Biden’s Opposition to Medicare for All: It’s All About the Billionaires, Baby

[Editor’s Note – this is a guest post by a friend of ours here at the Emptywheel Blog, Bob Lord. Bob is a longtime tax and finance attorney with some very salient thoughts on why the centrist Democrats are pushing back so hard on Medicare For All. One other note, we here at Emptywheel have purposefully not engaged on behalf of any particular candidate in the primary process, but the issues in play are fair game.]

By Robert J. Lord

Joe Biden has lots of reasons why he opposes the Medicare for All plan favored by Bernie Sanders and Elizabeth Warren.

The cost runs too high, the former vice-president tells us. People will have to give up their private health insurance. People will lose the right to choose their health insurance provider.

The list goes on, but do these reasons reflect Biden’s actual worries? Surely, he’s seen the studies that show Medicare for All would drive costs down, not up, as removing health insurance company profits and administrative costs from American health care totally changes the system’s accounting dynamics. Yes, an expanded Medicare would require administrative expenses, but nowhere close to the expenses that our current system requires.

Biden also knows Americans would welcome the chance to swap their private health insurance for Medicare. Don’t believe me? Speak to someone between the ages of 60 and 64 who’s relatively healthy. Ten to one she has her fingers crossed hoping to make it to age 65 without a major health challenge, so she can qualify for Medicare and never have to confront the insufficiency of her wonderful private insurance plan.

And very few Americans, we must keep in mind, choose their health insurance provider. Most of us get insurance through our employers. Employers choose the least expensive plan for all employees collectively, without regard to the needs and desires of individuals.

Given that Joe Biden’s stated reasons for opposing Medicare for All don’t pass the smell test, what could be the real reason for his opposition?

Could Biden simply be beholden to the health insurance industry and Big Pharma? Perhaps, but I suspect that something larger — the overall wealth of our wealthy — may be at play. After all, it’s not like health insurers and pharmaceutical companies are going to have his back come general election time.

Consider the difference between how Joe Biden, on the one hand, and Bernie Sanders and Elizabeth Warren, on the other, view the billionaires and centimillionaires who make up America’s super rich. Sanders believes the greed of America’s billionaire class threatens the social fabric of our country and has proposed a significant increase in the federal estate tax on grand fortunes. Warren has proposed a 2 percent annual wealth tax on all fortunes in excess of $50 million.

Biden’s differences with Warren and Sanders go deep. He has assured his rich donors — at big-dollar fundraising events — that their lifestyles will not change if he’s elected. Biden, whose donor list includes at least 13 ten-digit fortunes, has made it clear that he doesn’t think billionaires bear any more responsibility for America’s woes than any of the rest of us.

Just this week, he voiced his opposition to policies that would make it harder to become a billionaire.

But why would billionaires and centimillionaires particularly care whether we have Medicare for All versus the Obamacare-with-a-public-option plan Biden favors?

To answer that question, consider the fundamental difference between Obamacare and Medicare for All: who pays. Under Obamacare, individuals pay for their health care, through the insurance premiums they pay and their out-of-pocket expenses for the charges their insurance policies don’t cover. The government subsidizes insurance for lower income Americans through Medicaid, but the bulk of health insurance costs are paid by individuals or their employers.

The public option, Biden’s proposed fix to Obamacare, won’t change any of this. Even if every American healthcare consumer chose the public option, putting the private health insurance industry out of business in the process, individuals still would be responsible for their own health care costs.

Medicare works differently. Under Medicare, the government insures healthcare costs directly. Individuals don’t pay premiums or co-pays. Instead, tax dollars fund the cost of the program.

All this means that the transition from Obamacare to Medicare for All would transfer the burden of health care costs from health care consumers, who share in costs based on how sick or healthy they happen to be, to taxpayers, who would share in costs based on their respective incomes and tax rates.

The great majority of Americans live their lives as both health care consumers and taxpayers. Under Medicare for All, they would see an elimination of both insurance premiums and out-of-pocket medical costs. They would also see a tax increase, but ordinary Americans would save substantially more in health care costs than they’d pay in increased taxes.

But those billionaires and centimillionaires on Joe Biden’s donor list? Their tax increases would dwarf any savings they see in personal healthcare expense. Some could see seven figure tax increases.

Viewed through the billionaire lens, Biden’s loud opposition to Medicare for All makes distinct political sense. He needs billionaires to fund his White House aspirations, which still drive him three decades out from his first presidential run in 1988. He’s not only convinced himself that his billionaire supporters pose no threat to our social fabric, he even seems to believe that any health care reform that puts the squeeze on billionaire fortunes does pose a threat.

All in all, a classic case of why ambition often blinds us. In a 2018 speech, just a sentence or two after saying the billionaires he’s courting aren’t a problem, Biden lamented that the income gap in America is yawning.

What Biden’s ambition won’t let him see: Billionaires don’t exist in isolation. We have approximately 700 billionaires today in the United States. We have a larger number of half-billionaires and a still larger deep-pocket cohort of centimillionaires. And so on. Which leaves our top 1 percent controlling close to half the country’s wealth and the country with an income gap that Biden openly recognizes is “yawning” and, obviously, a problem.

In other words, those billionaires Biden’s won’t let himself see as a worry really are inseparable from the yawning income gap that he knows is a problem.

Sanders and Warren, by comparison, are clear-eyed. They can see that when the gap is so yawning that treatable or preventable injuries and illnesses are killing Americans who can’t afford healthcare and bankrupting millions of others, the only answer is that society — through taxation — must assume the cost of healthcare. Other countries, like Canada, recognized this reality decades ago.

And when America’s billionaires, with Joe Biden as one of their many mouthpieces, stand in the way of that process because they don’t want their taxes to increase, their greed tears at the fabric of American society.

Joe Biden can’t see that. His two leading rivals sure do.

[Robert J. Lord, a tax lawyer and former Congressional candidate, is an associate fellow at the Institute for Policy Studies. Bob previously served as an adjunct faculty member at the Arizona State University School of Law. Bob’s work focuses on the relationship of tax law to inequality. He contributes to both the website and to OtherWords, the Institute’s national syndicated editorial service. Bob also is a staff member at Blog For Arizona, the leading political blog in Arizona.]

142 replies
  1. David Anderson says:

    I think this is a bit simplistic. Donors definitely shape the possibility space as perceived by candidates and their policy staff but at the same time, it can be a longstanding judgement call that the probability of getting Medicare for All through a Congress where, best case scenario, Joe Manchin and/or Krysten Sinema is one of the critical votes in the Senate, is very unlikely. If we assume that a Democratic trifecta has enough time in a single Congressional term to get two or three big things (2009 it was stimulus, ACA, Dodd-Franks, 2017 it was failed Repeal and Replace and the tax cut) done, choices need to be made on prioritization. Medicare for All, in the best case scenario of a smooth and rapid implementation with no SCOTUS clawbacks, is a massive disruption to 20% of the US economy and US employer-employee relationships. Disruption means political risk as there will always be losers and winners even if on net, the average person is a winner from the policy. Does Medicare for All, a tough slog, deserve to be one of the two or three most important agenda items when de-fucking institutions, climate change, voter rights, civil rights also can lay legitimate claim to being a top 2 or top 3 agenda item under a Democratic trifecta in 2021?

    Losers, perceived to be losers and potential losers will scream far harder and louder in opposition than diffused winners. We are seeing that right now on the Hill as the surprise billing legislation is getting watered down as the potential losers ( a few private equity owned provider groups) are facing multi-billion dollar losses from their sociopathic exploit of bad contract law and regulatory uncertainty so they are flooding the airwaves with $30 million dollars in ads against anything that takes a dollar out of their pocket. If Medicare for All is to save significant money (trillions over a decade is significant) it will be by reducing payment rates to hospitals, doctors and pharmacies. Doctors are the most trusted professions, hospitals are usually the largest employer in a Congressional District so when those two groups start screaming, Congress-critters and the public will be inclined to listen.

    A donor will’s analysis is too simplistic when we take a look at the scope of possibility and the discretion of prioritization. Please don’t assume corrupt intent for reasonable discretion of priorities.

    • earlofhuntingdon says:

      You’ve described a corrupt system in dire need of change and called it realism – and its supporters realistic.

      Not every candidate thinks mega-donors should decide what’s possible for America or the Democratic Party.

    • bmaz says:

      Oh yes yes, Mr. Anderson, thank you for parachuting in to tell us we can’t have nice things. Talk about baloney that is too “simplistic”, your comment is right up there.

      “A donor will’s analysis is too simplistic when we take a look at the scope of possibility and the discretion of prioritization. Please don’t assume corrupt intent for reasonable discretion of priorities.”

      Uh huh. Very compelling word salad. Who bankrolls your blarney?

      • bmaz says:

        Just so it is clear where David Anderson parachuted into here from, he is a health insurance industry advocate. As in pretty much a lobbyist:

        “David Anderson joins the Health Policy Evidence Hub as a Research Associate. His background is as an insurance industry professional with a specific knowledge of Medicaid risk adjustment and provider network configuration. He has over 10 years of experience in data and quality management most recently with UPMC Health Plan, a leading innovating integrated delivery system in Pittsburgh, Pennsylvania. A prolific writer, David has written at since 2013 under the pen name Richard Mayhew. He focuses on explaining the logic and reasoning of insurance company decision making to an interested lay audience while also advancing policy proposals to improve the breadth and reach of insurance coverage for all Americans. Through his work and writing he embraces the challenges that the continual process of health care policy reform provides. David earned both his bachelor degree and a master degree in public policy from Carnegie Mellon University.”

        • earlofhuntingdon says:

          “He focuses on the logic and reasoning of insurance company decision making.”

          Anti-logic would be closer to the mark. Accurately explaining why insurance company payrolls and profits – and the myriad ways prices are gouged to pay for them – come before healthcare would never fly with an informed consumer.

        • David Anderson says:

          I’m a regular reader of Dr. Wheeler since FDL days as I know Marcy has particular expertise in areas that I know I am an interested layperson. I don’t comment as I don’t have expertise on most of the topics discussed here.

          Individual market health insurance is my area of expertise, so I will comment. As far as funding, I’m currently funded by a mix of FDA contracts and NIH grants plus a hard money university back-stop. I’m in the process of applying for other NIH funds plus some foundation funding for future work on how behavioral economics plays out in the ACA individual market. One of my big wins on a policy front was the popularization of the argument that the termination of CSR funding was a net progressive win (bringing the ACA in 2018/2019 far closer to the subsidy scheme that the House Dems proposed in 2009) and CSR appropriations should not be seen as a liberal “get” that requires concessions. CBPP has a good Health Affairs blog about that from yesterday:

          Now onto the “nice things” idea… show me a viable pathway given likely coalitions and realities. I think that massive restructuring on thin working majorities is a tough slog given history.

