Thursday, March 5, 2020

A Compromise Health Care Proposal Between Bernie and Biden

Bernie supports a singly  payer system resembling that of Canada's. Biden supports an extension of ACA(Obamacare) tp add a public option such that anybody can buy into currently existing US Medicare, but not guaranteeing uinversal coverage.

So, my proposal intermediate between theiir proposals undoes the two biggest political economic problems with each sides.  Bernie's problem is that eliminating private insurance he alienates 2/3 US voters who like their employer-supplied insurance. Biden's problem is that he has not offered universal coverage, which every other high income nation has.

So, here is my proposal. Let there be "Medicare for All," but make it what most people think that means, not just what Biden proposes of letting people buy into Medicare, but simply making any uninsured person on Medicare as it is.  It is not all that good, so most will buy supplemental private insurance like nearly all actually existing Medicare recipients. So we shall achiieve the universal coverage that all other high income nations have,  But this will avoid the politically disastrous proposal of Bernie to simply end  all private insurance.

Barkley Rosser

26 comments:

Peter Dorman said...

Barkley, what is the evidence that lots of people like their health insurance and don't want to exchange it for something else? I understand that people have preferences about their health care providers, but insurance? That just pays for stuff, yes? Why would I care whether my health care is paid by company X rather than government Y if they're both paying about the same? And how many people have private health insurance they don't have to fight with?

I often see the claim you make about popular attachment to existing health insurance plans, but it seems counterintuitive. I'm interested in whether there's evidence for it.

rosserjb@jmu.edu said...

Perer,

I have double checked this, actually not having looked at it for some time. The poll reuslts vaary a lot, although it is hard to find many that distinguish the precise point at hand, but it gets as low as 10 percent that support "Medicare for All" without private insurance, with that figure higher in other polls. But there is no poll I can find where indeed more support ending private insurance over keeping it, despite the many problems with US privaate insurance.

The main problem with it is that is vry expensive. But that is because US health care is very expensive, a seeious problem without an easy solution, although one not clearly resolved by firing all those people processing private health insurance claims.

I shall soon post on details of competing sytems, especially universal singel payer versus universal mixed system.

2slugbaits said...

Peter,
One reason people like their private plans is that some of those are "Cadillac" plans...think UAW contracts. The taxpayer ends up footing the bill for some of those luxury plans, so socially they're not good, but for the individual subscriber they're great. Another reason people like their private plans is that plans cover somewhat different medical issues, so you can buy what you think you'll need. Again, socially that's a bad thing, but for the individual it's a good thing. An example would be federal employees who have a large menu of health insurance plans from which they can choose a different plan each year during open season. Voters aren't going to want to give up those things.

One big practical problem with any kind of Medicare for All option, or as Biden calls it, Medicare for More, is that people will want to opt in and opt out as their life circumstances change. I don't see how that works. If you commit to Medicare when you're in your 20s, you would probably have to stay with Medicare until the day you die. It's also not clear if Medicare for More means Part A for More or Parts A & B for More. Part B is not free, which I suspect a lot of young Bernie supporters don't know. My recommendation is to begin lowering the age for Medicare eligibility to (say) 55. This should reduce the costs of private health insurance for those under 55 because the over 55 crowd (like me!) consume a lot of healthcare. Then have a streamlined Part B plan available for everyone that would cover annual doctor visits and vaccines. That's about as good as you're going to get given the realities of the Senate...even if the Democrats squeak by with a bare majority.

Peter Dorman said...

2SB, these arguments apply to Medicare too. Some people can afford to have more luxurious coverage, and some have particular health care needs that aren't well handled by the public system. So there's a whole smorgasbord of supplemental plans people can take out on top of Medicare. Presumably it would be the same with M4A. Is Sanders or anyone else saying that private health insurance should be illegal? My understanding is that M4A is a basic plan that covers everyone, and then they can top up if they wish.

