Universal coverage and pragmatic steps

I want to build on Betty’s post from late last week regarding universal coverage.

I’m grateful to Gillibrand for stating outright that a market-driven system will never achieve affordable, universal coverage, so the public aspects of the ACA will have to be expanded to move in that direction. President Obama and the Democrats who worked on healthcare reform during his first term knew that, which is why they built in Medicaid expansion nationwide, a provision the SCOTUS sabotaged.

Anyhoo, the whole thing is worth a read. Love it or hate it, I think Lemieux is correct when he says single payer is becoming a core part of the Democratic Party platform, at least as an objective. The disagreements will arise around how to get there.

If the disagreement is over how to get there, then it is a disagreement on pragmatism. How will something work? How does ERISA interact with each iteration of reform? What does Hyde and Hobby Lobby mean in this context? How is funding stabilized across the macro-economic cycle? How are transitions managed? What are the edge cases and why are they difficult?

Slogans have to translate into legislative text and then draft regulatory rules. 1,001 different questions need to be raised, examined, and answered. That is a long, ugly and loud process through which nothing pristine will emerge. And we need to be realistic about that process.

We recently saw how easy votes are to take for complete repeal of the ACA when there was no consequence to that vote. The inverse is true of any single payer vote when there are not 218 single payer voters in the House, 51 or 60 single payer votes in the Senate and a single payer signer in the White House. 218-49-1 or 218-51-0 coalitions are meaningless and anything that comes through that process except for mechanical feasibility studies have little value.

So if the goal is universal coverage, we need to get grinding through the boring policy work of figuring out what exactly that means and how exactly would it be implemented with what set of trade-offs.






71 replies
  1. 1
    Baud says:

    Neoliberal.

  2. 2
    Sab says:

    WTF labels. You just lost my vote. MSM shill.

  3. 3
    Spaniel says:

    So, has Trump sabotaged ACA in the execution of the program? Articles sprouting out over the weekend the money aspect is still in limbo but the behind the scene communication and coordination seems to be shot.

    I saw one article saying the administration cut funding about $213M for teenage pregnancies.

  4. 4
    Baud says:

    @Spaniel: He’s trying. Oddly enough, although the goal is to pressure Dems into dealing, at this point I think it may pressure the GOP into dealing with Dems.

  5. 5
    rikyrah says:

    Thought that you were on vacation 😉😉😉

  6. 6
    David Anderson says:

    @rikyrah: vacation ended yesterday

  7. 7
    Baud says:

    If Bernie Sanders tied you up in his basement and made you come up with a transition plan for moving us to single payer, what would you propose?

    ETA: Perhaps that’s an idea for a future post … or novel.

  8. 8
    Argiope says:

    @Baud: Yes, please. Assume Bernie leaves your hands free for typing, and provides nutritious and tasty snacks. Not doughnuts.

  9. 9
    Baud says:

    @Argiope:
    Ha! I think that “Have a donut” will soon become the new Die in a Fire.

  10. 10
    JPL says:

    @David Anderson: I hope that you and yours had a great time.
    Over the weekend Bloomberg mentioned that Manchin might become energy secretary, and Trump had said that he would hold a press conference today…

    On Friday, Trump said he would hold a press conference in D.C. on Monday. But there’s no press conference on his public schedule today.

    https://twitter.com/kylegriffin1

  11. 11
    Betty Cracker says:

    Dave, you seem to be suggesting that Democrats should actually think through what a transition would entail instead of braying “single payer now!” as mindlessly as the Republicans bellow about killing Obamacare. You, sir, are no politician!

    Regarding how to get to single payer, Gillibrand’s proposal is to expand access to Medicare as a first step. But as you point out, even a relatively modest expansion would require settling a ton of issues.