          We saw what happened in 2009 when the working majority (due to the filibuster) in the Senate was 0 and in the House was ~37 and the ACA was the result. We saw what happened in 2017 when the working majority in the Senate was 2 and in the House ~24 and Repeal and Replace failed. Major changes to the US healthcare system with thin working majorities is extraordinarily difficult even when that change is the governing trifecta’s #1 priority. This is especially true when the 218th Democrat in the House is in a Republican leaning seat (median US House seat leans GOP by 3-4 points) AND the 50th or 51st Democrat in the Senate is from a state that voted for Trump. Self-preservation incentives don’t line up with massive disruption incentives.

          If your theory of change is that a Democratic trifecta with 51-53 Senators (including Joe Manchin) and perhaps a 30-40 seat working majority in the House is enough to go all in on restructuring 20% of the US economy which will produce a lot of winners and losers and those losers will not scream loudly nor effectively, well that is a theory of change. Recent history says that a lot of things will need to go right for that to happen.

          Or the alternative is to focus on other priorities, of which there are several, and do a fix-it bill which produces far fewer losers even if it does not solve every problem. I think an ACA fix-it bill in a universe of Dems +1 to +3 in the Senate is far more likely to pass reasonably quickly and survive a hostile Surpreme Court challenge than Medicare for All. And in a decade, another bit of the apple can be eaten. It’s not sexy, it is not awe inspiring, but it is more likely to be implemented.

          • earlofhuntingdon says:

            Hypothetically, why do establishment advisers to major politicians spend so much time telling them what they can’t do?

            It’s as if they win by not changing the current system, its priorities, and its structures of power.

          • BobCon says:

            I’m partially in agreement and partially in very, very strong disagreement.

            I agree that the analysis of the forces behind Biden and others against M4A are heavily inluenced by parochial concerns. Medical device manufacturers, cosmetic surgeons, IP trolls, temp employee firms — there are a ton of people and companies besides billionaires who will fight M4A like crazy, and any analysis has to take this into account.

            HOWEVER, it is absolutely essential that Democrats stop negotiating with themselves and watering down proposals out of the starting gate. That approach is responsible for more failed progressive legislation than anything else. The Democrats end up giving up the high ground and end up fighting in no man’s land.

            The special interests will fight the Democrats on health care even if the Democrats promise to dismantle the ACA and put Grover Norquist in charge of Medicare and Medicaid.

            The squishy votes like Manchin get nothing by winning concessions now anyway, and they will rev up the fight again in 2021. So the position of people wanting strong national health care should recognize there is no point to getting bogged down in auto-compromise now. It must be dealt with at the negotiating table, not before.

            • coral says:

              This is why I am grateful for the Sanders campaign absolute unwillingness to budge from the strongest, most comprehensive Medicare for All proposal. I am not a Sander supporter, but am happy he has changed the public dialogue on this issue.

            • Mongoose says:

              “HOWEVER, it is absolutely essential that Democrats stop negotiating with themselves and watering down proposals out of the starting gate. That approach is responsible for more failed progressive legislation than anything else. The Democrats end up giving up the high ground and end up fighting in no man’s land.” Yes! This is instinctive with Moscow Mitch and his cronies. Democrats haven’t a clue.

            • Sonso says:

              I wholly agree that Democrats should stop negotiating against themselves. That said, Mr. Anderson’s seemingly cold-eyed analysis is probably correct vis-a-vis Congress (the House can’t even issue articles of impeachment against President Traitor). Bill Mahrer long ago said Americans were stupid, and we have to admit there’s a large and powerful cohort that answers to that description. If there’s a higher power, I sure hope it shows up to help us organize and make the changes desperately needed.

        • Peterr says:

          His background is as an insurance industry professional with a specific knowledge of Medicaid risk adjustment and provider network configuration.

          Seems to me that configuring the network of healthcare providers from n separate networks sanctioned and determined by the executives of insurance companies into a single network covering the entire nation might be somewhat cost effective.

          He focuses on explaining the logic and reasoning of insurance company decision making to an interested lay audience while also advancing policy proposals to improve the breadth and reach of insurance coverage for all Americans.

          I think most of the “interested lay audience” understands the logic and reasoning of insurance company decision making. Maximizing returns to shareholders and bonuses to senior executives is a well-known concept crossing all manner of industries.

          As for improving the breadth and reach of insurance coverage, I refer you back to my comment above regarding network configurations.

          As Ken Arrow noted in the second paragraph of his classic 1963 paper Uncertainty and the Welfare Economics of Health Care, “It should be noted that the subject is the medical-care industry, not health.” Arrow goes on to point out — in careful measured prose — that the administrative costs of insurance (especially market-based insurance) are a particular problem that is exacerbated by market forces. The solution? Says Arrow:

          This striking differential [in premium costs between individual insurance and group insurance cited earlier in the paper] would seem to imply enormous economies of scale in the provision of insurance, quite apart from the coverage of the risks themselves. Obviously, this provides a very strong argument for widespread plans, including, in particular, compulsory ones.

          The insurance industry has been fighting the logic of Ken Arrow’s paper for over 50 years, and the only way they have found that can beat it is to (a) ignore it themselves, and (b) encourage Congress, the executive branch, and corporate America to ignore it as well.

          Sadly for the insurance industry, it seems that people are beginning to see the flaws in the insurance industry’s logic and are siding with Arrow.

          • orionATL says:

            peterr –

            “I think most of the “interested lay audience” understands the logic and reasoning of insurance company decision making. Maximizing returns to shareholders and bonuses to senior executives is a well-known concept crossing all manner of industries.”

            well, you know, for the health insurance industry, a dead insuree is the best insuree.

            at that point you know the future value estimate of your outlays just went to zero. permanently.

            nice to see that trenchant kenneth arrow quote.

        • Gil Moore says:

          bmaz wrote: “David has written at since 2013 under the pen name Richard Mayhew.”

          Bringing a complicated world view on insurance to an interested, but unknowing audience for years. He also helped me bring my hospice experiences to that same audience. Great guy.

          He has a very particular set of skills. Skills he has acquired over a very long career. Skills that make him a nightmare for people like Republicans.

          • bmaz says:

            Um, NO, I did not write that at all. That was in the text of Mr. Anderson’s bio blurb at the Duke-Margolis Center. But, accuracy is a relative “skill” in and of itself it seems. Which is why I provided the relevant link. Oh well, there is “accuracy” in reading too. You might ponder that.

            And, thanks, I know you are new here, but few in this forum are “unknowing”.

              • bmaz says:

                Thanks. We will choose our own nomenclature and tenses.

                Your initial “two centavos” that you anted up previously were worth more than this response.

      • earlofhuntingdon says:

        This is precious: “the discretion of prioritization.”

        Is that insuranceese for private profit over all other human priorities? If so, it is a priority at least a few presidential candidates are trying to overcome.

        It is one European health care systems overcame decades ago. That success is now under attack – in the UK most spectacularly – by neoliberal forces trying to put profits first again.

        • P J Evans says:

          “The discretion of prioritization” is why I put off getting a mammogram year before last – it wasn’t immediately threatening, like the other stuff. Yes, it was a risk, and I knew it at the time. (I was sure what they’d find before I went in, and I went to a different place from the one the doc referred me to, because they weren’t going to require screening first, and also they weren’t associated with an RC-run hospital.)

    • SomeGuyInMaine says:

      Hey Dave!

      Know what seems simplistic? Saying there no real path forward because it’s all just too hard.

      Costs need to come out of the system. The bulk of those excess costs are in the private sector of the market. Medicare for all is a fast mechanism to do that with some clarity and momentum. Who know what it looks like when it finally gets done? I don’t. I do know we have to start now.

      Waiting around for some heaven sent list of other priorities won’t help at all. Not a bit.

      • David Anderson says:

        What are the major problems in the ACA framework that are solvable by a narrow Dem trifecta working within the ACA framework:

        * Medicaid administrative friction leading to more disenrollment — executive action primarily on waivers and validation
        * Premiums too expensive for too high of a deductible/Out of Pocket max — tweak subsidy formula, make Gold baseline plan instead of Silver, extend CSR obligations further up the income ladder so that everyone can get a plan that looks a lot like standard contracts via ESI for less than 8.5% of income (needs legislation, multiple versions proposed and going nowhere at the moment)
        * Remove family glitch (needs legislation, multiple versions proposed and going nowhere at the moment)
        * Remove income cap on subsidy eligibility from 400% FPL to a fixed % of income (see California doing that with state funds in 2020) ((needs legislation, multiple versions proposed and going nowhere at the moment))
        * Not enough insurer competition — introduce Medicare or Medicaid buy-ins that run parallel to the ACA QHP markets (needs legislation, multiple versions proposed and going nowhere at the moment (Sen. Schatz best example) or a very creative CMMI director and a friendly court)
        * Prices are too damn high — fully fund FTC and crack down on already established local provider monopolies (executive action + budgetary appropriations)

        Major problems not solvable by a narrow Dem trifecta within ACA framework due to SCOTUS:
        Medicaid expansion in hold-out states (although throwing more money at hold-out states per Sen. Warner’s SAME ACT may help)

        Does this solve every problem. Hell no. Does it solve some problems; yes.
        Can these things pass in a Senate with 51 to 53 Dem votes and 235-255 Dem Reps and survive a hostile Supreme Court? Highly likely.

        • Rayne says:

          So basically just jostle a little our existing system which costs 2-3X what other countries pay per capita for single-payer heath care while they continue to have better outcomes.


        • BobCon says:

          I’m not convinced ACA survives in the Supreme Court, even though Roberts backed it partially a few years ago.

          I strongly suspect that we will see an era of judicial activism by the conservatives on the court to rival the reactionary fever of the New Deal Supremes.

          I expect to see a flat out war on any legislation passed by Congress and the states and an attack on the authority of regulatory agencies to do anything to either fund health care expansion or rein in costs.

          Biden will cave. Some other candidates will not.

          • Karen G. says:

            The “New Deal Supremes”??? Who exactly are you referring to? If you were using the name of a black female musical group to a group of congresswoman of color that would be misogynistic, racist and well, not smart. Of course there has to be room for disagreement and varying degrees of leftism but it’s just handing Repubs a gift when otherwise smart, thoughtful people who care about democracy express their intra-party disagreement in demeaning and disrespectful ways. Please clarify?