Again, for the stuff public health insurance would cover, why would anyone be upset that they're getting that part of their coverage from the government and not from some private company?

Barkley, the polling numbers depend enormously, as always, on the exact way questions are worded. The main trope being used to attack public health insurance is the "you will lose your private coverage" thing. I'm sure some people will respond without much reflection, "Yeah, I don't want to lose what I have." But the question I'm interested in is, how many people really care where their coverage for a particular health care expense comes from? That would give us an idea of how sellable M4A could be.

pgl said...

How to pay for health care is an important issue. But Bernie keeps talking about cutting the cost of health care. Nice goal but the proposals to do so? Let's see allow qualified European doctors to move here, push back on the monopoly power of Big Pharma, etc. Proposed something like that and there will be a whirlwind of opposition from "the establishment". So let's do it!

Bill H aka run75441 said...

Hi Barkley:

I guess I am not too well read over here on healthcare, heh?

To answer Peter's question of "what is the evidence that lots of people like their health insurance and don't want to exchange it for something else." I am not sure there is any evidence of such. I did pull up a Kaiser News report:

most beneficiaries are “generally satisfied;" however while most like their policy, it is not all inclusive. C&P alert!

"about 40% of people with employer-sponsored coverage said they had trouble paying medical bills, out-of-pocket costs or premiums. About half indicated going without or delaying health care because — even with this coverage — it was unaffordable. And about 17% reported making “difficult sacrifices” to pay for health care.

Beneficiaries who have higher-deductible plans — that is, they are required to pay larger sums of out-of-pocket before health coverage kicks in — are also less likely to be happy with their coverage, and more likely to report problems paying for health care.

And it’s also worth noting that these high-deductible plans have grown increasingly common, even for the 160 million Americans who get insurance from work, though that trend may now be losing steam. Research from the Commonwealth Fund, meanwhile, notes that increasing numbers of “underinsured” people do, in fact, have employer-sponsored health insurance. Underinsured people are those who have coverage but delay care because they still can’t afford it.

Meanwhile, other polling, such as a January Gallup survey, suggests that about 7 in 10 Americans believe the nation’s health care system is in crisis.

Biden said 160 million people like their private insurance. That is not exactly true. There is a bit of context to it which I have mentioned above.

This is from Kaiser and I will leave the link; https://khn.org/news/do-160-million-americans-really-like-their-health-plans-kind-of/

Anonymous said...

PGL:

Bernie keeps talking about cutting the cost of health care. Nice goal but the proposals to do so? Let's see allow qualified European [international] doctors to move here, push back on the monopoly power of Big Pharma, etc. Proposed something like that and there will be a whirlwind of opposition from "the establishment". So let's do it!

[ Excellent, but there are fine doctors beyond Europe. Dean Baker has been pushing against monopoly pricing in drugs and medical equipment forever. ]

2slugbaits said...

Peter,
Is Sanders or anyone else saying that private health insurance should be illegal? My understanding is that M4A is a basic plan that covers everyone, and then they can top up if they wish.

It's hard to say. At times I have heard Sanders talk as though private health insurance plans would be illegal. And even if not outright illegal, he's certainly emphasized his eagerness to put them out of business, so I guess it's a distinction without a difference. And ideologically he's kind of forced into that position. Can you imagine him trying to defend why the top 1% would have access to super duper Cadillac plans while the rest of us get just a basic plan? At times it sounds like Sanders is talking about a Canadian single payer system, but at other times he seems to be talking about a British style single provider system. The Bernie supporters I know are all of the belief that Medicare for All means an entirely taxpayer funded system without any premiums and with equal coverage for all. They can't imagine a doctor or hospital telling them we're sorry, but Medicare for All won't cover this or that ailment. I've heard Sanders tell his supporters that vision and dental would be covered by Medicare for All...except that vision and dental aren't covered today.

Of course, none of these proposals, whether they be Obamacare or Medicare for All or Medicare for More or Trumpcare for the Rich, do much of anything to address rising healthcare costs.