  12. 12
    JCJ says:

    @Baud:

    Classic hockey coach meltdown with “Have another donut”

    https://www.youtube.com/watch?v=SNRWiFUf2_8

  13. 13

    @Baud: I am scared … but I will have something based on this prompt at some point this week

    @Betty Cracker: I only have to worry about implementation and not coalition building

  14. 14
    Amir Khalid says:

    @JPL:
    Maybe Trump decided on the spur of the moment to have a Monday media conference on something, but didn’t think to tell his staff — who weren’t around to hear his wishes, it being the weekend, let alone to set it up or put it on the schedule. That would be entirely consistent with the standard of professionalism at the Trump White House.

  15. 15
    satby says:

    Well, I work for a provider who bills Medicare for exams, and though providers like Medicare because it will eventually pay, it’s a lot of paperwork and requires one staff person almost full time to keep on top of. I hope rules about streamlining process are included if they expand eligibility.

  16. 16
    Another Scott says:

    @Amir Khalid: There were several times in the campaign when he said something was going to be announced and it wasn’t, or it came days/weeks later. It’s Donnie’s Great Management Skills™ in action.

    I agree with David-Richard and many others here – moving toward greater universality (whether it’s True Single Payer™ or not) is going to be incremental – lowered eligibility ages, raised income caps (and bigger subsidies), etc., and it may require changes to the RWNJ majority on the SCOTUS to really accelerate.

    We know how to get there, we know it will be a long and drawn-out process. We have to keep moving the ball forward and not shoot ourselves in the foot arguing about purity. Purity kills.

    Cheers,
    Scott.

  17. 17

    I am sorry, I don’t get the donut joke.

  18. 18
    Another Scott says:

    @schrodingers_cat: It’s the evil DNC dissing Nina Turner.

    Or something.

    (groucho-roll-eyes.gif)

    HTH.

    Cheers,
    Scott.

  19. 19

    @Another Scott: What is her problem, is she offended that there was no coffee?

  20. 20
    zhena gogolia says:

    @schrodingers_cat:

    Me either, I asked about this the other day but no one answered me.

    OT, thanks to Cole’s twitter feed, I now know how I can watch GoT — Seth Meyers does “Game of Jones” with Leslie Jones, where they watch it together, and THAT I can enjoy.

  21. 21
    Viva BrisVegas says:

    Merck CEO Ken Frazier has quit from the President’s Manufacturing Council citing “a responsibility to take a stand against violence and extremism”.

    Trump’s twitter response:

    “Now that Ken Frazier of Merck Pharma has resigned from President’s Manufacturing Council,he will have more time to LOWER RIPOFF DRUG PRICES!”

    I don’t think we’re meant to ask why Trump had him on the advisory council if he thought so little of Frazier and his company.

  22. 22
    JPL says:

    @Viva BrisVegas: Others should read Frazier’s message, and refuse to serve this president. Tweets can’t hurt them.

  23. 23
    tobie says:

    @Viva BrisVegas: @JPL: He really can’t let any slight go. Other CEOs should follow Frazier’s example. Once they do it, they’ll find out it’s actually rather easy.

  24. 24
    Amir Khalid says:

    @Viva BrisVegas:
    When all the world trembles before your awesomeness, lashing out at those who show disappointment and frustration with you is a sure way to win them back. That’s how Trump sees things.

  25. 25
    dr. bloor says:

    @Baud:

    ETA: Perhaps that’s an idea for a future post … or novel.

    Alas, Stieg Larsson died before he had a chance to finish the first draft.

  26. 26
    ThresherK says:

    Yep. Paper tiger votes for Medicare-for-all are the Dem version of Repeal ACA. Berners will be furious when it doesn’t magically happen.

    The Wilmerites emitted this feeling* of “When Bernie wins the White House, everything we cheered for becomes law!” since before Hillary cheated Wilmer out of his first lost delegate.

    Is there a critical mass of them who know how policy is made?

    *Carefully chosen term.

  27. 27
    Fair Economist says:

    Do the Berners even realize Medicare for All would be a substantial step *back* for much of the working class? Right now they get Medicaid, which covers almost everything, and the Berners want to move them to Medicare with substantive co-pays.