            [Welcome back to emptywheel. Please use the same username each time you comment so that community members get to know you. This is your second user name. Thanks. /~Rayne]

            • bmaz says:

              What in the living fuck are you talking about???? You don’t even have the historical background or knowledge to know about the travails of the Supreme Court during FDR’s New Deal era, but instead jump to those bogus conclusions?

              Jesus. Nice first comment.

            • Rayne says:

              Take a breath and sit down.

              He’s referring to the jurists of the Supreme Court during/immediately after the New Deal.

              There’s NOTHING in his comment referring to race/sex/gender. Believe me, I’d be the moderator up in his grill if there were.

              Welcome back to emptywheel.

        • Peterr says:

          The notion of an insurance industry person worrying about “Medicaid administrative friction” is rich. Insurance is based on the notion that the added friction on the payment side would be outweighed by the benefits on the provision of services side. What is missing from that equation in the real world is that the insurance companies, over time, have found wonderful ways to add additional friction to the system that do nothing to increase the benefits with respect to services provided.

          For example, the notoriously byzantine forms and procedures are designed in such a way as to encourage those who would challenge benefit decisions, charges for services, and other insurance company acts to throw up their hands in frustration and say “screw it – I give up.” The more administrative friction, the better – at least for the insurance company.

          Or consider, as has been noted below, most people do not choose their insurance company – their employer’s HR people do that. This adds another layer of friction to the system, as the incentives of HR do not match those of the employees themselves. Employees who have their policies and insurance carriers change three times in five years are well aware of the meaning — and costs — of “administrative friction.”

          • P J Evans says:

            The administrative overhead at Medicare is reported as about 3%. That’s a lot less than insurance companies. I suspect a lot of the overhead at those is from executive salaries and the long appeal processes when accounting types deny claims.

        • Jonf says:

          Sounds like you want to spiffy up a corrupt POS system and assume Trump or the next asshole and-or the Supremes will leave it alone. Riiight!

        • SomeGuyInMaine says:

          “…working within the ACA framework.”

          There’s your problem, right there.

          ACA tackled access, in a really complex half-assed ‘market-driven” way (thanks heritage foundation). I didn’t really tackle costs, not is it suited to do so.

          M4all addresses costs head on and fixes a bunch access issues too. No it’s not going to be easy, but it’s sure headed in the right direction.

          I’m not going to throw my hands up and say “whoa too hard.” Just like I won’t tell the Parkland kids not to take on the NRA because it’s too hard.

          Do what’s right, make progress one step at a time, even on really big stuff.

        • Ed Walker says:

          Medicaid and Medicare friction? Both are administered by private insurance companies under contract with the Government.

        • Wm. Boyce says:

          “* Medicaid administrative friction leading to more disenrollment — executive action primarily on waivers and validation”

          The main “friction” has been the refusal of most Republican governors to expand Medicaid in their states – helping to lead to fewer people covered and rural hospitals going out of business. Many people face an hour or two’s drive to get medical care now in these benighted places.
          In states where the rolls have been expanded, it’s never going back, not even West Virginia, one of the biggest per capita users of Medicaid.
          Insurance companies must maximize return to their shareholders – by law if they are publicly traded. It’s not an option to care about the insured.
          I have a friend who is a bill collector. (a great human being, too, believe it or not) He has long told me that his business was mainly health care cost collections.
          A recent column by the Center for Economic Policy and Research details how private equity is buying into emergency medical services and causing much of the “surprise medical bills” that people are talking about:

          This is a system that needs to go out the window – it’s killing us.

    • Rayne says:

      This: “Does Medicare for All, a tough slog, deserve to be one of the two or three most important agenda items when de-fucking institutions, climate change, voter rights, civil rights also can lay legitimate claim to being a top 2 or top 3 agenda item under a Democratic trifecta in 2021?

      YES. What part of Americans dying for lack of health care coverage do you not get? Moving away from our current, dysfunctional health care system *is* de-fucking when tens of thousands of Americans die because they don’t have access to health care.

      I’m sure I’m repeating what you’ve already heard when I note research in 2005 indicated 45,000 Americans died annually for lack of health care (pdf) pre-ACA implementation when 44 million Americans had no health care insurance. With 28 million Americans still uninsured today, the number of deaths extrapolates to 29,000 a year.

      And I’m sure you’ve probably hear that research found the odds of dying among the insured relative to the uninsured is 0.71 to 0.97.

      You’re probably familiar with testimony by Dr. John Z. Ayanian of the National Academies’ Institute of Medicine before Congress in 2009, in which he said,

      “Uninsured adults are also more likely to be diagnosed with later-stage cancers compared to their insured peers. If hospitalized for a serious acute condition, such as a heart attack, stroke, or major trauma, uninsured adults are more likely to die after admission to a hospital. Uninsured adults are 25 percent more likely to die prematurely than insured adults overall, and with serious conditions such as heart disease, diabetes or cancer, their risk of premature death can be 40 to 50 percent higher.”

      Hurricane Maria killed approximately 2,975 Americans because Trump deliberately neglected to do his job. De-fucking neglect is easy: elect an ethical, competent, non-racist president.

      De-fucking the annual deaths of tens of thousands of Americans will be more complicated but if we can completely upend our security infrastructure after the one-time event resulting in the deaths of 2,996 people, we can overhaul our health care system to save hundreds of thousands of lives over the next decade. We have the ability to de-fuck how we pay for health care and save fellow Americans; we’ve only lacked the ethics and political will to do so.

    • orionATL says:

      two things are for sure in the medical care discussion:

      1. starting with pregnant mothers, every child living in this country should have basic medical care thru age 18 as an economic imperative at least, if not a moral one. the same is true for food, for housing, and for education.

      2. talking about medical care is a terrible place for rhetorical grandstanding, a point i think david anderson addresses usefully. the key issue is making it happen. the key issue is not billionaire influence on politics. saying so is just stupid. why? because that influence is here, right now, in this society and is not going away due to rhetoric criticizing it. it is an encompassing reality. “americns for progress” is not going away, folks.

      as i have said, billionaires of all stripes are the offspring of corporations. corporations and their hyper rich offspring are, and have been since the 1970’s, the generators of severe economic unfairness and social unrest in this society. that is the current reality. changing it is the goal of a caring, well-functioning political system.

      no, the issue is to make good policy and actually deliver on an important promise to the citizens.

      a key issue in the medical care argument is the amount of time it takes to make a large scale government program begin working. it took years for the affordable care act to meet the promises of its supporters. people die from lack of available care in days, weeks, months, not years.

      i have no idea what is in biden’s mind. mostly it is clear he is deliberately, with verbal trickery, fudging every issue he addresses so that voters hear what message they want. i am not worried about his “centrism”. obama was a centrist too. i am concerned about the reality that biden is stupid, or at least slow, is politically unimaginative, inarticulate and uncaring. old joe is booorrrring!!

      a second key issue is the strong financial chains the last tax act placed this nation in. talk about breaking those chains needs to occur at the same time as we talk about such caring political actions as providing medical care to every child in this country.

      a third issue is not to frighten voters with talk that sounds like messing with their health insurance if they have adequate insurance. that is a new “third rail”.

      medical care for all is a fine umbrella term for political discussion – as is food, housing, and education for all children – but campaigning with caution about the details would be wise. elizabeth warren understands this, perhaps because she listens well to the citizenry, and is moderating her stand accordingly.

      • orionATL says:

        oh, and just keep in mind that when it comes to voters and medical care, those who have insurance, have medical conditions, know they need insurance, or have children are most concerned about protecting the promise that prior medical conditions not be allowed to influence one’s access to insurance or the price one pays for it.

      • orionATL says:

        i’ll add another imperative for the medical insurance/medical care discussion, as well as for dealing successfully with the destructive excess of political power corporations and their hyperrich offspring have bought for themselves in the last 45 years:

        there must be strong regulation of all sectors of the economy, medical insurance and medical care included. that regulation must permanently exclude individuals who have, or have had, any relation to a corporation including lobbying, public relations, and legal work.

      • Ollie says:

        “i am not worried about his “centrism”. obama was a centrist too. i am concerned about the reality that biden is stupid, or at least slow, is politically unimaginative, inarticulate and uncaring. old joe is booorrrring!!”

        You had me w/this statement oroinATL. I do NOT trust Biden and after the combo’s of: Bush, O and now Trump? I think he connives, deceives and overall lacks ‘energy’ for our future. I am not letting my clarity get fogged over. In other words, exactly like what a comment above stated: I’m sick of the Democratic party watering down their/our principals, ideals, to compromise so severe it does nothing in the end. I’m REALLY tired of always being 2-3 steps behind the GOP. My head spins over the contempt for laws …They are saying NO to our history as a Republic to defying wishes of their master . Trumps a really bad zit waiting to errupt. What are we going to do? Roll over? I wanted to bitch.slap that ‘party boy’ w/armed police and take that arrogant, smug NO BODY to jail for contempt. I think old Jerry is going to have health issues if he doesn’t get some backbone. Oh lord. I haven’t been reading here for a while and I apologize…Lots of sanity here and I’ve missed it. lol

        • orionATL says:

          yeah. i’m sick of democratic candidates and leaders who talk out of both sides of their mouth, too.

          our candidates need to be attacking trump and his senators and his congressmen for lying about the reality and the consequences of everything the republican party does or proposes to do. the Republican party has lived a lie of caring for values and pseudo-populism since 1980, and yet the democrats can never bring themselves to say “the emperor has no clothes”.

          democratic pols and their all-too-slick-and-smooth advisers need to start yelling about republican trickery of all sorts.

          “analysts” don’t seem to understand that a gteat deal of trump’s allure in 2016 was that he was shouting and contemptuous of the traditional american way of electioneering. anti-politics.

          a lot of americans HATE the slick, smooth, evasive way many politicians, including almost all democrats, talk in public. they crave some yelling, some passion.

          • bmaz says:

            Yes. But you knew I felt that way, and especially so as to Constitutional duties, oaths of office and necessity of the Congressional prerogative of oversight in the face of total obstruction.

            • orionATL says:

              bmaz –

              of course. your good heart was never the issue. your impatience and willing to tear down the only leadership available to do what you wanted done was.

              it coming, bmaz. but slowly. just as it must. lewindowsky was the firs🙂

              best of all, with the mysterious ic ig referral to schiff we may now have more than the technical sounding (to a voter) “obstruction of justice”.

              note that i am very specifically talking about dem politicians running for office speaking loudly, angrily, critically about our society’s problems like incomes stalled for 50% of the people for decades, like missing medical care, like debt and bankruptcy (why isn’t biden attacked on this for god’s sake). not Congresscroitters talking.