Bill H aka run75441 said...

Barkley:

Perhaps this KFN survey on providing healthcare may help bring an understanding of who favors what? https://www.kff.org/slideshow/public-opinion-on-single-payer-national-health-plans-and-expanding-access-to-medicare-coverage/

Bernie's Single Payer plan is not Single Payer. It still uses ACOs and it does not set budgets for hospitals, etc. Those are two of the 4 essential elements to Single Payer. Canada leaves out vision, dental, prescription medications, psychotherapists and physical therapy. About two-thirds of Canadians get private insurance to supplement Canadian “Medicare,” which accounts for about 70 percent of Canada’s health spending. Bernie's plan does set aside money retraining.

My Medicare Plan consists of Medicare ($144), Plan N ($134), Part D ($34) per month for me alone x 2 = $7488/year. Just do not allow a hospital to admit you for observation. Is that cheap for two people? Dental for us is another $1500 per year and Vision is $300. Younger clientele might be able to get lesser cost coverage. I do not think it is cheap.

And Medicare sets the prices it will pay.

rosserjb@jmu.edu said...

Peter,

It certainly does matter how these questions are worded, and it is up in the air what people really think or how intensely. Lots of people are unhappy with their health care plans, but many of these are also afraid of an alternative, just to reallyi confuse things.

I have also been looking at various Kaiser reports and surveys. One has 56% percent supporting "Medicare for All" while 68% support a public option. However, apparently 67% of those supporting Medicare for All believe it will allow them to keep their current insurance. That does not seem to be the case.

I have gone to the Bernie website and to an analyst of his site. Bernie's bill he introduced is 100 pages long, so kind of hard to pin some things down. But I got that it would cover much more than what Canada's single payer does. It would forbid any private insurance for what would be covered, but it would indeed allow people to get private insurance to "top up" what the Medicare for All would be. Doctors would be allowed not to take patients on it and simply ask fee for service from private patients. Not clear what is the deal with hospitals.

I would note that in my compromise proposal, which could be called Medicare for all but allowing people to keep their private insurance, which Kaiser found to be the most popular proposal, I was vague about how to do parts of it, such as how to pay for the Medicare that people would get who did not stay on private insurance. Biden has allowing people to buy in, which costs them money, whereas I am implicitly doing it like Bernie and just letting them in for free. I also did not address what to do about costs, although I have long supported Dean Baker's proposal to let foreign doctors in more readily, not to mention pay for drug R&D so we can crack on Big Pharma.

I note that most of the cost saving from Medicare for All comes from laying off people processing private insurance claims, although this does not take into account that some of these would need to be hired by the government to help out with the expanded Medicare system. I also note that the 70,000 laves saved comes entirely from the universal nature of the plan, which my compromise would have.

In any case, even though many support Medicare for All in some form, that there appear to be many who do not want to give up their private insurance, not to mention the cost matter, means that if Bernie is the candidate without changing his plan, he will be on the defensive in debates with Trump over these points rather than being able to easily put Trump on the defensive on health care, and that is where he should be, given what he has been doing ans supporting, including the lawsuit to completely undo ACA.

Bill H aka run75441 said...

2Slugs:

True Single Payer does not allow for healthcare insurance programs to duplicate what it pays for itself. I believe Bernie is offering a complete Med4All plan. It does not have Single Payer as it uses ACOs just like the Vermont plan did.

Canadian Healthcare pays 70% of the cost of healthcare as I mentioned earlier. It does not include vision, dental, prescription medications, psychotherapists and physical therapy. About two-thirds of Canadians get private insurance to supplement Canadian “Medicare.”

The Cadillac Plan penalty was supposed to kick on $dollar amount over a set limit and even then only 40% of the overage would be taxed. In the ACA, it was meant to penalize plans for Executives which were different and more extravagant than the regular employee plans. I guess they did not think about unions?