  28. 28
    NCSteve says:

    @ThresherK:

    No. They are, as they always have been, the pro-magic coalition. And anyone who doesn’t believe in magic is actively evil and trying to do in the real world, in the real, hard, non-magic way, what they want to do by magic is a sellout, a corporatist, a neoliberal, corrupt sellout.

  29. 29
    Viva BrisVegas says:

    @JPL:

    Bloomberg mentioned that Manchin might become energy secretary

    I would hope that even Manchin isn’t venal enough to fall for that. Anyway his job would only last so long as he could continue saying “I love you Mr President” without vomiting. In other words for the period of about one Scaramooch.

  30. 30
    ThresherK says:

    @NCSteve: Hey, who would ever come out against magic?

    If you’ll excuse me, I’m off to find someone who’ll primary Elizabeth Warren. That sellout needs to be knocked down a peg.

  31. 31
    randy khan says:

    @Viva BrisVegas:

    That’s about as perfect a Trump response as you could imagine, not even considering how much more it will result in stories shining a light on the CEO’s reason for resigning.

  32. 32
    Laura says:

    @Amir Khalid: Let’s all laugh at his mighty sword.
    I’m loath to endorse PHARMA, but heartily agree that other business leaders should see which way the wind blows and get as far away from trump as fast as possible.

  33. 33
    RobertDSC-iPhone 6 says:

    Federalization of Medicaid and expansion into all 50 states.

    Stronger regulations on insurers.

    Repeal of Hyde and legislative fix if possible for Hobby Lobby.

    Medicare buy in at age 55.

    What else?

  34. 34
    Jim, Foolish Literalist says:

    @Baud: Ha! I think that “Have a donut” will soon become the new Die in a Fire.

    I’m having flashbacks to the D-Kos comment-rating days…

  35. 35
    Laura says:

    @RobertDSC-iPhone 6: prescription drug pricing and patent chicanery.

  36. 36
    Jerry says:

    @RobertDSC-iPhone 6:

    Federalization of Medicaid and expansion into all 50 states.
    Stronger regulations on insurers.
    Repeal of Hyde and legislative fix if possible for Hobby Lobby.
    Medicare buy in at age 55.
    What else?

    Super-duper majorities in every single government in the nation. Federal, state, county, city, town, village, township…

  37. 37
    tobie says:

    @RobertDSC-iPhone 6:

    Stronger regulations on insurers.

    I think Elizabelle mentioned in yesterday’s healthcare thread that it’s better to say “consumer protections” than “regulations.” I tend to agree. Other than that, your list looks good.

  38. 38
    sk7326 says:

    One start could be for blue states to lead the way (they probably will anyway). What if a state like Massachusetts, New York, whomever – looks into expanding its MEDICAID program … allow universal buy-in? There won’t be a federal match – but can the federal government prevent its state partner from doing MORE, especially if they bring their own funding to the table? That would seem to have less red tape than other options – while simultaneously increasing Medicaid’s attractiveness to providers.

  39. 39

    @RobertDSC-iPhone 6: okay, how do we get working 218-60-1-5 majorities for all of these good ideas?

  40. 40
    dmsilev says:

    @Betty Cracker:

    Dave, you seem to be suggesting that Democrats should actually think through what a transition would entail instead of braying “single payer now!” as mindlessly as the Republicans bellow about killing Obamacare. You, sir, are no politician!

    You should come to California, where an appreciable number of our politicians not only brayed mindlessly about single-payer-now, they actually pushed through a bill in the state senate saying as much. And it was about as well thought through as the GOP’s endless Repeal Obamacare Now bills were, which is why it was a good thing that after it passed the Senate, the lower chamber basically said “we’re not going to take this up until you actually produce a bill that, you know, is thought through”. And yes, the local purity ponies are all a-twitter (or a-Twitter) about that decision to shelf.

  41. 41
    FlipYrWhig says:

    @ThresherK: Geez, man, Bernie himself explained this. You just get a crowd outside Mitch McConnell’s window and then quivers in fear and does everything you want! :/

  42. 42
    Betsy says:

    Again thanks to David for these posts. As a layperson to this topic, it is so good to have the policy details.