    • Jonf says:

      Health care now is 20% of the economy you say? Wow that comes to $4.2 trillion a year based on latest gdp of $21.3T. Check it out. Commonwealth Fund says in 2017 we paid $10224 per capita or about twice what other high income countries pay. Geez if we are spending over four trillion now a year that means that we pay nearly $13k a year each with 330 million of us. Holy shit, help. I’m not real good at math but this all sounds nuts. That is a realistic Economy to you? Talk about corruption, I got corruption for ya.

      • Sonso says:

        Yep; just 60 years old and I have the privilege of paying $30k a year for a bronze plan for myself & spouse. With a $13k total deductible. I would much rather pay that in taxes, with a severely reduced military budget in exchange for M4A.

        • Rayne says:

          This is what I am expecting to pay in the near future. And I think I have to get silver rather than bronze because of preexisting conditions and medications required. ~sigh~

    • Joe Bob says:

      (It’s been a while since i’ve commented here; I can’t remember for sure if this is the alias I used previously. Sorry.)
      Mr Lord writes:
      “Most of us get insurance through our employers. Employers choose the least expensive plan for all employees collectively, without regard to the needs and desires of individuals.”

      This is a crucial oversimplification/gloss-over by Mr. Lord. Polling of US voters shows that, not only do those who are covered by employer provided health care coverage rate their current private health insurance very highly, they also are overwhelmingly opposed to abolishing private health insurance. IOW the fact that those who currently receive employer-based health insurance are mostly happy with what they now have. Upshot being: why would they want that to go away, have to switch to an entirely different system/bureaucracy provided by a government that (for obvious reasons lately) can’t be trusted to do big things properly? What Lord writes here only works when “preaching to the choir” but I seriously doubt that even 20% (13% in the poll cited below) of the 156 million (I realize these aren’t all voters) who now have employer based health care.

      Here are two relevant polls:

      IOW: There are a lot(!) of regular, every-day Americans who oppose MFA and abolishing private insurance. You’ll need to convince these folks that MFA/no private insurance would be a change for the better…or have another plan.

      • bmaz says:

        Hi there Joe Bob Franks. That was the last handle, and the one on your only previous comment. You know what is “simplistic” Joe Bob? Blithely claiming howe many people just LOVE FUCKING LOVE their employer healthcare. That is an asinine discussion point. I was one of the managing partners in a law firm that provided healthcare to not just us, but all of our employees. We changed plans repeatedly because of cost, and, never, did the coverage get better. And that was long before the ACA, what goes on now is even more pathetic.

        No, that trope does not fly. There are a lot of “regular every-day Americans” that voted for Trump. It is a demographic that can be ignorant and uninformed. And, here is a “plan” for you: How about not criticizing people by saying they are “overly simplistic” when you, yourself, and David Anderson, are yourselves being overly simplistic. Try that one on for size.

        • Joe Bob says:

          Wondering whether or not you clicked through to look at the poll @ The Hill? 13% favor dumping private insurance. Are the other 87% billionaires?

          Slide 9 here:

          …shows that, overwhelmingly, in KFF’s polling, people favor a gradual Medicare buy-in, incremental approach to achieve universal coverage. (Of course, it’s well known that the Kaiser Family Foundation polls only billionaires.)

          and FWIW
          I have very good employer provided health care coverage and my impression is that my coworkers would agree for the most part (we’re doing anecdotals, right?). My son tore his ACL earlier in the summer; the care he received was stellar. He also had asthma when he was younger, which required frequent doctor visits. I couldn’t have asked for better care in during that (rather stressful for a parent) time.
          I’d FUCKING LOVE for this to be broken!

          • Rayne says:

            The survey is flawed. Employer health care is GREAT when you have no other alternatives — and that’s why it polls so well.

            Employers shouldn’t be in the business of health care (unless they’re health care providers). They should be able to allocate their resources to improving their products and services rather than spending them on additional HR time and resources to negotiate coverage.

            Health care has been a key reason why the American automotive industry wasn’t as competitive as it could have been as just one example of the problems with employer health care. It’s put workers at odds with their employer more so than conflicts over wages alone because health care costs have escalated faster than wages and in a way that neither the auto industry nor unions can control.

            The status quo has also heightened a monopsony condition for employers — take this job and get health care or you’re SOL. This reduces workers’ freedom to move to jobs which fit them better; it’s not good for productivity when ‘stickiness’ of employment drains on morale.

            • Sonso says:

              The number one thing that the gov’t could do to help every single genuine American business would be to do as you suggest: eliminate their need to provide health insurance/care. It’s a literal no-brainer (meaning the current policy makers have less than zero brains).

              • Rayne says:

                This is what I absolutely don’t understand: why aren’t businesses which now pay for health care demanding they are freed of it so as to compete more fairly with domestic and foreign businesses?

                Why isn’t the cost of insurance more tightly aligned with the users instead of helter-skelter across business?

                I could even see adding a tax on businesses based on experience rate — those with risky jobs and increased on-the-job injuries pay a tax not unlike unemployment tax. But why should businesses provide health insurance otherwise?

                Can’t even rule out a key reason for gender bias in hiring and promotion to management being tied to health care experience. I’ve run into bullshit from employers because I *might* get pregnant and when I was pregnant, for example.

      • Jonf says:

        Folks just loves them their private employer health care, right? That is until they get sick and choke on the deductibles or whether, in fact, the insurance even agrees to pay for it. But, what the hell we can have a fight with them. Eventually though everyone or one or more of his family runs afoul of the system or, they just get older and find themselves running into the borders more often or, heaven help us, they lose their job or quit or…. well you get the idea. How about a system with no deductible or co pay and portable wherever you work or go? And once we eliminate the excess cost and corruption of the current system, the savings will be like a tax cut since we pay twice what most other countries pay. And you know what? I’m willing to bet we pay no more in taxes. We can tax companies for this since they already pay for it and we just gave them a tax cut.

        • P J Evans says:

          When my father retired, he chose to keep his coverage from Aetna. My mother described it this way:
          At first, they covered 80% of the bill. (good)
          Then it went to 80% of what Medicare didn’t cover. (okay)
          The it went to “Medicare paid 80%, so we don’t have to pay anything”. (BAD!)

          Why would anyone want that kind of insurance???

  2. earlofhuntingdon says:

    What “choice” do most insureds have now? Their employers choose how much they’re willing to pay and what it will cost their employers. They choose the plan proposed by an insurance broker, often looking only at cost. The plan chooses which medical service providers are covered and affordable to the insured, and which are outside the plan.

    Even then, though, private equity is buying up practices and services across the country (ER physicians, road and air ambulances), and ensuring that they are “out of plan” even when provided by an in-plan hospital. Surprise! People have no choice about who transports them or fixes their bleeding artery or broken leg, so they are forced to pay out of network costs.

    That’s neoliberal resource extraction par excellence, an industrial water hose that blasts out mountains of American people, flushing them down river, looking for their nuggets of gold.

    Who doesn’t want to change that rigged system?

    • Old Antarctic Explorer says:

      It’s even worse than most people think. Insurers stand the word “insurance” on its head by setting rates for each company individually. They don’t share the load over all the companies they insure. One company I worked for years ago had less than 500 employees. Two employees had heart attacks in one year. The following year our costs/employee went up 20%. If they load had been spread over a million employees that the company probably had insured nationwide the two heart attacks wouldn’t have even raised a blip in their expenses. Some people think that’s “fair”, but it’s not “insurance”, which should spread the load over all subscribers to be “fair”.

      • earlofhuntingdon says:

        Reminds me of the car insurance company slogan, “Pay only for what you need.”

        The slogan – and the mandatory app that tracks precise car movements – individualizes rates rather than spreading risk through averaging the behavior and luck of many individuals.

        The aim, of course, is higher profits – and to access and commercialize the mountains of real time personal data that app generates, all unbeknownst to the insured (except in the unreadable fine print).

        • bmaz says:

          Those commercials, mostly Liberty Mutual (at one time a pretty good and elite carrier, now a TV outfit), but others too, drive me nuts. There has never been a time when individuals could not “buy the coverage they need”.

          It is one of the dumbest things ever to advertise on that. You want the bare minimum coverage in your state? The carriers in your state will sell that to you; indeed, they pretty much have to be certified to sell in your state. You want more coverage? They will sell that to you too. That has always been the case. It is a maddeningly stupid advertisement point.

          • P J Evans says:

            It’s the implication that if you’ve never needed collision or vandalism coverage, that you never will. Sells to some people, I’m sure.

          • earlofhuntingdon says:

            I think there are two methods to that madness. One is access to and commercializing that mountain of real time driving data.

            The other is an insurance company nirvana: normalizing individualized pricing – the opposite of real insurance – which permits higher profits, while blaming the victim.

            Sweet, but not as cute as that emu banging its head into its own image in the plate glass window, the experience of most insureds when dealing with their insurer.

            • earlofhuntingdon says:

              I’m partial to the two squirrels, high-fiving it after having caused a driver to swerve and crash to avoid them.

              As applied to insurance company pricing and practices, a Freudian slip of Enronian proportions.

      • BobCon says:

        Which points out another flaw in the idea that people love their employer-based health insurance.

        Employers change plans over and over as costs rise. The plan you like today can easily flip to a bad plan when the year ends. Your kids can’t keep seeing their favorite doctor because the plan changes, your deductables go up like crazy, things as annoying as needing to fill out ten million new forms, it is nuts.

        • coral says:

          I had to change my kids’ doctors 5 times over the course of 12 years because of insurance company changes. When you have a kid with severe asthma, and the specialist you relied upon is no longer available, this is life threatening. Plus the amount of time you have to spend researching and finding a decent doc who is in your insurance company’s network.

        • earlofhuntingdon says:

          Yes. And employers choose the plans and what they cover based on cost, not coverage. As coral notes, employers frequently change plans and providers, creating enormous workloads for employees and their families.

          An army of insurance broker advisers do most of the work “evaluating” available plans for employers. (The neoliberal magic of choice is restricted to what’s on offer, not what’s wanted.)

          Most are standard, off-the-shelf models designed for large for-profit employers, although they may be intended for, say, a small public library system. Employees, even unionized ones, rarely have meaningful input. The end result is that a narrow range of plans are chosen by most employers.

          Employees might be willing to pay more for better plans with greater coverage. The higher premiums are almost always less expensive than the higher cost of less coverage, with higher deductibles and co-pays. But better plans are rarely on offer.