Then too, companies and unions have been too liberal in what they paid commercial healthcare insurance companies.

Bill H aka run75441 said...

Anonymous:

Why does the US have to rob other countries of their doctors when we have the ability to produce more. Most recently, the numbers of NPs have doubled which should offset (somewhat) the lack of doctors.

A Commonwealth funded Health Affairs paper/article covering 2007 - 2014 pointed to inpatient costs increasing 42%, outpatient costs increasing 25%, and doctors costs increasing 7%. Kocher and Berwick suggested this is the #1 reason for healthcare insurance increases. I would look to there first. There are other places which I can point out; but, I have said too much here already.

pgl said...

"Anonymous:

Why does the US have to rob other countries of their doctors when we have the ability to produce more."

Talk to the AMA cartel. Milton Friedman warned about their restrictions to entry some 58 years ago.

2slugbaits said...

Bill H aka run75441,

My sense is that the typical young Bernie supporter is under the impression that current Medicare entirely replaces private insurance for anyone over age 65 and that all doctors accept Medicare and that Medicare pays for all hospital and all doctor costs and all procedures. And if they give any thought to prescription drug costs, it's usually in terms of low cost generics. My point is that there's a yawning gap between what a lot of people think Medicare covers and what it actually covers. This is anecdotal to be sure, but most of the Bernie supporters I know believe that Bernie's plan completely wipes out private insurance. Telling them that they will still have to buy supplemental plans isn't something that they'll swallow easily. Even if Bernie's plan passed Congress (which it never would), they'd still be severely disappointed and disillusioned.

The core moral argument behind Bernie's plan is that everyone has a right to the same level of healthcare. That's what fires up his crowds. Telling them that some affluent folks will have better health insurance because they will buy supplemental plans isn't something that will go down well with his base. His supporters are not demanding healthcare that's 70% as good as what the top 1% gets.

pgl said...

Greg Mankiw has some interesting news:

http://gregmankiw.blogspot.com/2020/03/the-biden-tax-plan.html

The Tax Policy Center has analyzed the Biden tax plan:

https://www.taxpolicycenter.org/publications/analysis-former-vice-president-bidens-tax-proposals

Increase Federal revenues with a more progressive tax system!

pgl said...

"My sense is that the typical young Bernie supporter is under the impression that" money grows on trees. Well not really. But most of these Bernie fanatics repeat slogans with little to no understanding of what the real issues are regarding our medical system. Warren on the other hand had Mark Zandi analyze her proposals. And Zandi had a lot of nice things to say about it. My #1 problem with Sanders and his supporters is their utter disdain for economists - oh wait, "establishment economists" whatever that means.

2slugbaits said...

pgl,
I dunno, sometimes I think Bernie Bros do believe money grows on trees. Can't really blame them given the economic proposals that came from Bernie's 2016 economic adviser, Gerald Friedman.

As to Biden's fiscal plan, I'm assuming this is really Jared Bernstein's plan. Biden has a lot of virtues, but he's never been known for being the smartest guy in the room. And with age he's definitely lost a step. Sometimes I listen to him and wonder if he hasn't had a few mini-strokes. But whatever his faults, he does seem to have a knack for surrounding himself with smart folks, and Jared Bernstein is clearly one of the smart guys...a trained sociologist who is also an accomplished economist.

rosserjb@jmu.edu said...

2slug,

Actually Bernie's proposal covers a lot more thingss than current Medicare does, which means that the label is misleading. It is Canada's "single payer" that more resembles current US Medicare in its coerage, with the upshot that as Bill H noted a majority of Canadians do what most Americans on Medicare do, purchase supplemental private health insurance to top up their care. Apparently a current fight in Canada is over whether to expand coverage to presciption meds or not. Bernie's plan would do that.

Something esle about Canada's system is that it is administrered at the province level, and there are substantial croo-province differences in how it operates. But this gets too complicated. This issue is already complicated enough as it is.