  43. 43
    Amir Khalid says:

    @FlipYrWhig:
    I wish someone in the American media had thought to ask Bernie the obvious follow-up question: “Senator McConnell shuts his window. Your move. What do you do?”

  44. 44

    @dmsilev: the purity brigade in San Francisco is sooooo mad about that. I’m upset that our senator supported it, but I suppose he was representing his constituents and not wanting to commit political suicide.

    Thanks, David, well-put.

  45. 45
    Mnemosyne says:

    @schrodingers_cat:
    @zhena gogolia:

    A group of Sanders dead-enders wanted to meet with the DNC, and their leader Nina Turner was OUTRAGED that they were offered doughnuts and bottled water.

    I’m still not quite clear on whether they weren’t allowed to meet at all, or if they just didn’t get to have the meeting on their own terms, set the agenda, and get their own way on everything.

  46. 46
    Villago Delenda Est says:

    Slogans have to translate into legislative text and then draft regulatory rules.

    This is where Bernie always fails.

  47. 47
    Jerry says:

    @Betsy:

    Again thanks to David for these posts. As a layperson to this topic, it is so good to have the policy details.

    Agreed. I didn’t know how little I knew about this topic until Richard-David came around. However, I do like to think that I know a lot more because of him.

    Since he now lives a town away, maybe it’s time for a Triangle area meet up.

  48. 48

    @Villago Delenda Est: b-but he’s the king of amendments!

  49. 49

    @Major Major Major Major: He is a legend in his own mind and that of his followers. Substantive achievements though are negligible.

  50. 50
    trollhattan says:

    @Another Scott:
    I won’t pretend to know or care who Tina Nina Turner is but boy oh boy, is she easily offended.

    “They tried to seduce us with donuts and water,” she said. “They’re pompous and arrogant enough to say to the people, you’re not good enough to be on our property — and, oh by the way, we’re just gonna hand you donuts and water over the barricade. That is insulting. Absolutely insulting.”

    I pity the next hostess who offers her a choice between table and booth.

  51. 51

    @schrodingers_cat: I find the ‘king of amendments’ thing very telling as a claim to fame and (i presume) self-footed horn. It’s the claim of useless second-stringers everywhere–I didn’t actually do anything but I was there when it happened and said words! It’s a participation trophy, he’s the king of passing classes because he got a 95 on attendance up and was shrewd enough to take it pass/fail.

  52. 52
    Amir Khalid says:

    @Mnemosyne:
    I haven’t been following this, either. Has this Nina Turner person never been to a work meeting? Most people have, and have seen light refreshments served as a courtesy to those attending. Did she think the doughnuts and water were some kind of bribe or insult?

    ETA: So she felt insulted. Hmm.

  53. 53

    @trollhattan: she’s one of those kids who would have failed Montessori for sure.

  54. 54

    @Fair Economist:

    Do the Berners even realize Medicare for All would be a substantial step *back* for much of the working class?

    No. The critical thing to realize about Berners is that for all they talk about how they get the white working class, they’re basically middle class people who don’t understand how middle class differs from working class. That’s why so many of their policy proposals (e.g. free college tuition) are about middle class problems rather than working class.

  55. 55
    rikyrah says:

    @RobertDSC-iPhone 6:

    Medicare buy in at age 55.

    Age 50.

    Universal health/dental from ages 0-26 (idea from a poster here on Friday, I think)

  56. 56
    Life in Queens says:

    I don’t think this is fair to Sanders. Some of his amendments really have been valuable, especially to the ACA. But it does underline his inability or uninterest in assembling a coalition of any size.

  57. 57
    Life in Queens says:

    @Roger Moore: This. I’ve always been astonished at how transactional their politics is, and how oblivious they are to that fact.

  58. 58
    Laura says:

    @dmsilev: What’s your thoughts on John Garamendi”s solution -to retain employer provided helth care and to expand madicare.