          The rationale is that they are “gold” or “Cadillac” plans that are too expensive, too luxurious for employees – who should have skin in the game, including teeth and bones – and beyond what employer peers are offering. (That’s usually enough to convince the board and the CEO, even in a non-profit.)

          Better plans are being dropped because Insurance companies do not want the risk. Even if the premiums cover it, high-coverage plans are not as profitable as plans with less coverage. So they normalize less coverage at higher cost as the new normal. Wash, rinse, repeat.

          • P J Evans says:

            And, as an employee looking at the very limited information on what the plan actually costs and covers, all their examples seem to be 20-something guys or people who are married with two kids – not useful if you’re not in either group. (So I tended not to sign up for any of them. Fortunately, I was healthy during that period.)

  3. P J Evans says:

    Correction: You don’t have to pay for Medicare part A. Part B currently has a premium of about $130 per month – and you need part B. (Medicare could use fixing, too: it doesn’t cover some things that it should.)

    • Eureka says:

      Yes, there is a lot that Medicare (even with most supplemental Advantage plans) doesn’t cover, and those gaps can and do financially devastate families as well.

      We truly need something more like the _coverage benefits_ that Medicaid provides, without the entry-fee of poverty or near-complete loss of resources (for the person and, increasingly, their caregivers) to get it.

      Because the next financial crisis looming is for families who have cared for their elders– losing income, paying costs– who have nothing left or not enough saved to care for themselves in their golden years. This problem is growing as family care arrangements increase, especially given the population structure and the aging of the baby boomers.

      But first things first…

    • Willis Warren says:

      Part A is free if you’ve worked 40 quarters. It’s also free if you are married to someone who has worked the 40 quarters for ten years or so, can’t remember.

      Part B premiums are 135.50 for 2019, unless your income is high, then they charge more.

  4. HanTran says:

    regarding “Under Medicare, the government insures healthcare costs directly. Individuals don’t pay premiums or co-pays. Instead, tax dollars fund the cost of the program.” Decent coverage is NOT fully funded by the government.

    Two years ago I was forced, due to my age, to change from the ACA to Medicare…… my costs doubled for similar coverage with a somewhat higher deductible. Most don’t pay for Part A, almost all pay for Part B, and most pay for private insurance to supplement that and for drug coverage.

    • Mary M McCurnin says:

      I pay the $130 for medicare part b and $148 for the supplemental coverage. I cannot afford it but I need it so I find a way to pay it. Every month I wonder if my housing and health care situations will collapse. So far, I have made to the end of each month.

      • bmaz says:

        Mary, that is, along with coverage to start with, precisely the issue. Most of us think about that to some degree. “When will it all overtake us?” “What if something catastrophic happens”? There are no perfect answers, but there is a better path to the eventual answers.

        Magic bullets are the only bullets in short supply these days.

  5. earlofhuntingdon says:

    There’s a first world because there’s a third. Billionaires exist because governments enable and subsidize the wealthy in their pursuit of wealth and in the ways they keep and grow it: business regulation, tax rates on income and investment gains, inheritance taxes, laws governing contracts and their enforcement, torts, the environment, and the courts.

    The money comes from lots of places. Much of it comes from abusing labor: Jeff Bezos and his factory warehouses, Uber and its drivers, General Motors and big coal vs. their unions. It comes when insurers deny coverage, and when lenders use predatory accounting, lending, and collection practices. It comes when Joe Biden closes the bankruptcy court door for most American consumers, enriching banks and forcing average Americans into debt peonage rather than giving them a way out.

    It comes from destroying the environment. It comes from unregulated – meaning government actively doing nothing – mergers and acquisitions. It comes from paying a million dollars for lobbying instead of ten million in normal taxes.

    Wealth doesn’t just happen, as Joe Biden would suggest. It is often inherited, it is sometimes actively worked for, it is always heavily subsidized and enabled by government. Governments can change that priority, which is why M4All is so threatening.

    • JamesJoyce says:

      I have a better Idea..

      Screw the corporate appeasers, their donor class and their rancid business model, just like the state based slaveowners?

      Servitude to
      monied interests takes many forms.

      Jefferson Davis and MBS can teach us all about servitude to monopoly, where the monopoly flourishes and people die as fugitives from monopoly, protected by law.

      Maybe Tobacco should
      be paying insurance premiums since they are murdering bastards in suits like Purdue?

      Tobacco commercial are corporate America..


  6. Scorpio Jones, III says:

    “Medicare works differently. Under Medicare, the government insures healthcare costs directly. Individuals don’t pay premiums or co-pays. Instead, tax dollars fund the cost of the program.”

    Gosh, I did not know I am not supposed to pay premiums and co-pays when I have medicare.

    I am writing to all my health care providers and to Medicare to demand a refund.

    Thanks so much for letting me know about this.

    • bmaz says:

      Hi there “Scorpio”. Thanks for the smarmy ass comment. You are two for two in your limited participation on this site.

    • coral says:

      The Medicare for All program proposed by Bernie and Warren would change all this. It would be much more inclusive (eyeglasses, hearing, dental), and would be paid for through taxes. It would eliminate copays, deductibles.

  7. Americana says:

    One thing which is not mentioned frequently enough in these debates about the next steps to take regarding health care in the U.S. is that most American employers are trying to get out from under offering health care as one of their corporate benefits. Should it ever come to pass the U.S. returns to the time when health care was NOT a corporate benefit and it was handled entirely by the individual, what will we do then? That’s the basis of what our debate should be — the situation of procuring health care when health care as a corporate benefit has been pulled from all American workers. At that point, there will be millions of Americans without the collective advocacy of corporate HR departments advocating for suitable and inclusive health care plans.

    One does pay premiums for Medicare as well as for individual components of Medicare including paying premiums for long-term drug coverage. There are four plans you can buy to add to your Medicare coverage, some of which are required to supplement an overall Medicare plan.

  8. SomeGuyinMaine says:

    Looks like the third link in the article, the one, has Facebook tracking code. I may be wrong, but if not, can we get a clean link?

  9. Drew says:

    I recently reached 65 and went on Medicare & Social Security. The thing I noticed above all else is the contrast of working with these two government agencies with working with private health insurers over the years, especially the last decade or so. Medicare and Social Security were uniformly courteous, professional and efficient, while the (various) private insurers were opaque, self-serving, and not interested in serving the customers. It was consistently and adversarial system when I never knew which claim would be denied or delayed for some obscure reason which would require several calls–mostly on terminal hold, and then having my wife put on her lawyer persona threatening litigation before they would suddenly discover that everything was ok and it would all be paid and why were we so upset anyway.

    It’s not that one doesn’t spend time on hold with Medicare or Social Security or that there is never a bump in the road, but I have consistently been treated as a citizen and not as an adversary, or source of scrabbling out a few hundred dollars more for the shareholders through sharp dealing.

    Having been a young adult during the transition to Reaganism that took place in the 70s & 80s, the argument that was made (and won the day in terms of public attitudes & perceptions) was exactly the opposite–i.e. that private sector would give better service & be more concerned for people because of *competition* and *markets* –we’ve learned the hard way that that is a load of BS.

    There’s one thing in the post which is elided over. Medicare does have copays and quite substantial deductibles as presently constituted. I’m fortunate to have an excellent supplemental policy provided through my pension. [BTW I have two pensions, one is an old-style defined benefit & the other is a TIAA-CREF defined contribution, the defined benefit pension operates with the helpfulness of Medicare/Social Security while the insurance company model, is followed by… the insurance company.]

    The Medicare for All that is envisioned is likely not exactly the program that will result in the end–particularly in the question of eliminating copays and deductibles, simply because of the cost. This is not to argue that it shouldn’t happen or that we shouldn’t pursue single payer health insurance with no copays or deductibles, but we shouldn’t be pollyanna and say that just extending the current program for seniors will give us that.

    • PeteT says:

      Generally agree with you – this coming from a 68 year old Medicare-Social Security participant. Are you straight Medicare or Medicare Advantage? I have been Advantage since day 1 and, so far, no complaints and get courteous treatment. But I do know other Advantage members that are given to ole run around all the time.

      Having said that, Medicare Advantage is a way for – for profit – companies to participate in a Medicare for All system so it does not have to be the elimination of private insurance companies.

      I admit I am not up on the detail fo the various Dem candidate Medicare for All plans.

      • Drew says:

        I am on straight medicare with a pretty standard supplement (I think pretty much the same profile as the AARP supplement). My pension provides this, fully subsidized and getting anything else I would have to pay, so we’re taking advantage of the $700/mo combined subsidy & not using Advantage or the other stuff.

        Manageable co-pays, deductibles & even premiums (i.e. the Medicare Part B ~$130/mo per person) aren’t problematic as long as you have the resources, though the simpler the better in my experience. The key is to get everyone covered, including having such charges manageable for those who can’t afford them. I’d prefer to have health care universally available on an equal footing without monitoring the means testing for everyone.

        It’s seldom allowed into the discussion (largely, I think, because of the billionaires etc. that are the subject of the main article choosing to jam the discussion) but a universally available healthcare system would be good for businesses overall, esp. small business. The universal pool would spread the actuarial risk, thus lowering premiums per capita (however those are paid) and relieving businesses of health insurance obligations puts them on a better footing internationally and un-encumbers them from the restrictions & damage to workforce morale in providing coverage, catching flak when the coverage isn’t good enough, negotiating with insurance providers and in the end having employees stick around only to keep their coverage rather than having the free flow of a flexible labor market.

        Of course, it’s *just* possible that having a labor market that’s flexible has not been a good faith argument from companies that look for contingent employees…

        • rip says:

          Excellent points, Drew.

          My other feeling is that having a universal health care plan would get rid of most of the friction that exists with commercial plans.

          Whether intentionally or not, the commercial/bottom-line/corporatist healthcare plans do not want to provide services or spend money if they can get away with it. They really don’t want you to keep on keeping on, they want you to just pay premiums and leave them alone.

  10. Rapier says:

    It isn’t just billionaires. Health care is 18% of GDP. Millions of middle and lower income people depend on the jobs provided by the health care industry as it is configured now. An industry which is designed to harvest the cash flow provided by the government and insurance. Including the opaque and bizarre world of billing for services.

    Health care work is a bread and butter issue for millions of workers who would rather not take a chance on some alteration of the system.

    • earlofhuntingdon says:

      I’m not sure someone who worked for an insurance company medical claims call center would agree with your conclusion about not wanting change.

      Or the hospital nurses who have to put billing over patient care. Or the doctors and their aides who wrestle with insurance company clerks over whether a procedure is “medically necessary.”

