Don’t Make Health Care a Purity Test
S E E D E D C O N T E N T
We’re now in the silly season of the Democratic primary — a season that, I worry, may last all the way to the nomination. There are many honorable exceptions, but an awful lot of reporting seems to be third order — not about the candidates, let alone their policy proposals, but about pundits’ views about voters’ views of candidates’ electability. It’s a discussion in which essentially nobody has any idea what he or she is talking about.
Meanwhile, however, there are some real continuing policy debates. They’re not mainly about goals: Whoever the Democrats nominate will profess allegiance to a progressive agenda aimed at reducing inequality, strengthening the social safety net and taking action on climate change. But there are some big differences about how to achieve those goals.
And the starkest divide involves health care. Almost surely, the eventual platform will advocate “ Medicare for TK .” But what word is eventually chosen to replace the placeholder “TK,” and more important, what that means in terms of actual policy, will be crucial both for the general election and for what comes after if Democrats win.
On one side, there’s “Medicare for All,” which has come to mean the Bernie Sanders position: replacing the entire existing U.S. health insurance system with a Medicare-type program in which the government pays most medical bills directly.
On the other side, there’s “Medicare for America,” originally a proposal from the Center for American Progress, now embodied in legislation . While none of the announced Democratic candidates has endorsed this proposal yet, it’s a good guess that most of them will come around to something similar.
The big difference from a Sanders-type plan is that people would be allowed to keep private coverage if they chose — but they or their employers would also have the option of buying into an enhanced version of Medicare, with substantial subsidies for lower- and middle-income families.
The most important thing you need to know about these rival plans is that both of them would do the job.
Many people realize, I think, that we’re the only advanced country that doesn’t guarantee essential health care to its legal residents. My guess is that fewer realize that nations achieve that goal in a variety of ways — and they all work.
Every two years the Commonwealth Fund provides an invaluable survey of major nations’ health care systems. America always comes in last; in the latest edition, the three leaders are Britain, Australia and the Netherlands.
What’s remarkable about those top three is that they have radically different systems. Britain has true socialized medicine — direct government provision of health care. Australia has single-payer — it’s basically Bernie down under. But the Dutch rely on private insurance companies — heavily regulated, with lots of subsidies, but looking more like a better-funded version of Obamacare than like Medicare for All. And the Netherlands actually tops the Commonwealth Fund rankings.
So which system should Democrats advocate? The answer, I’d argue, is the system we’re most likely actually to create — the one that will play best in the general election, and is then most likely to pass Congress if the Democrat wins.
And there’s one big fact on the ground that any realistic health strategy has to deal with: 156 million Americans — almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage.
A Medicare for All plan would in effect say to these people, “We’re going to take away your current plan, but trust us, the replacement will be better. And we’re going to impose a bunch of new taxes to pay for all this, but trust us, it will be less than you and your employer currently pay in premiums.”
The thing is, both of these claims might well be true! A simple, single-payer system would probably have lower overall costs than a hybrid system that preserves some forms of private coverage.
But even if optimistic claims about Medicare for All are true, will people believe them? And even if most people do, if a significant minority of voters doesn’t trust the promises of single-payer advocates, that could easily either doom Democrats in the general election or at least make it impossible to get their plan through Congress.
To me, then, Medicare for America — which lets people keep employment-based insurance — looks like a much better bet for actually getting universal coverage than Medicare for All. But I could be wrong! And it’s fine to spend the next few months arguing the issue.
What won’t be fine will be if activists make a no-private-insurance position a litmus test, declaring that anyone advocating a more incrementalist approach is no true progressive, or maybe a corrupt shill for the medical/industrial complex. As you might guess, my concerns aren’t drawn out of thin air; they’re things I’m already hearing.
So Democrats should try to make this a real debate, one about the best strategy for achieving a shared goal. Can they manage that? I guess we’ll find out.
Initial image by Andrew Harrer/Bloomberg
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I recommend this article to our conservative friends. Krugman successively criticizes the Democratic Party, and the media.
A simple, single-payer system would have Government Seeking to Regulate what was "ALWAYS" just another money making business …….. AGAIN !!
"Health Care' has never been some kind of "FREE Right" ! Sure, You have the "right" to go into the hospital to get "Care", but your gonna have to pay for it, Which is the business's "RIGHT" to do also.
Government can't even run "Itself" ! It's ALWAYS in the "RED" !
And folks want them to run "Health Care" for over 300 million ?
All Government will do is pass a few "Laws" saying …. "THIS IS WHAT WILL BE"....then just go on to some other subject, ignoring the "enforcement" part of these new "Feel Good" laws.....then 20 years down the road......They'll be running on "We will Fix the new system"...…. AGAIN !
Government "Regulation" ……. IS THE FUCKING PROBLEM !
Civilized nations take care of their citizens..... We are the wealthiest nation on the planet, and we don't seem to be able to accomplish that.
Regulations be damned...... we have to honestly want to fix the problem first. Lip service doesn't count.
A WONDERFUL "Feelings' comment that has NO MEANING !
"we have to honestly want to fix the problem first."
Gosh jeewillikers…..how about following and enforcing the laws that were already on the books ?
But I digress ?
All Government will do is pass a few "Laws" saying …. "THIS IS WHAT WILL BE"....then just go on to some other subject, ignoring the "enforcement" part of these new "Feel Good" laws.....then 20 years down the road......They'll be running on "We will Fix the new system"...…. AGAIN !
I don't suppose that you have anything to say about the seed. Did you bother to read it?
you didn't read Comment #2 ?
It was based on this part of YOUR own Seed :
"A simple, single-payer system would probably have lower overall costs than a hybrid system that preserves some forms of private coverage."