  59. 59
    FlipYrWhig says:

    @Roger Moore: Exactly. It’s predominantly a movement of well-educated, often underemployed, creative-class white people pretending to have insights into the plight of the working class. And as with Trump supporters, even on matters of economics and work it’s not “the government needs to create jobs that _I could have_,” it’s “the government needs to create jobs that someone else could be doing.” It would be great if campus radicals and working-class people were natural allies. In America at least, they really aren’t, even if both of them are wary of the power of banks.

  60. 60
    Fair Economist says:

    @Major Major Major Major:

    the purity brigade in San Francisco is sooooo mad about [the California legislature dropping single-payer].

    In California, they can put up a proposition for whatever kind of single-payer they want. I wish they would, because it would be a good reality check for them. The organizers also know it would be a reality check, which is why I expect only continued whining and not action that would actually work if their claims of broad public support were true.

  61. 61
    Uncle Ebeneezer says:

    @dmsilev: Sigh…yup, one of the women in my Indivisible group (SoCal) yesterday ended by urging us all to pressure Rendon to Release the Single Payer bill. I din’t want to get into it with her so I just kept silent.

    I’m no expert on the mechanics of how we get to Universal coverage but at least I ADMIT that. These Bernier-Than-Thous are absolutely positive that they have the one true solution, but can’t explain how or why nor tolerate anyone asking.

  62. 62

    @Jerry: Agreed… name a time and a place

  63. 63
    Jim, Foolish Literalist says:

    interesting

    Alexandra JaffeVerified account
    “The long-term solution to the healthcare crisis in America is to make Medicare available to all” @ BernieSanders says @ senior center event

    He’s made case 4 a public option before:
    Shift seems to be embrace of incremental change rather than all or nothing

  64. 64
    burnspbesq says:

    @Betty Cracker:

    Dave, you seem to be suggesting that Democrats should actually think through what a transition would entail instead of braying “single payer now!” as mindlessly as the Republicans bellow about killing Obamacare.

    Progressives love the idea of progress, but actually achieving it requires hard, sustained work, in which they have little interest.

  65. 65
    jl says:

    I think that a symbolic vote for single payer, medicare for all, or other big reforms are different from GOP symbolic votes to repeal and replace PPACA. These Dem votes are for what could be very good policies, and if/when Democratic majority could be used to support good reforms. The Congressional GOP never had a plan and their votes, symbolic of substantive, were dishonest. They were lying about what they were doing.

    So, I don;t think these votes are a bad thing.

  66. 66
    burnspbesq says:

    @Viva BrisVegas:

    In case you missed it, Merck’s stock is up a bunch since Frazier’s announcement.

  67. 67
    Sab says:

    Thanks again RichardDavidMayhewAnderson. My whole family’s survival depends on the success of your information campaign. I’ll keep plugging away on letters to the editor , Facebook and calls to Congress as long as you give me info. I’d still call and write, but you keep me from sounding like a distraught idiot.

  68. 68
    burnspbesq says:

    @Uncle Ebeneezer:

    Rendon is probably going to get primaried. I will show up to work for him. He did the right thing.

  69. 69
    The Question says:

    Donuts thing: NIna is mad because they brought signed petitions to consider the peoples platform instead of the “great” better skills better jobs mush mush. the people were met with barricades for their trouble because of fire safety theoretically. possibly reason to be upset.

    on health care why do we always have to pre-negotiate with ourselves and have ourselves primed to accept half a loaf? I am so tired of being sensible when there is no gorram reward. If loudly shouting the most extreme thing we want gets us even half what the republicans have gotten out of it why the hell not??

  70. 70
    Mark Regan says:

    @Fair Economist: Presumably any real Medicare for All proposal would include some sort of income-based premium and cost-sharing protections for relatively low-income people, as Medicaid provides now for low-income Medicare beneficiaries (Qualified Medicare Beneficiary, etc.).

  71. 71
    goblue72 says:

    Show us on the doll where Bernie Sanders touched you, Mr Mayhew.

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