      Or the nursing home staff who have to eject a bed-ridden patient at 4.00 pm on Friday because the insurance company called at 3.00 pm to say time was up.

      The health care system under M4All will continue to employ millions. It may not be as attractive to CEOs willing to do anything to become the richest man on the planet.

      Private equity may find it less appealing to buy up medical practices – and fib about MDs still being in charge of them – in order to reap exorbitant profits, which come from your pocket. But that’s the idea.

    • Rayne says:

      Insurance isn’t health care. We will still need people to process payments and audit them. We’ll still need a system to determine if treatments are effective enough to be part of normal care rather than elective. What we don’t need are added layers and redundancies between the health care provider and payments.

      And the existing layers and redundancies adding no value or improvement to the health care patients receive is costing 2-3X what it costs other countries for worse outcomes, including deaths. The bottom line is that some workers may need to shift to new industries to save tens of thousands of American lives. Nobody asked automotive workers when their jobs were shifted overseas for profits. Voting in 2020 is a request put to every American about the cost of American lives, more valuable than insurance companies’ profits.

  11. Jonf says:

    I am so happy someone finally said it. Thank you. I want to add a few thoughts. First insurance companies add marketing costs, executive salaries and taxes to the cost along with endless admin costs and profits plus added costs on the companies that employ them. Secondly, the meme that people want to keep their private insurance is, for the most part, a lie. What we all want is reliable and available health care at a reasonable cost and no follow on deductibles and fees. And finally, we already pay for health care, every damn nickel. So we need to devise a better way of paying for it like taxes. Here’s the thing. We could, as an option, require companies to continue to pay health care through a payroll tax on employees. The money would go to the government for payments just like other taxes and take companies out of it. Many companies today administer their own plans adding costs to health care. That would end. Period. After all corporations just had a gift of a tax cut. Now they get another one, no more costs and worries about health care.

    We should anticipate significant savings for M4A for simply what is described above and much more when the government handles all billings and negotiations, especially on drug costs and no more donut holes. In fact, a single payer system will likely be deflationary and create unemployment. Nice place to add the Green New deal here. Personally. I doubt taxes need to be raised at all at least initially. We can always do so later if needed.

    If we choose to we can cut out a niche for insurance companies here as we do on Medicare. Purely optional.

  12. Norman says:

    Yes, but do the call centers and insurance agents really count as “health care work[ers]?” Always thought that was nurses, technicians, custodians, etc.: people who actually “do the work” in health care, the actual physical labor that produces health results. Earlier in these threads, the phrase “resource extraction” was used, which very accurately (if also somewhat snarkily, but deservedly so) describes the runaway, hyper-financialization of our economy (and by extension) our culture.

    The caveats about “too quick a change” and “insufficient votes” and “priorities” notwithstanding, don’t we need to make a decision about whether the nation’s workers will be allowed to thrive and survive? It’s hard to guarantee that when so much government power (as accurately described above) is so directly in the service of an increasingly financialized (money changers, versus producers) economy. Like in the talk (above) about The Reagan Era: when will we stop assuming that The Id of The Markets is so sacrosanct, acting in the best interests of us all, when clearly it does not.

  13. Dave Noble says:

    dialling in from Canada (and I hope I’ve used the right email and user name….okay?)

    We’ve had Medicare for almost as long as I remember. It was introduced in the early 60s, I think, a few years after we emigrated here from the UK. I can truthfully say, and I have lived across the country and off-shore during my 30 year army service and further 25 years of employment, that our coverage is comprehensive, highly professional, cradle to grave (unfortunate term, I know…), and responsive.

    Having just been diagnosed in the past few months with Myeloma, a cancer of the white blood cells, I am fully into the diagnoses and treatment cycles and I can say that I am receiving exceptional service, professionally and personally – perhaps I’m a bit spoiled here in Ottawa – and only minor pharmaceutical bills to pay after my coverage pays the bulk of the costs.

    There is a trend to making for-pay services available in some areas – MRIs and other diagnostics, joint replacements, etc. But it is being done with the full knowledge that it will not jeopardize or prejudice the provision of our healthcare services.

    I know some folks love to cherry-pick a few examples and then cite these as global condemnation of our system – fine, fill your boots, I’m pretty sure you don’t really want to be convinced.

    The impact on a huge proportion of the American population must be massive, and I’m appalled to hear some of your politicians continue to defend the status quo. I recommend an interesting book to you all on one perspective of medicare among other sectors: “Dying of Whiteness – How the Politics of Racial Resentment is Killing America’s Heartland” by Jonathan M Metzl.

    My nickel thrown on the table.

    And be gentle on me if I’ve messed up the log in process please.

    • rip says:

      Dave from Canada –

      It appears that you have successfully navigated the corridors of the EmptyWheel web site. I’m still not sure that I have….

      Again, I hope that the US politicians, other decision-makers (not lobbyists), and voters read comments such as yours and understand that healthcare could be MUCH better than it is in the US, and at a lesser cost with more efficiency.

      Of course, many if not most of the US congress, current executive branch, and now the Supreme Court, are in the pockets of the “interested parties.” Maybe if we offered each blood-sucking critter a stipend of $1M for 5 years instead of being beholden to the corporatists… Pipe dream.

  14. Robert Britton Jr says:

    I worked as a Director of IT in Healthcare. Once for a Nursing home management firm. Once for a Home Care firm. And once for a non-profit / state wide Women’s health organization. I worked to implement all aspects of things: From Medical Billing, to EMR, to business processes, A/R Management, et al. I’m not an industry expert. But I’ve been inside the systems of these types of medical providers.

    What was eye-opening was the consistent goal of PROFIT MAXIMIZATION and COST MINIMIZATION. Patient Care was at the bottom of the rung.

    This is the root issue with health care costs: GREED, plain and simple.

    I participated in numerous board/director level conversations where the goal was to get staff to increase the services rendered so as to maximize revenue and income. If a P/T patient who just had a knee surgery only needed a couple P/T visits…heck with that. BILL THE MAX! Change the forms to reflect that there’s a deeper, longer term need. Same with O/T. Run the tests! BILL BILL BILL!

    One firm had a “personal pay” rate that seemed to more fairly charge appropriate fees when individuals had to pay out of pocket. But with any insurance provider, whether private, or Medicaid/Medicare, the goal was to UPSIZE THE CHARGE: Maximum billing.

    GREED is the problem of so much in not just healthcare, but in private and public providers (payers/insurers) so many other aspects of healthcare.

    Minimizing the profiteers by moving towards MEDICARE FOR ALL is a HUGE step in the right direction, IMHO.

    But there still remains all the greed and profiteering in the underlying medical service providers, big pharma, et al.

    When will we as a culture put and end to RAMPANT GREED, whether it’s in healthcare, banking, the MIC (Military Industrial Complex) or heck…even in how we operate our elections and republic/government.


    But everyone seizes the opportunity to benefit themselves at the expense of others. Very few are willing to make a sacrifice so that the WHOLE of us is better, rather than the .01%.

    This doesn’t matter, though. In today’s tribalism, gaslit nation festered with demagogues, partisans and snake oil grifters, nothing will happen on anything of any substance.

    These debates are ridiculous. We are morally and ethically lost as a nation. No matter how many thousands died from Opiode overdoses, we still have our government give Big Pharma a way out by paying a tiny portion of their illicit gains without admitting any wrong doing.

    America is a sick, vile, cesspool of greed and immorality and the lack of courage, dignity, ethics, morals, equitability, and charity are going to continue to destroy our society.

    [Welcome back to emptywheel. Please use the same username each time you comment so that community members get to know you. This is your second user name – your last visits were under ‘Robert Britton’. Thanks. /~Rayne]

      • robert britton jr says:

        TYVM BMAZ. will do. i’m a pessimist at heart and often try not to comment b/c i can be so negative.

        just so past any point of belief in my fellow citizen’s these days. way too much embracing of hatred and immorality and unethical behavior. i’m beyond jaded or hopeful. so i lurk frequently and try to not 🤮 all over the place. just hard not to lately.


    • P J Evans says:

      I read my Medicare statements, and the difference between what they’re billed and what they actually pay is – a lot. I’m glad they cover as much as they do, because otherwise I’d be much poorer (cancer sucks, even when the treatment works; some of the chemo sessions were being billed at more than 100K, each).

    • Eureka says:

      It’s not fair to characterize healthcare providers *generally* as about “greed” because of maximal billing tricks. Historically, such practices are part of an escalating capital race (cf. arms race) with insurers to get paid adequately for the actual services provided as opposed to shuttering the doors– to see this, just look exclusively at the history of *not-for-profit* orgs (such as many local hospitals, at least as of the not so recent past; the places where we’d all go when it matters most). What does anyone think would happen when non-profits are dependent upon for-profit entities for payment, especially when the latter are the ones setting the rules (including, I would add, by shared interests helping in DC to determine gold-standard Medicare reimbursement rates)?

      This is a really complicated issue to treat fairly in brief, especially because even more games-escalations (restructuring of medical practices, (now-ever-mega-)mergers of healthcare systems) followed the ACA and byzantine regulations that while perhaps well-meaning-sounding in the best of neoliberal ways (again, who influenced and wrote those rules…) have backfired as far as how the provision of care is entangled in financial incentives (recall an ICU doc has commented here about this before).

      It’s easy to attack here because we’ve all seen the crazy billing numbers and stacked billing codes on our EOBs. But it’s part of the game where providers never expect to get those numbers.

      The excess of outpatient procedures, services, and tests is itself a symptom of this arms race, and started decades ago when payors decided they’d pay more/better margins for outpatient than inpatient (virtually) anything. Inpatient charges kept places afloat back in the days when all those nice doctor shows ruled teevee. Until reimbursement trends changed and inpatient became the loss leader… so the care for grandma’s inpatient hip fracture is partially covered by junior’s outpatient lab tests.

      (That’s not even getting into separate problems of excess testing borne from liability fears or even the criticism of recent-era med professionals as so lacking in clinical skills that they can only ‘diagnose’ by throwing every test at the wall to see what sticks, etc.)

      Too many healthcare decisions by both the care-seeking (and -avoiding) public AND providers are driven by this capital race.

      Also, nursing home care – paid with private funds or Medicaid for the most part– is driven by a different set of financial incentives. (Medicare coverage for “SNF” or skilled nursing care is limited in duration such that the facility admits residents with their personal financial details and/or a Medicaid application in-hand, though some private insurance supplements (if it’s really good insurance) will extend those days, if not for a person’s natural life.)

