-sharing, but since Obamacare passed, states have imposed premiums and co-payments. Under Obamacare, various metal names—bronze, silver, gold, platinum, identify tiers of coverage, where bronze represents the lowest tier and platinum the highest.
  4. Complex multi-payer and multi-payment financing – financial flows under neoliberal health policies are complex (see Chart 7.1). There are four sources of these various financial flows.
    1. Outflow of payments – each insured person considered a “head” for whom a “capitation” must be paid to an insurance company or MCO.
    2. Inflow of funds – funds for capitation payments come from several sources. Premiums paid by workers and their families, contributions from employers is a second source. Public-sector trust funds are a third source, co-payments and deductibles constitute a fourth source, and taxes are a fifth source.
  5. Changes in the tax code – neoliberal reforms usually lead to higher taxes because they increase administrative costs and profits, Obamacare reduces tax deductions and imposes a tax for so-called Cadillac insurance plans. In addition, it calls for penalties for those who do not purchase mandatory coverage, administered by the IRS. I was unable to get on the ACA because I had not filed a return in several years due to long-term unemployment because of the financial collapse of 2007/2008, and the subsequent jobless recovery.

Chart 7.1 Financial Flows under Neoliberal Health Reform

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*Purchase of insurance policies for employers and patients mediated by large organizations of health care purchasers.

What is the outlook for single payer in the US, the authors ask?

They cite national polls that show that about two-thirds of people in the US favor single payer. See Joe Paduda’s post here.

If the US were to adopt single payer, the PNHP proposal would provide coverage for all needed services universally, including medications and long-term care, no out-of-pocket premiums, co-payments, or deductibles; costs would be controlled by “monopsony” financing from a single, public source, would not permit competing private insurance and would eliminate multiple tiers of care for different income groups; practitioners and clinics would be paid predetermined fees for services without and need for costly billing procedures; hospitals would negotiate an annual global budget for all operating costs, for-profit, investor-owned facilities would be prohibited from participating; most nonprofit hospitals would remain privately owned, capital purchases and expansion would be budgeted separately, based on regional health-planning goals.

Funding sources would include, they add, would include current federal spending for Medicare and Medicaid, a payroll tax on private businesses less than what businesses currently pay for coverage, an income tax on households, with a surtax on high incomes and capital gains, a small tax of stock transactions, while state and local taxes for health care would be eliminated.

From the viewpoint of corporations, the insurance and financial sectors would lose a major source of capital accumulation, other large and small businesses would experience a stabilization or reduction in health care costs. Years ago, when I first considered single payer, I realized that if employers no longer had to pay for health care for their employees, they could use those funds to employ more workers and thus limit the impact of recessions and jobless recoveries.

So how do we move to single payer and beyond?

According to the authors, and to this reporter, the coming failure of Obamacare will become a moment of transition in the US, where neoliberalism has come home to roost. This transition is not just limited to health care. The theory of Spiral Dynamics, of which I have written about in the past, predicts that at the final stage of the first tier, or Existence tier, the US currently occupies, there will be a leap to the next stage or tier, that being the Being tier, where all the previous value systems have been transcended and included into the value systems of the Being tier.

We will need to address, the authors contend, with the shifting social class position of health professionals and to the increasingly oligopolistic and financialized character of the health insurance industry. The transition beyond Obamacare, they point out, will need to address also the consolidation of large health systems. Obamacare has increased the flow of capitated public and private funds into the insurance industry and extended the overall financialization of the global economy.

The authors conclude the chapter by declaring that as neoliberalism draws to a close, and as Obamacare fails, a much more fundamental transformation needs to reshape not just health care, but also the capitalist state and society.

To sum it all up, all the attempts cure the ills of health care by treating the symptoms and not the cause of the disease will not only fail, but is only making the disease worse, and the patient getting sicker. We need radical intervention before the patient succumbs to the greed and avarice of Wall Street, big business, and those whose stake in the status quo is to blame for the condition the patient is in in the first place.

Therefore, Obamacare is the last stage of neoliberal health care reform.

Three Strategies for Improving Social Determinants of Health

A shoutout to Irving Stackpole for bringing this to our attention today on LinkedIn. This is an important topic that can address the serious issue of poverty in our inner cities.

The topic of food deserts first gained national attention thanks to the efforts of former First Lady, Michelle Obama, who not only created a vegetable garden on the White House grounds, but championed the creation of other gardens in inner city elementary schools.