I also note that I do not know how all those mixed systems that are not "single payer" manage to guarantee universal coverage. ACA tried tomove in that direction by imposing rhe individual mandate, but that was qite unpopular and never seriously endorsed, and has since been removed by the Trump admin anyway.

Jerry Brown said...

Well I like your plan a lot. I think it would be the first fallback position the Sanders administration would propose after Medicare for all didn't get through. There's nothing wrong with your plan except to explain why anyone, or their employers, would pay for anything approaching the cost of private current health care insurance policies if they could be on Medicare. That might be a feature actually. But this plan would be difficult to get through Congress also- so maybe we just shouldn't try at all and begin by proposing a public option addition on Obamacare. Or you start your argument on what you think is the morally right thing to do and push that hard and negotiate down if necessary. If we can win in the first place. Well I like your plan very much after all P. Barkley.
By the way, Obamacare has truthfully been very good for me- thank you President Obama!- it has saved me possibly my life and I call it Obamacare out of respect. But it could be improved.

Bill H aka run75441 said...

2slugs:

Thank you for your response. I was wondering if my words were seen or understood. This really is a broad topic. The right crowd is here to read it and critique what I have to say.

1. Supplemental is not a rich man's policy. As you know(?), Part B has a 20% gap which is huge when you think about it. Supplemental covers the GAP.
2. You get one shot at getting Medicare plus Supplemental Insurance. If you go beyond the time limit of getting supplemental, pre-existing conditions may apply to your getting Supplemental. If you leave Medicare and go to Medicare Advantage and then return, Supplemental may deny you insurance. There is more to MA plans (rip off alert).
3. I have plan N which is at a lower level than F or G. F & G plans are no longer available to new enrollees. They had more advantages such as paying for "Observation" in a hospital. Get up and leave if they ever use that word "Observation." Medicare pays less for Observation.
4. There are differences between Medicare4All and Single Payer. Bernie might mean Single Payer; but using the Medicare name tag causes confusion.
5. I really think Bernie means Single Payer but his plan is not Single Payer and Jayapal's plan can be said to be such, There are 4 elements to Single Payer:

- It relies on one payer (HHS, not multiple payers called ACOs) to pay hospitals and doctors directly,
- it authorizes budgets for hospitals,
- it establishes fee schedules for doctors, and
- it has price ceilings on prescription drugs.

Senator Sanders plan is missing the first two elements. I had an entire two part post at AB explaining this issue as taken from one authority on Single Payer I had struck up conversations with from time to time. I will not duplicate that post here. If you like, I can point it out to you.

Buying Supplemental Insurance is not a marker of affluency. It is a marker of the failure in our healthcare system. I am not in favor of going backwards. We should make it less costly in the mean time while we are on the road to single payer.
6. From 2007 - 2014, the biggest driver of Commercial Healthcare Insurance costs is what I mentioned above . . . inpatient and outpatient pricing of which 60% of the increase is due solely to pricing increases. Commonwealth funded Health Affairs paper/article. Insurance enjoys increases as they get a bigger slice of the pie at 15 and 20% and pay the cost along. Similar holds true for Pharma, rent taking with no increase in value to the patient, society, healthcare, technology which are the 4 elements the execs blab about. Humira is #1 is price per molecule and Rituxan is #2. The later I get doses of from time to time when my platelets disappear.
7. So what do we do in the mean time when Single Payer is a decade out there or beyond Barkley's and my life time?
- Robert Kocher and Donald M. Berwick, “While Considering Medicare For All: Policies For Making Health Care In The United States Better,” Health Affairs Blog - Open Access. They suggest we attack the costs of healthcare such as hospitals, supplies, and pharma. They also opt for increases in subsidies on a sliding scale up to twice 400% (todays). Hospitals would get 120% of Medicare pricing. This is on AB also or you can google it. Maggie Mahar and I talked about it.
- Philip Longman, author of the "Best Care Anywhere" detailing the VA which I also use. Philip recently suggested Medicare Pricing for all. In other words, Medicare would extend its pricing for all healthcare without enlarging it.
- "VA-Like Negotiations on Insulin Prices Could Save Medicare Billions,"MedPage Today" A brief article on what VA pricing could afford Medicare in using its formulary also. VA negotiates and Medicare Part D does not. This is part of a JAMA internal paper which I had limited access to. I did find another Jama Network source for this from which I was able to download a paper or two. This is also on AB.

