Wednesday, July 31, 2019

Bernie Sanders is the Pied Piper of Healthcare Hamlin

Political battles can be semantic, but important. Such is the case with Democrats wrestling with the meaning of Medicare for all.

This week Kamala Harris came out with a healthcare reform plan that seems designed to resolve her past flip-flops as to whether private insurance should be phased out entirely. In brief, she proposed a 10-year path to "Medicare for all" that includes Medicare Advantage -- private plans reimbursed by the federal government and conforming to strict coverage rules. Employers could also offer "Medicare Advantage" plans.  Lots of question marks, but the intent to preserve the public/private hybrid of Medicare as we know it is clear.

Bernie's camp lit into the plan, claiming in effect that the his bill's title (Medicare for All) is politically trademarked. “Call it anything you want, but you can’t call this plan Medicare for All," Sanders' campaign manager Faiz Shakir said in a statement. Pramila Jayapal, lead sponsor of the House version, tweeted, "as lead sponsor of #MedicareForAll, I find it misleading when my fellow Democrats use the #M4A name to describe proposals that are NOT #MedicareForAll."

That's a straight trademark play: we own the hashtag, we own the name. The subtext is that the One True Path to Medicare for All is Sanders and Jayapal's Big Rock Candy Mountain in which a single government entity provides 100% coverage of everything for everyone, funded entirely by over $3 trillion per year in new taxes ($1.5 trillion according to Bernie).

Charles Gaba sensibly pointed out that some Democrats "have interpreted Medicare-for-all to simply mean expanding the current program to more people while keeping the existing limitations on covered services, as well as premiums, deductibles and co-pays." And, more provocatively,
even if you do use the existing program structure as your baseline, Harris’s plan is actually closer to the current definition of Medicare, because it would retain Medicare Advantage. This is no small thing, as more than 22 million people — a third of all Medicare enrollees — have Medicare Advantage plans. In fact, David Bowen, who worked for the late senator Ted Kennedy (D-Mass.), said Harris’s plan “closely resembles” the Medicare-for-all bill that Kennedy and Rep. John Dingell (D-Mich.) introduced in 2006. 
This is manifestly true. It doesn't mean that Harris's plan is better than Bernie's bill, or that either has the remotest chance of being passed or enacted in the foreseeable future, but it's a simple statement of fact: Harris's endgame more closely resembles enrollment of all Americans in Medicare as it currently exists than does Sanders'.

So what? Well, Sanders is a Pied Piper, luring a large subset of the Democratic base into a cave from whence democracy may never emerge. That is, he is piping a utopian solution -- complete transformation of the $3.5 trillion/year healthcare system within four years, financed by a doubling of U.S. tax revenue -- that threatens to foreclose on any realistic plan to expand access and control costs -- and may sour a good number of progressives on any candidate who proposes something doable, as Bernie fervor did in 2016.

The Sanders camp's attack on the Sanders plan also perpetuates Democrats' rhetorical avoidance of the largest obstacle to affordable healthcare for all: provider payment rates. That's evident in the second half of Fakir's response to the Harris plan. Referring to the preservation of Medicare Advantage:
“Folding to the interests of the health insurance industry is both bad policy and bad politics.”
Possibly true, but...Harris's plan would pay MA plans less than the cost of insuring their members under the public plan. In their denunciations of healthcare profiteering in the U.S., Sanders, Warren, and almost every Democrat alway focus on insurers and pharma and leave out hospitals and doctors' trade groups -- which have joined in coalition with insurers and the pharmaceutical industry to oppose single payer and any public option that pays Medicare rates (or something like them) to providers. Insurers could in fact live with the latter; they are more or less neutral as to provider payment rates, i.e., playing and profiting very happily in the Medicare Advantage and managed Medicaid markets, where their payment rates to providers are effectively constrained by the per-member rates the government pays to them. (Whether they can be better policed than at present when government is their payer is another question.)

Two takeaways from that. First, BernieBrand Medicare for All proponents are as loathe as anyone to verbally assault healthcare providers -- notwithstanding that, as Axios' Caitlin Owens notes, "hospital care is the largest driver of U.S. health prices."  Second, plans that effectively establish one payment schedule for healthcare providers but preserve a role for private insurance, such as the Medicare for America bill, have the potential to split the healthcare industry coalition currently united against major reform.

More broadly, I seriously doubt that a Democratic president elected in 2021 with at best a bare Senate majority is going to have the bandwidth to do more immediately on the healthcare front than  a) end balance-billing, which effectively undermines everyone's insurance; b) patch the ACA, boosting subsidies, enlarging subsidy eligibility, and possibly adding a public option; and c) pass effective legislation to control drug prices. That would in fact constitute a ton of accomplishment. But you'd never know it while listening to Democratic candidates blather about single payer purity.

P.S. A reminder from the Kaiser Family Foundation that while Bernie & co. think they own the brand, they don't:
based on a poll fielded in early 2019, 55% of the public think that they and their families would be able to keep their current health insurance under Medicare-for-all; 54% think they would continue to pay health insurance premiums and 69% think they would continue to pay deductibles and copays for covered health services.

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