Maybe you should actually "READ" your own seed, and also understand the actual "Body" of the seed ?
don't put up with his nonsense, Bob
Don't put up with what.....Reality ?
There are such systems in the world, and they are efficient and effective. That's what the seed says.
That is the opposite of what the seed says... and demonstrates...
I'm trying to decide whether he actually believes what he posts... or is just stirring the pot.
Not for over 300 million residence.
Unless your talking about the likes of "China", which is a place residence don't have any choice.
So why not make yourself part of the solution? You seem to be intelligent. I'm being serious here, not placating either. Offer some suggestions to fix documentable problems to get us moving in the right direction...
Or at the very least..... Help me understand the problems as you see them.
I have been for decades !
I "FUND MYSELF" so No one else has to !
I here it's called.…. RESPONSIBILITY !
There are 450 million in the EU.
The EU provides ALL insurance for every country over there ?
Weird !
"Healthcare in Europe is provided through a wide range of different systems run at individual national levels"
Every country provides insurance.
Taxes....give us your money and YOUR government will supply !
I saw that "France" is having an expense issue.
Those damn "Yellow jackets" !
The topic is health insurance.
Changing the topic is a standard method of fascist propaganda.
Single payer....ISN'T "Health insurance" for all ?
INSURANCE COMPANIES have lost trust of the people and medical profession. They make money but do not do their job of providing healthcare
Local agent who sold me policy told me something was covered, week I am to get it before insurance company refused to pay. Try to get answer and they waste hours of your time trying to make you give up
Krugman makes the important point that there are many different organizations possible for universal health care, but sadly he does not insist on the single most important item, which is common to all successful systems: The insurer must have no role in medical decisions.
Medical decisions must be made by medical professionals. The role of the insurers must not be to make such decisions, but only to pay for them.
In America, health-care is run by entities whose mission is not the health of their customers, but rather the dividends paid to their shareholders. What could possibly go wrong???
Saying stuff that simply is not true is a standard method of fascist propaganda.
Bullshit!
I look at the VA as an example. Only 5% of their expenditures go towards administrative costs, the other 95% goes for treatment. Insurance companies routinely state 25-30% administrative costs (and share holders dividends) with the balance going to patient care.
Insurance companies spend millions to lobby lawmakers to make sure the medical industry goes as unregulated as it can....
Litigating what is or is not covered is a huge cost... that should not exist. Medical decisions should not be made by an insurer.
But they are many times
Yes, they are... and that is wrong, both morally and pragmatically.
The first the insurer should know of a medical act is the order (not "request") to pay. No "prior accord". No haggling. No administrative cost for all that crap!
The insurer would be motivated to greater administrative efficiency, rather than to gouging the patient.
I'm so sorry, Veronica. I hope they find something that helps her
At least her new insurance company (which she found outside her job) doesn't fight the doctor's calls on her meds. now. The one she is on now appears to be working and we are very thankful.
I think we should take a more incrementalist approach and keep private insurance on the table.
However....if a Medicare for America program is passed, I see employers opting out of providing insurance for their employees. That would be fine if the employer passes those savings on to their employees and gives the employees the opportunity to absorb higher taxes and possibly co-pays.
I agree. I like my plan through my employer. My daughter has purchased her own through a company that mainly relies on doctor's decisions, not their own.
I see employers that opt out will not compensate the employee for that benefit they used to provide. Just my opinion.
Unfortunately, I see that, too, so another law will have to be passed
"No, you cannot discontinue your employee's health insurance and put that in your pocket. It must be passed on to the employee"
I have French health insurance. Private insurers are a big part of the system. That's not a problem.
They are very efficient payers.
Considering that in my case it is part of my compensation package along with my salary I would say I should reap the benefit, not my employer.
Somebody a whole lot smarter than me needs to look at the French and Dutch systems (look at Sweden and Switzerland, too) and figure out how we can make that work in the US
Well hopefully it will work out here, somehow.
totally agree but we have unscrupulous companies that will take that savings and give it to themselves and their shareholders
"Part of your salary package? Bwah-hah-hah! Not any more!"
There has got to be a way for it to work here.
There is a way but first we have major attitudes to adjust
Yes, there would have to be adjustments, but there are very intelligent in this country that could make it work if someone asked them to.
Heresy!!
Learn from other countries?? Never!
Those countries have only been doing universal health-care for half-a-century. What do they know??
I know. But capitalism - LOL
I don't know about other countries, but in France both employer and employee pay into an independent fund. It's easy to change jobs, and if the company has problems the fund remains.
Here in Germany, they have both public and private insurance, and the system works pretty well.
Germany did the first "social safety net". It was created by that horrible Commie, Otto von Bismarck...
Question for the people here who live in Europe. Are the medical providers in France, Germany, Holland, etc similar to England where there are hospitals owned by the government and providers who are employees of the government? Or are they all mostly privately owned like the US is set up as? That makes a difference in how you can convert the US to a single payer system.
In the US as all these hospitals and providers are privately owned, it's difficult to get them to change how their repayments should be. If you have a doctor who in order to get through medical school, internship and residency can be over $1,000,000 in debt before they get into private practice. If you greatly reduce the payments to doctors then fewer people will be willing to even undertake the process to get there.
So IMO, any process to fix this problem has to include the entire system. It's easy to point to insurance companies as the problem but that's only one part of the problem. We already have a lot of providers that are not accepting Medicare/Medicaid patients due to the low re-imbursement rates. If you just mandate that all medical payments will be at the Medicare rates how many more doctors will just retire because they cannot make expenses much less make a living?
Each country has its own system. They run the entire gamut from totally government-run in the UK to totally private - under government supervision - in Switzerland.
Who does the insuring is not the problem. How claims are made is the problem.
America allows the insurer to make medical decisions. Wrong in s-o-o many ways!