There are three interim approaches while we figure out Single Payer and how to get to it.

Anonymous said...

Dean Baker has argued for years for allowing for simply cross-licensing of physicians to increase the migration of physicians to the US. There is no reason why the US cannot in turn support medical education abroad should there be a worry about loss of physicians in another country.

rosserjb@jmu.edu said...

Jerry,
Thanks. If we can't get anytinng else, I would go for publix option. But what would move the Biden proposal to something both more popular and better in terms of health outcomes would be to somehow make it unversal, although individual mandate is clearly not the way to do that.

Bill H.

Again, the Bernie plan does seem to allow for supplemental private isurance beyond ehat his plan has covered, but it covers a lot, way more than either current US Medicare or Canada's "single payer." I also note that Bernie's plan does allow for a four year transition to ending competing private insurannce, except that all children would go on the plan immediately. And the remaining odd loophole seems to involve hospitals. They have been an element of rising csts, but they are also , or many of them, facing serious financial problems. Something that has led even GOP-run states to expand Medicaid under ACA has been to help out rural hospitals in those states that have failing at a high rate.

Anonymous,

The AMA opposes even this, but I am certain Congress would be far more willing to support expanding medical education in the US than in other countries. That later will never ever be even proposed by anybody in Congress, much less get passed, even if that might be a moral thing to do.

Bill H aka run75441 said...

Barkley:

It has been my privilege to discuss healthcare here at Econospeak. Thank you for allowing me to present what I know on the topic as I have spent a great amount of time discussing it and bringing forth the issues.

I really do not see the emergence of single payer in my life time. I am aware of rural hospitals having issues and such can be resolved with policies which benefit them. I am also very aware of the continuing consolidation of hospitals much so the competition has disappeared with the concentration of as noted in the HHI index. Hospitals are the primary issue in the rising cost of commercial healthcare insurance. There are enough articles and experts pointing to this phenomena.

My purpose here was to provide detail which there appears to be a lack of in the discussion. I know of "no" four year transitional plan for commercial healthcare insurance in Bernie's plans. I will ask those who may have knowledge of such. If anything, to add this knowledge to my library.

Regards,

Bill

rosserjb@jmu.edu said...

Bill H.,

It has been an informative pleasure to have you here.

Regarding the four year transition, I do not know if it is Bernie's current plans, but it is/was supposedly opart of the 100 page bill that he was at least partly respoinsible for introducing.

Lord said...

Another suggestion, let those dissatisfied with their company insurance the choice of buying something else, medicare or not. Most satisfaction with it comes from not using it and minimally paying for it directly, the satisfaction of indifference and ignorance. Choice would bring information.

Bill H aka run75441 said...

Barkley:

I asked my resident expert and he said it is still 4 years for Sanders bill and Jayapal is 2 years. He ss written a 4000 word document on whether critiquing Pharma makes a difference. We should see it June or July in Minnesota Physician. Minnesota is going to attempt to implement Single Payer.

If we move beyond commercial healthcare insurance, there is a 15 - 25% savings. Single payer should give us another 15% saving in hospital Admin billing insurance companies, etc. I was trying to get him to post at AB. I can not promise him the venue which can be had at other blogs. He dot mind my posting his articles. He wants the coverage.

Then the other aspect is pricing of pharma, healthcare supplies, and hospitals. Big field . . .

Lord:

I kinda agree with your statement. There should be an option. Thank you Lord for your comment.