One in particular was created at a Washington, DC school, and Mrs. Obama invited Chef Robert Irvine of Restaurant: Impossible to cook for inner city school children at Horton’s Kids, a local community center that provides after-school meals for kids.

So an article last week in Managed Care magazine, discussed the three strategies health care systems and payer organizations are trying to address patients’ social needs.

The first strategy, Tackle a neighborhood, focuses on the work ProMedica, a 13-hospital not-for-profit system in Toledo, Ohio is undertaking.

In the UpTown neighborhood of Toledo, the average median household income is less than $21,000 a year, and more than a quarter of all adults have not completed high school. Few residents have homes or vehicles, and healthy food options are hard to come by.

One way they are dealing with the food deficit in the neighborhood is by opening a grocery store called Market on the Green, and is a joint project of ProMedica and the Ebeid Institute.

They also initiated a job-training program, a financial opportunity center, and personal-finance advice and programs.

Last year, ProMedica doubled down and announced a 10-year plan to invest $50 million to create a national model for neighborhood revitalization. In March, they announced a partnership with a New York City-based nonprofit to invest additional capital to spur further economic growth.

Lastly, they expanded their screened 4,000 Medicaid patients who use the food clinic, and found that emergency department utilization decreased by 3%, and 30-day readmission by 53%, with a modest increase in utilization of primary care.

They also expanded screening  to include housing, transportation, and other social needs.

The second strategy is Tackle the top problems.

Here, Humana has been working on its Bold Goal, a population health strategy to improve the health of the communities it serves by 20%.

Humana wants to increase the number of “healthy days” in seven markets: Louisville, KY; Knoxville, TN; San Antonio, TX; Broward County, Fl; Baton Rouge, La; New Orleans; and Tampa Bay.

In the first year, the San Antonio market showed a 9% increase in healthy days, which was attributed to several initiatives, namely a telepsychiatry pilot to increase access to behavioral health services, food insecurity screening at primary are offices, and a collaboration with other organizations to improve diabetes management,

Finally, the third strategy is Develop a social determinants workforce.

Trinity Heatlh, a 93-hospital health care system in Michigan, and one of the largest Catholic systems in the country, has been addressing their patients’ social needs through a series of small experiments.

Trinity’s strategy is to develop a cadre of community health workers who will use pathways, regimented, evidence-based multistep protocols to help individuals address their specific needs.

Trinity found that by focusing on patients covered by Medicare, Medicaid, or both, and assisted by community health workers, they reduced their emergency department and hospital utilization considerably.

Trinity also hired AmeriCorps workers to serve as community health workers in nine markets. They focused on the social determinants of health of a narrow group of patients: high-utilizing eligibles in an ACO or other at-risk contract.

The strategies these organizations are undertaking are bold initiatives that show some promise of success, but time will tell just how successful they will be.

Yet, in an era of huge tax cuts going to the wealthy, and budget cuts  eliminating many government programs or severely limiting them, these companies are taking decisive action to reverse decades of neglect and despair in our inner cities.

But they won’t be effective unless there is greater cooperation from the communities they wish to serve, and from the rest of the health care community, and those in other institutions.

There is an accompanying story here: Social Determinants of Health: Stretching Health Care’s Job Description.

Rural Hospitals to Fail If Medicaid Expansion Ends

In April of 2015, I wrote the following post, Hospital Closures Due to Failure to Expand Medicaid.

This morning, Health Affairs posted a brief, Ending Medicaid Expansion Would Cause Rural Hospitals to Go Under.

As the current regime in Washington, and its allies in Congress slowly dismantle the ACA, rolling back Medicaid expansion will lead to rural hospitals closing, and rural patients being forced to travel long distances to get to a hospital, or to forgo medical at all.

What impact this will have on the entire health care sector is too early to tell, and what this may mean for workers’ comp, is also speculative, but it can’t be good if hospitals in the heartland go out of business.

Some way to make America great again. On the backs of, and on the health of, rural Americans who voted for this clown.

No Paradox

Sometimes, the solution to a problem is staring you right in the face, but you refuse to see it because you are blinded by your perceptions, your beliefs, or the distortions others have placed in your mind by lies and falsehoods spread about the real benefits of the solution, or the downsides.

Case in point, the question of single-payer health care in the US. The health insurance industry and their lobbyists and defenders in Congress have done a great job poisoning the minds of many Americans against the idea of single-payer, whether on ideological or economic grounds.