      Home care has still-different parameters. The point being that right now, all realms of healthcare are driven by their payors, whether those providers are, in fact, “greedy” and trying to capitalize, or just trying to stay alive in this environment.

      • P J Evans says:

        Billing – I can’t even follow the bills sent by my chemo provider. I send them a check, and it’s diced into a little here and a little there, spread over (at this point) most of two years. It’s a major job just to track what’s being billed.

        • Rayne says:

          Swear to gods insurers hope it gets lost in the relentless press, expecting us to yield under the weight of the endless paper. Some health care providers aren’t much better.

          I had major surgery a little over 18 months ago. In spite of all the myriad phone calls my surgeon’s office manager and I made to nail down the costs in advance of the surgery, in spite of the mandatory meeting with the hospital’s billing office the morning of surgery before admittance to reiterate yet again what the hospital expected in payment and confirming my insurer’s agreed coverage AGAIN, it took nearly a fucking year for my insurer to cough up a check. The hospital changed its billing figures several times during that year; they managed to screw up the surgery’s description, too, all because some pre-surgical bloodwork was input in their system with a different number because the system wouldn’t take the correct number. The insurer changed the amount I was supposed to pay as a co-pay several times as well.

          It took a phone call to an insurance executive and a hospital VP to get a commitment to pay the bill. And I still had to follow up between the insurer and the hospital to make sure the check was cut and mailed and received.

          Friction, my eye.

          I hate to think what my family would have done if I had died and I hadn’t left them all my notes about the pre-admittance commitments.

          It was the worst hospital experience I’d ever had, too — it was a Catholic nonprofit facility. They just didn’t care.

          • bmaz says:

            Yeah. Not nearly that serious, of course, but early this year I got a colonoscopy and endoscopy. Had not had anything within the 5 year period, so it should have been routine covered diagnostic. Was assured ahead of time it was so fully covered.

            Last time, about eight years ago, the colonoscopy cost us about $400 out of pocket. This time? Over $7,500. I talked them out of a little, but what was said to have been “covered” still cost us, unexpectedly, about $5,000. I am a trial lawyer and know exactly how to mess with them, and that was still where it ended up. This is the “system” David Anderson is here shilling for.

            • posaune says:

              I spend at least 2 hrs/day filing and responding to medical insurance claims and filing appeals for our special needs child. It is a part-time job for me. Currently, I’m pursuing a 3rd-level appeal for a claim denial (third time for this service). Admittedly, this is a FEHB plan, and they ruled in our favor twice previously. However, this time, they want 3 years of FULL medical records for my son (arranged in chronological order by specialist). This is thousands of pages of documents from 7 specialists! multiple binders — looks like a bunch of trial exhibit books. Why should I have to spend weeks and weeks assembling tabbed binders of documents because of these a-hole insurers? All for $5K in services? I should be sleeping or helping my son or spouse. I hope they ALL go out of business.

          • P J Evans says:

            Mine know they’ll get the money – Medicare does cover this – but I can’t do it all at once. Some tests I know I’ll have to pay for, but generally it hasn’t been bad. But I think there’s 8 to 10K in bills still to come.
            The ones i hate are for the tests from my primary-care guy. The test lab he uses charges about 4 times their actual cost, according to the website “Healthcare Bluebook”.

          • Eureka says:

            Oddly enough it’s ~ near an anniversary of sorts for a very complicated situation like that that I had to deal with (as a family care giver in that case, but still bad enough and of course I have my own stories).

            That’s what I don’t get about the lobby to resist M4A: the audience knows better.

            Everyone has stories like these, some worse than others, and we have all witnessed really bad ones enough to imagine ourselves in those places, too.

        • Eureka says:

          That billing nightmare gets even worse for folks who aren’t cognitively sharp like you are, and can’t even keep track of the pieces of paper (and it’s hard to help second-hand).

          And I have a friend dealing with what you have been dealing with but earlier in the process. Her stuff is supposed to be well-covered as well, but I don’t know if she’s going to have to deal with lingering billing events for what seems like eternity.

          • posaune says:

            I finally had to design an interactive 3-spreadsheet system. One is a day file, by date of every action I take wrt medical claims. [Every phone call, every filing (electronic or hard copy), every payment, etc. I take detailed notes of every convo with an insurance rep, including time of day, claim #, provider, rep’s name and city (they won’t tell you last names). And I quote them if need be in my next response.] I have a second spreadsheet organized by provider, DOS, dx, tx, px, charge, claim #, EOB #, deductible, co-pay, check number for payments. A third spreadsheet is a cash flow tracker — how long the insurer’s had the claim, date filed, date paid, amount, etc. Common fields are linked and all three feed into our tax spreadsheet for medical expenses. I’ll be so happy when I can drop out of medical insurance claim filing! For Good.

            • Eureka says:

              Posaune, you have a great system (I mean also your whole care plan from prior comments, too), and I can empathize that the complexity of the administrative load (beyond other caretaking) is near impossible to convey. We were caring for a parent post-stroke who was ventilator and feeding-tube dependent, bed, hoyer, or wheelchair-bound, among many other needs. [I must add that our time together was a great joy, and her bright spirit lives with us still– I don’t want to in any way reduce a person to a list of some of their needs.]

              That means many MANY dozens of monthly prescriptions (each segment of tubing etc for the vent and trach alone), DME rentals, tons of non-covered supplies to price out and purchase (incontinence supplies, creams, etc add up– as do pricing scams for same, you have to ferret out *everything* in an ever-changing market).

              Anyway, different details, same issue: all of the “administrative” tasks that you have to stay on top of like a hawk take away from spending time together on enriching activities, or even just something as mundane as a cup of coffee and a breath. It’s perennial go-mode time.

    • Jonf says:

      Geez Robert, I have two family members who work in nursing homes, one a nurse, the other an OT. I have heard your refrain about greed and profit from them incessantly. And the idea of maximizing billing and care to the limit of part A, etc and then out. I believe they contributed to my cousins death bc of it. Terrible system, just terrible without long term care insurance for sure. So your comment rings true. Maybe single payer can help to stop the insanity.

  15. earlofhuntingdon says:

    Only slightly in jest, Joe Biden’s love affair with intellectual lightweight, NYT columnist David Brooks is reason enough not to vote for him. From a speech last night, via Amanda Terkel.

    He continued by quoting columnist David Brooks, saying that “an invisible moral fabric” holds the country together. He then joked that his campaign doesn’t like him quoting Brooks: “You know, the conservative columnist, my staff doesn’t like me quoting but I think he’s a damn smart guy.”

    That’s about on par with Biden’s record player comment. Per wikipedia, the mildly liberal Gail Collins hired Brooks to replace former Nixon speech writer and pedant, William Safire. She wanted a conservative who understood liberals, someone who “wouldn’t make our readers shriek and throw the paper out the window.” A curious hiring standard and a low bar, but Brooks routinely slips under it.

    Political candidates have staff for a reason. SafeHands Joe doesn’t get that either.

  16. Nehoa says:

    Disclosure – I have worked with healthcare systems in a number of countries, so have perspective on how other countries address these issues.
    I think it is important to separate out the key issues: 1) should everyone have comprehensive insurance coverage? I think most people would say “yes;” 2) who should pay for that coverage? Individual insurance premiums, group plans, dedicated taxes, or general tax funds?; 3) who should administer? there are many public v. private models across the developed world; and 4) how should costs be allocated across the wealth spectrum? again many models across the developed world.
    I would recommend examination of the systems in Canada, Taiwan, Germany, and Switzerland.

    • earlofhuntingdon says:

      I would add France and the Netherlands to that list.

      In principal European models, private insurers exist but are relegated to the traditional role of highly-regulated payments processor. In the manner of an old-style utility, fees and profits are intentionally kept low. Expectations of simplicity and prompt payment are high, as are penalties for delays.

      The US health insurance industry has moved a long way from that model. Like banking, its model has essentially become predatory rent collection. Insurers are relatively lightly regulated. They charge high fees – and are expected to generate high rates of return for shareholders.

      They bank on delay and complexity. They set rates of compensation for services, and assume the right to decide what services and goods are “medically necessary.”

      They avoid liability for practicing medicine without a license by having one or a few medical doctors oversee voluminous rulebooks and countless processing staff. The medical director of one large Connecticut insurer was famous for never having looked at a single patient file for years, making decisions in Trump fashion, based on his gut.

      That is a system ripe for abuse and for change

    • Anne says:

      I worked for 25 years in Italy where they have a fine health care system, just like in all the other industrialized countries.
      As a manager I was provided by my employer with a supplemental insurance policy so I didn’t ever have to wait for treatment. Other than that, employers have nothing to do with the system: no personnel department folks, all they do is send in the money, just like they send in the money for the pension system (Social Security here).
      As to how it works, I now have Medicare with Advantage or whatever it’s called and I go to Kaiser Permanente here in California. KP feels very much like a national system, familiar. Except that KP has become ruthlessly efficient: if they can solve a problem over the phone or email, they do it. Paperwork is all computerized. The Italians would do well to copy KP’s bureaucratic solutions.
      I did some free-lance work as a professional translator. Every American knows what “medical bankruptcy” means. I would be hard pressed to explain that to an Italian even with a couple of pages of space available!

      I will be glad to answer people’s questions.

  17. AitchD says:

    How to broadcast Senators Warren and Sanders’ ambitious but (positive) disruptive plan? The Internet failed at first with Obama’s ACA sign-up; the Internet and its social media are always subject to malicious pranksters and psychopaths. TV’s corporate media require ungodly monies for advertising.

    I am confident that Senator Warren has a plan and will provide a free and secure app that explains everything and won’t require millions of dollars for TV promotions, only a small staff to handle FAQ’s: “I have an app for that”.

    The private insurance industry will lose most of its jobs. But, Warren will explain how many new jobs will be created. There will be thousands of new PT/OT rehab providers along with dental technicians for prophylaxis and preventive care. I wouldn’t be surprised to see Walgreen’s, Walmart, and supermarket chains offering those kinds of services because it’s to their benefit, just like their providing flu shots and other preventive vaccines bring customers into their stores.

    So there will be major advantages for educational institutions as well as many other large corporations.

  18. Molly Pitcher says:

    bamz and Bob Lord as well as all of the commenters here, Thank You. This is the most civilized, intelligent discussion of American healthcare I have seen. It allowed me to contemplate many things I had not considered before and it was CALMLY done by presenting substantive discussion backed by experience.

    This is why this site is the best place on the internet. Period.

  19. Savage Librarian says:

    In the spirit of emptywheel, I’d also like to add to this conversation a reminder that some of the corruption in the health care field has ties to the investigation of Russian mobsters and satellite countries supporting them.