Yet, many of these same Americans are getting some form of government-sponsored health care, either Medicare, Medicaid, Tricare, or health care through the Veterans Administration. So, it was striking that before the enactment of the ACA, many Tea Party protesters shouted or carried signs that read, “Keep your hands off of MY Medicare!”

What they did not know or realize, was that it wasn’t THEIR Medicare, but the government’s Medicare. They were ones receiving the benefits.

So, it struck me this morning when I read an article by Tom Lynch of the Lynch Ryan blog, Workers’ Comp Insider.com.

The article, The American Health Care Paradox: A Lot Of Money For Poor Results, compares the US health care system with the health care systems of the OECD nations (Organization for Economic Cooperation and Development).

The OECD has 35 members, of which the US is one, and was formed in Paris in 1961. They promote policies that will improve the economic and social well-being of people around the world. It also performs annual comparative analyses of issues affecting its members.

Health care is one such issue, as is life expectancy, infant mortality, obesity, and death rates from cancer, among other health care-related topics.

But regarding health care, as Tom reports, on a per capita basis, we spend 41% more on health care than our wealthy nation peers in the OECD, and 81% more than the entire OECD average.

The following graph indicates amount of public versus private funding of health care among the OECD nations, as well as the OECD average. The light blue bars indicate private funding; the dark blue bars indicate public funding.

OECD Health Care Funding — 2015

According to Tom, while our public funding (Medicare, Medicaid, etc.) is comparable to many of the other countries in the OECD, private funding in the US is more than 100% greater tham Switzerland, and 300% greater than the OECD average.

Life expectancy:            US: 78.8 years (76.3 men, 81.2 women)
UK: 81 years (79.2 men; 82.8 women)
Japan: 83.9 years (80.8 men; 87.1 women)

Infant mortality:          US: 6.1% (per 1000 live births) 45% higher than UK at 4.2%, and 265%                                                higher than Japan’s at 2.3%.

Obesity and overweight rate is exceeded only by New Zealand. Finally, the rate of death from cancer per 100,000 people is 188, Mexico’s is 115, Japan’s is 177. But we lead the world in smoking cessation (whoopee!). So, I guess we can all breathe easier now than the rest of the world, especially the third world where so many start smoking at a very young age.

Into this discussion, Tom throws the current Republican tax plan, which he rightly says will throw 13 million people off of health care, and see $25 billion cut from Medicare.

Tom says that fixing health care will take time and a lot more money, and he is skeptical that the GOP tax scam will do that.

Duh! Of course it won’t. That’s the whole point of the tax scam and the umpteenth attempts to scuttle the ACA. They don’t believe in health care as a right for all Americans. It is in their DNA as Libertarian Conservatives. They are not Republicans, at least not like the two Republican presidents who tried to get health care passed, Theodore Roosevelt and Richard Nixon.

No, they want the money for their fat cat donors. They even said so publicly and bragged about it. And if all those votes to repeal and replace ACA didn’t convince you that they are fundamentally opposed to any government-sponsored health care, except their own, then you are blind.

The solution is staring you in the face on the above chart, Every other OECD member nation spends more publicly for health care than we do privately, and we are getting bad outcomes. Why is that? It is because health care is not like other consumer goods, and therefore should not be funded or marketed by private companies.

It is long past the time we should follow suit and do what every other OECD country has done, create a single-payer, improved Medicare for All system and stop fooling ourselves that the private market works. It does not, and the proof is in the metrics on cost, life expectancy, infant mortality, obesity and cancer deaths, etc.

Executive (Dis)order

The signing this morning of an executive order by the Orangutan will have, in the opinion of some of the bloggers and politicians, spell disaster for the nation’s health care system.

It will, if carried into action, likely siphon healthy people from the Affordable Care Act-compliant market, continuing a pattern of regulatory actions under the Trump administration that have undermined the ACA.

The rationale for such a move that has been given is that since Congress has not been able to repeal and replace the ACA, an executive order will, piece by piece.

Coupled with the recent budget move to eliminate the CHIP program for children’s health (New York State faces dire consequences if Congress does not act on CHIP), and cut backs to Medicare and Medicaid, the intent here is to privatize health care for some, and eliminate it for others, and to get government out of health care providing altogether.

There are provisions in this order for greater competition, short-term coverage, and lower premiums with less coverage. Why this is better is beyond me, unless the Orangutan is seeking to destroy health care so that single-payer will be the only option.

Cutting healthy people out of the ACA means leaving sick people to struggle with a health care law that many say needs to be fixed, not repealed and replaced. But because the Tea Party ranted and raved before it was enacted, and the Orangutan and the GOP campaigned on getting rid of it, they had no choice but to sabotage it if they could not do so through legislation.

I predict that we will soon see the total collapse of our health care system thanks to this stupid, overreaching, and ill-advised Executive Order. I even read today that the Vice President had to remind the Orangutan to sign the darn thing, something that almost slipped what is left of his so-called mind.

Welcome to Crackerbox Palace.

Now It’s Personal

Last week, some of my LinkedIn connections, as well as several other connections, learned of my recent hospitalization. The reason for this was not mentioned at the time, but I will tell you now.

Not having health insurance through an employer, and being denied renewal of a local county health care program, led to my going from Stage 4 to End Stage Kidney Disease.

The hospitalization last week was to place a catheter in me for peritoneal dialysis, and to repair an umbilical hernia.

My hospitalization was brought to light quite unexpectedly by my friend, Maria Todd. Maria’s sending best wishes for my speedy recovery and quick discharge from the hospital was much appreciated, and the warm words by others in response, and the thirty plus “likes” made me feel that people cared. For that. I am grateful.

But the events of the past month have brought home to me one very important point, given the current activity surrounding the so-called “repeal and replace” of the ACA, and the two Congressional bills that many consider doing more harm than good.

This nation needs Medicare for All.

There, I said it.

I know in the past, I have advocated single payer for others, but my illness has shown that anyone who loses health care for any amount of time, once they have reached adulthood, cannot go without health insurance.

This is what happens when men and women are removed prematurely from the workforce, for whatever reason, employer decides you are no longer wanted, economic downturn or just to eliminate positions that affect the bottom-line of the company, and are generally targeted to individuals in their 40’s, 50’s and early 60’s so that the company can save on health care costs for those employees, and so that younger workers can be hired to replace them.

This is not something new, and not related to automation and artificial intelligence disrupting whole industries, which is inevitable.

My initial view on single-payer was that if employers were no longer responsible for the health insurance of their employees, and they were guaranteed full coverage by the government, some of the job losses of the past decades would not have happened, and many talented men and women out of the workforce would be employed until their retirement.

If you don’t believe me, go to LinkedIn and read the many posts from such individuals who are still unemployed. One fellow in Texas even got turned down from jobs at fast food restaurants.

So, now it is personal for me.

I also know that many of you make your living from the health care system we currently have, and that some of you have expounded on why you think a single payer system is unrealistic.

I get it that your financial outlook depends on working in a broken, free-market system because it pays your salary, but healthcare was not supposed to be a business, nor was it supposed to marketed like any other commodity.

If you don’t believe me, read what Pope Francis said: “health is not a consumer good, but rather a universal right, and therefore access to health care services cannot be a privilege.”

But try telling that to Messrs. McConnell, Ryan, Paul, et al in Congress, and the current POTUS, all of whom want to eliminate medical coverage for millions of Americans they received under the ACA, cut back Medicare and Medicaid, and destroy Social Security.

Now that I will be receiving dialysis, and quite likely will qualify for disability, the prospect of not having those resources is very personal to me, and could literally mean my life.

Look in the mirror, then look at your spouse, your children, your parents, your neighbors, friends, etc. What do you think would happen to them if these programs were eliminated? Would you have enough money to care for them? Would you have money to pay for private insurance?

I lost my mother last month to dementia. She died on her 85th birthday in a nursing home some miles from my home (the home she and my father bought), but if the Republicans in Congress had gotten their way, and she had lived longer, I feared she would have been forced out of that nursing home, with no place to go, and would have been an even bigger burden to me.

So, I really don’t care if you are a Democrat, Republican, Independent, Libertarian, Socialist, Liberal, or Conservative, we all need health care at some point in our lives.

One of the friends I met here in Florida back in the 90’s died last July of a stroke. He was 73. He worked out, never smoked, had a good life, three kids, and like many of you, worked in Risk Management, as well as Human Resources, the legal profession, and served in Vietnam. But despite all that, he died prematurely, and went into involuntary retirement because he was in his 60’s. Luckily, his wife worked. But you get the picture.

We must all do our part to see that every American can get health care. Not just access to care, which is a Republican euphemism for being able to afford it, and if you can’t, too bad. But actual health insurance. Medicare for All.