    In the decades of sorting through Medicare and insurance documents for my mother (who lived to be 95) and myself, it is only recently that I came across something that appeared to be a blatant duplicate billing. It was obvious because of the detailed dollar and cents amounts and the very different reasons given on separate pages. When I showed it to my primary care doctor’s office, they reacted with visible alarm but discrete verbal response. Several weeks later, the problem seemed to disappear.

    But it had originated with a referral to a specialist my doctor had given me. That specialist referred me to another. And both of them ordered considerable lab work, an X-ray, and then other invasive procedures. All of this took place in a very prestigious new medical center in a large complex of other medical buildings in a prime real estate area of the city.

    Shortly before one appointment, I narrowly missed getting T-boned in my car when someone ran a red light and, unfortunately, plowed into someone else. So, my blood pressure shot up above 200 at that appointment, highly unusual for me. Nevertheless, that doctor sent me nonchalantly (alone) to another area of the vast building where, at one point, a professional had to physically turn my body left because my mind could not figure out how to do it. Later, I learned that the doctors were Republicans. This should not matter. But it did. And I altered my future interactions which then resulted in much better outcomes. Much simpler treatment which lead to much healthier results.

    But getting back to Russia…
    In the course of the lab work I had, a young woman from Belarus drew my blood. Not until just recently did this thought occur to me: “ I wonder if she knows Sergei Millian who was born Siarhei Kukuts in Belarus.” I know it sounds far fetched. But then, all of the past few years have sounded that way. But, the point is, we as Americans need to learn to be much less naive and begin paying much more attention to our surroundings.

    • Savage Librarian says:

      Adding also: the health care industry is overflowing with private data about people. We already know that an Alfa Bank computer has a connection to DeVos and Trump. And we know Rudy Giuliani also has a connection to health care data bases. Certainly, this cannot be good.

  20. Willis Warren says:

    What no one really knows is that Medicare currently pays insurers a capitation rate, a monthly rate on Medicare Advantage plans, which essentially takes people of Original Medicare’s books. That capitation rate can be as much as 1300 a month per person. Medicare advantage plans are often offered at 0$ addition premium (part B costs 135 a month and is required for an MA plan).

    What this amounts to is a HUGE giveaway to private insurance companies, most of which goes to agents and CEOs. The hospitals adjust their prices (up) to equate to the coinsurance (say, 20%) and the entire cost is on the consumers while the companies pocket the rest.

  21. ajcharnc says:

    I’m open to a Medicare for All plan. But like most people with corporate health plans, the devil is in the details. There would to great cost benefits in eliminating insurance middlemen. But my corporate health plan has better coverage than Medicare for quite a few things.

    Being almost 60 I’ve looked at Medicare, especially Part D. Part D will be a disaster for us given my spouse takes a 30K+/year drug with us paying 25% of it. My medications are all generic except one, it would only be a modest price increase of $500/year. Our only hope is that the medication goes generic before retirement.

    I’m all for starting to discuss Medicare for all in Congress but while the discussions are happening undo the damage Trump has done to current health insurance and make fixes to Medicare. After all, the ACA took 2-3 years to pass, I don’t see Medicare for All taking any less time.

  22. greengiant says:

    What was common knowledge in the 19th century is rarely found today. In the so called free market the name of the game is monopoly. Until you have seen the power of monopoly up front and personal you probably don’t want to think about it. The insidious nature of the monopoly is not just the higher prices charged it is the reallocation and misallocation of investment and consumption dollars to the holders of the monopoly.
    In a manufacturing case suppose a factory requires 10 different tools to manufacture their product. If one of the 10 tools is a monopoly the price that can be charged is not just the maximum such that there is no profit on using their tool, The price can be so high that the other 9 different tool manufacturers must lower their prices.
    Where there are multiple customers each with a different matrix of return on investment for their different tool sets then the monopolist varies their prices to suck down all competing investment dollars.
    Others have already pointed out the variable pricing of the US medical industry violates anti trust law. It is a big chunk of the increase in health care costs from 6 percent to over 20 percent of GDP.

    • P J Evans says:

      That’s part of what gets missed when political types tell people that they should shop for health care the way they do for cars of food: they forget that medical-care prices aren’t visible to the public, and also depend on the region, the hospitals, and the insurance you may or may not have.

      • Willis Warren says:

        The reason they’re not visible is because the insurance companies pay nothing compared to the consumer. The real price is just whatever coinsurance the patient has. What little information we do have, for instance, is in the “gap” on medicare prescription plans. The customer pays 25% of the price of the drug, while the plan (allegedly) pays 5%.

        • P J Evans says:

          You’re going to need to back that up.
          I can see what they billed Medicare, how much Medicare approved, what Medicare actually paid, and what my co-pay is.

          • Willis Warren says:

            I’m not talking about what Medicare pays. I’m talking about what private insurance companies pay in Part D donut hole coverage. This chart details what happens in initial coverage and then in the donut hole:


            So, if you look at “2020 and beyond”

            2020 – beyond
            Initial coverage you pay 25% the plan (supposedly) pays 75%

            Donut hole you pay 25% The plan pays 5%

            Now the “discount” is what you don’t pay. We have no *real* data on what the plans actually pay vs what they allegedly pay. What we do know is that for every PDP, the capitation rate per month is around 50$. For an MAPD that amount is somewhere around 900 – 1300 a month.

      • posaune says:

        Just try and get an insurance company to disclose the “customary and reasonable charge” for a particular procedure during “open season.” Or before you need the service. It’s a big black hole.

  23. Stacey says:

    I haven’t commented in a while…got sucked into a major bathroom remodel and doing much of the work myself. But enjoying this discussion.

    The perspective I have which I haven’t seen represented in here yet is that I used to be an alternative care provider…a specialty-neurofeedback clinic owner/operator, between 2009 and 2015 in Portland, OR. During the ACA healthcare debate something I and my patients, most of whom had been ensured their whole lives, noticed was that while everyone was discussing the long lines of uninsured people trying desperately to get INTO an allopathic medical facility who had never had access, no one was noticing the long lines of life-long and fully-insured people with complex or chronic conditions who were leaving out the back door of those same allopathic medical facilities. They were seeking alternative care modalities because western medicine had thrown everything they had at their ‘fill-in-the-blank’ chronic condition to no avail and now they were seeking out of pocket alternatives that insurance will never pay for because western medicine’s bag of tricks is essentially a pill or a knife and if that ‘hammer’ doesn’t drive your nail home, that’s still all they have to hit it with!

    I’m not at all saying that by now life-long uninsured people don’t need some big guns of allopathic medicine, only that allopathic medicine is incredibly poorly suited to so many of our chronic conditions (pain, in particular) which is why I left it as a patient 20 years ago! When my Kaiser Doc offered me Prozac for the chronic headache and tension that set in 2 years after a high-speed rollover accident (the normal thing the body does in response to that situation) I told him to keep his “Vitamin P” as my nurse friend that worked there told me they referred to it as ;-/ and I went to a chiropractor, which was immediately helpful. Then to a cranial sacral practitioner, a network chiropractor and eventually I discovered this neurofeedback modality that helped my brain re-establish the ‘normal’ that the accident had recalibrated for me and I got my life back! So I became a provider for 6 years and helped many other people get their life back from how their brain was trying to ‘protect them from repeating a given trauma’.

    Allopathic medicine has always been centered around it’s own financial incentives–wrapped around its own axel, as it were–and has really never been centered on patient outcomes such that patient outcomes represent exactly the place on the priorities list you’d expect them to occupy! The fight that scientifically-based efficacious alternatives have with allopathic medicine is the same one Tesla had with Standard Oil. Since we can’t meter Tesla’s electricity generator device, we’ll have to kill it because we need something we can meter, like various types of fossil fuels.

    It’s hard to measure/meter patient outcomes but number of tests, ml of injection, number of pills, feet of tubing, hours of anesthesia, etc. are ALL perfectly measurable and therefore billable, and since they have nothing whatsoever to do with patient outcomes, which aren’t even measured, extremely easy and predictable to exploit. Viola! American Healthcare System as designed–no bugs, all feature!

    And not for nothin’ I had one occasion that a car accident patient had insurance which we pre-approved would cover her 10 sessions of neurofeedback. It took 6 months to get the check they said was on its way and I had to bill for some 1/3 or something more to get the amount they had said they would pay for by the time they deducted the percentage they would not pay for. I was very thankful I didn’t take insurance and was therefore in charge of my practice–a privilege any medical or para-medical office looses as soon as they take insurance!

    I used to love that statement you hear people make: “I don’t want some gov’mint bureaucrat making my healthcare decisions!” Wow! Nimrod! Do you think you’re DOCTOR got invited to that meeting where decisions about your healthcare were made? No, sweetie, that Scaramucci-looking guy in the Italian suit shuffling between his 7 mansions in the Hamptons and various islands off Greece is the only one invited to that meeting about your healthcare! And you just made another installment into his lifestyle choices which happened at a meeting you were ALSO not invited to! Nothing more “American Way” than that!

    • P J Evans says:

      My medical-care providers go back and forth with Medicare, so I’m still getting bills covering stuff from 2017. I’m not complaining about the amount of the bill (though it would be easier if I got the bills in monthly pieces, rather than a grand-piano sized piece one or twice a year), but about the amount of time it takes to get billed at all. (When my father died, it took a year for my mother to get the bill for the ambulance that 911 sent. That kind of thing.)

      • Savage Librarian says:

        Yeah, the whole billing process is so stressful. And the mountains of paperwork. Very intimidating. I think all of that probably creates additional medical conditions for people.

    • Jesse says:

      Love your comment!

      Also a Portland resident and I have spent $1,200 a month, every month, for seven years out of pocket at ‘typical’ and ‘alternative’ local health and wellness professionals. Cash out of pocket while having expensive (for my employer, myself) somewhat decent (in typical terms) healthcare insurance that even included some notional alternative options. But it doesn’t cover the things that make me better: long term, continual full body and mental health therapy and treatments as needed. Healthcare and wellness that is integral to my life day to day, month to month, season to season.

      And I did so happily because it was the best healthcare I’ve ever received. I have transformed as a person and am living joyfully more regularly.

      I did and still do wish I could fire the middleman insurance companies (to borrow Mitt Romney’s phrasing) I would love to fire them and buy in at the same or greater cost to an improved and holistic Medicare system.

  24. Savage Librarian says:

    One new thing I think the medical and insurance fields should start preparing for:

    How to treat and reimburse for Trump Anxiety and Trump Depression. Maybe Trump Anger Management too.

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